rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
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 entrance stated, You can't leave that there (the over-the-bed table). There are two people with wheel chairs. Staff member T stated I know, and walked away. Staff member T's voice was rough, and her demeanor was abrupt. The female resident stated No you don't. Staff member T returned with a smaller table and stated See, I told you I knew, and I'm moving it now. Staff member T took the other table out of the dining room. Staff member T's demeanor was, abrupt and her voice sounded rough. During an interview on 3/9/17 at 9:30 a.m., staff member T stated Some residents say we are being rough with care, but it is because we are rushed. 2. Review of an incident report, dated 2/1/17, showed resident #14 was treated very very rough by staff member G, while assisting her with upper body dressing. Staff member C investigated the rough handling allegation between 2/1/17 and 2/6/17. On the reporting form, staff member C indicated staff member G was assigned to another cottage, during which time, interviews could be conducted with other residents. During an interview on 3/8/17 at 9:15 a.m., staff member C stated, usually alleged staff members were assigned to a different area until the investigation was final. However, about two weeks ago it was decided, during the managers huddle meetings, to put the alleged staff members on administrative leave with pay, until the investigations were finalized. This decision was made due to a recent increase in the number of allegations against the staff. Staff member C stated as a result of this investigation, two more residents came forward complaining about the same CNA rushing cares with them. She stated these allegations warranted further investigations about the CN[NAME] Staff member C provided the facility's abuse prevention protocol and stated the facility was in the process of updating the policy. 3. A record review of an incident report sent to the state agency, by the facility, dated 9/6/16, showed details of alleged staff rudeness and rough care during resident cares provided for resident #26 by staff member Y. The report showed that staff member Y was reassigned . pending further family interview and investigation of the complaint. A record review of an incident report sent to the state agency, by the facility, dated 1/17/17, showed details of alleged staff rudeness and rushed care, during personal cares for resident #28, by staff member T. The report showed that after the alleged abuse had been reported, staff member T was told by a nurse she needed to switch to another resident, and she was not supposed to work with the alleged abused resident. The report showed that staff member T said she did go into resident #28's room later that day because the call light was going and no one else was around. A record review of another incident report sent to the state agency, by the facility, dated 1/22/17, showed details for another report of rough cares by staff member T involving resident #32. The report showed that staff member T was placed on administrative leave until completion of this incident's investigation. A record review of an incident report sent to the state agency, by the facility, dated 2/9/17, showed details of alleged staff rudeness and disrespect during resident cares, provided to resident #27, by staff member Z. The accompanying investigation report, dated 2/14/17, showed that it was determined there was reason for concern with the care provided by staff member Z. The report said that staff member Z would be placed in discipline. The report showed, she will be moved to another Cottage until the current resident with concerns is discharged . The report did not indicate that staff member Z had discontinued providing resident cares after the allegation of abuse had been reported, or during the investigation of the allegation. During a meeting with the facility DON, and members of the abuse prevention committee, on 3/8/17 at 1:00 p.m., the committee members were asked what criteria was used to determine if a staff member, as an alleged abuser, was placed on administrative leave, or allowed to continue to perform cares for residents during the abuse incident investigation. Staff member B responded by saying that the committee members had recently concluded they needed to consider a change in the policy of how the facility conducted investigations of allegations of staff to resident abuse incidents. This was prompted by several allegations of staff to resident abuse events reported in the first two months of this year, and included one incident that was determined as substantiated following investigation. A new abuse education program had also recently been put together, and was to be conducted for all employees throughout all the LTC facilities within the next couple of weeks. It was discussed, during this meeting, that allowing an alleged abuser to continue to perform cares for any residents during abuse incident investigations had the potential of placing residents at risk for abuse. It was also discussed that the accused employee is due protection from those who might take the opportunity to allege further abuse. During an interview on 3/9/17 at 8:30 a.m., staff member A provided a copy of the facility's new abuse policy, and stated the changes in the policy had been signed into effect that morning, less than an hour earlier. A comparison review of the old and new facility abuse policies showed that changes had been made regarding removal from duty of staff members who were being investigated for an allegation of abuse. Under part II of Allegations of Abuse, Neglect, and/or Misappropriation of Funds, letter e of the old policy, was the statement The Resource Nurse, with support and guidance from the Unit Manager and/or their designee may remove from duty any employee being investigated for an allegation of abuse during the investigation process. The new policy states, The Resource Nurse . removes from duty any employee being investigated . The new policy goes on to show the employee suspected of abuse is to be placed on administrative leave pending completion of the investigation. If abuse is substantiated the administrative leave will be unpaid leave. It also stipulates that the employee's privacy is to be protected during the abuse investigation. It outlines the investigation process to be followed indicating who will review the alleged occurrence with the employee, who will inform the employee of the investigation results, and when the employee will be able to return to work.",2020-09-01
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 encouraged resident #19 to eat the bite. Staff member V left the side of resident #19. -At 5:01 p.m., resident #19 was reaching for an almost empty glass, secured with a lid and straw. The glass fell sideways on the table, dripping white liquid content from the glass onto resident #19's lap. -The resident tried lifting the glass to drink, again. After sipping the drink with a straw, the resident lowered her head towards her chest, hitting the edge of the table with her forehead. During an observation on 3/8/17 at 4:05 p.m., resident #19 was seated in a small broad chair, against the table, farthest from the Lodge dining room kitchenette. The resident's nose was level with the table top. During an observation on 3/9/17 at 9:30 a.m., resident #19 was seated in the Lodge dining room. The table had been lowered to shoulder level. During an interview on 3/8/17 at 1:44 p.m., staff member V stated the resident, as long as she could remember, was to have a lowered table for meals. Review of the interdisciplinary notes, dated 1/1/17, showed the resident had a bruise on her right eye due to bumping her head on the table in the dining room. Staff were educated to not push the resident too close to the table at meals, and the table was raised a bit to prevent the resident from bumping her head on the table. Record review showed a lack of documentation involving the table height, during meal times, for resident #19. 2. Resident #36 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation on 3/8/17 at 5:40 p.m., resident #36 was in the dining room waiting to eat dinner. Resident #36 was sitting at a round table with both her feet extended in front of her. Resident #36 was placed at the table with her left side closest to her plate. Resident #36 was reaching across her body, with a fork in her right hand. She would spear food with her fork, and bring her right hand back to the middle of her body to place the food in her mouth. Resident #36 was observed to eat 20 percent of her meal. During an interview on 3/8/17 at 5:40 p.m., resident #36 said it would be easier for her to eat if her food was placed in front of her. When resident #36 was asked if a bedside table, that could be placed in front of her, would be better, resident #36's comment was, Well sure! Then I wouldn't have to reach across myself to eat. Resident #36 then said, But they'll never think of that here. During an interview on 3/8/17 at 5:50 p.m., staff member HH said resident #36's feet were very sensitive, and needed to stay elevated. Staff member HH said she did not know if the facility had ever addressed using a bedside table for resident #36 during meals. Staff member HH said they would try a bedside table, at breakfast, for resident #36. During an observation and interview on 3/9/17 at 8:45 a.m., resident #36 had a bedside table placed in front of her. Her food was on the table, and resident #36 was eating breakfast. Resident #36 said it was easier to eat her food with it sitting in front of her. Resident #36 had eaten 85 percent of her breakfast. 3. During an interview on 3/9/17 at 8:00 a.m., resident #7's family member voiced several concerns for the resident: -The family member said if resident #7's wheelchair could fit through the bathroom door, resident #7 would be able to brush her own teeth, and wash her own face, which would allow resident #7 to be more independent. The family member said the mirror above the sink was to high, and resident #7 would not be able to see herself in it, if she could fit her wheelchair into the bathroom. -The family member said resident #7 had the ability to transfer herself from one surface to another. The family member said if resident #7 would toilet herself if her wheelchair could fit through the doorway of the bathroom. The family member said resident #7 could use a walker at times, and could get into the bathroom in that manner, but with trying to steady the walker, and grab the assist rails around the toilet, resident #7 was not, at times, able to get her pants down prior to her bladder releasing. The family member said the facility wanted resident #7 to use a bedside commode instead of the toilet. The family member said resident #7 was not comfortable with doing that, but at times she would. During a review of resident #7's Annual MDS, with an ARD of 8/6/16, showed the resident to be an extensive assist of 1 person for personal hygiene. This Annual MDS also showed the resident had no range of motion limitations. During an interview on 3/9/17 at 11:00 a.m., staff member T said there were several residents who could wash their faces, and brush their hair if they could get their wheelchairs into their bathrooms. Staff member T said resident #7 could do that for sure, if her bathroom door was wider so she could get in her bathroom. 4. Observations made from 3/6/16 to 3/9/17, throughout the Westview facility, showed all the mirrors in the resident bathrooms were at the same height above the bathroom sinks. Residents in manually operated wheelchairs were unable to view themselves in the bathroom mirrors.",2020-09-01
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 quarter of an inch in size bites). During an observation on 3/7/17 at 5:20 p.m., resident #15 was eating his evening meal unattended while nursing staff served other residents. He was taking large bites quickly and repeating this prior to swallowing his food. He began coughing with his face becoming reddened. At 5:25 p.m. resident continued to take quick bites while coughing. At 5:26 p.m., staff member [NAME] approached the resident and spoke with him. Resident #15 stopped eating and took a drink after the CNA redirected him. Staff member [NAME] sat with the resident and provided cues to the resident. With the CNA's supervision, the resident took less frequent bites. This continued until 5:37 p.m. and there was no further coughing. The CNA wheeled the resident away leaving the table. Review of the resident's most recent speech/swallow therapy discharge summary, dated 7/28/16, showed the following: a) Swallow Strategies/Positions: 1. Quality of life diet (regular textures of whatever the resident wanted). 2. All foods to be chopped to 1/2 inch bite sized pieces. 3. Extra gravy and sauces on foods. 4. Slow rate eating with one small bite followed by a sip of fluid. 5. Decreased distractions. 6. Dining room supervision at all times. b) Supervision for oral intake: Close supervision These instructions by the speech therapist were not observed during the aforementioned dining room observations. Review of the most recent care plan, dated 1/24/17, showed the following: 1. Small portions with seconds to avoid loading the oral cavity. 2. Encourage resident to sit at the kitchen counter for the close staff supervision. 3. Reflux precautions. 4. Staff was to remind him to eat at a slow pace with one bite of food followed by subsequent swallow. 5. Although chopped foods to 1/2 inch bite size worked in the past, the son requested food to be cut down to 1/8th or 1/4th of an inch size bites. 6. The resident had numerous choking incidents due to [MEDICAL CONDITION] structural deficits, large hiatal hernia, anxiety, paranoia and dementia. The resident refused pureed foods and thickened fluids. 7. The resident choked and the [MEDICATION NAME] maneuver was attempted on the following dates: 2/26/17, 1/16/17, 12/27/16, 10/10/16, 7/17/16, and on 7/13/16. The resident's care plan did not indicate that the resident was refusing staff's supervision during the meals with alternate methods for close supervision. During an observation of the meal service and an interview on 3/7/17 at 5:10 p.m., staff member D stated resident #15 did not like supervision or anyone sitting with him during meals. She stated he would throw his tray or food and/or quit eating. She stated he became paranoid when people watched him eat. When asked if the staff sat down and ate with him, while monitoring him and giving him instructions on his swallow precautions, she stated she did not not know. The resident was sitting alone at the table. During an interview on 3/8/17 at 8:30 a.m., staff member R stated she was very familiar with resident #15. The resident had psychological issues and quit eating if someone sat with him. She stated the resident refused pureed textures. She stated he truly needed to eat in a quiet place. She was asked if these statements were part of the resident's medical records and if so to provide it to the surveyor. As of the end of the survey on 3/9/17, no additional documentation was provided. During an interview on 3/8/17 at 3:45 p.m., staff member C stated the resident used to dislike it if staff supervised or helped him with his meals. She stated she understood that they were not really following the resident's care plan. She stated he was changing, and he did not have behaviors as before during meals. The resident declined an interview on 3/8/17 at 1:39 p.m. 2. Review of resident #19's Quarterly MDS, with an ARD of 1/27/17, showed the resident was cognitively impaired and required extensive assistance with ADLs. Review of physician orders, dated 5/29/13, showed resident #19 was to wear bilateral protective sleeves and Rooke boots (foam boots around the leg and foot) to be worn all the time. During an observation on 3/7/17 at 5:08 p.m., resident #19 was seated in a broda chair, in the Lodge dining room. The resident was wearing Rooke boots. During an interview on 3/7/17 at 5:20 p.m., staff member V stated resident #19 was to wear Rooke boots all the time, even in bed. During an observation on 3/8/17 at 4:05 p.m., resident #19 was seated in the Lodge dining room, awaiting the meal. The resident was sitting in the broda chair, wearing Rooke boots. Review of resident #19's Care Plan, with a start date of 2/1/17, showed the facility staff had not identified the need, goal, and procedure for the wearing of the bilateral protective sleeves and Rooke boots.",2020-09-01
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, - 1/24/17 and 2/20/17, a span of 27 days, - 2/20/17 and 3/5/17, a span of 13 days. Review of resident #20's Care Plan, with a start date of 1/3/17, did not address the resident's ADL needs including showering or bathing. During an interview on 3/8/17 at 8:55 a.m., staff member V stated resident #20 refused a shower. All the staff member could do was encourage the resident to have a shower, throughout the week. During an interview on 3/8/17 at 8:20 a.m., staff member U stated resident #20 refused showers often. The staff member stated, if she (the staff member) was available, she could usually get resident #20 to take a shower or bath for her. 3. During an interview on 3/9/17 at 9:32 a.m., resident #3 stated if she missed her shower, she was not offered another time to take one that week. She tried to take her showers on her shower day and not refuse or be unavailable. Review of resident #3's electronic bath reports, from 12/1/16 through 3/6/17, showed the resident did not have a shower between 2/9/17 and 2/23/17, a span of 14 days. Review of resident #3's Care Plan, with a start date of 2/21/17, showed the resident was to be as independent as possible with ADLs. Staff was to set up and provide assistance as needed. During an interview on 3/8/17 at 9:53 a.m., staff member V stated documentation for showers was to be documented on the Care Tracker. No other documentation was made available which showed the facility was showering or bathing the identified residents in a timely manner. HAIR CARE 4. During an observation on 3/7/17 at 5:08 p.m., resident #19 was seated at the table in the Lodge dining room. The resident's hair was flattened in the back, and on the sides of her head it was sticking up or laying in all directions. During an interview on 3/8/17 at 1:44 p.m., staff member V stated the CNAs were to comb resident #19's hair after getting her up from bed after napping. The staff member stated resident #19 had just got up from a nap. The staff member took her hand and caressed resident #19's hair down. During an observation on 3/8/17 at 4:05 p.m., resident #19 was seated in the Lodge dining room, awaiting the meal. The resident's hair did not appear to have been combed or brushed. The resident's hair was smashed to the right side of her head. Review of resident #19's Quarterly MDS, with an ARD of 1/27/17, showed the resident was cognitively impaired and required extensive assist with hygiene. Review of resident #19's Care Plan, with a start date of 2/1/17, showed staff were to encourage or assist her to eat, and she sometimes likes her plate in her lap so she can reach the food . The care plan showed the resident had a [DIAGNOSES REDACTED]. 5. Review of the Care Tracker Bath Type Detail Report for Goodnow cottage, for (MONTH) and (MONTH) of (YEAR), showed between 2/1/17 and 3/8/17, there were 16 resident showers or baths tracked in the Goodnow cottage with the following findings: Resident # 12 received one bed bath on 2/8/17. No other bathing activity was documented for the months of (MONTH) or (MONTH) of (YEAR). During an interview and observation, on 3/6/17 at 5:50 p.m., resident #12 stated she did not think she smelled bad, but the resident's hair was observed to be unclean. Resident #30 received a shower on 2/2/17, 2/23/17, and 3/2/17. The Care Tracker Bathing Type Report showed that during (MONTH) (YEAR), the resident experienced a 21 day span between showers. During an interview on 3/9/17 at 11:55 a.m., resident #30 stated she received showers on Thursdays, but she missed one recently. When she was asked about her preferred bathing frequency, she stated I prefer showers on Thursdays, every Thursday. During an interview on 3/9/17 at 12:00 p.m., resident #31 stated she preferred baths once a week, every week. She stated she was getting baths once a week. Review of the Care Tracker Bath Type Detail Report showed she was given a shower on 2/9/17 and a bath on 3/2/17, a span of 21 days between bathing events. During an interview on 3/9/17 at 10:20 a.m., staff member AA stated she was not currently aware of any residents who routinely refused baths. During an interview on 3/9/17 at 11:40 a.m., staff member H stated they had bath assignments which were by room numbers and shifts. She stated they usually gave two baths per shift. If the resident refused a bath, then the staff asked the resident two more times, and then reported to the nurse the refused bath if not given. She said they entered the occurrence of the baths in the Care Tracker electronic record. Some staff forgot to enter the baths were given. Staff member H stated they also had resident roster sheets that they carried with them when on shift. During the shift change the staff would exchange care issues and missed baths to the staff on the following shift. During an interview on 3/9/17 at 11:51 a.m., staff member C stated had no system in place for the validation of baths being given by the nursing staff to show residents were receiving their weekly or requested showers or baths. She stated the baths were missed during the evening shifts, and she would revisit the issue with the evening staff.",2020-09-01
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 [NAME] and I were in the kitchen in Goodnow cottage setting up for the evening meals. Neither of the staff members had donned aprons and hair nets when completing the tasks. They both leaned on the kitchen counters, and their uniforms came in contact with the kitchen counters. 3. Tour of the Ario cottage kitchen During an observation on 3/8/17 at 10:41 a.m., the following concerns were identified and documented: - The lower cupboard doors, located under the food warmer, were covered with dried food debris and stains on them. - The gasket to the small freezer, located on the culinary side, had an unknown fuzzy substance and food debris on it. - The lower gasket of the left door of the reach-in cooler, located on the culinary side, was stained and filled with sticky food substance. - Six ice cream containers, in the front side kitchen refrigerator freezer compartment,were opened and mostly consumed. They were not marked with the container open dates. Labels were stuck on these containers, but they were not filled out by the staff. - Five of the six Ziploc bags full of frozen raw cookies were not marked with dates of use or expiration, although perishable. During an interview on 3/8/17 at 11:10 a.m., staff member CC stated the staff were only responsible to clean the front side of the cottage kitchens. The culinary sides were cleaned by the kitchen staff. Staff member CC also stated when they opened the ice cream containers, they had to labeled it with the open date. She stated she was just going to mark the ice cream with open dates. She was told that at least 3 containers were almost empty, and she could not accurately guess the open dates. This was the task of the person who opened the container. She said they did not have cleaning schedules. She stated they cleaned the kitchen during downtimes or on the weekends. During an interview on 3/8/17 at 11:12 a.m., staff member Q stated the opened ice cream containers, found in the refrigerator that day, needed to be disposed of since they were not dated when the containers were opened. She said the containers were labeled, and the labels were left blank because CNAs and/or homemakers did not mark the items when they opened the container for consumption. 4. Tour of the TCC Cottage Kitchen During an observation of the TCC Cottage Kitchen on 3/8/17 at 11:16 a.m., the following concerns were documented: - The gaskets to the refrigerator and the freezer compartment of the refrigerator, located in the front kitchen, were showed an accumulation of food debris. - A Ziploc bag of the frozen cookies, located in the front kitchen refrigerator, was not dated. The frozen cookies were portioned into a Ziploc bag after being removed from their original packaging. The freshness of the cookies could not be determined. - On the culinary side of the kitchen, beyond the yellow line, two lower cabinet shelves, located under the food warmer, were damaged, the surface coating/laminate was missing and exposing the particle board, creating uncleanable porous surfaces. At the same time, the shelves were covered in large, dried, brown colored stains. - The plate warmer housing the china was left uncovered. This was allowed during meal service but between meals the plates must be covered to prevent potential dust or other contaminants landing on the china. - The culinary side of the reach-in cooler's gaskets, for both of the doors, were filled with food debris and dried stains. - The tip of the whipped cream tube was uncovered and exposed to air. - The ice scoop was left uncovered. 5. Tour of the Goodnow Cottage Kitchen During an observation on 3/8/17 at 11:26 a.m., the following concerns were documented: - The trash can, located in the culinary side of the kitchen, was covered with dried stains and food splatter. - The ice scoop was not covered. - The gasket to the small freezer, located on the culinary side, had a unknown fuzzy substance and was filled with food debris. - The gasket to the freezer compartment of the refrigerator, located in the front kitchen, was filled with food debris. The gasket was torn at the top of the right door of the same refrigerator. - The range oven needed to be cleaned. The interior side of the oven door, and the bottom surface, was covered in black and brown color stains and burnt debris. During an interview on 3/9/17 at 9:00 a.m., staff member GG stated he would visit these identified dietary issues in a timely manner. 6. During an observation on 3/7/17 at 10:20 a.m., the cooling unit of the walk in freezer was found to have ice build-up on it. The ice had thawed and refrozen. During that process, water had dripped onto a case of pastry dough, a case of brussel sprouts, a case of chopped spinach, and then refrozen. During an interview on 3/7/17 at 10:45 a.m., staff member FF said a new food service company had taken over four days ago, and the freezer door had been left open a lot due to boxes of frozen food being moved in and out of the freezer. Staff member FF said a lot of rearranging had been going on in the freezer, and the freezer door would be left open when that was occurring. Staff member FF said kitchen staff were supposed to shut the freezer fan off when the freezer door was left open for an extended period of time, to reduce the defrost cycle, which would in turn reduce the ice build up on the cooling unit.",2020-09-01
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 doesn't have any teeth so he can't eat it. The family member was referring to the garlic breadstick. During an interview on 3/9/17 at 10:00 a.m., resident #17's family member said the dietitian had modified resident #17's diet so he could eat better. The family member said resident #17's meat had to be chopped so he could eat it. The family member also said resident #17 might have an abscess in his mouth because he was having so much mouth pain. The family member said resident #17's dentures were broken. The family member said resident #17 had not seen a dentist since admission to long term care. The family member said facility staff notified her, on 3/8/17, that an appointment had been scheduled for resident #17 to see a denturist on 3/14/17. During an interview on 3/8/17 at 3:30 p.m., staff member HH said a denturist appointment had been scheduled for resident #17. Staff member S provided a copy of a document showing resident #17 was scheduled to see a dentist on 3/14/17.",2020-09-01
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 mask or the pipe on the bed or the table. Staff member C stated she was not aware of any process for the cleaning of the mask, pipe, or the cup, but the tubing was changed regularly and labeled with the date when changed. During an interview on 3/8/17 at 8:55 a.m., staff member N stated she did not rinse the nebulizer attachments, but mainly assessed the resident's status, lungs, and the effectiveness of the treatment. Review of the Benefis Health System Treatment/Guideline, titled Respiratory Therapy Benefis Senior Services, showed Nebulizers are rinsed after each use and air dried in the room. They are washed with soapy water, rinsed and air dried on the evening shift after the last treatment of [REDACTED].",2020-09-01
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 the concentrators' filters. During an interview on 3/7/17 at 2:53 p.m., staff member K stated there was no nursing policy on filter cleaning and/or replacement. He stated the housekeepers vacuumed them, and the concentrators received annual PMs. During an interview on 3/7/17 at 2:55 p.m., staff member I stated they wiped the concentrators, but the filters were not cleaned. She stated and they are filthy dirty. She stated she brought this issue to the facility's attention two years ago when she worked at Eastview, but she was told not to touch the filters. During an interview on 3/9/17 at 10:00 a.m., staff member P stated she did not perform routine cleaning of the filters of the oxygen concentrators. She also stated she did not clean the units between the resident use. She stated if the unit beeps she reported this to the nurse.",2020-09-01
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 was lying in bed, clutching a stuffed teddy bear. Review of resident #45's medical record, including physician orders [REDACTED]. Review of the facility's policy, Bedside Storage of Medications and Self Administration of Medications, read, Bedside medication storage is permitted and care planned for residents who are able to self-administer medications upon the written order of the prescriber and when it is deemed appropriate in the judgement of the facility's interdisciplinary resident assessment team.",2020-09-01
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 way staff member M talks to residents is unacceptable. Review of staff member E's communication of the situation showed, The patient could not remember the details (of the interaction with staff member M) when interviewed. I will speak to NF1 on Monday to determine the original issue as presented to (NF1). In the meantime, the staff member has been reassigned a different patient load. The follow-up note, dated 4/30/18, showed Per NF1, staff member M was insistent the resident wear a mask for his own safety. The resident refused and the CNA said that he wouldn't be able to leave his room without a mask. An RN became involved and allowed the resident to leave the room. During an interview on 5/17/18 at 10:20 a.m., staff member D stated she had been involved in the incident, but had thought it had just been a misunderstanding, and not verbal or mental abuse. 2. Review of a State Survey Agency Report provided from the facility, dated 5/13/18, showed resident #451 reported staff member M had been verbally abusive, arrogant, and not treating (resident) like a human being. Resident #451 expressed to a nurse that he felt like staff member M was verbally abusive towards him and that after he told staff member M off, and it could have gotten physical. He also stated he would be afraid if he saw staff member M at his door. During an interview on 5/17/18 at 9:40 a.m., resident #451 said, If you are asking me if staff member M acted like this before, the answer is yes. During an interview on 5/17/18 at 10:35 a.m., staff member P stated she absolutely believed resident #451's allegation. Review of a written communication, dated 5/13/18, by staff member Q, showed resident #451 felt embarrassed, and was made to feel a burden when staff member M would take care of him. The resident stated, He should not be taking care of people or have this kind of job. Staff member Q wrote Later, staff member M tried to explain why the resident did not want him in his room, but he mostly just shrugged it off. I told him you have to put yourself in their place and think about how difficult it is to be in their position and to have someone have to physically take care of your toileting needs. The event with resident #451 occurred after the event with resident #76, showing the event with resident #76 was not addressed sufficiently to ensure resident protection in the future relating to staff member M.",2020-09-01
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,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 #19 was seated in the dining room, and pointed to the table where resident #19 sat. Staff member K stated resident #35 was still in her room, on the other side of the MCU, and not in the dining room. During an interview on 5/17/18 at 12:13 p.m., staff member B stated she had given resident #19 medications prescribed for resident #35. Staff member B stated she had been oriented to the MCU by another staff member that was currently on vacation. Staff member B stated she was not familiar with all of the residents on the MCU, and had thought resident #19 was resident #35. 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. Staff member B stated she should have ensured the 5 medication rights prior to administering medications to resident #19; the right patient, the right drug, the right dose, the right route, and the right time. Review of the facility's document titled, Skills- Medication Administration: Oral, read, 3. Verify the correct patient (sic) using two identifiers. References: http://www.ihi.org/resources/Pages/ImprovementStories/FiveRightsofMedicationAdministration.aspx One of the recommendations to reduce medication errors and harm is to use the 'five rights': the right patient, the right drug, the right dose, the right route, and the right time.",2020-09-01
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 of the Care Plan showed the intervention method was doing half an hour checks on resident #131 when he is awake. The new intervention method put in place on the Care Plan was This is a repeated elopement for resident #131 and as per his usual pattern walks to the north/south security desk. The manager will follow-up with Security regarding the auto door lock in the north egress after 9 pm daily. Administratively, we are evaluating the cost of the Wanderguard System to purchase with contingency funds (sic). d. 7/3/17 at 9:20 p.m., resident #131 was reported to be walking by her husband's window. When the floor nurse went to go get resident #131 he could not be seen. Upon searching for him, another family member recognized him and had walked with him back to the Eastview front entrance. Resident #131 was reported to have been around the corner heading toward another medical facility building. A review of the Care Plan showed the previous intervention method was follow-up with security regarding auto door lock on the north egress after 9 p.m. daily. The new intervention method was A one to one is being assigned to resident #131 until the Wanderguard system can be installed. e. 7/29/17 at 9:55 p.m., CNAs discovered that resident #131 was gone from his room after they told him they would be back to assist him to get changed for bed. They immediately went searching for him and found him half way down the hall leading to the hospital. A review of the Care Plan showed the pervious intervention method established was A one to one is being assigned to resident #131 until the Wanderguard system can be installed. This intervention was not care planned and there was not a new intervention put in place for the event to protect the resident from eloping. f. 9/1/17 at 2:00 p.m., resident #131 was found outside the facility, by the bus driver, laying on his back on the ground near the parking area of Eastview. He was witnessed by the truck driver to fall on the grassy area near the parking lot. He was assessed and was found not to have obvious injuries from the fall. He was returned to Eastview by staff. A review of the Care Plan showed the intervention method established on 9/3/17 was A one to on is being assigned to resident #131 until the Wanderguard system can be installed. There was no new intervention method established for future protection from elopements. g. 9/26/17 at 6:50 p.m., resident #131 was found in the long hallway of the facility, near the trash compactor area. A housekeeping employee who knew resident #131 found him, called Eastview staff, and stayed with resident #131 until staff came and got him. Resident #131 stated I was just taking a stroll. A review of the Care Plan showed the pervious intervention method established was A one to on is being assigned to resident #131 until the Wanderguard system can be installed. The new intervention method established was Resident #131 is very frequently monitored - including one on one as frequently as possible. h. 10/30/17 at 6:00 p.m., a CNA went into resident #131's room for a routine check and he was not there. The CNA notified the floor nurse and a search was initiated. A CNA coming on shift notified the staff he was on his way back with a security guard. The security guard found him in the south tower of the hospital and escorted him back. A review of the Care Plan showed the previous intervention method established was Resident #131 is very frequently monitored - including one on one as frequently as possible. The new intervention method established was We will cont. the very frequent monitored - including 1:1 frequently as possible (sic). The interventions had shown to be ineffective to protect the resident from elopement. i. 3/30/18 at 7:00 p.m., another resident's family notified the facility that the resident was in the orthopedics parking lot with the fire department. The resident was warmed with blankets for 25 minutes and given a warm shower due to the cold temperature outside. Resident #131's left fingers had minor scrapes, and the resident complained of right hip pain. A review of the Care Plan showed the previous intervention method established was, We will cont. the very frequent monitored - including 1:1 frequently as possible (sic). The new intervention method established was We will cont. the very frequent monitored - including 1:1 frequently as possible, until the Wanderguard can be installed (sic). Record Review of resident #131's Care Plan showed one-on-one as an intervention method and one-on-one intervention frequently as possible. During an interview on 5/17/18 at 9:15 a.m., staff member F stated that resident #131 was supposed to have a one-on-one 24/7 (24 hours a day/7 days a week), unless he was in bed sleeping. During an interview on 5/15/18 at 9:00 a.m., staff member F stated, usually someone checks on resident #131 every hour and then when he has had an elopement they check on him every 15 minutes, and then every half an hour during the night. There is usually someone with him during the day at all times, but he is alone during the night. During an interview on 5/16/18 at 2:03 p.m., staff member U stated resident #131 was supposed to have one-on-one supervision, however it is hard for that to happen every day. Staff member U stated that when the resident eloped he was unpredictable. Staff member U stated in (MONTH) (2018) when he left the building in the cold we were just more relaxed that day. Staff member U recalled resident #131 saying I saw you weren't watching so I left (sic). During an interview on 5/16/18 at 2:20 p.m., staff member S stated that she was on shift when resident #131 eloped out of the building in (MONTH) of (YEAR). Staff member S stated she was washing dishes when she got a call that resident #131 could not be located. Staff member S stated the resident was found outside and brought back in. Staff member S stated that the CNA staff watching resident #131 had to leave to check on another resident. When they went back to check on resident #131 he was gone. During an interview on 5/16/18 at 2:30 p.m., staff member R stated resident #131 was very fast when he wants to leave. He is supposed to be a one-on-one and we cannot, and do not, provide that all the time because we do not have enough staf. Staff member R stated, she was there the night he eloped out of the building in March. Staff member R stated, she was not watching resident #131 when he left the building because there was an incident with another resident she had to help with. Staff member R stated there were only three CNAs and one nurse on that night. During an observation on 5/17/18 at 7:56 a.m., resident #131 had his door shut to his room, and no one-to-one was being provided. During an interview on 5/17/18 at 8:05 a.m., staff member C stated that she thought resident #131 was in his room. She said she would check to make sure, then stated Yep, he's still here. Staff member C stated that staff do not usually check on him when he was sleeping. During an interview on 5/17/18 at 8:30 a.m., staff member D stated staff did not see resident #131 leave the building in (MONTH) of (YEAR) because there was an incident with another resident. We did one-on-ones for a while after his elopement in (MONTH) (2018) for about a day and a half until he was back to normal. Staff member D stated currently staff were just checking in on him or getting visuals of him. We usually try to check in on him every hour and then get a visual of him every half hour.",2020-09-01
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. Review of resident #40's MAR and TAR failed to show the [MEDICAL CONDITION] order. During an interview on 5/17/18 at 2:31 p.m., staff member F stated the order for 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
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 she had contacted the nurses working within the past month on the East view campus. Staff member F stated she spoke with the nurse that did not document the [MEDICATION NAME] doses removed from the E-Kit. Staff member F stated she also called the pharmacy to inquire which resident on the East View campus had been started on [MEDICATION NAME] around that same time frame. Staff member F stated the [MEDICATION NAME] had been dispensed to resident #75. Review of resident #75's (MONTH) (YEAR) MAR indicated [REDACTED] 1. [MEDICATION NAME] 50 mg one tablet by mouth every 4 hours as needed, may couple with [MEDICATION NAME] 325 mg. Dated 4/13. Resident #75's MAR indicated [REDACTED]. A review of resident #75's Physician's Telephone Orders, dated 4/13/18, showed orders to Start [MEDICATION NAME] 50 mg- one by mouth every 4 hours for pain. (MONTH) couple with [MEDICATION NAME] 350 mg- one for additional [MEDICATION NAME] effect. #60 and 5 refills. A review of the resident #75's Narcotic Record in the Controlled Substance Record binder, dated 4/16/18 at 12:45 a.m., showed resident #75 was administered [MEDICATION NAME], one tablet by mouth, for pain. The remaining tablets were documented as 59. On 5/11/18 at 3:50 a.m., resident #75 was administered [MEDICATION NAME], one tablet by mouth, for pain. The remaining tablets were documented as 58. On 5/11/18 at 7:50 a.m., resident #75 was administered [MEDICATION NAME], one tablet by mouth, for pain. The remaining tablets were documented as 57. Review of resident #75's medical record, including the (MONTH) (YEAR) MAR, E-Kit, and Controlled Substance Record lacked evidence showing [MEDICATION NAME] had been removed from the E-Kit and had been dispensed to resident #75. During an interview on 5/16/18 at 12:27 p.m., staff member F stated nursing staff had not, but should have, started a new sheet in the Controlled Substance Record binder. Staff member F stated nursing staff were required to start a new page in the Controlled Substance Record when dispensing new narcotic medications to any resident. During an interview on 5/17/18 at 10:00 a.m., staff member D stated she had not been informed of staff failing to document missed doses of [MEDICATION NAME] signed out to resident #75. Staff member D stated she had been told there were discrepancies with the [MEDICATION NAME] in the E-Kit. Staff member D stated staff should have documented the [MEDICATION NAME] in the E-Kit record, in resident #75 MAR, and on the Controlled Substance Record. Staff member D stated she would ensure a thorough investigation would be conducted since [MEDICATION NAME] is a narcotic medication. Review of an Investigation of missing [MEDICATION NAME], dated 5/16/18, read, (staff name) started the investigation- called the pharmacy to see which resident had been started on [MEDICATION NAME] in the last month- there were 2 residents, one had his card the other did not- (staff name) reports writing the verbal order for the [MEDICATION NAME] late in the afternoon- (name) called nurses about taking [MEDICATION NAME] out of the E-kit on or around the date of the resident (without the card) starting [MEDICATION NAME]- discovered a nurse had taken them for the resident- they were not signed out- several nurses did not sign out the PRN medication on the MAR- there is no proof of using the [MEDICATION NAME] on the resident except for nurses stating that they administered the [MEDICATION NAME] to the resident. A review of the facility's policy, Medication Storage and Handling, read, Medication storage is designed to assist in maintaining medication integrity, promote the availability of medications when needed, minimize the risk of medication diversion, and reduce potential dispensing error .C. All drugs removed from a medication storage area are removed just prior to administration and only for one patient (sic) at a time.",2020-09-01
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 evening. - [MEDICATION NAME] 100 units/ml- 10 ml vial with sliding scale instructions. During an observation and interview on 5/16/18 at 9:30 a.m., review of Memory Care Unit medication cart showed an opened, undated, multi-dose vial of insulin for resident #45. Staff member T stated staff were required to write open dates on multi-dose vials of insulin when opened. Staff member T stated she had not noticed the multi-dose vial of insulin was missing the opened date. 2. Resident #45 was admitted to the Memory Care Unit with [DIAGNOSES REDACTED]. Review of resident #45's (MONTH) (YEAR) MAR indicated [REDACTED]. During an interview on 5/16/18 at 3:05 p.m., staff member D stated staff were required to write an open dates on multi-dose vials of insulin when opened. She stated vials of insulin were to be discarded after 30 days of being opened. Staff member D stated multi-dose vials of insulin were only stable until the 30 days, therefore staff were required to date each vial when opened. Review of the facility's policy, Expiration Dating of Medications, read, .B. Multi-Dose Vials . 2. Any multi-dose vial not marked with date and initials after opening, is discarded. References: https://www.cdc.gov/injectionsafety/providers/provider_faqs_multivials.html If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.",2020-09-01
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 beans. 2. During an observation on 5/14/18 at 11:17 a.m., in the cottage's main kitchen the following issues were observed a. Three bags of frozen pumpkin pie filling in the small freezer did not have a use by date. b. There was not an open date or label on a mixture that looked like powdered sugar. During an interview on 5/16/18 at 10:59 a.m., staff member A stated, the mixture appears to be powdered sugar. c. Vanilla pudding powdered mixture had no open date. During an observation on 5/14/18 at 11:45 a.m., there were two plastic containers of broken ready to drink prune juice cups in the dry storage room on the second shelf from the bottom. The prune juice containers appeared to have been smashed, cracking the plastic on the sides causing the containers to leak. Staff member A threw the prune juice packages away. During an interview on 5/17/18 at 10:38 a.m. staff member A stated they don't have scheduled cleanings for everything in the kitchen. Staff A stated that he goes through the kitchen to make sure that things have been cleaned and that if there are things that have not been cleaned he tries to figure out who is responsible for cleaning the item. Staff member A stated, They know as a team what needs to be done. Record Review of the Benefis Hospitals Policy/Procedure titled Sanitation, Food Safety, and Infection Control stated, Label all opened food items (exception bread) with: a. name of food b. date opened c. use by date d. staff initials Record Review of Benefis Hospitals Policy/Procedure titled Sanitation, Food Safety, and Infection Control stated, maintain non-food-contact surfaces free of dirt and debris. Record Review of Benefis Hospitals Policy/Procedure titled Sanitation, Food Safety, and Infection Control stated, provide ample space to facilitate self draining of equipment so that it can air-dry properly. Record Review of Benefis Hospitals Policy/Procedure titled Sanitation, Food Safety, and Infection Control stated, keep sanitary equipment covered when it is not being used.",2020-09-01
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 next to resident #65's water cup prior to lunch. Staff member H did not say anything to resident #65 about the medication and proceeded to walk away from the dining room table, and other residents were at the table. During an interview on 7/9/19 at 12:15 p.m., staff member H stated the medications were just Tums, and added that resident #65 self-administered Tums after lunch. During an observation on 7/10/19 at 9:54 a.m., staff member T administered medications to resident #65. After administering resident #65's oral medication, staff member T poured two Tums tablets into a plastic medication cup and left it on the dining room table. Staff member T stated resident #65 preferred to take Tums after she was done eating breakfast. Staff member T stated self-administration of Tums after meals should be in resident #65's care plan. Review of resident #65's current care plan did not reveal information about self-administration of medications. Review of resident #65's Admission Assessment, dated 4/20/18, showed resident #65 responded, No, to the following questions: Does rdt/pt want to self administer their own medications? And, Does the rdt/pt want medications to be left at bedside/at their table? (sic) Review of an Interdisciplinary Team note, dated 7/10/19 at 11:08 a.m., and signed by staff member T showed, Okay for (resident #65) to take scheduled morning Tums after meals and at the bedside after meals VORB per (provider). The note did not show approval for self-administration of medications. C. During an observation and interview on 7/10/19 at 8:35 a.m., staff member T pre-poured resident #530's medication and walked into the resident's room. Staff member T placed the medicine cup next to the resident's bedside on the table and walked out of the room to fill a cup of water. She then went back to the room and observed resident #530 take his medications from the medication cup which she had left previously. Staff member T stated leaving medications unattended at the bedside would be allowed if it were written in the resident's care plan. Staff member T was unsure if self-administration of medications was written in resident #530's care plan. She added she would always stay at the bedside of any resident to ensure they had taken all of their medications; otherwise, someone could come in and take the medications if staff were to leave medications unattended. Review of resident #530's Admission Assessment, dated 7/2/19, showed resident #530 answered No to the question, Does the rdt/pt want to self administer their own medications? (sic) Review of an Interdisciplinary Team Note, dated 7/10/19 at 10:39 a.m., and signed by staff member G, showed resident #530, .asked to self administer [MEDICATION NAME] eye drops. Order received from (provider) to self administer and leave at bedside. The note did not mention self-administration had been requested or approved for other medications. Review of the facility's Health System Policy/Procedure titled, Bedside Storage of Medications and Self Administration of Medications, with a revision date of (MONTH) (YEAR), showed, Nursing .obtains a written order for the bedside storage of medication and places the order in the resident's medical record .Uses self administration assessment form to evaluate resident.",2020-09-01
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 solids. ST provided pt. with skilled education regarding safe swallowing strategies including small bites/sips. (sic) Record review of an Alert, dated 7/10/19 at 3:14 p.m., for resident #89 showed, Due to recent aspiration/choking events, ST recommends (#89) receive 1:1 supervision in dining room during meals. Record reveiw of the facility policy titled, Initial Nursing Assessment and Development of Interdisciplinary Resident Care Plans showed, The interdisciplinary care team, physicians, licensed nursing staff, Social Services, Activities, Physical Therapy, Occupational Therapy, Speech Pathology, Pharmac, and licensed nutrtion staff are responsible for entering additions or changes to the care plan as the condition of the resident changes.Changes in conditions are reported to the provider and resident/family member/PO[NAME]",2020-09-01
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 wound on resident #1's left heel. Staff member I stated that the wound was a resolving blister, but since the bed of the wound could not be observed, it was diagnosed as an Unstageable pressure ulcer. Staff member G stated the measurements of the wound were 2.3 cm x 1.9 cm. The wound was a dark red/light brown color, with slight bogginess in the middle. Staff members I and G stated that resident #1 should always wear heel lift boots to help relieve pressure, except when ambulating. Staff members G and I then stated resident #1 also had a pressure ulcer on her right heel. Upon observing resident #1's right heel, staff members G and I stated this was also an Unstageable pressure ulcer with measurements of 1.9 cm x 1.8 cm. Staff members I and G were unable to verbalize the factors that led to the development of the pressure ulcer on resident #1's bilateral heels. After treating resident #1's right heel with [MEDICATION NAME], staff members G and I assisted resident #1 back to her recliner, lifted her heels on the foot rest of the recliner, applied foam boots to both heels, and positioned a pillow under resident #1's feet. During an interview on 7/11/19 at 8:57 a.m., staff member F stated resident #1 had a pressure sore on her left heel and did not recall how she got it. Staff member F stated resident #1 wanted pillows under her legs, and she had booties. Staff member F stated the other day resident #1 did not want her heels to touch the bed. Staff F did not mention using a care plan to know interventions are used for resident #1's pressure ulcers. During an interview on 7/11/19 at 8:58 a.m., staff member H stated she did not know how resident #1 had developed a pressure sore on her left heel, but the first time it was noted was on 7/4/19. During an interview on 7/11/19 at 9:26 a.m., staff member G stated the treatment order for resident #1 included: treating a left heel pressure ulcer with [MEDICATION NAME] and keeping the heel in a boot; and monitoring the sacral wound, which, according to staff member G, healed open to air (without a dressing). During an interview on 7/11/19 at 10:42 a.m., staff member G searched through resident #1's care plan, and stated she could not find interventions explaining the recommendations for pressure relieving devices (i.e. boots and seat cushion). During an interview on 7/11/19 at 10:50 a.m., staff member K stated there was no root cause analysis for resident #1's left heel pressure ulcer as noted on 7/4/19. Staff member K stated resident #1 should have an air mattress with a pump. Staff member K stated resident #1 had heel lift boots, and her seat cushion should have been under her at all times, even in her recliner. Review of resident #1's Braden Scale for Predicting Pressure Sore Risk, dated 6/10/19, showed, If the residents total is 18 or less, consider him/her at risk for a pressure ulcer development. Resident #1 scored a 15. Review of resident #1's admission note, dated 6/28/19, showed the presence of pressure ulcers to both buttocks but had no mention of pressure ulcers on her bilateral heels. Review of resident #1's Weekly Bath Day Assessment showed the following: -7/2/19 Skin interventions being utilized were, wound rounds, wound treatment, fluids, Foley catheter, education, wheelchair cushion, and protein encouraged. -7/9/19 Skin assessment in the comments showed, blackened area to L outer heel. -7/9/19 Skin interventions being utilized were, wound rounds, wound treatments, Foley catheter, [MEDICATION NAME], Rooke boots/float heels, turned/repositioned per policy, wheelchair cushion, and pressure reducing mattress. Review of resident #1's care plan showed the following: -6/28/19, At risk for breakdown. Turn and position as per policy guidelines or as directed. Monitor skin integrity weekly and when assisting with adl's. (sic) Notify charge nurse of changes. -7/1/19, Admit skin assessment 6/28/19 Left buttock: L: 1.4cm, W: 2cm, D: 0.1cm, Right buttock: L: 0.5cm, W: 0.4cm, D: 0.1cm. No mention of alteration of skin to either the right or left heel were noted in the skin assessment. -7/6/19, Left heel wound, identified on 7/4/19. The care plan had no mention of interventions that should be in place to prevent the worsening or development of new pressure ulcers. Review of resident #1's Interdisciplinary Notes showed the following: -6/10/19 resident #1 was admitted to the facility noted no pressure ulcer to left and right heel. -6/28/19 resident #1 was readmitted back to the facility with wounds to her buttocks. No mention of heel wounds were noted. -7/4/19 resident #1 was seen for wound rounds for buttock. Wounds to buttocks were open to air and deemed healed. (Resident #1) is noted to have foam heel protectors in place and when questioned she reports mild discomfort of her left heel. There appears to be a pressure sore, a dry blister that is unstageable and measures 3x4cm. Will paint with [MEDICATION NAME] BID and monitor. -7/9/19 resident #1 was noted to have a small blackened area to her right heel. Review of resident #1's Treatment Record showed, blister left heel paint with [MEDICATION NAME] BID heel lift boots in bed, initiated on 7/4/19. Family brought in heel lift boots on while in bed. Review of resident #1's wound care order dated 7/4/19, showed blister to left heel- paint with [MEDICATION NAME] BID- monitor. Heel lift boots in bed. Remind (resident #1) to have her family bring in a pair of heel lift boots. Review of resident #1's (Facility) Wound Alert dated 7/11/19 showed the following: -Right buttocks reddened area blanchable less than 2 seconds, cool and soothe with off loading using cushion on all surfaces. Left buttocks unstageable wound-dry scabbed area measures 2.7 cmx3.2 cmx0.1 cm with previous chronic scar tissue. -Right heel pressure sore unstageable dried eschar peri wound is blanchable within 2 seconds. measures 1.9 cm x 1.8 cm. Painted with [MEDICATION NAME]. -Left heel pressure unstageable dried dark area appears to be resolving, center of wound firm, 2.3 cm x 1.9 cm. Paint with [MEDICATION NAME] off load with heel foams at this time, family requested to bring in heel lift boots, not in room at this time.",2020-09-01
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 object res swallowed it so I was unable to see what it was. Res had been seen at res table by the pole, appeared he was taking food. He is currently resting in his room. (sic) During an observation and interview on 7/10/19 at 2:40 p.m., staff member L showed resident #89's diet card. The 1:1 for dining intervention was written on the bottom right corner of the diet card. This notation was covered by a yellow post-it note labeled puree. Staff member L stated that the staff members serving meals may not have seen the intervention, because of where the post-it was placed on the diet card. Staff member L stated the discipline that implemented the intervention was responsible for updating the diet cards. During an interview on 7/10/19 at 11:38 a.m., staff member N stated, Staff, as a whole, periodically keeps an eye on (resident #89). During an interview on 7/10/19 at 2:30 p.m., staff member O stated, an incident would create an alert in the Kardex of the electronic medical record. She stated therapy, dietary, nursing, and all management would receive an alert in the case of a choking incident. During an interview on 7/11/19 at 8:33 a.m., staff member M stated she was not present for the choking incident that occurred on 7/4/19, but heard resident #89 had taken another resident's bread and choked on it. Staff member M stated all staff are to keep a close eye on resident #89 as he wanders. Staff member M had noticed that resident #89 would push the adaptive spoon so far back into his mouth, he would gag on it, when eating too fast. Resident #89 coughed a lot but usually forcefully coughed enough to clear his throat on his own. Staff member M stated the protocol for notification after performing the [MEDICATION NAME] Maneuver was to notify management, doctor, resident representative, dietician, and therapy. Staff member M stated the expectation of the nurse is to implement interventions necessary to keep the resident safe, while waiting for a call back from the provider. Staff member M stated management, therapy, and the oncoming shifts would see an alert in the electronic medical record notifying staff of the incident. During an observation on 7/11/19 at 9:06 a.m., 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 had three bowls of pureed food and a drink. Resident #89 was using an adaptive spoon and had difficulty removing the food from his spoon. Resident #89 spilled food onto his clothing protector, scooped the food off, and ate it. Resident #89 then placed the spoon far back into his throat and gagged. Resident #89 tipped his head back and continued to cough, moan, and made a wet, gurgling sound with his tongue thrust out. Staff member O came over and adjusted the resident's clothing protector and told him he was okay. Staff member O walked away; no one was directly supervising resident #89. Record review of resident #89 Speech Therapy note on 7/8/19, showed a recommendation of 1:1 supervision for consuming food/liquids. High Choking/Aspiration Risk. No documentation was found for notification of the physician, resident representative, or assessment of resident #89's wellbeing related to the choking.",2020-09-01
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 sugars showed 37 blood sugars over 200 and three blood sugars not marked as high with a reference range of 68-110 from 6/10/19 to 7/3/19. 2. During an observation on 7/9/19 at 12:12 p.m., staff member W was serving lunch with the specialized diet spreadsheet book not visible and it was on the counter in the pantry. Resident #328 was served carrot salad, mashed potatoes and gravy, a hot turkey sandwich smothered in gravy, and a cookie for dessert. During an interview on 7/9/19 at 2:24 p.m., staff member X stated that the chef and CNA are responsible for making sure the residents receive the right diets by following the diet cards. Staff member X stated the expectation is that the chef is to follow the spreadsheets for diets. Staff member X stated that the meal cards that the CNA follows are pretty clear and capture what should and should not be served. Staff member X stated that she was not sure how specialized diets are monitored or how they prevent the wrong diets from being served. During an interview on 7/10/19 at 9:57 a.m., staff member AA and staff member Z stated that diet spreadsheets are given to the cooks for the day and should be utilized while serving. Staff member AA stated that a medical diet is a physician order [REDACTED]. During an interview on 7/10/19 at 10:35 a.m., staff member J stated specialized diet cards are orange (colored), for carb control. Staff member J stated responsibiity for going around and taking food orders for the day to see which of the two options on the menu the resident would prefer. Staff member J stated he had never seen nor been trained on the specialized diet spreadsheet menu. Staff member J stated, It would be helpful to know what is in the diet. During an interview on 7/10/19 at 10:39 a.m., staff member BB stated he had not been trained on specialized diets. Staff member BB was responsible for serving meals and providing diet cards to the chef. Review of the Week 5 Tuesday Specialized Diet Spreadsheet showed for lunch a resident on a carbohydrate control diet should have received a hot turkey sandwich, poultry gravy, carrot salad, and fruit. Review of resident #328's diet card showed was marked carb control under diet the sectional, and the rest of the card was blank. Review of resident #328's diet order showed the resident was on a carbohydrate controlled diet.",2020-09-01
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 any scheduled pain medications. Staff member T stated the dressing change she performed earlier in the morning on 7/10/19 was the first time resident #104 had requested pain medication prior to a dressing change. During an observation on 7/11/19 at 9:02 a.m., staff member G performed wound care on resident #104's right heel. While staff member G removed resident #104's compression wraps and bandage, resident #104 grimaced and tensed his right leg. Staff member G described the wound as a Stage II pressure ulcer, with dimensions of 1.9 cm x 1.2 cm (length x width); she continued to describe the peri-wound as dark pink and beefy red. The wound itself, she said, had slightl red drainage; and yellow, dry, and flaky skin was noted to the top part of the wound, which staff member G peeled off. Resident #104 continued to grimace and tense his right leg throughout wound care. Staff member G did not perform a pain assessment, alter treatment, or implement pain relieving measures for resident #104 during wound care. During an interview on 7/11/19 at 9:18 a.m., staff member G stated she was not sure if resident #104 took pain medications prior to wound care on his right heel. Staff member G said she had not performed a pain assessment with resident #104. Staff member G consulted resident #104's MAR indicated [REDACTED]. Staff member G stated resident #104 takes [MEDICATION NAME], 50 mg tablets, one tablet by mouth once daily, as needed for pain; and [MEDICATION NAME] 1% gel, apply 2-4 grams to affected areas of joint pain up to four times daily. Review of resident #104's care plan, dated 6/11/19, showed under the category, Pain, resident #104 will achieve a consistent level of comfort while maintaining as much function as possible. Interventions under this goal include: -administer pain medications on scheduled and/or as needed basis; -if finding that adequate pain control is not occurring and remains greater than a 5/10 after 30 minutes after pain medication administration, document and notify primary care provider; and, -pre-medicate for pain as needed to optimize participation in therapies, activities and meals. Review of a Training Competency document, dated 2/1/19-2/28/19, showed staff member T met the standard for assessing and reassessing pain; and utilizing appropriate pain management techniques. Review of resident #104's pain assessment notes, between 6/28/19 and 7/11/19, showed five out of 27 pain assessments were completed. Out of those five, one assessment, dated 7/8/19, did not note the location of the resident's pain; one assessment, dated 7/4/19, showed resident #104 was experiencing a burning and restless pain in his right foot; assessments dated 6/26/19, 6/27/19, and 6/30/19 showed resident #104 was experiencing pain in both knees only.",2020-09-01
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,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 non-sterile solution (exp. (MONTH) 2019); -One Creamy Vanilla Smoothie Readi-Cat 2, Rx only (exp. (MONTH) (YEAR)). During an interview on 7/10/19 at 9:33 a.m., staff member T stated the above supplies were not used regularly. Staff member T stated she was unsure if the facility had a specific policy on checking expiration dates. She added that the night shift usually had more time, so they probably checked medications and supplies that did not come directly from the pharmacy. During an interview on 7/10/19 at 10:14 a.m., staff member K stated staff checked for expiration dates as frequently as possible and pharmacy checked at least once every month. Staff member K added nurses were supposed to check the expiration date prior to administering medications. During an interview on 7/10/19 at 1:50 p.m., staff member V stated he checks expiration dates at least every other day, and on the first day of the week that (his) shift starts. He added that he checks expiration dates on insulin every day. Record review of the facility's Medication Administration Standards powerpoint document, provided to nurses during orientation, showed (in flow chart format): Select med(s) from patient Pyxis profile/MAR and verify on MAR: administration, due by, med name, dose, rte, time and check when last time given .Does med removed from Pyxis match MAR and is it expired? If the nurse answers Yes to the medication expiration question, the flow chart continues, Set aside med for Pharmacy. (sic)",2020-09-01
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 the tour and interview, staff AA stated: - There was a ticket (request to repair) in with maintenance to fix the pipe. - Staff member AA stated the convection oven was the only piece of equipment which had not been cleaned, and it needed a new fan, as the convection oven was still visibly dirty with crumbs and char in it, and the doors were covered in a greasy film. - Staff member AA stated they were revamping the cleaning schedule, and the stove tops get cleaned weekly, and as they get dirty. - Staff member AA stated each cottage chef was now responsible for 15 different items on the revamped cleaning schedule. - The cleaning schedule had previously not been assigned to a specific staff member. Staff member AA stated they were rolling out the revamped cleaning list and would be checking the cleaning on Wednesdays and Saturdays, to ensure it was getting completed. During an interview on 7/10/19 at 12:00 p.m., staff member CC stated the warmers were cleaned weekly unless there were spills, and the stove tops were cleaned monthly. During an observation on 7/10/19 at 4:02 p.m., the Transitional Care unit kitchenette's oven range top was still covered in food matter. The flat grill was also visibly dirty with crumbs and grease, and splatters on the back of the oven were continued to be present. During an observation on 7/11/19 at 10:01 a.m., the steam pipe, from the steamer, in the Grandview kitchen, was shooting steam straight up into the air continuing to create a hazard. During an observation on 7/11/19 at 10:48 a.m., the Transitional Care unit kitchenette oven range top continued to have food particles present on the stove top which had not been cleaned after use. Review of the cleaning sheets from 4/1/19 through 6/23/19 showed the following: - did not specify which cottage stove tops had been cleaned - ranges and ovens were to be cleaned weekly on Fridays and Sundays - warmers, both large and small, were to cleaned daily by the Goodnow cook - the current cleaning sheets, requested on 7/9/19 at 11:50 a.m., were not provided by the facility. Review of the cleaning sheets for the ranges and oven, dated 4/1/19 through 6/23/19, showed the ovens had been cleaned on 5/4/19 and 6/13/19. Review of the cleaning sheets for the large and small warmer, dated 6/1/19 through 6/23/19, showed they were cleaned only 7 of the 23 days in the month. Review of maintenance ticket, dated 1/12/18, showed, The sanitizer in the kitchen was not working. The maintenance ticket was requested to confirm the request to repair the steamer and pipe was completed, but the ticket did not address the pipe from the steamer. During an observation and interview on 7/8/19 at 2:01 p.m., with staff member Q, in the main kitchen, the dry storage top shelf had a clear bin of cantaloupes that were rotting. The cantaloupes had soft, dark spots and white, fuzzy mold growing on them. The pipes in the back corner were covered in thick, fuzzy gray/brown dust. The freezer had pallets of food in the back of the center aisle, which were blocking the back right shelves and walkway. Staff member Q stated the pallets were there because they got a shipment in that morning. In front of the pallets was a metal cart with an uncovered, cooked roast. Other metal pans were stored above and below the uncovered roast. Staff member Q stated the roast was cooling, and that was why it was uncovered and in the freezer. Two trays of orange-colored liquid Jell-o with fruit chunks, were on the bottom of the prep refrigerator. There were no dates or labels on the trays which contained the Jell-o. The bottom shelf of the prep table was stained and had brown food crumbs on it. There were open bags of various seasonings in an unsealed bin, stored next to a variety of clean pans and mixing bowls. There were dried streaks of batter on the underside of the mixer arm. The mixer was not in use. A nearly empty, large plastic mayonaise jug, was observed without a date label. In the small refrigerator, in the kitchen, cooked chicken breast, in an unsealed ziplock bag, was observed. Staff member Q stated it was his expectation that staff would label and date food when opened, and clean up as they go. During an observation and interview on 7/9/19 at 8:30 a.m., in the main kitchen, there were dried streaks of batter on the underside of the mixer arm. The mixer was not in use. The bottom shelf of the prep table was stained and had brown food crumbs on it. There were open bags of various seasonings in an unsealed bin, stored next to a variety of clean pans and mixing bowls. A cook dropped an open box of pre-packaged dry ingredients on the floor. He picked the box up off the floor and placed the box on a prep table containing open containers of food. The freezer had an opened, unsealed, and unlabeled bag of french fries on the middle shelf. The top shelf of the refrigerator contained an unsealed box of sunflower seeds. The roast was now on a metal rack in the refrigerator, uncovered in the center. To the right of the roast was a metal rack with cut up red potatoes in water, uncovered and unlabeled in a metal pan. On the shelf below the potatoes, there was a metal pan containing uncovered, seasoned raw chicken. The dry storage room pipes had thick fuzzy gray/brown dust on them which had not been cleaned. During an observation on 7/10/19 at 11:19 a.m., in the kitchenette on the 4th floor, the flooring had well worn and peeling black, purple, and red tape in areas around the doorway. There was dark grime stuck along the edges of the tape. There was a bottle of Louisiana hot sauce with no lid and no date label, half empty, sitting out on the counter. The cappuccino machine tray was pulled out, and there were spills of light brown liquid along the counter. One ziplocked bag of frozen prunes in the freezer was not labeled or dated. A cabinet, which had a sign labeled (#89) cups, contained one clear cup inside, which was soiled with a light brown dried substance on the side of it from the top to the bottom. During an interview on 7/10/19 at 11:45 a.m., staff member N stated all senior services staff must do a training and get a food-handlers permit. They (staff) all take turns to work in the kitchenette on the 4th floor, but don't go in the main kitchen. Staff are taught things for the kitchens, such as how to clean, temp, store foods, and understand resident diets. Record review of facility policy titled, Sanitation, Food Safety, and Infection Control showed: - Do not place or store deliveries directly on the floor. - Keep all foods covered while refrigerated. - Keep all food held in freezers frozen solid. - Label all opened food items (exception bread) with: a.name of food, unless clearly identified on the original packaging b.date opened c.use by date d.staff initials -Maintain good housekeeping, general cleanliness, and sanitation of the entire location. -Verify that a clean as you go mentality is adopted by all associates. - Maintain food-contact surfaces clean to sight and touch. -Keep food contact surfaces free of encrusted grease deposits and soil accumulations. -Maintain non-food contact surfaces free of dirt and debris.",2020-09-01
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 treatment for [REDACTED]. Staff member R stated that nursing staff prepare the medication in the nebulizer canister setup and then resident #29 self-administers the nebulizer treatment and calls the nurse when she is done. Staff member R stated after the resident is done with the treatment, the nursing staff separate the canister pieces and rinse the pieces with saline. Staff member R stated the saline is kept in the cabinet in resident #29's bathroom, however staff member R was not able to locate a bottle of saline in the bathroom cabinet at the time of the interview. During an interview on 7/11/19 at 10:23 a.m., resident #29 stated the nurses neither clean the nebulizer canister setup nor do they set it out to dry in between uses; they just come in and add the medicine. Resident #29 stated once a week on Tuesdays the nurses change the tubing on the nebulizer, and on Thursdays they change the tubing on the concentrator. During an observation on 7/11/19 at 10:25 a.m., a blue plastic bag containing oxygen tubing and nasal cannula was hanging on the front of the oxygen concentrator, located in resident #29's bathroom. No date labeling was observed on the oxygen tubing and cannula. A review of the facility's policy titled BSS-Respiratory Therapy, showed Equipment is cleaned in the following manner: Nebulizers - To be rinsed and allowed to air dry after each use. 2. During an observation and interview on 7/8/19 at 1:52 p.m., staff member A was observed wearing a mask, which covered her nose and mouth. The staff member was coughing. Staff member A stated she did not want to get pneumonia again. She said she thought her coughing was from the air, and she was wearing the mask, to keep the air off and trying not to get the condition worse. During an observation on 7/8/19 at 5:11 p.m., staff member A was assisting residents with their meals, in the Memory Care dining room. The staff member was wearing a mask. At times she would turn and cough. During an observation on 7/9/19 at 8:54 a.m., staff member A was in the Memory Care kitchenette/dining room area. Staff member A was wearing a mask, covering her nose and mouth. Staff member A was coughing repeatedly. Staff member A was trying to assist residents with their meal. Staff member A was observed stepping away from the resident as she was coughing so hard. After trying again, staff member A walked back into the office, behind the nurse's station. During an observation and interview on 7/10/19 at 9:00 a.m., staff member A was in the Memory Care dining area\kitchenette area, and hall, assisting with residents with their breakfast, seating, and transfers. Staff member A was not wearing a mask. Staff member A's cough sounded deeper in her chest than the day prior. She had a difficult time controlling the cough, while assisting residents. Staff member A stated she did not need a mask, her cough had gone to her chest. Staff member A was observed assisting residents, in between coughing periods, until 10:30 a.m. Staff member A was coughing into her arm and was not observed sanitizing her hands between coughing periods. During an interview on 7/10/19 at 5:00 p.m., staff member DD stated staff member A should have been wearing a mask, per facility policy, relating to the cough and being around the residents.",2020-09-01
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 #6's Quarterly MDS, with an ARD 10/3/17, showed the resident was total assistance of one staff for bathing. Review of resident #6's Bath Aide Skin Assessment records, for (MONTH) and (MONTH) (YEAR), showed the resident had a bath on 9/5/17 and another one on 9/17/17. The resident went 11 days without a bath. The resident had a bath on 9/29/17 and another on on 10/8/17. The resident went eight days without a bath. Review of resident #6's care plan failed to show the resident's bathing preferences of twice a week had been identified by the interdisciplinary team. 3. During an interview on 3/19/18 at 1:15 p.m., resident #8 said he had been getting a shower once a week lately. Resident #8 said, Awhile back we were having problems getting a shower once a week because there was no shower aide. Resident #8 said he would like to have shower more frequently than once a week, but is happy if he receives one a week. Review of resident #8's Quarterly MDS, with an ARD of 9/26/17, showed the resident had not received a shower or bath in the seven day look back period. Review of resident #8's Quarterly MDS, with an ARD of 12/26/17, showed resident #8 was a partial physical assistance of one staff for showers. Review of resident #8's Bath Aide Skin Assessment records, for (MONTH) and (MONTH) (YEAR), showed the resident had a bath on 9/6/17 and another one on 9/19/17. The resident went 12 days without a bath. Review of resident #8's care plan failed to show the resident's bathing preferences. 4. During an interview on 3/19/18 at 2:25 p.m., resident #9 said she generally gets a bath twice a week. Resident #9 said in (MONTH) of (YEAR) it was touch and go for awhile. Resident #9 said her baths were not twice a week in (MONTH) and (MONTH) of (YEAR). Resident #9 said she thought the bath aide had quit. Resident #9 said she preferred to have a bath every other day but was happy when she got two a week. Review of resident #9's Quarterly MDS, with an ARD of 2/13/18, showed the resident was total assistance of two staff for bathing. Review of resident #9's Bath Aide Skin Assessment records, for (MONTH) and (MONTH) (YEAR), showed the resident had a bath on 9/11/17 and another bath on 9/21/17. The resident went nine days without a bath. Review of resident #9's care plan failed to show her bathing preferences had been addressed by the interdisciplinary team. 5. During an interview on 3/19/18 at 2:40 p.m., resident #10 said she usually got a bath twice a week. Resident #10 said (MONTH) and (MONTH) of (YEAR) said she did not get baths twice a week. Resident #10 said she did not think the facility had a bath aide then. Resident #10 said she thought the facility had some problems in (MONTH) and (MONTH) of last year (2017) too. Resident #10 said she preferred to have a bath two times a week. Review of resident #10's Quarterly MDS, with an ARD of 1/2/18, showed resident #10 was total assistance of one staff for bathing. Review of resident #10's Bath Aide Skin Assessment records, for (MONTH) and (MONTH) (YEAR), showed the resident had a bath on 9/11/17 and another bath on 9/19/17. The resident received a shower on the eighth day. These bath records showed resident #10 had a bath on 9/22/17 and another bath on 10/3/17. The resident received a bath on the eleventh day. Review of resident #10's care plan failed to show her bathing preferences had been addressed by the interdisciplinary team. A review of the facility's policy, Shower and Hygiene, showed, 1. Administer resident shower once weekly and/or as often as necessary. 2. If reasonably practicable, try to accommodate resident's preference in the shower schedule. The facility's policy does not address the need to care plan the resident's shower preferences to create a more personal and individualized care plan for the residents.",2020-09-01
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 response from the facility.",2020-09-01
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 times she updated the care plans, and at other times, the MDS Coordinator or the floor nurse updated the plans. 2. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. 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 3/19/18 at 3:30 p.m., resident #5 said he wanted, and was getting, two showers a week. Resident #5 said NF1 and himself had addressed concerns with the provision of showers with the facility, repeatedly (refer to F550). The resident voiced concerns with not having showers provided, per his preference. Review of resident #5's care plan failed to show the resident's bathing preferences of twice a week had been identified by the interdisciplinary team. 3. During an interview on 3/21/18 at 7:45 a.m., resident #6 said she liked to have at least two showers per week due to her bowel incontinence issue. Resident #6 said she did not like to smell of body odor, feces or to have greasy hair. Resident #6 said she had made the facility aware of her preferences. Review of resident #6's Quarterly MDS, with an ARD 10/3/17, showed the resident needed total assistance of 1 staff for bathing. Review of resident #6's care plan failed to show the resident's bathing preferences of twice a week had been identified by the interdisciplinary team. A review of the facility's policy, Comprehensive Care Plans, Protocol, showed, 5. The care plan is reviewed with the first Comprehensive MDS Assessment is and revised to reflect personalization and resident specific preferences.",2020-09-01
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 of pressure relief for the spine. During an interview on 3/21/18 at 8:10 a.m., staff member D stated the facility had been watching the pressure area very closely, and she believed the resident had, at one point, a cushion for the back of the wheelchair. Weekly skin documentation for resident #2 was requested on 3/20/18. No skin checks were provided for the unstageable pressure area on the spine. 2. Review of resident #2's Progress Note, dated 3/9/18, showed the [DEVICE] was discontinued, for the Stage IV coccyx pressure ulcer. The treatment was changed to cleanse wound with normal saline, apply Iodosorb to alginate and pack in wound, cover with foam dressing. During an interview on 3/20/18 at 1:20 p.m., staff member C stated the facility was out of Iodosorb, and could not complete resident #2's dressing change. She stated staff member G was out of the facility looking for the treatment. During an interview on 3/20/18 at 1:30 p.m., staff member G stated the facility did not carry the Iodosorb, and the Hospice nurse would bring the supplies to the facility, and do the dressing change. Review of resident #2's Physician order [REDACTED]. During an interview on 3/21/18 at 8:40 a.m., staff member C stated Hospice did not have the Iodosorb dressing, so the order was changed. The facility was unable to determine if the prescribed Iodosorb treatment was provided from 3/9/18 to 3/20/18. During an interview on 3/20/18 at 10:40 a.m., staff member [NAME] stated the nursing department had difficulties getting the medications and supplies they needed from central supply. It does not flow well and it is not safe for the residents. During an observation on 3/21/18 at 9:10 a.m., of a dressing change to resident #2's pressure ulcer, the dressing from the day before was not dated, and there was no packing removed during the dressing change, as ordered by the physician.",2020-09-01
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 #11's wheelchair did not have dycem on the cushion. It did have a towel. d. Review of resident #11's Follow-Up report for the fall on 10/30/17, showed she was seen slipping to the floor and was holding on to arms of wheelchair. A transfer pole was installed in her room. During an observation on 3/20/18 at 10:05 a.m., resident #11's room do not have a transfer pole. Staff member D stated the therapy department removed it, because it was not safe for the resident. The transfer pole installation and removal were not documented on the Care Plan, or in the Nursing Progress Notes. e. Review of resident #11's Follow-Up report for the fall on 11/18/17, showed she was found sitting on the floor on her bottom. Resident's cushion had slid out of the chair with her and was still under her bottom when she was sitting on the floor. PT to evaluate wheelchair cushion for proper fit and stability. The dycem intervention to prevent slipping was not mentioned in the report. No evidence was provided for the PT evaluation for the cushion. f. Review of resident #11's Follow-Up report for the fall on 12/4/17, showed she was found on the floor, laying on her back. She stated the chair flew out from under me. The investigation did not include whether the wheelchair antilock breaks were in use. The root cause was Resident fell during self-transfer. g. Review of resident #11's Follow-Up report for the fall on 12/14/17, showed the resident stated she was transferring herself to the bathroom. The wheelchair was found in a corner of the room, away from the resident. The report did not specify why the wheelchair was in a corner. The root cause was toileting need. The resident complained of right hip pain, but no injury could be noted. The resident requested to go to the emergency room . Nurse asked the resident if she was certain she felt she needed to go and pointed out that no injury at this time could be found. Resident #11 was sent to the emergency room , and returned to the facility with a [DIAGNOSES REDACTED]. h. Review of resident #11's Fall Detail report for the fall on 1/21/18, showed the resident was found on her knees, next to the bed. She was on a fall mat. The root cause was toileting needs and restlessness. No new interventions were implemented. The need to anticipate resident #11's toileting needs was not addressed in the investigation. i. Review of resident #11's Fall Detail report for the fall on 2/4/18, showed her bed was in the low position, and she rolled out of bed. She hit her head and had a right eye hematoma. No root cause was identified, or new interventions implemented. Supervision was not addressed as an intervention, or lack of, for a root cause for resident #11's 12 falls. j. Review of resident #11's Fall Detail report for the fall on 2/27/18, showed she was barefoot, and found lying on the floor in her room. She stated she was taking herself to the bathroom. No root cause we identified; signs were placed in her room to remind her to call for assistance. During an observation on 3/20/18 at 10:06 a.m., resident #11's bed was not in the low position, and there was not a fall mat in the room. Resident #11 stated she moved the bed up and down, as she needed. During an interview on 3/21/18 at 8:40 a.m., staff member A stated the facility did discuss falls in their quality assurance meeting, and noted the fall rates were higher than the facility wanted. She stated the root causes on the fall reports were not meaningful. 2. Review of resident #3's Observed Fall report, dated 3/15/18, showed CNA called this nurse to resident's room, resident was on the floor sitting in front of her wheelchair with her legs on the EZ lift; sling was off and she was still hanging on to the right handle. CNA hooked her up to the sling for the EZ stand; everything was going OK, then the left sling slipped off and down to the floor. (The resident) landed on her bottom and tweaked her back and head, had a pain level of seven. The action taken was CNA was reinforced to use a 2 person transfer. The report did not include a signature or any other interventions. During an interview on 3/20/18 at 3:30 p.m., resident #3 stated she was hysterical and cried after the fall. My butt slugged the floor hard, and it hurt my sores that were just healing. During an interview on 3/21/18 at 8:50 a.m., staff member F stated she had been the staff member transferring resident #3 the day she fell . She stated she was frazzled that day, and so she did not check the placement of the sling. She stated she still transferred resident #3 by herself, and the resident was OK with that. She stated even with two people transferring the resident the day of the fall, she would still have fallen, but would not have hit the ground so hard. 3. During an interview on 3/19/18 at 3:30 p.m., resident #5 said staff transferred him using a Hoyer lift. Resident #5 said when using the Hoyer lift, only one CNA had been in the room operating the lift. Resident #5 said he did not feel safe when that happened. Review of resident #5's Quarterly MDS, with an ARD of 12/5/17, showed the resident was a total assist of two staff for transfers. During an interview on 3/20/18 at 2:28 p.m., staff member A said the Hoyer lift is to be used by two staff members when transferring a resident. Staff member A said a representative of the lift manufacturer was in the facility two months ago and did training for all the staff on the proper techniques used for the sit to stand and the Hoyer lifts. Staff member A said she did have a CNA come to her recently and tell her she had been using the Hoyer lift by herself to transfer residents. Staff member A said she asked the CNA why she had done that. The CNA said because there was no one to help her. Staff member A said she told the CNA the Hoyer lift required two staff members during a resident transfer, and if she couldn't find another CNA or nurse to help her, she needed to get the DON or anyone from the front office to assist her with the Hoyer lift transfers.",2020-09-01
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,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,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,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,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. She stated the facility did not serve the room trays until the CNA came to the kitchen to pick them up. During an interview on 4/17/19 at 8:30 a.m., staff member T stated the resident had been refusing meals for the past six months. Staff is offering her snacks and sandwiches. She needs more help now with eating. Staff member T stated the CNAs were responsible for making sure every resident eating in their room received a meal tray. Review of resident #17's Quarterly MDS, with the ARD of 6/20/18, showed a weight of 160 pounds. Review of resident #17's weight record, dated 11/4/18, showed the resident weighed 137 pounds. On 4/2/19, the resident weighed 120.2 pounds. Review of resident #17's Physician Order, dated 2/15/19, showed, Glucerna, one BID. During an observation and interview on 4/18/19 at 9:45 a.m., the nutritional supplement closet did not contain Glucerna. Staff member G stated she did not know any residents were to receive Glucerna. Review of resident #17's Physician Order, dated 3/26/19, showed the resident was too tired to chew her food, and her food texture was downgraded to a mechanical soft texture. No other interventions were implemented for resident #17's 40 pound weight loss. Review of resident #17's Care Plan, dated 11/15/18, showed one new intervention for the mechanical soft texture. All other interventions were dated 4/11/18. Review of resident #17's Notification to the Physician for weight loss, dated 4/10/19, showed a 15 percent weight loss in 90 days, and intakes variable but less than 50 percent. Supplements in use, sometimes accepted. No new interventions were recommended by the facility or physician. Review of resident #17's most current Dietary Evaluation, dated 2/4/19, showed Resident unwilling to accept food supplement or to eat more than 3 meals a day. Staff are providing cues and encouragement for nutrition and hydration. Recommend Glucerna or house equivalent supplementation with meals tid. No supplement was observed with the dinner meal served 4/16/19 at 6:23 p.m.",2020-09-01
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 policy, Storage and Expiration of Medications, Biologicals, Syringes and Needles, read, .4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines .are stored separate from other medications until destroyed or returned to the pharmacy or supplier. 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened.",2020-09-01
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 [REDACTED]. The start date was [DATE] at 6:00 p.m. A review of the facility's policy, Storage and Expiration of Medications, Biologicals, Syringes and Needles, read, .4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines .are stored separate from other medications until destroyed or returned to the pharmacy or supplier. 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened .12. Controlled Substances Storage: 12.1 Facility should ensure that Schedule II - V controlled substances are only accessible to licensed nursing, Pharmacy, and medical personnel designated by Facility .Facility should ensure that Scheduled II - V controlled substances are immediately placed into a secured storage area (i.e., a safe, self-locked cabinet, or locked room, in all cases in accordance with Applicable Law. 12.3 Facility should ensure that all controlled substances are stored in a manner that maintains their integrity and security. Unsecured E-Kit medications 2. During an observation and interview on [DATE] at 1:06 p.m., of the medication storage room on the 300 hall, with staff member S, there was an unsecured E-Kit with medications, including narcotics. Staff member S stated the E-Kit had not been locked for the last six months. Staff member S stated the management staff, and the unit manager, were aware of the unsecured E-Kit. During an interview on [DATE] at 1:15 p.m., staff member U stated the E-Kit had never been kept locked, and two nurses had keys to the medication room, where the kit was kept. During an interview on [DATE] at 1:28 p.m., staff member A stated she had not been aware of the unsecured E-Kit on the 300 hall. During an interview on [DATE] at 9:31 a.m., staff member R stated he was aware of the cabinet not locking. He stated he had the information in his monthly reports for the past few months. Staff member R said ideally the narcotics should be double locked per the regulations.",2020-09-01
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,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 antacids, an opened container of [MEDICATION NAME] topical powder, and a squeeze bottle of Equate nasal spray were on a shelf, above resident #61's bedside stand. During the interview, resident #61 stated he had a physician's orders [REDACTED]. Review of resident #61's Annual MDS, with an ARD of 7/4/17, showed the resident was capable of making reasonable decisions. Review of resident #61's Physicians' Recapitulation orders, dated 4/1/18 - 4/30/18, showed resident #61 had orders for: - Calcium antacid tablet chewable 500 mg, give one tablet by mouth every two hours as needed for heartburn, 15 times maximum, may keep at bedside, - Ayr saline nasal no drip gel, 1 unit in each nostril every eight hours as needed for dry nares. The order did not include self-administration of the medication and, - [MEDICATION NAME] 100,000 U/G powder, apply to affected area topically three times a day for rash. The order did not include self-administration of the medication. During an interview on 6/14/18, at 9:07 a.m., staff member J stated resident #61 was administering nasal spray and antacids by himself. The staff member stated resident #61 did not have an order to self-administer the nasal spray or powder. Review of resident #61's Self-Administration of Medication Evaluation, showed he had been assessed to have Tums, one by mouth as needed on 8/10/17. The evaluation did not include the [MEDICATION NAME] powder, or the nasal spray. The form showed the self-administration of the medication would be on the care plan. Review of resident #61's Care Plan, with a review completion date of 6/8/18, did not show that resident #61 was able to safely self-administer the Tums, the [MEDICATION NAME] powder, or the nasal spray. The care plan did not include a plan to address safety for other residents, related to the medications not being secured in a locked place, but in resident #61's room, on a shelf, viewable from the doorway. Review of a revision of resident #61's Care Plan, dated 6/13/18, showed an addition that the resident's ability to have only Tums by his bedside, and a self-administration review would be completed every three months, in conjunction with the MDS calendar. The care plan did not include the self-administration of the [MEDICATION NAME] or the nasal spray.",2020-09-01
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,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,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 at 10:00 a.m., staff member C stated both staff members G and R had been suspended pending an investigation. 2. During an observation of medication administration on 6/12/18 at 7:50 a.m., staff member AA administered resident #43 one calcium antacid chewable tablet of 500 mgs orally. A review of resident #43's Order Review Report, showed the resident was ordered to receive calcium [MEDICATION NAME] 600 mg tab, 1 tab PO one time per day. During an interview on 6/13/18 at 8:45 a.m., staff member U was shown resident #43's physician's orders [REDACTED].#43's corresponding medication bottle from the facility's medication cart. She provided the same stock bottle of calcium antacid tablets, 500 mgs per tab, that had been used to administer resident #43's calcium [MEDICATION NAME] on the morning of 6/12/18. Staff member U was shown resident #43's physician order [REDACTED]. During an interview on 6/13/18 at 3:00 p.m., staff member A said the new corporation took over the administration of the facility on (MONTH) 1st of this year. He said prior to (MONTH) the facility owned pharmacy allowed resident families to bring into the facility over the counter medications purchased from outside retail stores to be given to the resident by the nurses if the resident's physician had ordered the medication. Staff member A said this was no longer allowed by the present pharmacy. He said he thought this explained the reason for the discrepancy in the dose and type of calcium that resident #43 had been receiving as compared to what the resident's physician had ordered.",2020-09-01
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., staff members W and X stated they were traveling staff and staff W had no official training before working on the hall. They both said they were just trying to meet the needs of the residents, through their previous working experience. Staff member X stated she had worked one day on the hall, with a veteran CNA, and there had been more staff working on the entire hall, more than just two CNAs. Staff member M stated she had never worked on this floor. The three staff members stated they were unfamiliar with the residents and did not know their preferences. During an interview on 6/13/18 at 10:00 a.m., staff member Y stated traveling staff reviewed policies and she tried to have an experienced staff with them to assist on their first time in the facility. The staff member stated she was aware the staff on the floor were swamped and she tried to help when she could. The staff member stated the facility was hiring new staff and they should be on the floor soon.",2020-09-01
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 1/22/18 and the start date was 2/26/18, over a month from the order date. There was no documentation showing the physician had been made aware of the medication not being given for over a month. - An order, dated 4/23/18 for Tucks pads, to apply to hemorrhoids three times daily as needed; and, - The order for [MEDICATION NAME] 10 g/15 ml syrup, give 30 ml every 48 hours as needed, was changed on 4/23/18 to every day as needed. A review of the facility's Bowel Management Policy, with a revision date of 2/20/17, showed if there was a change in the resident's pattern of bowel movement, the facility would notify the physician and then follow up to ensure the physician's orders [REDACTED]. During an interview on 6/14/18 at 10:15 a.m., staff member B stated that reviewing the bowel documentation for resident #66, showed the resident was improving since the new company took over the facility in (MONTH) (2018). Review of the BM Reports showed from 3/22/18 until 5/8/18, resident #66's bowel regime had no consistency. There were many days between bowel movements. The physician's orders [REDACTED]. There was no documentation showing the physician was aware of resident #66 having pain related to constipation. The care plan showed no documentation that the facility staff were aware resident #66 was having constipation.",2020-09-01
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,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 instructions should be followed for the cleaning of each individual resident's type of [MEDICAL CONDITION] mask. During an interview on 6/14/18 at 10:00 a.m., staff member B said she was not aware that the facility had a [MEDICAL CONDITION] policy. She asked staff member Z if the facility corporation had a [MEDICAL CONDITION] policy that would apply to the facility. Staff member Z said as far as she knew the facility did not have a [MEDICAL CONDITION] policy that covered the procedures for cleaning and maintenance of resident [MEDICAL CONDITION] equipment.",2020-09-01
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 NAME] HCL 10 mg tablet, one tablet by mouth as needed for [MEDICAL CONDITION]. The order showed, Take at the beginning of [MEDICAL TREATMENT] and may repeat dose 1 hour before the end of treatment if needed. The MARS did not reflect resident #48 had received [MEDICATION NAME] during (MONTH) or June. A review of resident #48's [MEDICAL TREATMENT] Communication Records for (MONTH) and (MONTH) (YEAR), showed resident #48 received [MEDICATION NAME] on 5/4/18 and 5/14/18 as administered by the staff at the [MEDICAL TREATMENT] clinic. [MEDICATION NAME] had been sent by the facility with the resident went to the [MEDICAL TREATMENT] clinic on 5/4/18. The notes did not reflect the [MEDICATION NAME] had been sent with the resident on 5/14/18. During an interview on 6/13/18 at 8:57 a.m., staff member U said she had not sent [MEDICATION NAME] to the [MEDICAL TREATMENT] clinic for resident #48's use in the past. She said she did not know if the [MEDICAL TREATMENT] clinic had a stock of [MEDICATION NAME] to give to the resident if needed. During an interview on 6/13/18 at 9:00 a.m., NF1, at the ([MEDICAL TREATMENT] clinic) said, the clinic's renal doctor had ordered the [MEDICATION NAME] for resident #48 to be given as needed for [MEDICAL CONDITION] during [MEDICAL TREATMENT] treatment. She said the [MEDICAL TREATMENT] center did not keep stock medications. She said the facility had been called in the past and had sent [MEDICATION NAME] with the facility's driver to the [MEDICAL TREATMENT] clinic so resident #48 could be treated for [REDACTED]. When the [MEDICATION NAME] had been administered, the [MEDICAL TREATMENT] clinic had documented it on the resident's [MEDICAL TREATMENT] Communication Order. The resident had been scheduled for [MEDICAL TREATMENT] at the [MEDICAL TREATMENT] clinic twice a week for the months of (MONTH) and (MONTH) in (YEAR). Resident #48's prescription for [MEDICATION NAME] was to have been given at the beginning of each [MEDICAL TREATMENT] treatment and then it could have been repeated if needed. It had been given twice during the month of (MONTH) and had not been given in (MONTH) of (YEAR). 3. A review of resident #48's Order Review Report, dated (MONTH) 3, (YEAR), showed the resident was ordered to be monitored for thrill and bruit of her [MEDICAL TREATMENT] shunt/fistula daily, monitored for s/s of shunt/fistula for infection every shift, and not to have blood draws or her blood pressure taken on the arm with her shunt/fistula. The resident was also ordered a renal diet without potatoes, tomatoes, oranges and bananas. In an interview on 6/13/18 at 8:57 a.m., staff member U said resident #48 took all of her medications except for her insulin after she returned to the facility from her [MEDICAL TREATMENT] treatment. A review of resident #48's Care Plan showed only one intervention: Resident is at risk for End Stage [MEDICAL CONDITION] r/t Chronic Kidney Failure AEB weekly [MEDICAL TREATMENT]. Date Initiated 4/25/18. The care plan did not show specific information regarding the resident and her needs related to [MEDICAL TREATMENT]. It did not show how often, when, or where the resident was scheduled to receive [MEDICAL TREATMENT] treatments. It did not show how the resident was to be transferred to and from the facility for [MEDICAL TREATMENT] care. It did not show the residents need for the assessments of vital signs before and after [MEDICAL TREATMENT], shunt/fistula assessments for bruit, thrill or s/s of infection, weight measurements for potential fluid imbalance, or lab follow-ups for abnormal electrolyte concerns. The care plan failed to reflect the resident's medications were to be held until after her return from [MEDICAL TREATMENT] on the days she was scheduled to receive [MEDICAL TREATMENT]. The care plan did not show that the [MEDICAL TREATMENT] clinic had been notified of the resident's end of life wishes in case of emergency at the [MEDICAL TREATMENT] clinic. The care plan did not show the resident had been educated about her renal diet and to avoid potatoes, tomatoes, oranges and bananas. `",2020-09-01
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 out in the Narcotic Log Book immediately after removing them from the lock box for administration. b. During an observation on 6/13/18 at 2:26 p.m., staff member N reviewed the medications in the narcotic lock box of the Rehab Two Medication Cart. A comparison of the Narcotic Log Book, page 28, with the medication card numbered 28, showed a discrepancy. The Narcotic Log Book showed resident #234's [MEDICATION NAME] HCL 2 mg tablets, had a count of 15 tablets remaining. The medication card numbered 28, for resident #234's [MEDICATION NAME] HCL 2 mg tablets, showed a count of 16 tablets remaining. Review of resident #234's EMAR showed the resident was administered [MEDICATION NAME] 2 mg on 6/13/18 at 11:01 a.m. During an interview on 6/13/18 at 2:26 p.m., staff member N stated she must have forgot to sign the medication out in the Narcotic Log Book earlier that day. She stated it was the expectation to sign out the medication in the Narcotic Log Book immediately after dispensing the medication from the lock box. During an interview on 6/13/18 at 3:12 p.m., resident #234 stated she felt her pain was well managed by the staff, and had no concerns with not being able to get her pain under control. She stated once pain medication was given as ordered, it worked quickly. During an interview on 6/13/18 at 3:00 p.m., staff member B stated it was the expectation all controlled medications were accounted for in the Narcotic Log Book. She stated the Narcotic Log Book should accurately reflect what was remaining in the medication card for each resident. She stated any discrepancies should be reported to the nurse manager. She stated it was not an acceptable method to administer a controlled medication and sign it out at a later time. The staff member stated it was also not acceptable to prepare a medication, sign it out in the EMAR as administered, and give the medication at a later time than the time it was signed out as administered. During an interview on 6/14/18 at 9:16 a.m., staff member O stated he performed a 10% audit of the controlled medications once a month. He stated an audit was also conducted by the nursing quality review when the new administration became effective in (MONTH) (2018). He said they conducted a thorough audit of all the Narcotic log books and narcotics in the facility. He said a review of both audits, had no incidents of concerns with discrepancies between the two. c. During an observation on 6/13/18 at 1:45 p.m., staff member G was preparing medications for resident #52. Staff member G looked at the medication record, looked at the narcotic book for resident #52, and obtained a blister pack of medication for resident #52 out of the narcotic drawer. Staff member G popped the medication out of the blister pack and showed the card to the surveyor. Staff member G started to sign out the narcotic medication in the narcotic book. It was observed that the narcotic count was incorrect. The medication taken out of the blister pack was different than the medication in the blister pack and there was white tape placed on the back of the medication blister pack where staff member G had removed the medication. The medication staff member G removed was light pink in color and the medication in the blister pack was dark purple in color. During an interview on 6/13/18 at 1:45 p.m., staff member G stated she counted the narcotics with staff member R when she came on shift. She stated the narcotic count was right. She said she did not look at the book when she counted that morning. Staff member G stated she had only looked at the blister pack and staff member R looked at the narcotic book. Staff member G called for staff member C to inform her of the findings. During an interview on 6/13/18 at 2:25 p.m. staff member Q stated during the narcotic count, they normally call the page number out and one nurse looked at the narcotic book while the other nurse looked at the blister pack. She stated neither nurse looked at both the blister pack and the book. During an interview on 6/14/18 at 10:00 a.m., staff member C stated staff members G and R were both suspended pending an investigation. A review of the facility's policy and procedure titled, Controlled Medications Count, showed: It is the policy of the facility to maintain an accurate count of Scheduled II and controlled medications. 1. After removing the controlled medication from the blister pack or the individual packet, the nurse will sign off the accompanying controlled medication sheet indicating the medication is taken. 2. After administration of the controlled medication, the nurse will sign off the EMAR. 3. If the controlled medication needs to be wasted, another nurse should witness the wasting of the controlled medication. 2. Inaccurately Transcribed Order: 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, pages 57 and 59, with the medication cards numbered 57 and 59, showed a discrepancy. The medication cards showed resident #59 was to receive [MEDICATION NAME] 50 mg tablet, give half of a tablet (25 mg), by mouth every six hours, PRN pain. A review of the Narcotic Log Book pages 57 and 59, showed the order was written, [MEDICATION NAME] 25 mg tablet, give half of a tablet for a total of 12.5 mg, every six hours, PRN pain. Review of resident #59's Physician Orders, dated (MONTH) (YEAR), showed an order for [REDACTED]. During an interview on 6/13/18 at 1:58 p.m., staff member M stated she was not sure who had transcribed the order from the card into the Narcotic Log Book. She stated she had not noticed the discrepancy between the two, even after completing the narcotic count with the outgoing nurse. She stated it was the facility policy that a second nurse check the orders and the transcription of the medication card into the Narcotic Log Book for accuracy. She stated there was a time when the facility did not have enough staff and there was not always a second nurse to check the accuracy of the nurse transcription into the narcotic logs. During an interview on 6/13/18 at 4:33 p.m., staff member B stated it was the expectation the Narcotic Log Book accurately reflect the medication as on the medication card and the physician order. She stated it was the expectation the nurses double check the new order after it was transcribed into the Narcotic Log Book. 3. Narcotic Medications Recorded as Given but not Administered: During an observation on 6/13/18 at 2:00 p.m., a medication count was conducted of the narcotics on the medication cart and refrigerator on the Mountain View Hall, with staff member T. The count showed the number of [MEDICATION NAME] 0.5 mg tabs contained in the narcotic card, held in the cart, for resident #50 was 29. At the same time, the corresponding narcotic record for the [MEDICATION NAME] showed 28 tabs should still be contained in the card. The card was counted a second time by staff member T, and he verified the count was over by one, which was an [MEDICATION NAME] 0.5 mg tablet. Staff member U had signed out the last dose of [MEDICATION NAME], which was given at 10:10 a.m. that morning. During an interview on 6/13/18 at 2:00 p.m., staff member U reviewed the narcotic card and narcotic record counts. She said she had participated in the narcotic count at shift change in the morning and that it had been correct. She said she must not have poured an [MEDICATION NAME] 0.5 mg tab into the medication cup she had prepared for resident #50 at 10:10 a.m. She poured an [MEDICATION NAME] 0.5 mg tab into a disposable medication cup and crossed out the 10:10 a.m. time on the narcotic record, wrote above it 2:00 p.m., and proceeded to go to resident #50's room and gave resident #50 the [MEDICATION NAME] tablet. Staff member U stated she would provide a copy of the medication error report to the survey team when she completed it. The report was not received by the end of the survey.",2020-09-01
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 medications differently. The staff member stated she felt there was not always consistency with the way the medications were entered into the EMAR. She stated the only time she would intentionally omit medications from a resident's medication regimen, would be if there was a physician order, or the resident was outside of a safe parameter for administration; for example, if a pulse was too low, or a blood pressure was too low. During an interview on 6/13/18 at 11:45 a.m., staff member C stated it was the expectation of staff to use the rights of medication administration, follow any new physician orders, and administer medications as outlined in the EMAR for every resident. A review of the facility's policy and procedure, titled Medication Pass, showed, It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures . 2. During an observation of medication administration on 6/12/18 at 7:50 a.m., staff member AA administered resident #43 one calcium antacid chewable tablet of 500 mg orally. A review of resident #43's Order Review Report, showed the resident was ordered to receive calcium [MEDICATION NAME] 600 mg tablet, one tablet PO one time per day. During an interview on 6/13/18 at 8:45 a.m. staff member U was shown resident #43's physician's orders [REDACTED].#43's corresponding medication bottle from the facility's medication cart. She provided the same stock bottle of calcium antacid tablets, 500 mg per tab, that had been used to administer resident #43's calcium [MEDICATION NAME] on the morning of 6/12/18. Staff member U was shown resident #43's physician's orders [REDACTED]. She said the nurses giving medications should have clarified the order with the facility pharmacist and if what the physician had ordered was not available, the physician should have been called to order what equivalent medication was available.",2020-09-01
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,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,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 General Cleaning Policy showed that the resident rooms were to be cleaned daily.",2020-09-01
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. 2. During an observation on 12/12/16 at 4:40 p.m., a resident #6's room had a dirty bed side table with circular stains from a glass that had been dried onto the table. The floor of the resident room had food stains and foot prints throughout the room. During an interview on 12/13/16 at 8:35 a.m., resident #7 stated she had been having diarrhea and her toilet was dirty with dried stool. The resident stated she had asked several times for her toilet to be cleaned but no one had cleaned the toilet for one week. During an observation of resident #7's bathroom on 12/13/16 at 3:25 p.m., the resident's toilet was soiled with dried feces around the entire inside of the toilet bowl. During an observation and interview on 12/14/16 at 2:55 p.m., resident #7 stated, and pointed out that her toilet had finally been cleaned that afternoon. During an interview on 12/13/16 at 9:15 a.m., staff member F stated that the following areas were to be cleaned daily: -garbage's -bathroom sinks -bed side tables The staff member also stated they would clean the toilets and floors twice a week. 3. During an observation on 12/12/16 at 3:21 p.m., the dining room tables in Copper East were soiled. Two of the tables had a red ketchup like substance on it. Another table had a Kleenex box, and when the box was moved it stuck to the table and some of the cardboard packaging was left stuck to the table. During an interview on 12/12/16 at 4:24 p.m., staff member W stated cleaning the dining room tables was a job typically completed by the housekeeper, but Mondays and Tuesdays were the housekeeper's day off. She stated the head housekeeper or another person was assigned to keep the Copper East wing clean. She also said the CNAs could help out and clean the tables after the CNAs finished situating the residents after meals. During observations on 12/13/16 at 8:00 a.m., at 9:00 a.m., and 10:30 a.m. an entry way in the Copper East dining room had dry, muddy foot prints continuing into the dining room. Water had begun to pool up on the floor, and was tracked into the resident dining room. Cobwebs were observed in the family dining room, and the windows of the resident dining room. During an observation on 12/13/16 at 3:30 p.m., three dining room tables, in the Copper East dining room, were not wiped down after the noon meal. The tables had a sticky substance all over the top of them, and on the sides of the table which looked like dried food. During an observation on 12/14/16 at 2:00 p.m., the Crest East dining room tables were soiled with food, wrappers, sugar, dirty tissues, empty saltine cracker wrappers, and unopened packages of saltines. Also, observed on the various tables in the dining room, were plastic lids with salad dressings on them, a spilled milky white liquid, salt and/or sugar which had spilled, and crumpled napkins. During an interview on 12/14/16 at 2:15 p.m., staff member X stated she realized the tables were soiled. She stated the CNAs had already assisted the residents after their meals and the tables should have been cleaned. She agreed the dining room was messy, and stated she didn't want the guests of the facility seeing the dining room in that condition. She stated she was going to grab the CNAs and have them tidy up the dining area. During an observation on 12/14/16 at 2:50 p.m., the Copper East dining room tables were stained with cup rings that were dry and sticky. During an observation on 12/12/16 at 3:26 p.m., The dining room tables, located in the dining room on Rimview, were sticky to the touch from dried food debris. The dining room tables had a light brown rubber edging around the outside. The rubber edging on the tables had food particles and a black grime rubbed into the rubber edging. The surface of the tables were also sticky from dried food debris. The dining room tables had food debris and left over sauce on the tables. During an observation on 12/13/16 at 2:52 p.m., the tables in the dining room, on Rimview, had food and debris buildup around the edges of the table. Two dining room tables had a brown sauce smear on the surface of the tables. There were three residents sitting in the dining room. During an interview on 12/13/16 at 2:55 p.m., staff member S stated the tables were wiped down after each meal service by the CNAs. A disinfecting wipe would be used to remove any food debris and dried on sauces after the meal. Staff member S stated house keeping did not provide a deep cleaning or degreasing of the dining room tables. During an interview on 12/13/16 at 6:37 p.m., staff member D stated the tables were designed with the sticky rubber edging to prevent dining ware from sliding off the table. Staff member D stated the facility had attempted to clean the tables with the rubber edging and had not been successful. During an interview on 12/14/16 at 8:50 a.m., staff member D stated the dining room tables on Rimview were cleaned. The black, brown grease build up on the rubber edging of the tables, had improved. However, on other tables in the dining area, there was still dried on food debris around the edges and on the sides of the tables. This observation was made with the staff member D present. During an observation on 12/14/16 at 8:55 a.m., dining room tables on Rimview showed the black, brown grease build up was removed. On the other dining room table edges there was food debris and sauce build up on the outside of the table edge. During an observation on 12/14/16 at 3:26 p.m., the dining room tables in the Rimview dining room had food and dried dark brown sauce stain on three tables. There were three residents sitting in the dining room. During an observation on 12/14/16 at 3:39 p.m., a CNA brought a resident down to the Rimview dining room. The CNA seated the resident across from another resident. The table the resident's were sitting at had a dried dark brown thick stain on the table. The CNA retrieved a disinfecting wipe and cleaned the table after the resident was seated. The resident had to wait for the table to dry prior to being served his beverages. During the same observation, two tables still had a dried dark brown stain on the table. Residents were sitting at the dirty tables. During an observation on 12/15/16 at 4:37 p.m., a resident was seated at a dining room table in the Rimview dining hall. The table the resident was seated at had a dried, thick, brown stain on the surface of the table. The stain had been on the table since the lunch service. The table was not cleaned after the lunch meal service, or before the resident was seated at the dining table for dinner service. During an interview on 12/15/16 at 4:40 p.m., staff member D stated it was the expectation of staff to clean the dining room tables after each meal service and when visibly soiled. A review of the facility's user manual, titled, Urethane Edge Tables, showed, Edgemold's urethane edge tables feature. The urethane flows around the table, and shrinks as it cools resulting in a tightly sealed, durable edge with no seam between the edge and laminate top. An edgemold original table seamless edge totally eliminates a place for dirt, microbial growth or moisture to accumulate. Our proprietary formula includes an antimicrobial agent that helps keep the edges sanitary. Review of the facility's Daily General Cleaning Policy showed that the following areas were to be cleaned daily: -Common areas -Restrooms -Resident rooms -Dining areas -Hallways -Windows -Bathroom toilet and sink -Sweeping floor -Dusting -Fixtures -Spot cleaning.",2020-09-01
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 was lactose intolerant, the intervention was a lactose free diet. Review of Resident #7's Treatment Record, dated (MONTH) (YEAR), showed the resident was started on a continuous lactose free diet on 10/26/16. Review of Resident #7's Lunch Dining Card, dated 12/13/16, showed the resident was lactose intolerant. Review of the facility's Lactose-Free Diet guideline, showed all lactose products must be eliminated, which would have included foods that would have been prepared with milk. The guideline also showed food groups that would contain lactose such as: -Milk -Cheese -Ice cream -Cream soup, canned, and dehydrated soup mixes containing milk products Review of the facility's tuna and noodles recipe, from the Food for 50 book, showed the recipe contained cheese, canned cream of mushroom or celery soup, and milk. During an observation on 12/13/16 at 11:30 a.m., resident #7 was served tuna casserole, pickled beets with a lettuce garnish, and ice cream for dessert. The resident ate greater than 50 percent of her tuna casserole and 100 percent of her ice cream. The tuna casserole and ice cream contained lactose. During an interview on 12/13/16 at 12:10 p.m., staff member G stated that at the current time, they did not have any residents on a lactose free diet. During an interview on 12/13/16 at 12:25 p.m., staff member H stated the tuna casserole, served to resident #7, contained cream of mushroom soup, milk, and cheese. During an interview on 12/13/16 at 2:45 p.m., staff member I stated resident #7 had always been on a lactose free diet. He had also stated the Registered Dietitian would be the one who would update the interventions on a resident's care plan. During an interview on 12/13/16 at 3:00 p.m., staff member J stated resident #7 had a [DIAGNOSES REDACTED]. She also stated the resident was lactose intolerant and noted the resident had been served ice cream with her lunch. During an interview on 12/13/16 at 3:25 p.m., resident #7 stated she had diarrhea if she ate lactose. The resident stated she had been feeling queasy after lunch. 3. Review of the physician recapitulation orders, dated (MONTH) (YEAR), showed resident #1 had an order, dated 6/30/16, for a mechanical soft diet. The diet was documented in the order that the resident should be receiving mechanical soft, but also staff should send a pureed diet plate, and offer the puree if she refused to eat mechanical soft textures. Review of the Residents Care Plan, with an effective date of 3/31/16-current, showed the resident had the following nutritional interventions: - Provide max to total assist with eating. - Allow adequate time to eat; provide assistance, cueing, and encouragement as indicated. Feed the resident. - Offer alternates if - Provide diet as ordered: Mechanical Soft. Provide pureed foods as alternative. 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) 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 table, waiting for assistance, for a period of time after she appeared to be finished eating. No continued prompting or cuing was offered to her. The facility failed to allow adequate time for the resident to eat, and encourage her as the care plan showed. The resident ate less than 10% of her eggs or cereal at the meal. The staff members failed to offer her pureed eggs as an alternate as the doctor had ordered, and for what the care plan 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 stated the resident had been receiving pureed meals, and 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. The facility failed to follow the care plan by not offering her a mechanical soft diet menu item, prior to giving her a pureed meal. During an observation and interview on 12/14/16 at 9:00 a.m., a family member stated resident #1 ate well, and that the resident would not eat pureed food. The family member stated the resident ate the mechanical soft diet well. The family member also stated they had requested mashed potatoes and ice cream to be offered at meal. The resident would always eat those two foods items, because they were some of her favorites. The family member stated the diets had been a problem at the facility because there was a staff change over and sometimes she just doesn't get the assistance she needs. During the interview, the resident was observed eating a cookie that was broken into small pieces. The resident didn't appear to be having any struggles with eating the cookie, she just needed a bit more time to eat her snack. She was able to eat well with cueing and adequate time. 4. During an observation and interview on 12/13/16 at 8:30 a.m., in the dining room, resident #10's daughter assisted her with eating breakfast. The daughter stated she had a concern with her mother's hand, which was contracted. The daughter wanted a rolled up wash cloth in the hand which would keep the resident's fingers from curling inward. During an observation on 12/13/16 at 12:20 p.m. in the dining room, Resident #10 sat at the table with her right hand in her lap. Her fingers were curled into her palm. Review of resident #10's Physician order [REDACTED]. During an interview on 12/14/16 at 10:30 a.m., with staff members AA, BB, and R, staff member AA stated the PT department tried to work closely with resident #10 to meet her needs. Staff member BB stated she assessed Resident #10 quarterly for any changes the resident needed. Staff member R stated she did ask the resident to participate in restorative, but the resident usually refused. Review of the restorative care sheet showed the resident was to receive a TENS unit 2-3 times a week to her shoulder. There was no information on the care sheet for the splinting or bracing of the resident's hand. Review of resident #10's Care Plan showed a lack of restorative service, used as an intervention for the treatment of [REDACTED].#10's hand. During an interview on 12/15/16 at 9:00 a.m., staff member CC stated she missed putting restorative services on the resident's care plan. She thought resident #10 was no longer receiving restorative.",2020-09-01
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,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 to the psychiatrist in regards to resident #1's weight loss, asking for a review of the medications, and the psychiatrist failed to respond to that communication as well. 2. Resident #15 had a [DIAGNOSES REDACTED]. Review of resident #15's Quarterly MDS, section N0410, section D, dated 10/17/16, showed the resident had received a hypnotic medication 6 out of the 7 day look back period. Review of resident #15's MAR, dated (MONTH) (YEAR), showed [MEDICATION NAME] 5 mg, as needed, for [MEDICAL CONDITION], to be given at night. The order date was 4/26/16. The MAR showed the [MEDICATION NAME] had been given 12/1, 12/2, 12/3, 12/4, 12/5, 12/6, 12/7, 12/9, 12/10, 12/12, 12/13, and 12/14/16. Review of resident #15's medical record showed a lack of evidence for a gradual dose reduction for the [MEDICATION NAME] 5 mg, ordered 4/26/16. Review of resident #15's Chronological Record of Medication Regimen Review, reviewed by the pharmacist on 5/28/16, 6/25/16, 7/24/16, 8/27/16, 9/25/16, 10/29/16, and 11/27/16, showed a lack of evidence relating to a reduction or information on a reduction, for the [MEDICATION NAME]. During an interview on 12/14/16 at 2:15 p.m., staff member Y was unable to locate a GDR in the resident's medical records. Staff member Y stated a GDR probably was not completed for the [MEDICATION NAME] because the resident would never be taken off that particular medication due to her difficulty sleeping. During an interview on 12/14/16 at 4:30 p.m., staff member D stated the order was hand written for the medication, written in April, but there was no other paperwork in the resident's record for a GDR for the medication. Staff member D stated she consulted with NFS 2, and he was unable to find any paperwork related to a GDR or any other medication review for the [MEDICATION NAME]. 3. Resident #12 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the resident's Quarterly MDS, with an ARD of 11/15/16, showed the resident was cognitively intact, with a BIMS of 14. A review of resident #12's Physician Recapitulation Order, dated 12/12/16, showed the resident was on [MEDICATION NAME] 5 mg tablet, at the hour of sleep, for anxiety disorder, unspecified, which started on 6/28/16. A second order for [MEDICATION NAME] showed, [MEDICATION NAME] 5 mg tablet, as needed, every eight hours, for PRN anxiety, which started on 11/11/16. A review of resident #12's MAR, dated (MONTH) (YEAR), showed: [MEDICATION NAME] 5 mg tablet, at hour of sleep, starting on 6/28/16. The medication was given for anxiety disorder, unspecified, which was discontinued on 12/5/16. The order was changed to [MEDICATION NAME] 5 mg tablet, twice daily. The new order did not give a rationale for use. A second order on the resident's MAR for (MONTH) (YEAR), for [MEDICATION NAME], showed: [MEDICATION NAME] 5 mg tablet, as needed, every eight hours, starting 11/11/15, and discontinued on 12/5/16. There was no documented rationale for use of PRN anxiety medication. A review of resident #12's MAR, from (MONTH) (YEAR) to (MONTH) (YEAR), showed, [MEDICATION NAME] 5 mg tablet, at hour of sleep, starting 6/28/16, for anxiety disorder, unspecified. A second order on the resident's MAR's for (MONTH) through (MONTH) (YEAR), showed an order for [REDACTED]. A review of resident #12's physician progress notes [REDACTED]. Continue [MEDICATION NAME] 20 mg three times a day and 40 mg at bedtime. Continue [MEDICATION NAME] therapy. Medications listed on the Outpatient Encounter Prescriptions, as of 7/26/16, showed: [MEDICATION NAME] 5 mg tablet, take one tablet by mouth every eight hours as needed for Muscle Spasms. The indication noted in the progress note was not consistent for the use indicated in the resident's MAR and Physician Recapitulation Orders. A review of resident #12's physician progress notes [REDACTED]. A review of resident #12's physician progress notes [REDACTED]. [MEDICATION NAME] started last month. Change [MEDICATION NAME] to 5 mg BID and start [MEDICATION NAME] 0.5 mg by mouth every 6 hours as needed for anxiety. A review of resident #12's Monthly Drug Regimen Review, showed on 11/17/15, [MEDICATION NAME] 5 mg at bedtime as needed for anxiety. The Monthly Drug Regimen Review failed to show any further monthly reviews for [MEDICATION NAME]. A review of the facility's Gradual Dose Reduction Log, failed to show a gradual dose reduction was completed for resident #12 for the use of [MEDICATION NAME], dating back to 11/11/15. During an interview on 12/14/16 at 4:00 p.m., resident #12 stated she had felt the need for an increase in her [MEDICATION NAME] due to her anxiety, and due to her increased feelings of anxiety from the progression of her [MEDICAL CONDITION]. Resident #12 could not recall using the medication for muscle [DIAGNOSES REDACTED], but did mention she did take a medication for that as well. During an interview on 12/15/16 at 8:30 a.m., staff member D stated the gradual dose reductions needed to be completed at regular intervals as provided by the CMS regulation. Staff member D stated she was aware the gradual dose reductions had not been completed for resident #12's [MEDICATION NAME] dosing. During an interview on 12/15/16 at 9:33 a.m., NF1 stated she did get notifications from the pharmacist regarding the resident's gradual dose reductions. NF1 stated she recalled increasing resident #12's [MEDICATION NAME] due to muscle spasms, but did not recall completing any gradual dose reductions for resident #12. During an interview on 12/20/16 at 10:00 a.m., NF2 stated he had not completed a gradual dose reduction on resident #12, due to the medication being used for muscle spasms. NF2 stated he completed the monthly medication reviews for the residents, and when the quarterly reviews were due for [MEDICAL CONDITION] and hypnotic medications he would complete the gradual dose reductions, and notified the providers. NF2 stated he remembered the regulations showed if the resident was on a medication, which was exempt from needing a gradual dose reduction, he did not need to complete a GDR. A review of the [MEDICAL CONDITION] Medication policy showed: - 1. The facility will make every effort to comply with state and federal regulation related to the use of psychopharmacological medications in the long term care facility to include regular review for continued need, appropriate dosage, side effects, risk and or benefits . - 5. Efforts to reduce dosage or discontinuation of psychopharmacological medications will be ongoing, as appropriate, for clinical situations. A request was made on 12/15/16 at 7:40 a.m., for the gradual dose reduction policy. The facility stated there was no such policy, and they followed the federal guidelines on the completion of gradual dose reductions.",2020-09-01
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 airshot before each injection. Turn the dose selector to 2 units. Hold the pen with needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards and press the push-button all the way in. The dose selector returns back to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure. A review of the patient information pamphlet, provided by [MEDICATION NAME], showed: Giving the airshot before each injection. Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: E. Turn the dose selector to select 2 units. F. Hold your [MEDICATION NAME] with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. [NAME] Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times.",2020-09-01
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 be given to the resident, and when a diet was to be given. The card also included documentation that the resident may need assistance, but failed to show when she needed assistance. During an interview on 12/13/16 at 2:46 p.m., staff member I stated the pureed diet was really the only logical option for the resident, based on her age. Staff member I failed to explain why he thought two diets were ordered, and focused on why a pureed diet was the better option for the resident. During an observation and interview on 12/14/16 at 9:00 a.m., a family member stated resident #1 was a good eater, and that the resident would not eat pureed food. The family member stated the resident ate the mechanical soft diet well. The family member also stated they had requested ice cream be offered at meal times, along with mashed potatoes, because the resident would always eat those two foods. They were some of her favorites. The family member stated the diets were a problem with the facility because there was a staff change over and sometimes the resident just doesn't get the assistance she needs. During the interview, the resident was observed eating a cookie, broken into small pieces. The resident didn't appear to be having any struggles with eating the cookie. The resident was observed to need time to eat her snack, but was able with cuing from her family member. 2. Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the resident's Quarterly MDS, with an ARD of 9/21/16, showed the resident was cognitively intact, with an BIMS of 15. A review of residents #8's Physician Order, dated 9/21/16, showed, ST swallow eval (sic)completed. Patient appropriate for mechanical soft diet with chopped meat and nectar thick liquids. Pills to be given whole in pureed (pudding, applesauce). Patient swallow improves when completing chin tuck strategy. A review of resident #8's Physician Recapitulation sheet, dated (MONTH) (YEAR), showed, Thickened Liquids, nectar consistency, diet, mechanical soft diet with chopped meat. During an observation on 12/12/16 at 11:11 a.m., On resident #8's bed were four bags of Lays potato chips. Two of the bags were empty and placed inside an empty gray wash basin. The two remaining bags were full laying at the foot of the resident's bed. During an interview on 12/13/16 at 11:24 a.m., staff member G stated residents on altered therapeutic diets should receive snacks which are approved for the altered diet. The staff member stated potato chips were not an approved snack for a resident on a mechanical soft diet. A review of the facility's Dysphagia Diet, NDD Level 2, showed, The dysphagia diet is a transition from the pureed diet and requires the ability to chew and tolerate mixed textures. Foods are soft and moist. At times pureed versions of the menu items must be served to ensure integrity of the Dysphagia Diet. The Dysphagia Diet in the IMPAC Menu, showed, Food Groups: Desserts, avoid: Dry, course cakes and cookies. Potatoes and Starches: avoid: Potato skins and chips. During an observation on 12/13/16 at 11:30 a.m., resident #8 was in his bed. He had one empty bag of potato chips by him in his bed, and one unopened bag of potato chips on his bedside table. During an interview on 12/13/16 at 11:30 a.m., staff member N stated resident #8's favorite snack was potato chips and licorice. The staff member stated she knew resident #8 was on nectar thick liquids, but was not aware of him being on an altered diet. Staff member N stated the CNA kiosk (electronic system for documentation) showed the diets ordered for the residents, and it would also be posted on the white board at the Rimview nurses' station. During an interview on 12/13/16 at 11:35 a.m., staff member O stated she was aware resident #12 was on nectar thick liquids, but was not aware of him being on an altered diet. The staff member stated she was not aware the resident could not receive certain foods off the snack cart. Staff member O stated the refrigerator had a list of snacks approved for residents on altered diets, and for the type of altered diet, but the list did not show who was on altered diets. Staff member O stated she could look it up in the CNAs kiosk, or it might be on the white board in the report room. The staff member stated the last training she attended on altered diets was at last months, monthly training. During an observation on 12/13/16 at 11:49 a.m., staff member P gave resident #8 his medications. The staff member offered the medications to the resident whole, with thickened juice to swallow the medications. The resident started to cough. Staff member P offered another sip of thickened juice, and the resident stopped coughing. The resident's medication's were not administered with a pureed food item, such as applesauce or pudding, as the provider ordered. During an interview on 12/13/16 at 11:50 a.m., staff member P stated he was aware resident #8 was on thickened liquids, but did not know to administer his medications with a pureed food to swallow them. The staff member stated the MAR did not indicate the need to give resident #8 his medications with pudding or applesauce. Staff member P stated the resident had always taken his medications without pudding or applesauce. He stated the resident would cough at times after taking his medications. Staff member P stated he was not aware resident #8 was on an altered diet. He stated the resident would eat the snacks of his choice, and he could be very demanding for the type of snack he wanted. During an interview on 12/13/16 at 11:59 a.m., staff member M stated he was not aware of a specific diet change for resident #8. Staff member M stated he knew resident #8 was on nectar thick liquids, but was not aware of an altered diet, and snack options. Staff member M reviewed resident #8's record and found the diet order for mechanical soft diet with chopped meats and thickened liquids, and pills with puree. Staff member M stated the medications should have been ordered in the MAR. Staff member M stated it was the responsibility of the charge nurse to review all new orders and put the orders in the electronic medical record. Staff member M stated it did not appear the order for resident #8 was put in the record accurately. The staff member stated, by not providing the correct diet to a resident with dysphagia, it could have a negative result of choking, aspiration and/or pneumonia. He said if a resident had a specific snack preference, which conflicted with his diet order, the care plan would reflect that preference. During an interview on 12/13/16 at 12:10 p.m., staff member R stated she was aware resident #8 was on nectar thick liquids, but did not realize he was on an altered diet. The staff member stated she would know if the resident was on an altered diet, and what were the approved snack choices for the resident, by reviewing the white board at the nursing station. She could also look at the snack list on the refridgerator. Staff member R stated the snack cart did not have a list of approved snack alternatives for residents with altered diets. She stated it would be nice if the cart had a list of the residents receiving altered diets, and what would be an appropriate snack for them. An observation on 12/13/16 at 12:19 p.m., showed the snack cart located on Rimview had a blue cooler filled with ice, and on the second shelf a tray filled with snack options. The options on the tray consisted of Famous Amos chocolate chip cookies, Ritz Bits cheese crackers, peanut butter crackers, Fig Newtons, plain Lays Potato chips, and sugar free sugar waffle cookies. During an interview on 12/13/16 at 12:28 p.m., staff member G stated when an diet change was ordered by the physician, the nurse would take the order, enter the order into the electronic health record, then would provide her with the pink slip with the new diet order. The staff member stated she would take the diet order, and update the resident's diet ticket in the kitchen. Staff member G stated she prepared the snack options on the snack cart. Staff member G stated the snack carts did not have a list of diet alternatives or show which resident's receiveed an altered diet. She stated the resident refrigerators on the each unit had a list of alternate diets, and showed what was an approved alternative, per the diet. The refrigerators were stocked with snack options, such yogurts, applesauce, and puddings. Staff member G stated it was important for staff to follow the diet order to prevent a resident from choking or aspirating. The staff member stated resident #8 had a preference for potato chips. She stated the potato chips were not on the approved dysphagia diet. She stated resident #8 could get demanding about having his snack of choice (the potatoes chips). Staff member G stated the resident could deviate from his therapeutic diet, as long as the resident was aware of the risks and benefits, and it was documented on the resident's care plan. A review of resident #8's Care Plan, dated 9/29/16, showed, alteration in nutrition: Dysphagia, (resident) receives a mechanically altered diet. The interventions showed, provide diet as ordered: regular with nectar thickened liquids, report any chewing or swallowing difficulties to nurse. Offer snacks at HS and PRN. The care plan failed to reflect resident preferences for snack alternatives, such as, chips or cookies. During an interview on 12/13/16 at 12:40 p.m., staff member I stated it was the expectation of staff to follow the diet order for each resident. If the resident would like a food item not on the recommenced diet, the facility would need to educate the resident of the risk and benefits, then update the care plan. Staff member I stated if the staff did not follow the prescribed therapeutic diet, the resident could choke, or aspirate. During an observation on 12/13/16 at 3:11 p.m., staff member T brought the snack tray into resident #8's room and asked the resident if he would like anything off the snack tray. Resident #8 removed a bag of potato chips from the tray. During an interview on 12/13/16 at 3:15 p.m., staff member T stated she was not aware resident #8 was on an altered diet. Staff member T stated she was not aware of which residents had an altered diet, and may need a snack alternative. During an interview on 12/13/16 at 5:59 p.m., staff member D stated it was the expectation of staff to know what diets were ordered for residents. Staff member D stated the CNAs could look up what type of diet a resident was on, before passing snacks. The nurses had the orders in the electronic medical record. She stated there was a list on the refridgerator of the different altered diet snack options available for residents. It was the expectation of staff to follow the diet orders for residents as prescribed by the physician. During an observation on 12/14/16 at 4:06 p.m., resident #8 was eating Famous Amos chocolate chip cookies, while laying in bed. The head of the bed was up at 30 degrees, which was common for a person with a risk of aspiration. A review of the facility's policy and procedure titled, Therapeutic Diets, showed, Therapeutic diets, ordered by the health care provider, are supported in the community. Residents are encouraged to follow their prescribed diet; however, resident compliance cannot be ensured . 2. The community supports the following diet consistencies: a. Mechanical Soft/Soft to Chew Consistency served in ground of soft form . 5. Notify the Food Service leadership, in writing, of resident's dietary order. 6. Add the resident's name and diet to the Diet Roster. (The Diet Roster was a list of all residents and their specific diet as ordered by their health care provider). 7. Post the Diet Roster in the kitchen and in the dining areas. 8. Update the Diet Roster as needed with any diet changes (DON and Dietary Manager). 9. Add new residents to the Diet Roster immediately upon admission. 10. Maintain all diet orders received from the resident's health care provider in the resident's file. 11. Provide education to nursing and culinary staff regarding special diets. 12. Provide education to residents with special dietary needs and encourage compliance. 13. Provide supervised dining for residents with pureed foods and/or thickened liquids. A review of the facility's Suggested Snacks, for therapeutic diets, showed, Mechanical Soft Diet: Banana (ripe), Canned Fruit (soft), Cereal (No Raisins) Milk, Soft Cookies (No Nuts or Raisins), Fruit Juice, Grahan (sic) Crackers, Cottage Cheese, Applesauce, Pudding, Ice Cream, Jello, Yogurt, Milkshake, Vanilla Wafers, Cheese and Crackers, Sandwiches (Meat salad, P&J). 3. Review of resident #7's Care Plan, dated 9/13/16 to present, showed the resident was lactose intolerant. The interventions showed the resident would be on a lactose-free diet. Review of resident #7's Treatment Record, dated (MONTH) (YEAR), showed the resident diet to be regular lactose-free. Review of resident #7's Dining Card, dated 12/13/16, showed the resident was lactose intolerant. Review of Resident #7's Physician order [REDACTED]. During an observation on 12/13/16 at 11:30 a.m., resident #7 was served tuna casserole, pickled beets with a lettuce garnish, and ice cream for dessert. The resident ate greater than 50 percent of her tuna casserole, and 100 percent of her ice cream. The tuna casserole and ice cream contained lactose. During an interview on 12/13/16 at 12:10 p.m., staff member G stated that at the current time, they did not have any residents on a lactose free diet. During an interview on 12/13/16 at 12:25 p.m., staff member H stated the tuna casserole, served to resident #7, contained cream of mushroom soup, milk, and cheese. During an interview on 12/13/16 at 2:45 p.m., staff member I stated resident #7 had always been on a lactose free diet. He had also stated the Registered Dietitian would be the one who would update the interventions on a resident's care plan. During an interview on 12/13/16 at 3:00 p.m., staff member J stated resident #7 had a [DIAGNOSES REDACTED]. She also stated the resident was lactose intolerant, and noted the resident had been served ice cream with her lunch. Review of the facility's Lactose-Free Diet guideline, showed all lactose products must be eliminated, which would have included foods that would have been prepared with milk. The guideline also showed food groups that would contain lactose such as: - Milk - Cheese - Ice cream - Cream soup, canned, and dehydrated soup mixes containing milk products Review of the facility's tuna and noodles recipe from the Food for 50 book, showed the recipe contained cheese, canned cream of mushroom or celery soup, and milk. Review of the facility's policy on therapeutic diets, dated 11/10/16, showed that individuals who would present with lactose intolerance should avoid dairy products.",2020-09-01
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 incident report. A note should be placed into the resident's medical record of the incident and the facts, which would include the physician and family responsible party notification. The policy also showed that an investigation would be completed within 5 days and appropriate action would be taken. The facility policy was not followed relating to the deficient practice.",2020-09-01
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 disinfecting wipes between each resident use. The staff member stated staff had training on the disinfection of the glucometers after the last annual survey. A review of the facility's policy and procedure titled, Blood Glucose Monitoring, showed, Disinfect glucometer after each use with 0.52% sodium hypochlorite solution or equivalent wipes and follow infection prevention guidelines to prevent carry-over of blood and infectious agents. A review of the facility's user's guide titled, Even Care G3, Professional Blood Glucose Monitoring System User's Guide, showed, Cleaning and Disinfecting Procedures for the Meter. The Even Care G3 Meter should be cleaned and disinfected between each patient. The meter is validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years. To disinfect your meter, clean the meter surface with approved disinfecting wipes. 2. During an observation on 12/12/16 at 5:03 p.m., Staff member L did not wash his hands or put on gloves before he approached resident #22. He cleaned the residents finger with an alcohol wipe. Waited for the resident's finger to dry, took the lancet and punctured the resident's finger. Staff member massaged the finger to bring a drop of blood to the surface of the finger. Staff member L applied the droplet of blood to the test strip which was docked in the glucometer. Staff member L did not wear gloves during the procedure. Staff member L did not disinfect his hands before or after the procedure. During an interview on 12/12/16 at 5:05 p.m., staff member L stated he was aware half way through the procedure that he was not wearing gloves. Staff member L stated he knew he should have washed his hands prior to donning gloves, and should not have checked the resident's blood sugar without wearing gloves. Staff member L stated the last training he had on hand hygiene was at the last monthly meeting. During an interview on 12/12/16 at 5:15 p.m., staff member D stated it was the expectation of staff to wear gloves when an encounter with known blood contamination may occur, such as, during blood glucose monitoring. Staff member D stated all facility staff were educated and trained monthly on hand hygiene. A review of the facility's policy and procedure titled, Blood Glucose Monitoring, showed, Wear proper PPE during blood glucose testing and administration of insulin. A review of the facility's user's guide titled, Even Care G3, Professional Blood Glucose Monitoring System User's Guide, showed, Step 1. Wash hands with soap and water. Step 2. Put on single-use medical protective gloves.",2020-09-01
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 resident presented with a swollen foot with drainage, and she would have cleaned the wound then notified the doctor and wound care nurse. During an interview on 1/28/20 at 2:25 p.m., staff member E stated resident #1 was neither resistive, nor refused cares, when provided to the resident. During an interview on 1/28/20 at 2:46 p.m., staff member A stated, during the time of resident #1's admission, since the Director of Nursing was gone, the floor nurse was in charge of overseeing and ensuring cares. Staff member A stated if there were any issues, the floor nurse could not handle the Regional Clinical Nurse would have consulted in the matter. Staff member A stated he was confused on the matter of resident #1's foot, as it was noted the resident had a fall with mention of resident #1's socks, and all extremities were checked, but there was no mention of swelling noted. It was noted on 1/3/20 and 1/4/20 the resident experienced leg pain, and the foot was swollen red and hot to the touch. Staff member A stated he did not know what happened. During an interview on 1/28/20 at 3:50 p.m., with staff member A, B, and C, staff member B stated all skin checks would be either Braden scale assessments or documented in the progress notes if they occurred. Staff member B stated there was not a physician note for 1/3/20 or 1/4/20 to show facility staff made contact with a doctor to get direction on what to do with resident #1's foot condition. Staff member B stated on 1/3/20, a wound nurse consultation had already been set up, due to the resident's avoidable pressure ulcer to his buttocks, and back. Staff member B stated there was not an official process to document the completion of a head to toe assessment after falls to ensure they were completed. Staff member B stated she did not find any other skin checks for the resident, except the skin checks completed on admission, and 1/2/20. Staff member B stated she had just implemented skin checks on bath days. Staff member C stated she was in the facility for a few hours on 1/4/20, Saturday morning. She stated she performed catheter care and wound care for the resident and did not recall if the resident had socks on or not. Staff member C stated she could not recall looking at resident #1's foot. A review of resident #1's care plan, with a last revision date of 12/31/19, showed no documentation for catheter care, wound care, or skin checks to be performed. A review of resident #1's skin and wound assessments, dated 12/12/19 and 1/2/20, showed no documentation of resident #1's foot or swelling. A review of resident #1's Nursing progress notes, showed the following: - On 1/3/20 - Residents foot is red swollen and red to the touch. Will be trying to be getting ahold of the doctor to possibly get ABX (antibiotics). - On 1/4/20 at 2:14 p.m. - Pt very lethargic and unable to perform therex to lower ext 's., R. foot is badly swollen and in need of wound care. Nurse redressing foot and calling doctor.(sic) - On 1/4/20 at 3:15 p.m. - Res (family member) in today. He is Concerned that (resident) is declining. Res has been hiccupping again this day. Upon assessing res, RLE has +3 [MEDICAL CONDITION]. R foot hs developed 4 fluid filled blisters on top of foot and one blister on sm toe that has popped. There is necrotic tissue present on toe. R foot is seeping large amounts of fluid. Tissue under blisters appears to be very dark below fluid. Foot cleansed with normal saline and super absorbent pads placed on foot, then wrapped with gauze. Foot is elevated at this time. Will send note to provider and wound care nurse. (sic) - On 1/5/20 at 4:00 a.m. - CNA reports that this resident has a temp of 101. Temporal P 110 BP 110/57 R17. Resident is very confused .MD notified, and orders received to transfer to ER for evaluation and treatment. A review of resident #1's hospitalization documentation, dated 1/5/20, showed the following: - Resident #1 was noted to have had confusion, by family, on Friday the third and Saturday the fourth, of January. - (Family Member) saw (resident #1's) right foot yesterday the surface of the little toe was blackened, swollen, and red. Family member was told by nurse they would rewrap toe and get Wound Care involved Monday (the 6th). (sic) - Resident #1 was admitted to the hospital with [REDACTED]. A request for all physician communication for resident #1's length of stay was made on 1/28/20, and no further documentation was provided by the facility. A phone call was placed to staff member F, the floor nurse during the time of resident #1's stay, on 1/28/20 at 3:17 p.m A message was left for a return call. The phone call was not returned.",2020-09-01
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 review of resident #1's Comprehensive Skin Assessment, dated 12/12/19, showed redness to resident #1's coccyx. No other comprehensive skin assessments were provided by the facility for resident #1. A review of resident #1's Progress notes, showed the following: - On 12/12/19, resident #1 had a reddened area on his coccyx. -On 1/2/20, resident #1's, Skin check performed today, and mid coccyx area has a 0.5 cm X 0.5 cm X 0.1 stage 2 pressure sore noted. Area around is sore on bilateral coccyx is slightly macerated, red, scabby and fragile. This area cleansed with NS, patted dry with gauze, Opti foam adhesive placed with [MEDICATION NAME] around other closed areas of skin. Resident reported that it was sore and tolerated the procedure well. Resident then placed in his bed to help alleviate pressure and will plan to help turn and reposition often to relieve pressure and to continue with dressing changes. (Physician) will be notified via fax with this nurse note and TAR updated. (sic) -No monitored skin checks were noted in the medical record from 12/13/19 to 1/1/20 for resident #1. A review of resident #1's Care plan, last revision date of 12/31/19, showed no documentation of resident #1 being at risk for developing pressure sores, and no preventative interventions were noted for the prevention of pressure sores. A review of resident #1's Braden Scale Assessments, showed the following: - On 12/12/19, upon admission resident #1 scored a 16 on the assessment, and the score showed he was at risk for developing pressure sores. -On 12/19/19, 12/26/19, and 1/2/20, resident #1's assessment showed the resident scored a 17, and the score showed he was at risk for developing pressure sores. A review of resident #1's Initial Weekly Wound Documentation Form, dated 1/2/20, showed a Stage II Pressure Ulcer to the middle coccyx, measuring .5 cm x .5 cm x .1 cm, which was intact, macerated, [DIAGNOSES REDACTED], calloused edges, and no drainage. A box for pain associated with the wound was checked on the form. Under wound treatment and pain it showed, Change dressing daily with NS, gauze, [MEDICATION NAME] and [MEDICATION NAME] to bordered areas as needed. A review of resident #1's Physician Order, dated 1/2/20, showed Pressure ulcer of unspecified site, stage 2. Instruction to nursing home. Note to provider: 1) Start burst of [MEDICATION NAME] for back; 2) [MEDICATION NAME] to pressure ulcer in coccyx; 3) Frequent repositioning to off load; 4) Gel cushion (if available); 5) Wound nurse consulted. A review of resident #1's Verbal Physician Order, dated 1/2/20, showed, Assess bilateral coccyx daily and provide wound care: Cleanse with NS, pat dry with gauze to secure. Apply [MEDICATION NAME] to surrounding areas as needed. Discontinued when healed. every shift for Skin Care. A review of resident #1's Treatment Administration Record, showed the following: - In December 2019, resident #1 was to have weekly skin checks. No documentation of skin checks was provided by the facility, but they were initialed as completed on 12/19/19 and 12/26/19. Also, noted with a start date of 12/12/19, and an end date of 12/22/19, was, Please complete assessments. Do not sign off if not finished scheduled for two times a day. Resident #1 was monitored for pain for the month of December 2019 and January 2020. Resident #1 rarely had pain in the month of December 2020 and no pain was indicated on his pain assessments during the month of January 2020. Resident #1 had an as needed order for Tylenol for pain. - In January 2020, resident #1's wound care treatments were documented on 1/2/20 with a skin assessment, however the resident had no documented treatments on 1/4/20 to apply [MEDICATION NAME] to pressure ulcer on coccyx; reapply as needed. Frequent repositioning. A review of resident #1's emergency room Report, dated 1/5/20 showed the following: - (Resident #1) was then seen in the clinic on January 2nd by (Physician). At that time, he was noted to have pressure ulcers starting on his coccyx and buttock with a small, open wound. - Exam of his coccyx, shows an approximately 10 x 12 cm area of [DIAGNOSES REDACTED] consistent with an early pressure ulcer. On the superior aspect there is an area of about 1 to 1.5 cm that is an open wound. A review of resident #1's bathing record tasks for December 2019 and January 2020, showed no task for a bath skin check. A phone call was placed to staff member F, the floor nurse during the time of resident #1's stay, on 1/28/20 at 3:17 p.m A message was left for a return call. The phone call was not returned. 2. During an interview on 1/28/20 at 1:27 p.m., staff member B stated resident #2's pressure ulcer had been going on before her time at the facility. Staff member B stated resident #2's pressure ulcer would heal and then reopen. Staff member B stated resident #2 had recently had a wound nurse consult for the pressure ulcer. Staff member B stated the interventions utilized for prevention of pressure ulcers included an air pressure relieving mattress, and a pressure relieving cushion, for resident #2's wheelchair. Staff member B stated resident #2's wound care order was to cleanse and apply collagen to the pressure ulcer. Staff member B stated the wound is monitored through weekly wound assessments. Staff member B stated resident #2 had an increase in her [MEDICATION NAME] for pain management and receives health shakes for nutritional intervention. Staff member B stated due to resident #2's dementia, staff remind her to reposition herself in her chair. During an interview on 1/28/20 at 2:28 p.m., staff member D stated resident #2 received skin checks every week. Staff member D stated resident #2's treatment was collagen with collagen powder, hoping to thicken the skin that keeps opening. Staff member D stated resident #2 tends to slide on surfaces that cause the wound to reopen. Staff member D stated resident #2 had a pressure relieving mattress and cushion for her chair. A review of resident #2's Initial Weekly Wound Documentation Form, dated 8/23/19, showed resident #2's left buttock had a skin shear measuring 2.5 cm long, 1 cm wide, and .2 cm deep. Resident #2's wound was noted to not have drainage or odor. The wound edges were described as pink and rolled. The wound treatment was noted as, Apply [MEDICATION NAME] Lotion on left buttock 3 times a day with each bowel movement. A review of resident #2's Physician Order, dated 1/21/20, showed, Cleanse area of left buttock with normal saline. Apply collagen to wound bed. Cover site with hydrogel dressing. Change dressing QOD. Discontinue when healed. A review of resident #2's Braden Scale Assessments showed the following: - On 2/28/19, resident #2's assessment score was a 23, which was not at risk for developing a pressure sore. - On 6/3/19, resident #2's assessment score was a 19, which was not at risk for developing a pressure sore. - On 9/3/19, resident #2's assessment score was a 19, which continued as not being at risk for developing a pressure sore. - On 12/2/19. resident #2's assessment score was a 17, and the resident was at risk for developing a pressure sore. A review of resident #2's Skin/Wound Notes showed the following: - On 8/25/19, The left coccyx was shearing and was being treated with [MEDICATION NAME] cream. The documentation did not specify the cause of the shearing noted. - On 9/7/19, Soiled dressing removed from bilateral coccyx today, Wound to L. coccyx remains open with serosanguineous drainage and R. coccyx is very dry with pinpoint opening with serosanguineous drainage. - On 11/28/19, The weekly skin check was not noted to have any issues. - On 12/6/19, RN observed open area on left buttock and redness to right buttock. - On 12/9/19, Resident #2 had no open areas to buttocks. - On 1/1/20, Resident #2's, Bilateral coccyx continues to have irritated/scabbed skin and were cleansed today with NS, patted dry with gauze and [MEDICATION NAME] put in place for protection. Will continue to monitor. (sic) - On 1/15/20, Resident #2 had an Open area noted on residents left buttocks. Size 3 cm x .5 cm. MD notified via fax. Daughter called. No staging of resident #2's pressure ulcer was documented. - On 1/20/20, The open areas are decreasing in size and a dressing was applied. A review of resident #2's Care plan, with a revision date of 3/19/19, showed the following: - A focus for resident #2 as, My skin is intact. I am diabetic which increases my risk for developing pressure related breakdown. - A goal for resident #2 as, I want to keep my skin intact and healthy. - Interventions for resident #2 include, I want staff to monitor for any potential skin breakdown. I am able to reposition myself. I have a pressure redistributing mattress on my bed. No revisions were made to the care plan to reflect the current intervention and treatment to resident #2's current pressure sores. A request for resident #2's Medication and Treatment Administration record for the last three months was made on 1/28/20. No documentation was provided by the facility. A review of the facility's Skin Program Policy, with a revision date of 3/18/19, showed the following: - To ensure a resident who enters a facility with a pressure sore ulcer/pressure injury does not develop unless the residents clinical condition demonstrates that they were unavoidable. To provide care and services to prevent pressure ulcer development, to promote the healing of pressure ulcer/wounds development of additional pressure ulcers/wounds. - 1. On admission a baseline assessment of a resident's skin status will be completed within two hours of admission. It is recommended to repeat weekly x4. This will include a physical exam of the resident's skin, a risk assessment using a Risk Assessment tool, and a comprehensive assessment of the resident's history and physical condition. A temporary plan of care (POC) will be put into place for residents that are identified at-risk for breakdown. - 4. Nursing personnel will utilize the results of the physical exam and the Pressure Ulcer Assessment tools to determine an individualized pressure ulcer prevention program for each at-risk resident. This will include interventions to: a) Protect skin against the effects of pressure, friction, and shear; b) Protect the skin from moisture; . f) Immediate prevention plan instituted when potential areas are identified. - 7. Nursing personnel will develop a POC with interventions consistent with resident and family preferences, goals and abilities, to create an environment to the resident's adherence to the pressure ulcer prevention/treatment plan. POC to include; Impaired mobility, Pressure relief, Nutritional status and interventions. Incontinence, Skin condition checks, Treatment, Pain, Infection Education of resident and family, Possible causes for pressure ulcers and what interventions have been put in place to prevent. Skin checks are to be completed at least weekly by a Licensed Nurse. - 10. Monitoring results will be brought to the IDT workgroup (Pressure Ulcer team) who will meet to review current practices, assessment tools and schedules and to identify person(s) responsible for monitoring .",2020-09-01
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 resident #1 showed: -NF4 had not been notified by the facility of the incident that occurred on [DATE]. -NF3 reported concerns about resident #1 to NF4 on [DATE], after the resident was no longer at the facility. -The report showed that the facility had contacted the hospital and informed the hospital staff they would not accept the resident back at the nursing home. -The resident was not allowed back on the facility's premises, therefore, the facility would not accept the resident as return resident. When resident #1 was discharged from the hospital on [DATE], he did not have shoes, and did not have a location to live. -NF3 had came to the facility, and obtained the resident's shoes, and he then found the resident shelter. -The report reflected that the resident did not have placement assistance from the hospital or any discharge follow up care in place by the facility. The resident had been released into the community without any support. During an interview on [DATE] at 9:45 a.m., staff member B stated that the facility had discharged resident #1 right away. Staff member B also stated the facility staff had heard resident #1 had gone to the hospital, but the facility staff had not been notified of this. Staff member B stated that she thought the resident did come back to the facility later (with NF3) but would not come inside to get his personal items. During an interview on [DATE] at 2:30 p.m., NF4 stated that she was a case manager for resident #1 for a long time when he resided in the community. NF4 said that resident #1 was not known to be an aggressive person and it was out of character for him to be a drinker. NF4 wondered why the resident had not been checked for an infection, prior to his discharge, referring that this may have been the cause of the resident's behavior change. During an interview on [DATE] at 4:45 p.m., staff member P stated that resident #1 would not calm down and wanted to leave. Staff member P attempted to talk to resident #1 on [DATE], but the resident did not make sense. Staff member P told the resident he could leave but it would be AMA (against medical advice). The medical record did not show attempts of the facility to set up community services for ongoing care. During an interview on [DATE] at 9:05 p.m., staff member Q stated the resident thought the staff were stealing from him. He began to bring his clothes up and stack them by the handicap door to load them into his van. Staff member Q stated the resident said I will kill anyone who tries to stop me. The resident did not target anyone specifically, he just thought staff were going to detain him. He was able to read his rights from the Resident Right's board and the staff all agreed he had a right to leave. The facility had not addressed the resident's change, or concerns with his not making sense to ensure the change was not potentially a contributing factor in the resident's drive to leave to leave the facility, in an attempt to ensure safety. Review of resident #1's nurses' Progress Note dated [DATE] at 2:21 a.m., staff member P had wrote that staff member B was phoned a second time, updated on the situation, and staff member P was advised to call the physician. The physician on call was reached and staff member P had explained the situation occurring with the resident, as it occurred. Staff member B was notified a third time, updated on the situation, and staff member P was instructed to document the events. Review of another nurses' Progress Noted dated [DATE] at 8:48 a.m. showed resident #1 was unwilling to consent to an assessment. At 8:30 a.m. that same date, a peace officer was given resident #1's medication administration sheet and medications. No welfare check by the facility was initiated. Review of resident #1's Care Plan, with last review date of [DATE], showed under the Focus area: Behavior - The resident had exhibited rage which is evidenced by yelling and shaking fists when he became overwhelmed and does not comprehend complex questions. The intervention was to offer reassurance and attempt to redirect me when I am exhibiting indicators of psychosocial distress and notify nurse. Also, under the Focus area: Discharge Planning - showed the resident elected to stay at the facility for long term placement as his needs could not be met in the community. The last revision date was [DATE], and this was documented by staff member C. Information was requested for the incident that occurred on [DATE], and discharge information relating to the resident, which had not yet been provided. The following information was not received prior to the end of the survey: - A discharge order from the physician - A discharge summary - A discharge plan, or a follow up discharge plan. During an interview on [DATE] at 2:50 p.m., NF1 stated she was not notified of the resident's discharge from the facility, which took place on [DATE]. During an interview on [DATE] at 11:20 a.m., staff member C stated that if the resident had remained in the hospital on [DATE], she would have followed up with the resident to assist with a discharge plan. Since the incident happened over the weekend, and it happened so quickly, the situation did not allow time for her to complete this. The investigation showed the resident had expired after a motor vehicle accident on the early morning of [DATE].",2020-09-01
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., staff member J stated the resident's clothing was passed on Tuesday, Thursday and Friday. Staff member J stated the resident did have clean clothes to include sweat bottoms and shirts. Staff member J stated if a resident doesn't have any clothing the CNA caring for that resident would come and let her know and she would make sure the resident had clothing to wear. Staff member K joined the interview and stated the residents should always have clothing in their closets available to wear. Staff member K stated she was not aware that residents had complained about not getting their laundry in resident council. Staff member K stated the policy and procedure was the CNA would report to the Social Service director and the Social Service director would complete a grievance or just report the concern to the laundry. Staff member K stated the facility would consider delivering resident clothing daily. During an observation of a resident group meeting held on 10/11/17 at 10:50 a.m., several residents voiced the concern that it was taking too long, up to 7 or 8 days, for laundry staff to return clothing items to the residents after they were washed. 2. A review resident #9's MDS, with an ARD of 7/7/17, showed she had a BIMS score of 15 coded on the assessment, which was cognitively intact. During a resident group meeting, held on 10/11/17 at 10:50 a.m., resident #9 stated that in some cases missing clothing items have not ever turned up again. She says after an unsuccessful visit to the laundry, when she did not find her missing clothing, she was eventually reimbursed for a few of her items by the facility, with the help of the facility's activity director. 3. A review of resident #11's MDS, with an ARD of 10/31/16, showed she had a BIMS score of 15, cognitively intact. During a resident group meeting held on 10/11/17 at 10:50 a.m., resident #11 stated that she had been missing a pair of jeans after she had sent them to the facility laundry. Several weeks went by and she saw another resident in the facility wearing the jeans. She said she recognized them by the several tiny holes she knew her jeans had. After she complained to the facility, it was arranged for her to get her jeans back. She found her name, as she had written it, on the label inside her jeans: but, underneath it, the resident who she saw wearing her jeans had written her name also. She said she questioned whether any staff efforts were being made to return laundry items to their correct owners. She stated all clothing is suppose to be labeled with the resident owner's name.",2020-09-01
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 same time and day every month. She said she wanted the facility staff to verbally remind all of the residents, before scheduled resident group meetings, that they were invited to attend. During an interview on 10/11/17 at 11:45 a.m., NF1 stated that the prior facility administration had a history of [REDACTED]. She said the prior administrator said residents had to have a certain level of mental capacity and ability to verbally communicate to be able to participate in the group resident council. She said that staff members were told by the administrator which residents to invite to the resident group meetings. She said staff had been told not to make resident group council meetings a priority. NF1 expressed concern that staff members remaining in the facility, as a part of the present administration, would continue to sort of have the same attitude. A review of the Resident Council Minutes for the months of (MONTH) through (MONTH) of (YEAR), showed six residents attended on 5/11/17; five residents attended on 6/15/17; six residents attended on 7/13/17; three residents attended on 8/17/17; and four residents attended on 9/28/17. On 10/10/17, the facility had a total of 36 residents.",2020-09-01
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 of a lack of staff several times and had never received any feedback as to whether anything was planned to be done about it. He also said that he was getting tired of being told that requests for additional activities or attention to cares would not be considered at this time due to the lack of staff. A review of the monthly resident group council meeting minutes, for the months of (MONTH) through (MONTH) (YEAR), showed minimal documentation of the concern areas expressed by residents. How many residents were affected by the concerns was not mentioned. The documentation did not show to whom the concern was communicated to, when or if investigations of problems were conducted, and whether or not resident questions were provided a response. There was no indication to show the prior month concerns had been addressed and resolved to the satisfaction of the residents. During an interview on 10/12/17 at 11:00 a.m., staff member [NAME] said she attended the resident group council meetings for the purposes of taking the meeting minutes. She said she was also responsible for investigating the residents' concerns and communicating them to administration and other appropriate facility department directors as needed. She also said she did the follow up and reporting back to the residents about their concerns. She said she did not have written documentation on any of these activities except for the meeting minutes. During an interview on 10/11/17 at 11:45 a.m., NF1 stated that the prior facility administration had a history of [REDACTED]. She said staff had been told not to make resident group council meetings a priority. NF1 expressed concern that staff members remaining in the facility as a part of the present administration would continue to have the same attitude. During an observation and interview of the resident group meeting held on 10/11/17 at 10:45 a.m., a consensus was determined amongst the residents, to invite a member of the facility's administration to a resident group council meeting for the purpose of making sure resident complaints were heard. This occurred after residents discussed amongst themselves a need to meet face to face with administration to have someone they could hold accountable for responding to their concerns.",2020-09-01
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,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 that Resident #4 no longer needed to be supervised while he was in his Broda chair. She explained that originally the resident had a Broda chair that was much too large for him, and he slipped down and fell out of it often. She said the resident was using a different Broda chair, one made to fit him, and he no longer had falls. When she was shown the resident's care plan regarding the need to transfer the resident to a recliner and not leave him unsupervised in his Broda chair, she stated resident 4's care plan should have been updated a long time ago. She said his care plan did not show that the resident's physical condition had improved since his readmission on 4/14/17.",2020-09-01
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 inappropriate and he makes false accusations. She was unable to explain why resident #4 did not receive catheter irrigations every day, as ordered, for the period between 9/1/17 and 10/10/17. She stated that if a resident refuses a procedure it was supposed to be recorded as a refusal by signing the MARS box with a 2 and there was no documentation present to show the resident had refused treatment. An interview on 10/12/17 at 8:55 a.m., staff member A said resident #4 had a UTI on readmission on 4/14/17 that was treated and resolved. A repeat urine specimen on 4/26/17 showed a repeat UTI that was again treated [MEDICATION NAME] resolved. She said resident #4 had only one UTI since he was readmitted . During an interview on 10/12/17 at 11:10 a.m., staff member I stated she did not know why resident #4 had not received catheter irrigations as ordered by his physician. She stated it was one employee that had not provided the irrigations on her shifts. She also said the employee was no longer employed by the facility and would not be available for survey interview. 2. Review of resident #8's treatment administration record reflected an order to assess the resident's lung sounds before and after meals for seven days. The order start date was 10/5/17. The treatment administration record did not include documentation that the assessment had been done on the following days and times: 10/6/17 at 8:00 a.m., 12:00 p.m. and 6:00 p.m. 10/7/17 at 12:00 p.m. and 6:00 p.m. 10/8/17 at 6:00 p.m. 10/9/17 at 12:00 p.m. and 6:00 p.m. 10/10/17 at 8:00 a.m., 12:00 p.m. and 6:00 p.m. 10/11/17 at 6:00 p.m., and 10/12/17 at 8:00 a.m. Review of resident #8's nursing progress notes did not include documentation of the resident's lung assessments for the dates and times listed above. Review of resident #8's speech therapy progress notes, dated 9/27/17 at 2:29 p.m., reflected, consult with NSG to update on swallow precautions. Printed swallow precautions list for pt (patient) was faxed to B (facility) at 1:00 p.m. Pt will be seen to evaluate tomorrow. Review of a speech therapist progress note, dated 10/4/17 at 12:54 p.m., for resident #8, reflected, Data sheets were provided to NSG staff to document lung sounds and temperatures as well as other comments regarding signs of aspiration during each meal of the day over the next week. During an observation on 10/11/17 at 8:00 a.m., resident #8 was sitting at a table where other residents were assisted to eat. Resident #8's family member was seated next to him and encouraging him to eat. Staff were observed to guide resident #8 in chewing his food and swallowing before he placed more food in his mouth. Resident #8 was eating without noted difficulty at the time of the observation. During an interview on 10/12/17 at 8:50 a.m., staff member G stated the nurses were to check lung sounds after each meal and snacks. Staff member G stated she was not sure where the documentation was in the electronic medical record for the monitoring. During an interview on 10/12/17 at 9:15 a.m., staff member L stated the CNA charts in the medical record have the percent of each meal eaten, but the program did not have an area that CNA staff could document if the resident had symptoms of dysphagia such as choking, coughing, or emesis. Staff member L stated if he was assisting resident #8 and observed symptoms of dysphagia he would report the concern to the nurse. During an interview on 10/12/17 at 10:45 a.m., staff member M stated resident #8 received a soft regular diet and no bread as the bread was causing most of the choking. DeLaune, S. & Ladner, S., Fundamentals of Nursing, Standards and Practice, Albany, NY., (1998), pg. 237. Nurses are obligated to follow the orders of a licensed physician or other designated health care provider unless the orders would result in client harm.",2020-09-01
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,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 twice a week. 3. A review of the facility's resident Bath Schedule showed resident #5 was scheduled to receive a shower/bath once a week on Fridays. A review of resident #5's documentation showed she received a shower/bath on 9/2/17, after 16 days she received a second shower/bath, and after 12 more days she received a third shower/bath. The resident's record lacked evidence of the showers or baths provided once a week.",2020-09-01
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,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 of. - [DATE]; one staff member signed on page 11 when the [MEDICATION NAME] was disposed of. - [DATE]; one staff member signed on page 11 when the [MEDICATION NAME] was disposed of. During an interview on [DATE] at 12:54 p.m., staff member M stated two licensed staff members should always witness the destruction of a [MEDICATION NAME]. Staff member M stated two signatures were required to prevent medication diversion. During an interview on [DATE] at 1:22 p.m., staff member B stated she should have had a licensed staff member witness the disposal and destruction of a replaced [MEDICATION NAME] for resident #31. Staff member B could not recall why two signatures had not been obtained. During an interview on [DATE] at 1:56 p.m., staff member [NAME] stated staff did not always follow the policies and procedures with co-signing the destruction of [MEDICATION NAME]es, but staff should have. Review of the facility's policy, Disposal/Destruction of Expired or Discontinued Medications, read, .10. Facility should record destruction of controlled substances on: 10.1 Medication Disposition/Destruction Form; 10.2 Controlled Substance Count Form; or, 10.3 Medication Destruction Log Book .12.1 Facility should destroy (Scheduled II-IV) controlled substances in the presence of a registered nurse and a licensed professional in accordance with Facility policy or Applicable Law. 12.2 Destruction of controlled medications should be documented on the controlled medication count sheet and signed by the registered nurse and witnessing licensed professional who should record: 12.2.1- Quantity destroyed; 12.2.2- Date of destruction; and, 12.2.3- Signature of registered nurse and pharmacist. References: http://www.sahealth.sa.gov.au/wps/wcm/connect/eefc0c804dec81cab734ff6d722e1562/Circ+[MEDICATION NAME].pdf?MOD=AJPERES 4. Disposal process is recorded in the drug of dependence register, and countersigned by the witness.",2020-09-01
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 include the presence of a Stage II pressure sore. It showed a Braden score of 20, meaning no risk factors for the developing a pressure sore. During an interview on 11/15/18 at 12:20 p.m., NF1 stated she was not sure why resident #20 developed a pressure area, but guessed it was from not getting cleaned up adequately. During an interview on 11/15/18 at 1:08 p.m., staff member [NAME] stated she did not know why resident #20 developed a pressure area with out reviewing his chart. She stated the facility should have had an initial skin assessment report, and completed a weekly assessment until resolution of the pressure area.",2020-09-01
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,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,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 resident rinse her mouth with water and spit after use of the [MEDICATION NAME]. During an interview on 11/15/18 at 8:30 a.m., staff member C stated she was not aware resident #35 needed to wait 60 seconds between puffs of the [MEDICATION NAME]. Staff member C stated she was not aware resident #35 should have rinsed and spit with water after inhaling the [MEDICATION NAME] MDI. Review of the facility's policy, General Dose Preparation and Medication Administration, read, .5.7- Provide the resident with any necessary instructions (e.g., using an inhaler); 5.8- Follow manufacturer medication administration guidelines. Review of the facility's policy, Medication Administration and Ordering, read, 1. The nurse or TMA/CMA administering a medication is responsible for knowing: a. Nature of medication .f. Factors that affect or modify action of medication.",2020-09-01
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,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 [MEDICATION NAME] were not in it . (sic) Review of the facility Abuse Policy, dated (MONTH) (YEAR), showed the following for reporting allegations of abuse: [NAME] Reporting and Response: It is the policy of (facility name) that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and Montana State Law. (Facility name) will ensure that all alleged violations involving abuse, neglect, elopement, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported. Abuse is reported no later than 24 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do no result in serious bodily injury, to the Director of Nursing or designee of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident at (facility name) .",2020-09-01
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 resident #76's Non Fall Incident Report, dated 2/16/19, showed, under #7 Incident type: Smoking in bathroom, with a description of Nurse found elder had been smoking in bathroom and confiscated items after explaining policy. Notified Security. Review of a facility email, dated 2/18/19, from the DON to Administrator, showed resident #76 had been spoken to regarding the seriousness of smoking in the bathroom. The email showed resident #76 understood the concerns, and what the DON and Administrator has spoke to him about. Review of resident #76's care plan, dated 11/18, showed no problem areas, goals, or interventions that addressed the safety concerns regarding the resident smoking in the bathroom. 2. During an interview on 3/8/19 at 12:15 p.m., staff member K said she completed the Resident History and Preferences LTC Form for all the residents on the TCN. The staff member said the information in this form was added, by her, to section F of the comprehensive MDS. Staff member K said she would write an activities care plan for TCN residents if indicated. Staff member K said if residents needed reading material or something similar, she would get it for them. Staff member K said no directed activity program was provided on the TCN. Staff member K said she had not written an activity care plan for resident #125 because concerns with activities had not triggered on Section V of the Admission MDS. Review of resident #125's The Resident History and Preferences LTC Form, dated 2/1/19, showed it was very important for the resident to participate in group activities, and somewhat important to do favorite activities. Review of resident #125's Admission MDS, with an ARD of 2/8/19, Section F, F0500, Interview for Activity Preferences, showed it was somewhat important for the resident to participate in group activities and very important for her to do her favorite activities. This information did not coincide with the 2/8/19 Admission assessment. Review of resident #125's comprehensive care plan failed to address the resident's need for an activities program, although the resident felt it was important to participate in group and favorite activities.",2020-09-01
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 interested in trialing an antidepressant, and Her family also brought in a coloring book to help keep her mind busy and preoccupied. The physician's progress note also showed [MEDICATION NAME] 25 mg was started for the resident. Review of resident #100's physician's progress note, dated 2/6/19, showed, Discussed with nursing and feels patient is slightly depressed. Explained that she is encouraged to leave her room on occasion. For example to go look at the birds in the main lobby, watch the SuperBowl game this last Sunday, etc. Patient, however, prefers to stay in her room. Does not watch tv. Often seen sleeping. Discussed with patient and she states that her mood is stable, she just isn't used to not being active. She used to be a very active/busy person. She reports the more inactive she is the easier it gets to just sit around. We discussed increasing her [MEDICATION NAME] to 50 mg qhs. She is in agreement with this plan. Will start this tonight. Review of the resident #100's The Resident History and Preferences LTC Form, dated 1/10/19, showed it was very important for the resident to do group activities and to do her favorite activities. Review of resident #100's Admission MDS, with an ARD of 1/17/19, Section F, F0500, Interview for Activity Preferences, showed, it was not very important for the resident to participate in group activities, and it was somewhat important to participate in her favorite activities. The information varied from the assessment completed seven days prior. During an interview on 3/8/19 at 10:32 a.m., staff member A said the TCU was a short stay unit. The usual length of stay was about 20 days. The staff member said social services did a short assessment on admission regarding resident preferences, and we address those as appropriate. Staff member A said the residents were in the TCU for intensive therapy, and they would be too tired to participate in an activities program. Staff member A said, I do not feel it was worth having an activity staff for the TCU, or was it was a good use of resources, for an area (the residents) that would not participate in activities. During an interview on 3/8/19 at 12:15 p.m., staff member K said the facility did not provide directed activities for the TCN unit residents.",2020-09-01
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 medication on the MAR, so we can look at that to see what was administered. If there is a discrepancy we investigate. Staff member C stated if she would need to make a recommendation to administration regarding policy, she would not recommend counting all controlled medications, it would take too much time. During an observation and interview on 3/7/19 at 1:33 p.m., staff member [NAME] demonstrated the current system of keeping track of Schedule III-V medications, as only Schedule II medications are counted each shift. Staff member [NAME] first demonstrated the system for [MEDICATION NAME] scheduled TID. The process included: - There were three cards, each card had originated with 30 tablets, with a corresponding label for morning, noon and evening doses. - For the month of (MONTH) (2019), the medication was started on the 22nd, so that date was circled. - The month of (MONTH) ended on the 28th (due to the number of days in the month), so on (MONTH) 1st the nurse would move down to #1 on the card. - Because there are two left over pills from the 29th and 30th of (MONTH) 2019, staff member [NAME] stated, You would use those pills before starting a new medication card, which would end up being on the 24th of (MONTH) (2019). Staff member [NAME] stated, If I dropped one, I would either go to the 29th or 30th and use one of those pills, or if there were no left over pills, I would go to the start date and one back. Staff member [NAME] said, If a pill was taken from the wrong card, the staff would either replace the pill and tape the back of the card, or go to another card and take a pill from it. Staff member [NAME] stated, I write on the card the date I removed the medication and why. Some (nurses) don't write on the card. For medication that is scheduled PRN, staff member [NAME] stated, You really have no way of knowing if the count is accurate. Staff member [NAME] stated the information passed on, in report, and knowing your resident, would hopefully give you a red flag (alert), but if the medication wasn't used often, you wouldn't recognize a discrepancy timely. Staff member [NAME] stated the on-coming nurse would not know if the total number of tablets was accurate for any of the Schedule III-V medications when they started their shift, because they do not count them. During an interview on 3/7/19 at 1:20 p.m., staff member D stated, If I dropped a pill, I would waste it and get a new one by going backwards one, from the start date. I would verbally pass it on to the next shift. I don't routinely write on the card. During an interview on 3/8/19 at 8:01 a.m., staff member B described the process of accountability for Schedule II medications, and the double check process. When discussing the process of accountability for Schedule III-V medications, staff member B said the pharmacy knew the date the medication was started, and, We circle that on the card. Staff member B stated, If somebody sends that card back too quickly (to pharmacy), the pharmacy would know that. We have great accountability. Staff member B stated if a medication was refused, or needed to be wasted, it would be documented. Staff member B stated, I would have to double check for you, I don't know if wasting is documented on the MAR or somewhere else. I think they write on the back of the bubble pack. Staff member B stated if there were two [MEDICATION NAME] (contracted nurses working) in a row, a discrepancy wouldn't be identified until the next shift when a facility nurse worked. Then, the facility would immediately start an investigation. When asked how the facility would be alerted that PRN medications were missing, staff member B stated, You would discover it when you needed it. It may not be timely. Staff member B stated the facility would have to go back to the MAR and count how many times the medication was given. A review of the facility Medication Pass Procedure, which was not dated, showed, If a medication is dropped or contaminated, mark on bubble pack that it was destroyed/wasted and then take pill from earliest remaining date on the bubble pack to replace current dose .",2020-09-01
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 observation and interview on 3/6/19 at 1:10 p.m., staff member P demonstrated the location of a card of PRN [MEDICATION NAME]. The card was located in the main compartment of the medication cart with the non-scheduled medications. Staff member P stated, We were taught that only narcotics get locked and counted, not [MEDICATION NAME]. Only things like [MEDICATION NAME], and [MEDICATION NAME] get locked and counted. During an interview and record review on 3/7/19 at 10:00 a.m., staff member C stated that Schedule III-V medications are in a different category than Schedule II medications and there are different dispensing laws for Schedule II medications. When discussing if the facility practiced double locking all controlled substances, staff member C stated, I believe they are. Staff member C stated, I would recommend to double lock Schedule III-V medications if we were meeting to determine policy. Staff member C said the facility had one episode of missing controlled substances reported to the DE[NAME] Review of the facility document, Loss of Controlled Substances at (facility name), not dated, showed an outline of an investigation for the loss of twenty eight [MEDICATION NAME] tablets, and [MEDICATION NAME], on 11/16/18. During an observation on 3/7/19 at 1:33 p.m., three, pre-filled cards of [MEDICATION NAME] 50 mg TID, were found in the medication cart. Each card held up to thirty tablets, and were labeled with a sticker indicating the time of day the card was to be used. The cards with the [MEDICATION NAME], a Schedule IV medication, were located with the other non-scheduled medications in the cart, and were not separately locked. During an interview and observation on 3/8/19 at 7:40 a.m., staff member I stated the long term care cottages did not count [MEDICATION NAME] ([MEDICATION NAME]), [MEDICATION NAME], or [MEDICATION NAME] as narcotics, and were not counted at the change of shift. The staff member stated these medications were located in the residents' rooms, along side non scheduled medications. The staff member showed where the narcotics were located in the nurses room, in a stationary cupboard, inside a locked closet. The staff member stated for the medications discussed, if there was a physician's orders [REDACTED]. The cupboard had a single lock. Staff member I stated the facility was the only place where she had worked that did not require the above named medications be counted during shift change. During an interview on 3/8/19 at 8:01 a.m., staff member B said the facility did not double lock Schedule III-V medications because the DEA has different dispensing rules for those medications, than for Schedule II medications. Staff member B said the facility double locks and counts every Schedule II medication, each shift. In reference to the Schedule III-V medications, staff member B stated, There are only nurses and med aids, and they are not messing with narcotics at all. Staff member B said she misspoke the other day (3/7/19), when she said they did not have any issues with missing medications. Staff member B described the incident of missing [MEDICATION NAME] and missing [MEDICATION NAME], which occurred on 11/16/18, stating the facility investigated the incident and reported it to the DE[NAME] A review of the facility document titled Loss of Controlled Substances at (facility name), not dated, showed, It is the consensus of the DON, HR Director and Pharmacy Director that the [MEDICATION NAME]/APAP and [MEDICATION NAME] are lost. They do not suspect theft because of the long term employment of the staff members involved and the solid answers they gave during the interview which were consistent with the available security video. As a result, police were not called, but a DEA 106 for (sic) is being submitted. Review of facility policy titled Ordering And Receiving Controlled Medications, dated 10/1/12, showed, The pharmacy dispenses medications listed in Schedules II, III, IV and V in readily accountable quantities and containers designed for easy counting of contents Medications listed in Schedule III, IV, and V are stored under single lock. Alternatively, in a unit dose system, Schedule III, IV and V medications may be distributed with other medications throughout the cart, while Schedule II medications are kept under double lock.",2020-09-01
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,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 saturation was measured at 88% on room air. -On 6/30/19 resident #238's lungs were noted to have had crackles at the bases of both her lungs. Resident #238's oxygen saturation was measured at 88% on room air. -On 7/1/19 resident #238's cough was described as barking, productive, spontaneous, strong, and able to clear secretions. Resident #238's left lung was noted to have an expiratory wheeze. Review of resident #238's Physical Therapy Long Term Care Progress Notes, showed the following: - On 6/27/19, Pt (patient) desaturation to 87 after ambulation . - On 6/29/19, Pt (patient) continues to be on 1L of oxygen with activity. Review of resident #238's Care Management Progress Note, dated 7/2/19, showed resident #238 was sent to the emergency room related to, .increased [MEDICAL CONDITION] today and needing more supplemental oxygen, and persistant cough. She was admitted to (hospital) for acute [MEDICAL CONDITION] secondary to heart failure exacerbation. A request on 8/22/19 at 12:15 p.m., for physician communication and visit documentation of resident #238 was not provided by the facility.",2020-09-01
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 not notify the resident or resident's representative of a transfer to the hospital, in writing. 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 11:00 a.m. and 8/22/19 at 9:08 a.m., for the written transfer notification documentationfor resident #22 was not received from the facility. 3. During an interview on 8/22/19 at 9:18 a.m., staff member M stated she did not know what they currently do for transfer notifications for residents or resident's representatives. During an interview on 8/22/19 at 10:03 a.m., staff member A stated the facility had not been doing the transfer notifications right and had skipped the regulation all together. Review of resident #135's Progress note, dated 7/12/19, showed, Son (Name) notified of decline of condition and to be sent to the hospital. A request on 8/21/19 at 11:00 a.m. and 8/22/19 at 9:08 a.m., for the written transfer notification for resident #135 documentation was not received from the facility. 4. During an interview on 8/22/19 at 9:28 a.m., staff member L stated upon transfer to the hospital the facility calls the resident's representative and documents it in the electronic record. Review of resident #238's Care Management Progress Note, dated 7/2/19, showed resident #238 was hosptalized on [DATE]. A request on 8/22/19 at 9:08 a.m., for the written transfer notification documentation for resident #238 was not received from the facility. Review of facility's Transfer and Discharge Policy, dated (MONTH) 2008, showed the following: - When (Facility) transfers or discharges a resident under any circumstances above, the resident's clinical record will include the documentation by the resident's physician as to why transfer or discharge is necessary according to (a),(b), and (e) above. Documentation regarding transfer or discharge for any reason will be done by the nurses in the resident's clinical record. - The resident and/or the legal representative will be notified of the transfer or discharge thirty (30) days before the transfer or discharge is to take place except if health or safety is endangered due to medical needs. - The written notice will include the reason for transfer or discharge, the effective transfer or discharge, the location being transferred or discharged to, and the right to appeal the transfer or discharge .",2020-09-01
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 11:00 a.m. and 8/22/19 at 9:08 a.m., for bed hold information notification documentation on resident #22's most recent hospital transfer was not received from the facility prior to the end of the survey. 3. During an interview on 8/22/19 at 10:03 a.m., staff member A stated the facility had not been doing the bed hold notifications right and had skipped the regulation all together. Review of resident #135's Progress Note, dated 7/12/19, showed, Son (Name) notified of decline of condition and to be sent to the hospital. A request on 8/21/19 at 11:00 a.m. and 8/22/19 at 9:08 a.m., for bed hold notification information documentation on resident #135's most recent transfer to the hospital was not received from the facility. Review of the facility's Bed hold Policy Readmission Policy, dated (MONTH) 2019, showed the following: -Due to the excellence in care that our nursing facility provides to its residents and patients, it is not uncommon for our facility to be 98%-100% full. Therefore, some of our future and existing residents elect to pay bed holds when not occupying beds in order to ensure that these beds will be available when entering or returning to our facility. -No mention of notification of the bed hold information given to resident or resident's representative upon transfer to the hospital was addressed within the policy document.",2020-09-01
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 9:07 a.m., resident #76 was taking medications which were in four small medication cups. Resident #76 had taken pills during the interview from at least two of the four medication cups. No facility staff was present in the room during this interview. The resident took the medications unsupervised by facility staff. During an interview on 8/22/19 at 9:14 a.m., staff member B stated nurses were administering the medications. She stated the resident was not self-administering the medications because they were prepared by the nurse. Review of resident #76's medical record did not show any assessments regarding her ability to self-administer medications. Review of resident #76's physician orders, dated (MONTH) 2019, did not show an order for [REDACTED].",2020-09-01
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 NAME]. No mention of the use of lorazapam was found. Review of resident #30's Nursing Home Annual Assessment, dated 7/30/19, showed, .6. (A) Patient has chronic depression and anxiety, .Continue [MEDICATION NAME] 100 mg daily and [MEDICATION NAME] . There was no documentation related to the continued use of [MEDICATION NAME] on an as needed basis. Review of resident #30's MAR, dated (MONTH) 2019, showed [MEDICATION NAME] 0.5 mg had been given 14 times between 8/4/19 and 8/21/19.",2020-09-01
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 note showed, Nursing to administer meds while pt. @ TCN. (sic) All self-administration of resident #23's medication assessments were requested. No documention was provided prior to the end of the survey. Review of resident #23's physician orders, dated (MONTH) 2019, failed to show any documentation regarding 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.",2020-09-01
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 stated, The night nurse does the checking for expiration dates and the resource nurse checks the carts when she comes through. Last time she checked the dates was 8/19/19. During an interview on 8/21/19 at 12:48 p.m., staff member I stated the procedure was to have the expiration date on both the Ziplock bag that holds the syringe, and the barrel of the syringe. Staff member I stated, The usual pharmacy tech that works was on vacation. Staff member I stated if expiration dates were missing, her expectation, was to be notified. During an interview on 8/21/19 at 1:30 p.m., staff member I stated the medications with a missing expiration date label, had been fixed, and no residents had received expired medications. 2. During an observation on 8/21/19 at 2:05 p.m., in the Transitional Care Cottage, one bottle of Metaxalone 800 mg showed no expiration date. The bottle was labeled with the name of resident #117. During an interview on 8/21/19 at 1:48 p.m., staff member J stated, We look for expired meds one time a month. 3. During an observation on 8/21/19 at 2:25 p.m., in the Hansen Cottage, the following occurred: -four syringes, in one Ziplock bag, of [MEDICATION NAME] 20 mg/ml, filled to 1 ml, showed no expiration date on the syringes or the pharmacy label attached to the Ziplock bag. The Ziplock bag was labeled with the name of resident #105. -15 syringes, in one Ziplock bag, of [MEDICATION NAME] 20 mg/ml, filled to 1 ml, showed no expiration date on the syringes or the pharmacy label attached to the Ziplock bag. The Ziplock bag was labeled with the name of resident #105. -five 21 guage x one inch needles showed an expiration date of 3/18. -three 21 guage x one inch needles showed an expiration date of 1/19. -four 23 guage x one inch needles showed an expiration date of 9/18. -one female catheter showed an expiration date of 3/31/19. -one Ultrasite injection site supply showed an expiration date of 1/18. -five IV Ultra pac showed an expiration date of 1/18. -one IV universal showed an expiration date of 9/18. During an interview on 8/21/19 at 2:47 p.m., staff member K stated the resource nurse was in the cottage last night, 8/21/19, checking expiration dates.",2020-09-01
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 accessible and located as close to the immediate area where sharps are used or found. -Maintained upright throughout use. -Replaced routinely and not be allowed to overfill. -When moving containers of contaminated sharps from the area of use, the container will be: -Closed immediately prior to removal to prevent spillage or protrusion of contents. -Place in a secondary container if leakage is possible.",2020-09-01
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 cabinet housing the dish sanitizer in the transitional care unit's kitchen, was torn off and missing. The surface was rotted and uncleanable. The floor along the edge of the sanitizer was covered in a heavy accumulation of dirt and food debris. Staff member L was asked about the procedures for notifying the maintenance staff for concerns and issues. Staff member L stated they notified the maintenance via an email. She said she notified the maintenance about a month ago about the damaged cabinet. 4. During a fire safety tour observation and interview with staff F on 11/7/17 at 10:09 a.m., the east exit door in the Liggett cottage was warped and prevented a proper seal (light shining through the gaps) at the top and along the door and the frame, creating a potential for improper pest control. Staff member F, who accompanied the surveyor, stated the maintenance department would be notified. 5. During a fire safety tour observation and interview with staff F on 11/7/17 at 12:10 p.m., the west exit door in the Jensen cottage lacked a proper seal with the door frame, creating a potential for improper pest control. The light shone through the gaps between the door and the door frame. Staff member F stated the door would be repaired.",2020-09-01
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 summary score, when 99 (unable to complete the interview) should have been entered as the summary score. During the same interview on 11/7/17 at 3:35 p.m., staff member [NAME] said resident #19 was unable to complete the PHQ9 mood assessment using direct interviewing. Staff member [NAME] said she completed the mood assessment using general conversation with resident #19. She said that resident #19 would not have been, and was not, cooperative with answering questions, and that resident #19 tended to be suspicious of people. Staff member [NAME] said she used her knowledge of resident #19 to fill out the information on the mood assessment. An error was made when filling out the mood assessment as the resident, rather than as a staff member.",2020-09-01
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/dorsal foot, 3.3 cm x 3 cm. Elder wearing regular cowboy boots per his preference. Elder advised by medical staff boots can worsen Charcot's foot and cause pressure injury. Elder often refuses to remove boots. The intervention was to leave open to air, and monitor every 24 hours. During an observation and interview with staff O on 11/8/17 at 12:40 p.m., resident #12 was sitting in his recliner, with his boots off. He stated the nurse was going to take care of the sore on his foot. His [NAME] Hose had bloody drainage on it. Staff member O came in to clean the pressure sore, and covered it with a dressing. She stated it was now a Stage II pressure ulcer, and about the size of a quarter. During an interview on 11/8/16 at 12:10 p.m., staff member H stated the area had been charted as a bruise to the foot. She stated if the boots were the cause, the area would have developed long ago. She said the facility attempts to have one nurse look at skin issues, so the same pair of eyes see the progression, but staff do not have specific wound education.",2020-09-01
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 10/4/17, showed no risk factors or interventions were marked on each form. During an interview on 11/7/17 at 8:35 a.m., staff member H stated the Fall Data form and the Comprehensive Fall Management Program form, replaced a fall care plan. Review of resident #10's Physician Orders, dated 11/7/17, showed resident #10 received a routine antianxiety, twice a day. During an interview on 11/8/17 at 9:05 a.m., staff member H stated the facility addressed the medication as a possible contributing factor to resident #10's falls, but did not attempt to reduce or eliminate the medication. 2. Review of resident #12's Post Fall Evaluation form, dated 7/6/17, showed the resident fell five times, which occurred on: 2/21/17, 6/18/17, 6/27/17, 7/6/17, and 9/29/17. Review of resident #12's Root Cause for the fall, dated 2/21/17, showed, Elder slid out of recliner onto floor. The Plan for a new intervention showed Encourage elder to have feet elevated in recliner. The facility did not identify why the resident slid out of his chair. Review of resident #12's Root Cause for the fall, dated 6/18/17, showed, Elder rolled out of bed. The Plan for new intervention showed Keep bed in lower position and keep garbage and other hard object away from the bed. Elder was positive for a UTI. The facility did not identify why the resident rolled out of bed. During an observation and interview on 11/6/17 at 4:15 p.m., resident #12's room had three large bags of pop cans, stacked upon each other. A fall mat was folded up and against the wall, away from the bed. Resident #12 stated he did not use the mat. The mat was identified on the Fall Action Plan form as a fall intervention. Review of resident #12's Root Cause for the fall dated 6/27/17, showed, Elder lost balance. The Plan for new interventions showed positive for UTI. The analysis did not include the possible need for increased assistance or supervision for the resident. Review of resident #12's Root Cause for the fall dated 7/6/17, showed the resident had slid out of the recliner again. The Plan for a new intervention showed start 30 minute checks, and these were discontinued on 9/11/17. Review of resident #12's Root Cause for the fall dated 9/30/17, showed the elder rolled out of bed again. The Plan for a new intervention showed re-initiate 30 minute checks, and check urine for UTI. The facility did not identify why the resident rolled out of bed. During an interview on 11/6/17 at 4:15 p.m., resident #12 stated he was afraid of falling more than anything. Review of resident #12's Physician order [REDACTED]. The facility failed to attempt a dose reduction for the Seroquel (see F329). 3. Review of resident #16's Fall Data and Plan of Action forms showed the resident fell six times, from 10/1/17 through 10/28/17. Resident #16 was admitted to the long term care unit on 9/25/17. Review of resident #16's Root Cause for the fall, dated 10/1/17, showed elder was self transferring and fell . The Plan for a new intervention was, Therapy placed a second handle next to the toilet to assist with transfers. The analysis showed the elder had poor cognition and continued to attempt to transfer independently. The Root Cause did not show how toileting contributed to the fall. Review of resident #16's Root Cause for the fall, dated 10/5/17, showed the elder rolled herself out of bed. The Plan for a new intervention showed use a body pillow and fall mat. The Analysis showed elder continued to self transfer. The Root Cause did not show how or why the resident rolled out of bed, and how self transferring contributed to the fall. Review of resident #16's Root Cause for the fall dated 10/12/17, showed, Elder climbed out of bed, stood up at closet and when attempting to sit in the wheelchair, she fell . The Plan for a new intervention showed Place elder in recliner or bed when in room and remove wheelchair and walker from sight. If elder want (sic) to remain in wheelchair, encourage her to be in the day room. The facility did not address why she wanted to get out of bed, or the need for staff to anticipate and meet her needs. During an observation on 11/16/17 at 10:45 a.m., resident #16 was in her wheelchair, in her room. The walker was next to the recliner. The call light was placed on the recliner. When asked if she could reach her call light, resident #16 attempted to reach it, but her wheelchair got stuck by the recliner, and she was not able to reach it, therefore not able to call for assistance. Review of resident #16's Root Cause for the fall, dated 10/12/17, showed the elder was getting up to change the TV channel. The Plan for a new intervention showed 15 minute checks secondary to toileting, encourage elder to be in day room as much as she is willing. The intervention did not address why resident #16 was getting up to change the channel or why she fell when up. Review of resident #16's Root Cause for the fall dated 10/21/17, showed the elder attempted to get out of recliner while the resident's legs were extended. Staff caught her and lowered her to the floor. The plan for a new intervention showed Continue with 15 minute checks and keep recliner legs elevated, and pancake light strategically placed. Continue to encourage elder to be in dayroom. Elder continues to be impulsive. Review of resident #16's Root Cause for the fall dated 10/28/17, showed the elder attempted to get out of bed at 9:00 a.m., to go to the bathroom. The Plan for a new intervention was to toilet the elder during rounds and get resident up at night to use the bathroom. During an interview on 11/8/17 at 9:05 a.m., staff member H stated the facility had implemented a new fall prevention program, which included fall reviews for three residents one day a week. She stated the team may not understand what root cause analysis meant. She stated the unit nurse managers were responsible for monitoring and evaluating the effectiveness of the fall interventions. Record review of Fall Action Plans and progress notes showed no documented monitoring or evaluation for the effectiveness of the interventions, after repeated falls. Staff member H stated, If they fall again, the intervention did not work.",2020-09-01
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 failure. Listed in the interventions were instructions for staff to supervise and assist resident #6 as needed during tasks. During an observation and interview on 11/6/17 at 2:50 p.m., resident #6 was sitting in her room in her wheelchair looking out of her window. The resident's nasal cannula was in her nose, and was attached to the oxygen concentrator. The oxygen concentrator was not turned on. Resident #6 stated the staff had put her cannula on her when she got back from lunch. Resident #6 stated she did not notice the oxygen concentrator was not turned on. Staff member I turned on resident #6's oxygen concentrator and stated it should have been turned on. During an interview on 11/7/17 at 9:30 a.m., resident #6 stated she normally takes care of her oxygen and turns on her concentrator when she gets back to her room. Resident #6 stated she forgets to turn it on sometimes. Resident #6's Significant Change MDS, with an ARD of 8/19/17, reflected she had a decline in her short-term memory and required reminders and cues to assist her in her orientation. During an interview on 11/7/17 at 10:10 a.m., staff member J stated resident #6 turns her oxygen on independently. Staff member J stated the resident knows she needs to use the oxygen. Staff member J stated staff reminds her she needs to use the oxygen. During an observation and interview on 11/7/17 at 12:32 p.m., resident #6 was sitting in the dining room eating lunch. The oxygen cylinder was hanging on the back of her wheelchair, and the needle on the gauge reflected the cylinder was on empty. The resident did not exhibit signs of being short of breath and did not have any complaints. The resident was not aware the oxygen cylinder was empty. At 12:47 p.m., resident #6 left the dining room and went to her room. Her oxygen cylinder reflected empty and no staff assisted the resident to get another cylinder or check to ensure it still had oxygen in it. When the resident entered her room, she sat looking out of her window. The oxygen concentrator was running in the on position, but the resident did not put on the nasal cannula that went to the concentrator. At 12:49 p.m., staff member K entered the resident's room and asked her if she would like some ice water. Resident #6 stated she would like some ice water. At 12:50 p.m., resident #6 stood up from her wheelchair and staff member K brought in the ice water and asked the resident if she wanted to lay down and if she needed assistance. Resident #6 stated she was going to go to the bathroom. Staff member K left the room and did not check the oxygen tank or concentrator prior to leaving. At 1:02 p.m., resident #6 came out of the bathroom, removed the nasal cannula that was attached to the oxygen cylinder, and put on the nasal cannula attached to oxygen concentrator. Resident #6 had been without oxygen therapy from the time of the dining room observation at 12:32 p.m. until she placed herself on the oxygen concentrator at 1:02 p.m. During an interview on 11/7/17 at 3:40 p.m., resident #6 stated she did not know how to check her oxygen cylinder. She stated she thought staff needed to check the cylinder to make sure they had oxygen in them. Resident #6 stated when she woke up this morning she wasn't feeling well. Resident #6 stated she woke up with her nasal cannula in her hand. Resident #6 stated she believed she was not feeling well because she had taken off her oxygen in her sleep. Resident #6 stated she would want staff to wake her to put on her oxygen if they saw it was off. 2. Resident #26 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #26's Quarterly MDS, with an ARD of 8/24/17, reflected the resident received the respiratory treatment of [REDACTED]. The MDS reflected the resident did not resist care and required extensive assistance of one person with her ADLs. Review of resident #26's physician orders, dated 1/19/16, reflected the resident was to be provided with oxygen therapy per nasal cannula at 2 lpm to maintain a saturation level of 90% or above. Review of resident #26's care plan reflected a problem, with the effective date of 6/8/17, of alteration in resident #26's thought process related to a history of stroke with [MEDICAL CONDITION]. Interventions listed included for staff to give resident #6 short simple instructions, and provide a consistent routine environment. Another problem, with the effective date of 6/8/17, reflected a potential for alteration in gas exchange and ineffective breathing pattern related to [MEDICAL CONDITION]. Interventions listed included oxygen at 2 lpm per nasal cannula to maintain oxygen saturation at or above 90%, encourage resident #26 to deep breathe, and breathe through the nasal cannula if in place. During a meal time observation on 11/7/17 at 12:30 p.m., resident #26's oxygen cylinder was on empty. The empty oxygen cylinder was reported to staff member P by this surveyor. Staff member P observed the oxygen cylinder and instructed staff member K to obtain a new oxygen cylinder to replace the empty one. At 12:40 p.m. staff member K returned with a new oxygen cylinder and changed out the empty cylinder. Staff did not check resident #26's oxygen saturation prior to applying the new oxygen cylinder. 3. Resident #27 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #27's physician orders reflected the resident required oxygen at 2 lpm per nasal cannula. Review of resident #27's most current Annual MDS, with an ARD of 8/24/17, reflected the resident was not receiving a respiratory treatment during that assessment time. Resident #27's MDS reflected he had a BIMS of 14, cognitively intact. Resident #27 required extensive assistance of one person with his activities of daily living. Review of resident #27's care plan reflected a problem, with an effective date of 9/12/16, for an alteration in resident #27's thought process related to dementia. Interventions listed included for staff to give short simple instructions and reorient as needed. Another problem, with the effective date of 9/12/17, reflected an actual/potential alteration in self-care/ADL ability related to dementia with mild confusion. Interventions listed included for staff to supervise and assist as needed during tasks. During an observation on 11/7/17 at 1:05 p.m., resident #27 was in the dining room for lunch and had an oxygen cylinder attached to his wheelchair that he was receiving oxygen from, per nasal cannula. The gauge on the oxygen cylinder was in the red zone and was at the 200 psi mark. The resident was assisted back to his room from the dining room. The resident was not placed on his oxygen concentrator from the oxygen cylinder. The resident was sitting next to his bed and was visible from the doorway. At 1:07 p.m., staff member Q passed by the resident's room with the medication cart and did not place the resident on the oxygen concentrator. At 1:09 p.m., staff member R walked past resident #27's room, looked in on the resident from the door and did not place the resident on the concentrator. The resident was reading a newspaper and facing the window away from his door. The surveyor interviewed the resident as soon as staff member R walked away. The resident stated he was ok and did not notice his oxygen tank was on empty. During an interview on 11/7/17 at 1:10 p.m., staff member J was notified by the surveyor that resident #27 was not placed on his oxygen concentrator and his tank gauge showed it was in the red zone. Staff member J stated resident #27 had a health issue last Friday for a GI bleed and [MEDICAL CONDITION]. Staff member J stated resident #27 needed to be on oxygen continuously. Staff member J went into resident #27's room, and placed him on his oxygen concentrator. During an interview on 11/7/17 at 3:20 p.m., staff member S stated the night shift CNAs check the oxygen cylinders and change them out if needed. Staff member S stated staff should check the oxygen cylinder before they take the resident out of their room to ensure it had enough oxygen in it. During an interview on 11/7/17 at 3:30 p.m., staff member T stated staff check the oxygen cylinders on night shift and throughout the day, usually at the end of the shift. Staff member T stated it depended on if the resident was mobile and if the oxygen was continuous or had a gauge with an on-demand setting. Staff member T stated sometimes it was hard to check if the resident was independent. Staff member T stated the oxygen cylinders lasted approximately two hours if they were on continuously. During an interview on 11/8/17 at 8:35 a.m., staff member J questioned if resident #27's oxygen was in the red zone. Staff member J stated if the gauge got to the beginning of the red zone, 500 psi, the resident would have approximately 1.25 hours left. Staff member J showed a picture of resident #27's gauge at the time she was notified of the concern on 11/717 at 1:10 p.m. The picture showed the needle to be at the 200-psi mark. The staff should have changed out the oxygen cylinder according to the facility policy and procedure to ensure it did not go below the 200 psi mark. Review of the facility policy titled, St. [NAME]'s Lutheran Portable Oxygen Therapy Use, reflected instructions for staff to, change the cylinder when the needle gets to the lower part of the red section. The policy reflected, Be sure to change the cylinder before the needle gets below 200-psi. During the interview on 11/7/17 at 8:35 a.m., staff member J stated if staff took a resident to their room they should place the resident on the oxygen concentrator from the oxygen cylinder. Staff assisted resident #27 to his room and did not place him on the oxygen concentrator.",2020-09-01
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, showed Resident stable. No [MEDICAL CONDITION] noted. Resident has failed reduction in the past. Review of a Pharmacy Note, dated 8/29/17, showed Gradual Dose reduction declined by provider due to previously failed attempt. Review of a Pharmacy Note, dated 10/24/17, showed Caretracker showed no mood or behavior indicators. Provider declined GDR of [MEDICATION NAME] (10/10/17) due to previously failed attempt. During an interview on 11/7/17 at 3:45 p.m., staff member G stated no GDR's were attempted for resident #12 since his arrival to the unit, in April, (YEAR). Record review showed the reduction in [MEDICATION NAME] occurred on 4/23/16, and was successful. 2. Review of resident #10's Physician orders, dated 11/7/17, showed the resident was receiving [MEDICATION NAME] (anti-anxiety), routinely, twice a day. Review of resident #10's Care Plan, dated 5/5/16, showed a problem for dementia, thought process, and depression with anxiety. The interventions had not been updated since 5/5/16. Review of a Pharmacy Note, dated 7/10/17, showed the resident failed a dose reduction of the [MEDICATION NAME] 11/2016. Review of resident #10's Physician visit, dated 12/5/16, showed She recently had her [MEDICATION NAME] decreased to once a day. Nursing staff report that she was more irritable and would pick on other residents with this decrease. Therefore, her [MEDICATION NAME] was increased back to twice a day. Review of resident #10's Pharmacy Note, dated 10/2/17, showed Please evaluate [MEDICATION NAME] and [MEDICATION NAME] for dosing appropriateness, including rationale if no dose reduction attempted at this time. Record review showed no dose reduction occurred for the antianxiety medication [MEDICATION NAME] or the [MEDICATION NAME], for 2 years. Review of resident #10's Behaviors and Behavior Management forms, showed behaviors of agitation and hitting occurred on 10/31/16, 10/30/17, 1/20/17 and 4/5/17. During an interview on 11/8/17 at 9:05 a.m., staff member H stated the facility had addressed the medication as a possible contributing factor to resident #10's falls, but did not attempt to reduce or eliminate the medication. She said the facility could not override the doctor.",2020-09-01
101,ST JOHN'S LUTHERAN HOME,275024,3940 RIMROCK RD,BILLINGS,MT,59102,2017-11-08,371,E,0,1,8YVD11,"Based on observation, interview, and record review, the facility failed to ensure resident safety by not utilizing proper hand hygiene and glove use when they prepared and served food to residents. This practice had the potential to affect all 10 residents being served meals in the Fischer cottage. Findings include: During an observation on 11/7/17 at 8:40 a.m., staff member D did not remove the gloves she wore, wash her hands, or don new gloves throughout all the following tasks. After these tasks were completed the staff member removed her gloves and washed her hands. -Washed dishes in the sink; -Dished up a resident's plate, touching peeled oranges; -Put a lid on a food container and moved the container to the pantry; -Dished eggs from a frying pan onto plates; -Scraped eggs off a knife blade that was being used to cut up the eggs, then placed the knife blade on the edge of the frying pan; -Put pancakes on a plate and used the same knife to cut up the pancakes; -Served meals to two residents; -Put water in glasses and removed wrappers from a straw and placed them into the glass, and then served the glass of water to a resident. -Sat with a resident and assisted the resident with drinking juice, holding the glass and straw; -Retrieved stainless steel bowls from a cupboard in the kitchen; -Moved a resident who was in a wheelchair from the dining area of the kitchen to a new area in the living room; -Retrieved a cutting board and a new knife and placed them on the counter island in the kitchen; -Placed dirty dishes and cook ware into the sink and ran water over the items; and, -Opened a bag of carrots and a bag of lettuce, and pulled a handful of lettuce out of the bag. During an interview on 11/7/17 at 8:55 a.m., staff member D said, I know I'm supposed to be changing my gloves between tasks. That is how I was trained, and I have taken the Safe Serve course. A review of the facility's policy, Handwashing & Personal Cleanliness, showed staff were instructed to wash their hands before returning to work, handling food items, working with ready-to-eat foods, handling different types of foods, touching hair, face, nose or other parts of the body, cleaning, handling chemicals, handling dirty equipment, handling trash and other contaminated objects, and more.",2020-09-01
102,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2017-08-24,174,E,0,1,4UNG11,"Based on observation, interview, and record review, the facility failed to provide an area for telephone conversations which was private and large enough to accommodate residents who used a wheelchair, who did not have a personal telephone. Findings include: During an observation on 8/21/17 at 11:10 a.m., a public phone was observed across the hall from the nurse station. The phone was on a small table, at the entrance to a small, narrow, room. The room was set up where a person entered and directly took a right back to a desk. The narrow room was very small. A small, wooden table, was placed in front of the doorway to the room. During an observation on 8/22/17 at 7:10 a.m., the public phone was observed in the doorway of the small private phone room, and not in the location on the previous observation. During a private meeting on 8/22/17 at 10:00 a.m., a group of residents stated the facility did not have a phone the residents could use privately. The public phone was located in a small, narrow room, and they could not get into the room with their wheel chairs. The phone was left at the door opening of the small room, for the residents to use. The group stated they had no privacy where the public phone was located. During an observation on 8/22/17 at 2:18 p.m., resident #25 was talking on the facility's public phone. The phone was on the small, wood table, at the doorway of the small room, used for privacy. Resident #25 was in the hallway, across from the nurse station. The ward clerk was at the nurse station, reviewing paperwork. Resident #25's conversation could be heard from the nurse station. During an observation on 8/24/17 at 9:50 a.m., an unidentified resident was in a wheel chair, sitting next to resident #25, waiting to use the phone. Review of the facility's admission packet showed one of the residents' rights was to be able to make and get private phone calls.",2020-09-01
103,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2017-08-24,225,G,0,1,4UNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report physical and verbal abuse when they were observed by staff, which allowed continued abuse for 1 (#9), and failed to protect a resident by failing to recognize a resident's risk for elopements, assess the risk, and address an elopement thoroughly, for 1 (#13) of 21 sampled residents. Findings include: 1. Review of the State Survey Agency, facility event report, dated 7/25/17, showed physical and verbal abuse were substantiated, in which staff member Z was the aggressor, and resident #9 was the victim. Review of the Summary/Outcome of Investigation Findings, dated 7/19/17, showed Seven witness statements named staff member Z as being verbally aggressive/inappropriate with resident #9, and others. Two eye witness accounts of physical abuse with bruises consistent (sic) match with accounts. Both accounts reported late. The facility addressed staff member Z, who was no longer employed at the facility. Review of resident #9's Progress Note, dated 6/20/17, showed Has been awake most of the night yelling out. Had only slept about an hour. Continually yelling out 'help . why don't you like me .' Review of resident #9's Progress Note, dated 7/19/17, showed Bruising on each side of chest is hand-shaped with largest bruised area on each side measuring 6 cm x 6 cm. Review of staff member Y's witness statement, dated 7/20/17, showed she observed staff member Z walk past resident #9, who was exhibiting repetitive vocalizations, and said in a loud stern voice, with her hand raised in stop sign, You need to stop, stop. She also stated the week before, resident #13 had told her that staff member Z did not like any of the residents on the unit. During an interview on 8/22/17 at 9:20 a.m., staff member Y stated she did not follow-up with why the resident stated staff member Z did not like the residents, and she did not report the statement to management, because she did not believe it was abuse. Review of staff member J's witness statement, dated 7/19/17, showed staff member Z yells at (resident #9) when she is calling out for help, telling her to quit, saying help and to sit back in the recliner and be quiet. She will not let resident #9 get out of the recliner even when the resident says she has to go pee. Review of staff member X's witness statement dated 7/20/17, showed (staff member Z) called a resident pathetic, and moved her aggressively against the table. When assisting (resident #9) staff member Z is aggressive. I have witnessed (staff member Z) grabbing (resident #9's) hands and slamming them into her lap. I was uncomfortable saying anything and thought the nurse would report it forward. Review of staff member L's witness statement, dated 7/19/17, showed she had on many occasions seen (staff member Z) blatantly abuse (resident #9). She stood against the wheelchair and pinned (resident #9) against the table. (Resident #9) stated she could not breath (sic), and staff member Z told her to shut up. (Resident #9) has bruises on her chest and arms from (staff member Z) pushing her back so hard. Review of staff member JJ's witness statement, dated 7/19/17, showed On several occasions I have witnessed staff member Z's short temper and inability to control it with residents. She often tells them to 'shush' or 'shut up.' Residents with behaviors cause her to get highly agitated, and she has repeatedly pushed them back or held them in place while they are in their wheelchairs. During an interview on 8/24/17 at 9:10 a.m., staff member JJ stated the residents were 'riled up' when staff member Z was on shift. She stated she would report suspected abuse immediately to her supervisor. During an interview on 8/23/17 at 8:05 a.m., staff member L and K, staff member L stated she had reported the abuse in May, (YEAR), through a written document. She stated she told staff member K, and they went to staff member B together. Staff member K stated she thought this had occurred more recently than (MONTH) (YEAR). The facility showed no documentation of this report or abuse, until (MONTH) 19, (YEAR). Staff member L stated she did not know there was a State Survey Agency hotline she could call for suspected abuse. 2. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #13's 5-day PPS, MDS assessment, dated 7/23/17, showed she had wandered 1-3 days during the look back period. Review of resident #13's Progress Note, dated 7/9/17, showed. Patient is confused and thinks she is here working as the DON. Patient has been trying to leave the facility and is considered an elopement risk. She also wrote a personal check and gave it to staff ., Patient has been placed on watch and staff is locating and documenting Q 15 min as to where the patient is at. Review of resident #13's Progress Note, dated 7/18/17, at 1:38 p.m., showed, found (sic) resident pushing another resident in w/c (resident also from locked wing) down D wing hall Review of resident #13's Progress Note, dated 7/19/17, at 6:00 p.m., showed, Resident has escaped off locked unit three times this morning A review of the facility's policy, Elopement, reflected, the facility staff did not consider the resident eloping from the secured unit an actual elopement, but rather the threshold for elopement was a resident had to escape the building. During an interview on 8/23/17 at 1:30 p.m., staff member A and C stated they agreed with the facility policy, and unless a resident eloped out of the building, it was not considered an elopement.",2020-09-01
104,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2017-08-24,226,J,0,1,4UNG11,"Based on record review and interview, the facility failed to operationalize the abuse policies and procedures for the protection of residents, specifically when a resident (#7) was moved to the dementia secure unit, after the resident had exhibited sexual predatory behavior towards residents of the opposite sex, which continued after the move. Staff failed to ensure the residents were protected, and the needs of resident #7 were addressed adequately, to ensure a safe environment, free of sexual abuse. This deficient practice had the potential to affect the 28 residents on the unit who had contact with resident #7, and specifically females, and was identified to have affected four female residents (#s 8, 22, 23, and 24) of 30 sampled and supplemental residents. Findings include: On 8/23/17 at 2:04 p.m., staff members A, B, C, and U, were notified of an Immediate Jeopardy situation in the area of F226, Abuse, Policies and Procedures, cited at a severity and scope of [NAME] This included four residents. 1. Review of the State Survey Agency, facility event report, dated 6/4/17, showed resident #7 was observed groping resident #24's breast. Review of resident #7's Quarterly MDS, with the ARD of 6/2/17, showed the resident had a BIMS of 14, meaning he was cognitively intact. Review of resident #7's Progress note, dated 6/4/17, showed resident #24 cried loudly after the incident with resident #7. The documentation showed, The patient was distraught, the male was smiling. Review of resident #24's Annual MDS, with the ARD of 6/2/17, showed the resident had a BIMS of 10, meaning she had moderately impaired cognition. Review of the State Survey Agency, event report, dated 6/4/17, showed resident #7 was moved to another hall, and the sexual abuse was substantiated relating to resident #7. 2. Review of resident #7's Progress Note, dated 6/25/17, showed (the resident) was knocking on female resident door, opened door and was entering room. Staff stepped into door and told (resident #7) the other resident was asleep, and he was not to be in her room. (The resident) became angry and swung at staff member hitting them in the neck. Staff told him this was not appropriate behavior and he was escorted to his room. The Progress Note did not show future interventions to protect the resident in the room resident #7 was entering. 3. Review of resident #7's Progress Note, dated 6/28/17, showed staff intervened on 4 separate occasions this morning whenever (resident #7) was caught squeezing and fondling 3 different female residents' breasts. (Resident #7) was redirected away, and was reminded again that this is inappropriate behavior. Review of the State Survey Agency, facility event report, dated 6/28/17, showed the plan to prevent further abuse was to monitor (resident's) movements. The doctor had been contacted to assess (resident) who appears to be delusional, thinking the women are his lady friends. During an interview on 8/22/17 at 10:20 p.m., staff member BB stated she had not been made aware resident #7 had been touching females on the memory care unit, although the staff member provided medical oversight. Review of resident #7's Progress Note, written by staff member W, dated 7/5/17, showed Noc nurse reports increase in (resident #7's) inappropriate touching of female residents and resident's fixation on resident #22. Nurse also reported (resident #7) urinating in drinking glass and placing used toilet paper in sink. Day shift CNA reports staff need to monitor (resident #7) to avoid having female residents in his room. 'He will lure them in.' Also, same CNA reported (resident) consistently making sexual comments, inappropriate touching of multiple residents, exposing himself in the dining room, urinating in common areas, and demonstrating increased aggression when staff attempt to redirect. The administrator was contacted to discuss re: safety of residents on unit in relation to (resident #7's) behavior, with planned follow-up with MD. Review of resident #22's Quarterly MDS, with the ARD of 7/14/17, showed the resident had a BIMS of 4, meaning she had severely impaired cognition. The facility was unable to provide follow-up regarding the 7/5/17 note, to show steps taken to protect the residents on the unit. During an interview on 8/22/17 at 2:40 p.m., staff member A stated staff member V and W were on vacation, and could not provide further information. During an interview on 8/21/17 at 1:45 p.m., staff member B stated resident #7 was moved to the memory care locked unit, because there was more supervision. She stated the facility had not reassessed the resident, or the situation relating to the sexual behavior, since the room move on 6/5/17. She did not know what interventions were in place to protect the residents living in the locked memory care unit. 4. Review of resident #23's progress note, dated 6/28/17, showed resident #8 said hi to resident #7, in the dining room. Resident #7 grabbed and squeezed resident #8's breasts. The residents were separated. Resident #8 did not show any reaction. Resident #7 was reminded again that the behavior was inappropriate, although this has been unsuccessful prior. Review of resident #8's Quarterly MDS, with the ARD of 7/18/17, showed the resident had a BIMS of 2, meaning she had severely impaired cognition. 5. Review of resident #23's Progress Note, dated 7/22/17, showed resident #7 had attempted to persuade the resident to enter a room with him. Staff redirected male resident but (resident #23) was upset by interaction for brief time. Review of resident #23's Annual MDS, with the ARD of 6/2/17, showed the resident had a BIMS of 9, meaning moderately impaired cognition. During an interview on 8/21/17 at 2:20 p.m., staff member P stated the facility continued to monitor resident #7, and he had a psychiatry evaluation on 8/17/17. The results of the evaluation were not available. She stated the resident now had a dementia diagnosis, so she thought abuse was not substantiated. She stated the sexual contact by resident #7 did not bother resident #22, and resident #8 and #23 did not remember the incident with resident #7. She thought the move was a temporary change. During an interview on 8/21/17 at 1:30 p.m., staff member K stated she had witnessed episodes of resident #7 touching females, and the staff were to watch him closely when he was up walking through the hall. During an interview on 8/21/17 at 3:00 p.m., staff member J stated she had witnessed the resident touching other female residents, and the staff were told to redirect and separate resident #7 from the female residents. During an interview on 8/22/17 at 7:35 a.m., staff member L stated resident #7 was very sexual, even with the CNAs. She stated she was concerned about his placement on the memory care unit, and was told the move was only temporary. She also stated she had been the only CNA on the memory care unit on several occasions, and could not provide the expected supervision of the 28 residents.",2020-09-01
105,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2017-08-24,280,D,0,1,4UNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to update a resident's care plan after falls relating to the root causes, and interventions to prevent the falls; and failed to include diabetes interventions in the plan of care for 1 (#18) of 21 sampled residents. Findings include: Resident #18 had [DIAGNOSES REDACTED]. Review of resident #18's falls for 7/2/17 through 8/9/17, showed three unwitnessed falls, one with head injury and fractured pubic bone. Review of resident #18's progress note, dated 7/3/17, showed the resident triggered for falls, on the Care Area Assessment, due to unsteadiness, difficulty maintaining sitting balance, and balance during transitions. Review of resident #18's care plan did not show interventions for falls. During an interview on 8/24/17 at 10:20 a.m., staff member B stated if the problem was triggered on the CAA, it should be addressed on the care plan.",2020-09-01
106,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2017-08-24,281,D,0,1,4UNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure neurological assessments were completed following unwitnessed and witnessed falls when a resident hit their head , for 2 (#s 6 and 18) of 21 sampled residents. Findings include: 1. Resident #6 had a [DIAGNOSES REDACTED]. Review of resident #6's progress notes, dated 5/11/17 through 7/5/17, showed the resident had five unwitnessed falls. One out of five falls resulted in fractured ribs. During an interview on 8/23/17 at 10:09 a.m., staff member M stated the fall protocol was to assess the resident, check vital signs, check ROM (range of motion), check for injuries, use a lift to move the resident, and initiate neurological checks. Review of resident #6's incident report, dated 6/13/17, showed the bed was unlocked, and the resident had fallen during a self-transfer. Review of resident #6's clinical record did not show neurological checks for the unwitnessed falls. 2. Resident #18 had a [DIAGNOSES REDACTED]. Review of resident #18's falls for 7/2/17 through 8/9/17, showed three unwitnessed falls, one with head injury and fractured pubic bone. Review of resident #18's clinical record did not show neurological checks were completed for the unwitnessed falls. During an interview on 8/23/17 at 3:17 p.m., staff member H stated the protocol for falls was to check for injuries, complete neurological checks if the resident hit their head, complete a fall report and fall assessment, and notify the resident's physician and family. Review of the facility's policy for Fall Prevention showed neurological checks were to be initiated if the resident hit their head or the fall was unwitnessed. It is important to monitor changes in vital signs because changes can indicate deterioration in neurological status. Urdan, [MI] D., Stacy, K.M., & Lough, M.E. (2006) . Thelan's critical care nursing: [DIAGNOSES REDACTED].). St. Louis, Missouri : Mosby Elsevier. pg 727. For injuries to the head, spine and face, primary assessments include; airway, breathing, circulation, and neurologic disability. Subsequent assessments include; history, level of consciousness, vital signs, unequal or unresponsive pupils, confusion or personality changes, impaired vision, [MEDICAL CONDITION] activity, periauricular ecchymosis, rhinorrhea; and periorbital ecchymosis. Manual of Nursing Practice 8th Edition. Lippincott,[NAME] & Wilkins, 2006. pp. 1142 - 1148. Initial neurologic evaluations should be obtained as soon as possible following a head injury, and reevaluation should be performed frequently. Burrell, Gerlach, Pless. Nursing Management of Adults With Crisis Problems. Chapter 75, pp. 2082-2083.",2020-09-01
107,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2017-08-24,323,K,0,1,4UNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and observation, the facility failed to ensure adequate supervision, assessment, monitoring, and interventions, were implemented to prevent resident falls, which caused fractures, and in an attempt to reduce the number of falls for 5 (#s 6, 9, 14, 16 and 18); failed to provide timely evaluation and follow up for a resident who had a major injury after a fall, for 1 (#18), and failed to evaluate incidents of elopement and the risk for elopement, for 1 (#13) of 21 sampled residents. Findings include: On 8/23/17 at 2:04 p.m., staff members A, B, C, and U were notified of an Immediate Jeopardy situation in the area of F323, Accidents/Supervision, cited at a severity and scope of K for three residents with falls who had fractures. 1. Review of resident #18's progress notes, dated 7/2/17 through 8/9/17 showed the following: -On 7/2/17, resident #18 had an unwitnessed fall, without injuries. The resident was found on the floor next to her bed. The resident's nursing notes did not show ongoing neurological assessments, monitoring, or the implementation of interventions for future fall prevention. Review of the resident's care plan did not show interventions related to fall prevention. -On 7/15/17, resident #18 had an unwitnessed fall in which the resident sustained [REDACTED]. The fall scene investigation, not dated, showed the resident was sent to the ER for evaluation. Wound care was provided for the skin tear. Review of the resident's nursing note, dated 7/15/17, did not show ongoing neurological assessments, monitoring or interventions for future fall prevention. -On 8/9/17, resident #18 had an unwitnessed fall in which the resident sustained [REDACTED]. Review of nurse's notes, dated 8/9/17, showed the resident was assessed and complained of left hip pain with ambulation. Review of the resident's progress note, dated 8/10/17, showed the resident was transferred to the ER for evaluation. There was a 12-hour delay in the transfer, for the resident to receive a higher level of care, in an acute setting. Review of the resident's care plan did not show interventions for fall prevention. Review of the resident's clinical record did not show ongoing neurological assessments. The resident's fall scene investigation report, dated 8/9/17, showed the resident had difficulty pushing the call light. -On 8/10/17, the resident was sent to the emergency room for evaluation of left hip pain. The resident returned to the facility with a [DIAGNOSES REDACTED]. Review of the resident's care plan did not show updated information and interventions related to falls as of 8/10/17. Review of resident #18's clinical record did not show neurological assessments for the three unwitnessed falls. Review of the resident's care plan did not show interventions for fall prevention. Review of the CAA (care area assessment), dated 7/3/17, showed falls were triggered as a problem, due to the resident's unsteadiness and the need for staff assistance. Review of resident #18's Admission MDS, with an ARD of 6/28/17, showed a BIMS (brief interview for mental status) score of 13, cognitively intact. Review of the resident's MDS, with an ARD 8/16/17, showed a BIMS score of 6, severe cognitive impairment, a significant change from the previous assessment. Review of resident #18's nursing notes, for 7/2/17 through 8/17/17, showed the IDT met one time, on 7/12/17, to review the resident's fall. The one intervention put into place, was for staff to remind the resident not to wear slippery pajamas, although her cognition was impaired. During an interview on 8/23/17 at 10:09 a.m., staff member M stated the resident did not complain of hip pain. Staff member M stated the fall protocol was to assess the resident, check vital signs, check ROM (range of motion), check for injuries, and use a lift to move the resident. Staff member M stated neurological checks were started for resident #18, for the fall on 8/9/17, and were left for the next shift. During an interview on 8/23/17 at 3:17 p.m., staff member H stated the protocol for falls was to check for injuries, complete neurological checks if the resident hit their head, complete a fall report and fall assessment, and notify the resident's physician and family. During an interview on 8/24/17 at 10:20 a.m., staff member B stated the expectation for falls was for the nursing staff to follow the facility policy and procedure. 2. Review of resident #6's falls from 5/11/17 through 7/5/17 showed the following: -The resident had five falls, which were on 5/11/17, 6/4/17, 6/9/17, 6/13/17, and 7/5/17. -One out of five falls resulted in rib fractures. -Two out of five falls were related to toileting needs. -All five falls were during self transfers by the resident. Review of resident #6's care plan did not show interventions related to toileting needs, although two falls occurred related to toileting. Review of resident #6's Quarterly MDS, with an ARD of 6/15/17, showed the resident needed extensive assist by one staff for toileting needs. Review of the facility's Fall Prevention policy showed the following: 1. A fall risk assessment will be completed at the following times: a. upon admission/readmission to the facility b. quarterly - can complete a quarterly review instead of full assessment if no change since previous assessment c. prior to annual MDS d. change of condition 2. Fall precautions will be reviewed and appropriate precautions will be implemented after a fall occurs. 3. An incident report and a fall scene investigation form are to be completed after each fall. 4. Fall will automatically be logged through completion of incident report in PCC. 5. Initiate Neuro checks if the resident hit their head or if the fall was unwitnessed. 6. The resident's physician and family were to be notified of the resident's fall. 7. Once per week, the IDT (interdisciplinary team) fall committee will meet and complete a fall review on each resident who had fallen during the preceding week. The care plan will be updated with any new or decided interventions. This will continue for 3 weeks post-fall or until the resident has had no further falls for 30 days. 8. The Quality Assurance Committee will discuss all residents, who have fallen that month and the status of each resident and their current interventions. 3. Resident #14 was a long-term resident in the facility, and was re-admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. During an interview on 8/23/17 at 3:00 p.m., resident #14 said, I just lose my balance. He said, once or twice he transferred himself because he, Couldn't get to the call button. Resident #14 said he couldn't remember how he broke his hip, and felt maybe he had been in a car accident. Review of resident #14's Progress Note, dated 7/23/17 at 7:35 p.m., showed resident #14 fell in the dining room and the resident was sent to the ER. At 10:43 p.m., a progress note showed resident #14 had been admitted to the hospital with [REDACTED]. Review of resident #14's (hospital) History and Physical Report, dated 7/23/17, showed, . was walking today when his leg caught on the leg of a coffee table. He fell on the left side and immediately had pain in the left hip. Review of resident #14's (hospital) Discharge Summary, dated 7/27/17, showed, He was walking today (at the nursing home) when his leg got caught on the leg of a coffee table. He landed on his left side and had exquisite pain, and, He went to the Emergency Department and was found to have a left-sided hip fracture . Review of resident #14's Fall report, for 7/23/17, revised on 7/31/17, showed the report had only been partially completed, and showed, No injuries observed post incident. Review of resident #14's late Progress Note, dated 7/28/17 at 5:29 p.m., showed resident #14 had returned to the facility on [DATE], .early in the day. The facility staff had not documented resident #14's return until the evening of the following day. Review of resident #14's Fall risk assessment, dated 6/2/17, showed the resident fall risk had not been completed. Review of resident #14's Fall Risk Assessment, upon return to the facility on [DATE], was requested, but one was not provided. Review of resident #14's Progress Note, dated 8/2/17 at 12:37 p.m., showed resident #14 had Slipped off of the edge of his bed while trying to dress himself. Resident #14 had reported that he didn't think he needed any help. Review of resident #14's Progress Note, dated 8/2/17 at 5:18 p.m., showed. Resident was trying to put his pants on and slipped off bed onto the floor. Denied any new pain. No skin issues noted. Assisted resident with dressing and put into w/c. MD Notified. Review of resident #14's Significant Change MDS, dated [DATE], after re-entry to the facility, showed, resident #14 needed limited assist with transfers, he had not walked between locations in his room or in the corridor, and he required extensive assist with dressing, toilet use, and personal hygiene, and had not been bathed. The MDS showed resident #14 was, Not steady, only able to stabilize with staff assistance, for moving from seated to standing position, moving on and off toilet, and surface-to-surface transfer. Resident #14 had a functional limitation in range of motion for his lower extremities, on one side. Section GG of the MDS showed resident #14 required partial/moderate assistance with sit to stand, chair/bed-to-chair transfer, toilet transfer, wheel 50 (and 150) feet with two turns, and refused to perform sit-to-lying, and lying-to-sitting, on the side of the bed. The MDS showed the resident had only experienced one non-injury fall since admission of 7/27/17. Based on documented falls dated 8/2/17, this data did not accurately reflect the number of falls. Review of resident #14's Progress Note, dated 8/5/17 at 8:48 p.m., showed, Resident did not follow instructions and did not use the call light as instructed to call for assistance with transferring. Resident slid off his bed and ended up on the floor. At 4:35 resident was found sitting on the floor by the CNA, (name). Resident stated that he was trying to get up and slid off his bed. Resident said that he did not suffer any injuries and did not hit his head. Resident was assessed. Review of a fax to the provider regarding resident #14, dated 8/10/17, showed, Resid (sic) slid out of bed this evening. Moving all extremities without diff. 0 (zero) obvious inj. Review of resident #14's Progress Note, dated 8/11/17 at 1:06 a.m., showed on 8/10/17 resident #14, Was found sitting on the floor by his bed and w/c. 'I was trying to take my socks off.' Moving all extremities. No obvious injury. Review of resident #14's Physician/Prescriber orders, dated 7/16/17, showed, #3. Head CT without contrast (unreadable) r/t 8/7 fall was ordered. This order was not followed by nursing staff. Review of resident #14's Physician/Prescriber orders, dated 7/21/17 showed, #2 Head CT without contrast r/t fall tomorrow. During an interview on 8/22/17 at 10:00 a.m., staff member BB, expressed concerns that orders were not being carried out in a timely manner, and for resident #14 a CT scan had not been secured when ordered, on 7/16/17. She said, I don't know that I can trust that my orders are going to be carried out. During an interview on 8/22/17 at 2:30 p.m., staff member DD said, I wasn't aware of the need for the CT scan until the (physician) reminded me yesterday. I've been wearing a lot of hats lately. (Staff member EE) and I have been sharing the ward clerk duties since (named staff) has been on vacation. (Staff EE) has been working the floor. Review of resident #14's progress note, dated 8/19/17, showed resident #14 had been found lying supine on the floor next to his bed at 7:00 a.m., and showed a basic physical assessment had been performed and no injuries were noted. No neuro checks were conducted. No root cause analysis of the fall was conducted. The writer noted the resident had received two units of packed red blood cells on 8/18/17. Review of resident #14's Fall Risk Assessment, dated 8/19/17, showed the resident scored a 23, with a score of 10 or above considered a fall risk. During an interview on 7/22/17 at 10:30 a.m., staff member FF, said, I worked the E-Wing unit on 8/19/17, it was my first day. I wasn't oriented to this unit when I arrived. There was supposed to be a second CNA on that unit, but they never showed up. At about 11:00 a.m. another CNA arrived at the unit to help. The day nurse was also late showing up. When she did show up she wouldn't help me, and went to the dining room to pass medications. Every time I would come out of a room there would be eight lights going off, and no one came to help me. On the second day (8/20/17) there was a second aide, but they came and got her and took her to a different wing. Staff member FF said, When I arrived in the morning (8/19/17) there was a guy on the floor (resident #14.) He fell twice on that date. Staff member FF said, When he fell I didn't even know where to find the vitals equipment. I think he had been there long enough, because he had pulled down a pillow and blanket. They had only had one night aide. She said, The second slide out of bed was at the end of the shift. Review of resident #14's Progress Notes and Fall reports for 7/19/17, showed no evidence or documentation of a second fall for the resident. During an interview on 8/23/17 at 8:30 a.m., staff member GG said, I changed to the 6:00 a.m. to 2:00 p.m. shift to be a bath aide the 1st of this month. The baths are not getting done. I have been pulled to the floor all but about two days. I was on this hall (E-Wing) last Monday by myself, just one aide. The nurses won't help because they are overwhelmed themselves. The nurses never help with ADL's, they will tell you to ask a CNA from another wing. The call lights just go off for over thirty minutes. There are a lot of fall risks. There are two person transfers that I usually just use a sit-to-stand for because I don't have help, and don't have time to go to another hall to find help. During an interview on 8/23/17 at 3:15 p.m., staff member AA said resident #14, Is forgetful and probably doesn't always use his call light. He said resident #14 had been independent prior to falling and breaking his hip. Staff member AA said, Staff is working to ensure the call-light and chair are placed where they should be in resident #14's room. He said resident #14 had been moved to the rehab wing earlier today (8/23/17), and the nurses on the rehab wing were more attuned to resident #14's type of acuity. Staff member AA said, I have worked at the facility for some time, and I know what a normal staffing ratio looks like. He said, Lately we have been very short staffed. During an interview on 8/24/17 at 8:45 a.m., staff member B said, We have not been able to locate any neuro checks for resident #14, and there has been nothing specific about resident #14's falls discussed in the fall committee. A review of the facility's policy, Sufficient Staffing, showed, 4. Nursing direct care staffing ratios will be figured with changes in census and level of care needs. A review of the facility's policy, Fall Prevention, showed, Initiate Neuro checks if resident hit head or unwitnessed fall. Documentation showed the resident had fallen at least five times since returning to the facility on [DATE]. No neuro checks were provided by the facility for any of the falls. Review of resident #14's Risk of Falls Care Plan, provided by the facility, showed, PT/OT eval and treat, w/c for locomotion, and weight bearing as tolerated were added to the interventions on 7/27/17, after returning from the hospital. On 8/5/17, I am very passionate to direct my own care. Often refusing therapy. They continue to work with me in strengthening. The care plan, dated 7/27/17, did not address call lights or frequent monitoring. 4. Resident #13 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of resident #13's 5-day PPS, dated 7/23/17, showed she had wandered 1-3 days during the look back period. Review of resident #13's Admit Progress Note, dated 7/8/17, with no documented time, showed, Stated she was falling bc (sic) her ex husband took away her Norco and then made her come on this vacation. Spoke with (hospital staff) stated the patient is not here on vacation, she moved here. Review of resident #13's Progress Note, dated 7/9/17, showed. Patient is confused and thinks she is here working as the DON. Patient has been trying to leave the facility and is considered an elopement risk. She also wrote a personal check and gave it to staff . Patient has been placed on watch and staff is locating and documenting Q 15 min as to where the patient is at. Review of resident #13's Progress Note, dated 7/18/17 at 1:38 p.m., showed, found (sic) resident pushing another resident in w/c (resident also from locked wing) down D wing hall, redirected and amb (sic) with both residents back to locked wing and alerted staff of prior departure. Progress notes do not hold evidence of documentation of a prior departure. Review of resident #13's Progress Note, dated 7/19/17 at 6:00 p.m., showed, Resident has escaped off locked unit three times this morning when other staff have opened the secured doors. She swats (sic) down against the wall hidden from view then sneaks out behind linen or housekeeping carts unobserved until caught by staff by the main nurses station and escorted back to unit; DON brought a wander-guard down and resident was very agreeable to wearing it when I explained it was a safety device to help us from loosing rack (sic) of her; She informed me she looses herself all the time and was tankful for all the safety she could get. Review of resident #13's Care Plan, dated 7/25/17, showed no care plan was developed in regards to elopement, the risk of elopement, or the use of a Wander Guard. A review of the facility's policy, Elopement, reflected, the facility did not consider escaping the secured unit an elopement. The threshold for elopement was escaping the building. During an interview on 8/23/17 at 1:30 p.m., staff member's A and C, stated that unless a resident elopes out of the building it was not considered an elopement. Because she had only left the secure unit, the incidents were not reported to the State Survey Agency. Surveyor: Latham, Lori",2020-09-01
108,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2017-08-24,353,H,1,1,4UNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to provide sufficient staff for resident safety, and the provision of care and services, to include: the failure to provide restorative services for 2 (#s 3 and 20); for the failure to assess, supervise, monitor, and implement interventions to prevent and reduce accidents and hazards for 7 (#s 3, 6, 9, 14, 15, 16, and 18); for the failure to identify risk factors, and implement interventions, in an attempt to adequately protect the residents and prevent future occurrences of abuse, for 6 (#s 7, 8, 9, 22, 23, and 24); for the failure to provide timely and adequate service for the provision of answering call lights, for 1 (#26), hydration for 1 (#15), and psychosocial well being and safety, for 1 (#30); and failed to provide timely and adequate bathing and shower services to meet the residents individualized needs, for 4 (#s 3, 4, 15, and 20) out of 30 sampled and supplemental residents. Findings include: STAFFING During a private meeting on 8/22/17 at 10:00 a.m., residents stated staffing was bad, especially on weekends. Often one CNA was on the halls. Mail was not always delivered timely or received by residents, especially during the weekends. Medications were late, bathing was not getting done, restorative not being offered, and answering call lights could be up to an hour and a half before a staff member answered. The residents stated they were only receiving one to two showers/baths a month. The consensus was that the facility had a problem with not having enough staff. During an interview on 8/22/17 at 11:24 a.m., NF1 stated the facility was constantly short of staff. NF1 stated only one CNA was on [NAME] Hall, 8/19/17, until 11:00 a.m. NF1 stated the nurses did not help the CNAs if the facility was short of CNAs. Three weeks ago, NF1 stated giving a grievance to the administrator, about staffing, and stated being worried her husband would not receive the care he required, if she was not there. I have seen many, many times when there was only one CNA to 33 residents. During an interview on 8/21/17 at 1:49 p.m., resident #15 stated there was a shortage of CNAs for three months. Resident #15 stated knowing CNAs were working short when she did not received water one to two times a day, in her room, from the water wagon. During an interview on 8/22/17 at 2:35 p.m., resident #3 and NF2 stated staff were to use a hoyer lift for resident #3. Both stated when nursing staff was low, only one staff member would work the hoyer lift. Review of resident #3's Plan of Care, with a revision date of 2/19/16, showed resident #3 required a hoyer lift to transfer with two person assist. Review of resident #3's physician progress notes [REDACTED]. Resident #3 was to be primarily in bed, but sometimes a challenge with getting to bed due to staffing issues. During an interview on 8/24/17 at 11:55 a.m., staff member [NAME] stated she was new at the job, and had no previous orientation on the floor. Staff member [NAME] was placed with another staff member, for training. There was an altercation with a resident and the staff member who was training staff member E. Staff member [NAME] ended up working the floor by self and one CN[NAME] The next day, staff member [NAME] was to orientate with a staff member but there was not enough staff. Staff member [NAME] worked the floor again with no training. Two days prior to the interview, staff member [NAME] stated there was her and another nursing staff member, with three to four weeks experience, and two CNAs, on the night shift, for six halls, for care of approximately 102 residents. During an interview on 8/23/17 at 10:09 a.m., staff member A stated a large exodus of staff was noted in June, (YEAR). The Quality Assurance Program had not formally identified a staffing shortage, but had started a recruitment plan, and a retention plan, to address staff satisfaction, four days prior to the interview date. During an interview on 8/23/17 at 2:25 p.m., resident #26 stated he has had a hard time getting his call light answered and had to wait for as long as two and one half hours. Resident #26 stated there was usually one CNA on his hall. During an interview on 8/23/17 at 3:17 p.m., staff member H stated she didn't have time to answer call lights because of short staffing. During an interview on 8/21/17 at 3:50 p.m., NF3 stated the last three Mondays, the memory care unit had one CNA on day shift. The nurse on duty told him she could not watch all the residents, because she did not have two CNAs on shift. During an interview on 8/22/17 at 1:40 p.m., NF4 stated the facility did not have enough staff. She stated she was receiving lots of concerned phone calls from family members, and families were moving their loved ones because of care needs not being met. During an interview on 8/22/17 at 5:10 p.m., staff member II stated the facility was completely understaffed and it had gotten worse and worse since (MONTH) (2017). During an interview on 8/23/17 at 2:05 p.m., resident #30 stated her stay at the facility had been horrible and that there were too many residents for the CNAs. I feel abused here. They have problems here, big problems. During an interview on 8/22/17 at 10:30 a.m., staff member FF, said, I worked the E-Wing unit on 8/19/17, it was my first day. I wasn't oriented to this unit when I arrived. There was supposed to be a second CNA on that unit but they never showed up. At about 11:00 a.m. another CNA arrived at the unit to help. The day nurse was also late showing up. When she did show up she wouldn't help me, and went to the dining room to pass medications. Every time I would come out of a room there would be eight lights going off, and no one came to help me. On the second day (8/20/17) there was another aide, but they came and got her and took her to a different wing. Staff member FF said, When I arrived in the morning (8/19/17) there was a guy on the floor (resident #14.) He fell twice on that date. Staff member FF said, When he fell I didn't even know where to find the vitals equipment. I think he had been there a long enough, because he had pulled down a pillow and blanket. They had only had one night aide. She said, The second slide out of bed was at the end of the shift. During an interview on 8/23/17 at 8:30 a.m., staff member GG said, I changed to the 6:00 a.m. to 2:00 p.m. shift to be a bath aide the 1st of this month. The baths are not getting done. I have been pulled to the floor all but about two days. I was on this hall (E-Wing) last Monday by myself, just one aide. The nurse won't help because they are overwhelmed themselves. The nurse never helps with ADL's, they will tell you to ask a CNA from another wing. The call lights just go off for over thirty minutes. There are a lot of fall risks, there are two person transfers that I usually just use a sit to stand for because I don't have help, and don't have time to go to another a hall to find help. Staff member GG said the facility had been using a Companion Aide as a CNA, she said the Companion Aide was not CNA certified. During an interview on 8/23/17 at 1:30 p.m., staff member O said, I have worked as a Companion Aide for two months. She was to be trained as a CNA at the facility. She said she did not have a skills check list and was not a CN[NAME] Staff member O said mostly she has worked doing hydration, linen, answering lights, and shadowing another CNA on the floor. She said she had not received any class room training. Staff member O said, There has been a few times that we used the lift to get someone off the toilet, who had been there a while. I worked as a CNA about a week ago; combing hair, changing shirts, brushing teeth. I did not do peri care. I have done feeding in the dining room. Staff member O said, (Staff member K) told her to be a CNA when they were shorthanded. I never got trained to be a Companion Aide. During an interview on 8/24/17 at 9:50 a.m., staff member KK said, I used to do the staffing schedule. I was always asking for more staff and corporate would turn me down. The Administrator would try to get travel personnel, but he would not get any. In May, (YEAR), they said they would change to twelve hour shifts. This was mandatory. Some of the CNAs quit because they said they have nowhere to go for help and are working alone. BATHING Review of the Resident Council minutes, for (MONTH) 7, (YEAR), showed residents had concerns with nursing staff. Review of the Resident Council minutes, for (MONTH) 5, (YEAR), showed seven out eleven residents identified bathing as a concern. Review of the Grievance/Concern Report Form, dated 7/5/17, showed staff member B addressed the grievance by scheduling designated bath attendants. Review of the Resident Council minutes, dated (MONTH) 2, (YEAR), showed the residents at the meeting still had bathing concerns. A resident had identified staffing issues on the weekends. The resident had said in the meeting that she required a two person lift. Relating to the staffing shortage the weekend of 7/30/17, the resident remained in bed because of the staff shortage. Review of the Grievance/Concern Report Form, dated 8/2/17, showed staff member B had not addressed the concerns with the bathing issues, and the issue continued to cause stress for those residents who attended the resident council, on 8/2/17. During an interview on 8/21/17 at 1:49 p.m., resident #15 stated receiving one shower every 10 days. Resident #15 stated she used a wash cloth to bath herself, when there were no baths/showers provided. Review of the facility bathing sheets, with dates from the last bath/shower given until present, showed resident #15 received four showers from 5/13/17 until 8/21/17. Resident #15 had four showers in 101 days documented as provided. During an interview, on 8/22/17 at 11:24 a.m., NF1 stated resident #20 had not received a shower from 8/9/17 until 8/21/17. If no bath aides are on the schedule, no baths are given. During an interview on 8/22/17 at 2:35 p.m., resident #3 stated he received only one shower every two weeks. Resident #3 stated that was not enough showers. Review of the bathing sheets, with dates from the last bath/shower given until present, showed resident #3 received three showers from 5/16/17 until 8/21/17. Resident #3 had three showers in 98 days documented. During an interview on 8/22/17 at 9:00 a.m., resident #4 stated she would routinely go 15 days without a shower. Resident #4 stated there is not always enough staff to meet her needs. Review of resident #4's bathing sheets showed four showers in the last 11 weeks. During an interview on 8/21/17 at 2:28 p.m., staff member T stated residents were not receiving showers/baths timely related to the call offs and short nursing staff. During an interview on 8/21/17 at 4:30 p.m., staff member BB stated baths/showers did not get done because of short staffing due to call offs and no shows. During an interview on 8/22/17 at 10:09 a.m. staff member A stated the Quality Assurance Committee had identified residents not receiving baths, in the (MONTH) (YEAR) meeting. A bath aide was hired and quit, shortly after. A CNA was recently put into the bath aide position. During an interview on 8/22/17, at 5:00 p.m. staff member B stated the facility had instituted, a couple weeks before, two bath aides per day. Yes, they have been pulled to the floor. The restorative aides have been pulled to the floor. During an interview on 8/23/17 at 3:17 p.m., staff member H stated it had been hard to get baths/showers completed because of short staffing and some residents had not had a bath/shower for six weeks. Review of the most current MDSs for the 21 sampled residents showed 'no shower was completed' in section G, during the 7-day look-back period, for 14 out of 21 residents. RESTORATIVE During an interview, on 8/22/17 at 2:35 p.m., resident #3 and NF2 stated resident #3 was to receive restorative therapy three times a week. Resident #3 and NF2 stated the resident wasn't receiving restorative therapy as ordered. Review of resident #3's care plan, with a review completion date of 5/2/17, showed the resident had leg spasms with pain. Interventions were to complete range of motion on the resident's lower left extremity Review of the restorative aide's worksheets, dated 6/10/17 through 8/11/17, showed resident #3 received restorative 14 times out of 9 weeks. During an interview on 8/24/17 at 9:16 a.m., staff member R stated trying to work with resident #3 daily, but could not if the staff member was pulled to the floor, I can't do two jobs. Review of a Nursing restorative progress note, dated 6/1/17, showed resident #20 was to receive restorative, 3-5 times a week. Review of the restorative aide's worksheets, dated 6/10/17 through 8/11/17, showed resident #20 received restorative sessions 14 out of 27 required sessions. During an interview on 8/22/17 at 7:56 a.m., staff member R stated, when pulled to the floor to be a CNA, she was unable to work with the residents who required restorative services. Staff member R stated residents, on the restorative program, were not receiving what was specifically ordered. Staff member R identified that the CNA staffing shortage made it difficult to offer restorative services, as ordered. During an interview on 8/22/17 at 5:00 p.m., staff member B stated The restorative aides have been pulled to the floor, when there was CNA staff shortage. FALLS Review of the Incidents By Incident Type report for May, (YEAR), showed resident #9 had five unwitnessed falls. Review of the Incidents By Incident Type report for June, (YEAR), showed resident #6 had three unwitnessed falls, and resident #9 had two unwitnessed falls. Review of the Incidents By Incident Type report for July, (YEAR), showed resident #9 had two unwitnessed falls, resident #6 had one unwitnessed fall, and resident #15 had one unwitnessed fall. Review of the Incidents By Incident Type report for August, (YEAR), showed resident #14 had four unwitnessed falls, and resident #9 had two unwitnessed falls. Review of the Incidents By Incident Type reports showed the number of unwitnessed falls doubled from (MONTH) to August, (YEAR). During an interview on 8/23/17 at 4:30 p.m., staff member C stated the facility had no documentation regarding a fall for resident #16, that resulted in a dislocated hip. Review of resident #18's Progress Note, dated 8/9/17, showed resident #18 had an unwitnessed fall in which the resident sustained [REDACTED]. On 8/10/17, the resident was sent to the emergency room for evaluation of left hip pain. The resident returned to the facility with a [DIAGNOSES REDACTED]. During an interview on 8/23/17 at 3:15 p.m., regarding resident #14's falls in the facility, staff member AA, said, I have worked at the facility for some time, and I know what a normal staffing ratio looks like. He said, Lately we have been very short staffed. Refer to F323, Accidents and Hazards, relating to fall information. ABUSE Review of the State Survey Agency, facility event report, dated 6/4/17 and 6/28/17, showed resident #7 fondled the breasts of resident #s 8, 22, 23, and 24. Review of the State Survey Agency, facility event report, dated 7/25/17 showed physical and verbal abuse were substantiated against staff member Z toward resident #9. During an interview on 8/21/17 at 3:50 p.m., NF3 stated the last three Mondays, the memory care unit had one CNA on day shift. The nurse on duty told him she could not watch all the residents, because she did not have two CNAs on shift. During an interview on 8/23/17 at 3:00 p.m., staff member LL stated she could confirm a day where there was one CNA in the unit, during the month of August, (YEAR). During an interview on 8/22/17 at 7:35 a.m., staff member L stated she had been the only CNA on the memory care unit on several occasions, and could not provide the expected supervision for the 28 residents. Refer to F225 and F226 relating to abuse.",2020-09-01
109,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2017-08-24,425,D,1,1,4UNG11,"> Based on observation and interview, the facility failed to properly store colace 100 mg tabs, in 1 of 3 medication carts inspected, which had the potential to affect any resident using the medication. Findings include: During an observation of medication administration, on 8/24/17 at 7:54 a.m., four colace 100 mg tabs were in a souffle' cup in the top drawer of the medication cart. The souffle' cup was not labeled with the resident's name, drug, or time. During an interview on 8/24/17 at 7:54 a.m., staff member HH said, We are sharing the colace because we don't have enough of it. She said the nursing staff was sharing the colace throughout the building, for about the last week. We will run out of something and it doesn't come in. It happens. I don't like it. I got that cup this morning because I knew I needed it. Technically I should have wrote (sic) the dosage on the cup too. During an interview on 8/24/17 at 9:00 a.m., staff member B said, The nurses should not be taking medications out of the container before use. A review of the facility's policy, Medication Over the Counter, did not cover the protocol for storing medication that was no longer in its original container, in the medication cart. A review of the facility's policy, Medication Pass, showed the nurse would .4. a. Determine the medication name and dose needed and find the corresponding medication in that resident's card, box or bottle .Always follow the five rights; Right resident; right medication; right time; right does; right route. This would not have been possible as the medication was no longer stored in its original container.",2020-09-01
110,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2017-08-24,441,E,0,1,4UNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to implement infection control practices, by nursing staff handling medications with bare hands, and by not sanitizing the pill cutter after use, when administering medication to 2 (#s 27 and 28), and failed to implement infection control practices when cleaning a glucometer after use on 1 (#29), of 6 residents included in the medication pass observation. Findings include: During an observation of the medication pass on 8/24/17 at 7:26 a.m., while administering medications to resident #27, staff member HH used her bare hands to pick up a 1/2 pill out of the pill cutter, and place it in a souffle' cup. Staff member HH then picked up the other half of the pill with her bare hands and put the pill back into the blister pack, from where she had taken the pill. She then placed tape over the slot with the pill in the blister pack. Staff member HH did not clean the pill cutter after use. She said, the resident had received a new order for [MEDICATION NAME] yesterday, and, I called (the) pharmacy and they said the new order will be in soon and I should cut one in half. During an observation of the medication pass on 8/27/17 at 7:54 a.m., while administering medication to resident #28, staff member HH used her bare hands to take an [MEDICATION NAME] pill from resident #28. Resident #28 had said, Can you please break this in two for me. After cutting the pill, staff member HH picked the two halves of the pill up with her bare hands and returned them to resident #28. Staff member 28 did not clean the pill cutter after use. A review of the facility's policy, Medication Pass, did not show evidence that touching medications with bare hands was addressed. The policy showed, 17. Wash hands between each resident. (MONTH) use hand sanitizer. During an observation of the medication pass on 8/24/17 at 7:52 a.m., after using the glucometer on resident #29, staff member HH had placed the used meter on the top of the medication cart, and did not have a barrier between the glucometer and the cart top. She then cleaned the meter with a wipe and placed the meter back down on the top of the medication cart where it had sat prior to being cleaned. A review of the facility's policy, Blood Glucose Monitor Disinfection, showed, .Equipment .5. Towel/paper towel .7. The disinfected monitor will be placed on a towel/paper towel. During an interview on 8/24/17 at 8:30 a.m., staff member HH said she had been trained to not touch medications when she set them up and delivered them to the residents. She also said she knew she should place a barrier between the glucometer and the work surface, and should not return the glucometer to a dirty area. Staff member HH said, I guess I have developed some bad habits. During an interview on 8/24/17 at 9:00 a.m., staff member B said, Medications should not be handled with bare hands.",2020-09-01
111,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2017-08-24,490,K,0,1,4UNG11,"Based on record review and interview, the facility failed to utilize resources available and administer the facility adequately to ensure resident supervision, relating to care and services, and to protect residents from abuse, and to prevent and reduce falls with and without fractures for 9 (#s 6, 7, 8, 9, 14, 18, 22, 23, and 24) of 30 sampled and supplemental residents. Findings include: On 8/23/17 at 2:04 p.m., staff members A, B, C, and U were notified of an Immediate Jeopardy situation in the area of F226-J, Abuse, F323 Accidents - K, and F490 Administration - K. 1. Review of the State Survey Agency, facility event report, dated 6/4/17, showed the facility moved a resident with an identified behavior (resident #7) of unwanted sexual contact into a unit with 28 demented residents, to include resident #s 8, 22, 23, and 24. Record review of resident #7's progress note, dated 6/28/16, showed three female residents were identified as having their breasts fondled. Record review of resident #7's care plan and progress notes, for (MONTH) and July, (YEAR), showed the facility did not implement interventions after this incident on 6/28/17, to protect the residents from further abuse. Review of a Progress Noted, dated 6/9/17, four days after placement on the secured unit, resident #7 was observed kissing a female resident; he was told to go to his room, but no further action was taken. During an interview on 8/21/17 at 1:45 p.m., staff member B stated the facility had not reassessed the appropriateness of the resident's placement of the secured unit, which was meant to be a temporary move. Resident #7's Quarterly MDS, with the ARD of 6/2/17, showed he had a higher level of cognition than the residents who he fondled, or who he made unwanted advanced toward. Review of #7's Progress Note, dated 7/22/17, showed the resident was observed 'persuading' a female resident to come into a room. The facility implemented an increase in supervision on 8/22/17, after the survey team identified the concern. Refer to F226 for more information relating to this deficiency. 2. Review of the facility Incident By Incident Type report showed 13 unwitnessed falls in May, (YEAR), which had doubled to 26 unwitnessed falls in August, (YEAR). Three of the falls resulted in significant injuries, which were fractures, for residents #s 6, 14 and 18. Resident #9 fell 11 times in four months. During an interview on 8/23/17 at 10:15 a.m., staff member B stated falls had been identified as a concern for the facility, and the facility had just began implementing a fall prevention program. A 'Performance Improvement Project for falls had not been implemented. During an interview on 8/23/17 at 10:09 a.m., staff member A stated a large exodus of staff was noted in June. The Quality Assurance Program had not formally identified a staffing shortage but had started a recruitment plan, and a retention plan to address staff satisfaction, on 8/19/17. She stated the facility began using Agency staff on 7/31/17, related to the lack of adequate staff for the facility. Refer to F353 for staffing details, and deficient practices.",2020-09-01
112,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2017-08-24,494,D,0,1,4UNG11,"Based on interview and record review, the facility failed to ensure untrained staff did not function as a CN[NAME] This practice had the potential to affect any resident cared for by the staff member. Findings include: During an interview on 8/23/17 at 8:30 a.m., staff member GG said, The facility has been using a Companion Aide as a CNA, and The Companion Aide is not CNA certified. During an interview on 8/23/17 at 1:30 p.m., staff member O said, I have worked as a Companion Aide for two months. She said she was to be trained as a CNA at the facility. Staff member O said, she did not have a skills check list and was not a CN[NAME] Staff member O said she mostly had worked doing hydration, linens, answering lights, and shadowing another CNA on the floor. She said she had not received any class room training. Staff member O said, There has been a few times that we used the lift to get someone off the toilet, who had been there for a while. And, I worked as a CNA about a week ago; combing hair, changing shirts, brushing teeth. I did not do peri-care. I have done feeding in the dining room. Staff member O said, (Staff member K) told her to be a CNA when they were shorthanded. And, I never got trained to be a Companion Aide. A review of the State Certified Nursing Assistant program, CNA listing, failed to show staff member O had received the required education and CNA certification, for the provision of direct resident care, as stated above.",2020-09-01
113,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2017-08-24,520,E,0,1,4UNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the Quality Assurance Program was effective in identifying quality deficient practices, and implementing timely corrections for these practices, relating to abuse, fall prevention and adequate staffing; and, failed to have the Medical Director attend the Quality Assurance meeting, as required. This practice had the potential to affect all residents in the facility. Findings include: During an interview on 8/23/17 at 10:09 a.m., staff member B stated the Quality Assurance meeting occurred monthly, and the committee had been working on these areas: the provision of weekly bathing, following physician orders, and fall prevention. She stated the fall prevention plan had just started in August, (YEAR), and a fall committee was meeting weekly. She stated she had completed bath audits, and the outcome was not good. She also stated audits were completed on how physician orders [REDACTED]. Concerns with resident #7's abuse situation and move to the locked unit had not been discussed by the Quality Assurance committee. During an interview on 8/22/17 at 10:25 a.m., staff member BB stated she had attended maybe four meetings in three years. She stated she had asked to be invited, but was not notified of the meetings. She stated she felt she was not involved in the Quality Assurance Program for the facility. She had concerns regarding the care of the residents. During an interview on 8/23/17 at 10:20 a.m., staff member A stated the facility was implementing a recruitment and retention program to improve staffing. She stated the facility would be doing a better job of appreciating and communicating with the current staff. During an interview on 8/24/17 at 9:20 a.m., staff member A stated the facility could not find the bath audits, and the fall meeting notes were not adequate or meaningful, and the facility would be changing their fall policy and procedure.",2020-09-01
114,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2018-09-18,580,D,1,0,VB9B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to notify family members of a resident's transfer to the emergency department and subsequent hospital admission for 1 (#1) of 8 sampled residents. This failure caused undue anxiety for NF1. Findings include: During an interview on 9/17/18 at 4:35 p.m., NF1 said the facility had not called the family when resident #1 was transferred from the facility on 6/9/18. NF1 said the family received notification from a Hospitalist on 6/10/18 at 11:00 a.m. the resident #1 was in ICU. NF1 said the Hospitalist told the family they needed to come to the hospital quickly because resident #1's health was declining rapidly. NF1 said she and her husband, the resident's brother, got the hospital within an hour of the phone call. NF1 said resident #1 was in a coma like state when they got to her room in the ICU. NF1 said the resident did wake up but was not able to communicate with NF1 or the resident's brother. NF1 said resident #1 passed away on 6/12/18. NF1 said if the hospital had not called her, they would not have known resident #1 was not at the facility until NF1 had shown up for the scheduled hematologist appointment on 6/11/18. NF1 said she did not understand why the facility had not contacted them of resident #1's transfer to the emergency department, or the resident's admission to the hospital. NF1 said the facility had called her on 6/8/18 to tell her resident #1 had an appointment on 6/11/18 with a hematologist. NF1 said she or her husband, resident #1's brother, went to every doctor appointment with the resident. NF1 said they both had attended the initial care plan meeting for resident #1. NF1 said resident #1 had been admitted to the facility on [DATE]. NF1 said because of the delay in notification on resident #1's admission to the hospital, her other brother, who lived in Virginia, was unable to get to the hospital prior to the resident's death. NF1 said the whole situation increased her anxiety to unmentionable levels. During an interview on 9/18/18 at 11:45 a.m., staff member B said the family was not notified of resident #1 being transferred to the emergency department, or of the resident's admission to the hospital. Staff member B said resident #1 did not want her family knowing everything about her. Staff member B said that was why the facility did not notify the family of resident #1's transfer for a transfusion or admission to the hospital. The facility was unable to provide any documentation to show this was true. Review of resident #1's progress note, dated 6/9/18, showed the resident had been taken to the ER at 10:00 a.m. via the facility's van. The note further showed the resident was sent for a transfusion. Review of resident #1's progress note, dated 6/10/18, showed, Resident Family came in today upset that they were noted (sic) notified Resident went to the Hospital for a transfusion on Saturday. They only knew when the Hospital called and told them that she was in ICU. Review of resident #1's demographic information, dated 9/17/18, showed NF1 and her husband, the resident's brother, were emergency contacts for the resident. Review of the facility's policy, Resident, Physician and Resident Representative(s) Notification, with a revision date of 11/2016, showed, Procedures: The facility will immediately inform the Resident; consult with Physician/PA/NP; and inform the Resident Representative(s) when there is a change in condition such as but not limited to: C. A need to alter treatment significantly, such as discontinuing an existing treatment or commence a treatment. D. A decision to transfer or discharge the resident from the facility.",2020-09-01
115,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2018-09-18,623,D,1,0,VB9B11,"> Based on interview and record review, the facility failed to have a system in place for notification of transfer or discharge, in a emergent situations, for 2 (#s 1 and 2) of 8 sampled residents. Findings include: 1. Resident #1 was transferred to the emergency department on 6/9/18 for a transfusion, and was admitted to ICU at that time. The facility failed to provide a notice of transfer or discharge to the resident, a family member, or a resident representative. During an interview on 9/17/18 at 4:35 p.m., NF1 said the facility had not provided a transfer/discharge notice to the family for resident #1. Review of resident #1's medical record, dated 5/14/18 to 6/9/18, failed to show a transfer/discharge notice was provided to the resident or her family members. 2. Resident #2 was transferred to the emergency department on 2/11/18. The resident, a family member, or a resident representative, was not provided a notice of transfer or discharge. During an interview on 9/18/18 at 7:58 a.m., NF2 said resident #2 had been sent to the ER because she had yellow skin, a fever, and was complaining her stomach her. NF2 said she was at the facility, and insisted resident #2 be sent to the ER. NF2 said the facility did not provide her or the resident with a transfer/discharge notice. Review of resident #2's medical record, dated 1/5/18 to 2/11/18, failed to show a transfer/discharge notice was provided to the resident or her family members. On 9/17/18, transfer/discharge notifications were requested for resident #s 1 and 2. During an interview on 9/18/18 at 9:07 a.m., staff member A said residents transferred or discharged from the facility, prior to 8/1/18, were not provided with a transfer or discharge notification. A review of the facility's policy, Discharge Plan and Summary, with a revision date of 11/2017, showed, 13. Except for the 'Closure of a facility,' a notice of transfer or discharge will be made by the facility at least 30 days before the resident is transferred or discharged . b. Notice will be made as soon as practicable before transfer or discharge when: i. The safety of the individuals in the facility would be endangered d/t (sic) clinical or behavioral status of the resident ii. The health of the individuals in the facility would otherwise be endangered iii. The resident's health improves sufficiently to allow a more immediate transfer or discharge because he/she no longer needs the services provided by the facility iv. The resident has not resided in the facility for 30 days. The facility's policy does not outline that a system in place for notice of transfer or discharge in an emergent situation.",2020-09-01
116,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2018-09-18,842,B,1,0,VB9B11,"> Based on observation, interview, and record review the facility failed to have a system in place to access resident records discharged from the facility prior to 6/30/18. Findings include: During an observation on 9/17/18 at 11:15 a.m., access was provided to the facility's electronic health record. Several attempts were made to access the medical records of residents no longer residing at the facility. It was observed that residents discharged from the facility prior to 6/30/18, their records were unavailable for review. During an interview on 9/17/18 at 10:50 a.m., staff member A said the facility would not be able to give the surveyors access to residents discharged from the facility prior to (MONTH) of (YEAR). Staff member A said another person was working with the electronic health records software company to provide access. The facility was able to provide copies of discharged resident records after an extended delay of 8 hours. The facility was never able to provide direct access to the electronic health record for the discharged residents.",2020-09-01
117,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2017-11-22,166,D,1,0,D7BM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to identify a Grievance Officer; failed to promptly follow-up on a grievance, document the date the original grievance was filed, notify the resident in writing of the decision, and document the date the written decision was issued for 1 (#2) of 11 sampled and supplemental residents. Findings include: 1. Resident #2 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The resident was discharged to another facility on 11/3/17. During an interview on 11/21/17 at 9:36 a.m., resident #2's family member stated the day the resident was discharged on [DATE], he did not have his dentures in his mouth. She stated she asked the facility staff where his dentures were and she was told one of the CNAs took his dentures out the night before around 2:00 a.m. She stated she and the facility staff both looked in the room, the dining room, and other areas where the resident's dentures might have been placed. She was told by the facility staff they will file a concern regarding the missing dentures and had planned to follow up with her about the outcome. The family member stated she did not hear back for over a week from the facility. She stated she called several times during that week and left messages to have staff member A and/or staff member C call her back regarding the missing dentures. She stated she called for a third time a week later to follow up with the Staff member A, whether facility had found resident #2's dentures. She stated when she called, she was told by the person whom answered the phone, they believed they had found the dentures and she could come and pick them up. When she arrived at the facility, she was told staff member A wanted to discuss something with her first. She stated when she entered the staff member A's office, he held up a broken partial and told her they thought they had found resident #2's dentures. She explained to staff member A, the item they found was a partial, and not the resident's dentures. She stated staff member A told her the resident put his dentures in his pillowcase and they broke in half, and that was all that was left of the resident's dentures. She stated she had explained to staff member A, the resident had never placed his dentures in his pillowcase and the partial he was trying to claim was his fathers, was not. She told staff member A she had an invoice for the dentures in her vehicle and she would be happy to provide that to him for reimbursement of the lost dentures. She stated staff member A had proceeded to tell her it was not their responsibility but the resident's for putting the dentures in his pillowcase. Resident #2's family member stated she attempted to follow-up a couple more times with staff member A about the missing dentures and was told by staff member A they were still looking for the dentures and to call him back next week because he was currently too busy. She stated she called the staff member again on 11/21/17 and he told her to send in the invoice and they will review the cost, but he told her they could not commit to the cost of the dentures; and explained they were not sure yet if they would replace the cost or not. She stated she was not satisfied the grievance had been resolved as of 11/21/17. She stated since the dentures were lost on 11/3/17, she had made several attempts to contact the facility via the phone and left several messages, never hearing back. She stated she even called the hot-line number, which was posted in the entryway of the facility. She was told by the person on the hotline, either staff member A or C would call her back. She stated she never heard back from either staff member. She stated she had not received a letter of resolution on the grievance. Review of the facility's Grievance Log, showed a grievance was logged on 11/3/17 for resident #2, regarding missing dentures, the outcome was written as, initiating staff interviews relating the lost dentures. The grievance was not marked resolved and did not identify on the log the responsible associate for the investigation and follow-up of the concern. Review of resident #2's Grievance/Concern Report Form, dated 11/10/17, failed to establish the date and time the incident occurred. The nature of the grievance was marked as missing item. The following summary was written, (staff member C) looked in room, nurse station, nourishment room, laundry, and nurse cart for teeth (both dentures) not found. Interview with staff members, all staff state he kept taking them out and leaving them in blankets, wrapped in napkin, pocket for some reason he could not keep them in his mouth. The person responsible for follow up was left blank. The action taken to address grievance showed, waiting for faxed copy of invoice from (resident #2's family member). Administrator spoke with her 11/22/17 at 0900. The date of follow up with resident was written in as, discharged . The section which asked if the grievance was resolved within 72 hours, was checked no, but no additional documentation was provided for rationale. The form was signed completed by staff member A on 11/21/17. The grievance form failed to identify the date the original grievance was filed, which was 11/3/17. The facility failed to respond promptly with a written resolution for resident #2. During an interview on 11/20/17 at 7:00 p.m., staff member A stated staff member C had found resident #2's dentures in a pillowcase the Friday after the resident discharged . Staff member A stated they facility was still investigating the loss of the dentures. Staff member A stated the family member never brought an invoice in to him so they could consider replacing the dentures. During an interview on 11/21/17 at 1:30 p.m., staff member A stated it was the expectation to follow up on a grievance within 72 hours. He stated that time frame was difficult to follow because the facility was very busy. He stated he was the responsible individual for investigating the grievance for resident #2. He stated the resident was restless and kept removing his teeth, and putting his teeth in various places in his room. He stated staff member C searched in several different places and found his dentures in a pillowcase. He stated he called and left a message for resident #2's family member to let her know they had found the dentures. He stated he did not document the discovery of the dentures or the phone call to the family member. Staff member A stated there was no possible way to document everything he did for resident #2. Staff member A stated he did not have a Grievance Officer at the time of the grievance was placed by resident #2, so he managed the grievance. Staff member A stated resident #2's family member was angry and was demanding a check for the dentures. He stated he was still considering the missing dentures and had not completed the investigation yet. He stated even though he had signed the grievance form as completed, the investigation was not yet complete. He stated he did not have time to consider the missing dentures, and it did not do any good to spend hours looking for the missing dentures, since they were lost. Staff member A stated he planned to write a statement for the grievance regarding resident #2, showing what he did and did not do, as well as claiming the grievance was still under investigation. During an interview on 11/27/17 at 10:00 a.m., resident #2's family member stated she heard back from staff member A on Friday (11/24/17), and was told they would send a check to resident #2's dentist for the lost dentures. The facility failed to establish a Grievance Officer, and failed to accurately document time and date, in writing, the resolution of the grievance for resident #2. During an interview on 11/22/17 at 12:10 p.m., staff member B stated it was the expectation of the facility to identify a Grievance Officer, and follow up on any grievance with the outcome and resolution of the investigation. A review of the facility's policy and Procedure titled, Grievance/Concern, showed, To ensure the resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal. Such grievances include those with respect to care and treatment which have been furnished as well as that which has not been furnished, the behavior of staff and of other resident; and other concerns regarding their LTC facility stay. b. Thorough postings, in prominent locations throughout facility of the right to file grievances orally or in writing, the right to file grievances anonymously, the contact information of a grievance official with whom a grievance can be filed: name/mailing and/or email address; business phone number, that facility's policy is to complete and review results with resident/resident representative within 72 hours of receipt of concern/grievance; their right to receive a written decision regarding concern/grievance; and include contact information of independent entities with whom grievances may be filed .c. Will be responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility of all information associated with grievances; issuing written grievance decisions to the resident .",2020-09-01
118,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2017-11-22,225,G,1,0,D7BM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to report and investigate an injury of unknown origin which resulted in a right hip dislocation which required surgery for [REDACTED]. The facility failed to report a repeat in injury of unknown origin to the State Agency for 1 (#1) of 11 sampled and supplemental residents. This deficient practice had the potential to affect all vulnerable residents receiving care provided by the agency. Findings include: The facility failed to document the incident which resulted in the re-hospitalization of the resident for a left [MEDICAL CONDITION] on 11/10/17, and a right hip dislocation on 11/19/17. Review of resident #1's clinical record, showed the resident had an injury of unknown origin which resulted in the hospitalization and surgical repair of a right [MEDICAL CONDITION] which occurred on 10/31/17. The first injury, which occurred on 10/31/17, was reported and investigated by the facility. A second injury of unknown origin occurred on 11/10/17 which resulted in a second hospitalization for surgical repair of a right [MEDICAL CONDITION]. The facility failed to report the incident to the state agency, but an investigation was completed on 11/10/17 (see section B). The third incident which occurred on 11/19/17 resulted in injury of unknown origin which required a third hospitalization in less than one month, and a third surgical intervention to repair a dislocated right hip, this incident was not documented, reported or investigated (see section A). 1. Resident #1 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of resident #1's Quarterly MDS with 9/29/17, showed the resident had a BIMS of 9, severely cognitively impaired. During an observation on 11/22/17 at 10:00 a.m., resident was asleep, laying on his back in bed. He had a wedge between his legs, which was strapped to keep the wedge in place. During an interview on 11/20/17 at 9:30 a.m., resident #1's wife stated the resident had been admitted to the facility due to his advanced dementia, and she could no longer care for him at home. She stated the resident had been hospitalized three separate times since 10/31/17 for two [MEDICAL CONDITION] and most recently, a hip dislocation. She stated the resident required surgery on all three of these incidents. She stated the facility had notified her of all three occurrences, but she was worried about her husband, and could not understand why he had had so many injuries. [NAME] Right Hip Dislocation Review of resident #1's clinical record failed to reflect documentation which would explain the events which occurred on 11/19/17, to reflect why the resident was sent to the emergency department for evaluation of his right hip pain. Review of resident #1's Emergency Department Note, dated 11/19/17, showed, [AGE] year-old male sent over from (facility) via EMS with report of patient was found moaning in bed. He has a history of underlying dementia, and per EMS report he has had recent bilateral hip surgeries and has a spacer between his legs. Nursing notes .there is no report of recent falls. Review of resident #1's Pelvic X-Ray, dated 11/19/17, showed, dislocated right hip hemiarthroplasty with skin staples again noted laterally. There is an oblique latency overlying the femur at the tip of the femoral stem such that a fracture cannot be excluded and dedicate right femur radiographs should be obtained to follow-up to exclude fracture. Review of resident #1's Pelvic X-Ray, dated 11/19/17, showed, the current study demonstrates persistent dislocation of the right femoral prosthetic component in relation to the bony acetabulum. No fracture. The visualized right prosthetic component is well positioned. A review of resident #1's Physician Consultation Note, dated 11/19/17, showed, Dislocated right hip. (Physician) will under anesthesia attempt to reduce the hip. A review of resident #1's facility progress note, dated 11/20/17, showed, at KRMC. A review of resident #1's facility progress note, dated 11/21/17, showed, Resident at hospital. A review of resident #1's facility progress note, dated 11/21/17, showed, Resident back from hospital via ambulance at 1210 pm. Resident has abductor pillow between legs with Velcro straps keeping in place .Resident not to have head higher than 30 degrees per KMRC. Resident denies any pain at present . A review of the facility's incident log, failed to identify the third injury of unknown origin for resident #1, which occurred on 11/19/17. The incident was not reported or investigated for root cause. The injury was a dislocation and not a pathologic fracture, no investigation was conducted to investigate why resident #1's hip became dislocated. A request for documentation of the reporting and investigation for third injury of unknown injury for resident #1 provided to the facility on [DATE] at 12:00 p.m., the facility failed to provide documentation of reporting and investigation for the third injury of unknown origin for resident #1. Review of the facility reported incidents to the SA from 11/1/17 to 11/22/17, failed to reflect the facility reported the injury of unknown origin and the resulted investigation to the state for the incident which occurred on 11/19/17. During an interview on 11/22/17 at 10:00 a.m., staff member A stated the agency did not report or investigate the injury which occurred on 11/19/17 for resident #1. He stated the agency had already known the resident had a pathological reason for the fractures and therefore, the incident did not need to be investigated. Staff member A stated he could not explain the reason for the resident's dislocation since it was not investigated. The staff member stated the facility discussed the incident on 11/19/17 in their daily stand-up meeting the next day, but no investigation was completed or provided. He stated the incident was not discussed at the weekly IDT meetings. B. Left [MEDICAL CONDITION]: Review of resident #1's SBAR, dated 11/10/17, showed, Situation: resident holding his left hip and crying out in obvious pain this morning. CNA reports resident cried out in pain as soon as toes on left foot touch the floor. Background: Resident was reported to have required a Hoyer lift to transfer during the night, but no reported fall or apparent injury that would cause his left hip to hurt. Also told by CNA that evening shift had reported resident having hallucinations and strange behavior last evening including talking about dying and resident was overheard talking to someone invisible to them saying, No, I can't get to heaven that way, there must be another way. Assessment: Resident having severe acute left hip pain. Spoke with (NF1) and got order for mobile x-rays of left hip to rule out fracture. Response: Medicated for pain and x-ray contacted. Review of resident #1's SBAR Progress Note, dated 11/10/17, showed, resident was x-rayed by mobile imaging and found to have an acute left [MEDICAL CONDITION]. Background: Resident exhibiting severe pain in left hip this morning with no recent fall history or reported potential cause of hip injury. (NF1) reports it is possible resident may have suffered a spontaneous pathological fracture due to advanced [MEDICAL CONDITION] and recent stress on left lower extremity bearing most of resident's weight after he had right [MEDICAL CONDITION] and surgery. Response: Phoned (NF1) who looked at x-rays and gave order to transfer to ER at KMRC. Phoned resident's wife and notified her of the situation and transfer to ER. Review of resident #1's physician progress notes [REDACTED]. Sent to ED for evaluation. I reviewed the images from portable x-ray myself and my interpretation is a displaced left femur fracture. I suspect that he will require surgical correction for his hip as well. No report of fall, but if not as a result for fall, then I would suspect a pathologic fracture. He is not on bisphosphonate, but he isn't on a calcium supplement either. It is conceivable that as he is recovering and healing from his previous [MEDICAL CONDITION], that his body has been reabsorbing calcium from his other bones to use as raw material to heal his fracture. Review of resident #1's Skilled Nursing Progress Note, dated 11/12/17, showed: resident was transferred back to (facility) from KRMC where he underwent a left hip ORIF with IM nail for a displaced left hip intertrochanteric fracture on 11/10/17. Transported back to the facility by ambulance due to bilateral [MEDICAL CONDITION] with surgical repair. status [REDACTED]. Wife called shortly after return from hospital and spoke with ADON regarding her concerns for safety and fall prevention. Discussed why side rails are not used in facility and bed alarms are discouraged; Fall matts considered a tripping hazard for people that try to stand up and get out of bed and are not advised, but a scoop mattress might be beneficial. Hoyer lift for all transfers; wound care; log roll in bed for turning/changing, PT/OT to evaluate for additional recommendations. A review of the facility Internal Investigation Form, dated 11/10/17, showed the facility investigated the incident related to the left [MEDICAL CONDITION] for resident #1. Review of the facility reported incidents to the SA from 11/1/17 to 11/22/17, failed to show the facility reported the injury of unknown origin and the resulted investigation for the incident on 11/10/17. During an interview on 11/20/17 at 6:10 p.m., staff member [NAME] stated it was the expectation of staff to report all incidences which result in serious bodily injury to the state. She stated she would report to the incident to the Administrator, DON, or ADON, immediately. During an interview on 11/21/17 at 8:00 a.m., staff member H stated it was the expectation to report all injuries of unknown source to the Administration, immediately. During an interview on 11/22/17 at 10:00 a.m., staff member A stated it was the expectation of the facility to report to the state and complete a follow up investigation for suspicious injuries of unknown origin. He stated he did not feel either of resident #1's injuries which occurred on 11/10/17 and 11/19/17 were suspicious and required the need to report to the S[NAME] Staff member A stated the facility did an investigation into the left [MEDICAL CONDITION], but did not feel it needed to be reported since it was determined to be a pathological fracture. He stated the resident having a pathological fracture would be the same if the resident had an appendicitis, he stated it would not need to be investigated or reported. The staff member stated the facility did not discuss resident #1's incident and fracture from 11/10/17, at the IDT meetings. He stated the facility did not need to report or investigate the third incident which resulted in a right hip dislocation for resident #1 because the cause was pathological and was not an injury of unknown origin. Staff member A stated he did not feel it was possible to report all injuries of unknown origin which occurred in the facility. During an interview on 11/22/17 at 10:30 a.m., staff member B stated it was the expectation the facility would report and investigate all injuries of unknown source, especially if the injury resulted in major bodily injury, and because of the number of incidences which occurred for the same resident in such a small window of time. A review of the facility's policy and procedure titled, Abuse Prevention Plan (MT), showed, In accordance with the Vulnerable Adult Law of the State and Centers for Medicare and Medicaid, (CMS), it is our policy that all residents residing in the facility will be protected from abuse, neglect, misappropriation of funds/property, exploitation or involuntary seclusion, mistreatment and that interventions are implemented to provide ether vulnerable adult with a safe living environment. 5. Injuries of Unknown Source: the source of the injury was not observed by any person or the source of the injury could not be explained by the resident; AND the injury is suspicious because of the extent of the injury or the location of the injury (i.e.: the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. Reporting: The facility requires that all suspected maltreatment will be reported to the Administrator and the State promptly. All staff are required to report suspected maltreatment of [REDACTED]. If the Administrator is not in the building, direct care staff will report to the Nursing Supervisor, at the time of suspicion. The Administrator, DNS, or Nursing Supervisor will make sure that a report is filed, that the internal investigation begins immediately and the appropriate reporting takes place. All alleged violations involving abuse, neglect, exploitation, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials. Serious bodily injury is an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; or requiring medical intervention such as surgery, hospitalization , or physical rehabilitation. Investigation: Faculty will investigate all incidences such as falls, bruises, medication errors, resident complaints etc. Monday thru Friday, normal business hours, all incidents will be reviewed with the following disciplines: nursing, social services, Administrator, activities, and therapies .The facility will conduct its own internal investigation to the extent possible.",2020-09-01
119,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2017-11-22,312,E,1,0,D7BM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain adequate personal hygiene from regularly scheduled bath/showers for 7 (#s 3, 5, 6, 7, 8, 9, and 10) of 11 sampled and supplemental residents. This deficient practice had the potential to affect all residents who were dependent upon staff for assistance with bathing. Findings include: 1. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of resident #3's Admission MDS, with an ARD of 8/5/17, showed the resident had a BIMS of 5, severely cognitively impaired. The resident's Functional Assessment (Section G) showed the resident was an extensive assist with a two-person physical assist for bathing. A review of resident #3's Care Plan, with an imitated date of 9/20/17, and a target date of 11/22/17, showed the resident needed assistance with bathing. The Care Plan showed, I want to be well dressed and neatly groomed, and a need for extensive assist with one staff member needed for bathing. Review of resident #3's CNA Care Guide showed the resident was to receive a bath on Monday and Thursday evenings. During an observation on 11/22/17 at 7:45 a.m., resident #3 was sitting at the dining room table, he was wearing a white undershirt and green sweet pants. His hair was not combed and it was cow-licked in the front, on the sides and in the back. His hair had an oily appearance, and white flakes were noted on the top of his head. The resident smelled of unwashed hair. Review of resident #3's shower logs from 10/10/17 to 11/21/17, showed the resident was not provided a shower on: - 10/14/17 to 10/20/17, showed five days without a shower, and resident did not receive a shower on his scheduled bath day of Monday or Thursday. - 10/21/17 to 10/31/17, showed 10 days without a shower, and did not receive a shower on his scheduled bath days of Monday or Thursday. - 11/1/17 to 11/12/17, showed 12 days without a shower, the B2 Care Guide dated 11/9/17, showed a hand-written documentation of, didn't have time, noted for resident #3's shower for that day. - 11/13/17 to 11/21/17, showed nine days without a shower, the B2 Care Guide showed documentation on 11/16/17 of, refused. There was no documentation the resident was re-approached later time or notification of the refusal to the nurse. Review of the CNA charting in the EHR showed the resident was not applicable for a bath on 11/12/17. On 11/13/17 showed resident #3 was physical help in part of bathing activity. During an interview on 11/20/17 at 6:16 p.m., staff member [NAME] stated she had concerns with the staffing on the B-Wing. She stated sometimes it was only one nurse and one aide. She stated there was an expectation for the aide of the day to provide a total of three showers a day, and sometimes, they can't provide the showers because there was not enough staff to assist the rest of the residents on the B-Wing when the aide is providing showers. During an interview on 11/21/17 at 7:30 a.m., staff member H stated at times there was only one CNA on the B-Wing, she stated it was difficult for the CNA to provide the needed showers to all the scheduled residents. She stated it was the expectation for staff to notify the nurse on shift if a resident refused their shower. She stated it was important to re-approach the resident at a later date and time, however, if they continue to refuse showers, the nurse was expected to intervene. During an interview on 11/22/17 at 8:30 a.m., resident #3's POA stated when the resident was independent at home, he showered daily. He stated as the resident's disease progressed, he showered less, but would still shower 4-5 times a week. He stated it was important to the resident to be clean and well groomed. The POA stated he felt the staff were doing the best they could, but was concerned there were not enough staff to provide the needed care for the residents. 2. Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of resident #5's initial MDS with an ARD of 4/14/17, showed the resident had a BIMS score of 13, cognitively intact. The Functional Assessment (Section G) showed the resident was an extensive one-person assist for bathing. Review of resident #5's Care Plan with an initiation date of 4/27/17, showed the resident would like to participate in her own bathing and needed extensive assistance with bathing. Review of resident #5's CNA Care Guide, showed the resident was to receive a shower on Sunday mornings. Review of resident #5's shower logs from 10/10/17 to 11/21/17, showed the resident was not provided a shower from 10/10/17 to 11/21/17. A review of the shower log showed the resident refused showers on the following dates: - 10/16/17 - 10/23/17 - 10/26/17 - 11/1/17 - 11/3/17 - 11/6/17 - 11/7/17 - 11/10/17 There were no documented shower attempts from 11/10/17 to 11/20/17. Review of resident #5's Nursing Progress Notes, failed to address the continued refusal of showers by the resident. During an interview on 11/21/17 at 10:40 a.m., staff member L stated the baths were not adequately staffed. She stated sometimes there were not enough aides to help with all the resident cares, and many times the residents' showers were skipped because the staff could not provide them without jeopardizing the immediate needs of the residents. She stated it was the expectation to notify the nurse if they noticed a resident was continually refusing showers. During an interview on 11/21/17 at 11:40 a.m., resident #5 stated she did not like to be showered by the staff because they did not get the the parts that matter. She stated they would only clean her arms, back, and under her breasts. She stated she did not want a shower if the staff did not care to give her one. She stated phooey to the staff, they don't like to help me anyway and they don't care. During an interview on 11/21/17 at 11:50 a.m., staff member N stated it was the expectation of the CNAs to notify the nurse on shift if a resident refused their shower. He stated it would be important information to know, so the nurse may address the cause to why the resident was refusing showers. During an interview on 11/21/17 at 1:30 p.m., staff member O stated resident #5 had a history of [REDACTED]. She stated she was not aware the resident had continually refused a shower since 9/29/17. She stated it would be important to know if a resident had repeatedly refused a shower, so an assessment and intervention may be implemented for the resident. During an interview on 11/21/17 at 3:35 p.m., staff member P stated she had never provided a shower for resident #5, because the resident would refuse all attempts made to provide a shower. She stated she had shared her concern with resident #5's continued refusal for shows with the nurse, but did not see any change. 3. Resident #6 was admitted to facility on 11/18/13, with a [DIAGNOSES REDACTED]. Review of resident #6's Annual MDS, with an ARD of 1/19/17, showed the resident had a BIMS of 15, and was cognitively intact. A review of the Functional Assessment (Section G) for showers, showed the activity did not occur for the seven-day look back. The resident was shown to be an extensive one person assist for personal hygiene, toilet use, and dressing. Review of resident #6's Care Plan, failed to address showers. Review of the CNA Care Guide for resident #6, showed the resident was scheduled to receive showers on Wednesdays, Saturdays, and Monday evenings. Review of resident #6's shower logs from 10/10/17 to 11/21/17, showed the resident was not provided a shower on scheduled bath days from: - 10/11/17 to 10/15/17, the resident was not provided a shower on scheduled bath day Saturday 10/14/17. - 10/17/14 to 10/24/17, the resident was not provided a shower for seven days, and was not provided a shower on her scheduled shower days on 10/18/17, 10/21/17, and 10/23/17. - 11/17/17 to 11/25/17, the resident was not provided a shower for eight days, and was not provided a shower on her scheduled shower days on 11/18/17 and 11/20/17. During an observation on 11/20/17 at 5:00 p.m., resident was sitting in her wheelchair at the dining room table. Her hair was combed, but it was stringy with oil. During an interview on 11/20/17 at 5:06 p.m., resident #6 stated she had concerns with the staffing, because she was not being provided with showers. She stated she would prefer a shower three times a week, but has settled to getting a shower twice a week because there was not enough staff to assist with providing a shower three times a week. She stated recently she was not even getting a shower once a week, even when she asked for a shower, the staff would tell her no, because they didn't have enough help. She stated she was supposed to have had a shower Monday, but no one showed up to give her one. She stated an aide approached her Monday, and told her she was next in-line for a shower, then they never showed up to give her a shower. She stated she had requested a shower before her doctor's appointment, because she wanted to feel clean when the doctor examined her, but the staff told her no. She stated she had placed a grievance with the administration regarding this concern before, and nothing had changed. During an interview on 11/21/17 at 11:23 a.m., resident #6 stated before she came to the facility she used to take a shower every day, and on occasion, twice a day. She stated she would prefer a shower three times a week, but recently she was only provided a shower once a week. She stated she felt bad when she did get her showers and she felt like the staff did not care to help. She stated there were some staff who work very hard, and it was not their fault the facility could not appropriately staff the home. During an interview on 11/21/17 at 1:30 p.m., staff member O stated the resident was very particular about showers and the provided bath and showers had never been to her liking. A review of the facility's Grievance Log, dated 8/16/17, showed resident #6 provided a grievance for not getting her bath at least two days per week. The resolution was to provide a bath aid on the schedule, and showed the resident had no further concerns. On 6/25/17, resident #6 had a grievance regarding bathing issues. The resolution was noted as, resident getting showers. During an interview on 11/21/17 at 4:15 p.m., staff member Q stated they attempt to provide resident #6 with her showers, but sometimes they can't always provide the shower because they don't have enough help on the floor to provide cares to the residents. 4. Resident #7 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of resident #7's Annual MDS, with an ARD of 9/1/17, showed the resident had a BIMS of 9, moderately impaired cognition. Review the resident Functional Assessment (Section G), showed the resident was not provided a bath for the seven-day look back period. A review of resident #7's Care Plan with an initiation date of 9/25/17, showed the resident had a risk of sometimes refusing baths due to his self-care deficit and his cognition problem. The facility failed to provide a patient centered intervention regarding the resident's self-care deficit and refusal for baths. Review of the CNA Care Guide, showed the resident was scheduled to receive baths on Monday and Thursday evenings. Review of resident #7's shower logs from 10/10/17 to 11/21/17, showed the resident was not provided a shower on: - 10/26/17 to 11/3/17, showed eight days without a shower. - 11/5/17 to 11/11/17, showed six days without a shower, and no follow up attempts were made to reproach the resident. During an observation on 11/21/17 at 10:42 a.m., resident #7 was sitting in the recliner in his room. His shirt was stained with a brown liquid on the front, and he had stubble on his face. The resident hair was not combed and had cow-licks in the back. During an interview on 11/21/17 at 10:42 a.m., resident #7 stated he did like to get showers and preferred to be clean and well groomed. 5. Resident #8 was admitted on [DATE], with a [DIAGNOSES REDACTED]. Review of resident #8's Annual MDS, with an ARD of 6/3/17, showed the resident had a BIMS of 8, cognitively impaired. The Functional Assessment (Section G), showed the resident was an extensive one person assist with bathing. Review of resident #8's Care Plan, with an initiation date of 1/16/15, showed, I tend to like to stay in my room and need strong encouragement to take a shower and change my clothes. When I refuse cares please remind me of potential risk. Coax but do not force me to comply. Due to my poor memory, I may not be able to recall my previous declining of cares, re-approaching may be a huge benefit to improve compliance. Review of the CNA Care Guide for resident #8, showed showers scheduled for Wednesday and Saturday evenings. During an observation on 11/21/17 at 8:00 a.m., resident #8 was seated at the dining room table. Her hair was combed back, and was oily with white flakes. She smelled of unwashed hair. During an interview on 11/21/17 at 8:15 a.m., resident #8 stated she believed she had already had a shower last week. She stated she would just give herself a spit bath between the days she would take a shower. She stated she did need help getting into the shower. Review of resident #8's shower logs from 10/10/17 to 11/21/17, showed the resident was not provided a shower on: - The bath sheet dated 10/10 showed the last bath was 9/16/17, with no bath provided again until 10/15/17, showed 29 days without a bath. - From 10/16/17 to 11/8/17, showed 23 days without a bath. - From 11/9/17 to 11/21/17, showed 12 days without a bath. A review of the EHR CNA documented bathing report showed a bath showed Not applicable for a bath provided on 11/12/17. Review of resident #8's clinical record failed to show refusals or attempts to reproach the resident to provide a bath. During an interview on 11/21/17 at 7:30 a.m., staff member H stated she was aware the residents were not getting their regularly scheduled showers. She stated she was worried because they did not have enough staff to help provide cares on B-Wing. 6. Resident #9 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of resident #9's Annual MDS, with an ARD of 4/6/17, showed the resident had a BIMS of 3, severely cognitively impaired. The Functional Assessment (Section G) showed the resident was an extensive one person assist with bathing. Review of resident #9's Care Plan with an initiation date of 4/29/14, showed the resident was developmentally delayed and needed oversight and assistance with bathing, dressing and hygiene. The intervention showed, I like to have my hair washed. The interventions failed to address any further bathing interventions. During an observation on 11/21/17 at 8:00 a.m., resident #9 was wandering around the dining room. Her hair was only combed on one side, and she had several cow-licks in the front and back. Her hair was stringy with oil, and she had plaque buildup on her teeth. The resident smelled of unwashed hair and body. Review of the CNA Care Guide for resident #2, showed bath on Sunday morning. Review of resident #9's shower logs from 10/10/17 to 11/21/17, showed the resident was not provided a shower: - From 10/17/17 to 11/5/17, 19 days without a bath. - From 11/12/17 to 11/21/17, 10 days without a bath. Review of the EHR documentation for CNA bathing dated 11/12/17, showed, physical help in part of bathing activity. No further documentation was provided on showers from 10/10/17. 7. Resident #10 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of resident #10's Admission MDS, with an ARD of 4/10/17, showed the resident had a BIMS of 6, cognitively impaired. Review of the resident's Functional Assessment (Section G), showed the resident was an extensive assist with one person for showers. Review of resident #10's Care Plan, with an initiation date of 4/4/17, showed the resident needed assist with bathing. The Care Plan failed to address any interventions with bathing for resident #10. During an observation on 11/21/17 at 8:00 a.m., resident #10 was seated at the dining room table, her hair was stringy with oil, and combed straight back. Review of the CNA Care Guide for resident #10, showed the resident was scheduled to receive a bath on Monday and Thursday evenings. Review of resident #3's shower logs from 10/10/17 to 11/21/17, showed the resident was not provided a shower on: - 10/10/17 to 10/18/17, eight days without a bath. - 10/18/17 to 11/9/17, 21 days without a bath. - 11/16/17 and 11/17/17, the resident refused. -11/13/17 to 11/21/17, nine days without a bath. The Care Guide showed the resident refused a bath on 11/16/17, and 11/17/17, with no further attempt to reproach. Review of the resident record failed to show additional documentation for showers. During an interview on 11/21/17 at 8:18 a.m., resident #10 stated she enjoyed showers when she got them. She stated she did not need a shower, because she had one last week. During an interview on 11/21/17 at 8:44 a.m., staff member B stated it was the expectation for all residents to receive their scheduled baths. She stated if a resident refused a shower, it was the expectation for the CNA to attempt to reproach the resident later. If the resident continued to refuse a bath it was the expectation for the CNA to notify the nurse, and the nurse to follow up on why the resident had refused their bath. Staff member B stated it was not acceptable for a resident to go longer than one week without being addressed for a missed bath. Documentation was provided on 11/21/17 at 3:00 p.m., for the electronic documentation by the CNA for showers for resident #s 5, 6, and 7. These records indicate baths were given several times a day and up to five days in a row. During an interview on 11/21/17 at 3:15 p.m., staff member C stated the report generated did not show yes or no, if a bath was provided for a resident, instead the report would indicate, Self-Performance. She stated it was possible for the residents to have received two baths in one day if they were heavily soiled. She stated she felt the documentation to accurately reflect when baths were provided for the residents. Review of EHR CNA documentation for resident #5 showed, staff member P provided a bath for the resident #5 on 11/2/17, 11/3/17, 11/4/17, 11/10/17 and 11/16/17. For resident #6, the documentation showed staff member P provided shower for resident #6 on 10/21/17 and 10/27/17. For resident #7, computer generated documentation showed staff member P provided a bath for the resident on 11/2/17, 11/3/17, 11/4/17, and 11/16/17. During an interview on 11/21/17 at 3:35 p.m., staff member P stated she had never provided resident #s 5, 6 or 7 a bath. She stated she thought she had to put something in the column which auto-populated, and was not aware she was not supposed to document for that section, until another staff member explained to her that she was documenting baths for residents when she had not actually provided them. Staff member P stated she had also noted staff member R had written on the bath sheet she had provided a bath to a resident, but she did not document the bath in the electronic health record. Staff member P stated she wanted to help staff member R, so she documented staff member R's baths for the day. Staff member P stated she did not know it was not appropriate to document the care another staff member provided. Review of the CNA electronic documentation of baths provided for resident #s 5 and 6, showed staff member K provided baths for resident #5 on 11/12/17 refused and resident #6 on 11/12/17 refused. During an interview on 11/21/17 at 3:45 p.m., staff member K stated she had never given resident #5 or resident #6 a bath. She stated the charting system shows PRN bathing and is required to document something for every day care is provided. She stated she would either put refused or not applicable. During an interview on 11/21/17 at 3:50 p.m., staff member C stated she was not aware staff were documenting for showers given, when they had not actually provided a shower. She stated she was also not aware staff were documenting work they did not complete to help other CNAs complete their documentation. Staff member C stated it made the validity of the bath electronic bath sheets questionable. During an interview on 11/21/17 at 4:00 p.m., staff member B stated the EHR system was set on the wrong prompt. It was set to prompt for bath or shower, PRN. She stated the prompt needed to be changed and would be changed to only prompt the CNA to document a shower was provided on the resident's scheduled shower day. She stated due to the inaccuracy in the CNA current documentation it made the current documentation for showers and baths questionable. A review of the facility's policy and procedure titled, Shower/Tube Bath, showed, The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Residents will be offered a choice of shower or bath if physically appropriate for either. The following information may be recorded on the resident's ADL record and/or in the resident's medical record: 5. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. Notify the supervisor if the resident refuses the shower/tub bath.",2020-09-01
120,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2017-11-22,353,E,1,0,D7BM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the agency failed to provide timely and adequate services for the provision of answering call lights, for 3 (#s 4, 5, and 11) of 11 sampled and supplemental residents. The deficient practice had the potential to affect all residents who were dependent on staff to provide assistance with transfers, and toileting. Findings include: 1. Resident #4 was admitted the facility on 10/21/17, with [DIAGNOSES REDACTED]. Review of resident #4's Initial MDS, with an ARD 10/28/17, showed the resident had a BIMS score of 15, cognitively intact. The Functional Assessment (Section G) showed the resident was an extensive one person physical assist with toileting and transfers. The resident had a functional limitation for the upper and lower extremities for one side of his body. Review of resident #4's Care Plan, initiated on 10/27/17, showed: Transfers, bed mobility, and ambulation, I need assistance with my transfers, bed mobility ambulation. I want to be safe in all my movements. I need extensive assistance in transport to areas of destination. For toileting, with an initiated date of 11/7/17, I need assistance with my toileting. I want to participate in my toileting. I need total assistance of two staff in toileting. During an observation on 11/21/17 at 6:38 a.m., four call lights were on in the TCU wing. There was not a nurse or aide available. During an observation on 11/21/17 at 6:51 a.m., the same four call lights were on in the TCU, there was not a nurse or aide available. During an observation on 11/21/17 at 7:00 a.m., resident # 4's bathroom light was on and his bedroom door and bathroom door were open to the hall. The resident assisted himself off the toilet into his wheelchair. During an observation on 11/21/17 at 7:10 a.m., two staff members were at the nurses' station, one of the four call lights had been answered. Resident #4's bathroom call light was still flashing. Neither staff member answered the call lights which had been on since 6:38 a.m. During an interview on 11/21/17 at 7:10 a.m., staff member H stated it was time to give report to the on-coming nurse and complete the medication count. Staff member H stated it was the responsibility of all staff to answer the call lights. During an interview on 11/21/17 at 7:13 a.m., resident #4 stated he had a stroke and he was currently working hard to rehabilitate so he could go home. He stated he had turned his call light on when he finished going to the bathroom to get assistance, but no one came to help him off the toilet. He stated this was not uncommon to wait extended periods of time for staff to answer his call light, and he had decided he needed to start doing things for himself. When no one answered his call light, he brought himself to the toilet and got himself off the toilet. He stated he knew he still needed help with transfers because he did not want to fall and get hurt, which would delay his rehabilitation. He stated he felt the staff did a good job for being so short staffed. During an observation on 11/21/17 at 7:22 a.m., resident #4 stopped the CNA in the hall and explained he left his call light on, but he had taken himself to the bathroom and did not need any assistance. The staff member acknowledged resident #4 and told him she would turn his call light off. During an observation on 11/21/17 at 7:27 a.m., all four call lights were answered by CNAs and turned off. 2. Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of resident #5's initial MDS with an ARD of 4/14/17, showed the resident had a BIMS score of 13, cognitively intact. The Functional Assessment (Section G) showed the resident was an extensive two-person assist for transfers and toileting. The resident had functional limitation on one side of her body both upper and lower extremity. During an observation on 11/21/17 at 9:52 a.m., resident #5's bathroom call bell was sounding at the nurses station, and the light was on over the resident's bedroom door. During an observation on 11/21/17 at 10:00 a.m., resident #5's bathroom call light was alarming at the nurses' station. Three staff members E, J, and M were at the nursing station and the call bell was sounding. During an interview on 11/21/17 at 10:15 a.m., staff member J stated she was on light duty, but could still answer call lights when they went off. She stated her duties were to answer call lights, and help other staff with resident cares. Staff member J stated the call bell for resident #5's room was on the other CNA's hall, and they were currently giving another resident a shower. She stated it was still part of her duties to check on other wings and address any active call lights. During an observation on 11/21/17 at 10:17 a.m., staff member J did not get up to answer the call bell for resident #5, and remained sitting at the nursing station. Staff member M also did not attempt to leave the nurses station to answer resident #5's call light. Staff member [NAME] left the nurses station and continued to pass medications. During an observation on 11/21/17 at 10:30 a.m., staff member K completed the shower for another resident and went to answer resident #5's call light. During an interview on 11/21/17 at 10:38 a.m., resident #5 stated she was used to waiting long periods of time for someone to answer her call bell. She stated it feels awful when an incident occurred and can't get to the bathroom in time. Resident #5 stated the previous night, she had asked two CNAs to take her to the bathroom and they wouldn't take me. She stated it felt awful to sit in my own poo-poo and the CNAs wouldn't help. During an interview on 11/21/17 at 10:42 a.m., staff members K and L stated they were answering the call bells as quick as possible. They stated not all nurses or aide's answered the call lights. Staff members K and L stated they feel they don't always have enough help to answer the call bells timely, especially during the busy times before and after meals, and when residents first get up, and when they want to be laid down. Both staff members stated there was not enough staff to provide the scheduled showers for the residents. During an interview on 11/21/17 at 10:50 a.m., staff member M stated she was responsible for scheduling appointments. She stated she was a CNA and was capable to help answer call lights and assist with resident cares. She stated she would answer a call light if she noticed it when she was walking by the resident room. She stated if she was at the nurses' station and the call light was on for a long period of time, she stated she would let a CNA who was heading that direction know the resident's call light was on, so they could answer it. 3. Resident #11 was admitted to the facility on [DATE]. The resident was admitted for rehab services. Review of resident #11's Initial MDS, showed in progress. During an interview with resident #11 on 11/22/17 at 8:01 a.m., resident #11 stated she had been admitted to the facility to rehabilitate after a recent hospital stay for abdominal pain. She stated she was weak and trying to improve before going home. She stated she had a lot of pain and anxiety, as well as a new [DIAGNOSES REDACTED]. Resident was oriented to her current surroundings. During an observation on 11/21/17 at 7:23 a.m., resident #11's call bell was flashing. Three staff member's were standing at the nurses station directly across from the resident room, talking amongst themselves. During an observation on 11/21/17 at 7:39 a.m., resident #11's call bell was flashing. The resident's room was directly across from the nurses' station. There were three staff members talking at the nurses' station. Staff member T and U, and one other unidentified CN[NAME] One staff member explained to the other two staff members standing at the nurses station, it will be forever before I get my license. During an interview on 11/21/17 at 7:41 a.m., staff member T stated they were giving report to the staff who came on at 7:00 a.m. She stated resident #11 was always on her bell, and they were just about to answer her light. She stated the staff had already been into resident #11's room quite a bit that morning and the resident had just turned her light back on. Staff member T stated the resident was independent with her own cares, and can assist herself with many things, but preferred to turn her call light on instead of getting up. Staff member T stated it was the expectation to answer all call lights as soon as possible. During an observation on 11/21/17 at 7:50 a.m., staff member U entered resident #11's room and brought the resident something to drink. During an interview on 11/21/17 at 8:00 a.m., resident #11 stated she had waited for long periods for staff to answer her call light. She stated she was independent and able to get out of bed and to the toilet with limited assistance, but still needed help getting something to drink, a snack, or medications. She stated she understood the staff were busy and she knew she pushed the call bell a lot, but stated, since she was diagnosed with [REDACTED]. She stated she also pushed the call bell for her pain medication. She stated with her [MEDICAL CONDITION], she has had increased pain, and was attempting to get control of the pain level. She stated she had to get up and out of her room to find a staff member to help her before, because no one would answer her call bell. She stated one time when she got up to ask the nurse for help, the nurse said to her, why are you even here (resident #11)? She stated she felt bad for asking for help from the staff. During an interview on 11/21/17 at 12:15 p.m., staff member B stated it was the expectation of all staff to answer call lights, regardless of the assignment or duty. She stated any employee can check on a resident to see if they can help with their need, if not, to get someone who could. A review of the facilities policy and procedure titled, Answering the Call Light, showed, The purpose of this procedure is to respond to the resident's requests and needs. 9. Answer the resident's call as soon as possible.",2020-09-01
121,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2017-11-22,514,E,1,0,D7BM12,"> Based on interview and record review, the facility failed to keep medical records which were complete, readily accessible, and systematically organized, for 3 (#s 6, 7, and 8) of 8 sampled residents. Findings include: Review of resident shower records for the month of (MONTH) and (MONTH) (YEAR), reflected resident #s 6, 7, and 8 had not been given showers or baths on their scheduled days and documentation of refusals was not evident. Electronic medical records were reviewed, as well as hard copy records for resident #s 6, 7, and 8, all of whom reside on the memory care unit. Review of the resident shower records, in the electronic health record, and the hard copy record, reflected the documentation was neither complete, organized, nor available for review, at the time of the survey. The electronic medical records showed showers for resident #6 on 1/20/18 and 2/2/18. For resident #7, the electronic medical record showed no data for bathing. And resident #8 showed bathing completed on 1/3/18, 1/14/18, and 2/3/18. There were no refusals documented in the electronic medical record for the scheduled bath days for the residents. Resident #7 did not have a documented bathing schedule in the medical record. On 2/6/18 at 11:00 a.m., the facility provided a binder, which contained a hard copy schedule of bathing, for the memory care unit. This hard copy schedule showed some refusals and more bathing times for the resident #s 6, 7, and 8. There were still extended periods of time, to include more than a week long, showing the residents were not bathed. During an interview on 2/6/18 at 12:15 p.m., staff member B stated the idea for documentation is to keep everything in one place to maintain consistency in the documentation. She stated the CNAs and nurses should be documenting refusals of bathing. During an interview on 2/7/18 at 8:45 a.m., staff member A stated the facility talked to each CNA providing care on the memory care unit about the dates and times they had given the residents baths. The CNAs were able to identify dates and times which they had given the residents baths or showers on the memory care unit, and the other times they had refused since 1/2/18, which was the date of stated compliance for the facility.",2020-09-01
122,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2019-11-27,552,D,0,1,92Z111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform one (#219) of 28 sampled residents, and the resident's representative, of the risks and benefits of [MEDICAL CONDITION] medications that were administered during resident #219's stay in the facility. Findings include: During an interview on 11/26/19 at 4:28 p.m., staff member A stated she did not have an informed consent for the [MEDICATION NAME] or [MEDICATION NAME]. Staff member A stated the only documentation she could find was a Nurse's Note, which showed a nurse had spoken with resident #219's family member (see below). During an interview on 11/27/19 at 9:48 a.m., staff member A stated resident #219 had been admitted in early (MONTH) of 2019 from another long-term care facility and only stayed for one week before being transferred to the hospital. Staff member A stated she was not sure what resident #219 had been taking at the first long-term care facility, and the previous facility had not provided a past medications list. Staff member A stated her facility required consents for [MEDICAL CONDITION] medications, and staff were unable to get signatures from the family, as the family was unwilling to come into the facility. Review of resident #219's Nurse's note, dated 7/9/19, showed: Resident's POA .called to ask how (resident #219) was doing at approximately (9:30 a.m.), I explained that we were planning to do some diagnostic testing and were going to give her some medication to relax her so the testing could be done. She stated she had some questions, i offered to transfer to (staff member B) for additional information, she stated that she had a lawyer on the other line and she would call back later. (sic) Review of resident #219's physician's orders [REDACTED]. - [MEDICATION NAME], 50 mg/ml: inject 25 mg intramuscularly every 2 hours as needed for agitation/aggressiveness; may repeat in 2 hours if needed to complete procedures. (MONTH) repeat complete order 1 day if needed to complete all procedures. Dated 7/3/19. - [MEDICATION NAME] ([MEDICATION NAME]), 2 mg/ml: inject 1 mg intramuscularly every 12 hours as needed for agitation. Dated 7/1/19. - [MEDICATION NAME] ([MEDICATION NAME]), 2 mg/ml: inject 1 mg intramuscularly one time only for anxiety; agitation for 2 days, give 1-2 mg x 1, to be administered 30 minutes before procedure. Dated 7/2/19. Review of resident #219's MAR indicated [REDACTED]. Review of the facility's policy, Psychopharmacologic Medication Assessment and Review Policy, revised 3/2019, showed: Each resident receiving ([MEDICAL CONDITION] medications) will have an initial assessment prior to a medication being initiated, at admission, quarterly, annually, and with a change in condition. An assessment will be completed if Dementia Resident is on an antipsychotic medication at time of admission/readmission or its use is being considered at any time and the resident does not have an approved diagnosis. Residents are not to receive PRN orders for [MEDICAL CONDITION] drugs unless the drugs are intended to treat a condition that is documented in the clinical record.",2020-09-01
123,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2019-11-27,656,D,0,1,92Z111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to create a care plan for 1 (#8) of 28 sampled residents for a resident who needed toileting on the night shift, which had the potential to affect the resident's well being. Findings include: During an observation and interview on 11/25/19 at 2:29 p.m., resident #8 had white gauze bandaged on both arms around the mid forearm to the upper arm covering the elbows. Resident #8 stated, she had took a tumble out of bed last night. Resident #8 then lifted her right pant leg to her thigh, and showed the large black and blue bruise with a raised area on the inner side and back of the knee area. During an interview on 11/27/19 at 10:29 a.m., staff member B stated resident #8 had fallen and could not recall why. Staff member B stated resident #8 was on two-hour checks and reminded to ask for assistance. During an interview on 11/27/19 at 1:00 p.m., staff member F stated nurses can add intervention recommendations for events initially to keep the resident safe on event reports, progress notes, or during the shift report. Staff member F stated ultimately the interdisciplinary team will review the event report for the resident's needs, place interventions, and update the care plan to make sure the interventions are appropriate. Review of resident #8's current physician orders [REDACTED].@ 2am for bathroom assistance every night shift for incontinence, and the order was active since 6/8/19, with no stop date. Review of resident #8's care plan received on 11/26/19 showed no content for waking resident #8 at 2:00 a.m. for toileting.",2020-09-01
124,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2019-11-27,689,D,0,1,92Z111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent three falls in five months for a resident, resulting in a large black and blue bruise with a raised area and skin tears on both elbows, for 1 (#8) of 28 sampled residents. Findings include: During an observation and interview on 11/25/19 at 2:29 p.m., resident #8 had white gauze bandaged on both arms around the mid forearm to the upper arm covering the elbows. Resident #8 stated, she had took a tumble out of bed last night. Resident #8 then lifted her right pant leg to her thigh and showed the large black and blue bruise with a raised area on the inner side and back of the knee area. During an interview on 11/27/19 at 10:29 a.m., staff member B stated resident #8 was on two-hour checks, was reminded to call for assistance, had a medication discontinued for a cluster of falls in (MONTH) 2019, but would have to look at the last few falls to know what had happened and any interventions placed. During an interview on 11/27/19 at 1:00 p.m., staff member F stated the nurse evaluated the resident for injuries and tried to deduce what occurred if the resident was not able to tell. Staff member F stated the nurse could add intervention recommendations initially to keep the resident safe on the fall report, but ultimately the interdisciplinary team would review the falls for root cause and patterns, place interventions, and care plan them to make sure they are appropriate. Review of resident #8's fall reports showed: -7/27/19 at 2:45 a.m., resident #8 slipped out of bed and her husband helped her up and then needed assistance getting up also. Resident #8 was noted to be ambulating without assistance, had no footwear on, low lighting, and did not have any injuries. The report did not show when the resident was last checked on or toileted. -9/18/19 at 3:27 a.m., resident #8's legs slipped from under her while self-transferring to the toilet. Resident #8 sustained skin tears to the right elbow. The report did not show when the resident was last checked on or toileted. -11/25/19 at 4:00 a.m., resident #8 rolled out of bed and sustained bilateral skin tears to elbows, and a large bruise with a raised area to the inner right knee. Resident #8 was noted with predisposing factors of gait imbalance, incontinence, and impaired memory. The Other information section showed, Res husband states she rolled out of bed. This has happened before with her. Requested half side rail order. (sic) The report did not show when the resident was last checked on or toileted. Review of resident #8's current physician orders [REDACTED].@ 2am for bathroom assistance every night shift for incontinence, with a start date of 6/8/19 and with no stop date. Review of resident #8's care plan, for fall prevention showed, My last fall assessment was done on this date 9/20/19 Per that assessment, I am at risk for falls due to impaired cognition and poor safety awareness and unsteady gait. (sic) The Fall interventions care plan showed, -10/14/19: A leaf has been placed outside of my door for the Keep Falls out of your Autumn campaign. -9/18/19-trial toilet riser with hand rails to assist with my transfers in the bathroom -Due to fall on 3/27/19, encourage to wear shoes when out of bed. (4/4/19) -Due to fall, where I slipped out of my bed, will trial a mattress with delineated edges. (11/25/19) -Encourage resident to ask for assistance when she feels weak. (1/30/19) -Place call light cords on the inside of the recliners to prevent tripping on them. (3/13/19) -PT eval and treat as indicated. (10/15/19) Review of resident #8's interdisciplinary team progress note, dated 11/27/19 for the 11/25/19 fall, showed resident #8 refused the delineated mattress edges to prevent falls out of bed, and the facility would have to review the fall again for interventions. No intervention was care planned for two hour checks per staff member B's interview or the physician order [REDACTED]. All three falls occurred in a five month period between the hours of 2:00 a.m. and 4:00 a.m. Two falls were shown to involve toileting/incontinence, and two falls caused skin tears to the elbow. There was no information found to address preventing the pattern of falls or preventing the skin tears from the falls.",2020-09-01
125,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2019-11-27,692,D,0,1,92Z111,"Based on observation, interview, and record review, the facility failed to ensure facility staff accurately monitored a resident for acceptable nurtitional standards, and that a recorded weight loss was followed-up on timely to ensure a resident did not have a significant weight loss or that further interventions were necessary for 1 (#43) out of 28 sampled residents. Findings include: During a dining observation and interview on 11/25/19 at 4:58 p.m., resident #43 was seen picking at her food and stated the food could be better and it was tasteless. Review of resident #43's weight summary sheet showed from 10/01/19 to 11/02/19, resident #43 had a significant weight loss of 12.2 pounds. The resident's BMI went from 27 to 24.1, an 8.7% loss. There was no documentation in the resident's medical record to show a Significant Change assessment had been completed to prompt a review and possible revision to the resident's care plan. Review of resident #43's progress notes showed the last Dietary note was on 5/16/19. The resident's Electronic Health Record showed (in red type) the resident's current weight of 127.6 pounds, reflecting a concern. During an interview on 11/27/19 at 9:05 a.m., staff member [NAME] explained a weight report was run weekly from the Electronic Health Record by staff member [NAME] and was reviewed with staff member B at the Nutrition at Risk meeting. Resident #43 was not on this list when the process was demonstrated in PCC (electronic health record system) by staff member E. During an interview on 11/27/19 at 10:10 a.m., staff member N could not recall a weight change for resident #43. A re-weigh of resident #43 was requested on 11/27/19 at 10:15 a.m., and the weight was noted to be 135.8 pounds. Review of resident #43's weight summary sheet included: -143.0 lbs 3/13/19 (BMI 27) -137.2 lbs 5/23/19 -136.0 lbs 8/1/19 -139.8 lbs 10/1/19 -127.6 lbs 11/2/19 (BMI 24.1) Last weight of 127.6 lbs appeared in red in resident #43's Electronic Health Record. During an observation (re-weigh of resident #43) on 11/27/19 at 10:15 a.m., by staff member N, the scale showed a weight of 135.8 lbs. During an interview on 11/27/19 at 10:15 a.m., staff member N stated that CNAs weighed residents and brought the weight to the nurse who entered it into the chart. Upon entering the weight, if there was an increase or decrease in weight, the Electronic Health Record would flag it.",2020-09-01
126,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2019-11-27,697,D,0,1,92Z111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide scheduled pain medication for 1 (#37) of 28 sampled residents, which had the potential to result in preventable pain for the resident. Findings include: During an interview on 11/25/19 at 3:10 p.m., staff member M stated she had one resident, #37, who was out of her [MEDICATION NAME] ([MEDICATION NAME]), 37.5-325 mg tablets. Staff member M stated resident #37 would miss two doses of her scheduled pain medication while they waited for the pharmacy to deliver the medication. Staff member M stated resident #37 had not been exhibiting signs/symptoms of pain since she had missed the morning dose of [MEDICATION NAME]. During an interview on 11/26/19 at 10:02 a.m., staff member L stated, A lot of residents here are not great at asking for medications, which is why resident #37's [MEDICATION NAME] was changed to scheduled (instead of as needed). Staff member L stated staff use a non-verbal pain scale to assess resident #37's pain, due to resident #37's [DIAGNOSES REDACTED]. During an interview on 11/27/19 at 9:32 a.m., staff member L stated if she were responsible for administering medications to resident #37, and saw that she did not have any pain medication remaining, she would consider the risks vs. benefits. Staff member L stated she had not observed any signs/symptoms of pain in resident #37, so it would not be a big deal if she missed a day. Review of resident #37's [DIAGNOSES REDACTED]. Review of resident #37's care plan, dated 9/8/19, showed resident #37 had chronic back pain and required pain medication as ordered. Review of resident #37's MDS, with an ARD of 9/25/19, showed that a pain assessment should be conducted with resident #37, and that pain was not present at the time of the assessment. Review of resident #37's medication list showed [MEDICATION NAME] tablet 37.5-325 mg ([MEDICATION NAME]-[MEDICATION NAME]): give one tablet by mouth two times a day for pain. The medication was originally ordered on [DATE]. Review of resident #37's MAR for (MONTH) 2019 showed [MEDICATION NAME] had not been administered 11/25/19. A note was attached to the MAR, dated 11/25/19 at 10:20 a.m., that showed: Call placed to (pharmacy) and will be on tonight's shipment, resident is not in distress or seemingly in pain. Review of resident #37's pain level charting on 11/26/19, the day after she missed two doses of [MEDICATION NAME], showed her pain level was a 6/10 (10 being the worst pain). Out of 53 [MEDICATION NAME] administrations and opportunities to assess pain in (MONTH) 2019, resident #37's pain level was rated a 5/10 or more on seven occasions, two of which were following the missed doses on 11/25/19. Refer to F755 for Pharmacy Services and concerns related to medication availability.",2020-09-01
127,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2019-11-27,710,D,0,1,92Z111,"Based on interview and record review, the facility failed to ensure the primary physician was aware of a significant weight loss, for 1 (#42) of 28 sampled residents. Findings include: During an interview on 11/27/19 at 9:05 a.m., staff member [NAME] stated she was unaware of a weight change in resident #43, and the resident's name had not come up in the Nutrition at Risk meeting. [NAME] Review of resident #43's weight summary sheet, showed the resident had a significant weight loss, which was: -139.8 lbs 10/1/19 -127.6 lbs 11/2/19 During an interview on 11/27/19 at 10:15 a.m., staff member N stated she was unaware of a weight change in resident #43. However, staff member N stated if there was any weight change noted, the physician would be notified. Review of resident #43's dietary progress note by staff member E, dated 5/16/19, showed the resident had, no significant weight loss, but did not eat a large portion of her meals so she should be started on a shake supplement. No documentation was found, prior to the end of the survey, to show the physician had been notified of resident #43's significant weight loss for the opportunity to determine if further care needs or interventions were required.",2020-09-01
128,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2019-11-27,755,D,0,1,92Z111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain medications from the pharmacy in a timely manner, which resulted in 1 (#37) of 28 sampled residents, missing two doses of a scheduled pain medication. Findings include: During an interview on 11/25/19 at 3:10 p.m., staff member M stated she had issues getting medications from the pharmacy on time. Staff member M stated she had one resident, #37, who was out of her [MEDICATION NAME] ([MEDICATION NAME]), 37.5-325 mg tablets. Staff member M stated resident #37 would miss two doses of her scheduled pain medication while they waited for the pharmacy to deliver the medication. Staff member M explained she had spoken to management about this being a pattern with several residents, and management was working on a new way of ordering medications online. During an interview on 11/26/19 at 10:12 a.m., staff member M stated she had called resident #37's prescription into a satellite pharmacy yesterday, but they required a new prescription from the provider, which she had been unable to obtain. During an interview on 11/26/19 at 11:42 a.m., staff member L stated, Everyone should be doing the ordering (of medications). If they know something is going to run out, they should be sending the faxes. If there are no orders left on the prescription, the doctor is here every week, but everyone is scrambling to get the script signed, so it does not always get signed. Staff member L continued, If it doesn't get signed when (the provider) is here, it has to get faxed to him, get back to us, and then it has to go to the pharmacy. Staff member L stated she was not sure why resident #37's prescription was not refilled in a timely manner. During an interview on 11/27/19 at 12:36 p.m., staff member A stated getting medications delivered on time from the pharmacy was an ongoing issue. Staff member A explained the facility was working with the pharmacy to develop a [MEDICATION NAME] online system. Staff member A stated, There have been incidents when medications are not onsite when they should be, mostly because we run into insurance issues. Staff member A explained staff can pull a medication from the emergency medication supply (Omnicell), but that was not always the case. Review of the facility's policy, Pharmacy Consultant Agreement, dated 8/1/18, showed: Consultant shall collaborate with Facility and Facility's medical director to: develop, implement, evaluate, and revise .procedures for the provision of pharmaceutical services; and strive to assure that medications are requested, received and administered in a timely manner as ordered by the authorized prescriber.",2020-09-01
129,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2019-11-27,756,E,0,1,92Z111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the physician and facility reviewed and followed the pharmacist recommendations or provided rationale for declining the recommendations for 3 (#s 8, 23, and 36) and failed to provide a sufficient pharmacy review and report for 1 (#319) of 28 sampled residents, which had the potential to adversely affect the residents health. Findings include: 1. During an interview on 11/27/19 at 10:29 a.m., staff member B stated, pharmacy reviews and recommendations were reviewed by herself and the pharmacist. Staff member B stated she would then follow up with the medical director for any needs. During an interview on 11/27/19 at 12:50 p.m., staff member G stated medication orders and recommendations go through a three-part system of the doctor, nurse, and pharmacist. During an interview on 11/27/19 at 1:00 p.m., staff member F stated it was everyone's responsibility to check the pharmacy recommendations. When the floor nurses received the recommendation they would forward it to the medical director for review and signature, and then it was returned to the facility. a. Record review of resident #8's pharmacist review dated 6/28/19 showed a recommendation to discontinue [MEDICATION NAME] HCL ordered at 25 mg nightly for [MEDICAL CONDITION]. The review noted, As you are aware [MEDICATION NAME] is a BEERs medications and not recommended in the elderly due to its highly [MEDICATION NAME] properties that can remain in the elderly Can cause increased and long [MEDICATION NAME] sedation, decreased mentation, behavioral changes, constipation and dry mouth among others. (sic) The recommendation was not signed by the physician or noted to be reviewed, or declined. b. Review of resident #23 last DISCUS assessment showed completion on 4/4/19. Record review of the pharmacist review dated 10/31/19 showed the recommendation for the facility to complete either and AIMS or DISCUS assessment every six months due to resident #23 receiving [MEDICATION NAME], and resident #23 was due for an assessment in October, however, an assessment was not in the resident's medical record. c. Record review of resident #36's monthly pharmacy reviews, dated 3/31/19, 8/28/19, and 9/30/19, showed, (Resident #23) has received an antidepressant, [MEDICATION NAME] 10 mg daily and [MEDICATION NAME] 10 mg in AM and Noon and 15 mg nightly for management of depressive/anxiety symptoms. A recommendation for a GDR attempt of [MEDICATION NAME] 10 mg TID was requested by the pharmacy review each time. There was no documentation of accepting the recommendation or declining with rationale for the reviews on 3/31/19 and 8/28/19. On 10/2/19 the medical director checked the declination box and signed the 9/30/19 review, however, did not provide rationale for declining the GDR attempt. 2. During an observation on 11/26/19 at 09:11 a.m., resident #319 was observed to have bruising on his forearms. Review of resident #319's MAR indicated [REDACTED]. Review of resident #319's physician order [REDACTED]. Review of resident #319's lab work showed an INR of 2.2 on (MONTH) 11, 2019. Review of resident #319's Interdisciplinary Progress Notes, did not reveal any additional orders for an INR. It did not show any monitoring of INR from 9/11/19-11/26/19. There were no notes from the attending physician regarding [MEDICATION NAME] administration, cautions, or rational for not monitoring the INR. Review of a Potential Drug Interaction notice from (Pharmacy provider), dated 9/06/19, showed a possible interaction with [MEDICATION NAME] and [MEDICATION NAME], and stamped by staff member P. Review of a Potential Drug Interaction notice from (Pharmacy provider), dated 9/12/19, showed a possible drug interaction between [MEDICATION NAME]-[MEDICATION NAME] and [MEDICATION NAME], and stamped by staff member P. Review of a Potential Drug Interaction notice from (Pharmacy provider), dated 10/09/19, showed a possible drug interaction between [MEDICATION NAME] and [MEDICATION NAME], and stamped by staff member P. During an interview on 11/26/19 at 2:45 p.m., staff member O stated that she did not know the patient's current INR, she also stated she did not know how often you are supposed to check the INR of a person who is on [MEDICATION NAME]. After questioning staff member O about this, a STAT order appeared in the Resident's chart to check INR and every week thereafter. Staff member O also was not aware of the advisories from the pharmacy. During an interview on 11/27/19 at 08:13 a.m., staff member B stated, (Resident #319) does not have anything out of the ordinary, he's only been here a few months.",2020-09-01
130,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2019-11-27,758,E,0,1,92Z111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to monitor, assess, and provide rationale for the use of [MEDICAL CONDITION] medications, to ensure 4 (#s 8, 23, 36, and 219) were free from unnecessary [MEDICAL CONDITION] medication use, which included: failing to ensure dosing was appropriate for a resident who was ordered [MEDICATION NAME] and [MEDICATION NAME], for 1 (#219); failing to ensure 1 (#23) received an attempted GDR or rationale for declination; failing to ensure 1 (#8) had a PRN [MEDICAL CONDITION] for 14 days or less with evaluation and rationale to continue physician orders; and failed to ensure 1 (#36) received a preventative assessment for [MEDICAL CONDITION] side effects, out of 28 sampled residents. Findings include: 1. Review of a State Survey Agency report showed resident #219's condition had deteriorated quickly partially due to the facility over-medicating resident #219. During an interview on 11/27/19 at 9:42 a.m., staff member B stated [MEDICATION NAME] was prescribed for the resident so they could perform a chest x-ray, draw blood, and perform a catheterization. During an interview on 11/27/19 at 9:48 a.m. staff member A stated she returned to the facility after 7/4/19 and had not been in the facility when resident #219 was admitted . Staff member A stated resident #219 admitted from a different facility and that facility had not sent a comprehensive medications list for resident #219, so they were not sure if resident #219 had taken [MEDICATION NAME] previously. Staff member A stated [MEDICATION NAME] was not given to sedate resident #219; it was specifically for the diagnostic procedures. Staff member A added the facility did know resident #219 had taken [MEDICATION NAME] in the past, and so staff administered that prior to the [MEDICATION NAME]. Staff member A stated the [MEDICATION NAME] had little to no effect. Staff member A stated the provider associated with the facility in (MONTH) was no longer working with the facility, and she was not able to provide the provider's notes or assessments related to resident #219. During an interview on 11/27/19 at 10:19 a.m., staff member K called the consultant pharmacist to ask about the [MEDICATION NAME] dose for resident #219 as normal dosing ranges from 2-5 mgs, with a maximum of 20 mgs. Staff member K stated that the consultant pharmacist explained it was a higher dose than normal for a geriatric resident with dementia, but providers will prescribe a higher dose if it is a one-time administration. Staff member K stated 20 mg would be more normal. Staff member K stated the facility was not sure if resident #219 had received [MEDICATION NAME] previously, but she did not have any adverse reactions from it, and they were able to complete the diagnostic testing. Staff member K stated resident #219 was discharged to the hospital on [DATE] for a respiratory issue; something she had been showing signs of upon admission on 6/28/19. During an interview on 11/28/19 at 9:30 a.m., staff member L stated they suspected resident #219 had a urinary tract infection, and the [MEDICATION NAME] was ordered so they could catheterize resident #219 and get a chest x-ray. Staff member L stated resident #219 was very combative and agitated, which was why the [MEDICATION NAME] was ordered. Review of resident #219's medication orders showed she was prescribed the following: -[MEDICATION NAME], 50 mg/ml: inject 25 mg intramuscularly every 2 hours as needed for agitation/aggressiveness; may repeat in 2 hours if needed to complete procedures. (MONTH) repeat complete order 1 day if needed to complete all procedures. Dated 7/3/19. -[MEDICATION NAME] ([MEDICATION NAME]), 2 mg/ml: inject 1 mg intramuscularly every 12 hours as needed for agitation. Dated 7/1/19. -[MEDICATION NAME] 2 mg/ml: give 1 mg by mouth every 12 hours as needed for anxiety; agitation. Dated 7/2/19. Review of resident #219's MAR indicated [REDACTED]#219 received: -2:13 a.m.: 1 mg [MEDICATION NAME] injection -10:24 a.m.: 1 mg [MEDICATION NAME] liquid concentrate -10:28 a.m.: 1 mg [MEDICATION NAME] injection -3:13 p.m.: 25 mg [MEDICATION NAME] injection Review of resident #219's [DIAGNOSES REDACTED]. 2. During an interview on 11/27/19 at 10:29 a.m., staff member B stated, pharmacy reviews and recommendations were reviewed by herself and the pharmacist. Staff member B stated she would then follow up with the medical director for any recommendations or concerns and [MEDICAL CONDITION] were also reviewed at QAPI. During an interview on 11/27/19 at 12:50 p.m., staff member G stated the floor nurses do assessments. Staff member G stated medication orders and recommendations go through a three-part system of the doctor, nurse, and pharmacist to make sure there are no discrepancies or interactions. During an interview on 11/27/19 at 1:00 p.m., staff member F stated nursing assessments were done on admission. For ongoing nursing assessments the MDS nurse brought a list of assessments that were due for the floor nurses to complete. Staff member F stated it was everyone's responsibility to check the pharmacy recommendations. When the floor nurses received the recommendation they would forward it to the medical director for review and then it was returned to the facility on ce signed off. a. Record review of resident #8's current physician orders, received on 11/26/19, showed resident #8 was ordered, [MEDICATION NAME] Allergy Tablet ([MEDICATION NAME][MEDICATION NAME] HCL) Give 50 mg by mouth every 12 hours as needed for itching, rash or Anxiety. The order was active with a start date of 8/13/19 with no stop date. There was no other documentation provided to show the ongoing monitoring and evaluation to continue to reorder the 14 day [MEDICAL CONDITION] medication for anxiety, or rationale to continue a PRN [MEDICAL CONDITION] medication for anxiety that is also on the BEERs list for geriatrics. b. Review of resident #23's last DISCUS showed completion on 4/4/19. Review of the monthly pharmacist reviews, dated 5/29/19 and 10/31/19, showed the recommendation for the facility to complete either an AIMS or DISCUS assessment every six months due to resident #23 receiving [MEDICATION NAME], and resident #23 was due for an assessment in October, however, no other assessment was in the resident's medical record. c. Record review of resident #36's pharmacist reviews dated 3/31/19, 8/28/19, and 9/30/19, showed, (Resident #23) has received an antidepressant, [MEDICATION NAME] 10 mg daily and [MEDICATION NAME] 10 mg in AM and Noon and 15 mg nightly for management of depressive/anxiety symptoms. A recommendation for a GDR attempt of [MEDICATION NAME] 10 mg TID was requested by the pharmacy review each time. On 10/2/19 the medical director checked the declination box and signed, however, did not provide rationale for declining a GDR attempt. The physician declination was not timely or complete. Review of the facility's policy, Psychopharmacologic Medication Assessment and Review Policy, revised 3/2019, showed an initial assessment prior to a medication being initiated was required, and completed if the resident was a Dementia Resident with an antipsychotic medication on admission, or if there is an approved diagnosis. The policy showed residents were not to receive PRN orders for [MEDICAL CONDITION] medications unless the medications treated a documented condition.",2020-09-01
131,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2019-11-27,761,C,0,1,92Z111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to dispose of an expired medication for 1 (#26) of 28 sampled residents; and failed to dispose of expired supplies. The expiration of the supplies had the potential to introduce infection into a vulnerable population. Findings include: During on observation on [DATE] at 3:10 p.m., [MEDICATION NAME] Gelcaps (eye health vitamin) was found on a medication cart and had an expiration date of ,[DATE]. During an interview on [DATE] at 3:10 p.m., staff member M stated no one was currently taking the [MEDICATION NAME] Gelcaps, but it had been prescribed for resident #26. Staff member M stated the last time resident #26 took the vitamin was in (MONTH) of 2019. During an interview on [DATE] at 3:12 p.m., staff member M stated RNs, LPNs, and CMAs review expiration dates on medications all the time. During an observation on [DATE] at 3:31 p.m., one container of sterile water and eight bottles of Epiclenz were found in the medication storage room on the Memory Care Unit, and had the following expiration dates: -Sterile water: [DATE] -One bottle of Epiclenz: ,[DATE] -Three bottles of Epiclenz: ,[DATE] -Three bottles of Epiclenz: ,[DATE] -One bottle of Epiclenz: ,[DATE] During an interview on [DATE] at 5:08 p.m., staff member L stated she was not sure who exactly was responsible for reviewing medications and supplies for expiration dates. Staff member L said nurses and medication aides were likely responsible for completing the task once every month. During an interview on [DATE] at 5:16 p.m., staff member F stated everyone was responsible for reviewing medications and supplies for expiration dates. Staff member F stated unit managers were usually good about taking care of storage rooms. Review of the facility's policy, General Dose Preparation and Medication Administration, revised [DATE], showed: Facility staff should: verify each time a medication is administered .check the expiration date on the medication. Review of the facility's policy, Disposal/Destruction of Expired or Discontinued Medications, revised [DATE], showed: Facility staff should destroy and dispose of medications in accordance with facility policy and applicable law, and applicable environmental regulations. Facility should place all discontinued or outdated medications in a designated, secure location .",2020-09-01
132,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2019-11-27,800,D,0,1,92Z111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the diet preferences for 1 resident (#36) of 28 sampled residents Findings include: during an observation and interview on 11/25/19 at 5:17 p.m., resident #36 stated she had to watch what was served because the facility served items she was not supposed to have because she was diabetic. Resident #36 showed the dinner served and pointed to the dinner roll and butter on her plate and stated, I can't have this. I just don't eat it. I send it away. Review of resident #36's meal printout for the 11/25/19 dinner showed: ccd- mech soft -Monday (w2-d9) dinner -swiss steak with gravy 3 oz -brown gravy 2 oz -veg 1/2 cup pureed cream style corn -milk 8 oz -coffee or hot tea 6oz. Dinner roll and butter were not listed. During an interview on 11/27/19 at 9:04a.m., staff member D stated the meal printouts would only show the items the resident could be served for the diet and preferences for that meal. Staff member D stated she was the one who had given resident #36 the roll at dinner by accident, but resident #36 would not have eaten it because she knew she shouldn't have it. Record review of resident #36's, RD Nutritional Assessment Updated, dated 9/18/19, showed resident #36's current diet order as, CCD, mechanical soft, regular consistency. Record review of resident #36's current [DIAGNOSES REDACTED].",2020-09-01
133,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2019-11-27,812,C,0,1,92Z111,"Based on observation, interview, and record review, the facility failed to follow safe personnel hygiene standards in food preparation areas, and failed to follow safe food storage in accordance with professional standards, to ensure the necessary precautions were provided for food service and sanitation. This had the potential to affect any resident receiving food from staff who failed to follow safe food preparation practices, or who received food prepared in areas frequented by these staff members. Findings include: 1. During an observation on 11/25/19 at 1:45 p.m., during the initial tour of the kitchen, staff member J had a hat on, but his shoulder-length hair was not contained. During an interview on 11/26/19 at 8:21 a.m., staff member D, stated staff member J had put on a hair net shortly after he started last evening, and his hair was completely covered. b. During a dining room observation on 11/26/19 at 8:30 a.m., a cook was observed in the small food preparation area near Hallway G with his beard net around his neck and not on his face. After 5-10 minutes he noticed the surveyor and disappeared out of sight only to return a minute later with his beard net properly placed. During an interview on 11/26/19 at 2:53 p.m., staff member D stated, The policy is that any hair is supposed to be covered, top of the head with baseball cap is OK, however, if any (hair) is sticking out beneath it must be covered with a hair net. Facial hair must be covered as well with a beard net. Review of the facility's contracted food services provider's policy, Staff Attire, showed, 1. The Food Services Director insures that all staff members have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. (sic) 2. Observations on 11/25/19 at 1:45 p.m., during the initial tour of the kitchen the following items were found: -bags of cereal, removed from original packing boxes, without expiration dates. -a variety of snack items, e.g., granola bar and cookies, not in their original packing boxes, in a large box, with no individual expiration dates. During an interview on 11/25/19 at 1:45 p.m., staff member I, stated all food containers are dated with an expiration date and an open date. The open date showed staff when the item was to be disposed of, based on a chart on the wall by the refrigerator. During an interview on 11/26/19 at 5:08 p.m., staff member D, stated all food containers were dated with an expiration date and an open date. The open date indicated to the staff when the item was to be disposed of, based on the type of food item and the kitchen personnel knew how to determine that. During an interview on 11/26/19 at 5:08 p.m., staff member D, showed several packages of food with expiration dates and open dates. Some dates were from a label gun and some dates were handwritten. During an interview on 11/26/19 at 5:08 p.m., staff member D, explained the snack box process. Staff take a variety of snacks, as needed for the resident's choices at each meal and snack time. There was a date, 7/15, on the box, when staff member D turned the box around. Individual items in the box had no expiration dates. Staff member D explained the date was show when the one-year expiration date would be for the items in the box. The box was added to regularly. Keeping items in the box made it easier for kitchen staff to get the snack trays ready.",2020-09-01
134,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2019-11-27,883,E,0,1,92Z111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer pneumococcal vaccines to 4 (#s 3, 12, 37, and 51) of 28 sampled residents, which had the potential to introduce infection into the resident population. Findings include: During an interview on 11/26/19 at 8:10 a.m., staff member M stated the facility had given her a stack of incomplete pneumococcal vaccine consent documents she was responsible to review for their residents. Staff member M also mentioned she had residents ask her when they were going to receive their pneumococcal vaccines, and she had been unable to provide an answer. During an interview on 11/26/19 at 5:08 p.m., staff member L stated she was unsure what the facility's policy was on pneumococcal vaccines but she knew that residents had to be at least [AGE] years of age to receive it. Staff member L stated, It depends on when the (residents' primary care provider) wants them to have it. During an interview on 11/26/19 at 5:18 p.m., staff member F stated the facility offered the pneumonia vaccine upon admission, and then annually thereafter. During an interview on 11/27/19 at 7:42 a.m., staff member K stated staff member B called in the order for 2019 [MEDICATION NAME] yesterday (11/26/19). Staff member K stated the facility still had some vaccines left over from (YEAR), and they were continuing to use those. During an interview on 11/27/19 at 10:11 a.m., staff member B stated, All residents should be asked if they have had the vaccine when they come in .If not, they receive the Prevnar 13 first then a year later, the [MEDICATION NAME] 23. Staff member K stated the facility still had nine doses of [MEDICATION NAME] 23 and ten doses of Prevnar 13. Staff member K stated those do not expire until 2020, and showed the expiration date on the vaccine boxes. Staff member K stated, When the (previous owners) were operating the facility, it was our understanding that (the vaccines) were not given. Staff member K added the facility was working on identifying the residents who had not yet received the pneumococcal vaccines. During an interview on 11/27/19 at 12:36 p.m., staff member A stated management had identified vaccinations as an ongoing issue during QAPI meetings, and the facility was currently collaborating with the local hospital to gather residents' histories of vaccinations. Review of resident #37's immunization record, showed she had not received Prevnar 13, nor the [MEDICATION NAME] 23 vaccine as of 11/25/19. Resident #37 admitted to the facility on [DATE]. Review of resident #51's immunization record, showed she had not received Prevnar 13, nor the [MEDICATION NAME] 23 vaccine as of 11/25/19. Resident #51 admitted to the facility on [DATE]. Review of resident #3's immunization record showed she had refused Prevnar 13 on 11/26/19. Resident #3 admitted to the facility on [DATE]. Review of resident #12's immunization record showed she had received Prevnar 13 on 11/26/19 and [MEDICATION NAME] 23 on 7/20/19. Resident #3 admitted to the facility on [DATE]. Review of the facility's vaccine invoice showed five of the [MEDICATION NAME] 23 and five of the Prevnar 13 vaccines were delivered 12/1/18. The facility did not provide a 2019 invoice. Review of the facility's Clinical Admission Checklist for 2019 showed: Determine status of flu, PPSV23 ([MEDICATION NAME] 23), and PCV13 (Prevnar 13). Provide (vaccine information) statements if not vaccinated. Review of the facility's policy concerning pneumococcal vaccines showed residents should, .receive a single dose of PCV13 followed by a dose of PPSV23 12 months after the PCV13 vaccination was administered .Residents of nursing homes or long term care facilities should all be vaccinated.",2020-09-01
135,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2018-11-29,600,G,0,1,BMUS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the protection of a resident and ensure the resident was free from ongoing abuse from a facility staff member for 1 (#21) of 22 sampled residents. Resident #21 had ongoing anxiety and anger due to staff member F's hostile behavior. Findings include: During a resident council meeting on 11/27/18 at 1:30 p.m., resident #21 and her daughter, NF1, stated they had filed grievances for verbal abuse by staff members to the facility. NF1 stated, No one ever got back to us once the grievances were filed. Resident #21 stated, I wrote a letter and everything. She stated she signed and dated the letter and gave it to a staff member. During an interview on 11/27/18 at 4:45 p.m., resident #21 stated she had been subjected to verbal abuse by staff member F the previous month. She stated staff member F was angry, Because I had to use the bathroom so much. Resident #21 stated staff member F called her, Wicked. She stated she reported the incident via a hand-written letter and she dated and timed the letter when she signed it. Resident #21 stated she gave the letter to a staff member. She stated she was, Very angry, and the incident caused her anxiety. During an interview on 11/28/18 at 12:17 p.m., staff member A stated she had no knowledge of an allegation of verbal abuse to resident #21 by staff member F. She stated, There was an allegation of verbal abuse made in late September, but I don't have anything for October. Staff member A stated, I think (resident #21) and her daughter are confused. Staff member A stated staff member F was an employee of the facility but was not currently working and on leave. During an interview on 11/28/18 at 1:52 p.m., staff member B stated resident #21 gave a letter to staff member D which alleged verbal abuse by a staff member F on 10/31/18 at 8:00 p.m. She stated the letter was placed inside of a sealed envelope and staff member D gave the sealed envelope to staff member C. Staff member B stated staff member F was not currently working at the facility. She stated her last day of work was 11/4/18. During an interview on 11/28/18 at 2:20 p.m., staff member D stated resident #21 gave her a letter around the 7th or 8th of November. She stated that she gave the letter to a facility nurse the day that she received it. Staff member D stated the letter was placed in a sealed envelope. She stated she did not read the letter, but she engaged in a conversation with resident #21 about the contents of the letter. Staff member D stated resident #21 shared with her several concerns about staff member F and she mentioned, Abuse once or twice, during their conversation. She stated resident #21 told her that the tone used by staff member F, Wasn't what she expected to hear, from a staff member. Staff member D stated she reported the abuse and turned in the letter to a facility nurse. She stated she did not report the allegation of the abuse to the medical director of the facility and stated, In retrospect, the medical director should have been notified. Staff member D stated it was her understanding that if she reported the allegation of verbal abuse to the facility, the facility would take the necessary steps to investigate the incident. She stated she was not sure if she included the allegation of verbal abuse in resident #21's physician progress notes [REDACTED].#21) does not make false accusations. She stated, (Resident #21) has a sense of relief because (staff member F) is no longer here. During an interview on 11/29/18 at 9:41 a.m., staff member C stated, So the letter was received by me and at that time, the nurse was not here. She stated, staff member D gave her a sealed envelope, which contained a letter from resident #21, alleging verbal abuse by staff member F. Staff member C stated she could not recall the exact date she received the letter, or if she had informed the Administrator about the allegation, and stated, There was a lot going on. Review of the letter written by resident #21, signed and dated on 11/1/18 at 11:00 p.m. showed on 10/17/18, (Staff member F) . complained about me having to go to the bathroom so many times during the night. On 10/31/18, resident #21 wrote, Verbal abuse, she complained about me getting up at 8 p.m.; when she gave me my night time pill said I was being wicked having to go so often. The letter further read, I should not have to go thru (sic) that kind of abuse. Review of resident #21's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of resident #21's (MONTH) (YEAR) Medication Administration Record [REDACTED]. The facility failed to protect resident #21 and ensure that the resident did not experience harm nor was subjected to ongoing abuse by staff member F.",2020-09-01
136,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2018-11-29,609,D,0,1,BMUS11,"Based on interview and record review, the facility failed to identify and report a situation as an alleged violation involving resident abuse for 1 (#21) of 22 sampled residents. Findings include: During an interview on 11/28/18 at 12:17 p.m., staff member A stated, I have no knowledge of an allegation of verbal abuse for (resident #21). She stated all allegations of abuse are to be reported to the State Surveying Agency, and she would begin an investigation immediately. During an interview on 11/29/18 at 9:41 a.m., staff member C stated she received a letter that was written by resident #21 a couple of weeks prior. She stated the letter alleged that resident #21 had been verbally abused by staff member F. Staff member C stated she could not recall if she reported the allegation of abuse to the Administrator of the facility and stated, Oh, absolutely I should contact the Administration if I receive an allegation of abuse. She stated the facility policy is to report all allegations of abuse to the Administrator, investigate, and report the allegation to the State Surveying Agency. Staff member C stated she did not report the alleged abuse to the State Surveying Agency, nor did she investigate and she, Should have. Review of the facility Abuse Prevention Plan (MT), effective 2012, last revised (MONTH) of (YEAR), identified verbal abuse as: The use of oral written, or gestured language that willfully includes disparaging and derogatory terms to residents. It is the policy of the facility that, All residents residing in the facility will be protected from maltreatment. Further, The facility requires that all suspected maltreatment will be reported to the State promptly. The Administrator, or designee shall: Make sure the report is filed, that the internal investigation begins immediately, the appropriate reporting takes place and that interventions are implemented to provide the vulnerable adult with a safe living environment.",2020-09-01
137,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2018-11-29,610,D,0,1,BMUS11,"Based on interview and record review, the facility failed to thoroughly investigate, and follow and utilize the facility written policies and procedures for abuse, for the investigation and allegations of abuse for 1 (#21) of 22 sampled residents. Findings include: During an interview on 11/27/18 at 4:45 p.m., resident #21 stated she had been subjected to verbal abuse by staff member F in (MONTH) (YEAR). She stated she reported the incident via a hand-written letter, and she dated and timed the letter when she signed it. Resident #21 stated she gave the letter to a staff member. She stated no one from the facility followed up with her. During an interview on 11/28/18 at 12:17 p.m., staff member A stated she had no knowledge of an allegation of verbal abuse to resident #21. During an interview on 11/28/18 at 1:52 p.m., staff member B stated resident #21 gave a letter to staff member D which alleged verbal abuse. Staff member B stated the incident occurred on 10/31/18. During an interview on 11/28/18 at 2:20 p.m., staff member D stated resident #21 gave her a letter around the 7th or 8th of (MONTH) (YEAR). She stated she gave the letter to a facility staff member the day that she received it. During an interview on 11/29/18 at 9:41 a.m., staff member C stated, So the letter was received by me and at that time, (staff member F) was not here. She stated, staff member D gave her a sealed envelope which contained a letter from resident #21 alleging verbal abuse by staff member F. Staff member C stated she could not recall if she had informed the Administrator about the allegation and she did not complete an investigation and stated, I should have. Review of the facility Abuse Prevention Plan (MT), effective 2012, last revised (MONTH) of (YEAR), identified verbal abuse as: The use of oral written, or gestured language that willfully includes disparaging and derogatory terms to residents. It is the policy of the facility that All residents residing in the facility will be protected from maltreatment. Further, The facility requires that all suspected maltreatment will be reported to the State promptly. The Administrator, or designee shall: Make sure the report is filed, that the internal investigation begins immediately, the appropriate reporting takes place and that interventions are implemented to provide the vulnerable adult with a safe living environment. Review of facility incident reports and filed grievances revealed no documentation of the incident prior to 11/28/18. Refer to F600 for more information related to resident #21.",2020-09-01
138,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2018-11-29,657,B,0,1,BMUS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a care plan was updated for a residents change in [MEDICAL CONDITION] medications, which had the potential to affect the desired outcome of the resident's mental well-being for 1 (#32) of 22 sampled residents. Findings include: During an interview on 11/28/18 at 9:41 a.m., staff member C stated resident #32 takes [MEDICATION NAME] for depression. She stated, I don't see anything for depression on her care plan. Staff member C stated resident #32 did not take medication for anxiety, and she did not take an antipsychotic medication, but she had in the past. She stated, The care plan should have been updated when the medication changes took place. Record review of resident #32's care plan, revised on 10/30/18 showed, Focus area: I am taking [MEDICAL CONDITION] medications for anxiety and depression. Interventions for the care plan focus area showed, I take anti-psychotic medication . Staff will observe for side effects of these drugs; ANTIANXIETY MEDICATION. Record review of resident #32's MAR for (MONTH) (YEAR) showed, resident #32 takes [MEDICATION NAME] 15 mg by mouth one time a day for depression. The order for [MEDICATION NAME] was initiated by resident #32's physician on 9/7/18. The resident did not take medication to treat anxiety, and the resident did not take an antipsychotic medication.",2020-09-01
139,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2018-11-29,677,D,0,1,BMUS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide necessary ADL services to the residents to maintain personal hygiene, for 2 (#s 10 and 62) of 22 sampled residents, which caused resident #10 to feel as though the facility did not care about her well being, and resident #62 had greasy hair which appeared unclean. Findings include: 1. During an interview on 11/27/18 at 7:51 a.m., resident #10 stated, I get about seventy percent of the care I need. She stated, I don't get showers that often, I'm lucky if I get two showers a month. Resident #10 stated that not receiving the care she needs and not getting showers made her feel like the facility staff did not care about her. Review of resident #10's bathing documentation for (MONTH) (YEAR) showed resident #10 received a bath on 11/6/18 and 11/22/18. Review of resident #10's care plan, revised on 11/21/18 showed, I prefer to take a shower. I prefer 3 a week. During an interview on 11/29/18 at 9:41 a.m., staff member C stated resident #10 will at times refuse her bathing. She stated her care plan showed a shower three times a week, and it should be listed on the bathing schedule to match what is listed on her care plan. Staff member C stated facility staff could document resident refusals. She stated there should be at least three entries per week for resident #10's bathing documentation. Staff member C stated it would not be acceptable for resident #10 to go three weeks without a shower. She stated resident #10's last shower was on 11/22/18. She said, Before that she was showered on (MONTH) sixth. Review of the facility policy, Bathing, effective (MONTH) (YEAR), showed, A minimum of a complete tub bath or shower once a week shall be provided for all residents, and more often if desired/necessary. Review of the facility policy, ADL Assistance Provided Per Care Plan, effective (MONTH) (YEAR), showed, Based upon resident/resident representative desires, assessment, and care plan, ADL assistance will be provided to any residents deemed necessary. Some examples would be: Bathing/showering. 2. During an observation and interview on 11/26/18 at 3:15 p.m., resident #62's hair was greasy. Resident #62 stated he was supposed to get a bath two times a week. The resident stated, It's been 13 days since my last shower. The resident stated he was washing up in the sink since he had not received a shower. The resident stated he needed assistance with showering. During an interview on 11/27/18 at 9:00 a.m., resident #62 stated he still had not received a shower. The resident stated, I would like routine showers without having to ask for them. During an interview on 11/27/18 at 5:20 p.m., staff member T stated resident #62 was scheduled for a bath two times a week. The staff member stated the Bathing Schedule was used as a guide to track resident's baths. Staff member T stated, CNAs document in the resident's chart, either resident refusal or bath completed. Staff member T stated, Sometimes staff don't document when a shower was given. During an interview on 11/28/18 at 10:13 a.m., staff member H stated, Residents are supposed to get a shower twice a week. Staff member H stated, Sometimes CNAs forget to write down when showers are completed. Review of resident #62's medical record showed a [DIAGNOSES REDACTED]. Review of the facility's Bath Schedule for (MONTH) (YEAR) showed resident #62 was scheduled for baths on Sunday and Thursday evenings. Review of resident #62's Flow Sheet Report for (MONTH) showed resident #62 received a bath on 11/01/18, 11/07/18, and 11/14/18. Review of the facility policy, ADL Assistance Provided Per Care Plan showed, Based upon resident/resident representative desires, assessment, and care plan, ADL assistance will be provided to any residents deemed necessary. Some examples would be: Bathing/showering. Review of resident #62's Care Plan, with a focus area of Dressing/Grooming/Bathing, showed a goal of, I want to participate in my dressing, grooming and bathing. The intervention for Dressing/Grooming/Bathing showed, I prefer to take a shower. I prefer 3 a week.",2020-09-01
140,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2018-11-29,686,G,0,1,BMUS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility and staff failed to prevent the development of a pressure ulcer, document the interventions attempted to heal the pressure ulcer, and the ongoing status of the wound, and the wound continued to worsen over time, turning into an unstageable pressure ulcer, for 1 (#75) of 22 sampled residents. Findings include: During an observation on 11/27/18 at 10:26 a.m., staff member Z changed the dressing for resident #75's unstageable pressure ulcer. The wound, as stated by the staff member, was the size of a half dollar, measuring 3 cm x 3 cm. Review of a wound assessment dated [DATE], showed the wound bed contained approximately 24 percent slough and had undermining around the edges. There was no odor, and the resident stated she was not in pain. Serosanguineous drainage was noted on the dressing. Staff member Z stated the ulcer had not improved, and would probably never heal. Staff member Z changed gloves during the treatment, but did not wash her hands before or after the procedure. Review of resident #75's Nursing Progress Notes, dated 4/5/18, showed pressure injury was found on residents right buttock/bony prominence of sacrum. Wound is a stage II with eschar present in the wound bed. Wound measure 2 cm x 1 cm. No drainage at this time. Wound was cleansed with wound cleaner and covered with an [MEDICATION NAME]. Review of resident #75's Nursing Progress Notes, dated 4/12/18, showed Has a full thickness, unstageable pressure injury to left ischial tuberosity. Measure 4 cm x 2.5 cm, depth unknown related to area of firmly adherent yellow/brown slough to center of wound bed. Resident is on low air loss mattress, prefers to lie on left side. Will ensure regular repositioning to aid in wound healing. The wound had worsened since the discovery on 4/5/18. Review of resident #75's Nutrition at Risk IDT Committee Notes, dated 4/25/18, showed Review of weight related to wound to left ischial tuberosity. weight 85.8 pounds. Diet: Regular mechanical soft. Meal intake 0-25 percent. Family aware and spoke with RD. Hi cal supplement with meals and PM hydration pass. Hospice consult regarding noted decline. Will continue to monitor until wound healed or changed in therapy. Review of resident #75's Weekly Wound Documentation Form showed documentation for 4/12/18 to 4/25/18 and 10/4/18 to 11/21/18. No documentation on the wound was provided from (MONTH) (YEAR) through (MONTH) (YEAR). Staff member A stated the facility had significant staffing concerns through the summer, for why documentation was not completed. Review of resident #75's Treatment Administration Record for the month of (MONTH) (YEAR) showed missing treatments for 6 out of 20 days. The dressing was ordered to be changed daily. Review of resident #75's Quarterly MDS, with the ARD of 11/11/18, showed she was totally dependent on staff for positioning in bed, toileting, and eating. Review of resident #75's Quarterly MDS, with the ARD of 8/11/18, showed she experienced a significant weight loss of five percent. Review of resident #75's weight records showed no weights were provided from 10/3/17 through 3/1/18. The reason for the lack of weight documentation was requested, but a response was not received from the facility on the question. During an interview on 11/26/18 at 2:40 p.m., staff member S stated she did not know much about resident #75's pressure ulcer, but she kept her clean, although the wound had been present for many months. During an interview on 11/29/18 at 12:40 p.m., staff member R stated she did not know why the pressure area was not discovered until it was unstageable. She stated if she had been notified in a timely way, the area would not have developed to a full thickness loss. She stated resident #75 was bed bound but she did not know why. She stated the resident used to get up for a whirlpool bath, which helped with the healing of the pressure ulcer.",2020-09-01
141,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2018-11-29,692,G,0,1,BMUS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide adequate interventions to prevent significant or severe weight loss for 2 (#s 15 and 75) of 22 sampled residents. Findings include: 1. During an observation on 11/26/18 at 1:05 p.m., resident #75 was lying in bed, asleep. Her lunch tray was on a bedside table, untouched. Review of resident #75's weight records, showed her weight was 98.6 pounds on 3/1/18 and down to 85.8 pounds on 4/20/18, after developing an unstageable pressure sore on 4/5/18. She was placed on hospice in (MONTH) (YEAR) secondary to her decline in status. The facility stopped weighing the resident related to her enrollment in hospice care. Review of resident #75's weight records showed no weights were obtained from 10/3/17 through 3/1/18. The reason for the lack of weights was requested but not answered. Review of resident #75's current diet order showed she was on a pureed diet with regular liquids. During an interview and observation on 11/27/18 at 9:36 a.m., staff member X was feeding resident #75. Breakfast service started at 8:00 a.m. Staff member X stated resident #75 did not like the meat or eggs, but would eat her hot cereal and drink her boost. Review of resident #75's food likes and dislikes showed no breakfast dislikes, and the document was not dated or signed. Review of resident #75's Care Plan showed she was at nutritional risk due to increased nutritional needs related to an unhealed pressure ulcer. Interventions included honor food preferences/intolerance's as they become known. (Resident) is have a difficult time making food likes/dislikes known. We are honoring past food preferences, and family will let dietary know if they are in facility what to serve at meals. This was initiated on 9/28/15 and revised on 2/27/17. No evidence of preferences on the diet card were noted. During an observation on 11/29/18, the room trays were delivered to the nurses station at 9:13 a.m. Breakfast service started at 8:00 a.m. Staff member O stated the room trays should arrive by 8:30 or 8:40 a.m. Resident #75 was assisted with her meal at 9:24 a.m. The cereal and eggs were 92 degrees. The resident was unable to verbalize if the food was unpalatable for her to consume. Review of resident #75's Nutrition at Risk IDT Committed Notes, dated 5/4/18, showed Weight review for weight loss of 11.7 percent in 30 days (severe weight loss). Resident has been admitted to Hospice. Continues with high-calorie Boost 4 times a day, meeting 46 percent of estimated needs. Appetite varies, MD ordered unavoidable weight loss. Continues with unstageable pressure injury to right (sic) ischial tuberosity. Review of resident #75's Nutrition at Risk IDT Committee Notes, dated 9/27/18, showed Review of weight with stage II (sic) pressure injury to right heel and pressure injury to right ischial tuberosity. Wound nurse is following. Expected weight loss related due to decline. Diet; Regular, mechanical soft texture. Receives Boost four times a day. Meal intakes 26-50 percent. Consumes roughly one supplement per day. No diuretic therapy. On hospice care. Will continue to monitor. No interventions were implemented for weight loss. Review of resident #75's Nutrition at Risk IDT Committee Notes, dated 10/19/18, showed review of weight, wound to right ischial tuberosity and left heel. Currently on hospice. No weight as hospice has discontinued weights. Weight decline expected. No changes at this time. Will continue to monitor. No interventions were addressed by the Committee for the prevention of resident's ongoing weight loss. 2. During an observation and interview on 11/29/18, at 8:40 a.m., resident #15 received a large bowl of yogurt for breakfast, which she refused. She stated she did not feel well, and had very little appetite. The resident stated I doubt I'll dwindle away. I'm not ready to go yet. She stated the quality of the food had gone down. Review of resident #15's Quarterly MDS, with the ARD of 9/3/18, showed a current weight of 268 pounds, and a significant non-physician prescribed weight loss. Review of resident #15's Quarterly MDS, with the ARD of 6/19/18, showed a weight of 305 pounds. Review of resident #15's Nutrition at Risk IDT Committee Notes, dated 6/9/18, showed Review of weight. Weight is 305 pounds. Weight is trending upwards. BMI qualifies as obesity grade III. Diet: NAS. Good meal intake. Receives eggs for protein needs for breakfast. Educated daughter for resident's increased protein needs. Daughter brings in meals for resident. Currently on diuretic therapy. RD meets weekly regarding healthy eating and decreasing processed food intake. Will continue to monitor. Review of resident #15's Nutrition at Risk IDT Notes, dated 9/20/18, showed Review of weight: weight: 274.6 pounds. Diet: Cardiac. Meal intake: 75-100 percent. Supplement: Boost each day. Current diuretic therapy. Skin issues to BLE. Per RD no changes at this time. Will continue to monitor until weight stable x 4 weeks. The review did not include the 30 pound, 10 percent weight loss in the past three months. No interventions were implemented to prevent further weight loss. Review of resident #75's Nutrition at Risk IDT Committee Notes, dated 11/15/18, showed reviewed weight loss: weight 261 pounds. Diet: Cardiac, high protein. Meal intake: 50-75 percent. Supplement: Boost every day. Skin issues BLE. Currently on diuretic therapy. Weight fluctuates related to [MEDICAL CONDITION]. RD to discuss diet preference. Will continue to monitor until weight stable x 4 weeks. The note did not include the five percent weight loss from 9/20/18, or the decrease in the percent eaten by the resident, and interventions implemented. Review of resident #75's Nutrition at Risk IDT Committee Notes, dated 11/23/18, showed Review of weight: weight 264.2 pounds. Diet: Cardiac high protein. Meal intake: 25-50 percent. Boost each day. Diuretic therapy. Skin issues to BLE. Weight fluctuates related to [MEDICAL CONDITION]. Will continue to monitor until weight stable x 4 weeks. The note did not address the further decline in appetite, and no interventions were implemented to prevent further weight loss. During an interview on 11/27/18 at 5:06 p.m., staff member L stated resident #15's current weight was down to 257 pounds. She said the continued weight loss was related to the resident's declining appetite. She stated the resident would only drink one Boost per day, and she thought the resident was ready to move on, and no other interventions had been implemented. Resident #15 had lost 45 pounds in six months, with no preventative interventions implemented, to include interventions to assist with pressure ulcer healing.",2020-09-01
142,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2018-11-29,758,D,0,1,BMUS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to discontinue a PRN antipsychotic medication after 14-days, without documented rational in the medical record for continuing the medication, for 1 (#10) of 22 sampled residents. Findings include: During an interview on 11/27/18 at 7:51 a.m., resident #10 stated she had trouble being around people as a result of the abuse she went through in the past, and she took, Quite a bit, of medications to help her cope. Record review of resident #10's (MONTH) (YEAR) Medication Administration Record [REDACTED]. The order was initiated on 10/13/18. Record review of resident #10's nursing progress notes, dated 10/18/18, signed by staff member C showed, Review of [MEDICATION NAME] 0.5 mg Q12 PRN. Per review, will request GDR, if declined will need rationale provided. Record review of resident #10's pharmacy consultation report, dated 10/31/18 showed, (Resident #10) has a PRN order for an anxiolytic, which has been in place for greater than 14 days without a stop date .Please discontinue or give a stop date of no longer than 14 days. The facility did not produce documentation to show that the resident's physician reviewed the PRN (as needed) medication, every fourteen days, prior to 11/29/18.",2020-09-01
143,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2018-11-29,760,D,0,1,BMUS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident received the correct medication for an acute behavior intervention in which the resident was given an intramuscular antipsychotic instead of an oral dose of a sedative, for 1 (#61) of 22 sampled residents. Findings include: During an interview on 11/29/18 at 12:09 p.m., staff member D stated I got a call (he had just transferred from another facility) and I believe the nurse was a traveling nurse, and I knew he was having some behavior issues and was declining. I ordered [MEDICATION NAME] for him for behaviors instead he got [MEDICATION NAME]. It was brought to my attention the following Monday by (staff name). She told me he got [MEDICATION NAME] and not [MEDICATION NAME] and I told her I did not order [MEDICATION NAME] and never have. I never got called about the [MEDICATION NAME] being given. I followed up on Monday with staff and no one had reported an adverse reaction. I examined him that Monday and he was at base line. I don't know if it was reported as a medication error. With a medication like that, I would have a concern because of over-sedation. Resident #61 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #61's physician progress notes [REDACTED]. The night nurse had requested an order for [REDACTED]. would be a less sedating medication. I also instructed the night nurse to give another dose of 0.5 mg of [MEDICATION NAME] p.o. after 60 minutes if the patient's behaviors did not reside. Apparently there was miscommunication and the patient was administered 0.5 mg of [MEDICATION NAME] IM at 0217 hours. I am uncertain as to the discrepancy of the orders. Review of resident #61's nurse's notes showed 7/23/2018 02:17 Behavior Note Text: Resident agitated, verbally and physically aggressive towards staff, kicked CNA, swinging at other staff. Spoke with (provider) and received order for [MEDICATION NAME] 0.5ml x 1 dose, may repeat in one hour if ineffective. 130/82 98.4 76 18 unable to get pulse ox. During an interview on 11/29/18 at 12:30 p.m. staff member C stated there was not a record of the medication error. She stated medication errors are to be reported and investigated to prevent further incidents.",2020-09-01
144,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2018-11-29,761,E,0,1,BMUS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility staff failed to label insulin pens with a date the medications were opened, for 3 (#s 58, 63, 68) residents; and the facility failed to ensure that a resident did not receive expired medications for 1 (#13) of 26 sampled and supplemental residents. Findings include: 1. The medication cart on the [NAME] wing was observed on 11/28/18 at 10:44 a.m. The following items were not labeled with an open date: - 1 opened [MEDICATION NAME]pen for resident #58; - 1 opened [MEDICATION NAME]pen for resident #63; - 1 opened [MEDICATION NAME]pen for resident #68. During an interview on 11/28/18 at 10:44 a.m., staff member [NAME] stated the insulin pens for resident #58, resident #63, and resident #68 had no opened date listed. She stated, I know they have been used, the vials are half gone. Staff member [NAME] stated the pens should be discarded and new ones should be opened. She stated an open date should be written on the new insulin pens. During an interview on 11/28/18 at 12:52 p.m., staff member B stated insulin pens, Should be dated with the open date when they are first used. During an interview on 11/29/18 at 9:41 a.m., staff member C stated the open dates should be written on insulin pens on the date they are opened. Record review of the facility policy, medications: [REDACTED]. 2. The medication cart on the C wing was observed on 11/28/18 at 1:36 p.m. There were two medication cards containing Carvedilol 12.5 mg tablets for resident #13, observed with an expiration date of 10/31/18. During an interview on 11/28/18 at 1:36 p.m., staff member H stated resident #13's Carvedilol expired on 10/31/18. She stated resident #13 takes Carvedilol twice a day and she was administered the expired medication earlier that morning. Staff member H stated the two expired medication cards of Carvedilol should be discarded and new ones should be ordered. During an interview on 11/28/18 at 4:39 p.m., staff member G stated he goes through the medication carts at the facility each month and performs spot checks to check for outdated medications. He stated all expired medications should be discarded, and it was not acceptable for a resident to be administered an expired medication. During an interview on 11/29/18 at 9:41 a.m., staff member C stated it would never be acceptable to administer an expired medication to a resident. Record review of the facility policy, medications: [REDACTED].",2020-09-01
145,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2018-11-29,804,E,0,1,BMUS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to serve palatable, tender, seasoned food at an appetizing temperature, having the potential to affect the quality of life and nutritional status for 13 (#s 10, 15, 18, 25, 32, 39, 40, 49, 62, 63, 74, 75, and 82) of 26 sampled and supplemental residents, and failed to provided a variety of nourishing snacks, affecting most residents that eat at the facility. Findings include: 1. During an observation in the main dining room on 11/26/18 at 12:47 p.m., approximately 60 to 70 percent of plates had food left on the plate. The majority of residents did not eat the breadstick, which looked hard and cold. A breadstick was requested to taste, but the facility had no breadsticks left. During an interview on 11/26/18 at 12:44 p.m., staff member B stated resident #25 was not eating because her gluten free meal had been given to someone else, and the kitchen had to boil gluten free pasta. She waited for 15 minutes to receive her meal. During an observation in the main dining room on 11/27/18 at 12:22 p.m., the stir fried pork had dry and tough pieces of pork in it. Several residents complained the rice did not have any flavor. During an observation on 11/27/18 at 1:31 p.m., resident #39 was having difficulty chewing the pork that was part of the lunch meal. During an observation on 11/27/18 at 1:54 p.m., the alternate to the stir fried pork was a [MEDICATION NAME] Herb Chicken. The chicken breast was plain with no seasoning, and was dry and tough. Review of the recipe for [MEDICATION NAME] Chicken at 4:08 p.m., showed the chicken should be breaded with crumbs and [MEDICATION NAME] and margarine. Staff member P said it was her and staff member O's responsibility to ensure food was prepared according to the recipe. During an interview on 11/27/18 01:54 p.m., staff members I, J, and K reported the pork is always tough and they serve it often. Staff member I stated the residents were not able to chew the meat at least 3 out of 7 days of the week, and the dietary department had been notified. During an observation and interview on 11/27/18 at 4:08 p.m., the pizza for dinner included sauce and cheese. When staff member P was asked about seasonings, the recipe was reviewed and showed the pizza should have basil and Italian seasonings. She stated the seasonings would be put on the pizzas later. The brownies for dessert were packaged in plastic bags. Staff member P stated the facility did have dessert plates, but the residents liked them in bags, in case they wanted to take the brownie back to their room. During an observation on 11/27/18 at 5:35 p.m., three residents stated the pizza was undercooked and not hot. There was no visible herbs on the pizza. The tossed salad was comprised of shredded iceberg lettuce. Staff member P stated the residents could request toppings for the salad. Resident #62 stated How do you like this Spring salad? He did request cheese and tomatoes for the salad. Review of the Food Council Meeting Notes, dated 9/6/18, showed the residents stated there was too much pork and chicken on the menu, the vegetables were overcooked, and the meats were tough. Review of the Food Council Meeting Notes dated 10/4/18, showed the residents stated they were having the same thing over and over. Review of the Food Council Meeting Notes dated 11/1/18, showed the resident asked for kale and more spinach, and less pasta, rice and potatoes. Review of the current weekly menu showed turkey and chicken were served five times, and pork was served twice. Rice, pasta and potatoes were served 10 times out of 14 meals. The facility was not able to provide evidence the facility had followed up on potential menu changes as requested by the residents. During an interview on 11/27/18 at 10:40 a.m., resident #63 stated she had gained 50 pounds since (MONTH) 2019 because the meals were too high in carbohydrates. She stated she had just been hospitalized for [REDACTED]. During an interview on 11/26/18 at 3:15 p.m., resident #62 stated the food was cold, and sometimes it takes an hour to get your food in dining room. The resident stated, We don't know what's on the menu, because it's not posted all of the time. During an observation and interview on 11/27/18 at 5:35 p.m., resident #62's pizza was cold, and the cheese was not melted. The resident's salad consisted of finely chopped lettuce. No other vegetables were on the salad. The resident stated the pizza was cold, the crust was undercooked, and the salad was a joke. It only had lettuce and it was chopped up so bad it looked like mush. During an interview on 11/26/18 at 3:08 p.m., resident #18 stated, The food is terrible and it is getting worse. She stated, It is always cold if you eat in your room. It sits in the hallways until everything else is done. Resident #18 stated, People who are in their rooms should be served first, and should be given something healthy. What we eat is not healthy, but it's something you could exist on. You just can't be healthy on it. During an interview on 11/27/18 at 7:51 a.m., resident #10 stated, The food is terrible. They call it food, it's not. It's usually cold, about ninety-five percent of the time. During an interview on 11/27/18 at 9:54 a.m., resident #32 stated, They serve us rice every day, it is a waste of food. She stated the previous Saturday she talked to a man in the dining room and he told her that the food was so hard and dry that he could not eat it. She stated, If the men can't eat it how are we supposed to? Resident #32 stated, The food is just awful. We used to have a good cook. I suppose she retired. I think administration should look into the situation. During an interview on 11/27/18 at 5:18 p.m., staff member [NAME] stated she had received numerous complaints from residents about the food served at the facility. She stated, I get complaints twenty-four seven, and said, The food sucks. I wouldn't feed it to my dog. Staff member [NAME] stated resident meals are, All bread. She stated, Why do you think that our diabetics blood sugar is so high? Staff member [NAME] stated the kitchen served a lot of bread and carobs. She stated that a banana is the only fresh fruit that the facility served, minus an occasional tomato on a salad. During an interview on 11/28/18 at 9:41 a.m., staff member C stated she had received numerous complaints about the food at the facility and it had been an ongoing struggle. She stated she had received complaints from residents, such as, The food is crap. They have complained that they are not following the menu. Staff member C stated she had also received complaints about food temperatures and stated, Eggs will come out cold, their food is sometimes cold, meal trays can be cold. Staff member C stated, It is a facility problem. We have been working on it and we are trying to get the issues resolved. During an interview on 11/27/18 at 4:31 p.m., staff member B stated the resident preferences are addressed when the resident enters the facility. The staff member stated residents have an alternative option if they do not like what is being served. Staff member B stated the alternative option is based on their preferences. 2. During an observation an interview on 1/27/18 at 2:12 p.m., a snack cart was delivered to the Memory Care unit. It contained 3 shelves of snacks, including sandwiches, yogurt, and cheese. The third shelf contained the usual snack of crackers, animal crackers, and fig newton's. Staff member I and J stated the only reason there were sandwiches and yogurt was because of the presence of the surveyors. During an interview on 11/27/18 at at 10:40 a.m., resident #15 stated the quality of the food had gone down, and there was a shortage of fresh fruit. The snack cart contained no nutritious food, but cookies and crackers. During an interview on 11/27/18 at 5:06 p.m., staff member L stated she had been attempting to improve the facility snacks. During an interview on 11/27/18 at 12:50 p.m., resident #63 stated the food at the facility was crummy and the snacks were no longer good. We get too many carbohydrates. 3. During an observation on 11/ 27 and 11/28/18, during preparation of the lunch meal, a plate warmer was not in use. During an interview on 11/28/18 at 8:40 a.m., staff member O stated it was up to staff member A to order the plate warmers, and the dietary department had requested them. Staff member Q stated he would order them, and that would be the best answer to cold food. During an interview on 11/26/18 at 2:52 p.m., resident #40 stated, The food here is always cold! She stated, I have no complaints except for the lousy food. Review of the Resident Council Notes, dated 11/27/18. showed The food is stone cold. Everyday is cold scrambled eggs. There has to be a way to get warm food. During an observation on 11/2918, the room trays were delivered to the nurse's station at 9:13 a.m. Breakfast service started at 8:00 a.m. Staff member O stated the room trays should arrive by 8:30 or 8:40 a.m. Resident #75 was assisted with her meal at 9:24 a.m. The cereal and eggs were 92 degrees, according to an infrared thermometer. During an interview on 11/27/18 at 1:45 p.m., resident #49 said his breakfast was cold and his lunch was cold. Resident #49 stated Something needs to be done. I will not recommend this place to anyone. Resident #49 continued to complain from 11/27/18 through 11/29/18 that the food was cold and did not taste good. A sample test tray was provided on 11/27/18 at 5:28 p.m. The tray of food consisted of a slice of cheese pizza, a roll, a chopped lettuce salad, a brownie with peanut butter. The pizza was cold with the crust still doughy and the cheese was not melted. There was no butter provided for the roll, the salad contained only very finely chopped lettuce, dressing was provided. The brownie was doughy and appeared to have a tablespoon of peanut butter placed inside it. During an interview on 11/27/18 at 5:28 p.m., resident #74 said her pizza was cold and asked Do you have a puke bucket? During an interview on 11/29/18 at 12:23 p.m., resident #82's family member NF2 stated he food could use some 'spicing up.' NF2 stated that a carafe of cold coffee was brought to them on 11/28/18 and it had to be replaced with hot coffee. The resident's family member said the facility does not serve many fresh fruits, so, I bring what I can and share it, like bananas. During an interview on 11/27/18 at 11:55 a.m., staff member O stated she was doing everything she was supposed to do for the dietary program and could not please everyone.",2020-09-01
146,HERITAGE PLACE,275025,171 HERITAGE WAY,KALISPELL,MT,59901,2018-11-29,880,E,0,1,BMUS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide proper perineal care for 1 (#73) of 22 sampled residents, which placed residents at increased risk for bladder infections. The facility trended high for bladder infections in (MONTH) culturing ecoli for several residents #82 and #83 and made it necessary to retrain staff on Handwashing and peri care. Findings include: During an interview and observation of toileting and peri care on 11/27/18 at 3:10 p.m., resident #73 was observed to be seated on the toilet. Staff member M asked the resident if he was finished and resident #73 indicated he had finished toileting. Staff member M asked the resident to stand and grab the hand bar with both hands. Staff member M took a wet wipe and cleaned some stool from the resident's rectal area. Staff member M took the same wipe, folded it over, and started to clean the resident's penis. When asked if using the same wipe was okay, staff member M said no and stated she should have used a clean wipe, I forgot. Staff member M grabbed a clean wipe and finished peri care. Staff member M had attempted to grab a clean brief with the same gloves used to provide peri care. When asked if the gloves were soiled and if the the brief was clean, staff member M said she should have changed gloves. Staff member M changed gloves, but did not wash hands. Staff member R said the CNA Coordinators train the CNAs on hand hygiene and glove changes. Review of resident #73's Order Listing Report for (MONTH) and (MONTH) showed resident #73 was treated with antibiotics for a bladder infection on 10/9/18 and again 10/22/18. During an interview on 11/29/18 at 10:01 a.m., staff member Y said she had peri care and hand washing review within the past two months. Staff member Y said when peri care is provided it is completed from front to back. Staff member Y stated that a staff should never provide peri care from back to front due to possible bladder infections. The staff said gloves need to be changed, hands washed and then place a clean brief. Staff member Y stated that resident #83 was getting frequent bladder infections due to staff not providing proper peri care. Staff member Y said since staff were retrained on peri care and hand washing, resident #83 has done better. During an interview on 11/29/18 at 10:18 a.m., staff member W said they recently trained staff on peri care and hand washing. The staff member said she had the CNAs sign off on hand washing. Staff member W said if they were seeing a trend, they would retrain the staff working that area on peri care and hand washing. Staff member W also stated that if it seems that one staff person continues to have problems, she would have the CAN Coordinator provide one on one training with staff. During an interview on 11/29/18 at 10:23 a.m., staff member R stated that last month (November) several residents' urine cultured the same bacteria ecoli. Staff member R said she reported this to the Infection Control staff member A[NAME] Staff member R stated one of the residents had gone home, the other two residents remained in the facility. One resident was #82. Resident #82 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of resident #82's Medical Record showed resident #82 was sent to the hospital on [DATE] for increased confusion and rigors. A urinalysis was completed and showed consistent with a bladder infection. The resident was started on an antibiotic. The hospital report also showed the most obvious cause of [MEDICAL CONDITION] is from a urinary source. The resident's urine was cultured on 10/31/18 and the laboratory results showed a bladder infection with the bacteria ecoli. The resident was started on an antibiotic. Resident #82 was started on an antibiotic for a bladder infection on 11/21/18, and the lab results showed the bacteria ecoli. During an interview on 11/29/18 at 10:35 a.m., staff member AA said there was a high incidence of bladder infections at the beginning of November. Staff were educated in (MONTH) with hand washing, hand hygiene and reviewed peri care. Staff member AA also said that ecoli was one of the bugs cultured. Staff member AA said that with training the bladder infections decreased by the middle of November, stayed steady for about a week then started going back up. Review of a form titled C.N.[NAME] Agenda, (MONTH) 5, (YEAR) showed staff member AA trained staff on peri care, Handwashing and infection control. Review of a hand written signature sheet, dated 11/5/18 on Handwashing showed that staff member M had attended. Staff member M also signed for attendance on Infection Control for that same day.",2020-09-01
147,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2017-01-26,176,D,0,1,9GWT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 1 (#19) of 25 sampled residents was assessed by the interdisciplinary team for the self-administering of eye drops. Findings include: Resident #19 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the resident's (MONTH) (YEAR) MAR, and physician recapitulation orders, reflected an order for [REDACTED]. A review of the resident's medical record failed to reflect an assessment by the interdisciplinary team for the self-administration of eye drops. During an observation on 1/24/17 at 12:01 p.m., staff member C removed a bottle of Refresh eye drops from the medication cart, and handed the bottle to resident #19. The resident administered drops into her right eye, then her left eye. The resident was never asked to wash her hands prior to instilling the drops. During an interview on 1/24/17 at 12:06 p.m., staff member C stated the resident did not have an order to self-administer eye drops. She stated the resident would not allow staff to administer the resident's eye drops. The staff member stated, It's been done like this for a very long time, and as long as staff were watching, it was ok to let her self-administer the (eye) drops. During an observation on 1/26/17 at 12:20 p.m., staff member D removed a bottle of Refresh eye drops from the medication cart. The staff member administered the eye drops to the resident while in the resident's room. During an interview on 1/26/17 at 12:30 p.m., staff member D stated the resident did not have an order to self-administer eye drops. A review of the facility's policy entitled Medication: Self-administration, revised 1/2/14, read, Patients (sic) who request to self-administrate medications will be assessed for capability. If it is determined that the patient is able to self-administer a physician/mid-level provider order is required. Self-administration must be care planned. Patient (sic) must be instructed in self-administration. Periodic evaluation of capability must be performed.",2020-09-01
148,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2017-01-26,241,D,0,1,9GWT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to protect, enhance, and promote the rights of 1 (#18) of 25 sampled residents by administering insulin while the resident was seated in the dining room. Findings include: Resident #18 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation on 1/24/17 at 12:05 p.m., staff member C administered insulin to the resident while the resident was seated in the dining room. The staff member lifted the resident's blouse, exposing the resident's abdomen, and administered the insulin to the resident's right lower abdomen. It was lunch time, and the dining room was full of residents. During an interview on 1/24/17 at 2:20 p.m., staff member C stated she should have taken resident #18 to her room to administer the insulin injection. The staff member stated she normally administered the resident's insulin in a private area but was busy today. During an interview on 1/26/17 at 11:01 a.m., staff member D stated all invasive procedures should be done within the privacy of the resident's room to promote dignity. A review of the facility's policy entitled Treatment: Considerate and Respectful, revised 9/1/13, read, 1.8 Privacy: Maintain patient (sic) privacy of body including keeping patients sufficiently covered .",2020-09-01
149,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2017-01-26,280,D,0,1,9GWT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to update the care plan for two (#s 4 and 9) of 25 sampled residents. Resident #9 had a catheter changed from a foley catheter to a suprapubic catheter, without any update to the care plan, and resident #4 had the catheter removed without any update to the care plan. Findings include: 1. Resident #9 was admitted to the facility with the [DIAGNOSES REDACTED]. Review of resident #9's Treatment Administration Record, dated 01/01/17 - 01/31/2017, showed his suprapubic catheter was to be changed every four weeks. Review of resident #9's care plan, with a target date of 2/1/17, showed resident #9 had a focus area and interventions that were for a foley catheter. During an interview on 1/25/17 at 9:00 a.m., staff member B stated the resident had a suprapubic catheter for some time now. The staff member stated the careplans were generally updated by the nursing department, and the MDS should have triggered a care plan update because the resident went from a foley catheter to a suprapubic. Staff member B provided an updated care plan on 1/25/17 at 9:30 a.m., that showed the suprapubic catheter was initiated on 10/27/2015. Review of resident #9's MDSs, with ARDs of 2/3/16 and 11/3/16, showed the resident triggered in section H0100 as having an indwelling catheter on both MDS assessments. 2. Resident #4 was readmitted to the facility with [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. A review of the resident's Care Plan, revised on 12/13/16, with a target date of 3/6/17, read, Catheter care twice a day and PRN. During an observation on 1/25/17 at 11:01 a.m., staff member J changed a dressing to the resident's bilateral lateral malleolus. The resident did not have a Foley catheter bag. During an interview on 1/25/17 at 11:22 a.m., staff member J stated the resident no longer used an indwelling catheter, and was always incontinent of urine. The staff member was unsure why the resident no longer used an indwelling catheter. During an interview on 1/26/17 at 10:50 a.m., staff member F stated the resident pulled out the Foley catheter a while back. She stated the care plan should have been updated to reflect his current status which was always incontinent. A review of the facility's Person-Centered Care Plan policy, initiated 11/28/16, read, 5. Care plans will be: 5.2 Reviewed and revised a minimum of quarterly and as needed to reflect the response to care and changing needs and goals; and 5.3 Documented on the Care Plan Evaluation Note.",2020-09-01
150,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2017-01-26,281,E,0,1,9GWT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assure the administration of PRN medications by facility staff was followed by an evaluation and written record of the efficacy of the medication received. Medication efficacy was not recorded for 4 (#s 5, 6, 22 and 24) of 25 sampled residents. Findings include: 1. Resident #22 was readmitted with [DIAGNOSES REDACTED]. He was legally blind, and suffered a major [MEDICAL CONDITION]. A review of resident #22's PRN Pain Management Flow Sheet showed he had been evaluated for complaints of generalized pain at the following times and dates: - 1/18/17 at 7:45 a.m. - received tylenol 650 mg po, time not indicated. - 1/18/17 at 8:00 p.m. - received tylenol #3 at 9:00 p.m. - 1/19/17 at 8:00 p.m. - received tylenol #3 at 9:00 p.m. - 1/20/17 at 12:30 p.m. - received tylenol 650 mg po, time not indicated. - 1/20/17 at 8:00 p.m. - received tylenol #3, time not indicated. - 1/23/17 at 8:00 p.m. - received tylenol #3 at 9:00 p.m. - 1/25/17 at 6:30 a.m. - received tylenol #3, time not indicated. The records showed the resident was given medication following each of these assessments, but for four dates the record does not show the specific time the medication was given. For all seven dates, the record was empty in the columns meant to record the resident's response to the medication given. 2. Resident #24 was admitted with [DIAGNOSES REDACTED]. A review of the resident's PRN Pain Management Flow Sheet showed he had been evaluated for left leg pain at the following times and dates: - 10/4/16 at 7:35 a.m. - 10/8/16 at 1:00 p.m. - 10/7/16 at 7:45 a.m. - 10/9/16 at 8:10 a.m. - 10/14/16 at 7:55 a.m. - 10/17/16 at 7:50 a.m. The records showed the resident was given [MEDICATION NAME] 2 mg p.o. following each of these assessments but did not give the specific time the medication was given. The columns on the flow sheet to record the resident's pain rating after receiving the medication, and the resident's level of sedation, were empty for the above dates. During an interview on 1/25/17 at 4:48 p.m., staff member S showed the surveyor a check off list she used to remind herself to return to patients she had given PRN pain medications to assess the medication effectiveness. She stated they (the nursing staff) were required to record the effectiveness of all PRN medications. During an interview on 1/26/17 at 10:30 a.m., staff member B stated that if any staff noticed unsigned areas on the MARS for medications what were to be given on a prior shift, they had been told to leave the records as they are and not try to give late dosages or sign the record for another person. She stated, auditors will pursue the matter with the staff responsible. 3. Resident #5 was readmitted to the facility with [DIAGNOSES REDACTED]. A review of the resident's Care Plan, revised on 4/21/16, page 10, read, Administer meds (sic) as ordered and assess for effectiveness and side effects and report abnormalities to physician. Page 20 read, Medicate resident per physician order [REDACTED]. Page 23 read, Medicate resident as ordered for pain and monitor for effectiveness and monitor for side effects, report to physician as indicated. Page 27 read, Medicate as ordered and monitor for effectiveness and observe for signs/symptoms of side effects. Report to physician as indicated. A review of the resident's (MONTH) (YEAR) MAR indicated [REDACTED]. A review of the resident's (MONTH) (YEAR) PRN Pain Management Flow Sheet reflected she was medicated thirty-two times with a PRN pain medication. Staff did not document medication efficacy eight times, and did not document a given dose five times. 4. Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the resident's Care Plan, revised on 12/5/16, page 13, read, Medicate (resident's name) as ordered for pain and monitor for effectiveness and monitor for side effects, report to physician as indicated. A review of the resident's (MONTH) (YEAR) MAR indicated [REDACTED]. A review of the resident's (MONTH) (YEAR) PRN Pain Management Flow Sheet reflected she was medicated twenty-four times with a PRN pain medication. Staff did not document medication efficacy six times, and did not document a given dose five times. During an interview on 1/26/17 at 10:40 a.m., staff member D stated PRN medications given should have been documented on the PRN Pain Management Flow Sheet. The flow sheet showed monitoring of the efficacy of the medication so the physician could be informed of any changes to the resident's pain condition. During an interview on 1/26/17 at 10:50 a.m., staff member [NAME] stated PRN medications must be documented on the PRN Pain Management Flow Sheet. The flow sheet showed the monitoring of the efficacy of the medication, so the physician could be informed of any changes to the resident's pain condition. During an interview on 1/26/17 at 11:25 a.m., staff member B stated nursing staff should have documented efficacies for all PRN medications on the PRN Pain Management Flow Sheet. REFERENCES Ann Perry and [NAME] Potter, Clinical Nursing Skills and Techniques, 5th ed., Mosby, Inc., St. Louis-Missouri, 2002, pg.449. After administering a drug, record the following information on the MAR indicated [REDACTED] - Drug name - Dose - Route of administration - Time of administration - Any expected client responses - Pertinent data or assessment collected at time of administration - Signature and title of nurse administering drug Once a medication is administered, the nurse is responsible for critically evaluating what is known about the client's condition, how the drug is expected to affect the client, and how the client actually responds. This means the nurse is looking for therapeutic effects as well as adverse outcomes. Should adverse outcomes develop, the nurse recognizes the clinical signs and responds quickly. 1. Monitor client's physical response to the drug (e.g., vital signs, urine output, relief of pain or other symptoms. 2. Monitor client's behavioral responses to the drug (e.g., level of anxiety, agitation, consciousness). 3. Observe injection sites for bruises, inflammation, localized pain, numbness, or bleeding. 4. Determine client's understanding of drug therapy and ability to self-administer medication. Center for Clinical Standards and Quality/Survey & Certification Group, Centers for Medicare and Medicaid Services, Department of Health & Human Services, Ref: S&C: 14-15-Hospital Requirements for Hospital Medication Administration, Particularly Intravenous (IV) Medications and Post-Operative Care of Patients Receiving IV Opiods, Baltimore, [NAME]land, (MONTH) 14, 2014, pg. 14. Observing the effects medications have on the patient is part of the multi-faceted medication administration process. Patients must be carefully monitored to determine whether the medication results in the therapeutically intended benefit, and to allow for early identification of adverse effects and timely initiation of appropriate corrective action. Depending on the medication and route/delivery mode, monitoring may need to include assessment of: 1. Clinical and laboratory data to evaluate the efficacy of medication therapy, to anticipate or evaluate toxicity and adverse effects. For some medications, including opiods, this may include clinical data such as respiratory status, blood pressure, and oxygenation and carbon [MEDICATION NAME] levels. 2. Physical signs and clinical symptoms relevant to the patient's medication therapy, including but not limited to, somnolence, confusion, agitation, unsteady gait, pruritus, etc As part of the monitoring process, staff are expected to include the patient's reports of his/her experience of the medication's effects.",2020-09-01
151,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2017-01-26,282,D,0,1,9GWT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide services in accordance with the resident's care plan for bathing services for 1 (#15) of 25 sampled residents. Findings include: Resident #15 was readmitted to the facility with [DIAGNOSES REDACTED]. A review of a Quarterly MDS, with an ARD of 12/16/16, reflected the resident required total, extensive 2+ person's physical assistance, when performing activities of daily living. He rarely/never understood others and was rarely/never understood by others. A review of the resident's Care Plan, revised on 9/20/16, page 3, read, Provide (Resident's name) with total, extensive 2 person assist for personal hygiene/bathing. Page 5, read, (Resident's name) requires 2 person (sic) assistance with bathing. During an observation on 1/24/17 at 3:23 p.m., resident #15 was seated in a shower chair, in the shower room, and was being assisted with a shower by staff member T. The staff member gave the resident a wash cloth to hold, and she used one wash cloth to wash the resident's back, face, feet, legs, perineal, and rectal areas. The resident frequently grabbed at the staff member's arm, hand and wash cloth. During an interview on 1/24/17 at 3:52 p.m., staff member T stated she usually gave the resident a shower unassisted. She stated the resident frequently grabbed her hands, arms and clothing while assisting him with bathing/hygiene care. The staff member stated she was unaware the resident required extensive 2 person's assistance with hygiene/bathing. A review of the facility's Person-Centered Care Plan, initiated 11/28/16, read, The interdisciplinary team, in conjunction with the patient (sic) and/or resident representative, as appropriate, will establish the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care.",2020-09-01
152,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2017-01-26,309,G,0,1,9GWT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to adequately assess and provide an appropriate means for a resident to call for assistance as needed; failed to utilize a bedside commode, which was an intervention on the resident's care plan; and failed to provide necessary ADL care in a timely manner to ensure the resident's highest practicable well being was met. The resident felt concerns voiced were not addressed relating to care, and feared that staff would stop providing care if assistance was requested, and staff were rude when assistance was needed, for 1 (#4) of 25 sampled residents. The facility also failed to ensure a timely assessment and treatment was provided for the resident who struggled to use their call light failed to ensure the resident had a bedside commode, and failed to ensure the resident was functioning at her highest psychosocial well-being. Findings include: Resident #20 was admitted to the facility with the [DIAGNOSES REDACTED]. Review of resident #20's Admission MDS, with an ARD of 1/20/17, Section G, reflected the resident required extensive assist including a 2+ person physical assist with her ADLs. Review of section C0500 showed she had a BIMS (Brief Interview of Mental Status) score of 15; cognitively intact. During an interview on 1/25/17 at 11:40 a.m., resident #20 stated she was recently unhappy with the care she was receiving at the facility. She stated that she was upset with the way staff had been treating her when she was using her call light. She stated she struggled to use her call light due to disease related weakness. The resident stated she felt certain staff were rude to her when they entered her room to answer her call light, and she felt she was not treated with respect, and she felt the staff were always in a rush. Resident #20 stated that on 1/23/17, before lunch time, staff member V placed her on a bed pan, and told her to ring her call light when she was done going to the bathroom. The resident stated she urinated and a few seconds later pushed her call light. She stated she sometimes struggled with the call light because of contracture's in her hands. The resident stated she watched the clock and the staff were not returning. She stated she then began to bite her call light, thinking it may reset the alarm, and the staff would come faster. She stated that the facility had not assessed her for an alternative call light that would be easier for her to push. The resident stated she watched the clock for 45 minutes before staff member W entered her room. The resident stated she said to the staff member, Finally, and staff member W replied, What do you mean finally, it's not like you are the only one here in the facility. Resident #20 stated the staff member then took her off the bed pan. The resident stated she overheard the staff talking about her out in the hallway, and she became sad and fearful to ask for further assistance from staff because she felt like a burden to them. Resident #20 stated that after this experience on 1/23/17, she felt scared that the staff were no longer going to help her if she spoke up about the situation. She stated that staff member W worked on her hallway often, and that she felt threatened by the staff member. The resident stated that she became scared to ask for water because she didn't want to have to go to the bathroom excessively or get left on the bed pan again. The resident stated she did not prefer to use the bed pan, but the staff often placed her on it because they were short staffed, and didn't have extra staff to put her on the toilet or the bed side commode. She stated she sometimes struggled with the call light due to the limited function in her hand. Review of Resident #20's Progress Notes and medical record, showed a lack of evidence of the resident being left on the bed pan, or any other documentation of the incident that the resident stated occurred on 1/23/17. No documentation of the incident could be located in the resident's medical record. During an interview on 1/25/17, at 4:20 p.m., staff member B stated she had not heard of the incident that involved resident #20 being left on a bed pan, or of a poor interaction between staff member W and the resident. During the interview, staff member B was asked for a policy and procedure that explained the use of a bed pan, and also an employee schedule for 1/23/17. Staff member B provided the schedule, and staff members V and W were both working on 1/23/17. Staff member B stated staff member W had previously been reprimanded for her behaviors. During an interview on 1/26/17 at 2:20 p.m., staff member B stated she could not locate a policy and procedure for the use of bed pans. She stated the procedure to use a bed pan was explained and completed with the skills check list that the CNAs completed upon hire. Review of resident #20's pocket care plan showed she was to use a drop arm bedside commode. There was no documentation about utilizing a bed pan. Review of resident #20's care plan, with a target date of 2/1/17, showed the following interventions: - use a drop arm bedside commode - allow opportunities for expression of feelings or concerns - provide emotional support to resident/family - place call light within reach while in bed or close proximity to the bed - monitor for, and assist with, toileting needs - encourage 100% consumption of all fluids provided - offer/encourage fluids of choice - monitor for changes in nutritional status, including changes in intake - place call light within reach at all times Resident #20 stated she felt the facility failed to utilize and follow the interventions on the care plan by: -not consistently using the bedside commode. -she felt the facility staff did not provide emotional support to her, and was mistreated by staff and felt they often rushed her to get her cares completed. -She stated the facility placed the call bell within reach of her, but she struggled to use the call bell due to her weakness and limited use of her hands. She stated she had not been assessed for a call bell that was easier for her to use. -She felt the facility failed to offer her adequate assistance with her toileting needs due to lack of staff. The lack of staff also contributed to her not being offered to use the bed side commode. -She stated she was not consuming fluids adequately due to the interaction with staff member W. She felt intimidated to ask for fluids because she didn't want to have to continue to ask for assistance to go to the bathroom. During an observation on 1/25/17 around 2:30 p.m., resident #20 had two cups filled with tea. She stated the cups were from the prior day, and that she had not received any water that day. Her call bell was in reach, but again she said she sometimes struggled to use the call bell, and sometimes had to bite the call bell in order for it to sound. Review of resident #20's progress notes, failed to show any documentation of a completed assessment for an alternative call light, or an assessment ensuring the resident was appropriate to use a bed pan. The concerns the resident voiced regarding staff were reported to the facility for appropriate action, as it was identified the resident had not reported her concerns at the time of the interview.",2020-09-01
153,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2017-01-26,312,E,0,1,9GWT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide toenail care for 3 (#s 1, 26, and 29) of 29 sampled and supplemental residents. Findings include: 1. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the resident's Annual MDS, with an ARD dated of 12/9/16, showed the resident was severely cognitively impaired with a BIMS score of 3. The resident was discharged from the facility at the time of the survey. During an interview on 1/23/17 at 9:44 a.m., a family member of resident #1 stated when the resident was admitted to the hospital, both she and her sister were shocked by the condition of the resident's toenails. She stated the toenails were long, thick, yellow, and some of the toes appeared to have blood underneath the nail. She stated her sister trimmed the resident's nails while he was in the hospital, since it appeared it had not been done in some time. During an interview on 1/23/17 at 10:58 a.m., a second family member of resident #1 stated the resident's toenails were long, thick, yellow, and appeared to not have been trimmed in a long time. She stated she was a professional manicurist, and had to take great care to trim his nails since the quick underneath had grown so long under the nail bed. She stated his nails were about an inch long, and she took pictures of the nails at the time of the resident's hospitalization . A review of resident #1's clinical record, from 8/18/16 to 1/19/17, failed to show documentation of the resident receiving toenail care by the facility. A request for toenail care was made for resident #1 on 1/25/17 at 5:00 p.m. No further follow-up documentation was received prior to the end of survey. 2. Resident #26 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the resident's Quarterly MDS, dated [DATE], showed the resident was cognitively intact with a BIMS score of 15. A review of resident #26's Care Plan, with a target date of 2/21/17, showed, interventions: Diabetic foot check daily. Observe feet/toes/ankles/soles/heels, noting alteration in skin integrity, color, temperature, and cleanliness. Toenails for shape, length and color. During an observation on 1/25/17 at 10:56 a.m., resident #26 was barefoot, seated in a wheel chair, and self-propelling in the corridor. The nails of her left foot were long, jagged, with chipped edges. During an interview on 1/25/17 at 10:58 a.m., the resident stated her toenails had not been cut in over a year. She stated she files her toenails by rubbing her foot against her cane, and would prefer to have a licensed professional maintain her nails. 3. Resident #29 was admitted with [DIAGNOSES REDACTED].#29's Admit MDS, with an ARD date of 1/19/17, showed the resident was not cognitively intact with a BIMS score of 0, which was the lowest score for cognition. During an observation on 1/23/17 at 4:15 p.m., resident #29 was sitting in a chair by the nursing station. The resident had removed his non-slip socks. The toenails on the resident's right foot were thick, long, yellow, and uneven. During an interview on 1/23/17 at 4:10 p.m., staff member H stated the residents' toenails were trimmed by the CNAs on shower days. She stated if a resident was diabetic, the resident was seen by the podiatrist to have their nails trimmed. She stated the podiatrist no longer came to the facility, so residents were sent to the podiatrist's clinic for diabetic nail care. During an interview on 1/26/17 at 11:57 a.m., staff member B stated it was the expectation of staff to provide toenail care to residents per the facility's policy and procedure. The procedure showed the CNAs were not allowed to trim nails, it was the responsibility of the nurses. She stated if the resident was a diabetic, the toenails are trimmed by the podiatrist every 98 days, per insurance guidelines. Staff member B stated when the CNAs provide a shower to a resident and note the resident's nails are long, or are not within normal limits, they are to report to status to the charge nurse, so the nurse could assess the resident's toenails. A review of the facility's policy titled Activities of Daily Living, showed: - Based on the comprehensive assessment of a patient, and consistent with the patient's needs and choices, the Center must provide the necessary care and services to ensure that a patient's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. - Activities of daily living include: Hygiene-bathing, dressing, grooming, and oral care. - 1.2. A patient who is unable to carry out ADLs receives the necessary services to maintain food nutrition, grooming, and personal oral hygiene. A review of the facility's policy titled Toe Nail Trimming, showed: -Toenail trimming may be performed by a licensed nurse. Toe nail trimming must be performed by a physician/mid-level provider, or podiatrist for patients who have toe infections, diabetes mellitus, neurological disorders, [MEDICAL CONDITION], or [MEDICAL CONDITION].",2020-09-01
154,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2017-01-26,322,D,0,1,9GWT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to check for gastric content prior to administering medications and enteral tube feeding, for 1 (#15) of 25 sampled residents. Findings include: Resident #15 was readmitted to the facility with [DIAGNOSES REDACTED]. A review of a Quarterly MDS, with an ARD of 12/16/16, reflected the resident required total, extensive 2+ person's physical assistance, when performing activities of daily living. A review of the resident's care plan, revised 9/20/16, read, (Resident's name) is NPO related to dysphagia/aspiration risk. A revision on 12/28/16, reflected staff were to check patency and placement of tube daily and before administering feedings and meds (sic). A review of the resident's (MONTH) (YEAR) MAR, page 3, read, Enteral Feed: Check for residual every shift prior to feeding or administering medications. If 250 ml or over, hold feeding for 1 hour and recheck. If residual 250 ml or over notify physician. Document amount of residual in mls (sic). Page 5 read, Enteral Feed Formula: [MEDICATION NAME] 1.5 CAL .gravity 5x daily . CHECK TUBE PLACEMENT PRIOR TO ADMINISTRATION five times a day for nutrition. During an observation on 1/25/17 at 2:46 p.m., staff member F administered 30 cc of water into the resident's feeding tube, checking for patency. The staff member aspirated, then administered medication and 8 ounces of [MEDICATION NAME] 1.5. She did not check for residual prior to administering the required amount of water into the feeding tube. During an interview on 1/25/17 at 3:05 p.m., staff member F stated she did not check for residual prior to the administration of medication and the enteral tube feeding.",2020-09-01
155,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2017-01-26,367,D,0,1,9GWT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the therapeutic diet ordered by the physician when providing snacks for 1 (#3) of 25 sampled residents. Findings include: Resident #3 was admitted to the facility with a [DIAGNOSES REDACTED].#3's most recent Significant Change MDS, with an ARD of 12/21/16, showed the resident was cognitively severely impaired with a BIMS score of 03. During an observation on 1/23/17 at 4:15 p.m., resident #3 was yelling out that he was hungry and had not eaten in 30 days. The nurse provided the resident a ham and cheese sandwich. The resident ate the sandwich quickly, and started to cough while eating the sandwich. The cough was a dry, non-productive cough. Resident #3 ate the sandwich unsupervised. A review of resident #3's Diet Order, dated 1/18/17, showed the resident's physician ordered diet was a regular, dysphagia puree, and nectar thick liquids. The previous diet order for resident #3, dated 1/12/17, showed the resident was prescribed a consistent carbohydrate diet with ground meat and nectar-like liquids. A note on the diet order showed, No diet change, just a reminder to please give ground meat. A review of resident #3's Order Recap Report, with an order date of 1/17/17, and a start date of 1/18/17, showed an order for [REDACTED]. During an interview on 1/23/17 at 4:25 p.m., staff member L stated she gave resident #3 a ham and cheese sandwich for a snack. She stated the resident's meals were pureed, but she thought he could have regular snacks. The staff member stated a better choice of a snack for a resident on a puree diet would be applesauce or pudding. Staff member L stated the resident was on the pureed diet because he had a difficult time swallowing, and could choke or aspirate. During an observation on 1/23/17 at 4:40 p.m., staff member L did not notify the charge nurse of resident #3 receiving the wrong diet type for a snack. During an interview on 1/23/17 at 4:45 p.m., NF1 stated resident #3 had a history of [REDACTED]. NF1 stated the resident is currently on a pureed diet related to his dysphagia and history of [MEDICAL CONDITION] exacerbations. During an interview on 1/23/17 at 4:50 p.m., staff member H stated resident #3 was on a dysphagia pureed diet. The staff member stated an appropriate snack for a resident on a dysphagia puree diet would be applesauce, yogurt, or pudding. The kitchen provided those types of snacks and they were available in the unit refrigerators. Staff member H stated she realized she provided a meat and cheese sandwich to resident #3, and stated that was not an appropriate snack for the resident. She stated the resident could potentially choke or aspirate. The staff member stated she was not notified by the CNAs that the resident started to cough after eating the sandwich earlier that day. The staff member stated she would notify the physician and family immediately, and implement aspiration precautions on resident #3. During an observation on 1/23/17 at 5:10 p.m., staff member H called and notified the physician regarding resident #3 receiving the wrong therapeutic snack. The staff member left a message for the resident's family. During an interview on 1/26/16 at 11:57 p.m., staff member B stated it was the expectation of all staff to follow the diet orders provided by speech therapy and the physician. Staff member B stated appropriate snack alternatives for a dysphagia pureed diet would be applesauce, pudding, or yogurt. She stated all those food items are provided by the kitchen and are stocked in the resident refrigerators on the units. Staff member B stated it was her expectation if the resident was provided the wrong diet, to monitor the resident for aspiration complications, and to notify the physician and the family. A review of the facility's policy and procedure, titled, Diet Orders, showed: - Purpose: to enhance the quality of life and obtain optimal acceptance of meals while managing medical conditions. - 1. Nutrional assessment includes an assessment of the diet order in relation to the patient's/resident's clinical condition. Recommendations for a diet order changes are made based on this assessment. - 2. Physician/Advanced practice nurse (APN/PA) diet orders are written according to the terminology of the GHC Diet Manual. A review of the facility's Diet and Nutrition Manual, dated 2014, showed: -Dysphagia Puree (Level 1) Diet is used only for people who have severe chewing and/or swallowing problems. All foods are pureed to simulate a soft food bolus, eliminating the whole chewing phase. Thoroughly evaluate individuals before placing on a puree diet, and periodically re-evaluate for ability to advance to the next level dysphagia diet . provide adequate nutrients by following these daily guidelines to plan three balanced meals and up to three snacks per day. - All foods must be the consistency of moist mashed potatoes or pudding. - Pureed Diet menus follow the foods on the Regular Diet as closely as possible with the main difference being food consistency. - Foods to avoid: any non-pureed meats or meat alternatives, any non-pureed or non-slurried bread/starch foods.",2020-09-01
156,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2017-01-26,371,E,0,1,9GWT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure food was stored in a sanitary manner; and that food in dry storage, the refrigerator, and food that was thawing, was covered and dated. This deficient practice had the potential to affect all residents who received food from the kitchen and food storage areas. Findings include: During an observation on 1/26/17 at 7:46 a.m., the following concerns were observed in the main kitchen, in the presence of staff member K: - 12 loaves of bread which had been removed from the freezer to thaw were thawing on a rack in the kitchen. The bread was not dated with a use by date. - In the dry storage was one box of [MEDICATION NAME] hot cereal, which was open at the top, and was not covered. The cereal was not dated with a use by date. In the main refrigerator the following was found: - A clear plastic container with pineapple juice and pieces. The container was not labeled or dated with a use by date. - A clear plastic container which contained a mix of fruit pieces floating in juice. The container was not labeled, and did not have a use by date. - On the top shelf, were two metal trays with a vegetable medley that was thawing. The vegetables were not covered and were not dated. During an interview on 1/26/17 at 8:00 a.m., staff member K stated items in the dry storage, as well as in the cold storage, should be covered, labeled, and have a use by date on the food item. Staff member K stated he had re-educated staff on the importance of proper food storage and labeling prior to the survey, as well as during the time of the survey. Staff member K stated he started working at the facility recently, and was still new to the position. He stated he was working on starting a new cleaning schedule, and also educating staff on proper and safe storage of food. Staff member K stated he was the only staff member in the kitchen who has had Serve Safe training.",2020-09-01
157,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2017-01-26,425,D,0,1,9GWT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure multi-dose bottles of insulin were dated when opened for 1 (# 27) of 29 sampled and supplemental residents. Findings include: Resident #27 was recently diagnosed with [REDACTED]. During an observation on 1/26/17 at 12:20 p.m., the medication cart for the Horseshoe unit had a multi-dose insulin bottle of Humalog in the top drawer. The bottle did not have an open date. During an interview on 1/26/17 at 12:25 p.m., staff member D stated she had opened the multi-dose bottle of insulin earlier that day, but had not dated it. During an interview on 1/26/17 at 12:55 p.m., staff member G stated all multi-dose insulin bottles were to be dated upon opening, and not used after 28 days. A review of the facility's Storage and Expiration Dating of Drugs, Biologicals (sic), Syringes, and Needles Skilled Nursing Center policy, revised 5/16/11, read, 3. Drugs and biologicals (sic) that have an expired date on the label or are after manufacturer/supplier guidelines/recommendations, or if contaminated or deteriorated, are stored separately, away from use, until destroyed or returned to the provider. 3.1 Once any drug or biological package is opened, follow manufacturer/supplier guidelines for in use expiration dating. A review of the facility's Medication Safety Alert document, read, Check the expiration date on insulin before dispensing or use: Insulins(sic) usually expire in 28 days once opened, it is important to date the insulin when opened. Pharmacy may provide a place on the label or ancillary sticker for 'date opened.",2020-09-01
158,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2017-01-26,441,E,0,1,9GWT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to follow standard precautions to minimize the spread of infection by not washing or sanitizing their hands in between glove changes, during a dressing change, for 1 (#4); washed 1 (#15) resident's face after washing his body and genitals, of 25 sampled residents; and failed to change gloves and disinfect hands between resident rooms during an ice water pass. This failure had the potential to affect all the residents on the 300 hall. Findings include: 1. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. A review of the resident's Admission MDS, with an ARD of 12/6/16, showed the resident was moderately cognitively intact, and required extensive 1-2 person's physical assistance with activities of daily living. His primary mode of transportation was a facility wheelchair. During an observation on 1/25/17 at 11:01 a.m., staff member J entered the resident's room, and asked the resident to put his right foot on the bed next to the dressing supplies. The resident's right shoe and the dressing supplies were directly on the comforter of his bed. The staff member removed the resident's right shoe and sock, opened a skin prep gauze, cleaned the resident's right lateral malleolus and scabbed area to the 2nd toe. The staff member did not change her gloves. At 11:07 a.m., she opened an [MEDICATION NAME] AG dressing, cut it to size, and placed it over the right ankle wound covering the dressing with an adhesive bandage. The staff member put a clean sock and the resident's shoe back on his foot. At 11:09 a.m., the staff member changed her gloves, but did not wash or sanitize her hands prior to donning clean gloves. At 11:10 a.m., the staff member removed the resident's left shoe and sock, opened a skin prep gauze, and cleaned the resident's left medial and lateral malleolus. The staff member changed her gloves but did not wash or sanitize her hands prior to donning clean gloves. The resident became upset talking about his electric wheelchair not working and demanded us to leave his room. The staff member put an adhesive bandage over the lateral malleolus without the [MEDICATION NAME] AG dressing, and put the resident's sock and shoe back on. During an interview on 1/25/17 at 11:20 a.m., staff member J stated she should have washed or sanitized her hands prior to donning clean gloves. She stated she should have put a barrier on the resident's bed prior to putting the dressing supplies on the comforter. A review of the facility's Aseptic Dressing Change Technique Flow Chart, revised 10/2007, read, Cleanse hands .Don gloves #1, cleanse hands .Don gloves #2, cleanse hands. 2. Resident #15 was readmitted to the facility with [DIAGNOSES REDACTED]. A review of a Quarterly MDS, with an ARD of 12/16/16, reflected the resident required total, extensive 2+ person's physical assistance, when performing activities of daily living. During an observation on 1/24/17 at 3:23 p.m., resident #15 was seated in a shower chair in the shower room, and he was being assisted with a shower by staff member T. The staff member gave one wash cloth to the resident to hold and she used one wash cloth to wash the resident's back, face, feet, legs, perineal, and rectal areas. At 3:33 p.m., she re-wiped the resident's face with the same wash cloth. During an interview on 1/24/17 at 3:52 p.m., staff member T stated she did not realize she had re-wiped the resident's face after wiping the resident's perineal/rectal area. 3. During an observation on 1/24/17 at 3:17 p.m., staff member M was passing ice water on the 300 hall. Staff member M was wearing a pair of gloves. She opened the door to a resident's room while wearing the gloves. She brought the resident a cup of ice water. The staff member exited the resident's room and pushed the cart to the next room. The staff member did not change her gloves or wash her hands. She than entered another resident's room, opening the door with her gloved hands. She entered the room and returned to the ice cart with a plastic water mug from the resident room. The staff member opened the lid of the water mug and added ice to the mug from the cooler, using the scoop which was left inside the cooler of ice. She put the scoop back into the ice in the cooler and closed the cooler's lid. While wearing the same gloves, she entered the resident's room again, and returned the ice water to the resident. The staff member returned to the ice cart and moved the cart to the next room. The staff member did not remove her gloves or wash her hands. Staff member M then knocked and opened the door of another resident's room. She entered the room, and brought out an empty mug with a lid. The staff member removed the lid to the mug and opened the ice cooler and added ice to the mug. The staff member returned the ice scoop to the scoop holder and re-entered the resident's room. The staff member returned to the ice cart and moved it to the next room. Staff member M did not remove or change her gloves and did not disinfect her hands between resident rooms. The staff member entered another resident's room and returned to the ice cart with an empty mug. She opened the cooler's lid, and the lid on the mug, and poured ice into mug. She than replaced the mug's lid. The staff member attempted to return the ice scoop into the ice inside the cooler, but stopped herself and put the scoop in its holder on the cart. The staff member re-entered the resident's room and returned the ice water to the resident. When Staff member M left the resident's room, she did not remove or change her gloves, she did disinfect her hands. Staff member M completed the water pass while wearing the same pair of gloves. She did not disinfect her hands between residents' rooms. She did not disinfect her hands after coming into contact with potentially contaminated surfaces such as door handles, and the drinking cups and lids. During an interview on 1/24/17 at 3:33 p.m., staff member M stated she was a germaphobe and wore the same pair of gloves because she did not want to get sick. The staff member could not explain the importance of removing or changing her gloves and disinfecting her hands between resident rooms. The staff member stated she did not wash or disinfect her hands between the residents' rooms when she passed the ice water. She stated she did not like the alcohol disinfectant which the facility provided, because it made her hands crack. She stated she did not have her own disinfectant with her to use in place of the facility's. The staff member could not remember the last time she had training on hand hygiene. She could not explain why keeping the ice scoop in the ice could be an infection control concern. The staff member offered to empty the ice and get clean ice before repeating the ice pass. During an interview on 1/26/17 at 11:57 a.m., staff member B stated it was the expectation of her staff to wash or disinfect their hands between resident rooms or coming into contact with potentially dirty surfaces. If passing ice water on a pass which re-used the mugs in the resident rooms, the staff were to wash or disinfect their hands between contact with the resident, and after touching possible contaminated surfaces such as a door handle. Staff member B stated the ice scoop was not to be left inside the ice in the cooler. She stated doing so could potentially contaminate the ice. The ice scoop was to be kept in the scoop holder on the cart. During a review of the facility's policy and procedure, titled Hand Hygiene, showed: - Adherence to hand hygiene practices is maintained by all Center personnel. This includes hand washing with soap and water when hands are visibly soiled and the use of alcohol based hand rubs for routine decontamination in clinical situations. Per the Centers for Disease Control and Prevention (CDC), when hands are not visibly dirty, alcohol-based hand sanitizers are the preferred method for hand hygiene. - Process: Perform hand hygiene: 1.1 Before patient care; 1.5 After contact with the patient's environment.",2020-09-01
159,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2018-05-03,554,D,0,1,OUUG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor residents' ingestion of medication and failed to take action to not leave non-ingested medication in the control of residents who did not have self-administration orders for 2 (#s 40 and 46) of 42 sampled residents. Findings include: 1. During an interview and observation on 5/1/18 at 8:23 a.m., resident #40 stated that staff member U gets distracted while doing med pass and sometimes makes medication errors. Resident #40 stated that she had been over-dispensed medications during the last several months and had saved the extra meds in her dresser. Resident #40 was observed removing a weekly pill [MEDICATION NAME] from her dresser and displaying the pills located in the [MEDICATION NAME]. Resident #40 stated that each medication was dispensed in excess of the prescribed amount and that it was staff member U that had dispensed the pills each time. Resident #40 said that sometimes the pills were given at a time of day when there was no prescribed dosage (i.e. stated that she had been given an extra glimepiride at lunch time). During an interview and observation on 5/1/18 at 9:27 a.m., staff member V was notified of resident #40 being in possession of the medications. Staff member V was observed removing the pills from resident #40's room. Staff member V documented the medications that resident #40 had possessed: glimepiride 4 mg, dosage listed as 1 tablet twice daily; [MEDICATION NAME] 160 mg, dosage listed as once daily at bedtime; [MEDICATION NAME] 50 mg tablet, dosage listed as once daily at bedtime; four vitamin C tablets, 500 mg each, no order for this medication was in effect; one aspirin 81 mg, no order for this medication was in effect; and one folic acid 1 mg, no order for this medication was in effect. During an interview on 5/1/18 at 9:28 a.m., staff member V stated nurses should have watched the resident take her medication when it was administered Record review of resident #40's physician orders [REDACTED].>During an interview on 5/1/18 at 10:11 a.m., staff member V stated that there is no self-administration order for resident #40 regarding any of her pills. It was requested of staff member B on 5/2/18 that the facility make staff member U available for an interview. Staff member U, who was scheduled off on 4/30/18 and 5/1/18, called in sick on 5/2/18, and was also not present in the facility on 5/3/18. 2. During an interview and observation on 5/1/18 at 9:42 a.m., an [MEDICATION NAME] Diskus 250/50 mcg inhaler was observed in resident #46's room. The medication was prescribed for resident #46. The inhaler was located on top of the electronics near the door. During an interview and observation on 5/1/18 at 9:44 a.m., staff member V was notified the medication was in the resident's room. Staff member V was observed removing the medication from resident #46's room. Staff member V stated that she had made an honest mistake in forgetting to collect the medication before moving on to other residents during med pass. Review of resident #46's Physician order [REDACTED].",2020-09-01
160,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2018-05-03,558,D,1,1,OUUG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to provide a male chaperone per a resident's request during his showers for 1 (#106) of 42 sampled residents. Findings include: During an interview on 5/1/18 at 10:11 a.m., resident #106 stated he wished he could shower by himself. He said he could understand why there needed to be a nurse in the shower room with him but he did not like having a woman in the shower room with him, looking at my junk. He stated he had asked the nurses if he could have a male aide in the shower instead of female aide. He said he had asked this of the staff several times and no one listened. He said he had become so embarrassed with having a woman wash him, he had resorted to sneaking into the shower room in the middle of the night to give himself a shower. Resident #106 was admitted to the facility on [DATE]. Review of the resident's Care Plan with a creation date of 4/4/18, failed to include the resident's preference for male assistance with showers until 5/1/18. The resident was to be discharged on [DATE]. During an interview on 5/1/18 at 9:11 a.m., staff member G stated if a resident preferred a male shower aide, then it would be care planned and should be provided for the resident. She stated it was usually a woman on the day shift for this hall, and male CNAs did not usually work until the evening shift. She stated she was not aware of resident #106's preference for male chaperones. She said she had provided a shower to the resident on different occasions. During an interview on 5/1/18 at 9:15 a.m., staff member H stated she would update the resident's care plan to reflect his preference for male assistance in the shower. She said she was not aware of the resident's preference for male assistance in the shower. During an interview on 5/1/18 at 9:20 a.m., staff member I stated she was not aware of the resident's preference for male assistance in the shower. She stated it would be important to ensure every resident was comfortable and to provide this accommodation for the resident's dignity. During an interview on 5/2/18 at 10:00 a.m., resident #106 stated no staff had come to talk to him about his preference for a male assistant in the shower, but said he was not surprised since they did not listen the first time. He stated he felt like he did not have any dignity when he was showered by a female aide.",2020-09-01
161,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2018-05-03,583,E,0,1,OUUG11,"Based on interview and record review, the facility failed to deliver mail to residents on Saturday. This deficient practice had the potential to affect all residents whom receive mail on Saturdays. Findings include: During an interview on 5/1/18 at 10:01 a.m., members of the Resident Council stated they did not receive their mail on Saturdays and would like to have their mail when it was delivered. They stated this was a frustration for them since it had been a problem for a very long time. The members of the Resident Council stated the mail was delivered to the canteen on Saturday and locked away, where it was not distributed to the residents until Monday. During an interview on 5/1/18 at 12:51 p.m., staff member L stated the mail was delivered Monday through Friday to the front office, where it was sorted and delivered to the residents. She stated the mail was not sorted or distributed to the residents on Saturdays because there was no one in the front office to complete the task; instead, it was delivered to the canteen and locked up until Monday. During an interview on 5/1/18 at 2:00 p.m., staff member B stated the mail was not delivered to the residents on Saturdays. She said the mail was delivered to the canteen where it was locked up until it could be sorted and delivered on Monday. During an interview on 5/1/18 at 3:05 p.m., staff member M stated the mail was delivered to the canteen on Saturdays, since the front office was closed. She stated she took the mail and locked it up until Monday when it could be sorted and delivered. She said she was not able to sort or deliver the mail on Saturdays since she could not leave the canteen. A review of the facility's policy and procedure titled, Patient/Resident Mail Delivery, showed, Patients/Residents/Guests have the right to privacy in written communication, to send promptly and receive unopened mail and other letters, packages, and other materials delivered to the facility for the patient/resident/guest, including those delivered through means other than a postal service, and to have access to stationery, postage and writing implements at the patient's/resident's own expense. 1.2 Ensure that mail is delivered to the person unopened or postmarked (for outgoing mail) within 24 hours, including Saturday.",2020-09-01
162,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2018-05-03,607,D,0,1,OUUG11,"Based on interview, observation, and record review, a staff member suspected abuse of a resident by another staff member but administration did not receive a report of the suspected abuse, causing the facility to fail to have effective policies in place regarding prevention and reporting of abuse of residents, due to lack of implementation by the staff member that observed the suspected abuse, for 2 (#s 5 and 46) of 42 sampled residents. Findings include: 1. During an interview on 5/3/18 at 8:47 a.m., staff member Y stated that she had witnessed staff member U treating resident #40 and resident #5 poorly. Staff member Y stated that she was concerned because staff member U was rude and dismissive with resident #40 on an ongoing basis and staff member U treated resident #40's valid requests as behaviors, failing to grant the request. Staff member Y said that staff member U used frustration or agitation expressed by resident #40 as justification for classifying the requests as behaviors. Staff member Y said that these requests specifically included linens and an ointment for resident #40's perineal area. Staff member Y said that other requests were deemed behaviors and denied as well. During an observation and interview on 5/3/18 at 9:34 a.m., resident #40 was observed to not be cognitively impaired and according to her MDS had a BIMS of 15. Resident #40 stated that staff member U had not treated her with respect and dignity. Resident #40 stated that staff member U treats me like I have no brains in my head. Resident #40 further stated that staff member U poo-poo's (dismissed) any concerns that resident #40 had voiced. Resident #40 stated (t)here really is a (psychological impact) to the way (staff member U) treats me; she makes me feel like I don't have a brain in my head and like she has to think for me. Resident #40 stated that staff member U treats me in a 'you don't matter' sort of way. Resident #40 stated that she had frustration regarding staff member U's failure to respect resident #40's religious dedication of honoring Saturday as the Sabbath. Resident #40 stated that when staff member U attempted to have environmental services conduct routine cleaning of resident #40's room on a Saturday, resident #40 explained that she was refusing due to her decision to keep and honor the Sabbath on Saturday. Resident #40 stated that staff member U retorted, with attitude, I see you do what you want to do. Resident #40 stated that she felt this response was disrespectful towards her religious beliefs. Resident #40 stated that her treatment from staff member U was so poor that when staff member U was working, resident #40 simply does not ask for anything, in an attempt to avoid interacting with staff member U. It was requested of staff member B on 5/2/18 that the facility make staff member U available for an interview. Staff member U, who was scheduled off on 4/30/18 and 5/1/18, called in sick on 5/2/18, and was also not present in the facility on 5/3/18. During an interview on 5/3/18 at 10:27 a.m., resident #40 stated that staff member U had once thrown away a nebulizer treatment prescribed to resident #40. Resident #40 stated that she had questioned staff member U about throwing it away and staff member U said that resident #40 would get a new one at the time of the next administration. Staff member U then said something under her breath. Resident #40 could not understand what staff member U said under her breath. Resident #40 stated that approximately a month prior to survey, she informed staff member DD about poor treatment by staff member U. The resident said that she got very upset talking about it and was crying so she was not sure how much of what she reported was understood by staff member DD. During an interview on 5/3/18 at approximately 10:40 a.m., staff member DD stated that she had no recollection of resident #40 reporting poor treatment by a staff member. A record review request was made on 5/3/18 for records regarding resident #40's reports to social services. There were no records pertinent to this matter provided by the time that the survey ended. 2. During an observation and interview on 5/3/18 at approximately 9:50 a.m., resident #5 was observed to not be cognitively impaired and according to her MDS had a BIMS of 15. Resident #5 stated that staff member U had been nasty to her. Resident #5 stated that staff member U had been very rough, on an ongoing basis, when caring for resident #5 and that staff member U calls her crazy. Resident #5 stated that she had heard, second hand, that staff member U stated that she puts up with resident #5 so that she can work on 300 hall. Resident #5 was observed and stated that she cannot hear very well. She said that staff member U came into her room and jerked the covers off her bed, then shined a light on resident #5's vagina and stated that she was checking to see if resident #5 was dry. Resident #5 stated that she felt that jerking the covers off and shining the flashlight on her genitals, without permission, were inappropriate and abusive actions. Resident #5 stated that she had not reported the incident to any staff at the facility. During an interview on 5/3/18 at approximately 10:10 a.m., staff member A was notified by the survey team of the allegations from residents regarding abuse by staff member U. Staff member A stated that she had not previously been notified of these allegations. A record review of GenSTAR Daily Staffing Sheet (wTimes) showed that staff member U had been regularly scheduled to work on 300 wing. A record review of the facility's Abuse Prohibition policy showed in section 5.1, Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately.",2020-09-01
163,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2018-05-03,637,D,0,1,OUUG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a significant change assessment within 14 days after significant changes occurred for the resident in the areas of: pressure ulcers, mood, refusal of care, incontinence, pain, and functional status had occurred for 1 (#107) out of 42 sampled residents. Findings include: 1. Over the time period from 9/1/17 to 2/28/18, resident #107 had a significant change in her mood severity score from 6 to 14, an increase in PUs, a decrease in her physical functional status, a decrease in continence of bowel, and an increase in pain medication from scheduled and non-medication interventions to scheduled and PRN. The MDS did not capture that resident #107 refused cares daily according to staff report and physician progress notes [REDACTED]. a. Review of resident #107's Annual MDS, with an ARD of 9/1/17, showed resident #107 was not cognitively impaired and had a BIMS score of 15. Review of section D-Mood had a score of 6 and showed resident #107 exhibited signs of feeling down, depressed, or hopeless nearly every day; had trouble falling asleep, staying asleep, or sleeping too much (half or more of the days); and a poor appetite or overeating several days. Review of section E-Behavior showed resident #107 exhibited verbal behavioral symptoms directed toward others 1-3 days out of 14. The assessment showed resident #107's behavioral symptoms significantly interfered with her care and participation in activities or social interactions. The assessment showed resident #107 did not exhibit rejection of care. A Change in Behavior or Other Symptoms was scored as worse as compared to the previous assessment. Review of section F-Daily Preferences showed resident #107 reported it was very important for her to take care of her personal things, choose between a shower or a bath, choose her own bedtime, and use the phone in private. Activity preferences showed it was very important for her to do her favorite activities, and somewhat important to keep up with the news. Review of section G-Functional Status showed resident #107 was extensive assist of two person physical assist with bed mobility, transfers, walking in her room, walking in the corridor, and toilet use. The assessment showed she was extensive assist of one in maintaining her personal hygiene including combing her hair, brushing her teeth, washing her face and hands, and bathing. The assessment showed resident #107 used a wheelchair for mobility. Review of section H-Bladder and Bowel showed resident #107 was always incontinent of urine and occasionally incontinent of bowel. Review of section I-[DIAGNOSES REDACTED]. Review of section J-Health Conditions showed resident #107 received a scheduled pain medication, and a non-medication intervention for pain. The assessment showed resident #107 reported she had almost constant pain that made it hard for her to sleep at night, and limited her day to day activities. Her verbal descriptor of pain was scored as severe in rating the intensity of her pain over the last 5 days. Review of section M-Skin Conditions showed the resident was at risk for developing a PU and had one stage I pressure ulcer with [MEDICATION NAME] tissue in the wound bed. The assessment showed the resident had MASD as an additional skin condition. Skin treatments listed were pressure reducing device for her chair, bed, and pressure ulcer care with applications of ointments/medications. Review of section N-Medications showed resident #107 received an antidepressant and diuretic 7 days per week. Section O-Special Treatments, Procedures and Programs showed resident #107 received physical therapy 2 out of 7 days, restorative services for ROM 3 out of 7 days, and training and skill practice in walking 3 out of 7 days. The Care Area Assessment Summary showed resident #107 triggered in the areas of cognitive loss (although her BIMS was 15 meaning no cognitive impairment), ADL functional/rehabilitation potential, psychosocial well-being, behavioral symptoms, falls, nutritional status, pressure ulcer, [MEDICAL CONDITION] drug use, and pain. The Care Planning Decision included ADL functioning, mood state, falls, nutrition, [MEDICAL CONDITION] drug use, and pain. b. Review of resident #107's Quarterly MDS, with an ARD of 11/30/17, showed resident #107 was not cognitively impaired and had a BIMS score of 15. Review of section D-Mood showed resident #107 had a severity score of 7 and showed resident #107 exhibited symptoms of feeling tired or having little energy and poor appetite or overeating several days. The assessment showed resident #107 exhibited feeling down, depressed, or hopeless nearly every day. Review of section E-Behavior showed resident #107 exhibited verbal behavioral symptoms 1-3 days out of 14. Review of section G-Functional Status showed resident #107 was an extensive two person physical assist for bed mobility, transfer, walk in room, walk in corridor, dressing, and toilet use. The assessment showed she was a limited one person physical assist with locomotion on unit, and locomotion off unit. The assessment showed she was an extensive one person physical assist for personal hygiene. The assessment showed bathing did not occur. Review of section H-Bladder and Bowel showed resident #107 was frequently incontinent of urine and always continent of bowel. Review of section J-Health Conditions showed resident #107 received scheduled pain medication, a PRN pain medication, and did not receive a non-medication intervention for pain. The assessment showed resident #107 reported she had frequent pain with a verbal descriptor of moderate. Review of section M-Skin Conditions showed resident #107 was at risk for PUs. The assessment showed she had 2 stage II PUs with [MEDICATION NAME] tissue at the wound bed. The assessment showed one of the stage II PU was worsening since the prior assessment. Review of section N-Medications showed resident #107 received an antipsychotic, antidepressant, diuretic, and opioid 7 days per week. The assessment showed the antipsychotic was received on a routine basis only. Review of section O-Special Treatments, Procedures, and Programs showed resident #107 received active range of motion restorative services 3 days per week. c. Review of resident #107's Quarterly MDS, with an ARD of 2/28/18, showed resident #107 was not cognitively impaired and had a BIMS score of 15. Review of section D-Mood had a severity score of 14 and showed resident #107 exhibited symptoms of feeling little interest or pleasure in doing things several days; feeling down, depressed, or hopeless, had trouble falling asleep, felt tired with little energy, and had trouble concentrating on things such as reading the newspaper, or watching TV nearly every day. Review of section E-Behavior showed resident #107 did not exhibit rejection of care or behavioral symptoms. Review of section G-Functional Status showed resident #107 was extensive assist of two person physical assist for bed mobility, and toilet use. The assessment showed transfer activity occurred only once or twice with a two person physical assist. The assessment showed walk in room, walk in corridor, locomotion on unit, and locomotion off unit did not occur. The assessment showed resident #107 was an extensive assist of one person physical assist for personal hygiene, and dressing. The assessment showed bathing did not occur. Review of section H-Bladder and Bowel showed resident #107 was always incontinent of urine and always incontinent of bowel. Review of section J-Health Conditions showed resident #107 received a scheduled pain medication, and a PRN pain medication. The assessment showed she reported her pain was almost constant, and made it hard for her to sleep at night. She rated her pain intensity as a 9 (which meant unable to answer). Review of section M-Skin Conditions showed resident #107 was at risk for pressure ulcers, and had two stage II PUs with [MEDICATION NAME] tissue in the wound bed. The assessment showed one of the current PUs was worsening. Review of section N-Medications showed resident #107 received an antidepressant, diuretic, and opioid 7 days per week. Review of section O-Special Treatments, Procedures, and Programs showed resident #107 was not receiving any therapy or restorative services. Resident #107 continued to refuse care and decline in the areas of skin, mood, pain, activities, and her functional status with no further revisions to the interventions or goals to prevent the decline. During an interview on 5/3/18 at 11:00 a.m., staff member EE stated when she considered a significant change, she had to have two out of four areas change to include: skin, significant weight loss, significant ADL changes, and/or a significant nutrition change. Staff member EE stated if there were changes in those four areas, they would have done a significant change assessment. Staff member EE stated the process she used included reviewing the rounds information that the nurse, social services, and therapists documented. She stated she would visit with the resident 1:1 and review all of the same questions that were asked through the rounds. She stated if the resident could not report to her, she would visit with the interdisciplinary team. During an interview on 05/03/18 at 12:35 p.m., staff member A stated the resident declined assistance with ADL care including bathing, getting out of bed, hair care, and taking her medications. She stated the goal for the resident was to maintain what was and/or improve, as she allowed, with keeping health and safety parameters in mind. Staff member A stated, going forward we would spend 1:1 time when the resident was declining to establish her goals and needs. Staff member A stated the change of decline was based on the medical records, assessments, quality of life rounds, and looking at changes in condition in CNA alert documentation. Staff member A stated the facility started walking rounds with the nurses and CNAs in (MONTH) (YEAR). Staff member A stated the facility needed to change their thinking that care plans were revised and updated quarterly, to a resident centered care plan where changes were made with the resident's changes. She stated staff needed to drill down to understanding that behavior was communication. Staff member A stated, I told staff yesterday to keep asking why when a resident had a behavior.",2020-09-01
164,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2018-05-03,657,D,0,1,OUUG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and policy review, the facility failed to address, monitor, and re-assess the interventions on the individualized resident care plan, for a wound vac to the left lower extremity for 1 (#103); and failed to review and revise care plan goals for 1 (#107) of 42 sampled residents. Findings include: 1. Resident #103 was observed on [DATE] at 11:15 a.m., with a wound vac and dressing covering his left lower extremity. Resident #103 stated he went to the wound clinic to have the dressing changed and they also managed the wound vac there. Resident #103's skin breakdown Care Plan, with a revision date of [DATE], was reviewed. The care plan did not address the wound vac to the left lower extremity and the wound clinic over sight and management of the wound vac. The facility policy titled Person-Centered Care plan was reviewed. The policy included that a comprehensive person-centered care plan must be developed for each patient and must describe the services that are to be furnished. 2. Resident #107 was admitted to the facility with [DIAGNOSES REDACTED]. During an interview on [DATE] at 12:35 p.m., staff member A stated the resident declined assistance with ADL care including bathing, getting out of bed, hair care, and taking her medications. She stated the goal for the resident was to maintain what was and/or improve, as she allowed, with keeping health and safety parameters in mind. She stated, going forward we would spend 1:1 time when the resident was declining to establish her goals and needs. Staff member A stated the change of decline was based on the medical records, assessments, quality of life rounds, and looking at changes in condition in CNA alert documentation. Staff member A stated the facility started walking rounds with the nurses and CNAs in (MONTH) (YEAR). Staff member A stated the facility needed to change their thinking that care plans were revised and updated quarterly, to a resident centered care plan where changes were made with the resident's changes. She stated staff needed to drill down to understanding that behavior was communication. She stated, I told staff yesterday to keep asking why when a resident has a behavior. Review of resident #107's current Care Plan, with the last care plan review date of [DATE], showed focus areas for: decreased ability to perform ADLs; limited and/or meaningful engagement related to indicators of depressed mood or anxious behavior; verbal behaviors and refusing medications, treatment, cares, and self isolation due to refusing to get out of bed; alteration in comfort related to chronic pain; being at risk related to the use of an antidepressant medication; and skin breakdown related to moisture associated skin damage with stage II PUs. Review of the Goal section for the focus areas, showed the last target date was [DATE] for the goals to be met using the interventions listed. No further reviews or revisions were made after [DATE]. The focus area for refusal of care, medications, treatments, and choosing not to get out of bed showed goals that resident #107 would not have more than five episodes per week of refusal of medications, treatments, and/or cares x 90 days, initiated on [DATE]. No further goals were set or revised for resident #107's continued refusal of care and getting out of bed after the 90 days had expired. Resident #107 continued to refuse care and decline in the areas of skin, mood, pain, activities, and her functional status with no further revisions to the care plan interventions to prevent the decline. During an observation and interview on [DATE] at 10:48 a.m., staff members FF and I assisted the resident with a transfer from her bed to her wheelchair with a Hoyer lift. Resident #107 was cooperative with the transfer. She stated to staff members FF and I she didn't understand why they couldn't just let her sit on the side of the bed and grab under her arms and let her get in her wheelchair that way. Staff member FF and I did not respond to the comment/question. Staff member FF and I applied the lift sling to the resident and prepared the resident for transfer. Resident #107 stated to staff members FF and I she was not sure she liked this thing. Resident #107 asked staff member FF and I to place a draw sheet on her wheelchair cushion. She asked that they put on her Crocs shoes. During the lift experience resident #107 was cooperative and did not exhibit refusal of care or verbal abuse. The care plan showed transfers were to be done using a sit-to-stand lift. Review of the focus area that addressed a decreased ability to perform ADLs showed resident #107 was to be transferred using a sit-to-stand lift. During observations of care for the resident, staff used a Hoyer lift for transfers. The same intervention for the use of the sit-to-stand was listed under the focus area addressing at risk for falls. The care plan did not address/include transfers with the use of a Hoyer lift.",2020-09-01
165,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2018-05-03,675,G,0,1,OUUG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care and services necessary for the resident to maintain the highest practicable physical, mental, and psychosocial well-being by not providing education to the resident of the risks associated with refusal of care; and the facility failed to identify the underlying causes of the refusal of care that resulted in a decline in mood, physical functioning, skin status to include the development of pressure ulcers, and incontinence of bowel, for 1 (#107) of 42 sampled residents. Findings include: Resident #107 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation on [DATE] at 9:59 a.m., resident #107 was in bed. Her eyes were closed and she was wearing a hospital gown. The head of her bed was elevated slightly, and her call light was within reach. Her TV was on. During an observation and interview on [DATE] at 2:52 p.m., resident #107 reported concerns of right hip pain, and staff not finding someone to cut her hair and wash it. Resident #107 reported she had lived in the facility for two years. Resident #107 was eating a late lunch per her request. She stated she wanted to discuss other concerns as soon as she was done eating her lunch. Her hair appeared oily and she was dressed in a hospital gown. She was laying on her left side with the head of the bed slightly elevated. During an observation and interview on [DATE] at 10:39 a.m., resident #107 reported she wanted her hair done and she had a concern staff were not doing it. She was in bed on her left side. Her hair appeared disheveled and oily. She was wearing a hospital gown. She stated she had constant pain in her right shoulder because of arthritis. She stated it was at a severity level between ,[DATE] out of 10. She reported her doctor took away her pain medication that she used to take for years for her arthritis. During an observation on [DATE] at 2:43 p.m., resident #107 was in bed with her eyes closed The door was ajar and her lights were off. The TV was on. Resident #107 was laying on her left side and back, with the head of the bed slightly elevated. She was wearing a hospital gown. During an observation of wound care and interview on [DATE] at 10:48 a.m., resident #107 stated since her right leg turned in she had quit getting out of bed. She stated her hip had been twisted for ,[DATE] months now. She stated, they change my brief when I call. Resident #107 was cooperative with the wound care and followed directions with no difficulty. She joked with the staff and was able to communicate her needs during the process. During an observation and interview on [DATE] at 10:48 a.m., staff members FF and I assisted the resident with a transfer from her bed to her wheelchair with a Hoyer lift. Resident #107 was cooperative with the transfer. She stated to staff members FF and I she did not understand why they could not just let her sit on the side of the bed and grab under her arms and let her get in her wheelchair that way. Staff members FF and I did not respond to the comment/question. Staff members FF and I applied the lift sling to the resident and prepared the resident for transfer. Resident #107 stated to staff members FF and I she was not sure she liked this thing. Resident #107 asked staff FF and I to place a draw sheet in her wheelchair cushion. She asked that they put on her Crocs shoes. During the lift experience, resident #107 was cooperative and did not exhibit refusal of care or verbal abuse. During an observation and interview on [DATE] at 12:00 p.m., resident #107 stated she wanted her right hip put back into place, and she wanted to walk. She stated she did not know why her right leg turned out. She stated she had a hip replacement several years ago by (surgeon's name) and he was no longer living. She stated normally she would like to have been in her wheelchair and outside. She stated she did not like to be in the lift so she tells them (staff) she does not need it. She stated she tells them she wanted to stand to get in her wheelchair. After resident #107 was up in her wheelchair, her hair was matted close to her scalp on the back and left side of her head. Staff assisted resident #107 to the beautician's area via wheelchair. Resident #107 was placed in front of the mirror in the beauty shop. When she saw herself in the mirror she exclaimed, Oh my God! I can't even look at it! and was tearful. She stated, if they would have used my Head and Shoulders this never would have happened. She stated, it was hurting my scalp. She stated after she (staff) dumped the soap on my head that's the last time I got my hair washed and a shower. She stated, my hair is matted like an old dog. Resident #107 shared she asked for physical therapy to come and work on her legs and it never happened. She stated she needed them to figure out why her right leg was slipped out. She said (doctor's name) came in yesterday at her request and gave her back her arthritis medicine. She stated she wanted to stand to get in and out of her wheelchair. NF3 stated resident #107's hair would have to be cut off short as she was not able to comb out the matting on the back of the resident's head. NF3 stated the hair was matted to the scalp and was pulling on the scalp. NF3 stated in her opinion it would take at least two weeks for a person's hair to become matted to the scalp that way. NF3 showed the area of the scalp that was under the matted hair after she cut the hair off and stated the resident had cradle cap. There was debris coated on the scalp and when NF3 combed over the scalp the debris flaked off in clumps. NF3 stated resident #107 needed to have her hair shampooed. NF3 stated resident #107 had not had a hair appointment with her this year (2018). During an interview on [DATE] at 12:55 p.m., staff member HH stated she believed resident #107 had not had a shower and her hair washed since (MONTH) (YEAR). Staff member HH stated the resident had behaviors and a history of refusing care. She stated resident #107 made verbal threats toward staff. She stated staff tried to encourage her and if they assisted resident #107 with two staff versus one, the refusal and verbal abuse was not as bad. She stated if the resident continued to refuse care she would notify the DON. During an interview on [DATE] at 1:15 p.m., staff member II stated resident #107 had good days and bad days. She stated resident #107 ignored staff and gave no verbal response when she refused care. Staff member II stated staff could re-approach her and then she would usually cooperate, but sometimes she would absolutely refuse. Staff member II stated resident #107 would accept a bed bath. She said the resident did not like to get up because she did not like to use the lift. Staff member II stated resident #107 would allow staff to the use the lift infrequently. She stated she did not know why resident #107 agreed to get in the lift for staff today. She stated staff documented her refusals, but did not document reasons why the resident was refusing care and use of the lift. Staff member II stated she was not aware that resident #107's hair was matted to her scalp. During an interview on [DATE] at 9:25 a.m., staff member O stated resident #107 had a history of [REDACTED]. She stated the resident was incontinent of urine and was noncompliant with repositioning to her right side. Staff member O stated resident #107 had a history of [REDACTED]. She stated the PU to the left hip was newly developed ,[DATE] days ago. Staff member O stated staff had tried to prevent PUs from developing by providing an air mattress, encouraging the resident to turn and off load her left side, and provide incontinent care. During an interview on [DATE] at 4:07 p.m., staff member DD stated she had been asked to visit with resident #107 about her medication refusal in the past. She stated she was asked yesterday to visit with resident #107 regarding moving her bed to facilitate her getting off of her left side. She stated resident #107 told her she was staying on her left side because of pain in her right shoulder. Staff member DD stated resident #107's family quit visiting recently because she was verbally abusive to them. Staff member DD stated when her family would come to visit they would help with getting her up. Staff member DD stated when resident #107 first got to the facility she was a pivot transfer, then was downgraded to a sit-to-stand lift transfer, and then she refused. Staff member DD stated, she used transfers with the sit to stand as a reason why she would not get out of bed. Staff member DD stated she knew resident #107 thought she could stand on her own. Staff member DD stated on average resident #107 did not get out of bed. She stated approximately ,[DATE] months ago the facility changed her mattress. Staff member DD stated resident #107 used to get up daily to go smoke a cigarette at 4:00 p.m. She stated she had not asked her why she no longer gets up to smoke. Staff member DD stated resident #107 had been resistant to cares and not getting of her bed for probably one year. Staff member DD stated she believed since resident #107 had a room change and did not have a room mate her daily social contacts were less. She stated she thought resident #107 was enjoying having a room to herself, but it could also be causing her to have less stimuli and causing her to isolate. She stated resident #107 told her she was angry because her son did not visit her anymore, and her other son was on drugs. During an observation and interview on [DATE] at 8:15 a.m., resident #107 stated she learned she could not walk yesterday. She stated, the girls got on each side under my arms and my legs did not function. It scared the hell out of me. She stated if her right shoulder would quit hurting she would lay on her right side if the staff moved her TV. Resident #107 stated she called her daughter in (state name) and learned that she was not able to get around because of her depression and she was using a wheelchair. She stated concerns that she was worried about her son who is [MEDICAL CONDITION] because, no one knows where he is right now. She shared she was still grieving the loss of her other son who died from [MEDICAL CONDITION] of the liver two years ago. She was observed to be tearful when she talked about her sons and daughter. She stated the thing she wanted to do the most was to move back to (state name) and be closer to her children. During an interview on [DATE] at 7:40 a.m., staff member A stated staff is good about realizing that if residents are refusing care it is their right, but we are missing step two with our staff. We needed to initiate a discussion with the resident about the risks and benefits of refusing to follow the plan of care. During an interview on [DATE] at 12:35 p.m., staff member A stated the resident declined assistance with ADL care including bathing, getting out of bed, hair care, and taking her medications. She stated the goal for the resident was to maintain what was and/or improve, as she allowed, with keeping health and safety parameters in mind. She stated, going forward we would spend 1:1 time when the resident was declining to establish her goals and needs. Staff member A stated the change of decline was based on the medical records, assessments, quality of life rounds, and looking at changes in condition in CNA alert documentation. Staff member A stated the facility started walking rounds with the nurses and CNAs in (MONTH) (YEAR). Staff member A stated the facility needed to change their thinking that care plans were revised and updated quarterly, to a resident centered care plan where changes were made with the resident's changes. She stated staff needed to drill down to understanding that behavior was communication. She stated, I told staff yesterday to keep asking why when a resident had a behavior. Review of resident #107's Annual MDS, with an ARD of [DATE], Quarterly MDS, with an ARD of [DATE], Quarterly MDS, with an ARD of [DATE] showed resident #107 had a significant change in her mood severity score from 6 to 14, an increase in PUs, a decrease in her physical functional status, a decrease in continence of bowel, and an increase in pain medication from scheduled and non-medication interventions to scheduled and PRN. None of the MDS assessments captured in Section-E Behaviors, that resident #107 refused cares daily according to staff interviews and physician progress notes [REDACTED]. The Care Area Assessment Summary for the Annual MDS, with an ARD of [DATE], showed resident #107 triggered in the areas of cognitive loss(although her BIMS was 15 meaning no cognitive impairment), ADL functional/rehabilitation potential, psychosocial well-being, behavioral symptoms, falls, nutritional status, pressure ulcer, [MEDICAL CONDITION] drug use, and pain. The Care Planning Decision included ADL functioning, mood state, falls, nutrition, [MEDICAL CONDITION] drug use, and pain. Review of resident #107's current Care Plan, with the last Care Plan review date of [DATE], showed focus areas for: decreased ability to perform ADLs; limited and/or meaningful engagement related to indicators of depressed mood or anxious behavior; verbal behaviors and refusing medications, treatment, cares, and self isolation due to refusing to get out of bed; alteration in comfort related to chronic pain; being at risk related to the use of an antidepressant medication; and skin breakdown related to moisture associated skin damage with stage II PUs. The last target date listed to address goals to be met for the interventions put in to place for the focus areas was [DATE]. The focus area for refusal of care, medications, treatments, and choosing not to get out of bed showed goals that resident #107 would not have more than five episodes per week of refusal of medications, treatments, and/or cares x 90 days, initiated on [DATE]. No further goals were set or revised for resident #107's continued refusal of care and getting out of bed after the 90 days had expired. Resident #107 continued to refuse care and decline in the areas of skin, mood, pain, activities, and her functional status with no further revisions to her interventions to prevent the decline. The care plan did not address the resident's fear of experiencing pain with the use of the sit-to-stand lift, loss of family visitation and loss of her son, pain in her right shoulder, and the desire to move to another state where she could be closer to her family. Review of resident #107's medical record failed to show documentation that the resident was educated about the risks and consequences that could occur by refusing care, medications, treatments, transfers, and remaining on her left side while in bed. Through the resident interviews during the survey process, other underlying risk factors not considered in providing care and services to the resident included: fear of pain caused by the sit-to-stand lift used for transfers, grieving and the loss of family contact, wanting to relocate to another state to be closer to her family, and pain in her right shoulder. The resident exhibited crying and reported family loss and grief. She reported pain during transfers with the lift and pain in her right shoulder that was keeping her from changing her position and resulted in PUs.",2020-09-01
166,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2018-05-03,677,E,1,1,OUUG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to provide showers and regular shaving for residents who were not able to carry out their own ADL's for 2 (#s 77 and 336) of 51 sampled and supplement residents; failed to identify the underlying cause of the refusal of care to ensure the resident maintained her hair care to avoid matting of her hair and cradle cap; and failed to identify the underlying cause of the refusal of care for extended periods of time for personal hygiene and/or baths for 1 (#107) of 42 sampled residents. Finding include: 1. During an observation and interview on 4/30/18 at 2:52 p.m., resident #107 reported concerns of right hip pain, and staff not finding someone to cut her hair and wash it. Resident #107 reported she had lived at the facility for two years. Resident #107 was eating a late lunch, per her request. She stated she wanted to discuss other concerns as soon as she was done eating her lunch. Her hair appeared oily and she was dressed in a hospital gown. She was laying on her left side with the head of the bed slightly elevated. During an observation and interview on 5/1/18 at 10:39 a.m., resident #107 reported she wanted her hair done and had a concern staff were not doing it. She was in bed on her left side. Her hair appeared disheveled and oily. During an observation on 5/1/18 at 2:43 p.m., resident #107 was in bed with her eyes closed. The door was ajar and her lights were off. The TV was on. Resident #107 was laying on her left side and back with the head of the bed up slightly. She was wearing a hospital gown. During an observation and interview on 5/2/18 at 10:48 a.m., staff member FF and I assisted the resident with a transfer from her bed to her wheelchair with a Hoyer lift. During the lift experience, resident #107 was cooperative and did not exhibit refusal of care or verbal abuse. During an observation and interview on 5/2/18 at 12:00 p.m., resident #107 was up in her wheelchair her hair was observed to be matted close to her scalp on the back and left of her head. Staff assisted resident #107 to the beautician's area via wheelchair. Resident #107 was placed in front of the mirror in the beauty shop and when she saw herself in the mirror she exclaimed, Oh my God! I can't even look at it! and was tearful. She stated, if they would have used my Head and Shoulders this never would have happened. She stated, it was hurting my scalp. She stated after (staff) dumped the soap on my head that was the last time I got my hair washed and a shower. She stated her hair was matted like an old dog. NF3 stated resident #107's hair would have to be cut off short as she was not able to comb out the matting on the back of the resident's head. She stated the hair was matted to the scalp and was pulling on the scalp. NF3 stated in her opinion it would take at least two weeks for a person's hair to become matted to the scalp that way. NF3 showed the area of the scalp that was under the matted hair after she cut the hair off and stated the resident had cradle cap. There was debris coated on the scalp and when the beautician combed over the scalp the debris flaked off in clumps. NF3 stated resident #107 needed to have her hair shampooed. NF3 stated resident #107 had not had a hair appointment with her this year (2018). During an interview on 5/2/18 at 12:55 p.m., staff member HH stated she believed resident #107 had not had a shower and her hair washed since (MONTH) (YEAR). Staff member HH stated the resident had behaviors and a history of refusing care. She stated resident #107 made verbal threats toward staff. She stated staff tried to encourage her and if they assisted resident #107 with two staff versus one, the refusal and verbal abuse was not as bad. She stated if the resident continued to refuse care she would notify the DON. During an interview on 5/2/18 at 1:15 p.m., staff member II stated resident #107 had good days and bad days. She stated resident #107 ignores staff with no verbal responses. She stated staff can re-approach her and then she will usually cooperate, but sometimes she absolutely refuses. Staff member II stated resident #107 will do bed baths. She stated the resident did not like to get up because she did not like to use the lift. Staff member II stated resident #107 will allow staff to use the lift infrequently. Staff member II stated she didn't know why resident #107 agreed to get in the lift for staff today. She stated staff document her refusals but did not document reasons why the resident was refusing care and use of the lift. Staff member II stated she was not aware that resident #107's hair was matted to her scalp. Review of resident #107's medical record failed to show documentation that the resident was educated about the risks and consequences that could occur by refusing care. 2. During an observation on 4/30/18 at 11:10 a.m., resident #77 was laying in his bed, wearing a hospital gown. His face and neck had long gray stubble and his hair was oily with dandruff. His hair was spiked around his pillow and the back of his head had a large cowlick from laying on his pillow. The room smelled strongly of body odor. During an observation on 5/1/18 at 8:40 a.m., resident #77 was laying in his bed, his face and neck had a thick gray stubble. His hair was long past his ears and was spiked up around his pillow; it was oily and had dandruff. His room smelled of body odor. During an observation on 5/2/18 at 8:09 a.m., the resident was laying in his bed, his face and neck had thick gray stubble and his hair was combed back, but it was oily and had flecks of dandruff throughout. The room smelled of body odor. Review of resident #77's Annual MDS, with an ARD of 3/14/18, showed the resident was cognitively impaired, with a BIMS of 6. The MDS showed the resident was totally dependent with two-person assistance for bed mobility, dressing, bathing, and personal hygiene. Review of resident #77'S bathing scheduled showed the resident was to receive a bath/shower on Tuesdays and Fridays. Review of the CNA's Task Sheet showed the resident was scheduled for tub/shower bath during the day shift on Tuesdays and Thursdays per resident preference. Review of resident #77's Care Plan, revised on 1/19/18 showed, the resident was at risk for decreased ability to perform ADL(s) in bathing, grooming, personal hygiene, eating, bed mobility, transfer, locomotion, and toileting related to [MEDICAL CONDITION] resulting in fatigue, activity intolerance, confusion, and self-isolation due to (resident #77) choosing to stay in bed. A goal was set to maintain his highest capable level of ADL ability throughout the next review period. The interventions in place to assist the resident in achieving this goal was as follows: Provide opportunity for bathing preference: based on resident's tolerance. I prefer to wear a hospital gown instead of my personal clothes. Review of a report titled, Documentation Survey Report from 1/1/18 to 5/3/18, which showed the dates a bath/shower/bed bath were provided to resident #77, the following showed the resident did not receive a bath on the following dates: - From 1/24/18 to 2/1/18, the resident did not receive a bath for nine days, - from 2/3/18 to 2/12/18, the resident did not receive a bath for ten days, - from 2/21/18 to 3/1/18, the resident did not receive a bath for nine days, - from 3/3/18 to 3/12/18, the resident did not receive a bath for ten days, - from 3/28/18 to 4/11/12, the resident did not receive a bath for 15 days. Review of a report titled, Tub/Shower Day Shift for resident #77, showed the following: - Thursday 4/12/18, the resident was provided a bath, - Tuesday 4/17/18, the resident refused a bath, - Thursday 4/26/18, the resident had refused a bath, - Tuesday 5/1/18, the resident had refused a bath. Resident #77 had refused a bath/shower/bed bath for 20 days. Review of the resident's medical record failed to show the resident was educated on continual refusal of cares. During an interview on 5/2/18 at 8:15 a.m., staff member D stated the resident did not always like to have a bath or shower because it can be painful for him to move. The nurses would give him pain medication before he was given a shower. She stated she would bribe (resident #77) with a candy bar to get him to take a shower. She stated if he does not want a shower she would provide a bed bath. She said the resident was to have a shower last Friday, and he was due today but did not want one, so he had agreed to a shower tomorrow (5/3/18). She stated the resident sometimes liked to have a beard, but when the weather was warmer, he preferred to be clean shaven. The staff member said she would notify the nurse if a resident was continually refusing to take a shower or bed bath. During an interview on 5/3/18 at 8:30 a.m., staff member [NAME] stated for resident #77, she used a three-step approach with him if he refused a shower or to be shaved. She stated if he refused, she would wait and approach the resident again later. If he still refused, she would notify the nurse. She stated the resident should have had a bed bath yesterday. During an interview on 5/3/18 at 8:52 a.m., staff member I stated she was not aware resident #77 had been refusing his showers. During an interview on 5/3/18 at 9:00 a.m., resident #77 stated it did not matter any longer to him if he was provided a bath or not. During an interview on 5/2/18 at 5:00 p.m., resident #77's son stated the resident was a former school administrator and took great pride in his appearance. He stated the resident wore his hair short and was always clean shaven, unless he had a beard, it was well groomed. He stated he expected the facility to notify him if his father had been refusing to shower, but he was not aware he had been refusing his shower. He stated he has had concerns in the past that his father was not being provided a regular shower or being shaved. He stated he just figured the staff were busy. 3. During an interview on 4/25/18 at 4:00 p.m., NFI stated he had concerns with the staff not providing showers and shaving resident #336 on a regular basis. NFI stated the resident could be difficult to shave if his beard had grown out longer than every other day. He stated on several occasions the resident was not shaved and he would have to use the beard trimmer on the resident first before he could shave the resident. He stated the resident had also not been provided regular showers. He stated on several occasions he was told by staff the resident had refused his shower, but when he asked the resident if he wanted a shower, he would agree to one. He said on several visits the resident had smelled of body odor, urine, or BM. NFI stated they had provided the facility with the protocol used for the resident at another facility, which outlined his daily preferences, which included his shaving and showering preferences. During an interview on 4/26/18 at 10:00 a.m., NF2 stated they had several concerns regarding the resident not being shaved regularly and not being provided regular showers. She stated the resident had a strong smell of body odor and urine at times during their visits. Review of the resident's medical record showed, Personal Support Plan Tools, which showed a plan that was important for the health and safety of the resident as follows, having staff assist with his daily hygiene, and he needs to be shaved by staff every other day. The protocol also outlined a list of routines for the resident as follows, (Resident #336) takes his shower at 6 a.m. Review of a report titled, Documentation Survey Report from 1/31/18 to 3/9/18, which showed the dates a bath/shower/bed bath were provided to resident #336, showed the resident did not receive a bath on the following dates: - From 2/9/18 to 2/18/18, the resident did not receive a bath for ten days, - from 2/20/18 to 2/25/18, the resident did not receive a bath for six days, - from 2/27/18 to 3/9/18, the resident did not receive a bath for eleven days. Review of resident #336's Care Plan developed on 1/31/18, showed the resident required assistance/was dependent for ADL care in all ADLs related to developmental delay. The Goal was to anticipate and meet the resident's ADL care needs through the next review period. The interventions were to monitor for a decline in the resident's ADLs and to arrange his environment as much as possible to facilitate his ADL performance. During an interview on 5/3/18 at 8:52 a.m., staff member I stated if a resident continued to refuse showers, the nurse would be expected to check with the resident to assess for any rationale why the resident would refuse his showers or to be shaved, or if the resident had a different preference in his shower routine. She stated if a resident continued to refuse showers, she would notify the Interdisciplinary Team, family, and the physician for further guidance on providing showers for a resident who has been refusing care. Review of the facility's policy and procedure titled, Activities of Daily Living (ADLs), showed, Based on the comprehensive assessment of a patient and consistent with the patient's needs and choices the Center must provide the necessary care and services to ensure that patient's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. Activities of daily living (ADLs) include: hygiene bathing, dressing, grooming, andn (sic) oral care .1.2 A patient who is unable to carry out ADLs receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.",2020-09-01
167,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2018-05-03,686,G,1,1,OUUG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to educate the resident of the risks of refusal of care and repositioning to prevent the occurrence of pressure ulcers and the worsening of pressure ulcers for 1 (#107); and failed to implement preventative interventions to prevent the development of a left heel pressure ulcer for 1 (#283) of 51 sampled and supplmental residents. Findings include: 1. Resident #107 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation of wound care and interview on 5/2/18 at 10:48 a.m., resident #107 stated since her right leg turned in she had quit getting out of bed. She stated her hip had been twisted for 3-4 months now. She stated they change my brief when I call. Resident #107 was cooperative with the wound care and followed directions with no difficulty. She joked with the staff and was able to communicate her needs during the process. During an interview on 5/2/18 at 9:25 a.m., staff member O stated resident #107 had a history of [REDACTED]. She stated the resident was incontinent of urine and was noncompliant with repositioning to her right side. Staff member O stated resident #107 had a history of [REDACTED]. She stated the PU to the left hip was newly developed 1-2 days ago. Staff member O stated staff has tried to prevent PUs from developing by providing an air mattress, encouraging the resident to turn and off load her left side, and provide incontinent care. (see F0675) Review of resident #107's nurse's Notes from 2/12/18-5/1/18 failed to show documentation that the resident was educated about the risks and consequences that could occur by refusing care, medications, treatments, transfers, and remaining on her left side. Review of resident #107's Annual MDS, with an ARD of 9/1/17, showed resident #107 was not cognitively impaired, with a BIMS score of 15. Review of section M-Skin Conditions, showed the resident was at risk for developing a PU and had one stage I pressure ulcer with [MEDICATION NAME] tissue in the wound bed. The assessment showed the resident had MASD as an additional skin condition. Skin treatments listed were pressure reducing device for her chair, bed, and pressure ulcer care with applications of ointments/medications. Review of resident #107's Quarterly MDS, with an ARD of 11/30/17, showed resident #107 was not cognitively impaired, with a BIMS score of 15. Review of section M-Skin Conditions showed resident #107 was at risk for PUs. The assessment showed she had 2 stage II PUs with [MEDICATION NAME] tissue at the wound bed. The assessment showed one of the stage II PUs was worsening since the prior assessment. Review of resident #107's Quarterly MDS, with an ARD of 2/28/18, showed resident #107 was not cognitively impaired, with a BIMS score of 15. Review of section M-Skin Conditions showed resident #107 was at risk for pressure ulcers, and had two stage II PUs with [MEDICATION NAME] tissue in the wound bed. The assessment showed one of the current PUs was worsening. During an interview on 5/3/18 at 7:40 a.m., staff member A stated, staff is good about realizing that if residents are refusing care it is their right, but we are missing step two with our staff to initiate a discussion with the resident about the risks and benefits of following the plan of care. During an interview on 5/3/18 at 12:35 p.m., staff member A stated the resident declines assistance with ADL care including bathing, getting out of bed, hair care, and taking her medications. She stated the goal for the resident was to maintain what was and/or improve, as she allowed, with keeping health and safety parameters in mind. She stated, going forward we would spend 1:1 time when the resident was declining to establish her goals and needs. Staff member A stated the change of decline was based on the medical records, assessments, quality of life rounds, and looking at changes in condition in CNA alert documentation. Staff member A stated the facility started walking rounds with the nurses and CNAs in (MONTH) (YEAR). Staff member A stated the facility needed to change their thinking that care plans were revised and updated quarterly, to a resident centered care plan where changes were made with the resident's changes. She stated staff needed to drill down to understanding that behavior was communication. She stated, I told staff yesterday to keep asking why when a resident has a behavior. 2. Resident #283 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. During an interview on 5/3/18 at 11:00 a.m., staff member O stated resident #283's wound was caused by pressure from the bed. Staff member O stated she did not know if protective boots or a heel floating device had been used prior to the identification of the wound. During an interview on 5/3/18 at 11:30 a.m., staff member S stated a heel float device (flat and elevated in the middle with one pillow on each end) was used for residents with [MEDICAL CONDITION]. During an interview on 5/3/18 at 11:50 a.m., staff member T stated heel floats or protective boots were used for residents with [MEDICAL CONDITION]. Staff member T stated that unless specific orders were written by the physician, the interventions for preventing pressure ulcers on the heels would be standard. Review of resident #283's Progress Notes showed the following: -1/24/18; A blood blister was identified, measuring 4.6 x 5.0 cm to the resident's left heel. The fluid inside the blister was serosanguineous, and had not allowed for a clear view of the wound base. The wound had been considered unstageable at that time. -1/25/18; The blister remained intact and fluid filled. IDT reviewed the resident's recent skin change. Staff were encouraged to float the resident's heels. -1/26/18; No changes were noted to the wound. [MEDICATION NAME] was clean and intact, and the skin underneath appears intact. -1/27/18; No changes were noted to the wound. -1/29/18; The left heel was purple. A new [MEDICATION NAME] was applied. -1/31/18; The left heel blister remained intact. Current measurements were 5.0 x 5.0 cm. Unable to see wound base secondary to fluid. Appeared to be more fluid filled. The skin was very taut. The area remained unstageable, covered with a suresite for protection. -2/2/18; The blister to the left heel was no longer intact. Fluid had drained and the top layer of skin had dried over the blistered area. The area was cleansed and [MEDICATION NAME] was applied. -2/6/18; The wound to the left heel was bleeding when the resident's sock was removed. -2/7/18; A skin assessment was performed. The left heel fluid filled blister remained. The top blister drained revealing a second blister underneath. The blister had also drained leaving a hard necrotic shell. Measurements were 2.0 x 2.7 cm. The area remained unstageable. -2/10/18; Pressure ulcer to left heel -2/12/18; The wound to left heel was maroon in color. -2/13/18; The wound to the left heel was maroon in color. [MEDICATION NAME] was applied. -2/15/18; Left heel blister remained. -2/16/18; The wound to the left heel is black and hard. Continued with [MEDICATION NAME] treatment. No drainage was noted. -2/17/18; The left heel was black in color. [MEDICATION NAME] was applied. -2/18/18; A padded boot was on the left foot. The left heel was hard and black. [MEDICATION NAME] was applied. -2/20/18; The left heel was black and hard. -2/21/18; The wound to the left heel was black. [MEDICATION NAME] was applied. -2/22/18; The wound to the left heel was black. [MEDICATION NAME] was applied. -2/26/18; The left heel continued to be black. [MEDICATION NAME] was applied. Review of resident #283's care plan showed the following for skin breakdown: -1/13/18; Braden Assessment per policy, evaluate hip wound area daily including surrounding tissue for the presence or absence of drainage/infection and/or new wound pain and report to MD as indicated, monitor for verbal and nonverbal signs of pain related to wound or wound treatment and medicate as ordered, monitor skin for signs/symptoms of skin breakdown, observe skin condition with ADL care daily, obtain dietician consult as needed/ordered, provide wound treatment as ordered, and weekly skin assessment. -1/14/18; Encourage resident to consume all fluids during meals, and skin check per policy. -1/25/18; Heel pro to left heel, and off-loading of heels. Review of resident #283's care plan failed to show, prior to 1/25/18, a focus area with goals and interventions to prevent a pressure ulcer from forming on the resident's heels.",2020-09-01
168,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2018-05-03,688,D,0,1,OUUG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide ordered PROM to prevent further decline in the resident's range of motion for 1 (#77) of 42 sampled residents. Findings include: During an observation on 4/30/18 at 11:00 a.m., resident #77 was lying in his bed on his back. His right hand was partially contracted shut; he did not have an assistive device in his hand to prevent further contracture. During an observation on 4/30/18 at 3:30 p.m., resident #77 was lying in bed with a rolled washcloth in his right hand. During an interview on 4/30/18 at 3:30 p.m., resident #77 shook his head no when asked if he received exercises for his mobility. Review of resident #77's Medication Administration Record, [REDACTED]. evening shift every Mon, Wed, Fri, Sat as resident allows. (sic) Review of resident #77's Annual MDS, with an ARD of 3/14/18, showed the resident was totally dependent on two staff for bed mobility, transfers, dressing, and physical hygiene. The resident's MDS showed a decrease in the resident's functional capabilities as compared to the resident's Quarterly MDS, with an ARD of 12/14/17, which showed the resident was an extensive one person assist with resident involvement for bed mobility, transfers, dressing, and physical hygiene. Review of resident #77's Care Plan with an initiation date of 11/16/17, showed a focus of, Restorative Range of Motion: PROM to BUE and BLE on all planes of motion to be done once a day for at least 3-4 week. The Goal was to prevent contractures and maintain skin integrity. The interventions were as follows, Every night shift every Mon, Wed, Fri, Sat as resident allows. For passive ROM, move joint slowly and gently. Never forcing past resistance. Avoid fast movements or stretching. (sic) A review of the provided PROM for resident #77, from 4/19/18 to 5/2/18, showed the resident received five minutes of PROM on 4/30/18. No additional PROM was provided for the resident. During an interview on 5/2/18 at 11:20 a.m., staff member D stated the resident was to receive PROM for his [MEDICAL CONDITION]. She stated he should also have a brace for his right hand so it did not contract. She stated she was not sure he was still getting the PROM exercises. The staff member said PROM was important to maintain a resident's range of motion in the joints and to prevent contractures. During an interview on 5/2/18 at 3:58 p.m., staff member F stated he thought resident #77 was only to have PROM to his upper extremity, but not his lower. He stated he did not recall the last time he provided PROM for the resident. During an interview on 5/3/18 at 5:00 p.m., resident #77's son stated he understood the resident would have deconditioning related to his [MEDICAL CONDITION]. He stated he wanted his father to receive ROM exercises so he could do small things for himself, for example, scratch his own nose or grab his own remote. He stated he would want the facility to provide the services to keep him from having further contractures. During an interview on 5/3/18 at 4:00 p.m., staff member A stated it was the expectation that residents receive ROM exercises as ordered to prevent deconditioning and contractures. A review of the facility's policy and procedure titled, Restorative Nursing, showed, (Facility) may provide restorative nursing programs for patients who: are admitted to the center with restorative needs, but are not candidates for formalized rehabilitation therapy; have restorative needs arise during the course of a longer term stay .Restorative programs are coordinated by nursing or in collaboration with rehabilitation and are patient specific based on individual patient needs. A registered nurse or licensed practical nurse must supervise the activities in a restorative nursing program. 2. Develop restorative nursing programs appropriate to the patient's identified needs. 3. Develop specific measurable goals and document goals and intervention on the patient's restorative care plan. 4. Implement the restorative nursing program according to the specifics on the care plan. 5. Evaluate the program monthly if reimbursable or quarterly if non-reimbursable.",2020-09-01
169,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2018-05-03,689,D,0,1,OUUG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a Hoyer lift was in safe working condition before using for resident transfers for 2 (#s 85 and 107) out of 42 sampled residents. Findings include: 1. Resident #85 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #85's Care Plan showed she required assistance from staff with her ADLs. During an observation on 5/2/18 at 8:30 a.m., staff members JJ and KK assisted resident #85 with a Golvo 7007 ES- 200 Hall Hoyer lift transfer from her wheelchair to her bed. Staff members JJ and KK placed the sling on resident #85. Staff member JJ placed the lift in front of the resident while staff member KK stood behind the resident's wheelchair. The lift legs would not open fully when staff member JJ tried. Staff members JJ and KK attached the sling to the Hoyer lift and lifted the resident up out of her wheelchair. Staff member JJ stated she did not know why the lift legs failed to open. The resident was transferred using the lift onto her bed. 2. Resident #107 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #107's care plan showed she required extensive assistance with her ADLs. During an observation and interview on 5/2/18 at 10:48 a.m., staff members FF and I assisted resident #107 with a Golvo 7007 ES- 200 Hall Hoyer lift transfer from her bed to her wheelchair. Staff members FF and I applied the lift sling to the resident and attached it to the lift and lifted the resident off of the bed. Staff members FF and I positioned the lift in front of the wheelchair and the legs on the lift failed to open to clear the wheelchair. Staff members FF and I pulled the resident over the wheelchair and lowered her into the wheelchair by tipping the wheelchair slightly forward to accommodate the legs of the lift not opening. The resident was lowered into her wheelchair. Staff members FF and I stated they did not know why the lift legs failed to open. Staff member I stated she would inform maintenance that it needed to be repaired. Review of the facility policy titled Resident Lift Maintenance Process showed, If at any time a lift is found to not be working properly, the nursing staff fills out a work request form and contacts the maintenance department .",2020-09-01
170,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2018-05-03,741,E,0,1,OUUG11,"Based on interview, observation, and record review, the facility failed to ensure direct care staffing was sufficient to provide care for residents of the 300 Wing including 5 (#s 16, 40, 53, 71, and 109) of 51 sampled and supplemental residents and potentially affecting every resident of that Wing. Findings include: During observations of the 300 Wing, interviews with the residents, and record review of MDS information on 4/30/18 and 5/1/18, the 300 Wing of the facility was found to be a long term care wing with 25 rooms and 24 residents. It was staffed with one LPN and two CNA's. During an interview on 4/30/18 at 10:51 a.m., resident #109 stated that the residents need the facility to schedule more CNA coverage for the 300 Wing. Resident #109 said that there was sometimes only one CNA working on the 300 Wing. Resident #109 stated that she feels that one CNA for approximately 15 to 30 residents is not sufficient. Resident #109 said that it sometimes takes 25 minutes to get any response to a call light. Resident #109 stated that the staffing is lower on the days following the staff's payday due to call outs. Resident #109 was concerned about staff burnout from having to cover shifts and from low staffing coverage in general. During an interview on 4/30/18 at 11:08 a.m., resident #16 stated that they need more CNAs. Resident #16 stated that the wing needs three or four CNAs and they are assigned only two. Resident #16 stated that call lights often take 20 to 30 minutes to get answered. Resident #16 attributed the delayed response to insufficient staffing. Resident #16 stated that many CNA positions were empty and the facility should fill those positions. During an interview on 4/30/18 at 11:43 a.m., resident #40 stated that there are usually two CNAs working per shift on the 300 Wing, where resident #40 resides. Resident #40 stated two CNAs is not nearly enough to provide proper care to the residents of 300 Wing. Resident #40 stated that though residents are scheduled for two baths or showers per week, it sometimes does not happen due to only having two CNAs, and no shower aide, working. Resident #40 stated that the 300 Wing had been staffed with four or five CNAs previously, but now was staffed with only two CNAs. Resident #40 stated that the staffing is often even lower, due to call offs, during the weekends after payday. During an interview on 4/30/18 at 3:11 p.m., resident #53 stated that the staff are often not answering call lights quickly. During an interview on 5/1/18 at 9:07 a.m., resident #71 stated that there are not enough CNAs scheduled for the 300 Wing. Resident #71 stated that many of the residents have a two person lift requirement. She said that when residents need to use the commode, it was often difficult to get both CNAs to the room in a timely manner due to the second CNA often being busy working in another resident's room or when providing showers. Resident #71 stated that residents, including herself, are often incontinent of bowel due to the delay in getting a second CNA to properly perform the two person lift. Resident #71 stated that the current CNAs work their butts off but they have been short staffed and could only be in one place at any given time. During an observation on 5/2/18 at 11:10 a.m., resident #16's call light became activated. Staff responded to resident #16's room at 11:34 a.m., a 24 minute response time. During an interview on 5/3/18 at 9:24 a.m., resident #16 stated that he remembered the delayed call light response from 5/2/18 at 11:10 a.m. Resident #16 stated that similar delays were common and he was sometimes incontinent due to the delayed call light responses but he was not incontinent due to the delayed call light response on 5/2/18 at 11:10 a.m. During an observation on 5/3/18 at 9:04 a.m., resident #40's call light was activated. Staff entered resident #40's room at 9:24 a.m., a 20 minute response time. During an interview on 5/3/18 at 9:34 a.m., resident #40 stated that she had been waiting on the commode for assistance between call light activation and call light response. Resident #40 stated that the delayed response was common and that the delays resulted in a loss of dignity. Resident #40 said that she often experienced frustration and anger accompanying her loss of dignity. Resident #40 stated that the CNAs worked hard but there were simply not enough of them scheduled. Resident #40 stated that staff was supposed to use an all-hands-on-deck approach to call light response as a result of a previous survey but resident #40 did not believe that was happening. During an interview on 5/3/18 at 8:47 a.m., staff member Y stated that the 300 Wing does not have enough staff to properly care for residents. Staff member Y said that residents are occasionally incontinent due to the delayed response to call lights. Staff member Y said that the delayed response to call lights was due to not enough staff being scheduled.",2020-09-01
171,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2018-05-03,758,D,0,1,OUUG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an adequate indication of use for an antipsychotic for 1 (#39) of 42 sampled residents. Findings include: During an observation on 5/1/18 at 10:00 a.m., resident #39 was seated at a table, in his wheel chair, with his head down and his eyes closed. No behaviors were observed. During an observation on 5/2/18 at 8:15 a.m., during the morning meal, resident #39 was seated at a table with his head down and eyes closed. Staff had to wake the resident up multiple times during the meal. During an observation on 5/2/18 at 4:18 p.m., resident #39 was observed sleeping in his bed. During an interview on 5/2/18 at 11:08 a.m., staff member Z stated resident #39 exhibits the following behaviors: sexual comments, punching, grabbing, and yelling at others. During an interview on 5/3/18 at 8:02 a.m., staff member AA stated resident #39 received an antipsychotic for behaviors. During an interview on 5/3/18 at 1:40 p.m., staff member A stated the facility had been working to educate the clinicians on appropriate [DIAGNOSES REDACTED]. She stated they have been working on reducing the use of [MEDICAL CONDITION], however the process of educating the clinicians was ongoing. Review of resident #39's (MONTH) (YEAR) Physician order [REDACTED]. Review of resident #39's Behavior Monitoring sheets for April, (YEAR) showed the resident was being monitored for behaviors including physical aggressiveness such as hitting, kicking, grabbing, pinching, scratching, biting, punching, and refusal of cares. The resident's documentation showed no behaviors were exhibited for physical aggressiveness, or refusal of cares. The Behavior Monitoring sheets showed some behaviors including screaming, cursing, and disruptive noises. Review of resident #39's Pharmacy Consultation Report, dated 1/24/18, showed a GDR was declined by the resident's physician due to behaviors.",2020-09-01
172,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2018-05-03,761,D,0,1,OUUG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the facility failed to ensure medications in the central supply storage area were not expired. These failures had the potential to affect all the residents receiving over the counter medications from the facility. Findings include: During an observation on 5/2/18 at 9:45 a.m. of the central supply area for storing over the counter medications, the following expired medications were observed: One bottle of Senna syrup 8 oz, with an expiration date of 2/18; One bottle of liquid pain relief [MEDICATION NAME] 8 oz, with an expiration date of 3/18; and Two bottles of children's [MEDICATION NAME] 4 oz, with an expiration date of 2/18. During an interview on 5/2/18 at 9:45 a.m., staff member N stated when an order comes in, the staff rotate the new medications to the back. Staff member N stated they check the medication supply once a month for expired medications. She stated she is filling in for central supply as the normal staff member was off for a short time. Staff member N destroyed the expired medications. The facility policy titled House Supplied (Floor Stock) Medications included to inspect the medication dates monthly to remove expired medications.",2020-09-01
173,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2018-05-03,804,E,0,1,OUUG11,"Based on observation and interview, the facility failed to ensure that food and drink was served at a safe and appetizing temperature, potentially affecting all residents that eat at the facility. Findings include: During an interview on 4/30/18 at 10:49 a.m., resident #109 stated food that should be hot has been served cold. During an interview on 4/30/18 at 11:40 a.m., resident #40 stated that she thinks there are not enough staff members and food often takes 15 minutes or more to be distributed to the residents. During an interview on 5/1/18 at 8:49 a.m., resident #46 stated that food that should be served hot has often been served cold. During an interview on 5/1/18 at 9:09 a.m., resident #71 stated that hot food has been routinely served cold. Resident #71 stated that only a few times was the food warm enough to be considered lukewarm. During an interview on 5/1/18 at 3:57 p.m., resident #18 stated that hot food was served hot only some of the time. Resident #18 stated that cooked vegetables are not served hot. Resident #18 stated that the problems of food temperature and quality of food are worse on the weekends. During an observation on 4/30/18 at 12:19 p.m., resident #23's hot food was served at 111 degrees. During an observation of the kitchen and dining on 5/2/18 at 8:00 a.m., a test tray was ordered to be delivered with the 600 trays. At 8:10 a.m., when the 600 Wing dining area residents had been served but the residents eating in their rooms had not yet been served, the sample tray was tested for temperature. The test tray's oatmeal recorded having on internal temperature of 114 degrees Fahrenheit. The eggs were 110 degrees. The toast was 109 degrees. The milk was 55 degrees.",2020-09-01
174,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2018-05-03,812,E,0,1,OUUG11,"Based on observation, interview, and record review, the facility failed to ensure that foods were held at safe temperatures to reduce the likelihood of food-borne illness and failed to maintain a clean and sanitary kitchen to reduce the likelihood of contamination of food, potentially affecting all residents who eat in the facility. Findings include: 1. During an observation and record review on 4/30/18 at 9:55 a.m., the 4/29/18 supper temperature sheet and the 4/30/18 breakfast temperature sheet were blank. The cook later filled out the 4/30/18 breakfast temperature sheet. During an observation on 4/30/18 at 11:57 a.m., lettuce salad to be served to residents was held at 58 degrees, measured via infrared thermometer. During an observation and interview on 4/30/18 at 12:06 p.m., milk cartons in vertical coolers were recorded at 46 degrees. The cooler displayed a digital reading/setting of 39 degrees but the internal temperature was actually 46 degrees. No thermometer was present inside of the cooler to independently measure the internal temperature. Staff member X stated that she thought that the milk cooler should be at approximately 30 degrees. During an observation on 5/2/18 at 7:43 a.m., scrambled eggs were held at 116 degrees on the steam table. During an interview on 5/3/18 at 8:42 a.m., staff member W stated that meats should be cooked to an internal temperature of 165 degrees and should be served at 165 degrees. Staff member W stated that cold items should be at or below 41 degrees and should be served at or below 41 degrees. 2. During an observation on 4/30/18 at 9:26 a.m., staff member W was working in the kitchen while not wearing a hat or hairnet. During an observation on 4/30/18 at 9:30 a.m., a beverage cup, approximately 75% full, with no lid, was on the edge of a shelf above the clean dishes processing area (where the clean dishes are taken out of the dishwasher). During an observation on 4/30/18 at 9:46 a.m., staff member BB had a large quantity of hair, appearing to be animal hair, covering the back of her shirt. During an interview and observation on 4/30/18 at 9:42 a.m., staff member CC stated that the cleaning schedule was supposed to be posted on the bulletin board at the back of the kitchen. Staff member CC attempted to locate the cleaning schedule but could not do so. Staff member X stated that cleaning schedules are normally posted on the bulletin board at the back of the kitchen. Staff member X was unable to locate the current cleaning schedules. Staff member X stated that some of those things had not been getting done lately due to the position of Dietary Director being vacant. During a record review of the weekly and monthly cleaning schedules, no monthly cleaning schedule sheet for either (MONTH) or (MONTH) was located. Of the previous 14 weekly schedules, from 1/16/18 through 4/23/18, only one, 2/17/18 - 2/24/18, could be located. During an interview on 4/30/18 at 9:53 a.m., staff member X stated that she was unaware of where any of the missing pages might be and was unsure if they had been posted or completed. During an observation on 4/30/18 at 9:25 a.m., the electric can opener with a rectangular housing had grime on the housing, near the cutting blade and under the handle. The entire electric can opener was observed on top of a table where food was being prepared. During an observation on 5/2/18 at 7:39 a.m., the electric can opener with the rectangular housing had the same food material on the top of the housing, near the cutting blade and under the handle. The table, upon which the can opener was positioned, was observed being utilized for food preparation by the kitchen staff.",2020-09-01
175,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2018-05-03,880,E,0,1,OUUG11,"Based on observation, record review, and interview, the facility failed to ensure staff changed gloves when moving from a dirty task to a clean task during the provision of ADL care and dressing changes for 4 (#s 77, 78, 85, and 107) of 42 sampled residents; and failed to handle and transport linens in a manner as to prevent the spread of infection to other residents residing at the facility. Findings include: 1. During an observation on 4/30/18 at 12:14 p.m., staff member P walked down the hall to the soiled linen room with a bag of soiled linen. Staff member P had gloves on and tried to open the door with her gloved hands. Staff member A observed this from the dining room and motioned to staff member P to remove her gloves. Staff member P removed her gloves, opened the door, and placed the dirty linen bag in the room. During an interview on 5/1/18 at 9:20 a.m., staff member R stated clean linen should be placed in a bag to take to a resident's room and dirty linen should be placed in a bag to take to the soiled linen room. During an interview on 5/1/18 at 9:32 a.m., staff member P stated staff should place soiled linen in a bag and take it to the soiled linen room. She stated you should not wear gloves in the hallway and to wash or sanitize your hands after removing gloves. The facility linen handling policy was reviewed. Included in the policy was transport clean linen in covered carts or bags and do not hold contaminated linen and laundry bags close to the body or squeeze them when transporting. 2. During an observation on 5/1/18 at 10:00 a.m., staff member O and staff member Q were observed changing a dressing for resident #78. Staff member O had arranged all the supplies needed on the over bed table. Staff member O entered the room and washed her hands and placed a pair of gloves on her hands. Staff member Q was at the bedside with her gloves on talking to resident #78. Staff member O unfastened resident #78's brief and assisted her to roll onto her right side while staff member Q held onto her. Staff member O removed the dressing from the left trochanter, placed it in the garbage, removed her gloves, and washed her hands in the bathroom. Staff member O opened the bathroom door with her hands after washing them, placed new gloves on, cleansed the area on the left trochanter, removed her gloves, washed her hands, and opened the bathroom door with her hands. Staff member O donned new gloves, applied a new dressing to the area, removed her gloves, and washed her hands. Staff member O assisted staff member Q in fastening the brief, and repositioned resident #78 in her bed. Staff member Q failed to keep her hands clean after washing them and prior to donning gloves. 3. During an observation and interview on 5/2/18 at 8:30 a.m., staff members JJ and KK assisted resident #85 with incontinent care. Staff members JJ and KK washed their hands and applied gloves. Staff member JJ removed the resident's brief and provided incontinent care to the front of the resident. Staff member JJ removed her gloves, threw them in the trash, and applied clean gloves without sanitizing between the glove change. Resident #85 was log rolled onto her side and staff member KK provided incontinent care to the resident's buttocks and rectal area. Staff member KK pulled wipes from the clean package with her contaminated gloves. After staff member KK had provided the incontinent care she threw her soiled gloves in the trash and re-gloved with clean gloves. Staff member KK did not sanitize her hands between the glove change. Staff member KK stated she should have removed her gloves and not touched the wipes package with her soiled gloves. Staff member JJ stated she should have washed her hands between glove changes or used sanitizer. 4. During an observation and interview on 5/2/18 at 10:48 a.m., staff members FF and I assisted resident #107 with incontinent care. Staff members FF and I washed their hands and applied clean gloves. Staff members FF and I provided incontinent care to resident #107. Staff member I cleansed the resident's front perineal area then log rolled the resident onto her side. Staff member FF cleansed the resident's buttocks and rectal area. Staff member FF grabbed a clean brief with the same gloves she used to provide incontinent care. Staff members FF and I log rolled, and touched the resident's clean gown with the soiled gloves, staff member FF touched the dirty brief and used wipes, and the resident's leg. Staff members FF and I then removed their soiled gloves and washed their hands. Staff members FF and I stated after they provided incontinent care to the resident they should have removed their gloves and washed their hands after a dirty procedure. 5. During an observation on 5/2/18 at 9:05 a.m., staff member D cleaned resident #77 of a BM. With gloved hands, the staff member wiped the resident with a wet wipe and threw the wet wipe away, then removed another wet wipe from the wet wipe package, and repeated this process for several swipes until the resident was clear of BM. When staff member D was done cleaning the resident, she did not remove her gloves or wash her hands. The staff member replaced the resident's clean brief, and rolled the resident back onto his back. She then pulled down the resident's hospital gown, and pulled up the bed linens. The staff member then put a rolled washcloth into the resident's right hand. The staff member then removed her dirty gloves and washed her hands. During an interview on 5/2/18 at 9:30 a.m., staff member D stated she did not change her gloves or wash her hands after assisting the resident with his BM. She stated she should have removed her gloves and washed her hands before assisting the resident with any further clean care. During an interview on 5/2/18 at 11:30 a.m., staff member A stated it was the expectation for staff to wash their hands between clean and dirty care. The facility policy for hand hygiene was reviewed. Included in the policy was perform hand hygiene before patient care, before an aseptic procedure, after any contact with blood or other body fluids, even if gloves are worn, after patient care, and after contact with a patient's environment.",2020-09-01
176,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2019-05-30,584,E,0,1,FRDK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure housekeeping and maintenance services were provided to maintain clean and sanitary rooms for 4 (#s 19 and 337) of 38 sampled and supplemental residents, and resident rooms #s 100, 117, 120, 121, 123, 124, 125, 126, 211, 214, 222, and 227; and failed to provide a clean and sanitary environment in the Horseshoe dining area, which had the potential to affect residents who resided on or frequented the 100 or 200 hallways, or the Horseshoe diningroom. Findings include: During the initial walk through of the facility on 5/28/19 at 11:55 a.m., the floors through the hallways on halls 100 and 200 were scattered with brown, dried spills. Significant grime build-up was noted on the floor trimming throughout the hallways, particularly surrounding the blue trim on the door frames of residents' rooms. The floors in residents' rooms were dirty with dried spills and food debris. room [ROOM NUMBER], bed A, had dried food and spills on the bedside table. During an interview on 5/29/19 at 10:06 a.m., resident #19 stated that on one occasion, housekeeping did not clean my room for ten days. Resident #19 also stated there was a large fecal stain on his bathroom floor, which was removed five days after he had discovered it. Resident #19 explained he had filed a grievance, and the facility responded by cleaning his room regularly; however, more recently, the facility had not been cleaning his room as often. During an observation on 5/30/19 at 7:35 a.m., the handwashing station had brown stains down the front of the white skirting. There was a brown scummy build-up around the trim on the upper back splash. Pink drips and splatters were also scattered around the upper back splash. Paint was chipping and peeling and was scattered on the floor near the hand washing station on the 100 and 200 halls. The walls throughout the 100 and 200 halls were scuffed with black marks, dried spills, and chipping paint. The floor trim was caked with brown, dried liquid near the beverage station in the dining hall. The beverage station was stained with circular, pink stains, and had dried brown and pink drips on the sides of the beverage station. The inside of the drawers of the beverage station, where clean straws, cups, and condiment packets were stored, had dried brown spots and spills in and on them. The conditions remained the same and cleanliness remained unchanged on the 100 and 200 halls throughout the survey. During an observation on 5/30/19 at 7:42 a.m., in the dining area in between the 100 and 200 halls, the floor in between the hand washing station and dining tables had six circular, brown stains ranging from two to four inches in diameter. The floor next to the hand washing station had one large black stain that was sticky when walked on. During an observation and interview on 5/30/19 at 7:45 a.m., staff member C stated, Sometimes it is housekeeping, sometimes it is us (staff), that clean the beverage station. The night shift (staff), is supposed to do the cleaning, or it should be cleaned first thing in the morning. Staff member C was observed to place a tray of clean plastic drink cups on the soiled countertop of the beverage station before cleaning the counter, then staff member C removed the tray of clean cups and began wiping down the countertop. During an interview on 5/30/19 at 7:48 a.m., staff member F stated, Right now we don't have a floor guy. My floor guy quit last week; no notice. The floors, walls, trim, and every resident room, are supposed to be cleaned daily. We clean all horizontal surfaces, blinds, empty trash, clean the resident restrooms, and mop our way out of the rooms. (The housekeeping department) is responsible for cleaning the beverage and hand washing stations. The maintenance department takes care of the chipping paint. During an observation on 5/30/19 at 7:52 a.m., the paint in the doorways on the 100 and 200 halls of the residents' rooms was chipped off. The plastic moldings around resident rooms 100, 120, 121, 123, 124, 125, 126, 222, and 227, were cracked near the floor. The floor at the nursing station on the 100 hall was dark brown in areas from dirt and spills, and was littered with small pieces of paper, rubber bands, and paperclips. There was a dried glob of orange-pink colored crusted debris on the shred bin in the nursing station on the 100 hall. All the hallway floors on the 100 and 200 halls were scattered with bits of dried food, dried spills. There was a large, dried, brown spill on the wall next to room [ROOM NUMBER]. The walls around light switches were dirty with dark spots. The drinking fountain near the pantry door, across from the nursing station on the 200 hall, was crusted white and green with mineralization around the tip and button. The dining room floor had bits of dried food and drink spills scattered throughout. The seats of the dining chairs had dried bits of food and drink spills on them. During an observation on 5/30/19 at 8:08 a.m., room [ROOM NUMBER] had dried, brown splatters to the left of the light bar on the wall. room [ROOM NUMBER] had a dried, dark brown-black spill on the floor in front of the night stand with the resident's television on it. Resident #337's wheel chair seat was covered in crumbs and food debris. There were dried food bits scattered on the floor resident #337's room. The sink in the bathroom of room [ROOM NUMBER] had hard water stains around the handles. During an interview on 5/30/19 at 8:58 a.m., staff member D stated, There is always room for improvement with cleanliness on the unit. The team does very well; I keep up with them. We also have residents who have their own style of living (related to cleanliness and the room). During an interview on 5/30/19 at 10:41 a.m., staff member I stated, I scan the building for cleanliness. I do think the cleanliness of the facility is contributing to infection control. I try to make sure that contracted staff are aware of educations and protocols regarding infection control. Staff member I stated, (Facility management staff) has those concerns about the lack of maintaining the cleanliness of the building. A week goes by and I have to finally do it myself. I asked them (housekeeping staff) to come in and clean the education room, but I usually end up taking out the garbage.",2020-09-01
177,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2019-05-30,604,D,0,1,FRDK11,"**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 adequately assessed for restraints after her air mattress was moved and replaced, to ensure the mattress was not restraining the resident, and the resident had restricted movement due to the mattress, and had reported the concern to the facility, but the mattress was not addressed by the facilty, for 1 (#4) resident of 36 sampled residents. Findings include: During an observation on 5/28/19 at 1:28 p.m., resident #4 had a trapeze bar at the head of the bed, positioned in the center of the bed, and bedrails on both sides of the bed. Resident #4 was observed to be lying in bed and had double lower extremity amputations. During a resident interview on 5/29/19 at 2:08 p.m., resident #4 stated the siderails and trapeze were for mobility, but I hate the mattress since I moved rooms a few days ago. Resident #4 explained there was a hump on the mattress on each side of her, so it was hard to use the siderails to position herself and less room to lay in bed comfortably. It was found the mattress was restricting her movement. Resident #4 stated the mattress sides were not like that prior to her moving. During a resident interview on 5/30/19 at 8:30 a.m., resident #4 stated she had told the day nurse and a facility manager three days ago about the mattress being different and restricting her movement, but nothing had changed with the mattress. During an interview on 5/30/19 at 8:49 a.m., staff member R stated the air mattress was the same air mattress the resident had before. During an interview on 5/30/19 at 9:07 a.m., staff member S stated she was not aware the resident did not want the raised sides on the air mattress or why the raised sides were not up before the move, and maintenance would automatically inflate raised sides when placing mattresses in rooms, per the manufacturer guidelines. Staff member S stated the staff would not have assessed, or checked the bed, or the raised side inflation as that was how the beds were set up. During an interview on 5/30/19 at 9:15 a.m., staff member Q stated maintenance only processed and carried out work orders when they were received. Resident #4 had switched rooms and maintenance staff had switched out the mattress because the hoses were out on the previous one. Review of resident #4's care plan, last updated 2/22/19, showed the use of a trapeze and side rails for mobility. There was no documentation on the care plan pertaining to the air mattress. Review of the current restrictive device consent for resident #4 showed it was only for bed rails and trapeze dated 8/30/17. No other updated consent documentation was located to address the mattress. Review of resident #4's current physician orders did not show orders for the use of side rails or trapeze. There was no other documentation found for an assessment or an updated consent for the low air loss mattress. Record review of resident #4's Quarterly MDS, with an ARD date of 2/12/19, showed bed mobility self-performance as extensive assistance, and support as one-person physical assist. A review of the facility's policy titled, Guideline for Selecting a Low Air Loss (LAL) Mattress, showed the following verbiage: -Always review manufacturer's guidelines for instructions on settings, maintenance, and cleaning; -most require an initial and weekly 'hand-check' for settings; -most require daily check of setting panel; -Low Air Loss mattresses are used as a treatment surface; -Important: To decrease risk of falls and entrapment, the CNE (Director of Nursing) reviews and approves all LAL use. Review of facility policy Bed Rails showed 'The Bed Rail Evaluation' will be completed upon admission, re-admission, change in bed or mattress, and with significant change in condition. Review of facility policy Restraints: Use of showed physical restraint is defined as any manual method, physical or mechanical device, equipment, or material that meets all the following criteria: -Is attached or adjacent to the patient's body, -Cannot be removed easily by the patient, and -Restricts the patient's freedom of movement or normal access to his/her body. There must be documentation identifying the medical symptom being treated and an order for [REDACTED]. No documentation was located to show that after resident #4 moved and the mattress was changed, that the resident was unable to move freely or had restriction of movement.",2020-09-01
178,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2019-05-30,656,D,0,1,FRDK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement fall prevention interventions during transfers, as noted in the individualized care plan, to ensure the resident was wearing shoes, and the 1/4 bedrails were up on the resident's bed for 1 (#57) of 36 sampled residents. Findings include: During an observation on 5/30/19 at 9:12 a.m., resident #57 was observed in a wheelchair in his room, positioned beside his bed. The resident was attempting to self transfer from the wheelchair to his bed. Resident #57 was not wearing shoes and was wearing white crew socks on both feet without non-skid surfaces on the bottoms of the socks. Staff member M was observed in the dining room outside the resident's room and noticed the resident attempting to self transfer from the wheelchair to his bed. Staff member M stated loudly to resident, No (resident #57), I will help you. The resident loudly responded What? in response to staff member M. Staff member M ran into the resident's room just as the resident self transferred from his wheelchair to his bed and lost balance and fell on to his bed. Staff member M moved the resident's wheelchair away from the bed and assisted the resident with positioning in his bed. The resident's bed was set at the low position with no siderails up on the bed. Staff member M did not remind the resident to use the call light when attempting to ambulate or transfer or address the resident's use of shoes for safety. During an interview on 5/30/19 at 9:15 a.m., staff member M stated resident #57's bedside mat was up against the wall, at the foot of the resident's bed, when she had started her shift earlier that morning. Staff member M also stated she was just certified that day as a CNA, and had been a unit assistant for one month and a nursing assistant for three months. Review of resident #57's current comprehensive care plan, dated 4/4/19, showed interventions not utilized, such as: - 1/4 siderails to enable bed mobility and assist with transfers for focus on resident's required assistance with ADL's due to history of [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder - watch transfers and offer assistance as allowed - encouraging resident #57 to wear shoes - reminding resident to use call light when attempting to ambulate or transfer for focus on resident's risk for unavoidable falls",2020-09-01
179,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2019-05-30,686,G,0,1,FRDK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide services and modify the care plan with appropriate interventions to prevent pressure areas for 2 (#s 20 and 337) of 36 sampled residents. Resident #20 developed a stage II pressure area to her coccyx and resident #337 developed a stage II pressure ulcer to left heel, was not always cooperative with care, and the resident's care plan was not up to date with wound interventions identified or in place. Findings include: 1. During an observation on 5/30/19 at 9:10 a.m., resident #337 was laying in his bed on his back, and his heels were not bridged off the bed. A blue foam heel cushion was noted at the foot of resident #337's bed, on the floor. During an observation and interview on 5/30/19 at 9:15 a.m., staff member [NAME] and D performed wound care and dressing changes to resident #337's left lower extremity. Resident #337 had three open wounds, one wound to the anterior shin, one wound to the lateral shin, and one large wound on the left heel. Staff member [NAME] stated the wound looked a little bit worse. Resident #337 received the anterior shin wound when he bumped his shin on the bed. The wound bed was very light pink and quite deep. The second wound on resident #337's anterior shin was caused by a blister that opened. The large pressure area to the left heel was macerated at the wound edges and had a large area of black eschar covering the wound bed. There were two large blisters, which were intact, on the left lateral shin, and a large blister to the posterior calf just above the Achilles tendon. During an interview on 5/30/19 at 8:56 a.m., staff member D stated resident #337 was non-compliant with wearing his Rooke boot (used for pressure relief), and stated, I have attempted to educate the resident on the importance of wearing the boot. The Rooke boot is removed during weekly skin checks. Staff member D stated she had not recently seen resident #337's wounds. During an interview on 5/30/19 at 9:20 a.m., staff member [NAME] stated, (Hospital staff) reported the resident was admitted for [MEDICAL CONDITION]. The area to the heel is pressure, yes ma'am. No, I seen him two days ago for wound care. Staff member [NAME] stated, I do worry about the surgical shoe putting additional pressure on the heel wound, but it's far better than his regular shoe. We have tried multiple different protective and supportive footwear for the left foot, but the resident refuses to wear them. Review of resident #337's Risk Management System Form, dated 2/4/19, showed the resident had complaints of pain in the resident's left heel. Staff member [NAME] observed a wound on his left heel. There was a open area to the heel, and the skin surrounding the wound was non-blanchable. During an interview on 5/30/19 at 8:31 a.m., staff member [NAME] stated, I know (facility CNAs) are told about (the wounds), because I tell them when I need (the residents) laid down for dressing changes. Review of resident #337's care plan, dated 5/26/19, did not show the resident currently utilizes a surgical shoe to the left foot as an intervention to prevent further breakdown to the left heel, nor did it reflect to bridge the resident's heels while in bed. 2. During an observation and interview on 5/30/19 at 8:08 a.m., staff members D and [NAME] performed wound care and a dressing change to resident #20's coccyx wound. Staff member [NAME] performed hand hygiene before starting the wound care. Staff member [NAME] stated the pressure ulcer had been present since (MONTH) 2019. Staff member [NAME] stated, I try to get her (treat) at least twice a week; I am only required to see her once a week, but with her I see her more because (the wound) should have been closed by now. I tried a collagen and [MEDICATION NAME] powder into the wound bed and cover with a Hydrogel, but I had trouble getting the mixture right. Staff member [NAME] stated the house-wide standard is to reposition all dependent residents every two hours while in bed. Staff member [NAME] stated, (The order for wound care) should be on the care plan, but I am not allowed to touch the care plans because I have a tendency to delete them. I go right to the MDS office and tell them if there are changes that need to be made on the care plans. Staff member [NAME] stated resident #20 had an air mattress and ROHO cushion in place to help off-load pressure on the coccyx. Resident #20's wound on the coccyx was noted to be healed. The surrounding skin was intact. There was scaring where the wound had been and was light brown at the edges. Regarding future care to ensure the wound remains closed, staff member [NAME] stated, I would keep a Hydrogel dressing on (the pressure ulcer) for about a month with her, and then skin prep after that because she has such fragile skin. I will follow her for another month to make sure the wound stays healed. During an interview on 5/30/19 at 10:16 a.m., staff member [NAME] stated resident #20's pressure ulcer occurred when the facility got the resident a new high back wheel chair for positioning. When facility staff had resident #20 recline in the high back wheel chair, the amount of pressure to resident #20's coccyx area increased. Staff member [NAME] stated the facility did not have a ROHO cushion in place when the pressure area occurred, but resident #20 had a ROHO cushion now. Review of resident #20's care plan, dated 3/7/19, did not show a ROHO cushion as an intervention to prevent further skin breakdown. Review of resident #20's care plan, dated 3/7/19, showed the resident required assistance for ADL care related to: poor cognition, advanced dementia, weakness, impaired mobility, staff to anticipate her needs as she is unable to use the call light related to her cognition. Review of resident #20's Risk Management System Form, dated 1/15/19, showed a small, dark purple area to the crease of the buttocks, which does not blanche. Review of resident #20's Quarterly MDS with an ARD of 1/23/19, showed section G: Functional Status, under bed mobility and transfers, resident #20 was a two-person, extensive assist, therefore positioning assistance was required for pressure relief.",2020-09-01
180,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2019-05-30,689,D,0,1,FRDK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident was wearing shoes, and that the 1/4 side rail was up on the resident's bed, when the resident was transferring from his wheelchair to his bed and the resident lost his balance while transferring and fell to the bed, for 1 (#57) of 36 sampled residents. Findings include: During an observation on 5/30/19 at 9:12 a.m., resident #57 was observed in a wheelchair in his room, positioned beside his bed. The resident was attempting to self transfer from the wheelchair to his bed. Resident #57 was not wearing shoes and was wearing white crew socks on both feet without non-skid surfaces on the bottoms of the socks. Staff member M was observed in the dining room outside the resident's room and noticed the resident attempting to self transfer from the wheelchair to his bed. Staff member M stated loudly to resident, No (resident #57), I will help you. The resident loudly responded What? in response to staff member M. Staff member M ran into the resident's room just as the resident self transferred from his wheelchair to his bed and lost his balance and fell on to his bed. Staff member M moved the resident's wheelchair away from the bed and assisted the resident with positioning in his bed. The resident's bed was set at the low position with no assistive rails or bars on the bed to help the resident with transfers. When in the room, staff member M did not remind the resident to use the call light when attempting to ambulate or transfer or address the resident's use of shoes for safety. During an interview on 5/30/19 at 9:15 a.m., staff member M stated resident #57's bedside mat was up against the wall, at the foot of the resident's bed, when she had started her shift earlier that morning. Staff member M also stated she was just certified that day as a CNA, and had been a unit assistant for one month and a nursing assistant for three months. Review of resident #57's current comprehensive care plan, dated 4/4/19, showed interventions which were either not utilized by staff, or in place at the time of the resident's fall, to the bed. Interventions included: - 1/4 side rails to enable bed mobility and assist with transfers for focus on resident's required assistance with ADL's due to history of [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder - watch transfers and offer assistance as allowed - bed in low position - encouraging resident #57 to wear shoes - reminding resident to use call light when attempting to ambulate or transfer for focus on resident's risk for unavoidable falls",2020-09-01
181,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2019-05-30,801,F,0,1,FRDK11,"Based on interview, observation, and record review, the facility failed to ensure the Director of Dietary Services completed a certification program approved by a national certifying body; or had an associate's or higher degree in food service management or in hospitality from an accredited institution of higher learning. The failure of the dietary manager to possess the necessary education would affect any resident receiving meals or services from the dietary department, and the facility dietitian was not aware of the required oversight the dietitian was to be providing for the kitchen, to ensure the department was maintained adequately. Findings include: During the initial tour and observation of the kitchen on 5/28/19 at 3:30 p.m., concerns with kitchen equipment, staff practices, kitchen sanitation, and improper food storage were identified (See F 812 for more information). During an interview on 5/29/19 at 10:48 a.m., staff member B stated he was not certified or have an associates degree in food service. He stated he had no past training as a director of dining services and only had on-the-job training since starting his position about a year ago. The staff member stated neither the administrator nor the dietitian had told him he needed to be certified, and he had not signed up for any certified dietary manager course. During an interview on 5/30/19 at 10:10 a.m., staff member A stated he was unsure if his job duties included overseeing the dietary manager or the kitchen portion of the dietary department. He was in the kitchen at least once a day when he was in the facility but did no monitor the cleaning of the kitchen or audit for cleanliness. The staff member did not know if the dietary manager was a certified dietary manager. He stated he would have to check for the dietician position's job duties, as he was not sure of all his duties. Review of the Director of Dining Services job description, with a revision date of 10/21/14, showed the staff member was responsible for adhering to sanitary and food service safety regulations, governing the handling and serving of food, and maintaining the department in regulatory compliance. The staff member would participate in monitoring and auditing for quality assurance and improvement processes, as required. The job description did not show that the staff member holding the position was required to have a certification program approved by a national certifying body; nor had an associate's or higher degree in food service management, nor in hospitality from an accredited institution of higher learning, just completion of high school. Review of the Dietician job description, with a revision date of 5/29/17, showed the dietitian was responsible for other assignments as requested and approved by the administrator, including sanitation audits. During an interview on 5/30/19, at 10:30 a.m., staff member H stated the dietician was to oversee the cleanliness of the kitchen.",2020-09-01
182,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2019-05-30,808,D,0,1,FRDK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents' physician ordered diet was served to 1 (#4) of 36 sampled residents. Findings include: During an observation and interview in the kitchen during meal service, on 5/28/19 at 5:52 p.m., it was identified by the surveyor that there were no alternatives for the renal diet and fresh fruit was not available for the renal diet dessert. Staff member P stated resident #4 did not have any current renal diet orders. During an observation and interview in the kitchen during meal service, on 5/28/19 at 5:55 p.m., staff member B stated the facility did have residents on renal diets. When asked what alternatives to the dessert were offered for renal diets, staff member B then went into the refrigerator and retrieved fruit cups for the renal dessert. When asked for how staff know what consists of a renal diet, a copy of menu with the renal food options was provided, but portioning was not included for what was to be served. During an interview on 5/29/19 at 2:08 p.m., resident #4 stated when food was delivered it was something she could not have like bananas or orange juice. Resident #4 stated that she is a diabetic and has is [MEDICAL TREATMENT] dependent, with end stage [MEDICAL CONDITION] with high potassium labs. Review of resident #4's diet order, dated 5/15/19, showed a liberalized renal diet with regular texture, related to End Stage [MEDICAL CONDITION]. During an interview on 5/29/19 at 4:33 p.m., staff member A stated resident #4 had recently changed to a renal diet to improve her health. During an interview and observation on 5/30/19 at 8:22 a.m., resident #4 stated, This is the breakfast I am supposed to get on [MEDICAL TREATMENT] days. The resident stated she preferred fresh fruit, cold cereal, and toast for breakfast for off days, but this was not served. They keep giving me things I am not supposed to have, like oranges or orange juice and tomatoes. Last night I got chicken with tomatoes all over it. I am not supposed to have that because my potassium is high. They just scraped the tomatoes off and brought it back. Review of resident #4's daily diet printout showed her diet as Liberalized Renal Consistent Carbohydrate and listed dislikes as hot cereal, oranges, spicy food, tomatoes, scrambled eggs, orange juice, and tomato juice. During an interview on 5/30/19 at 9:44 a.m., staff member B stated he had not completed meal audits of diets, preferences, and tray setup for the last few weeks. Staff member B stated there was no set frequency for completing the meal audits. The meal audits were completed when the kitchen received reports of wrong diets or dislikes being served.",2020-09-01
183,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2019-05-30,812,F,0,1,FRDK11,"Based on observation and interview, the facility failed to clean and maintain sanitary conditions in the kitchen, affecting 148 of 149 residents residing at the facility. Findings include: During observation and interview on 5/28/19 at 3:30 p.m., at the initial tour of the kitchen, areas of concern identified included: - The kitchen floor tile, around all the walls, counters, and legs of equipment, had a build up along the border of food crumbs, splatters, and a brown, greasy, caked food. The floor's white tile was stained with food spills, crumbs, and scuffed with black marks throughout the kitchen. - A cardboard box, partially filled with frozen bread dough, was next to the hand sink. The lid was open. Contaminated water droplets were landing into the box of bread, onto the dough, from staff during hand washing at the sink. - A manual can opener, connected to the preparation table was greasy with food crumbs and shavings around the blade and above the blade. - The motor fans, on the back of the convection ovens, had greasy dust, dangling and blowing in the direction of a food preparation area. - Splattered, burnt on food particles, were stuck to the back wall of the cooking range. - The floor drain, in the walk in refrigerator, had a gooey white substance on the edge of the drain hole. No cover was on the drain. - A large overhead fan, between the three sink and the two sink washing area, was observed blowing in the direction of the convection ovens, where food was taken in and out of. The fan's backside had black, greasy, dust and fuzz blowing from the air flow vents in the kitchen. Above the fan, dark, greasy dust floated with the air flow. - An air exchange vent, on the back wall of the two sink wash area had long, dusty, black, greasy strands of fuzz. The air flow, coming out of the vent, was directed toward the large food preparation table, the convection oven, and the steamer. The steamer door was open, and a pan of broccoli was inside the oven. - During an interview on 5/28/19 at 3:45 p.m., staff member O stated he washed pots and pans in the two sink area. There was no dishwashing sanitizer located at the two sink area. - During an interview on 5/28/19 at 3:56 p.m., staff member N stated the three sink area was to be used for the pots and pans. The staff member pointed down to the three sink wash area and said that was where the sanitizer was for both areas. - A fan was being used in the dish room. The fan guard had dark colored moist dust blowing from the fan blades. The fan was placed in the direction of the clean dishes. The fan was blowing the moist, greasy dust in the direction of the clean dishes. During an observation and interview on 5/29/19 at 11:00 a.m., a plastic cup, with a hole cut in the end, was observed connected to the dirty water pipe, emptying from the dish machine. Water was spraying all over the dish room floor, from the water pipe. Staff member O was in the dish room, washing dishes, trying to walk around the puddle of water, which was swelling on the floor. The staff member stated the dietary supervisor was aware of the leak in the drain from the dish machine. The styrofoam cup was being used to try and stop the water from spraying onto the dish room floor. The floor had one fourth to one half inch of contaminated water on the dish room floor.",2020-09-01
184,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2017-06-20,253,E,1,0,BUF811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to provide housekeeping services to resident rooms for 5 residents out of a facility census of 141 residents, one dining room in the 200 horseshoe unit, and 3 resident hallways in the 300, 400, and 500 units. This deficient practice had the potential to affect most residents in the facility. Findings include: 1. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation on 6/19/17 at 10:00 a.m., staff member C provided perineal care. On the resident's floor was a large area that had a sticky substance with black tire marks from the resident's electric wheel chair. Staff member C stated it had been like that since last night. Staff member C stated some of rooms didn't get touched until the last minute, if at all. During an observation on 6/19/17 from 11:10 a.m. to 11:30 a.m., an observation of the resident rooms and hallways was conducted. Resident #2's floor continued to have a sticky substance with black tire marks from resident #2's electric wheel chair. During an observation on 6/19/17 at 1:15 p.m., the resident #2's floor continued to have a sticky substance with black tire marks from her electric wheel chair. During an observation on 6/19/17 at 4:00 p.m., the middle of the resident #2's room was observed. The area continued to have black tire marks from the electric wheelchair that were lighter in color. 2. During an observation on 6/19/17 from 11:10 a.m. to 11:30 a.m., an observation of the resident rooms and hallways was conducted on the 200, 300, 400, 500, and 600 units. The following was found: -Room 506 had large amounts of debris around the resident's recliner, with most of the debris between the bed and recliner. The debris included popcorn, a white granulated debris, gray debris, white flakes of debris, and food particles. Under the night stand next to the recliner was white flakes of debris. Popcorn was scattered from the recliner towards the doorway to the hall. -Room 507 was observed with white debris under the front of the recliner and to the sides. -In the 500 hallway were black and gray spots in a line throughout the hallway. -The 400 hallway had black wheelchair tracks, and brown/gray/black drop marks. -Room 405 had several wheelchair tracks, food debris, and was sticky when walked on. -[RM #]3 had brown debris, paper scraps, candy wrappers, reddish debris, and the floor was sticky when walked on. The fall mat was observed to have sticky reddish and brown spots on it. -The hallway between rooms 310-325 had several brown/black droplet spots with black tire marks from wheelchairs observed. During an observation on 6/19/17 at 12:30 p.m., room 220 was observed to have brownish red smeared substance on the middle of the floor extending to the bathroom with tire marks from a wheelchair running through it. During an interview on 6/19/17 at 12:45 p.m., staff member [NAME] stated she did not have a weekend floor care person for days or nights. She reported the staff was no longer working there as of the weekend, and she was in the process of advertising to fill the empty positions. Staff member [NAME] stated she had just started working at the facility and was in the process of recruiting and training staff. Staff member [NAME] stated she started a quality control surveillance program this week. She stated she was working on getting cleaning tasks on a schedule. During an observation on 6/19/17 at 1:15 p.m., room 405 was observed. The room continued to have several wheelchair tracks, food particles, and was sticky when walked on. During an observation on 6/19/17 at 4:00 p.m., room 303 continued to have brown debris, paper scraps, candy wrappers, a reddish substance, and the floor was sticky when walked on. The fall mat was observed to still have sticky reddish and brown spots on it. Review of the resident council meeting minutes from (MONTH) (YEAR)-May (YEAR) reflected several reported concerns from resident's wanting housekeeping to clean their rooms on 6/14/17, 5/10/17, 4/12/17, 3/8/17, 11/9/16 and 10/12/16. The resident council minutes did not contain a response from the facility regarding the concerns voiced by the council. During an interview on 6/19/17 at 4:30 p.m., staff member F stated when concerns are brought up during resident council, a discrepancy form was filled out and given to the people who were responsible to address the concern, and to the social service director. Staff member F stated the biggest concern voiced by the residents were the dirty and sticky floors. Staff member F stated it seemed the cleanliness of the building started getting worse when the facility started using a contracted housekeeping service. During a confidential interview, a resident stated she had asked the housekeeping staff to wipe down her bed frame and she was told this was done when they clean the floors. The resident stated her bed frame had not been cleaned since she asked. The resident stated the housekeeping staff did not clean the floors in her room every day. She stated the floors were not cleaned on the weekend. The resident believed the floors were supposed to be cleaned every day. During an interview on 6/20/17 at 8:30 a.m., staff member A stated the resource nurse had a key to the mop rooms for the hours that the housekeeping staff was not in the building. During an observation on 6/20/17 at 9:40 a.m., room 303 continued to have brown debris, paper scraps, candy wrappers, reddish debris, and the floor was sticky when walked on. The fall mat was observed to still have sticky reddish and brown spots on it. The floor had silver candy wrappers from Hershey kisses on it near the doorway, which were not there on the prior observation. During an interview on 6/20/17 at 10:30 a.m., staff member G stated in (MONTH) of (YEAR), or (MONTH) of (YEAR), the complaints were the worst for concerns about room cleanliness. The staff member stated the complaints were given to housekeeping, and the housekeeping staff were monitored while the resident rooms were cleaned to ensure it was done. Staff member G stated things have improved in the last few weeks since the new housekeeping supervisor had started. Staff member G stated the housekeeping staff had not been well managed, and the rooms and floors were not being done because some of the staff were not showing up or working a whole shift, prior to the new manager's arrival. During an observation on 6/20/17 at 12:10 p.m., room 303 continued to have brown debris, paper scraps, candy wrappers, reddish debris, and the floor was sticky when walked on. The fall mat was observed to still have sticky reddish and brown spots on it. During an observation and interview on 6/20/17 at 12:15 p.m., room 506 continued to have large amounts of debris around the resident's recliner, with most of the debris between the bed and recliner. The debris included popcorn, a white granulated substance, gray debris, white flakes of debris, and food particles. Under the night stand, next to the recliner, was white flakes of debris. Popcorn was scattered from the recliner towards the doorway to the hall. Room 507 was observed with white debris under the front of the recliner and to the sides. Between the recliner and the resident's bed was three plastic water mugs, one thermos, an aluminum container with what the resident stated was barbeque sauce and marinara sauce. The resident stated he changed out the condiments every once in a while. The resident stated the housekeeping staff didn't clean his room that day. The resident stated the housekeeping staff sometimes cleaned his room daily or weekly. The resident stated he wanted to have his room cleaned every day. During an observation on 6/20/17 at 1:00 p.m., room 220 continued to have brownish red smeared debris on the floor. The debris was not centered in the middle of the floor, but more scattered with small pieces in the resident's doorway that went into the hallway. During an observation on 6/20/17 at 3:40 p.m., room 303 continued to have brown debris, paper scraps, candy wrappers, reddish debris, and the floor was sticky when walked on. The fall mat was observed to still have sticky reddish and brown spots on it. During an observation and interview on 6/20/17 at 4:15 p.m., staff member A observed rooms 303 and 506 with the surveyor. [RM #]3 continued to have brown debris, paper scraps, candy wrappers, reddish debris, and the floor was sticky when walked on. The fall mat was observed to still have sticky reddish and brown spots on it. Room 506 continued to have large amounts of debris around the resident's recliner, with most of the debris between the bed and recliner. The debris included popcorn, a white granulated substance, gray debris, white flakes of debris, and food particles. Under the night stand next to the recliner was white flakes of debris. Popcorn was scattered from the recliner towards the doorway to the hall. Room 507 was observed with white debris under the front of the recliner and to the sides. Staff member A stated both residents spilled snacks in their room and were resistant to having their rooms cleaned. Review of the resident's care plans for room 303 and 506 did not reflect the resident's refused to have their rooms cleaned. No other documentation was provided by the facility to reflect the resident's in room 303 and 506 resisted having their rooms cleaned or interventions to ensure housekeeping staff would be able to clean their room. During an observation and interview on 6/20/17 at 5:45 p.m., staff member A, and the surveyor observed rooms 303 and 506. Room 506 was cleaned. The resident stated he was happy with the clean floor. The resident stated he would like the staff to clean his floor every day. [RM #]3 was in the process of being cleaned by staff member E. Staff member [NAME] stated the room should have been cleaned that day. Staff member [NAME] had swept a large amount of debris into a pile in the center of the floor. Staff member [NAME] was cleaning the fall mat and stated the housekeeping staff was responsible for cleaning the fall mats. Review of the facility cleaning schedule reflected housekeeping staff started their day at 7:00 a.m. Resident rooms and dining rooms, hallways, and bathrooms were to be cleaned daily. The schedule reflected housekeeping staff would be done with resident rooms by 1:00 p.m. During an interview on 6/20/17 at 1:10 p.m., staff member [NAME] stated she had started a quality control inspection that week and would choose 3 rooms in each resident hall to inspect, weekly. During an observation on 6/19/17 at 11:15 a.m., residents were sitting at their tables in the Horseshoe dining room. The dining room floor had dried smeared coffee, dried smeared green food particles, wrinkled pea like substances, left over pieces of a bread like substance, pepper packets, a plastic cap, wheel chair tire marks, a brown substance with wheel chair tire marks through it, and the counter had fine food granules spread all over the counter, left over oatmeal in a bowl, a carton of white milk, a tray with pink liquid, thickener and an empty glass. Residents that wanted coffee brought their cups to two large insulated containers that sat on a cart and used the lever to dispense their coffee. After their cups were full, they would turn the lever to off and walk away. The coffee would continue to drip from the spout, onto the floor. Also, the garbage can was overflowing with used brown paper towels. During an interview on 6/19/17 at 11:20 a.m., staff member I said that staff usually picked up the big stuff off the floor and housekeeping mopped after each meal. She also said cleaning by housekeeping was better. Staff member I could not tell me who cleaned after the breakfast meal that day.",2020-09-01
185,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2017-06-20,441,E,1,0,BUF811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility staff failed to use gloves properly to prevent the spread of infection, on 6/19/17 and 6/20/17, for 3 (#s 2, 6 and 7) out of 7 sampled residents. Findings include: 1. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation on 6/19/17 at 10:00 a.m., staff member C provided perineal care. The resident had been incontinent of urine. Staff member C washed her hands and applied gloves. Staff member C obtained a wipes package, draw sheet, peri wash spray bottle, and a tube of barrier cream which was placed on the resident's bed. Staff member C lowered the resident's brief in the front and provided perineal care while the resident was in bed. Staff member C pulled another wipe from the wipes package, touching the package with her soiled glove. Staff member C picked up the spray bottle of perineal wash, with her soiled glove, and sprayed the wipe. Staff member C then assisted the resident to roll on her side. Staff member C cleansed the resident's buttocks and perineal area using the same process of touching the wipes package and perineal spray bottle with her soiled gloves. Staff member C picked up the tube of barrier cream and placed some of the cream on her soiled glove. Staff member C applied the barrier cream to the resident's buttocks. Staff member C assisted the resident to roll back onto her back, and applied barrier cream to the resident's abdominal fold and perineal folds with the soiled gloves. Staff member C emptied the trash and removed her gloves. Staff member C washed her hands. 2. During an observation on 6/20/17 at 11:00 a.m., staff member H provided perineal care for resident #6. Staff member H washed her hands and applied gloves. Staff member H obtained a wipes package, and a tube of barrier cream. Staff member H pulled several wipes from the wipes package and placed them on the bed next to the resident for use. Staff member H lowered the resident's soiled brief and used the wipes to cleanse the front perineal area and penis. Staff member H assisted the resident to log roll onto his side and cleansed the resident's buttocks and perineal area. Staff member H grabbed a clean brief, with the soiled gloves and placed the clean brief under the resident. Staff member H assisted the resident to roll onto his back and applied barrier cream to his left abdominal fold. Staff member H lifted the resident's legs and pulled out the soiled brief. Staff member H pulled the clean brief out from under the resident. Staff member H wiped the left buttock, grabbed the barrier cream tube, and applied barrier cream to the left and right groin folds, with the soiled gloves. Staff member H pulled the brief up between the resident's legs and fastened it. Staff member H picked up the wipes package and the barrier cream tube, with the soiled gloves and placed it in the resident's night stand drawer. Staff member H opened the bathroom door and then removed her soiled gloves. Staff member H washed her hands. Staff member H stated she should have taken her gloves off after she was done with the perineal care. 3. During an observation on 6/20/17 at 3:10 p.m., staff member I provided perineal care for resident #7. Staff member I washed her hands and applied gloves. Staff member I obtained a cleansing wipe package and a clean brief. Staff member I lowered the resident's pants and soiled brief. Staff member I pulled a wipe out of the package and used it to cleanse the resident's groin folds and perineal area in the front. Staff member I continued to pull wipes from the package with her soiled gloves. Staff member I log rolled the resident with her soiled gloves. The resident was incontinent of stool. Staff member I cleansed the resident's rectal area and buttocks. Staff member I continued to pull wipes with the soiled gloves from the wipes package. Staff member I removed her soiled gloves and washed her hands. Staff member I said she should take off her gloves between dirty and clean procedures of care. Review of the facility policy and procedure, titled Personal Protective Equipment, reflected under the heading Gloves: .change gloves after contact with each individual resident or after contact with contaminated articles.",2020-09-01
186,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2019-10-03,675,G,1,0,MHIF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to provide services necessary for the resident to maintain the highest practicable physical, mental, and psychosocial well-being, by changing the resident from a powered wheelchair to a manual wheelchair which caused the resident to feel like an invalid, caused him a loss of independence, pain in his spine and back, and pain in his upper extremities when attempting to propel himself in the manual wheelchair for 1 (#1) of 8 sampled residents. Findings include: During an interview on [DATE] at 10:45 a.m., resident #1 stated he had stenosis of his spine which had caused him to lose function of his legs, and he had limited sensation below his waist. It had also caused him to be incontinent of his bowel and bladder. He stated he currently wanted to lose 50 pounds so he could have surgery to have a suprapubic catheter and [MEDICAL CONDITION] placed. He stated he also had arthritis and bone spurs in his shoulders, which made it difficult for him to use his upper extremities without pain. Resident #1 stated he first came to the facility for rehabilitation related to the incontinence of his bladder and bowel. He stated he had since moved from the rehab side of the facility to the long-term care side. The resident stated when he was in the hospital, before admitting to the rehab unit of the facility, the hospital had provided him with a powered wheelchair. He stated that electric wheelchair had fit him well, and it was comfortable. Resident #1 stated after he admitted to the facility, he had to return the electric wheelchair provided to him from the hospital, because of the cost of the wheelchair. He stated the facility then offered him a power wheelchair which was donated by a deceased resident. He stated that power wheelchair did not fit him well, since it was meant for a resident who weighed 300 pounds, and he weighed 350 pounds. He said since the donated power wheelchair did not fit him correctly and was uncomfortable, the facility had rented him a different power wheelchair while he was on the rehab unit. The resident stated he had run out of rehab days, and was not ready to discharge home, so he was admitted on to the long-term care side of the facility. He said when he was transitioned from the rehab unit to the long term care side, the facility took his power wheelchair away and gave him a manual wheelchair. He stated this was due to the cost of the power wheelchair, and that the facility was not being reimbursed as much as when he was on the rehab side of the facility. He said the electric wheelchair allowed him independence and the ability to participate in social activities and bible study. He said having use of the power wheelchair made performing activities of daily living easier as well and he did not have increased pain in his upper extremities or his back. He stated since he was given the manual wheelchair, he could not propel himself in his wheelchair, because it hurt his arms too much. He stated he now must rely on staff to push him everywhere. Resident #1 stated since he has been in the manual wheelchair, he has experienced an increase in discomfort in his spine and back. He has also had an increase in pain in his upper extremities when he must propel himself, even short distances in his room. He stated he had been trapped in the shower room twice because he was not able to open the door by himself. He stated he now must rely on staff to bring him to bible study, or down to the cantina, or to use the bathroom for ADLs. He said there was not always someone available to take him to activities when he wanted to go, and sometimes he must wait long periods for someone to bring him back to his room. The resident said he had missed a bible study once because staff were too busy to take him down. He stated he had made friends with other residents on the rehab unit but had not been able to visit with them since he was changed to a manual wheelchair, because there was not someone to push him all the way to the rehab unit. He stated he was also worried about going that far because he might not be able to find someone to bring him back to his room from the rehab unit. He stated since the facility took away the powered wheelchair, he has felt like an invalid and had a loss of independence. He said it was very distressing for him to feel that way. During an observation and interview on [DATE] at 11:30 a.m., resident #1 wheeled himself into his adjoining bathroom. While self-propelling the resident complained of pain in both of his arms and shoulders after moving the short distance in his room. He stated he felt his pain, which was usually at a 7 out of 10 was now at a 9 out of 10. The cushion in the manual wheelchair was pulling away from the back of the seat and left a gap between the back of the chair and cushion. The resident stated this caused him discomfort in his lower back and spine, and he felt like he had no back support at all in the manual wheelchair. The resident sat slumped forward in the wheelchair. Review of resident #1's Care Plan, initiated on [DATE], showed, (Resident #1) is resistive to care related to: Difficulty adjusting to facility requirements, resistive to change in lifestyle, attention seeking behavior. (Resident #1) will allow staff to assist him with changes in his care plan as needed, including using manual wheelchair instead of electric, adjusting to LTC from Skilled room, sharing a bathroom with other residents. During an interview on [DATE] at 2:30 p.m., staff member G stated resident #1 had discharged from the hospital and had been provided an powered wheelchair while he was at the hospital. She stated the resident had admitted to their facility with a powered wheelchair. She stated since the facility was considered a 24-hour care facility, his insurance payer would not pay for him to have a powered wheelchair while at the facility. She stated the facility was expected to provide the necessary transport for a resident who was unable to self-propel in a manual wheelchair. She said after resident #1 admitted to the facility they had tried a donated powered wheelchair, which the resident stated did not fit him well. She stated the facility then rented a different powered wheelchair for the resident while he was on the rehab side of the facility. She stated when the resident transitioned to the long term care side of the facility, they returned the resident's powered wheelchair and provided him with a manual wheelchair. Staff member G stated this was due to the resident's insurance coverage. During an interview on [DATE] at 7:52 a.m., staff member N stated resident #1 was working on using a slide board to transfer himself. During that time, he started to have complaints of increased upper extremity pain. He stated the resident had arthritis and bone spurs in his shoulder and with increased use, it became very difficult for him to continue to use the slide board. He stated the physician had injected his shoulder, and they were reluctant to make the resident over-use that shoulder because it can move the medication out of the socket. Staff member N stated he had noticed a decline in the resident willingness to participate in physical therapy after he transitioned from the rehab unit to the long term care unit. He stated the resident would most likely not be able to regain full use of his upper extremities, without pain, even with rehab. During an interview on [DATE] at 10:04 a.m., staff member B stated it was important for residents to maintain as much independence as possible. She stated it was important for residents to make their own choices and to have a lifestyle which supports their best quality of life. She stated staff care for multiple residents at a time and will provide transport for dependent residents as soon as possible. She stated if a resident was able to bring themselves to activities they should be encouraged to participate as much as possible. A review of the facility's policy and procedure titled, Resident Rights, with a revision date of [DATE], showed, Purpose: To treat each patient with respect and dignity and care for each patient in a manner and in an environment that promotes maintenance or enhancement of his/her self-esteem and self-worth. To incorporate the patient's goals, preferences, and choices into care. To recognize each patient's individuality as well as honor and value his/her input. To protect and promote the rights of the patient.",2020-09-01
187,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2019-10-03,676,D,1,0,MHIF11,"> Based on observation, interview, and record review, the facility failed to provide services to maintain activities of daily living for an independent resident with his personal grooming for 1 (#1) of 8 sampled residents. Findings include: During an interview on 10/2/19 at 10:45 a.m., resident #1 stated he could not access his bathroom to shave his head, brush his teeth or wash his face and hands. He stated the bathroom was too small to accommodate his wheelchair, and he can only access the sink in his bathroom to his right side, and can not face the sink. He stated he can turn to the right and turn on the water in the sink but he can not access the soap dispenser. He said the facility offered him a basin and mirror, but he did not feel he could get clean using a basin to wash his face and hands, brush his teeth and shave his head. He did not feel the staff would be able to provide him with a clean basin of water every time he wanted to wash his hands. He stated the facility had never provided him with a basin or mirror to even try using it. Resident #1 stated he was offered to use the main shower room on the unit, but it was not always available when he wished to use it, since he had to wait for other residents to use it first. He also stated the unit shower room was locked, and he needed to wait for a staff member to unlock the room. Resident #1 said in the past when he did use the unit shower room, he was left unattended, and became stuck in the bathroom, twice for over twenty minutes. He stated he was not strong enough to open the bathroom door and maneuver his manual wheelchair out of the shower room while holding the door open. He said the call light was by the toilet, and he could not maneuver his wheelchair close enough to push the call light because there was other equipment in the way. The resident stated he felt a loss of independence and has been made to feel like an invalid. He stated not being able to perform his own ADLs has made him feel dirty. He stated he had not brushed his teeth since being moved to his current room. During an observation and interview on 10/2/19 at 11:30 a.m., resident #1 wheeled himself into his adjoining bathroom. The manual wheelchair only fit sideways in the bathroom. The resident demonstrated his inability to access the sink completely to perform ADLs. He had to rotate himself at his hips to his right side to get to the sink. He was not able to reach the soap dispenser. The resident stated it caused him discomfort to turn to the right and try to access the sink. During an observation on 10/2/19 at 11:30 a.m., resident #1 had dirt buildup underneath his fingernails on both hands. His teeth had small amount of plague buildup, and his breath smelled stale. During an observation on 10/2/19 at 2:00 p.m., the communal shower room on resident #1's unit had a call bell located in the bathroom wall to the right of the toilet. The call bell was blocked by a white shower chair. The call bell did not have a string to grab to improve it's accessibility. Review of resident #1's Care Plan, initiated on 5/30/19, showed, (Resident #1) requires assistance is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: Impaired mobility, pain. Interventions: Tub/Shower Schedule: Tuesday and Friday; evening shift. No gender preference. Turn and reposition has (sic) resident allows. Provide resident/patient with limited assist of 1 for bed mobility. Provide (Resident #1) with 2 person - Minimum to moderate assist with slide board transfer. The resident's Care Plan failed to address his inability to access his personal bathroom, and the need to use the units shower room to perform his routine ADL care. During an interview on 10/2/19 at 2:41 p.m., staff member H stated she was aware the resident was not able to access his bathroom. She stated they had offered the resident a mirror and basin to use to perform ADLs. She stated the resident had refused the basin and mirror, stating he felt that he would not be able to get clean. She stated she had not provided the resident with the basin or mirror at all since he refused. She stated the resident had been offered the use of the unit shower room. She stated she was not aware he was not able to get out of the shower room without assistance, and had become stuck in the shower room on two different occasions. During an interview on 10/3/19 at 10:04 a.m., staff member B stated she was aware the resident was not able to utilize the sink in his adjoining bathroom. She stated the resident had been offered a basin and mirror to use, but had refused to use it, so one was not provided. She stated the resident was offered the use of the unit shower room, but had not known the resident became stuck in the bathroom for 20 minutes on two different occasions, and was not able to access the call light. Staff member B stated the resident had been unhappy with his new room accommodations, and he wanted a room on the rehab unit. She stated that was not possible since he no longer was receiving rehab services. She stated it was important for residents who were able to perform their own ADLs maintain their independence and dignity.",2020-09-01
188,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2019-10-03,686,D,1,0,MHIF11,"> Based on observation, interview, and record review, the facility failed to prevent and evaluate the cause of an avoidable, Stage II pressure ulcer to the penis, of a resident with an indwelling catheter, for 1 (#1) of 8 sampled residents. Findings include: During an observation and interview on 10/2/19 at 12:10 p.m., staff members C and D provided peri-care for resident #1. The resident had an indwelling catheter which the tubing was pulled to the right side and secured to the resident's right leg. When staff member C pulled back the catheter tubing from the indwelling catheter, underneath where the tubing was exiting the urethra, there was a 1 x 1 cm round Stage II pressure ulcer. The wound bed was bright red and had frank blood. There was not a sponge between the catheter tubing and the resident's penis. The resident stated he was not aware he had a sore on his penis from the catheter tubing. He said he had diminished sensation below his waist and could not feel any discomfort. He stated the staff never change the leg which the catheter tubing was affixed. He stated the tubing had always been affixed to the right leg. During an interview on 10/2/19 at 12:10 p.m., staff members C and D stated they were not aware of the new area of skin breakdown on the resident's penis. They stated it was the expectation to notify the nurse of any skin changes immediately. Staff members C and D stated they were not sure if the catheter tubing was ever changed to his right leg. They thought it had always been strapped to his right leg. During an interview on 10/2/19 at 12:39 p.m., staff member [NAME] stated she had completed a full skin assessment on resident #1 the day before. She stated when she had checked the resident's penis, there was no change in his skin condition. She stated the resident had a sponge placed under the tubing between the tubing and the penis. She said she had removed the sponge, and did not replace it, because there was no evidence of skin breakdown. During an interview on 10/2/19 at 4:27 p.m., staff member J stated she had noted a reddened area on resident #1's penis, where the catheter tubing exited the penis on 9/30/19. She stated she had made a note for staff member [NAME] to check the area. The staff member stated she did not change the side to which the catheter tubing was affixed to relieve the pressure from the tubing on the reddened area. She stated she was not trained on how to manage pressure ulcers by the facility and she had not contacted the physician regarding the reddened area on the resident's penis. She stated she left the wound care to staff member E. She stated she was not familiar with the facility's policy and procedure for new skin issues. During an interview on 10/3/19 at 6:48 a.m., staff member B stated nurses did not receive wound care training by the facility, since nurses were nurses. She stated it was the expectation for nurses to generate a change of condition report when a resident has a newly identified skin breakdown. Staff member B stated it would be beneficial for wound care to start as soon as possible for a resident with skin breakdown to prevent further decline. A review of resident #1's Braden Scale, dated 6/21/19, showed the resident was scored at 17, mild risk to develop pressure ulcers. There was not another Braden Risk Assessment completed for the resident for the current quarter. A review of resident #1's Change of Condition Forms, from 9/30/19 to 10/2/19, failed to show staff member [NAME] was notified of the reddened area on the resident's penis, observed by staff member J on 9/30/19. A review of resident #1's Physician Orders, from 9/30/19 to 10/2/19, failed to show orders for wound care or skin breakdown prevention. A review of resident #1's Care Plan, failed to show interventions to prevent the development of pressure ulcer associated with the resident's indwelling catheter until 10/2/19.",2020-09-01
189,IVY AT GREAT FALLS,275026,1130 17TH AVE S,GREAT FALLS,MT,59405,2019-10-03,919,D,1,0,MHIF11,"> Based on observation, interview, and record review, the facility failed to ensure access to the call light system in a shower room for 1 (#1) of 8 sampled residents. Findings include: During an interview on 10/2/19 at 10:45 a.m., resident #1 stated in the past when he used the unit shower room, he was left unattended, and became stuck in the bathroom, twice for over twenty minutes. He stated he was not strong enough to open the bathroom door and maneuver his manual wheelchair out of the shower room while holding the door open. He said the call light was by the toilet, and he could not maneuver his wheelchair close enough to push the call light because there was other equipment in the way. During an observation on 10/2/19 at 2:00 p.m., the communal shower room on resident #1's unit had a call bell located in the bathroom wall to the right of the toilet. The call bell was blocked by a white shower chair. The call bell did not have a string to grab to improve it's accessibility. During an interview on 10/3/19 at 10:04 a.m., staff member B stated it was the expectation call lights were accessible to all residents in their rooms, and in bathroom facilities. A review of the facility's policy and procedure, titled Call Lights, with a review date of 3/1/16, showed, All (facility) patients will have a call light or alternative communication device within their reach at all times when unattended .",2020-09-01
190,HILLSIDE HEALTH & REHABILITATION,275027,4720 23RD AVENUE,MISSOULA,MT,59803,2017-06-14,224,D,1,0,JR0I11,"> Based on interview and record review, a facility staff member mistreated a resident when the staff member retaliated against the resident, who was exhibiting behaviors, and dumped ashes from cigarettes in the resident's lap, for 1 (#1) of 4 sampled residents. The employee had been trained on resident abuse. Findings include: A record review of an abuse event, involving resident #1 and staff member C, showed the event occurred on 5/20/17 at 10:00 p.m. The facility substantiated the allegation of abuse on 5/23/17. The following occurred: Resident #1 was in the outside smoking area of the facility and was digging through the used cigarette butt containers. Resident #1 was looking for cigarette butts she could finish smoking. Staff member C repeatedly tried to convince resident #1 to stop digging through the containers, because it was disgusting and dirty. Resident #1 continued with her behavior of digging through the containers. Staff member C picked up a cigarette butt container out of frustration and dumped it on resident #1's lap. Staff member C self reported the incident to the charge nurse after the event. During an interview on 6/14/17 at 10:15 a.m., resident #1 said she remembered the incident when staff member C dumped the container of cigarette butts on her. Resident #1 said she could not remember why staff member C was upset with her. Resident #1 said she was not afraid of staff member C. Resident #1 stated, It's all over now and everything is fine. Resident #1 said staff member A had asked her if she, resident #1, wanted any counseling regarding the abuse incident. Resident #1 said she told staff member A, No. During an interview on 6/14/17 at 1:45 p.m., resident #2 was interviewed about the incident that occurred on 5/20/17, between resident #1 and staff member C. Resident #2 said resident #1 was digging through the butt cans in the smoking area, and staff member C was trying to get resident #1 to stop. Resident #2 said resident #1 was calling staff member C a lot of bad names, and was telling staff member C to leave her alone. Resident #2 said he was surprised when staff member C dumped the butt cans on resident #1's lap. Resident #2 said resident #1 behaved badly all the time. He said resident #1 cusses at everyone, especially staff, when she didn't get her way. During an interview on 6/14/17 at 2:15 p.m., resident #3 said she was in the courtyard when the incident occurred between resident #1 and staff member C. Resident #3 said resident #1 was calling staff member C lots of bad names. Resident #3 said resident #1 wouldn't get out of the butt cans. She said staff member C was trying to convince resident #1 by saying, Dirty butts, leave them alone. Resident #3 said, I think (name) reached her breaking point and just dumped the butts on (resident name) out of frustration. Resident #3 said staff member C said, Here, have them then. During an interview on 6/14/17 at 10:30 a.m., staff member A said the incident on 5/20/17 happened on a weekend, and she was contacted at home. Staff member A said staff member C was on days off when the investigation was started. Staff member A contacted staff member C at home about the allegation. Staff member A said staff member C was very appalled at her own actions, and told staff member A she was very sorry about what had happened. Staff member C told staff member A she had apologized to resident #1. Staff member A said when staff member C returned to the facility the facility carried out corrective measures to address the staff member's actions. Staff member A said resident #1 was asked if she wanted to talk with social services, or another counselor about the incident. Resident #1 said she did not. A review of the facility's policy titled Abuse, Neglect and Exploitation showed: #4 Mistreatment means inappropriate treatment or exploitation of a resident. Facility's Corrective Action: - The facility was notified of the abuse/mistreatment event by the employee, and took appropriate action to address the event, and the protection of the resident. - The facility completed an investigation for the event, which identified abuse/mistreatment did occur, due to the staff member acting out towards the resident who was displaying behavior. - The facility addressed the behavior of the staff member, which was substantiated abuse/mistreatment. - Education on abuse was provided for abuse prevention. - The facility reported the allegation, and the final outcome of the abuse event, to the State Agency. (Refer to F225) - The facility continued to operationalize the abuse policies and procedures for the identification, prevention, and protection of the residents, which included monitoring for abuse and neglect. Corrective action for the deficient practice had occurred prior to 6/14/17.",2020-09-01
191,HILLSIDE HEALTH & REHABILITATION,275027,4720 23RD AVENUE,MISSOULA,MT,59803,2017-06-14,225,D,1,0,JR0I11,"> Based on interview and record review, the facility failed to report an allegation of abuse to the federally designated entity within the required timeframe; and failed to complete the follow-up investigation within five days of the alleged abuse incident, for 1 (#1) of 4 sampled residents; and failed to report an alleged incident of abuse for 1 (#1) of 4 sampled residents to the appropriate state agencies. Findings include: A review of an abuse allegation and investigation showed the event occurred on 5/20/17. The documentation showed the facility did not report the incident to the federally designated entity until 5/23/17, which was 72 hours after the alleged incident, and the requirements was 24 hours. The investigation, which included a five day follow-up summary report, was required to be reported within five days to the appropriate agencies, and this did not occur until 5/29/17. The record showed resident #1 to be the victim, and staff member C was identified as the aggressor. The record showed the facility investigated the abuse allegation, and the facility substantiated the allegation of abuse. This was not reported to any state agencies except the local ombudsman. During an interview on 6/14/17 at 10:30 a.m., staff member A said she had delayed in reporting the abuse allegation to the federally designated entity because she was not sure if the incident met the definition of abuse, although an allegation was received, and the facility had begun the investigation. Staff member A said she had never reported an alleged or substantiated abuse allegation to any other state entity than the local ombudsman. During an interview on 6/14/17 at 1:30 p.m., staff member B said he had completed abuse training for the staff. Staff member B said he had sent incident reports to the federally designated entity in the past. Staff member B said he was unaware of needing to report allegations of abuse to any state agencies. During an interview on 6/14/17 at 3:00 p.m., staff member D said she had been working at the facility for three months. Staff member D said she would report any allegations of abuse to staff member [NAME] She would follow staff member A's lead and report to whatever state agencies staff member A indicated. A review of the facility's policy titled Abuse, Neglect and Exploitation showed: Report allegations or suspected abuse, neglect or exploitation, immediately to: - Administrator - Other Officials in accordance with State Law - State Survey and Certification agency (CMS-Federal) following state protocols. Section VII, Response and Reporting of Abuse, Neglect, Exploitation and Misappropriation of this policy showed: - Anyone with knowledge or concerns about the care of a resident in the facility must report suspected abuse to the Facility Administrator, abuse agency hotline, or file a complaint with the State Survey agency immediately (but no later than 2 hours after an allegation is made).",2020-09-01
192,HILLSIDE HEALTH & REHABILITATION,275027,4720 23RD AVENUE,MISSOULA,MT,59803,2016-07-07,243,C,0,1,CBC511,"Based on observation, interview and record review, the facility failed to allow the Resident Council group to remain autonomous and free from interference. This practice has the potential to affect all residents who participate in the council. Findings include: During an observation at a Resident Council meeting on 7/5/16 at 2:36 p.m., staff member B provided ballots for a number of residents who had not yet voted for the Resident Council president. Four residents were listed on the ballot as candidates. During an interview on 7/6/16 at 7:30 a.m., staff member B stated the resident council had been without a president for 4 or 5 months. Staff member B had tried to find an interested resident to be nominated for the president position. During an interview on 7/6/16 at 12:50 p.m., staff member B stated the voting for council president had been in progress for about 3 weeks. Staff member B produced a stack of 21 ballots showing four candidates in the election. The ballots contained only a check mark beside the name of the candidate, and no identification of the resident casting the ballot. Staff member B had a resident census which had 21 names marked as having voted. No residents were involved in the voting process. Staff member B created the ballots, individually and as a group invited residents to register to vote, collected and counted the votes, determined the voting was closed and congratulated the winner; then she reopened the voting, and un-elected the Resident Council president. The un-election of the president happened because staff member B was approached by four residents who had not yet voted. During an interview on 7/6/16 at 12:30 p.m., staff member B explained that she had informed resident #5 they had been elected president of the council on 7/5/16 at 3:45 p.m. Staff member B had posted resident #5's picture on the activities board near the entrance to the dining room, underlined by the word Congratulations at 3:00 p.m. During an interview on 7/6/16 at 12:10 p.m., resident #5 stated she did not know if she was elected or not to the council presidency. Resident #5 explained that she had been told by staff member B the election had been extended in order to allow some residents who had not voted the opportunity to do so. Resident #5 stated she was told by staff member B the voting process was not complete. This was the day following the posting of her picture and receiving congratulations on the election. Resident #5 stated she did not feel sure they actually had a resident council, rather facility staff seemed to be in control. A review of Resident Council Meeting Minutes from 6/2/2105 to 6/7/2016, showed issues brought before the group were often not resolved. For example, between 6/2/15 and 12/1/15, approximately 31 issues were raised by council members, most were never addressed again, and 7 appeared to be successfully resolved. A request for a copy of the Resident Council By-Laws, showed the council operates without guidelines.",2020-09-01
193,HILLSIDE HEALTH & REHABILITATION,275027,4720 23RD AVENUE,MISSOULA,MT,59803,2016-07-07,278,D,0,1,CBC511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide an accurate assessment for 1 (#16) of 17 sampled and supplemental residents. Findings include: A review of the quarterly MDS, dated [DATE], for resident #16 showed a BIMS score of 12, indicating moderate cognitive impairment. A review of section L0200, Oral/Dental Concerns, coded dental concerns as z. None of the above are present. During an interview on 7/7/16 at 9:40 a.m., staff member D stated the quarterly MDS, dated [DATE] was an error. The section L0200 for resident #16 should have triggered d. Obvious or likely cavities or broken natural teeth. During an interview on 7/7/16 at 9:40 a.m., staff member D stated she had spoken with resident #16 regarding his teeth and was told he did not want to go to a dentist.",2020-09-01
194,HILLSIDE HEALTH & REHABILITATION,275027,4720 23RD AVENUE,MISSOULA,MT,59803,2016-07-07,411,D,0,1,CBC511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure routine dental services were provided, and the risks and benefits of care discussed for 1 (#16) of 17 sampled and supplemental residents. The findings include: During an observation on 7/5/16 at 4:30 p.m., resident #16 was seen in his wheelchair near the nurses' station. Resident #16 smiled and showed decayed and ragged teeth. During an interview on 7/7/16 at 7:10 a.m., staff member C stated she did not know if resident #16 had ever seen a dentist. During an interview on 7/7/16 at 10:05 a.m., resident #16 stated he had lost his front teeth in a car wreck in 1961. Resident #16 stated he used to have an upper plate but had lost it about a year ago and had not seen it since. Resident #16 stated his teeth hurt at times and he could eat everything he wanted if he had an upper plate. A request for records on the dental care received by resident #16 yielded two clinical notes from the time of admission, (MONTH) 2014. A dietician stated Resident has natural dentition with multiple missing teeth. A nursing admission note dated 7/21/2014 reported, Mouth: Mucous membranes pink and moist, no mucosal [MEDICAL CONDITION]/[MEDICAL CONDITION], lips moist. Tongue midline and moist. Own teeth, multiple missing and noted random broken teeth. Denies concerns. The facility did not provide any further documentation. A request for records documenting that the facility had explained the risks and benefits of obtaining or refusing dental care to Resident #16 was not produced. During an interview on 7/7/16 at 9:40 a.m., staff member D stated she had spoken with resident #16 regarding his teeth and was told he did not want to go to a dentist.",2020-09-01
195,HILLSIDE HEALTH & REHABILITATION,275027,4720 23RD AVENUE,MISSOULA,MT,59803,2016-07-07,441,F,0,1,CBC511,"Base on observation, interview, and record review, the facility failed to maintain proper infection control practices during laundry sorting and while transporting 2 residents (#s 8 and 17) of 17 sampled and supplemental residents. The laundry sorting failure had the potential to affect all residents in the facility. Findings include: During on observation on 7/6/16 at 7:35 a.m., staff member [NAME] lifted resident #17's feet, touching his shoes, from the floor and placed them on the foot rests attached to his wheelchair. Staff member [NAME] then pushed the resident into the dining room and up to a table. Staff member [NAME] placed a clothing protector around resident #17's neck. Staff member [NAME] then placed eating utensils and drinking glasses on the table in front of the resident. Staff member [NAME] picked up a glass, carried it to a cart containing several juices, filled the glass and placed it in front of resident #17. Staff member [NAME] then wheeled resident #8 into the dining room. Staff member [NAME] rolled a bedside table up beside resident #8. Staff member [NAME] placed a napkin, glass, and silverware on the bedside table. Staff member [NAME] then handed an apron to another staff member and also placed an apron on herself. Staff member [NAME] washed her hands at 7:45 a.m. and proceed to assist with serving food to the residents sitting in the dining room. Staff member [NAME] was not observed to wash her hands at any time prior to 7:45 a.m. on 7/6/16. During an interview on 7/6/16 at 10:20 a.m., staff member [NAME] stated she did not sanitize her hands after touching resident #17's shoes. Review of the facility's titled Hand Hygiene with an approval date of 10/08/15 showed staff were to observe hand hygiene requirements b. Before and after contact with residents., and d. Before assisting residents with eating or handling food. During an observation in the laundry on 7/7/16 at 8:47 a.m., staff member A sorted both residents' dirty clothing and dirty linen. Staff wore gloves and a gown. When finished with sorting, staff member A removed her gloves and gown. Staff member A then opened the dryer and removed clean laundry without first washing her hands. Review of the facility's policy titled Handling Soiled Linens with an approval date of 7/5/16 showed staff were to wash their hands after contact with soiled linen and before handling clean linen.",2020-09-01
196,HILLSIDE HEALTH & REHABILITATION,275027,4720 23RD AVENUE,MISSOULA,MT,59803,2017-08-17,253,E,0,1,8NP711,"Based on observation, interview, and record review, the facility's resident rooms #s 10, 33, 35, 36, and 47 were found lacking housekeeping services. Findings include: 1. During a group interview on 8/15/17 at 2:00 p.m., residents voiced concerns about the cleanliness of their rooms and bathrooms. During observations on 8/16/17, the following concerns were identified: -Room #36: The toilet had a build-up of a dark unidentifiable substance around the base of the toilet. -Room #35: The air vent had an accumulation of dust, dirt, and a rust like substance covering the vent. -Room #33: Two tissues, two candy wrappers, and several dust bunnies were observed under the bed next to the window. The toilet, shared by room 32 and room 33, had a dark unidentifiable substance around the base of the toilet. -Room #10: The floor, under furniture, was dirty with dust and small pieces of an unidentifiable substance. A review of resident council meeting minutes showed housekeeping concerns had been voiced by residents in June, July, and (MONTH) of (YEAR). Resident council minutes also showed the concerns were being addressed by the housekeeping supervisor. Resident council minutes showed staff member D was instituting a cleaning schedule, and each resident room would be deep cleaned. The council minutes showed this cleaning schedule had not be started though. During an interview on 8/16/17 at 1:30 p.m., staff member G said she was always cleaning resident rooms because housekeeping was shorthanded on staff. Staff member G said she noticed that furniture, in resident rooms, was never moved by housekeeping staff, so the floors, under the furniture, could be cleaned. During an interview on 8/16/17 at 4:00 p.m., staff member D said the toilets for rooms #32, 33, and 36 had old caulking around the bases and the caulking was discolored. Staff member D said the caulking would have to be removed in order for the bases of the toilets to look clean. Staff member D said the air vent in room #35 did have dust and rust on the surface of the vent. Staff member D said the vent would be removed and cleaned. Staff member D did indicate there was garbage under the bed in room #33. 2. During an observation of room #47 on 8/14/17, at 2:00 p.m., surfaces in the room appeared free of dust, the room sink was clean, and the middle of the room floor appeared clean. Under the sink, under tables and the bed, and around the perimeter of the room for about 2 to 3 feet, the floor appeared unswept with an accumulation of dust and dirt particles that scattered when walked through. In the bathroom there was torn toilet tissue on the floor, along with dust and dirt particles in the corners of the room behind the commode. The tile floor in front of the commode was thinly smeared with a dried brown substance. A piece of dark brown dried substance approximately 1.5 inches by .25 inch by .25 inch in height was adhered to the floor in front of the commode. During an observation of room #47, on 8/15/17, at 8:15 a.m., the room appeared unchanged from the day before. The toilet paper on the floor in the bathroom was gone, but the floor in front of the commode in the bathroom remained smeared and the dried dark brown substance remained unchanged. During an interview on 8/15/17, at 10:00 a.m., the resident in room #48 said she shared the bathroom with the resident in room #47, but rarely used it. She used a commode chair at her bedside due to mobility problems. She said the facility housekeeping staff cleaned her room daily, usually when she was not there. She did not know if the housekeeping staff cleaned her room's adjoining bathroom. During an observation of room #47 on 8/16/17 at 1:00 p.m., the accumulation of dust and dirt particles in the room remained unchanged, and the bathroom floor remained uncleaned. The commode contained stool and a large amount of wet toilet paper in yellow colored liquid. During an interview on 8/16/17 at 1:30 p.m., staff member [NAME] stated she cleaned in all the resident rooms on her assigned hall on a daily basis. She dusted surfaces, mopped floors, washed sinks, and used bleach to clean the toilets, every day. She washed window blinds only on Wednesdays and Fridays, and on Tuesdays cleaned over the vents. Every day she picked four rooms in which she did deep cleaning. She was unable to state how it was communicated to other housekeeping staff which rooms she deep cleaned on what day. When she was shown room #47, she said it needed deep cleaning, and she had not cleaned rooms on that side of the hall yet. She had recently been reassigned from another hall. During an interview on 8/17/17 at 8:00 a.m., staff member D said that he left it up to the facility housekeeping staff to determine the scheduling of individual rooms for cleaning. He denied having a list of rooms cleaned on specific dates. When he was shown room #47 at 8:08 a.m. some cleaning of the perimeter of the room had been done. The bathroom remained unchanged from the previous observations. Staff member D cleaned the dried dark brown substance from the floor in front of the bathroom commode.",2020-09-01
197,HILLSIDE HEALTH & REHABILITATION,275027,4720 23RD AVENUE,MISSOULA,MT,59803,2017-08-17,323,E,0,1,8NP711,"Based on observation and interviews, the facility failed to ensure furniture, specifically a rocking chair, accessed by residents in the memory care unit, was in proper working condition, thereby creating a safety hazard. This had the potential to affect 11 of 11 residents on the memory care unit. Findings include: During an observation 8/15/17 at 10:50 a.m., a rocking chair in the Serenity Garden of the memory care unit was off its rocker and resting on the floor. The chair was not attached to the left rear rocker. The chair was placed back on the rocker and was easily pushed off the rocker. During an interview on 8/15/17 at 10:54 a.m., staff member F said she was not aware the rocking chair was broken. Staff member F said the broken rocking chair could be dangerous if someone sat in it. Staff member F said she would let the maintenance supervisor know. During an observation on 8/15/17 at 11:00 a.m., the broken rocking chair had been removed from the Serenity Garden of the memory care unit.",2020-09-01
198,HILLSIDE HEALTH & REHABILITATION,275027,4720 23RD AVENUE,MISSOULA,MT,59803,2018-10-30,689,G,1,0,1PNL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to prevent an accident when a resident was smoking with oxygen on and caused a fire, and the resident was unsupervised by staff, for 1 (#1) of 3 sampled residents. The resident sustained [REDACTED]. Findings include: During an interview on 10/29/18 at 12:50 p.m., resident #3 stated she was an independent smoker and came outside often to smoke. She stated the smoking rules had changed since (resident name) caught herself on fire. Resident #3 stated since then We have to leave our oxygen with a staff member before we can go outside to smoke. She stated before the lady caught herself on fire we just had to hang our oxygen by the door to the smoking area and go out. Resident #3 stated, We could only have two cigarettes at a time and we have to take our oxygen up to the front desk and trade it for our two cigarettes and lighter. Review of resident #1's Smoking Risk Evaluation showed, on 6/28/18 at 7:00 p.m., staff member A signed off on resident #1 as Must be supervised and Smoking materials must be secured by staff. On 6/28/18 at 8:35 p.m., staff member A signed off a new Smoking Risk Evaluation as, Independent and, Smoking materials must be secured by staff. Review of resident #1's progress notes, dated 8/27/18 showed, At approx. 1330 I was called to go out to the smoking area as res was in distress, as I entered the dining room res was sitting in her w/c hunched over in pain holding her face, I could see her oxygen cannula was burnt and melted off, as I get close to res I see black area covering below her nose and cheeks, right and left, she said she was smoking, forgot to take off her oxygen, cold compress being applied for comfort but res crying in pain, another O2 mask and tube provided .mask being held lightly in front of her nose, it appears that small amt of plastic attached to her cheeks as well, normal saline used to try to cleanse area causing some peeling off 1350 ambulance here to take res to the (hospital name) family notified by staff (sic). E-Signed by staff member D on 8/27/18 at 3:57 p.m. Review of resident #1's Care Plan showed Burn of first degree of nose (septum), subsequent encounter, Burn of unspecified body region, unspecified degree. Review of the facility's smoking policy, with a Date Reviewed of 10/2/17, showed Facilities that have residents that smoke at the health care community will do so on a safe and responsible manner to ensure that all residents are safe. Oxygen use is prohibited in smoking areas. During an interview on 10/29/18 at 1:25 p.m., staff member A stated residents who are smokers are assessed at the time of admission whether they are an independent or a dependent smoker. Both independent and dependent smokers have their supplies (cigarettes and lighter) secured up at the nurses station. An independent smoker could go out to smoke whenever they want, between the hours of 7:00 a.m. and 10:30 p.m., weather permitting. They do not have to have any supervision while smoking. Those who are assessed as a dependent smokers have four times a day they can go out; 9:30 a.m., 1:00 p.m., 3:30 p.m., and 8:00 p.m. The dependent smokers always have a staff member with them when they smoke. The staff members have a bag with all the dependent smoker's supplies; and take it outside during smoking times. Both independent and dependent smokers were allowed two cigarettes at a time. Staff member A stated around three months ago the smoking policy changed. She stated this was because resident #1, an independent smoker at the time, burnt herself pretty bad because she forgot to take her oxygen off before entering in the smoking area and began to smoke with her oxygen still on. She stated no staff member was in the smoking area at the time and a fell ow resident had told her to drop her cigarette because She was on fire. Before the rules changed, independent smokers had to remember themselves to take their oxygen off and hang it by the entrance to the smoking area. During an interview on 10/30/18 at 9:00 a.m., staff member C stated, We changed our smoking rules after the incident with (resident's name). Now independent smokers have to come up to the front desk with their O2 and trade us for their smoking items. Before it was up to the independent residents to remember to hang their O2 up on the hooks outside the designated smoking area, then go outside. Staff member C stated there was an assessment done for smokers to determine if they have the physical and cognitive ability to be an independent smoker. The independent smoking residents must be cognitively intact and be able to physically hold the cigarette safely. If any resident had a change of condition, it would require a new smoking assessment to be completed. There was not a change in condition for resident #1 at the time of the incident, that is why we changed our protocol. When residents were required to hang their oxygen up on their own there was not a staff member present to make sure this happened. Review of Resident #1's Independent Smoking Policy Acknowledgement, signed by resident #1 on 6/29/18, showed If resident is using portable oxygen this equipment will be checked in to the staff at the nurse's station upon receiving the smoking materials and returned to the resident upon check in of all smoking materials after the smoking session is complete. No oxygen will be present in the smoking areas during a smoking session. Resident #1's oxygen was not checked in to the staff at the nurses station upon receiving the smoking materials. Review of resident #1's Smoking Risk Evaluation showed, on 8/29/18 at 10:46 a.m., the resident must be supervised and Smoking Materials must be secured by staff. Signed off by staff member [NAME] Review of resident #1's Un-Titled document, dated 9/7/18, and written for resident #1, showed On 8/30/18 you told the nursing staff that you were only going to, go out and sit with a fell ow resident however you were observed to be smoking unsupervised at that time and issued a second violation notice. During an interview on 10/30/18 at 9:00 a.m., staff member C stated dependent smokers are allowed to be out with independent smokers unsupervised. Review of resident #1's Un-titled document dated 9/7/18 showed, Due to the events that occurred at approximately 8:00 pm on (MONTH) 7, (YEAR) you were found by no less than two staff members in the South hall restroom and the staff noted a strong cigarette smell coming out of the bathroom. The staff stayed and investigated that the source of smoke was the bathroom you were observed to be in for no less than 15. When approached about the smoke smell and the ashes that were found in the toilet on the top of the stool, you denied smoking. A hand rolled cigarette was found in the trash can in the bathroom you were in. There were two separate occasions where resident #1 was smoking without supervision when her Smoking Risk Evaluation showed she, Must be supervised and, Smoking materials must be secured by staff. Review of resident #1's progress notes showed, Decision made by ED to evict resident/discharge . E-Signed by staff member B, and dated 9/8/18 at 12:26 a.m. The resident is no longer residing at the facility.",2020-09-01
199,HILLSIDE HEALTH & REHABILITATION,275027,4720 23RD AVENUE,MISSOULA,MT,59803,2018-12-13,804,E,0,1,LDX711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide resident preferred foods and menus, which increased food waste, for 7 (#s 3, 8, 16, 27, 30, 37, and 106) of 19 sampled and supplemental residents. Findings include: During an interview on 12/10/18 at 5:39 p.m., resident #16 said the food did not taste good, and he did not like most of what the facility served at meals. The resident said the facility did offer alternates to the main meal. He said the alternates were not very good either. During an observation on 12/10/18 at 5:57 p.m., resident #37 was served her meal. A CNA opened an eight ounce carton of milk and poured it into a glass. The resident picked up a fork and pushed the food around on her plate. The resident then picked up and started drinking from her glass of milk. During an observation on 12/10/18 at 6:02 p.m., resident #37 left her table and returned to her room. The resident had finished her glass of milk. The resident had not eaten any food from her plate. The staff failed to offer the resident alternate food prior to the resident leaving the dining room. During an interview on 12/11/18 at 8:25 a.m., resident #3 said she had the fish stick for dinner on 12/10/18. The resident said it tasted freezer burnt. The resident said she had complained about the food being served since she had been admitted to the facility. Resident #3 said none of the other residents liked the food either. Resident #3 said she had spoken to management about this, repeatedly, but nothing about the food had changed. During an interview on 12/11/18 at 9:38 a.m., resident #30 said the food was good sometimes, but most of the time it was slop. During an interview on 12/11/18 at 9:40 a.m., resident #106 said the food was not very good. The resident said the facility served a lot of fish, pasta, and squishy vegetables. The resident said she had been told the menu the facility served was called FFL. The resident said, FFL meant Food For Life. Resident #106 said she would rather have meat and potatoes, plain food. During an observation on 12/12/18 at 8:06 a.m., resident #37 was observed leaving her table after drinking her milk and taking several bites of the egg from her muffin sandwich. The resident did not eat her oatmeal, or turkey sausage patty. During an observation and interview on 12/12/18 at 8:45 a.m., resident #37 was in her room, lying on her bed, watching television. When asked about the food, palatability, and if the food met the resident's preferences, the resident shook her back and forth to the left and right side, showing it had not. Resident #37 was not able to verbalize the word No. During an interview on 12/12/18 at 9:40 a.m., staff member B was fixing six pizzas for lunch. She said she had been a cook at the facility for [AGE] years. She said pizza was the alternate for lunch that day and the main menu option was fish. She said the Food For Life diet was a lot of fish, and most of the residents did not like fish. She said most of the residents would want pizza for lunch, and that was why she had fixed so many. Staff member B said, Corporate keeps saying they are going to make changes to the menus but it has not happened yet. She said a new menu was supposed to start in (MONTH) (YEAR), but had been put off until (MONTH) 2019. Staff member B said she did not know what had caused the delay. She said the residents were not interested in eating all the fish, greens, and pastas. The staff member said there was a lot of wasted food in the kitchen due to the residents' dislike of the food. Staff member B said the majority of the residents wanted beef and potatoes. During a group interview on 12/12/18 at 3:00 p.m., the residents said the food served by the facility was not very good. The residents said the facility served too much fish, pasta, and vegetables. Resident #27 said the facility had started a new menu, Food for Life, back some time ago. Resident #27 said the resident council had complained to administration, about the new menu and the food being served, repeatedly. The resident said the facility's response was, Residents can request the alternate being served for that meal. Resident #27 said the other residents in the facility understood alternates could be requested, but they still complained about the taste and quality of the food. The resident said the facility's other response was, Just give it a chance. The resident said the resident council had quit complaining, about seven months ago to the facility, because nothing had changed. She said resident council had just given up. Resident #27 said the facility had told the residents, in (MONTH) (YEAR), a new menu would be started in (MONTH) (YEAR). The resident said the menu had not changed, and the facility said the new menu would be started in (MONTH) 2019. Resident #8 said the kitchen did finally quit serving quinoa because no one would eat it. During an interview on 12/13/18 at 9:29 a.m., staff member C said the facility's menu was supposed to change in (MONTH) 2019. The staff member said there had been many complaints by the residents about the food. Staff member C said she had known for quite a while the residents did not like the Food For Life menu. Review of the facility's menu showed fish based meals were served six times in six days: -12/10/18; Dinner was spinach and mushroom quiche, with an alternate of a baked fish sandwich, -12/12/18; Lunch was baked fish with lime tomato pesto, with an alternate of steak and potato soup or pepperoni pizza, -12/12/18; Dinner was steak and potato soup, with an alternate of chicken oscar, -12/13/18; Dinner was flounder Florentine, with an alternate of rustic beef soup, -12/14/18; Lunch was vegetable taco with salsa, with an alternate of Manhattan fish chowder, and -12/14/18; Dinner was Manhattan fish chowder, with an alternate of Italian seafood salad.",2020-09-01
200,HILLSIDE HEALTH & REHABILITATION,275027,4720 23RD AVENUE,MISSOULA,MT,59803,2018-12-13,812,F,0,1,LDX711,"Based on observation, interview, and record review, the facility failed to maintain kitchen equipment in a sanitary manner; and failed to serve food in a sanitary manner. This had to potential to expose residents to germs and pathogens due to unsanitary practices, for all residents in the facility. Findings include: During an observation on 12/10/18 at 2:30 p.m., a three tiered black plastic cart was covered with unidentified splatters and spots, on all three shelves, and on both ends. The ice machine was placed next to a single sink. The ice machine had a build up of uncleaned grime, and unidentified substances covering the side next to the sink. During an observation on 12/10/18 at 5:30 p.m., the steam table was pushed into the main dining room. Unidentified substances had run down both sides of the steam table, and appeared to be dried on. During an observation on 12/11/18 at 8:00 a.m., the steam table was pushed into the main dining room. Unidentified substances had dripped and ran down both sides of the steam table, and appeared to be dried on. The substances had not been cleaned off after the steam table was soiled with the substances. During an observation on 12/11/18 at 8:06 a.m., staff member D placed a serving tray over a large square tub filled with ice. The tub also contained small cartons of milk, and small plastic, covered, glasses of juice. The staff member would place the utensils, plates, and bowls on the tray. A CNA would take the tray to a resident table, place the tray on the table, serve the resident the food, and return to the serving line. The tray would be given to staff member D, the tray would then be placed on top of the tub containing the milk and juice. The CNAs would also place garbage, from the resident's table, on the tray. The CNAs would bring the tray back to the serving line, and dump the garbage into a small garbage can that was sitting next to the steam table. Several times the tray would touch the garbage can as it was being dumped. The CNA or the dietary aide would then place the tray on top of the tub containing the milk and juice. Staff member D was also observed putting her thumb over the edge of the bowls and plates as she was placing them on the serving trays. During an observation on 12/11/18 at 9:15 a.m., three ceiling fans; one above a food preparation table, and two in the cooking area, all had a greasy, fuzzy build-up, hanging from the vents. Two black, three tiered, plastic carts were observed to have unidentified substances on them on the ends of the carts, and the shelves had dirt and food particles on them. An oven rack had been place on top of the oven. It had a burnt, baked on build-up of unidentifiable substances on it. The hand washing sink and the garbage can beside the hand washing sink were not clean. During an observation on 12/11/18 at 12:15 p.m., the steam table was pushed into the main dining room. Unidentified substances had run down both sides of the steam table and appeared to be dried on. During an observation on 12/12/18 at 7:55 a.m., staff member D wiped the tops of the trays down with sanitary wipes as the CNAs were returning them to the serving line. The staff member was not wiping off the bottoms of the trays. CNAs were still placing the trays on the resident tables to serve the food, and to pick up discarded garbage on the tables. During an interview on 12/12/18 at 9:02 a.m., staff member C said she had been the dietary manager since (MONTH) (YEAR). The staff member said she had been working in the kitchen about one year prior to becoming the dietary manager. Staff member C said all the dietary staff had a ServSafe certificate, and they renewed their training annually on the computer. The ServSafe program was training for the safe, sanitary handling of food. During an interview on 12/13/18 at 9:29 a.m., staff member C said she had honestly not had a chance to look at the areas that needed to be cleaned. The staff member said she would get the ceiling fan/vents cleaned later in the week. The staff member said the black three tiered carts were dirty and should be run through the wash. Staff member C said she did not realize how dirty the carts were. Review of the facility's kitchen weekly cleaning task list showed the cook and the aide were to wash/wipe down all carts, and ensure all sinks were clean. The cleaning task list failed to show a time frame for the cleaning of the ceiling fan vents, the cleaning of the steam table, the cleaning of the ice machine, or the cleaning of the oven racks. Review of the facility's training records showed each member of the kitchen staff had received hand hygiene training.",2020-09-01
201,AVANTARA OF BILLINGS,275029,2115 CENTRAL AVE,BILLINGS,MT,59102,2019-03-21,554,D,0,1,GJC711,"Based on observation, record review, and interview, the facility failed to assess 2 (#s 84 and 85) of 31 sampled residents for safe self-administration of medications. Findings include: 1. Resident #84 was observed on 3/19/19 at 7:45 a.m. and on 3/20/19 at 8:03 a.m., with medication sitting on the breakfast table, in front of her, in the main dining room. A review of resident #84's care plan did not show that resident #84 was able to self administer her own medication at the breakfast table. 2. Resident #85 was observed on 3/19/19 at 7:45 a.m. and on 3/20/19 at 8:03 a.m.,with medication sitting on the breakfast table, in front of him, in the main dining room. A review of resident #85's care plan did not show that resident #85 was able to self administer his own medication at the breakfast table. During an interview on 3/19/19 at 2:15 p.m., staff member D stated the facility did not have a self-administration of medication assessment for resident #84 or resident #85.",2020-09-01
202,AVANTARA OF BILLINGS,275029,2115 CENTRAL AVE,BILLINGS,MT,59102,2019-03-21,623,C,0,1,GJC711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the necessary transfer and discharge notifications to 6 (#s 6, 26, 56, 57, 107, and 114) of 33 sampled and supplemental residents. Findings include: 1. During an interview on 3/19/19 at 9:49 a.m., resident #26 did not remember going to the hospital on [DATE]. The resident did not remember being given any transfer/discharge forms from the facility. Review of resident #26's Discharge Assessment MDS, with an ARD of 12/28/18, showed the resident was discharged to the hospital on [DATE]. During an interview on 3/21/19 at 8:15 a.m., staff member D said resident #26 was not given a transfer/discharge notification form at the time of her transfer to the hospital. 2. During an interview on 3/19/19 at 9:57 a.m., resident #107 said he did not remember going to the hospital recently. Record review of resident #107's Discharge Assessment MDS, with an ARD of 12/22/18, showed the resident was transferred to an acute hospital at that time. During an interview on 3/20/19 at 7:41 a.m., staff member D said resident #107 was not given any discharge information because the resident was sent to the hospital by the [MEDICAL TREATMENT] clinic, and not the facility. 3. During an interview on 3/19/19 at 8:59 a.m., resident #114 was not able to answer questions regarding any recent hospitalization s. Review of resident #114's Discharge Assessment MDSs, with ARDs of 10/2/18, 11/3/18, and 1/15/19, showed the resident had been transferred to an acute hospital on [DATE], 11/3/18, and 1/15/19. During an interview on 3/21/19 at 8:15 a.m., staff member D said the facility had not provided resident #114, or the POA, with any transfer/discharge notifications at the time of the resident's transfers to the hospital. During an interview on 3/21/19 at 8:18 a.m., staff member D said the facility had identified residents not receiving a notice of transfer or discharge as a concern, and it would be addressed in the facility's QAPI. Staff member D said no resident had previously received a notice of transfer or discharge from the facility. Staff member D said, We just haven't been doing it. The facility's Notice of transfer/discharge for resident #s 26, 107, and 114 were requested from the facility on 3/20/19 at 9:15 a.m. The facility had not provided the requested information by the end of the survey. 4. Review of resident #6's medical record showed the resident was discharged to the hospital on [DATE]. There was no transfer/discharge notification in the medical record. 5. Review of resident #56's medical record showed resident #56 was discharged to the hospital on [DATE]. There was no transfer/discharge notification in the medical record. A copy of the facility notice of transfer/discharge provided to the POA or guardian for resident #s 6 and 56 was requested from the facility on 3/20/19 at 9:15 a.m. The facility had not provided the requested information by the end of the survey. 6. Review of a progress note, dated 11/25/18, showed resident #57 went by ambulance to the emergency room . The writer stated the resident couldn't walk or hold his cup related to weakness and shaking. The physician was called and the daughter was notified, agreeing on the resident's transfer. Resident #57 was admitted to the hospital, related to a possible TI[NAME] No bed hold was located in the resident's medical records. There was no documentation showing a notification that a transfer or discharge was given to the resident or the PO[NAME] During an interview on 3/19/19 at 4:00 p.m., staff member D stated the facility did not give a written notice of transfer and discharge when resident #57 left, as it was an emergency. The staff member said that since it was an emergency, a transfer/discharge was not needed. During an interview on 3/20/19 at 9:30 a.m., resident #57 stated he did not remember being given any transfer/discharge forms from the facility. Review of the facility's policy, Transfers and Discharges, dated 2/20/17, showed: 2. Notify the resident, family, or legal representative of the transfer or discharge and the reason for move in writing and in the language and manner they understand. 9. The resident will then be given a bed reserve policy upon discharge to hospital. Otherwise, the notice may be made as soon as practicable before transfer or discharge when: a) The safety of the individuals of the facility would be endangered; b) The health of the individuals in the facility would be endangered; c) The resident's health improves sufficiently to allow a more immediate transfer or discharge; d) An immediate transfer or discharge is required by the resident's urgent medial needs; or e) The resident has not resided in the facility of 30 days.",2020-09-01
203,AVANTARA OF BILLINGS,275029,2115 CENTRAL AVE,BILLINGS,MT,59102,2019-03-21,625,C,0,1,GJC711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the required bed-hold notifications to 6 (#s 6, 26, 56, 57, 107, and 114) of 33 sampled and supplemental residents. Findings include: 1. During an interview on 3/19/19 at 9:49 a.m., resident #26 did not remember going to the hospital on [DATE]. The resident did not remember the facility giving her a bed-hold form. Review of resident #26's Discharge Assessment MDS, with an ARD of 12/28/18, showed the resident was discharged to the hospital on [DATE]. During an interview on 3/21/19 at 8:15 a.m., staff member D said resident #26 was not given a bed-hold form at the time of her transfer to the hospital. 2. During an interview on 3/19/19 at 9:57 a.m., resident #107 said he did not remember going to the hospital recently. The resident said he did not remember getting a bed-hold form from the facility. Record review of resident #107's Discharge Assessment MDS, with an ARD of 12/22/18, showed the resident was transferred to an acute hospital at that time. During an interview on 3/20/19 at 7:41 a.m., staff member D said resident #107 was not given a bed-hold notification because the resident was sent to the hospital by the [MEDICAL TREATMENT] clinic, and not the facility. 3. During an interview on 3/19/19 at 8:59 a.m., resident #114 was not able to answer questions regarding any recent hospitalization s. During an interview on 3/19/19 at 11:32 a.m., NF 1 said the facility had not given him a bed-hold notification for any of the resident's transfers to the hospital. Review of resident #114's Discharge Assessment MDSs, with ARDs of 10/2/18, 11/3/18, and 1/15/19, showed the resident had been transferred to an acute hospital on [DATE], 11/3/18, and 1/15/19. The facility's notification of bed-hold forms for resident #s 26, 107, and 114, were requested from the facility on 3/20/19 at 9:15 a.m. The facility had not provided the requested information by the end of the survey. During an interview on 3/21/19 at 8:15 a.m., staff member D said the facility had not provided resident #114, the spouse, or the POA, with any bed-hold notifications at the time of the resident's transfers to the hospital. During an interview on 3/21/19 at 8:18 a.m., staff member D said the facility had identified residents not receiving a notice of transfer or discharge as a concern, and it would be addressed in the facility's QAPI. Staff member D said no resident had previously received a notice of transfer or discharge from the facility. Staff member D said, We just haven't been doing it. 4. Review of resident #6's medical record showed the resident was discharged to the hospital on [DATE]. There was no bed hold information in the medical record. 5. Review of resident #56's medical record showed resident #56 was discharged to the hospital on [DATE]. There was no bed hold information in the medical record. A copy of the facility notice of bed hold, provided to the POA or guardian for resident #s 6 and 56 was requested from the facility on 3/20/19 at 9:15 a.m. The facility had not provided the requested information by the end of the survey. During an interview on 3/20/19 at 9:53 a.m., staff member G stated she had just put the bed hold policy in place for the facility. During an interview on 3/20/19 at 1:00 p.m., staff member D stated the information for transfers, discharges, and bed hold, was all on the facility policy Transfers and Discharges. 6. Review of a progress note, dated 11/25/18, showed resident #57 went by ambulance to the local hospital's emergency room . The writer stated the resident couldn't walk or hold his cup related to weakness and shaking. The physician was called and the daughter was notified, agreeing on the resident's transfer. Resident #57 remained at the hospital, related to a possible TI[NAME] No bed hold was located in the resident's medical records. Review of resident #57's Discharge Assessment MDS, with an ARD of 11/25/18, showed the resident had discharged to an acute hospital, with return anticipated. During an interview on 3/19/19 at 4:00 p.m., staff member D stated the facility's procedure for bed holds was on admission, the resident or POA signed a blank bed hold form and then staff would date the blank bed hold form when it was needed. Staff member D stated on 3/21/19 at 10:00 a.m., that there was no bed hold for resident #57's hospital stay on 11/25/18. The facility's notification of bed hold forms for resident # 57 was requested from the facility on 3/20/19 at 9:15 a.m. The facility had not provided the requested information by the end of the survey. Review of the facility's policy Bed Hold and Readmission, dated 2/20/17, showed: 1. The facility must inform the resident or family members being transferred of the duration of the bed hold in writing.",2020-09-01
204,AVANTARA OF BILLINGS,275029,2115 CENTRAL AVE,BILLINGS,MT,59102,2019-03-21,656,B,0,1,GJC711,"**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 comprehensive, person centered care plan that included problems, goals, and interventions for alteration in respiratory status or the use of oxygen over a period of 11 months, and completion of three MDS assessments and care plan reviews, for 1 (#67) of 31 sampled residents. Findings include: During observations on 3/18/19 at 12:14 p.m., 12:25 p.m., 12:41 p.m., and 3:02 p.m., resident #67 was noted to be wearing oxygen via nasal cannula. Review of resident #67's physician's orders [REDACTED]. Review of resident #67's Admission MDS, with an ARD of 4/30/18, Quarterly MDS, with an ARD of 10/18/18, and a Quarterly MDS, with an ARD of 1/18/19, showed the resident had a [DIAGNOSES REDACTED]. Review of resident #67's care plan on 3/20/19, showed no problems, goals, or interventions related to respiratory status or the use of oxygen on 3 consecutive assessments. This represents a pattern of failure to include respiratory care and oxygen use on the resident's care plan. During an interview on 3/20/19 at 3:02 p.m., staff member C stated resident #67 wore oxygen at all times, and had worn oxygen since admission in (MONTH) of (YEAR). Staff member C stated she was unaware that resident #67's care plan did not show any reference to her respiratory status or the use of oxygen. Subsequent review of resident #67's care plan on 3/21/19, after the interview with staff member C was completed, showed the addition of problems, goals, and interventions related to respiratory care dated 3/20/19. One of the interventions specifically identified the use of oxygen as ordered by provider.",2020-09-01
205,AVANTARA OF BILLINGS,275029,2115 CENTRAL AVE,BILLINGS,MT,59102,2019-03-21,657,D,0,1,GJC711,"Based on observation, interview, and record review, the facility failed to revise a person-centered, comprehensive care plan to include oxygen use for 1 (57) and for self administration of medications for 2 (#s 84 and 85), of 31 sampled residents. Findings include: 1. During an interview and observation on 3/20/19 at 9:35 a.m., resident #57 stated he used oxygen. The resident was observed wearing a nasal cannula, connected to a concentrator. During an interview on 3/21/19 at 8:09 a.m., staff members A and B stated resident #57 returned from the hospital, using oxygen. The staff members stated the resident currently used oxygen. The two staff members stated they attended care plan meetings and added information to the care plan as needed, but people come and go so fast, we have a hard time keeping up. Staff members A and B stated either the MDS person or the interdisciplinary team updated the resident's care plan. Review of resident #57's Nursing Admission/Readmission, dated 9/27/18, showed the resident used oxygen at 1.5 liters. Review of resident 's Significant Change MDS, with an ARD of 1/11/19 showed resident #57 was using oxygen, while in the facility. Review of resident #57's care plan, with a target date of 1/5/19, 2/28/19, and then 6/3/19 showed no documentation that resident #57 used oxygen. 2. Resident #84 was observed on 3/19/19 at 7:45 a.m. and on 3/20/19 at 8:03 a.m., with medication sitting on the breakfast table, in front of her, in the main dining room. A review of resident #84's care plan did not show a revision for resident #84 to self-administer her own medication at the breakfast table. 3. Resident #85 was observed on 3/19/19 at 7:45 a.m. and on 3/20/19 at 8:03 a.m., with medication sitting on the breakfast table, in front of him, in the main dining room. A review of resident #85's care plan did not show a revision for resident #85 to self-administer his own medication at the breakfast table.",2020-09-01
206,AVANTARA OF BILLINGS,275029,2115 CENTRAL AVE,BILLINGS,MT,59102,2019-03-21,761,D,0,1,GJC711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure expired medications and supplies were removed from use, and failed to ensure insulin pens were labeled with an open date for 2 (#s 30 and 109) of 33 sampled and supplemental residents. Findings include: 1. During an observation on 3/20/19 at 2:30 p.m. of the[NAME]Unit medication room, the following medications and supplies were expired: -Reliamed lubricating jelly, six packets with an expiration date of 2/2019, -Vashe Skin-Wound-Burn cleansing solution, 8.5 oz with an expiration date of 2/2019, -Hemoccult routine screening test for fecal occult blood, one box of single slides with an expiration date of 6/2018, -Epsom Salt 4 lb box with an expiration date of 7/2017. During an interview on 3/20/19 at 3:00 p.m., staff member C stated the medication room had just been gone through recently. 2. During an observation on 3/21/19 at 9:05 a.m. of unit one's medication cart, the following insulin pens were found without an open date: -Resident #30's Basaglar insulin pen did not have an open date, -Resident #109's [MEDICATION NAME]pen did not have an open date. During an interview on 3/21/19 at 9:24 a.m., staff member [NAME] stated the medication carts were checked weekly.",2020-09-01
207,AVANTARA OF BILLINGS,275029,2115 CENTRAL AVE,BILLINGS,MT,59102,2019-08-22,689,D,0,1,EQGK11,"Based on observation, interview, and record review, the facility failed to safely store six oxygen tanks for 1 (#100) of 31 sampled and supplement residents. This had the potential to affect other residents living on the 100 unit. Findings include: During an observation on 8/20/19 at 11:30 a.m., six oxygen tanks were observed in a cardboard container next to the sink area in resident #100's room. During an observation on 8/21/19 at 12:50 p.m., the six oxygen tanks remained in resident #100's room, in the same carboard container next to the sink area. During an interview on 8/21/19 at 1:05 p.m., staff member A stated, the resident was on hospice and (name of company) delivered resident #100 the oxygen tanks. She stated (name of company) was to put the tanks in the storage room. Staff member A stated if (name of company) did not put the tanks in the storage room then the staff were to move the tanks to the storage room. During an interview on 8/22/19 at 7:40 a.m., staff member B stated the oxygen tanks were not supposed to be in the resident room. She stated they should be stored in the oxygen room. During an interview on 8/22/19 at 7:48 a.m., staff member C stated the tanks should be stored in the oxygen room. She stated there was a very high chance of the tanks exploding. She stated the tanks should only be in the resident room if they were in use and they should be in the container. Review of the facility policy titled Oxygen Storage showed, . it is the policy of the facility to store oxygen safely and properly .",2020-09-01
208,AVANTARA OF BILLINGS,275029,2115 CENTRAL AVE,BILLINGS,MT,59102,2019-08-22,710,D,0,1,EQGK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have the physician evaluate and address the changing nutritional status, and the development of a pressure ulcer, for 1 (#70) of 30 sampled residents. Findings include: During an observation on 8/21/19 at 10:00 a.m., resident #70 had a quarter sized reddened area on his right trochanter. Review of resident #70's progress note, dated 6/3/19, showed an open sheer skin 2 cm x 2 cm wound, bordered by scar tissue from a previous ulcer. During an interview on 8/22/19 at 4:30 p.m., staff member A stated the only evidence the facility had regarding evaluation of the pressure injury for resident #70, by the physician, was the initials of the physician assistant at the bottom of the progress note. The initials were not dated. Review of resident #70's progress note, dated 8/17/19, showed the resident had a 'great decline' and was Barely eating anything, today he had two bites for breakfast and the same amount for lunch, increased sleeping, lost 13 pounds in one week, he is no longer trying to get up on his own, very weak and stiff, afraid to fall, note in provider box. Documentation of the physician's evalution of the decline in resident #70's status was not provided by the facility. Review of the facility's Weight Monitoring Policy showed, The physician should be encouraged to document the [DIAGNOSES REDACTED].",2020-09-01
209,AVANTARA OF BILLINGS,275029,2115 CENTRAL AVE,BILLINGS,MT,59102,2018-09-06,657,D,1,0,J9SE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to update care plans, causing increased bowel incontinence, for 1 (#1); and increased anxiety for 1 (#3) of 17 sampled residents. Findings include: 1. During an observation on 9/4/18 at 1:53 p.m., a handwritten sign had been taped up on resident #1's bathroom door. The sign read, To be toileted 5 times a day per MD order. During an interview on 9/4/18 at 2:04 p.m., NF1 said resident #1 had bowel issues. NF1 said the resident had several bowel resections, irritable bowel syndrome, and had constant diarrhea. NF1 said the resident needed to go the bathroom after each meal because food runs right through him. NF1 said this was a constant problem and had been for years. NF1 said resident #1 had been to a gastrointestinal doctor, in (YEAR), and he was unable to do anything for the resident's constant diarrhea other than prescribe an anti-diarrhea medicine and fiber. NF1 said the gastrointestinal doctor had written an order for [REDACTED]. During an observation on 9/5/18 at 12:15 p.m., resident #1 was seated in the dining room visiting with another resident at his table. During an observation on 9/5/18 from 12:35 p.m. to 2:45 p.m., resident #1 was seated at his table in the dining room. The resident had completed his meal, and was sleeping. A kitchen staff member woke resident #1 up as the staff member was cleaning the resident's table off. The resident moved to a chair in the dayroom. The resident was not assisted to the bathroom after the meal. During an interview on 9/5/18 at 3:31 p.m., staff member C said said staff were supposed to assist resident #1 to the bathroom several times a day to help with the resident's incontinence issues. During observations on 9/6/18 at: - 8:01 a.m., resident #1 was eating breakfast in the dining room, - 8:19 a.m., resident #1 had finished eating and was still seated in the dining room, - 8:45 a.m., resident #1 was still seated in the dining room. The resident was sleeping. The resident was not assisted to the bathroom after the meal. During an observation on 9/6/18 at 8:55 a.m., resident #1 was woken up by a kitchen staff member cleaning off the resident's table. The resident moved to a chair in the dayroom. No staff members were seen approaching the resident, to assist him to the bathroom, from 8:01 a.m. to 8:55 a.m., when he moved himself into the dayroom. During an interview on 9/6/18 at 11:15 a.m., staff member A said resident #1 did have diarrhea constantly. Staff member A said she had been the unit manager of the Crossroads unit where resident #1 lived. Staff member A said the resident would have a diarrhea episode in his incontinence product, go to his room, and try to change his clothes by himself. Staff member A said when that happened, resident #1 would get feces on his clothing and shoes. Staff member A said the resident was a very private person and he appeared to be embarrassed by his incontinent episodes. Staff member A said resident #1 had a physician's orders [REDACTED]. Staff member A said the resident's diarrhea concerns were not identified on resident #1's care plan. Staff member A said the physician's orders [REDACTED]. Review of resident #1's (MONTH) (YEAR) Medication Administration Record [REDACTED] - [MEDICATION NAME] 4 gram packet, in 6-8 ounces of water, every day, - [MEDICATION NAME] powder 3 gram/3.5 gram, twice a day, and - Anti-diarrhea 2 milligrams, two tablets, three times a day. Review of resident #1's medical record showed a physician's orders [REDACTED]. Review of resident #1's Quarterly MDS, with an ARD of 7/4/18, Section H, H0400, showed the resident was frequently incontinent of bowel. Review of resident #1's Quarterly MDS, with an ARD of 10/6/17, Section H, H0400, showed the resident was continent of bowel, reflecting a decline in bowel status had occurred. Review of resident #1's current care plan showed as a focus, date initiated 4/5/18: The resident has an ADL Self Care Performance Deficit r/t Impaired balance, weakness, Cognitive impairment. One of the Goals, target date of 10/02/18, was: The resident will maintain current level of function in Toilet. The related intervention, date initiated was 7/17/18, showed: Offer and assist (name) to the restroom every 2-3 hours. Assist with any personal hygiene that (name) may need. 2. During an interview on 9/6/18 at 11:15 a.m., staff member A said the staff did have problems getting resident #3 to shower. Staff member A said resident #3 experienced increased anxiety because she did not like to get her hair wet or shampooed. Staff member A said that concern was not identified on the resident's current care plan. Review of resident #3's bathing records for (MONTH) and (MONTH) of (YEAR) showed: - No shower from (MONTH) 24 to (MONTH) 3 of (YEAR), - No shower from (MONTH) 17 to (MONTH) 28 of (YEAR). Review of resident #3's Quarterly MDS, with an ARD of 7/31/18, Section G, G0120, showed the resident did not have a shower in the seven day look back period. Section N, N0410, B, showed the resident had received antianxiety medication six days of the seven day look back period.",2020-09-01
210,AVANTARA OF BILLINGS,275029,2115 CENTRAL AVE,BILLINGS,MT,59102,2018-09-06,675,E,1,0,J9SE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to provide a shower or bath in a seven day period, which affected the self esteem, for 1 (#2) and; affected the quality of life for 5 (#s 3, 4, 5, 6, and 9) of 17 sampled residents. Findings include: 1. During an observation on 9/4/18 at 1:55 p.m., resident #2's t-shirt was stained and soiled. The resident's hair appeared oily. During an interview on 9/6/18 at 8:19 a.m., resident #2 said he had gone longer than seven days without a shower. The resident said he had gone up to ten days without a shower. Resident #2 said due to his [MEDICAL CONDITION], incontinent issues, and obesity, he liked to have a shower twice a week. Resident #2 indicated his physical presence with a sweep of his hand, and said he did not want to have body odors. Resident #2 said he did not like going over seven days between showers. Review of resident #2's bathing record for (MONTH) of (YEAR) showed no shower from (MONTH) 10 to (MONTH) 21 of (YEAR). Review of resident #2's Annual MDS, with an ARD of 8/7/18, Section G, G0120, showed the resident required the physical assistance of one staff for bathing. 2. During an interview on 9/6/18 at 10:25 a.m., resident #4 said she did not like going over a week without a shower because she did not like her hair being oily or to feel dirty. The resident said there were a couple of times she had gone longer than seven days between showers. Review of resident #4's bathing records for (MONTH) and (MONTH) of (YEAR) showed: - No shower from (MONTH) 18 to (MONTH) 28 of (YEAR), - No shower from (MONTH) 3 to (MONTH) 13 of (YEAR). Review on resident #4's Admission MDS, with an ARD of 6/23/18, Section G, G0120, showed the resident had not received a shower or bath in the seven day look back period. 3. During an interview on 9/6/18 at 9:05 a.m., resident #6 said he was supposed to get a shower twice a week. The resident said he did not like it when he could smell himself. Review of resident #6's bathing records for (MONTH) and (MONTH) of (YEAR) showed: - No shower from prior to (MONTH) 1 to (MONTH) 10 of (YEAR), - No shower from (MONTH) 29 to (MONTH) 10 of (YEAR), - No shower from (MONTH) 11 to (MONTH) 24 of (YEAR). Review of resident #6's Quarterly MDS, with an ARD of 7/27/18, Section G, G0120, showed the resident was totally dependent on one staff for bathing. 4. During an observation 9/4/18 at 5:05 p.m., resident #5 was in the dining room. He was visiting with other residents. Resident #5's hair appeared to be oily, and his shirt was stained. During an interview on 9/6/18 at 10:45 a.m., resident #5 said he wanted a shower at least one time a week. The resident said he did not like being dirty or smelly. Review of resident #5's bathing records for (MONTH) (YEAR) showed no shower was provided, from (MONTH) 9th to (MONTH) 20th, of (YEAR). Review of resident #5's Quarterly MDS, with an ARD of 6/14/18, Section G, G0120, showed the resident was totally dependent on two staff for bathing. 5. During an interview on 9/6/18 at 11:15 a.m., staff member A said resident #3 was difficult to bathe because the resident did not like to have her hair shampooed. Review of resident #3's bathing records for (MONTH) and (MONTH) of (YEAR) showed: - No shower from (MONTH) 24 to (MONTH) 3 of (YEAR), - No shower from (MONTH) 17 to (MONTH) 28 of (YEAR). Review of resident #3's Quarterly MDS, with an ARD of 7/31/18, Section G, G0120, showed the resident did not have a shower in the seven day look back period. 6. Resident #9 had a [DIAGNOSES REDACTED]. Review of resident #9's bathing records for (MONTH) and (MONTH) of (YEAR) showed: - No shower from prior to (MONTH) 1 to (MONTH) 13 of (YEAR), - No shower from (MONTH) 21 to (MONTH) 31 of (YEAR). Review of resident #9's Annual MDS, with an ARD of 8/1/18, Section G, G0120, showed the resident was totally dependent on two staff for bathing. During an interview on 9/5/18 at 7:53 a.m., staff member A said it was her expectation that residents would receive showers or baths twice a week. Staff member A said all residents were bathed at least every seven days. Staff member A said the facility was in the process of hiring a bath aide for the Crossroads unit. During an interview on 9/5/18 at 3:43 p.m., resident #12 said she lived on the Crossroads unit. Resident #12 said she always got a bath twice a week. The resident said she knew of other residents, on the Crossroads unit, that did not even get a bath once a week. Resident #12 said one day recently, in the last week, a CNA had been scheduled to do baths for the day. The resident said the CNA got two of the scheduled seven resident baths done. Resident #12 said the CNA had sat at the Crossroads unit nursing station the rest of the day.",2020-09-01
211,AVANTARA OF BILLINGS,275029,2115 CENTRAL AVE,BILLINGS,MT,59102,2018-09-06,755,C,1,0,J9SE11,"> Based on interview and record review, the facility failed to provide physician ordered medications in a timely manner. This deficient practice, due to the prescribed medication refills not being reordered timely manner and running out, caused increased pain for 1(#14) of 17 sampled residents; and had the potential to affect all residents residing in the facility as it was a systems issue. Findings include: During an interview on 9/4/18 at 4:07 p.m., staff member A said the facility had started Ad-Hoc quality assurance meetings. The provision of medications, timeliness of administration, and reordering of medications had been identified as a concern in the facility. Staff member A said these concerns were being followed up on, audited, and reported to the monthly quality assurance committee. During an interview on 9/5/18 at 3:10 p.m., resident #14 said there had been a time when the facility did not have her pain medications to give her. Resident #14 said this had happened several times, causing her an increase in pain. Resident #14 was not able to pin-point a specific time frame for these incidents. During an interview on 9/6/18 at 12:30 p.m., staff member A said the facility did have a problem with pharmacy services several months ago and with the residents receiving their medications on time. Staff member A said the facility had a pharmacy in the building at one time but that service had been discontinued. Staff member A said a pharmacy company outside the facility was now providing services to the facility, and when that company first took over it was difficult. Staff member A said the nursing staff did not understand how to monitor and reorder medications in a timely manner. Staff member A said the outside pharmacy was not providing over the counter medications either, and the facility had to put a system in place to address that. Staff member A said this concern was being addressed by the facility's quality assurance committee. Review of the facility's Ad-Hoc agendas showed the facility was addressing the identified concerns, lack of staff training, and systems failures for: the provision of medications, timeliness of administration, and reordering of medications, but the concern was still being addressed. Review of the facility's policy, Providing Pharmacy Products and Services, showed, 4.1 If a medication is considered essential and cannot be substituted or delayed, contact the emergency number provided by pharmacy. and Orders should be received directly from a facility nurse or a licensed physician/prescriber .",2020-09-01
212,AVANTARA OF BILLINGS,275029,2115 CENTRAL AVE,BILLINGS,MT,59102,2017-11-21,202,D,1,1,S6P111,"> Based on record review and interview, the facility failed to complete the discharge process for 1 (#23) of 23 sampled residents. Findings include: Resident #23 was admitted to the facility for post surgical care. Review of resident #23's medical records showed the resident discharged from the facility on 2/17/17. Physician orders for medications, home health, and continued physical therapy, were signed by the physician. The physician orders did not show a reason the resident was being discharged from the facility. A review of resident #23's facility generated document titled, Discharge Summary - Recapitulation of Stay was found in resident #23's record. The document was not complete, and had not been signed by the physician. Review of resident #23's document, titled Assessment, dated 2/6/17, showed the resident would discharge home, via car, no equipment was needed and services and referrals included home health, occupational therapy and physical therapy, medications ordered from the pharmacy, diet information, appointments, functional status, and documents given on discharge. This document contained an area for the medical provider to sign and date. This area was blank. During an interview on 11/21/17 at 9:35 a.m., staff member K said she thought the discharge to home orders signed by the physician at the end of resident #23's stay constituted a Recapitulation of Stay. Staff member K said she was sure the physician would have a discharge summary in the records at his office, but that discharge summary would not be part of resident #23's record at the facility. Staff member K said the Discharge Summary - Recapitulation of Stay would not be signed by the physician since the facility really doesn't use it. Staff member K said the facility used the physician's orders for this purpose. Review of the facility's policy titled; Discharge Summary and Plan of Care showed: Upon discharge of a resident (other than in emergency to hospital or death) a discharge summary is provided to the receiving care provider. The Discharge Summary should include: 1. A recapitulation of the resident's stay that includes but not limited to: diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. 2. A final summary of the resident's status at the time of discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative. 3. Reconciliation of all pre-discharge medications with the resident's post discharge medication to include prescription and over the count medications.",2020-09-01
213,AVANTARA OF BILLINGS,275029,2115 CENTRAL AVE,BILLINGS,MT,59102,2017-11-21,248,D,1,1,S6P111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to provide individual activities designed to meet the individual interests of, and support the physical, mental, and psychosocial well-being, for 1 (#1) of 23 sampled residents. Findings include: Resident #1 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The resident was discharged from the facility on 8/21/17. Review of resident #1's Admission MDS, with an ARD of 4/24/17, section C, showed the resident had a BIMS of 15; cognitively intact. Review of this MDS, section F 0500, Activity Preferences, showed it was very important for resident #1 to read books, newspapers, and magazines. It also showed it was very important for resident #1 to be around animals such as pets, and it was very important for resident #1 to go outside to get fresh air when the weather was good. Review of resident #1's Care Plan, with a goal date of 10/31/17, showed, Interventions- (resident's name) enjoys reading hood books (style of book), listening to all types of music, sometimes keeping up with the news, some socializing, being with family and friends, going outside for fresh air, going out to eat, visiting with others at times, traveling, playing solitaire and poker, playing football and basketball, watching movies and comedies, beading, fishing, using his kindle, attending movies, rodeos, powwows, the [MEDICATION NAME], and being around pets. Review of resident #1's Activities Engagement Records showed facility staff documented the following: - (MONTH) (YEAR): the resident watched TV daily, and had Family visits most days. He refused one event titled, Outing. - (MONTH) (YEAR): the resident watched TV daily, and he had weekly visits from family members. The resident participated in one movie provided by the facility, and participated in five events titled, Social/Parties. - (MONTH) (YEAR): the resident watched TV daily, and he had weekly visits from family members. The resident participated in one event titled Candy Store, one event titled, Games/Cards, and participated in one event titled, Socials/Parties. - (MONTH) (YEAR): the resident watched TV daily, and he had weekly visits from family members. The resident participated in one event titled, Socials/Parties. - (MONTH) (YEAR): the resident watched TV and listened to the radio daily, and had weekly visits from family members. The resident participated in one event titled, Socials/Parties. Review of resident #1's Clinical Notes, dated 5/11/17 at 2:11 p.m., showed, Resident for the past two days has been refusing to participate with therapies, refusing meds (sic), sleeping late, crabby with staff when they attempt to get him up .He is a younger Resident (sic) et is bored . During an interview on 11/21/17 at 9:13 a.m., staff member F stated resident #1 was admitted to the facility as a short-term rehabilitation resident. She stated the facility did not have, therefore, did not provide, Hood books, which were geared towards the younger generations. Staff member F stated the resident chose not to attend activities provided by the facility. She stated she did not have a way of documenting the resident's refusals on the Activities Engagement Records. During an interview on 11/21/17 at 11:42 a.m., resident #1 stated he was frequently bored while at the facility, and was not provided hood books which were very important to him. The resident stated in mid-July (YEAR) he was moved to a different room, and did not have easy access to a TV. He stated, It felt like jail.",2020-09-01
214,AVANTARA OF BILLINGS,275029,2115 CENTRAL AVE,BILLINGS,MT,59102,2017-11-21,250,E,1,1,S6P111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, observation, and interview, the facility failed to provide adequate social service interventions for adjustment to the facility, decreased mood, and discharge planning, for 3 (#s 10, 17 and 23) of 23 sampled residents. Findings include: 1. During an interview and observation on 11/19/17 at 12:30 p.m., resident #17 stated her mood mostly sucks. She stated her ADL's had worsened since her admit in (MONTH) (YEAR). She said she could not receive therapy until recently due to her insurance. She stated she was only [AGE] years old, and did not want to be in a nursing home. Her affect was flat. Review of resident #17's care plan for Potential for alteration in comfort related to depression showed interventions regarding pain medication. Her depression was not addressed on the care plan. During a second interview on 11/21/17 at 10:40 a.m., resident #17 stated she was relatively depressed, and her goal was to get out of the nursing home. She stated she was in a lot of pain, and nothing seemed to help. Staff member N stated the resident did not have anything she could give her for pain, but she would call the MD. Resident #17 asked for an antianxiety pill, and was not aware the MD had decreased the medication to evening only. During an interview on 11/20/17 at 9:30 a.m., staff member [NAME] stated she had visited with resident #17, but nothing was documented. There was no initial formal social service assessment. She stated the resident did have a flat affect, but was excited about a new grandchild. Staff member [NAME] was not aware of any discharge plan. She was not aware of resident #17's feelings of depression. She stated the facility would have a care conference in the near future for resident #17. 2. Review of resident #10's medical record showed she admitted to the facility on [DATE], discharged [DATE], after a fall with a cerebral hemorrhage, and readmitted on [DATE]. Review of resident #10's Admission MDS, with the ARD of 11/01/17, showed the resident had severe cognitive impairment. During observations on 11/19/17, 11/20/17, and 11/21/17, resident #10 was tearful, and unable to explain what she was feeling. During an observation on 11/19/17 at 10:20 a.m., resident #10's family member was sitting on her bed, crying. He stated nobody gives a damn, and walked away, referring to facility staff. During an interview on 11/20/17 at 11:00 a.m., staff member I stated the resident and her husband were having a difficult time adjusting to the nursing home. She also stated the resident .went downhill pretty quickly, according to her husband. Review of resident #10's care plan, dated 10/27/17, showed no concerns for mood or adjustment issues at the facility. During an interview on 11/20/17 at 3:08 p.m., staff member [NAME] stated she had completed resident #10's social service assessment on 11/16/17, which was late, because she was behind on her assessments. She was not aware of resident #10's sad mood or adjustment problems at the facility. 3. Resident #23 was discharged to home on 2/17/17. Review of resident #23's 5-Day MDS, with an ARD of 1/19/17, showed section Q0300, Resident's Overall Expectations, was blank. Section Q0400 showed there was no discharge plan in place for resident #23. Review of resident #23's 30-Day MDS, with an ARD of 2/8/17, showed section Q0300, Resident's Overall Expectations, was blank. Section Q0400 showed there was no discharge plan in place for resident #23. Review of resident #23's Discharge MDS, with an ARD of 2/17/17, showed section A0310, F. coded as Discharge: return not anticipated, and as an unplanned discharge to the community. Review of resident #23's Assessment document, dated 2/6/17, showed the facility had started the discharge process for resident #23 on that date. During an interview on 11/21/17 at 9:25 a.m., staff member [NAME] said section Q of the MDS should be completed and should show if discharge planning was being done. Staff member [NAME] said social services would be the department that would complete sections A and Q of the MDS. Staff member [NAME] said she had just started working at the facility when resident #23 discharged from the facility. Review of a facility policy titled, Discharge Summary and Plan of Care showed under 1. b., During the initial Discharge Comprehensive Assessment, the social service designee should determine the resident and family's goals for discharge and the support systems available to the resident.",2020-09-01
215,AVANTARA OF BILLINGS,275029,2115 CENTRAL AVE,BILLINGS,MT,59102,2017-11-21,278,F,0,1,S6P111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately complete MDSs by: failing to complete MDSs in the specified 14 day time frame based on the RAI manual instructions, and failed to have a registered nurse sign the assessments after the 14 day requirement certifying the assessments were complete for 5 (#s 2, 7, 11, 15, 18); failed to accurately show the vaccination status and attempt resident the resident interview, for 1 (#11); and failed to accurately show stagable and unstageable ulcers and deep tissue injuries for 1 (#2) of 23 sampled residents. Findings include: 1. Review of resident #15's Admission MDS, with an ARD of 3/1/17, showed a completion date of 4/3/17. The assessment was not completed timely. Review of resident #15's Quarterly assessment, with an ARD of 8/28/17, showed a completion date of 10/2/17. The assessment was not completed timely. During an interview on 11/20/17 at 11:00 a.m., staff member G said, We have had a turnover of four MDS staff over the course of one year, so there has been no consistency (in updating and input of MDS data.) 2. Review of resident #2's Quarterly MDS, with an ARD of 7/11/17, showed a completion date of 8/21/17. This was a span of 42 days, and did not meet the required MDS completion timeline. Review of resident #2's Quarterly MDS (section M), with an ARD of 7/11/17, showed resident #2 had no pressure ulcers. Review of Clinical notes dated 6/27/17, showed resident #2 had three, active, stagable or unstageable wounds. Review of resident #2's Clinical Notes from 6/27/17 to 7/11/17 showed no evidence the ulcers had been resolved. During an interview on 11/21/17 at 11:00 a.m., staff member Q said, We have had some issues with staffing. Some nurses have had problems, and there was turn over. Others we have hired did not actually work out. We have a new MDS nurse now so that should help out. She said to determine that resident #2 did not have skin issues she looked back through the seven day assessment window. She had not seen documentation of a wound and did not believe resident #2 had a wound during that time period. For this reason, no wounds were entered in the MDS. 3. Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #7's Annual MDS, with an ARD of 3/13/17, showed a completion date of 4/10/17. Review of resident #7's Quarterly MDS, with an ARD of 3/13/17, showed sections D0200, D0300, and E0100 through E1100 were dashed (not assessed). These sections provide assessment information regarding the resident's mood and behaviors, depression severity, hallucinations and/or delusions, and behaviors with impact affecting the resident and/or others. In an interview on 11/20/17 at 9:15 a.m., staff member [NAME] said she did not know why resident #7's 3/13/17 Quarterly assessment sections D and [NAME] had not been completed. She said at that time she was new to the facility, and she probably had not yet had direct contact with resident #7. Review of resident #7's Quarterly MDS, with an ARD of 9/12/17, showed a completion date of 10/9/17. This date exceeded the 14 day completion requirement by 13 days. 4. a. Review of resident #11's Admission MDS, with an ARD of 8/4/17, showed the influenza vaccination had been offered and declined. During an interview and record review on 11/20/17 at 11:40 a.m., staff member Q stated the answers for the vaccination questions came from an assessment document completed by the staff nurses. Review of resident #11's nursing assessment document, with staff member Q, showed the resident had been offered an influenza vaccination and had declined. She stated the timeframe for the Admission MDS was outside of the influenza season and should have been coded as, resident not in this facility during (the) influenza season. During an interview on 11/20/17 at 3:10 p.m., NF2 stated she had authorized the facility to provide an influenza vaccine, and declined for resident #11 to receive a pneumococcal vaccine. b. Review of resident #11's Admission MDS, with an ARD of 8/4/17, and a Significant Change in Status MDS, with an ARD of 11/1/17, showed resident #11 was sometimes able to make herself understood. Sections C and D of the MDS's were coded that the resident should not be interviewed because she was rarely or never understood. During an interview on 11/20/17 at 11:40 a.m., staff member Q stated staff member [NAME] was responsible for coding MDS sections C and D. During an interview on 11/20/17 at 5:30 p.m., staff member [NAME] stated she completed sections C and D on resident #11's Admission and Significant Change in Status MDS's. Staff member [NAME] said the resident interview should be attempted for all residents, including resident #11. She stated she determined when talking to the resident whether the resident was interviewable. Staff member [NAME] was uncertain why she had coded resident #11 as rarely or never understood when section B showed the resident was sometimes understood. During an interview on 11/21/17 at 10:36 a.m., staff member [NAME] stated she had completed sections C and D within the assessment reference period, but section B was not completed timely so she determined through her own personal assessment that resident #11 should not be interviewed. During an interview on 11/21/17 at 12:12 p.m., staff member [NAME] stated she could not determine a resident's interview status independently, and the coding of resident #11's interview status should have been based on the communication assessment completed for section B. c. Review of resident #11's Admission MDS, with an ARD of 8/4/17, showed a completion date of 9/14/17. This was a span of 42 days. Review of resident #11's Significant Change in Status MDS, with an ARD of 11/1/17, showed no completion date, and had questions that had not been answered as of 11/20/17. The assessment was incomplete. During an interview on 11/20/17 at 11:40 a.m., staff member Q stated the facility had fallen behind the required completion schedule. She said this had been identified as an issue several months ago and the facility had hired new staff, and brought in outside resources to assist in catching up. Staff member Q said the MDS currently in progress for resident #11 was late. 5. Review of resident #18's Annual MDS, with an ARD of 2/15/17, showed a completion date of 3/15/17. This is a span of 29 days. Review of resident #18's Quarterly MDS, with an ARD of 8/18/17, showed a completion date of 9/19/17. This is a span of 33 days. During an interview on 11/20/17 at 12:00 noon, staff member R stated he had been training staff related to MDS coding and completing MDS's intermittently to help them catch up. Staff member R said the issue of late MDS's had been identified, and an action plan was developed and implemented through the QAPI process. He stated additional resources had been delegated to help the facility get current with the MDS process.",2020-09-01
216,AVANTARA OF BILLINGS,275029,2115 CENTRAL AVE,BILLINGS,MT,59102,2017-11-21,280,E,1,1,S6P111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure the resident was provided the opportunity to have a care plan meeting and participate in their own treatment, for 3 (#s 4, 5, 15); the facility failed to review and revise the care plan to accurately reflect a resident's changing care needs for impaired skin integrity for 1 (#2) of 23 sampled residents. Findings include: 1. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #4 has been a resident at the facility for over one year. During an interview on 11/19/17 at 3:55 p.m., resident #4 stated she had been to one care plan conference meeting since her admission. Resident #4 stated she had not participated in a care conference meeting for several months. During an interview on 11/20/17 at 2:55 p.m., resident #4 stated she had asked staff several times for ice to be placed in her water. Resident #4 stated staff was supposed to pass fresh water every shift, but many times they did not have time. Resident #4 stated she had a catheter and was prone to urinary tract infections and must have a lot of water. Resident #4 stated she had a difficult time drinking water if it was room temperature. Resident #4 stated she had told staff several times she did not want to continue to take her medication, Senna, as it caused her to have diarrhea. Resident #4 stated the nurses continued to give it to her, and she had refused to take it. The resident did not understand why the nurses did not call her physician and notify him that she did not want the medication scheduled daily. Resident #4 did not have an opportunity to report her concerns at her care plan meeting, or request that a change be made to her care plan, to address the need for ice water. She was unable to discuss the change of treatment to address the prescribed Senna. Review of resident #4's medical record did not include documentation, through notes or signatures of participation, that the resident had participated in a care plan process. 2. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #5's medical record did not include documentation, through notes or signatures of participation, that the resident participated in a care plan process. A request was made for documentation that would reflect resident #5 attended a care conference meeting quarterly and annually, but not received. During an interview on 11/20/17 at 2:10 p.m., staff member J stated there were no care plan meetings documented for resident #5. Staff member J stated the Social Services department was responsible for scheduling care conferences. During an interview on 11/21/17 at 8:00 a.m., staff member [NAME] stated care conferences were to be scheduled by the Social Services department. Staff member [NAME] stated a letter was sent to the resident's family member or representative to notify them of the care conference meeting date and time. Staff member [NAME] stated residents were notified face to face by the Social Service department. Staff member [NAME] stated the resident would be given a face to face reminder of the care conference the day before it was scheduled. Staff member J stated she did not have additional documentation that resident #4 and #5 were provided a care plan conference meeting quarterly or annually. Staff member J stated when the facility document, titled Care Conference, was completed, then the document was given to medical records to be scanned into the resident's medical record. Review of the facility policy and procedure titled, Care Conference, showed the resident had the right to attend care conference meetings to identify goals for admission and desired outcomes, to express individual preferences, and review current plans of care. During an interview on 11/20/17 at 2:10 p.m., staff member J stated there were no other care plan meetings documented for residents #4 and #5 other than what was submitted to the surveyor for resident #4. 3. During an interview on 11/20/17 at 12:30 p.m., resident #15 said she had never had a care plan meeting and was not invited to care plan meetings. During an interview on 11/19/17 at 5:00 p.m., staff member [NAME] said resident #15 did not receive a specific invitation to a care plan meeting because a specific meeting was not held. She said staff communicated frequently with resident #15 and this was how they incorporated the resident into the care planning process. 4. During an interview on 11/19/17 at 4:00 p.m., resident #2 said she had never attended a care plan meeting and had not been invited to care plan meetings. Resident #2 said she had many discussions with staff at the facility. Resident #2 said there had been challenging situations during her stay at the facility, and she expressed concerns, but wanted those concerns to remain private. During an interview on 11/19/17 at 5:00 p.m., staff member [NAME] said the latest reviews, for residents #2 and #15, were conducted by gathering collective data. She said this system was also used to develop the assessments and care plan for resident #2. No actual IDT care planning meetings had been held. A review of the facility's Care Conference Action Plan, dated 11/13/17, showed a lack of actual care conferences taking place, and the failure to ensure residents were invited to participate in the care planning, had been identified by the facility as a concern. A plan of correction was in place for the concern. The facility had not had enough time to fully implement and evaluate the correction(s) made on the identified concern. During an interview on 11/20/17 at 10:50 a.m., staff member J said, What they (the facility) were doing is implementing a new written process for residents to receive an invitation to their care conference. This was started last week. We had identified the problem. 5. During an interview on 11/20/17 at 1:30 p.m., seven residents were present. During the interview the residents said they had not been invited to their care conferences. The group of residents said the last time any one of them could remember invitations to care conferences was last Spring. Another resident said he had notified of only three care conferences in the last two years. During an interview on 11/21/17 at 9:25 a.m., staff member FF said she just found out residents and family members were supposed to be invited to care conferences. Staff member FF said she had not been doing that. Staff member FF said she had a list of all the care conferences scheduled for the next two weeks, and she was in the process of sending out invitations.",2020-09-01
217,AVANTARA OF BILLINGS,275029,2115 CENTRAL AVE,BILLINGS,MT,59102,2017-11-21,281,E,1,1,S6P111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to administer insulin as prescribed by the attending physician for 1 (#5); and failed to accurately document the administration of narcotic medications in the EMR and Controlled Substance Treatment Book for 1 (#1) of 23 sampled residents. Findings include: 1. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #5's medication administration record, dated (MONTH) (YEAR), showed several doses of [MEDICATION NAME]had not been administered according to the attending physician's orders [REDACTED].>Review of resident #5's administration of [MEDICATION NAME] 100 unit/ml subcutaneous before meals, with a start date of 8/4/17, reflected several doses had not been given by the nurse per the sliding scale order according to resident #5's blood glucose level. Review of resident #5's medication administration record for (MONTH) (YEAR) showed: -11/1/17 for the p.m. dose, resident #5 was administered 9 units of insulin for a blood glucose recording of 305 by staff member S. The resident should have received 10 units. -11/3/17 for the a.m. dose, resident #5 received 3 units for a blood glucose recording of 204 by staff member T. The resident should have received 6 units. -11/9/17 for the noon dose, resident #5 received 6 units for a blood glucose recording of 290 by staff member T. The resident should have received 10 units. -11/11/17 for the p.m. dose, resident #5 received 6 units for a blood glucose recording of 258 by staff member S. The resident should have received 8 units. -11/19/17 for the noon dose, resident #5 received 5 units for a blood glucose recording of 284 by staff member T. The resident should have received 10 units. During an interview on 11/21/17 at 10:15 a.m., staff member S stated resident #5 was to receive insulin only if she ate her full meal. Staff member S stated the blood glucose amount and insulin were entered manually into the electronic medical record. Staff member S stated she noticed the window (for the electronic medical record system) on the resident's order, shifts. During an interview on 11/21/17 at 11:50 a.m., staff member T stated she does not give resident #5 the insulin if she does not eat. Staff member T stated she used her nursing judgement and if the resident ate half of her meal she would adjust and give less units. Staff member T stated if resident #5 ate all of her meal she would follow the sliding scale. Review of a facility policy and procedure titled, Medication Administration, showed, Medications will be administered to residents as prescribed by the physician or only by persons lawfully authorized to do so in a safe and prudent manner. Review of the facility standard of practice showed the facility used the American Association of Diabetes Education to train the nursing staff on 7/18/17 and 7/25/17, regarding teaching injection practices to people with diabetes. 2. Resident #1 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The resident was discharged from the facility on 8/21/17. Review of resident #1's Admission MDS, with an ARD of 4/24/17, section C, showed the resident had a BIMS of 15; cognitively intact. Review of this MDS, section J, showed the resident had frequent episodes of pain, which measured 7 of 10 on the pain scale. The pain interfered with resident #1's day-to-day activities. Review of resident #1's Quarterly MDS, with an ARD of 7/17/17, showed the resident was in pain almost constantly. The pain measured 9 of 10 on the pain scale. The pain interfered with day-to-day activities, and made it hard for the resident to sleep at night. Review of resident #1's (MONTH) (YEAR) recapitulation Physician Orders, showed the following had been ordered for pain management: - [MEDICATION NAME], 15 mg extended release, three tablets every 12 hours. - [MEDICATION NAME], 2 mg tablet, one tablet if pain was 5 of 10 on the pain scale, and two tablets when the pain was 6 of 10 on the pain scale, every 4 hours as needed for pain. Review of resident #1 MARs (Medication Administration Record) showed the following: - (MONTH) (YEAR); Orders showed [MEDICATION NAME] 2 mgs and 4 mgs, as needed, every four hours (for pain). a. On 4/17/17 at 8:58 p.m., staff documented in resident #1's MAR that his pain was at a 10 of 10 on the pain scale. Staff had documented the administration of [MEDICATION NAME] 4 mgs at 6:10 p.m., and 9:00 p.m. in the Controlled Substance Treatment Book. Resident #1's MAR did not match the Controlled Substance Treatment Book. - (MONTH) (YEAR); Orders showed [MEDICATION NAME] 2 mgs, 1-2 tablets, as needed every four hours (for pain). b. On 5/3/17 at 12:30 p.m., staff documented in resident #1's MAR that his pain level was a 6 of 10 on the pain scale, and the resident was administered [MEDICATION NAME] 4 mgs. A review of the Controlled Substance Treatment Book did not show the resident had been given [MEDICATION NAME] 4 mgs at 9:19 a.m. Resident #1's MAR did not match the Controlled Substance Treatment Book. c. On 5/17/17 at 9:09 p.m., staff documented in resident #1's MAR that his pain level was an 8 of 10 on the pain scale, and the resident was administered [MEDICATION NAME] 4 mgs. A review of the Controlled Substance Treatment Book did not show the resident had been given [MEDICATION NAME]. Resident #1's MAR did not match the Controlled Substance Treatment Book. d. On 5/19/17 at 8:39 p.m., staff documented in resident #1's MAR that his pain level was a 6 of 10 on the pain scale, and the resident was administered [MEDICATION NAME] 4 mgs. A review of the Controlled Substance Treatment Book showed the resident had been given [MEDICATION NAME] 4 mgs at 10:45 p.m. Resident #1's MAR did not match the Controlled Substance Treatment Book. e. On 5/20/17 at 9:26 p.m., staff documented in resident #1's MAR that his pain level was an 8 of 10 on the pain scale, and the resident had been administered [MEDICATION NAME] 4 mgs. A review of the Controlled Substance Treatment Book did not show the resident had been given [MEDICATION NAME]. Resident #1's MAR did not match the Controlled Substance Treatment Book. f. On 5/21/17 at 12:52 p.m., staff documented in resident #1's MAR that his pain level was a 6 of 10 on the pain scale, and the resident had been administered [MEDICATION NAME] 4 mgs. A review of the Controlled Substance Treatment Book showed the resident had been given [MEDICATION NAME] 2 mgs. Resident #1's MAR did not match the Controlled Substance Treatment Book. g. On 5/21/17 at 8:51 p.m., staff documented in resident #1's MAR that his pain level was an 8 of 10 on the pain scale, and the resident had been administered [MEDICATION NAME] 4 mgs. A review of the Controlled Substance Treatment Book did not show the resident had been given [MEDICATION NAME]. Resident #1's MAR did not match the Controlled Substance Treatment Book. h. On 5/21/17 at 10:00 a.m., staff documented in resident #1's MAR that his pain level was a 5 of 10 on the pain scale, and the resident had been administered [MEDICATION NAME] 4 mgs. A review of the Controlled Substance Treatment Book reflected the resident was given [MEDICATION NAME] 2 mgs. Resident #1's MAR did not match the Controlled Substance Treatment Book. i. On 5/22/17 at 2:00 p.m., staff documented in resident #1's MAR that his pain level was a 5 of 10 on the pain scale, and the resident had been administered [MEDICATION NAME] 4 mgs. A review of the Controlled Substance Treatment Book reflected the resident was given [MEDICATION NAME] 2 mgs. Resident #1's MAR did not match the Controlled Substance Treatment Book. - (MONTH) (YEAR); Orders reflected [MEDICATION NAME] 2 mgs, 1-2 tablets, as needed every four hours. Noted- One tablet for pain 0-5, two tablets 6-10 (on the pain scale). a. On 6/29/17 at 4:13 a.m., staff documented in resident #1's MAR that his pain level was a 7 of 10 on the pain scale, and the resident had been administered [MEDICATION NAME] 4 mgs. A review of the Controlled Substance Treatment Book did not reflected the resident was given [MEDICATION NAME]. Resident #1's MAR did not match the Controlled Substance Treatment Book. During an interview on 11/21/17 at 8:00 a.m., staff member DD stated nurses were responsible for counting and balancing all narcotics at the beginning and end of their shifts. The staff member stated he had found narcotic discrepancies in the past, was concerned, and had reported them to the facility's previous Director of Nurses. Staff member DD stated the physician should have been notified when ineffectual doses of narcotics for pain management were discovered by the nursing staff. During an interview on 11/21/17 at 9:35 a.m., staff member B stated the nurses were required to review the MAR at the time of administering narcotics to the residents. The staff member stated staff should be comparing the MAR with the card containing the narcotic to the Controlled Substance Treatment Book. Staff member B stated the MAR and the Controlled Substance Treatment Book should always have the same information. During an interview on 11/21/17 at 10:10 a.m., staff member H stated the discrepancies with resident #1's MAR, and Controlled Substance Treatment Book, may have happened because the Submit button on the MAR was not clicked. She stated she doesn't always click the submit button on the MAR because of frequent interruptions by other staff or by a resident. Staff member H stated she should have ensured resident #1's MAR and the Controlled Substance Treatment Book had matching information. During an interview on 11/21/17 at 11:42 a.m., resident #1 stated he was frequently in a lot of pain and couldn't get out of it someday's. The resident stated he had increased episodes of pain which prevented him from leaving his room much. Resident #1 stated he started having problems with sleeping at night because of pain. Review of the facility's policy, Narcotics, (sic) Controlled Substances, read, 2. A Narcotic Count Sheet will be maintained for all narcotic medications .c. At the end of each shift, the staff member responsible for medication completing his/her shift, and the staff member responsible for medication who is starting his/her shift, count all narcotic medications and confirm that the amount on hand matches was it listed on the Narcotic Count Sheet for each medication. Both staff members will sign a Narcotic Reconciliation Sheet confirming the accurate count of narcotics on hand.",2020-09-01
218,AVANTARA OF BILLINGS,275029,2115 CENTRAL AVE,BILLINGS,MT,59102,2017-11-21,309,G,1,1,S6P111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to adequately control a resident's pain, which interfered with the residents daily activities and made it hard for him to sleep, and provide adequate pain intervention to maintain the resident's highest practicable well-being, 1 (#1) of 23 sampled residents. Findings include: 1. Resident #1 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The resident was discharged from the facility on 8/21/17. Review of resident #1's Admission MDS, with an ARD of 4/24/17, section C, showed the resident had a BIMS of 15; cognitively intact. Review of this MDS, section J, showed the resident had frequent episodes of pain, which measured 7 of 10 on the pain scale. The pain interfered with resident #1's day-to-day activities. Review of resident #1's Quarterly MDS, with an ARD of 7/17/17, showed the resident was in pain almost constantly. The pain measured 9 of 10 on the pain scale. The pain interfered with day-to-day activities and made it hard for the resident to sleep at night. Review of resident #1's (MONTH) (YEAR) recapitulation Physician Orders, showed the following had been ordered for pain management: - [MEDICATION NAME], 15 mg extended release, three tablets every 12 hours. - [MEDICATION NAME], 2 mg tablet, one tablet if pain was 5 of 10 on the pain scale, and two tablets when the pain was 6 of 10 on the pain scale, every 4 hours as needed for pain. Review of resident #1 MARs (Medication Administration Record) showed the following for the resident's inadequate pain management program, and lack of documentation showing the physician was notified of the resident's ongoing pain even after medication was provided: - (MONTH) (YEAR); Orders reflected [MEDICATION NAME] 2 mgs, and 4 mgs, as needed every four hours (for pain). a. On 4/18/17 at 6:01 a.m., staff documented in resident #1's EMR that his pain level was an 8 of 10 on the pain scale. The resident was administered [MEDICATION NAME] 4 mgs. At 8:01 a.m., staff documented the resident's pain level was still an 8 of 10. The physician was not notified that the [MEDICATION NAME] was ineffectual. At 10:07 a.m., the resident's pain was documented as being a 7 of 10 on the pain scale. He was administered [MEDICATION NAME] 4 mgs. At 12:07 p.m., staff documented the efficacy as 5 of 10. The physician was not notified of the ineffectual doses of [MEDICATION NAME] 4 mgs. b. On 4/20/17 at 5:58 p.m., staff documented in resident #1's EMR that his pain level was an 8 of 10 on the pain scale. The resident was administered [MEDICATION NAME] 4 mgs. At 7:58 p.m., staff documented an efficacy of 6 of 10. The physician was not notified of the ineffectual dose of [MEDICATION NAME]. c. On 4/21/17 at 12:10 p.m., staff documented in resident #1's EMR that his pain level was a 9 of 10 on the pain scale. The resident was administered [MEDICATION NAME] 4 mgs. At 2:10 p.m., staff documented an efficacy of 6 of 10. The physician was not notified of the ineffectual dose of [MEDICATION NAME]. d. On 4/21/17 at 5:23 p.m., staff documented in resident #1's EMR that his pain level was a 9 of 10 on the pain scale. The resident was administered [MEDICATION NAME] 4 mgs. At 7:23 p.m., staff documented an efficacy of 6 of 10. The physician was not notified of the ineffectual dose of [MEDICATION NAME]. e. On 4/22/17 at 8:06 a.m., staff documented in resident #1's EMR that his pain level was a 10 of 10 on the pain scale. The resident was administered [MEDICATION NAME] 4 mgs. At 10:06 a.m., staff documented an efficacy of 6 of 10. The physician was not notified of the ineffectual dose of [MEDICATION NAME]. f. On 4/22/17 at 12:19 p.m., staff documented in resident #1's EMR that his pain level was an 8 of 10 on the pain scale. The resident was administered [MEDICATION NAME] 4 mgs. At 2:19 p.m., staff documented an efficacy of 6 of 10. The physician was not notified of the ineffectual dose of [MEDICATION NAME]. - (MONTH) (YEAR); Orders reflected [MEDICATION NAME] 2 mgs, 1-2 tablets, as needed every four hours (for pain). a. On 5/5/17 at 5:29 p.m., staff documented in resident #1's EMR that his pain level was a 7 of 10 on the pain scale. The resident was administered [MEDICATION NAME] 4 mgs. At 7:29 p.m., staff documented an efficacy of 7 of 10. The physician was not notified of the ineffectual dose of [MEDICATION NAME]. b. On 5/15/17 at 5:40 p.m., staff documented in resident #1's EMR that his pain level was a 6 of 10 on the pain scale. The resident was administered [MEDICATION NAME] 4 mgs. At 7:40 p.m., staff documented efficacy of 6 of 10. The physician was not notified of the ineffectual dose of [MEDICATION NAME]. - (MONTH) (YEAR); Orders reflected [MEDICATION NAME] 2 mgs, 1-2 tablets, as needed every four hours. Noted- One tablet for pain 0-5, two tablets 6-10 (on the pain scale). a. On 6/7/17 at 5:15 p.m., staff documented in resident #1's EMR that his pain level was a 6 of 10 on the pain scale. The resident was administered [MEDICATION NAME] 4 mgs. At 7:15 p.m., staff documented an efficacy of 7 of 10. The physician was not notified of the ineffectual dose of [MEDICATION NAME]. b. On 6/12/17 at 4:59 p.m., staff documented in resident #1's EMR that his pain level was a 6 of 10 on the pain scale. The resident was administered [MEDICATION NAME] 4 mgs. At 6:59 p.m., staff documented an efficacy of 6 of 10. The physician was not notified of the ineffectual dose of [MEDICATION NAME]. c. On 6/30/17 at 5:54 p.m., staff documented in resident #1's EMR that his pain level was a 6 of 10 on the pain scale. The resident was administered [MEDICATION NAME] 4 mgs. At 7:54 p.m., staff documented an efficacy of 6 of 10. The physician was not notified of the ineffectual dose of [MEDICATION NAME]. - (MONTH) (YEAR); Order reflected [MEDICATION NAME] 2 mgs, 1-2 tablets, as needed every four hours. Noted- One tablet for pain 0-5, two tablets 6-10 (on the pain scale). [MEDICATION NAME] 4 mgs, 1 tablet as needed every four hours. Noted- for severe pain. a. On 7/1/17 at 5:47 p.m., staff documented in resident #1's EMR that his pain level was a 6 of 10 on the pain scale. The resident was administered [MEDICATION NAME] 4 mgs. At 7:47 p.m., staff documented an efficacy of 6 of 10. The physician was not notified of the ineffectual dose of [MEDICATION NAME]. b. On 7/9/17 at 5:28 p.m., staff documented in resident #1's EMR that his pain level was a 5 of 10 on the pain scale. The resident was administered [MEDICATION NAME] 4 mgs. At 7:28 p.m., staff documented an efficacy of 5 of 10. The physician was not notified of the ineffectual dose of [MEDICATION NAME]. c. On 7/13/17 at 4:48 p.m., staff documented in resident #1's EMR that his pain level was a 5 of 10 on the pain scale. The resident was administered [MEDICATION NAME] 4 mgs. At 6:48 p.m., staff documented an efficacy of 6 of 10. The physician was not notified of the ineffectual dose of [MEDICATION NAME]. d. On 7/18/17 at 5:28 p.m., staff documented in resident #1's EMR that his pain level was a 5 of 10 on the pain scale. The resident was administered [MEDICATION NAME] 4 mgs. At 7:28 p.m., staff documented an efficacy of 6 of 10. The physician was not notified of the ineffectual dose of [MEDICATION NAME]. e. On 7/19/17 at 4:23 p.m., staff documented in resident #1's EMR that his pain level was a 6 of 10 on the pain scale. The resident was administered [MEDICATION NAME] 4 mgs. At 6:23 p.m., staff documented an efficacy of 6 of 10. The physician was not notified of the ineffectual dose of [MEDICATION NAME]. f. On 7/22/17 at 5:23 p.m., staff documented in resident #1's EMR that his pain level was a 5 of 10 on the pain scale. The resident was administered [MEDICATION NAME] 4 mgs. At 7:23 p.m., staff documented an efficacy of 6 of 10. The physician was not notified of the ineffectual dose of [MEDICATION NAME]. During an interview on 11/21/17 at 8:00 a.m., staff member DD stated the physician should have been notified when ineffectual doses of narcotics for pain management were discovered by the nursing staff. During an interview on 11/21/17 at 10:18 a.m., staff member EE stated resident #1's physician should have been notified when the ineffectual doses for pain management was documented by the staff member. She stated the physician might have decided to increase, or change, the dose of narcotics being administered to resident #1. During an interview on 11/21/17 at 10:25 a.m., staff member Y stated when ineffectual doses of narcotics for pain management were observed for resident #1, the staff member(s) should have contacted the resident's physician. During an interview on 11/21/17 at 11:42 a.m., resident #1 stated he was frequently in a lot of pain and couldn't get out of it someday's. The resident stated he had increased episodes of pain which prevented him from leaving his room much. Resident #1 stated he started having problems with sleeping at night because of pain. An unsuccessful interview on 11/21/17 at 11:57 a.m., was attempted with resident's #1's physician. Review of the facility's policy, Pain Management and Assessment, page 2, read, 3. Pain Management . If the resident's pain is not controlled by the current treatment regime the physician should be notified.",2020-09-01
219,AVANTARA OF BILLINGS,275029,2115 CENTRAL AVE,BILLINGS,MT,59102,2017-11-21,314,H,1,1,S6P111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to prevent the development and worsening of pressure ulcers for 4 (#s 1, 2, 17, 18); failed to complete timely assessments, accurately stage pressure ulcers, consistently identify anatomical location of a pressure ulcer, accurately identify eschar in a wound bed, analyze the root cause of pressure ulcers, and implement appropriate interventions for 1 (#18); and failed to identify, monitor care for, develop care plans for, and document the resolution of unstageable deep tissue ulcers for 1 (#2) of 23 sampled residents. Findings include: 1. Review of resident #17's Bath Sheet, dated 10/14/17, showed the resident had a sore to the heel, and the wound nurse was informed. Review of the resident #17's Weekly Wound Log, dated 10/16/17, showed a deep tissue injury, and an order for [REDACTED]. Review of the resident #17's Weekly Wound Log, dated 10/30/17, showed a new intervention of an ankle roll. Review of a PT note, dated 11/22/17, showed the resident did not like the foam boot, because she said it kept her up all night. During an interview and observation on 11/21/17 at 8:20 a.m., NF1 stated the resident's heel looked better, but the skin area was covered with eschar, so the wound was not stagable. Review of resident #17's Significant Change MDS, with the ARD of 10/16/17, showed the resident had a Stage II pressure ulcer, with no pressure ulcer care in place. During an observation on 11/20/17 at 1:00 p.m., resident #17 was lying in bed with her shoes on. She stated she was waiting for therapy. She was not aware of any foot-wear restrictions, and she said she had a bed sore on her heel. Review of a physician order, dated 10/20/17, showed In sandals with no strap or covering on right heel due to pressure to the heel, and Heel floating right heel and foam boot to both feet when in bed. During an observation on 11/21/17 at 1:40 p.m., resident #17 was asleep in her bed and without the ankle roll. Review of resident #17's Physician Visit, dated 10/3/17, showed Due to patient's severe diabetic [MEDICAL CONDITION], she is unable to feel foot (sic) pain. Review of resident #17's Braden Scale for pressure ulcer risk factors, dated 10/15/17, showed no risk for pressure ulcers. During an interview on 11/21/17 1:05 p.m., staff member U stated she did not know anything about resident #17's heel or treatment for [REDACTED]. During an interview on 11/21/17 at 1:30 p.m., staff member K stated she knew resident #17 had a sore on her heel, and stated the nurses take care of the treatment. She did not know about pressure reduction for the heel. Review of resident #17's Physician Orders, dated 10/20/17, showed a dietary consult was requested for wound healing. Review of the Physician order [REDACTED]. During an interview on 11/20/17 at 8:40 a.m., staff member O stated she would have reviewed resident #17 during the skin and wound meeting. She said resident #17 had a poor appetite after admission to the facility, but had recently experienced a severe weight gain. During an interview on 11/21/17 at 10:45 a.m., staff member J stated staff would learn about the care and treatment for [REDACTED]. She also stated resident #17 had the right to wear any type of shoe. Staff member J stated the facility was unable to provide documented education for resident #17's risk and benefits regarding pressure reducing interventions. Record review of skin care and treatments provided by the facility showed no pressure ulcer care or interventions until 10/20/17, one week after it was discovered, and the wound had deteriorated from a blister to an unstageable pressure ulcer. 2. Resident #1 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. He was discharged from the facility on 8/21/17. Review of resident #1's Admission MDS, with an ARD of 4/24/17, showed resident #1 required extensive assistance with activities of daily living, and he had a BIMS of 15; cognitively intact. He was admitted to the facility with one Stage IV pressure ulcer to his coccyx. The dimensions of the pressure ulcer were 06.2 cm x 02.1 cm x 05.8 cm. The most severe tissue type for this ulcer was coded as 3; Slough - yellow or white tissue that adhered to the ulcer bed in strings or thick clumps, or is mucinous. Review of resident #1's Quarterly MDS, with an ARD of 7/17/17, showed resident #1 required extensive assistance with activities of daily living, and he had a BIMS of 15; cognitively intact. He was coded as having four Stage III pressure ulcer and 1 Stage III pressure ulcer upon admission. The dimensions of the pressure ulcer were 08.7 cm x 06.1 cm x 0.1 cm. The most severe tissue type for this ulcer was coded as 3; Slough- yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous. Review of resident #1's Discharge MDS, with an ARD of 8/21/17, showed resident #1 required extensive assistance with activities of daily living, and he had a BIMS of 15; cognitively intact. He was coded as having four Stage III pressure ulcers. The dimensions of the pressure ulcer were 08.7 cm x 06.1 cm x 00.1 cm. The most severe tissue type for this ulcer was not coded. A review of resident #1's TAR (treatment administration record) reflected the following: - 4/19/17 to 4/27/17, staff provided wound care twice weekly. Orders read, Remove dressing. Rinse with NS (normal saline) and pat dry. Apply 4x4 soaked in Vasche x 15 minutes. Apply Santyl. Apply NPWT with bridge technique to hip. Use Adapt to gluteal cleft to seal. 125 mmHg continuous. Will be changed at wound care appointment on Mondays. - 4/24/17 to 7/2/17, orders read, offload sacral / sacrum at all times. - 4/27/17 to 5/9/17, staff provided wound care three times weekly. Starting 4/28/17. Orders read, Remove dressing. Rinse with NS and pat dry. Apply 4x4 soaked in Vasche x 15 minutes. Apply Santyl. Apply NPWT with bridge technique to hip. Use Adapt to gluteal cleft to seal. 125 mmHg continuous. Will be changed at wound care appointment on Mondays. PLEASE SEND DRESSING CHANGE. - 5/9/17 TO 5/28/17, Orders read, Wound Care every eight hours .PU stage (sic) II right ischial tuberosity. Apply [MEDICATION NAME] TID. - 5/9/17 to 7/2/17, staff provided wound care three times weekly. Orders read, Remove dressing. Rinse with NS and pat dry. Apply 4x4 soaked in Vasche x 15 minutes. Apply Santyl. Apply NPWT with bridge technique to hip. Use Adapt to gluteal cleft to seal. 125 mmHg continuous. Will be changed at wound care appointment on Mondays . - 5/16/17 to 5/28/17, staff provided wound care every seven days, starting 5/15/17. Orders read, DTI bulla left proximal posterior heel. 0.5 x 0.7 x 0.0 cm. Serosanguinous filled bulla to posterior heel. Tx: offload and cover with foam border every 7 days and as needed if soiled. - 5/22/17 to 7/2/17, staff provided wound care three times weekly. Orders read, [MEDICATION NAME] 1 over bone. Skin prep and Duoderm to periwound (sic). - 6/5/17 to 7/2/17, orders read, offload feet ulcers at all times. - 7/7/17 to 7/9/17, orders read, heels/ ankle: offload on feet, [MEDICATION NAME] with alginate, Kerlix. - 7/10/17 to 7/25/17, orders read, Pressure ulcer of sacral region, stage (sic) 4. Remove old dressing. Rinse with NS and pat dry. Apply 4x4 soaked in Vasche x 10 minutes. Apply Santyl. Apply NPWT with bridge technique to hip. Use Adapt to gluteal cleft to seal. 125 mmHg continuous. Change Monday, Wednesday, Friday, and as needed if unable to maintain pressure. - 7/10/17 to 7/25/17, orders read, Pressure ulcer of right heel, unspecified stage, pressure ulcer of left heel, unstageable. Remove old dressing. Rinse with NS and pat dry. Soaked wound in Vasche on 4x4 x 10 minutes. Apply felt to off load wounds to bilateral heels, bilateral lateral foot, and right toe cluster. Apply [MEDICATION NAME] and Alginate to wounds. Cover with Curlex (sic) and tape to secure. - 7/25/17 to 8/4/17, orders read, Pressure ulcer of sacral region, stage (sic) 4. Remove old dressing from coccyx. Rinse with NS and pat dry. Apply Vasche to 4x4 x 10 minutes. Apply skin prep to Periwound are and (sic) allow to dry. NPWT using black foam with bridge technique to hip. Apply negative pressure at 125 mmHg continuous. Change Monday, Wednesday, Friday, and as needed if unable to maintain pressure. - 7/25/17 to 8/4/17, orders read, Pressure ulcer of right heel, unspecified stage, pressure ulcer of left heel, unstageable. Remove old dressing. Rinse with NS and pat dry. Soaked wound in Vasche on 4x4 x 10 minutes. Apply felt to off load wounds to bilateral heels clusters, bilateral lateral feet, and right 3rd toe. Apply [MEDICATION NAME] and Alginate to wounds. Cover with Curlex (sic) and tape to secure. Change Monday, Wednesday, Friday, and as needed if unable to maintain pressure. - 8/7/17 to 8/21/17, orders read, Document resident position every 2 hours. Staff did not document twenty-two instances of positioning. - 8/7/17 to 8/21/17, orders read, Wound care three times weekly. Remove old dressing from injuries to feet. Rinse with NS and pat dry. Apply skin prep and allow to dry. Apply felt to off load wounds to bilateral heels clusters, bilateral lateral feet, and right 3rd toe. Apply [MEDICATION NAME] and Silver Alginate to left heel wounds. Apply silver alginate to right heel wound. Cover both feet with Kerlix and tape to secure. Change Monday, Wednesday, Friday, and as needed if soiled. Float feet at all times. A review of resident #1's BRADEN skin assessments reflected the following: - 4/17/17 at 4:13 p.m., staff documented a score of 19; not at risk- no interventions necessary at this time. - 4/24/17 at 2:02 p.m., staff documented a score of 15; at risk- if other risk factors are present e.g. advanced age, fever, poor dietary intake of protein, hemodynamic instability advance to next level of risk. - 5/1/17 at 3:44 p.m., staff documented a score of 14; moderate risk- if other major risk factors are present advance to next level of risk. - 5/12/17 at 9:10 a.m., staff documented a score of 14; moderate risk. - 7/7/17 at 6:27 p.m., staff documented a score of 15; at risk. - 7/22/17 at 12:26 a.m., staff documented a score of 16; at risk. - 7/28/17 at 11:06 a.m., staff documented a score of 16; at risk. A review of resident #1's ADL Verification Worksheet reflected the following: - 4/18/17 to 4/30/17, staff provided extensive assistance to the resident eighteen times with repositioning in bed, and provided extensive assistance twelve times with transfers. - 5/1/17 to 5/31/17, staff provided extensive assistance to the resident thirty-five times with repositioning in bed, and provided extensive assistance to the resident with transfers twenty-three times. - 6/1/17 to 6/30/17, staff provided extensive assistance to the resident twenty-eight times with repositioning in bed, and provided extensive assistance to the resident with transfers sixteen times. - 7/1/17 to 7/31/17, staff provided extensive assistance to the resident twenty-one times with repositioning in bed, and provided extensive assistance to the resident with transfers twenty times. - 8/1/17 to 8/21/17, staff provided extensive assistance to the resident thirteen times with repositioning in bed, and provided extensive assistance to the resident with transfers nine times. Review of resident #1's Clinical Nurse's Notes read: - On 4/18/17 at 2:03 a.m., PU (sic) Stage IV coccyx. 6.2 x 2.1 x 5.8 cm. Tunneling at 1100-0100. Wound bed is 75% granulation and 25% slough .Wound edges are slightly macerated but intact . Change dressing at (hospital name's) wound clinic Monday, and at the facility on Wednesday and Friday. - On 4/27/17 at 6:50 a.m., PU (sic) Stage IV coccyx. 7.3 x 3.0 x 7.0 cm. Tunneling at 1000-0300 to depth of 5.0 cm. Wound bed is 75% necrotic eschar and slough .Wound edges are slightly macerated but intact . Change dressing at (hospital name's) wound clinic Monday, and at the facility on Wednesday and Friday. - On 4/28/17 at 10:49 a.m., .Left heel has black spot that measures 1.7 cm x 1 cm. On his right heel, black spot measures 0.8 x 0.5 (cm). [MEDICATION NAME] applied to the site. Will inform provider and wound care nurse about this. - On 5/2/17 at 12:05 a.m., .PU (sic) Stage IV coccyx .PU (sic) Stage III left buttock 0.6 x 1.4 x 0.1 cm. 75% eschar/slough, 25% granulation. - On 5/9/17 at 3:08 a.m., PU (sic) Stage IV coccyx. Assessment per (Dr.'s name) 7.5 x 5.5 x 4.5 cm . Change dressing at (hospital name's) wound clinic Monday, and at the facility on Wednesday and Friday .PU (sic) Stage III left ischial tuberosity 0.6 x 1.4 x 0.1 cm. 75% eschar/slough, 25% granulation. PU stage II right ischial tuberosity 0.6 x 0.9 x 0 cm. OTA (open to air) DTI (deep tissue injury) Bulla Achilles tendon 1.0 x 1.5 x 0 cm. OTA DTI posterior heel 2.5 x 2.5 x 0 cm .TA open lesion anterior tibial boarder 0.5 x 0.9 x 0 cm .OTA DTI right lateral #5 metatarsal head 2.0 x 1.5 x 0 cm. PU stage 1 right posterior heel 2.0 x 3.0 x 0 cm. DTI right lateral heel 1.4 x 1.0 x 0 cm. - On 5/16/17 at 2:16 a.m., PU (sic) Stage IV coccyx. Assessment per (Dr.'s name) 14.9 x 11.2 x 5.0 cm. S/p revision. Wound bed 25% granulation, 50% adherent slough, 25% eschar. Bone and fat layer exposed .Tunneling at 0300 4.8 cm .Change dressing at (hospital name's) wound clinic Monday, and at the facility on Wednesday and Friday .PU (sic) Stage III left ischial tuberosity 0.5 x 0.5 x 0.1 cm. 75% eschar/slough, 25% granulation .OTA DTI Bulla left Achilles tendon 1.0 x 1.0 x 0 cm .OTA DTI Bulla left proximal posterior heel 0.5 x 0.7 x 0 cm .DTI posterior heel 2.0 x 2.5 x 0 cm .OTA open lesion left anterior tibial boarder 0.5 x 0.4 x 0 cm .OTA DTI right lateral #5 metatarsal head 1.6 x 1.0 x 0 cm .OTA DTI right lateral heel 1.0 x 1.1 x 0 cm .DTI left hallux plantar 0.5 x 1.1 x 0 cm .Wound care to continue monitoring pt. (sic) weekly. - On 5/28/17 at 12:27 a.m., PU (sic) Stage IV coccyx. 12.7 x 12.0 x 5.4 cm. S/p revision. Wound bed 25% granulation, 50% adherent slough, 25% eschar. Bone and fat layer exposed .Tunneling at 0300 - 1200 4.0 cm .Change dressing at (hospital name's) wound clinic Monday, and at the facility on Wednesday and Friday .OTA Unstageable left Achilles tendon 2.0 x 2.0 x 0 cm. Wound bed crusted .OTA unstageable left proximal posterior heel 0.5 x 0.5 x 0 cm .DTI left posterior heel 2.0 x 2.3 x 0 cm .OTA open lesion left tibial boarder 0.5 x 0.5 x 0 cm .OTA DTI right lateral #5 metatarsal head 2.0 x 1.5 x 0 cm .OTA DTI right Achilles tendon 1.9 x 1.0 x 0 cm .OTA DTI right lateral heel 2.0 x 1.7 x 0 cm .DTI left hallux plantar 0.5 x 0.9 x 0 cm .OTA Shear injury left ischial crest 5.0 x 10.0 x 0 cm .Wound care to continue monitoring pt. (sic) weekly. - On 6/6/17 at 1:25 a.m., PU (sic) Stage IV coccyx. 11.0 x 9.5 x 4.3 cm. Wound bed 50% granulation, 50% adherent slough. Fat layer exposed .Undermining at 0900 - 1200 4.0 cm . Change dressing at (hospital name's) wound clinic Monday, and at the facility on Wednesday and Friday .OTA Unstageable left Achilles tendon BCWC, 100 % black eschar .PI Unstageable left proximal posterior heel. BCWC. 100% black eschar .DTI left posterior heel. BCWC. 100% black eschar .OTA DTI right Achilles tendon. BCWC. 100% eschar .OTA DTI right lateral heel. BCWC. 100% eschar .DTI left hallux plantar 0.4 x 0.9 x 0 cm . - On 6/12/17 at 10:52 p.m., PU (sic) Stage IV coccyx. 11.4 x 9.0 x 4.0 cm. Wound bed 50% granulation, 50% adherent slough. Fat layer exposed .Change dressing at (hospital name's) wound clinic Monday, and at the facility on Wednesday and Friday .DTI left lateral #5 metatarsal head. BCWC. 100% black eschar .PI Unstageable left Achilles tendon. BCWC, 100 % black eschar .DTI left posterior heel. BCWC. 100% black eschar .DTI right lateral #5 metatarsal head 2.0 x 1.0 x 0 cm . black eschar .DTI right Achilles tendon. BCWC. 100% eschar .DTI right lateral heel. BCWC. 100% eschar . DTI left hallux plantar 0.4 x 0.9 x 0 cm . - On 6/20/17 at 4:37 a.m., PU (sic) Stage IV coccyx. 10.9 x 8.5 x 3.0 cm. Wound bed 75% granulation, >25% adherent slough. Undermining from 1000 to 0300, 3.0 cm . Fat layer exposed .Change dressing at (hospital name's) wound clinic Monday, and at the facility on Wednesday and Friday .DTI left lateral #5 metatarsal head. 1.5 x 1.0 x 0 cm .100% black eschar .Chg at facility Friday and (hospital name) WC on Monday DTI right Achilles tendon. Dimensions changed to right heel cluster. DTI right lateral heel .DTI left hallux plantar 0.4 x 0.9 x 0 cm .50% black eschar and 50% granulation .Chg at facility Friday and (hospital name) WC on Monday PI left heel cluster. 8.0 x 10.5 x 0 cm. 100% black eschar .Chg at facility Friday and (hospital name) WC on Monday right #2 LRE digit 1.0 x 0.5 x 0 cm. Dorsum of toe braided after foot fell of W/C foot pegs Secure with contour gauze Abrasion right #3 LRE digit 1.2 x 0.7 x 0 cm . During an interview on 11/20/17 at 4:30 p.m., staff member Y stated resident #1 developed pressure ulcers to both heels, which worsened at the facility. She stated the resident was dragging his feet while propelling in the hallways in his wheelchair. During an interview on 11/20/17 at 4:45 p.m., staff member H stated the resident was admitted from the hospital to the facility with a pressure ulcer to his coccyx. The staff member stated within a month, that ulcer became worse, and within a few months, the resident had developed ulcers to both of his heels. Staff member H stated the facility should have done a better job in assistance with bed mobility, turning and repositioning, and ensuring resident #1 did not develop or have worsening pressure ulcers. During an interview on 11/20/17 at 5:05 p.m., staff member Z stated she had reported to the facility nursing staff resident #1's coccyx and heels looked worse. Staff member Z stated she was not sure what interventions were in place to prevent the development and worsening of pressure ulcers for resident #1. During an interview on 11/20/17 at 5:30 p.m., staff member AA stated resident #1 was admitted to the facility with a pressure ulcer to his coccyx area. He stated the resident required limited assistance with activities of daily living, and only provided minimum skin assessments, and treatments for the resident. During an interview on 11/20/17 at 8:22 p.m., staff member BB stated resident #1 developed new pressure ulcers to his heels while residing at the facility. She stated the facility could have done a better job at ensuring worsening, or the development of pressure ulcers, was avoided. During an interview on 11/20/17 at 9:00 p.m., staff member CC stated the resident developed heel ulcers while at the facility. The staff member stated she reported skin changes to the charge nurse, but did not know if new interventions were implemented. 3. Review of resident #2's Admission MDS, with a ARD of 4/19/16, the Quarterly MDS, with and ARD of 7/11/17, and a Significant Change MDS, with an ARD of 9/14/17, showed that resident #2 did not have any stagable or unstageable ulcers, but was at risk for developing ulcers. Review of resident #2's Clinical Notes, dated 4/25/17, showed resident #2 had a Stage 1 ulcer on her left upper gluteus, and a deep tissue injury (unstageable ulcer) on her right medial posterior heel. Documentation on the assessment and treatment of [REDACTED]. Upper Left Gluteus: 4/25/17-described as a Stage one ulcer 5/1/17-described as a DTI (deep tissue injury), non blanchable, no open area 5/8/17-described as resolved 5/9/17-described as a DTI, dark purple area under intact hyperkeratinized dermis, soft. No open area . 5/15/17-gluteus not addressed 5/26/17-the Clinical Notes lacked evidence of the DTI status, or resolution of the DTI Right medial posterior heel: 4/25/17- heel described as DTI (deep tissue injury); 5/1/17-heel described as DTI ulcer, dark purple area under intact hyperkeratinized dermis, soft .; 5/9/17-heel was described as resolved; 5/16/17- heel was described as a right medial posterior heel .Dark purple area under intact hyperkeratinized dermis, soft. No open area, No drng (sic), no odor, no pain .; 5/26/17-heel was described as having black eschar over area. No open area .; 6/6/17-heel was described as having hard black eschar over area. No open area .; 6/12/17-heel was described as having black eschar over area. No open area.; 6/20/17-heel was described as having black eschar over area. No open area .; 6/23/17-follow up to white areas on resident's heels. Resident with hx s/p . Areas to be observed daily by nursing staff with tx as ordered and followed weekly by wound care nurse. Float heels and apply foam boots. Resident is aware of importance of offloading.; and, 6/22/17-heel was described as, Suspected deep tissue injury of heals (sic) resolved. Review of resident #2's Clinical Note for 6/27/17, showed there were two new ulcers on the left and right plantar surfaces of resident #2's feet, and a reopening or possible continuation of a previous ulcer on the medical posterior heel: 6/27/17-heels were described as, PI DTI R (Plantar Deep Tissue Injury Right) medial posterior heel. 1.0 x 1.1 x 0.0 cm. Black eschar over area. No open area. No drng, no odor, no pain. Periwound intact with intact wound edges. TX: Foam boot at all times not in shoes and pillow under calves while in bed. PI DTI R (Plantar Deep Tissue Injury Right) heel plantar. 3.0 x 2.0 x 0.0 cm. Intact dermis. Light purple coloration. No drng, odor, No edges but well demarked border. Periwound Pink and cool. TX: Offload heels. Float heels while in bed. Wear shoes or foam boots during wake hours. PI DTI L (Plantar Deep Tissue Injury Left) heel plantar 2.0 x 2.2 x 0.0. Intact dermis. Light purple coloration. No drng, odor, No edges but well demarked border. Periwound Pink and cool. TX: offload heels. Float heels while in bed. Wear shoes or foam boots during wake hours. Wound care to continue monitoring pt. Review of resident #2's Clinical Notes lacked evidence that the three new foot wounds (ulcer or DTI) and the left gluteus ulcer had been resolved at the time of the Quarterly MDS assessment, with an ARD of 7/11/17. Review of the Quarterly MDS assessment, with an ARD of 7/11/17, did not reflect any skin issues for resident #2. Review of resident #2's, Skin Risk Assessment / Braden, dated for the 7/11/17 MDS, showed, Resident has a stage (sic) 1 or greater, a scar over bony prominence, or a non-removable dressing/device. The assessment lacked evidence the three newly developed foot wounds were addressed as DTIs (deep tissue injuries). Review of resident #2's care plan showed interventions were put in place for, Risk for alteration in skin integrity r/t decreased mobility and bowel incontinence, on 4/12/17, and updated on 4/19/17. The care plan did not address resident #2's having developed four separate skin issues in the facility. Review of resident #2's Clinical Notes, dating back to 4/12/17, showed resident #2 she had orders to Turn q 2 hours. The care plan showed an intervention of wearing Podus type boots while the resident was in bed, and to check for incontinence, monitor skin, supplements, weekly skin audits, education on offloading and pressure reduction, cushion in wheelchair, and assist with turning and positioning every two hours. Interventions put into place by the house nurses, the house wound care nurse, or either the on-site or off-site Certified Wound Care nurses were not added to the care plan. After the discovery of the of the open heel wound on 4/24/17, an additional intervention was initiated by the nurse in elevating the heels on pillows and moisturizing the feet. The patient was referred to the wound nurse. Dressing changes were ordered to be administered, along with orders for TED Hose, wearing shoes or foam boots during wake hours, weekly skin audits, Wound Care to monitor, and, Ace wraps utilized for [MEDICAL CONDITION]. The care plan was not updated to include any of these interventions. Review of resident #2's Clinical Notes, dated 8/5/17, 9/8/17, 9/26/17, and 10/24/17 showed no further ulcers, or unstageable DTI's. Review of resident #2's Physician order [REDACTED]. With TX to include offload heels, float heels while in bed, wear shoes or foam boots during wake hours, and to conduct a skin audit weekly on bath days. During an observation and interview of resident #2 in her room on 11/19/17 at 4:00 p.m., she was up in her w/c and did not have on shoes or Podus boots. She said she had some skin issues in the past, but thought the wounds were better. She said she sometimes wears the boots. During an observation of resident #2 in her room on 11/20/17 at 8:15 a.m. she was lying in bed, her heels were not floated, and she was not wearing the Podus boots. During an observation and interview regarding resident #2's heels and gluteal fold on 11/21/17 at 10:30 a.m., with staff members U and V, the heels and gluteal fold areas appeared to be CDI and healed. Staff member's U and V said they had not seen any skin wounds on resident #2 for a while. On 11/21/17 at 8:59 a.m., a request was made to staff member's G, J, and K, for any documentation that showed the continuation of care, or the resolution of the ulcers and DTI's experienced by resident #2 in the facility. During an interview on 11/21/17 at 12:04 p.m. staff member B said, We do not have any more documentation of the heel wounds for (resident #2) past the date of 6/27/17. We have looked, and this was all that we could find. During an interview on 11/21/17 at 12:55 p.m., staff member K said the Certified Wound Nurse who had worked for the company left his position on 8/7/17. She said that when he did work for the company, he sometimes worked in conjunction with the (local clinic). He was considered to be the house wound nurse and was certified as a wound nurse. During an interview on 11/21/17 at 1:04 p.m., staff member U, who was charged with caring for resident #2 at that time, said she did not know if resident #2 had any skin issues, and would not know where to locate this information unless there was an actual wound care order. She said she was not sure where the CNA's would document the implementation of interventions, such as turning and positioning but that sometimes a note would pop up as a reminder for the nurse to turn and position a resident. Staff member U said each time a nurse changed a dressing they would be assessing and monitoring a wound. She said she thought a nurse could update a care plan if needed, but was unsure of this process. Staff member U said she was not sure if a change in wound status was reported by the floor nurse, the charge nurse, or the wound nurse. She said she was relatively new and unsure of the facilities policies. During an interview on 11/21/17 at 1:30 p.m., staff member V said the CNAs report skin problems to the nurse when they see them. She said she gets her information about the residents in report when she comes on shift and did not look at care plans. 4. Review of resident #18's Annual MDS, with an ARD of 2/15/17, showed resident #18 had a risk for the development of pressure ulcers but had no pressure ulcers during the assessment reference period. Review of resident #18's Quarterly MDS, with an ARD of 8/18/17, showed the presence of two Stage II pressure ulcers. a. Review of resident #18's clinical notes showed the following: -7/18/17, A large blister had popped on the right heel. -7/20/17, The right heel had a blister draining serous fluid. -8/6/17, An area on the heel was open. Drainage on the removed dressing was yellowish green with foul odor. -9/5/17, A nurse reported the right heel had healed. -9/11/17, Treatment was done to heel wound, which was a pea size scab. -9/17/17, No dressing was applied to heel. Wound not open with a small scab area. -9/16/17, . had (a) Stage 2 area to right heel which has now resolved only small scab area that will soon be off (sic). -9/19/17, Right heel had reopened and was draining serosanguinous fluid. No dressing was in place, and ace wraps had not been applied to legs when assessed. -9/20/17, Scabbing was present to right heel. -9/22/17, Heel wound was open and a small amount of blood noted. -9/23/17, Right heel wound is healing nicely .not completely scabbed over. 9/25/17, Right heel wound was deeper. Loose slough was removed, and discolored drainage was noted. 10/5/17, Legs wrapped and right heel left OT[NAME] Very small dry scab on her right heel. 11/10/17, Right heel had a pea sized scab area. Review of resident #18's assessments titled, Other Ulcers/Injuries, Wounds, & Skin Problems Weekly Assessment, showed four assessments completed from 8/4/17-8/22/17 for a Stage II pressure ulcer to the right heel. Two of the assessment were dated as signed on 8/4/17, and the next assessment was dated as signed on 8/17/17. Each of these assessments showed the presence of slough, necrotic tissue, or both. The next assessment following 8/22/17 was dated 9/4/17. Four assessments were completed in (MONTH) (YEAR), with the fourth one dated 9/25/17. The pressure ulcer was documented as a Stage III on each (MONTH) (YEAR) assessment. The next assessment was completed on 10/10/17, followed by assessments on 10/23/17, an undated assessment, and on 11/16/17, per sequential order of the records in the EHR. There were no assessments provided for (MONTH) (YEAR). On multiple occasions, there were gaps of greater than one week between assessments, with gaps of 13-14 days at least three times. b. Review of resident #18's clinical notes showed the following excerpts: -7/10/17, sore on her buttocks still red and (sic) with black spot on the center, non-draining. -7/12/17, Resident buttocks sore still red, non-draining and no pain reported. Encourage resident to off-load her buttocks. -7/17/17, Resident seen by wound care today for dressing to right buttock. -7/23/17, Her buttocks re-opened with a size 1 cm x 1.3 cm and wound nurse was notified. -7/24/17, Resident has open sore on buttocks and barrier cream applied . -7/29/17, No open area on buttocks. -8/4/17, resident has redness on buttocks and barrier cream applied, [MEDICATION NAME] (sic) applied to pannus, buttocks and groin. -8/11/17, Resident has redness and wound on buttocks and barrier cream applied. -8/16/17, Resident buttocks improving but still has redness and wound, barrier cream applied during toileting. Review of resident #18's Weekly Wound Log showed an entry, dated 8/16/17, for an in-house acquired, un-staged wound to buttocks. The word healed was written under the column for the wound measurement. Review of resident #18's clinical notes from 8/16/17-9/16/17 showed the buttocks continued to have redness and or open areas. A clinical note, dated 9/16/17 at 1:24 p.m., showed there was an open area to the buttock. A clinical note dated 9/19/17 showed resident #18's buttock wound was healed. Review of resident #18's Weekly Wound Log showed measurements, and the presence of slough for an unstaged buttocks wound on 9/4/17 and 9/12/17. The entry dated 9/19/17 showed measurements of 0 x 0 x 0, and the word closed was written. The last entry for the buttocks wound, dated 10/10/17, with a single line through the date only, showed measurements and a change of treatment. The word recurrent was written under the Treatments/Comments column. Review of resid",2020-09-01
220,AVANTARA OF BILLINGS,275029,2115 CENTRAL AVE,BILLINGS,MT,59102,2017-11-21,323,G,1,1,S6P111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and interview, the facility failed implement meaningful interventions, complete adequate root cause analysis, or monitor the effectiveness of fall interventions, to prevent three falls, one with injury, for 1 (#10) of 23 residents. Findings include: Resident #10 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of resident #10's admission fall risk assessment, dated 10/27/17 showed a score of 15, and a high risk for falls, related to diminished safety awareness, balance problems while standing and walking, use of an antidepressant, and jerkiness and instability when making turns. Review of resident #10's hospital discharge report, dated 10/26/17, showed 2 security guards at the bedside all night. Haldol 5mg with minimal benefit. Benzodiazepines perhaps made worse. The fall risk assessment did not include the use of these medications. Review of resident #10's Nursing Note, dated 10/26/17, showed CNA informed me that the resident fell . She tried to get up from the chair, where she was sitting, lost balance and fell . No injuries were sustained. It was the resident's first day in the facility. Review of resident #10's Follow up Report, dated 10/28/17, showed the Root Cause was dementia, agitation, unsteady gait, and attempting to transfer self. It did not include why she was attempting to get up from the chair. Resident often requires one on one attention throughout the day and night due to cognitive deficit and unsteadiness, and inability to respond to cues of safety or direction. No interventions were implemented. Review of resident #10's Follow up Report, dated 11/6/17 showed the resident had another fall on 11/5/17. The root cause was she tripped. The fall was witnessed by staff. Resident has a history of poor safety awareness and unsteady gait. No root cause or interventions were provided. Review of resident #10's clinical Nursing note, dated 11/13/17, showed CNA came to get this nurse and stated that (resident) had fallen and hit her head and was bleeding. When this nurse got to (resident) she was on the floor sitting up by the med room and had a large welt, was bleeding from a cut by her left eye about one inch long. (Resident) was unable to follow commands for neuro's. She was not able to answer any questions appropriately. When asked her name, she replied with '15.' Husband decided to have her sent to the ER. She was diagnosed with [REDACTED]. Review of resident #10's Follow up report, dated 11/20/17, showed the resident fell on [DATE]. The documentation showed the resident was in the day area by the nursing station and staff observed her standing next to the wall. As staff passed her she was noted to have fallen to the floor. There were no other staff members or residents within the vicinity of the resident. The Root Cause identified was poor safety awareness. The facility did not attempt to identify why she fell after standing next to the wall. Review of resident #10's Care Plan, dated 10/27/17, showed the interventions to reduce falls with injury were: 1. Assist for transfers, as needed. 2. (Resident) has been seen to sit self-down on the floor to sit and watch happenings, she is able to get self-up. 3. Encourage use of call light and keep call light, remotes, and personal items, in reach. 4. Keep pathways free of clutter in room. 5. Observe for side effect of psychotropic drug use. 6. Encourage use of walker with assistance and to rise slowly and get balance before ambulating. 7. Encourage rest periods and frequent rests when ambulating to decrease fall risk. The care plan had not been updated after the falls identified above, and no new interventions directly relating to the root causes of the falls were implemented to prevent the third fall, in which the resident sustained [REDACTED]. During an observation and interview on 11/20/17 at 11:15 a.m., resident #10 was unable to understand what the call light was for, had a fading yellow bruise over her right eye, and was ambulating without a walker throughout the unit and other resident rooms. During an interview on 11/21/17 at 9:45 a.m., staff member K stated the facility discussed falls daily and trended them. During an interview on 11/21/17 at 1:30 p.m., staff member J stated the facility had nothing more specific for resident #10's falls interventions.",2020-09-01
221,AVANTARA OF BILLINGS,275029,2115 CENTRAL AVE,BILLINGS,MT,59102,2017-11-21,329,D,0,1,S6P111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to identify and document an appropriate [DIAGNOSES REDACTED].#9) of 23 sampled residents. Findings include: Review of resident #9's Physician fax order, dated 4/28/17, showed Resident is having increased episodes of yelling, being repetitive, and calling staff and other residents names. Notice increased agitation and worsen when staff try to redirect and/or just with visiting with her. The physician added [MEDICATION NAME], an antipsychotic, once daily for agitation related to dementia. Review of resident #9's Nursing TAR Behavior Monitoring record for the month of April, (YEAR) showed no documented behaviors. Review of resident #9's Physician fax order, dated 9/5/17, showed the resident had been hollering out at residents from her room and was irritable. Could we increase her [MEDICATION NAME]? We are having to move her out of dining room related to behaviors. (Potential verbal abuse to other residents.) The physician increased the [MEDICATION NAME] to twice a day. Review of resident #9's Nursing TAR Behavior Monitoring record for the month of September, (YEAR), showed no documented behaviors. During an interview on 11/21/17 at 9:45 a.m., staff member K stated the CNA worksheets should show resident #9's behaviors. Review of resident #9's ADL Verification Worksheet for the month of September, (YEAR), showed the resident swore on 9/4/17 and 9/5/17, and the resident had improved on 9/5/17 with redirection. No other behaviors were documented for the month of September, (YEAR). During an interview on 11/21/17 at 1:05 p.m., staff member J stated the facility had no other documents to support the need for an antipsychotic for resident #9. The facility lacked documentation for resident #9's targeted symptoms, and the effect of the [MEDICATION NAME] on the severity, frequency, and other characteristics of her symptoms.",2020-09-01
222,AVANTARA OF BILLINGS,275029,2115 CENTRAL AVE,BILLINGS,MT,59102,2017-11-21,371,E,0,1,S6P111,"Based on observation and interview, the facility failed to ensure food was served in a sanitary manner to the residents in the dining room. This had the potential to affect any resident receiving food from the cart which was uncovered. Findings include: During an observation on 11/20/17 at 12:07 p.m., a three tiered cart was wheeled from the dining room, across the fireplace sitting area, and put next to a table set up beside the glass fronted activity area. The items on the top shelf of the cart were uncovered, and included: a plate of food, two cups of cauliflower soup, a turkey sandwich. The second shelf had 20 dessert cups with diced pears, which were also not covered. The cart was wheeled back to the serving line in the main dining room. Dietary staff were plating hot food from the steam table, and then a plate with food was handed to a CNA, who would then grab a dessert cup off the second tier of the cart. The CNA would then take the food to a resident. During an observation on 11/20/17 at 12:20 p.m., the three tiered cart, containing the dessert cups, was being wheeled around the main dining room. During an interview on 11/21/17 at 9:45 a.m., staff member O said she did not see any problem with the soup, sandwich, and dessert cups of diced pears, which were not being covered. Staff member O said she was sure the food would have been covered when it was in the kitchen. Staff member O said the covering had probably been removed for ease of serving. During a review of the FDA, 2013, Food Code, Chapter 3, it showed: - Preventing Contamination from the Premises 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and, (3) At least 15 cm (6 inches) above the floor. And: - Preventing Contamination by Consumers 3-306.11 Food Display. Except for nuts in the shell and whole, raw fruits and vegetables that are intended for hulling, peeling, or washing by the CONSUMER before consumption, FOOD on display shall be protected from contamination by the use of PACKAGING; counter, service line, or salad bar FOOD guards; display cases; or other effective means.",2020-09-01
223,AVANTARA OF BILLINGS,275029,2115 CENTRAL AVE,BILLINGS,MT,59102,2017-11-21,441,F,0,1,S6P111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to practice infection prevention for 1 (#6) of 23 sample residents, when the facility failed to have a policy and procedure for the routine cleaning of the resident's CPAP mask, and a resident's CPAP mask was not adequately cleaned; and failed to prevent the flow of contaminated air from the facility's dirty laundry room into the clean laundry room, which resulted in the potential return of contaminated clean laundry to those residents who used the facility's laundry service. Findings include: 1. During an observation on 11/20/17 at 10:15 a.m., the facility's dirty laundry room was observed to have a large air vent in the middle of the room's ceiling. Another smaller vent was high on the wall adjacent to the facility's clean laundry room. Both vents were very dirty with dust pile-up. Air flow coming from the ceiling vent made the dust, which had formed into larger dust balls, were moving due to the air flow from the vent. There was no evidence of air flow from the vent which was in the wall. Staff members were observed to bring dirty linen in through a door from the hall and sort it while wearing gloves and a protective apron. Then the soiled laundry was taken into the clean laundry room through the other room's door to the washers and dryers. During an interview on 11/20/17 at 11:05 a.m., staff member D said the facility had a contract company that serviced all the facility vents on a regular basis. He said he had not been made aware of any nonfunctioning vents after the last service check. He took a ladder into the dirty laundry room and determined that the larger ceiling vent had strong positive airflow into the dirty laundry room. The smaller wall vent had no airflow at all. He said that without an out going vent in the dirty utility room, any build up of positive air pressure in the dirty laundry room, would force contaminated air from the dirty laundry room to flow into the clean laundry room whenever the door between the rooms was opened. The door was usually opened by laundry staff several times a day to take dirty laundry to the washing machines. During an interview on 11/21/17 at 10:45 a.m., staff member B said she was unaware of the potential for airflow contamination of the facility's clean laundry room. During an interview on 11/21/17 at 11:00 a.m., staff member A stated that he intended to call the facility contract company to see what could be done to change the direction of airflow between the dirty and clean laundry rooms. During the exit conference on 11/21/17 at 2:00 p.m, staff member A said the smaller vent in the dirty laundry room wall was found to have been previously blocked and had no air flow. 2. Resident #6 admitted to the facility with [DIAGNOSES REDACTED]. He used oxygen per nasal cannula on a continuous basis and used the CPAP at night while he slept upright in a recliner chair. During an observation of resident #6's room, on 11/20/17 at 11:45 a.m., resident #6 dozed in his recliner chair. He wore his oxygen cannula, on at 2 L/min. His CPAP machine and CPAP mask lay on the floor near his chair. During an observation of resident #6's room on 11/20/17 at 12:20 p.m., resident #6's CPAP mask was again on the floor. Resident #6 said that he did not wash his CPAP mask, and had never known any of the facility staff to wash it or to change the tubing that connected his mask to his CPAP machine. A review of the facility's procedure for resident use of CPAP showed the following: Assemble the CPAP, tubing, and mask, and make sure connections are secure. Follow all manufacturer's recommendations of each CPAP unit. CPAP tubing to be changed weekly and documented in medical record. A review of the resident #6's treatment administration records and nursing care plan did not show that his CPAP mask was to be cleaned or his CPAP tubing was to be changed. During an interview on 11/20/17 at 10:45 a.m., staff member B said usually residents brought their own CPAP equipment from home for use while they were in the facility. She said there were several different kinds of CPAP equipment being used in the facility by different people at different times. She said that the facility did not keep track of each CPAP manufacturer's instructions for cleaning each brand of CPAP mask. She said the facility did not have a written policy for how CPAP masks were to be cleaned. During an interview on 11/21/17 at 10:50 a.m., staff member H said she cleaned CPAP masks with Microkill wipes. She said she had researched the product and determined it did not need to be rinsed from the mask before resident use. She did not know what the mask manufacturer recommended and did not know if the facility policy said to use a particular cleaning product. During an interview on 11/21/17 at 10:51 a.m., staff member N said she only used liquid soap and water to wash CPAP masks because any other chemical might irritate residents' facial skin when the masks were worn. She did not know if there was a facility policy or procedure for cleaning CPAP masks.",2020-09-01
224,AVANTARA OF BILLINGS,275029,2115 CENTRAL AVE,BILLINGS,MT,59102,2017-11-21,463,E,0,1,S6P111,"Based on observation and interview, the facility failed to provide a properly functioning resident call light system for the facility's dementia unit. Call lights in four resident rooms could not be turned off when answered, but continued to signal staff pagers. The resulting confusion delayed response time to legitimate resident call bells. All residents on the dementia unit who used call bells had a potential to be affected. Findings include: During an observation of resident shower rooms on the facility's dementia care unit on 11/20/17 at 9:55 a.m., a test of the shower room call light system was conducted. There was a minor delay in staff response to the activated call light. Staff member I came and canceled the call light by deactivating it from within the shower room. She explained the unit's call light system had not been working since the beginning of the weekend- three days earlier. Some of the call lights could not be turned off from the residents' room after they had been answered. The call lights continued to signal staff pagers and caused staff confusion when they could not be differentiated from legitimately functioning call lights. Staff were going from room to room to determine which resident needed assistance whenever a pager went off. A handwritten note on the unit's call system's computer monitor said the call bells for beds 211-2, 207-1, 209-2, and 212-2 could not be turned off from the resident's rooms. The monitor showed the call bells in these rooms were activated and unanswered along with other legitimately activated call lights. Staff were adding room numbers to the list to isolate the nonfunctioning call bells from the functioning ones. The facility had not established an alternate means for the residents to call for assistance. During an interview on 11/20/17 at 2:15 p.m., staff member P said when a call bell went off, she would first go to all the rooms where it was known call bells were not functioning, to see if any resident in those rooms needed service. If residents in those rooms had not called for assistance, then she checked the monitors, and went to other rooms where call lights had been activated. That way she was assured that all the residents who might have had need of assistance were covered. During an interview on 11/20/17 at 10:00 a.m., staff member I said a written request had been submitted over the weekend for maintenance to repair the system again. The call bell system had malfunctioned and had been fixed once before. She said the unit did have some residents with dementia who were capable of using the call bell system. She said when the call bell system didn't work, the confusion it caused staff, was noted by the residents, and alarmed some of them. During an interview on 11/20/17 at 11:05 a.m., staff member D said he was unaware that the call light system on the dementia unit was still malfunctioning. He said he had been unable to do anything to fix the system when it malfunctioned before. The system had required a remote online fix that could only be done by the corporate maintenance director from the corporate central office. Staff member D said he had received a request from the dementia care unit to fix the call light system about two weeks ago. He said he had called the corporate office and asked the corporate maintenance director to make the necessary remote online repairs, but had not checked back with the unit to see if they had been accomplished. He had not received the dementia unit's request for maintenance repair written over the last weekend.",2020-09-01
225,AVANTARA OF BILLINGS,275029,2115 CENTRAL AVE,BILLINGS,MT,59102,2017-11-21,514,E,0,1,S6P111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide resident and facility information in a timely manner so as not to impede the survey process, for 4 (#s 12, 13, 14, 18) of 23 sampled residents. Findings include: 1. A review of information requested for resident #13, showed that the resident's MARs, TARs, and Physician orders, were requested three times on 11/19/17, 11/20/17, and on 11/21/17. The requested information was received the day of the end of the survey. Further review of the same information requested for resident #14, showed that the resident's MARs and Physician orders [REDACTED]. 2. During the facility's survey entrance meeting on 11/19/17 at 11:35 a.m., one of the surveyor team leaders met with staff member A to discuss the survey entrance information. Staff member A was given a Long Term Care Entrance Conference and Information Request Sheet and was asked to provide the information listed on it within the specified time frames written on the sheet. The survey team had arrived on a Sunday morning, and had completed most of the entrance tour of the facility before any administrative staff arrived. Consequently, staff member A was asked to provide an updated roster matrix with resident conditions as his first priority request task to allow the survey team to pick a list of sampled residents. The roster matrix was not maintained by the facility, therefore, was not available immediately. The matrix was requested again later in the day, and received. Some of the required information requested to be provided to the survey team within one hour of the entrance conference had been given to the survey team by 6:30 p.m. on 11/19/17. A meeting was held on 11/20/17 at 2:45 p.m. with surveyor team members and administrative staff. The survey team expressed concerns about not receiving requested information in a timely manner. The remaining items requested on 11/19/17 were given to the survey team at 4:00 p.m. on 11/20/17. On 11/21/17 at 8:00 a.m., the survey team again requested the remaining list of items from Staff member [NAME] 3. a. A written request was given to the facility, on 11/20/17 at 8:00 a.m., for resident #12's (MONTH) (YEAR) MAR and TAR. The documents were not provided prior to the end of the survey. b. A written request was given to the facility, on 11/20/17 at 8:00 a.m., for resident #12's admission orders [REDACTED]. c. A written request was given to the facility on [DATE] at 8:40 a.m., for resident #18's wound assessments. A second written request for the assessments was given to the facility on [DATE] at 12:18 p.m. The information was provided, by the facility, just prior to the end of the survey. d. A written request was given to the facility, on 11/19/17 at 5:10 p.m., requesting the directions for use of a disinfecting wipe utilized to clean glucometer's. A second written request was given to the facility on [DATE] at 2:07 p.m. The information was received at the State Survey Agency office after the conclusion of the survey. During an interview on 11/21/17 at 12:15 p.m., with staff member J and G, staff member J stated the facility wound care guidelines were not available. She said those documents were on a tablet provided by (the wound care supply company), and the tablet was in the possession of staff member W. Staff member J stated staff member W was off on medical leave. Staff member G stated he would obtain the information through alternate means. The general information was provided shortly before the end of the survey. Additional information, showing it was from (the wound care supply company) was sent to the State Survey Agency after the end of the survey. Wound notes were included in the information. These notes were resident specific (#18) and were not a part of the medical record during the survey. The delay in the receipt of the requested information impeded the investigation and survey process for areas of identified concern.",2020-09-01
226,PARK PLACE TRANSITIONAL CARE AND REHABILITATION,275030,1500 32ND ST S,GREAT FALLS,MT,59405,2020-01-08,760,D,1,0,1JHJ11,"**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 free from significant medication errors, by not following physician orders [REDACTED].#35) of 2 sampled residents. This had the potential to cause loss of medication efficacy, for relief of [MEDICAL CONDITION] symptoms for the resident. Findings include: During an observation on 1/7/20 at 5:20 p.m., resident #35 was seated at a table in the dining room, with three other residents. Resident #35 exhibited upper body tremors while seated. During an interview on 1/7/20 at 5:20 p.m., staff member F stated, (Resident #35) was seated at a table next to the feeding assist table, where staff could prompt, cue or assist him if he needed help during the meals; his table was not a feeding assist table. During an interview with NF2 on 1/7/20 at 3:01 p.m., NF2 stated, It was critical for (resident #35) to receive his [MEDICATION NAME] 25-100 milligram at the times ordered; 2 tablets at 7:00 a.m., 1 tablet every 3 hours after at 10:00 a.m., 1:00 p.m., 4:00 p.m., and 7:00 p.m. The medication provided optimal control of (resident #35's) [MEDICAL CONDITION] symptoms and the ability to feed himself. During an observation and interview on 1/8/20 at 8:06 a.m., resident #35 was asleep in his bed. Staff member D stated, She was going to get (resident #35) up for the day, and that he usually got up between 8:00 a.m. and 9:00 a.m., and then ate his breakfast in his room. During an interview with staff member E on 1/8/20 at 8:50 a.m., staff member E stated she had awoken resident #35 earlier in the morning, and had given him his 7:00 a.m. meds. Staff member E stated, I review and compare the medication administration times on the medication packaging with the Medication Administration Record [REDACTED]. During an interview with staff member E on 1/8/20 at 10:23 a.m., staff member E stated, Meds are to be given within the hour due. During an interview with staff member F on 1/8/20 at 10:25 a.m., staff member F stated, Meds are to be given between 1 hour prior and 1 hour after the ordered time; that was the facility's medication administration policy. Review of resident #35's medication administration order for the [MEDICATION NAME] 25-100 milligram tablet, dated 12/12/19 showed, 2 tablets at 700 1 tablet at 1000 1300 1[AGE]0 1900 must be given precisely at these times Orally 30 days. Review of the facility medication administration policy titled Administering Medications dated December 2012, showed 4. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified. Review of resident #35's Resident Details Report for administration of [MEDICATION NAME] 25-100 milligram from 11/24/19 at 7:35 a.m. through 1/6/20 at 5:35 p.m., showed 226 administrations of the medication. Of the 226 doses administered, 74 doses were administered outside the facility's allowable times for medication administration.",2020-09-01
227,PARK PLACE TRANSITIONAL CARE AND REHABILITATION,275030,1500 32ND ST S,GREAT FALLS,MT,59405,2018-03-23,656,D,1,0,0TDM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to include interventions, ordered by the physician, on the plan of care, resulting in failure to provide needed care and services for positioning for 1 (#1); and failed to provide education of the possible risks, of prolonged periods of pressure, necessary for the resident to make informed choices for 1 (#1) of 10 sampled residents. Findings include: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of resident #1's Annual Nursing Facility Assessment, dated 3/6/18, showed services were being provided by the wound clinic for a chronic sacral ulcer, and chronic wounds to the right leg. During an observation on 3/21/18 at 11:48 a.m., resident #1 was lying in bed, partially turned onto his right side, with a pillow behind his back. Review of resident #1's (MONTH) (YEAR) physician's orders [REDACTED]. The orders showed an order, dated 4/3/17, that resident #1 was to be up only for meals, and in bed at all other times. Review of resident #1's care plan focus for impaired skin integrity, revised 3/8/18, showed the presence of wounds (pressure vs vascular) to the right lower extremity, and a sacral pressure ulcer. Interventions for the focus area included: -Noncompliant with pressure relieving measures/recommendations at times.; - Treatment per MD's orders; -Turn and reposition every two hours when in bed during the day, every four hours at night, and as needed. The care plan did not show the prohibition against right-side lying, or the plan for resident #1 to be out of bed for meals only. The care plan did not show what measures staff were to utilize when resident #1 was noncompliant with pressure relieving measures/recommendations. During an interview on 3/21/18 at 12:42 p.m., resident #1 stated he lies in his bed most of the day. He stated he can move himself slightly, using his overbed trapeze bar, but staff position him in the bed, and reposition him routinely throughout the day and night. Resident #1 stated the staff position him on his right side, left side, and on his back. He stated he cannot straighten his legs, or use his legs to reposition himself. During an interview on 3/21/18 at 3:54 p.m., staff member [NAME] stated resident #1 was usually in his bed, but did get out of bed for meals, activities, and to stroll the hallways in his wheelchair. She stated when he was in bed, resident #1 usually laid on his right side, with a pillow between his legs. Staff member [NAME] said after dinner resident #1 watches TV, while in his wheelchair, or lies down in bed, depending upon his choice. During an interview on 3/21/18 at 4:01 p.m., staff member F stated resident #1 needs extensive assistance from two staff members for transfers, and assistance from one staff member for bed mobility. He said resident #1 was usually in bed, but sometimes went to activities. He stated he alternates resident #1's positioning by rotating the resident from his left side, right side, and his back. Staff member F stated he bases the positioning on the position resident #1 was in when staff member F started his shift. During an interview on 3/22/18 at 9:30 a.m., staff member A stated resident #1's order regarding not placing him on his right side means staff should not place the resident on his right side. She said resident #1 positions himself on his right side. A verbal request was made for evidence resident #1 had been educated regarding the risks of lying on his right side, and evidence the physician was aware resident #1 was positioning himself on the right side. During an interview on 3/22/18 at 9:47 a.m., staff member H stated she was not aware resident #1 had an order to be out of bed for meals only. Review of resident #1's activity logs for (MONTH) (YEAR)-March (YEAR) showed attendance at music events, outdoor events, movies, and strolling and visiting in the facility. One activity was a day at the State Fair. The log showed resident #1 was at the event for six and a half hours. During an interview on 3/22/18 at 10:40 a.m., staff member D stated there were no special instructions for positioning resident #1 except to alternate his position, going from his back to one side, and then the other side. She stated resident #1 is usually in bed, except for meals, and riding around the facility in his wheelchair. During an observation on 3/22/18 at 11:25 a.m., resident #1 was propelling himself throughout the dining room and adjacent day room, in his motorized wheelchair. During an interview on 3/22/18 at 11:30 a.m., staff member B stated lunch was served at noon. During an interview on 3/22/18 at 1:35 p.m., staff member G stated resident #1 had a significant vascular component (impairment) as a cause of the wounds to his right lower extremity. She stated the orders prohibiting right-side lying, and not being up in the wheelchair, should be followed. She stated she, or the physician, should be notified if resident #1 was choosing to not follow the orders. She stated resident #1's medical record should show evidence the resident was educated regarding the possible risks of not following the orders. Staff member G stated resident #1 had no pressure sensation to his right leg, and would not recognize when pressure was present. A written request was made for documentation resident #1 was educated regarding the possible risks of lying on his right side, and of being up in his wheelchair, other than at meals. No documentation the facility had educated resident #1 regarding the risks of right-side lying, or being up in wheelchair when not at meals, was provided. A written request was made for documentation the physician was notified resident #1 had chosen to lie on his right side, or he had chosen to be up in his wheelchair other than at mealtime. No documentation of physician notification of those choices was provided. During an interview on 3/22/18 at 2:45 p.m., staff member A stated she believed vascular dysfunction was the major cause of resident #1's right lower extremity wounds. She said she was aware the wound clinic classified the wounds as pressure ulcers, but she did not think pressure was a factor. Staff member A stated resident #1 never had pressure to the right lower extremity. She stated directives, for the staff, from the orders, would generally be in the care plan and on the Kardex. After reviewing the orders and the care plan, staff member A stated she did not see the directives for staff to not lay resident #1 on his right side, and for him to be up only for meals included in the care plan. She stated resident #1 received education from the wound clinic at each visit. Staff member A stated she did not see documentation resident #1 had been educated by the facility. Review of resident #1's wound clinic progress notes, dated 11/1/17-3/14/18, showed each progress note included a section regarding discharge instructions for the clinic visit, and a nursing note showing education was provided regarding planned therapy/procedures. The generic notes do not show what education was provided, or who received the discharge instructions. During an interview on 3/22/18 at 3:25 p.m., resident #1 stated he had been told he should not lie on his right side, and that he tried not to. He said he had not been told what the possible risks were of right-side lying. Resident #1 stated he had not been educated that his physician had ordered he be out of bed only for meals, or what the possible risks were from being out of bed at other times. During an interview on 3/23/18 at 10:37 a.m., staff member C stated resident #1 was to be turned every two hours, have his Rooke boots on, and have a pillow between his knees. She stated he was last up for meals, meaning that he was up 15-30 minutes prior to the meal. She stated he was laid down 15-30 minutes after meals so he had time to socialize while he was out of bed. During an observation on 3/23/18 at 10:42 a.m., resident #1 was in bed, lying fully on his right side, neatly covered from his chest to his feet. During an interview and record review on 3/23/18 at 10:43 a.m., staff member C stated resident #1's side-lying order meant he could not be fully side lying. She stated the order to be out of bed for meals only meant he could not attend activities, but did not mean he could not be up for short periods of 15-30 minutes before and after meals for socialization. During an observation and interview on 3/23/18 at 10:48 a.m., staff member C entered resident #1's room, looked at his positioning, and stated he was fully on his right side. She said resident #1 must have positioned himself, on the right side, by scooting little by little so his covers were not disturbed. After leaving the room, staff member C stated she was aware resident #1 should not be fully side lying on his right side, but did not recall there was an order. After reviewing resident #1's physician's orders [REDACTED]. She said the first part of the order addressed the Roho cushion, and all of it displayed. She said the second part of the order was the side lying directive and it did not display on the treatment orders unless the user clicked on the word more to display the entire order. Staff member C stated the order for resident #1 to be out of bed only for meals was entered into the EHR in a way that prevented it from displaying on the TAR. During an interview and record review on 3/23/18 at 11:03 a.m., staff member I stated resident #1 did not have orders for not being laid on his right side, or for being out of bed only for meals. After reviewing resident #1's orders, staff member I stated those orders were in place. She stated she thought the order to be out of bed for meals only had been changed. She stated she was unaware of the order prohibiting right-side lying, so it had not been included on resident #1's care plan. Staff member I stated the CNAs could not see the order/directive if it was not included on the care plan. She stated she would update the care plan with the directive that day. Due to the failure to include the physician-ordered treatment interventions on the TAR and the care plan, the staff did not carry out the interventions.",2020-09-01
228,PARK PLACE TRANSITIONAL CARE AND REHABILITATION,275030,1500 32ND ST S,GREAT FALLS,MT,59405,2017-04-20,240,D,0,1,05GH11,"Based on observation, interview, and record review, the facility failed to maintain the resident's room in an individualized manner that promoted and enhanced the resident's quaility of life, by failing to clean and remove clutter and debris from the room; and failed to assist with resetting a clock, which had been set to the wrong time. The resident was cognitively impaired and needed extensive assistance, for 1 (#7) of 17 sampled residents. Findings include: Review of resident #7's Significant Change MDS, with an ARD date of 3/14/17, showed the resident was severely cognitively impaired. The MDS showed the resident was an extensive two person assist with bed mobility and toileting. During an observation 4/17/17 at 9:15 a.m., resident #7 could answer yes and no questions by shaking her head yes or no, or blinking her eyes. The resident was not able to move herself in her bed and was not able to communicate verbally. During an observation on 4/17/17 at 9:15 a.m., resident #7 was laying on her back in bed. Her room was dark, the curtains were drawn. The bedside table and recliner had several pink wash basins on them with toiletries and wound care supplies in the basins. The recliner had pillows and blankets piled on the seat. The red clock on the wall was set an hour behind. The room was void of personal affects. There were no pictures on the walls, no books on the shelves, and the bulletin board had a single piece of paper dated (YEAR), showing the resident would only eat 4 sandwiches a day. There was a mouse trap on the resident's window sill and dead insects and trash behind her bed. The garbage bin was half full, and there were used gloves on the floor by the garbage can, as well as used alcohol wipes on the floor. There was a metal walker with a tray folded up and tucked beside the recliner. The two drink holders in the tray had a large amount of crumbs and a thick dried liquid, brown and black in color, with a white fuzz on top of the dried liquid. During an interview on 4/17/17 at 10:45 a.m., resident #7 was asked if she could answer yes and no questions. The resident shook her head yes. When asked if she liked her room, the resident shook her head no. The resident was questioned about reading books, and shook her head yes showing she missed reading books (The resident was stated to be an avid reader). When the resident was asked if she would like a picture in her room she shook her head yes. During an observation on 4/18/17 at 9:20 a.m., resident #7's room still had the curtains drawn. The bedside table and recliner had several pink basins with toiletries and wound care supplies. The recliner had pillows and blankets piled on the seat. The red clock on the wall was set an hour behind. The room was void of personal affects. There were no pictures on the walls, no books on the shelves, and the bulletin board had a single piece of paper, dated (YEAR). The paper showed the resident would only eat 4 sandwiches a day. There was a mouse trap on the resident's window sill. The metal walker had two drink holders, which remained soiled with the dried liquid substance as in the prior observation. A review of the facility's Night shift Wheel Chair Wash List, showed resident #7's chair and walker to be cleaned on the first Thursday of the month. During an interview on 4/17/17 at 12:30 p.m., staff member Q stated the housekeeping was responsible for cleaning the horizontal surfaces, floors, walls, and the bathrooms. He stated there was a 5-step procedure for the resident rooms and a 7-step procedure for the resident bathrooms. Staff member Q stated it was the responsibility of the aides to clean up the clutter in the resident's rooms and wash the resident's wheelchairs and walkers. During an interview on 4/17/17 at 10:00 a.m., staff member A stated resident #7 had not used her walker since her readmission on 3/8/17. She stated the resident had a stroke and had not been able to use the walker since returning to the facility. Staff member A stated leaving the walker dirty in the resident's room was an oversight. She stated it was the responsibility of the nursing staff to clear clutter and put personal hygiene items away for the resident's who need the assistance. This should be completed daily. During an interview on 4/17/17 at 4:41 p.m., staff member V stated it was the responsibility of the night nurses to clean the wheelchairs and walkers. Staff member V stated it was the responsibility of both nursing and CNAs to clean up clutter and put away items in the resident's rooms. During an interview on 4/18/17 at 10:50 a.m., staff member H stated she was the responsible CNA for the 100 hall. She stated she was responsible to pick up clothes and belongings in the resident's rooms and to make the beds. She stated the night nurses were responsible for cleaning the resident equipment, such as wheelchairs and walkers. During an interview on 4/18/17 at 2:45 p.m., staff member B stated she cleaned resident #7's room. Staff member B stated she still needed to get the broom from housekeeping to sweep in resident #7's room. Staff member B stated she changed the time on the clock as well. During an interview on 4/20/17 at 8:24 a.m., staff member W stated there was available housekeeping seven days a week. She stated housekeeping cleans the resident rooms and the bathrooms, using a 5-step method in the resident rooms, and a 7-step method in the bathrooms. She stated the rooms received a deep clean once a month. She stated housekeeping cleans the horizontal services, floors and walls. Staff member W stated she provided oversight three times daily and had an assistant manager which also made rounds daily. There was also housekeeping available during the weekends. The staff member stated the nursing staff was responsible for cleaning clutter and the resident's wheelchairs and walkers. During an interview on 4/20/17 at 9:50 a.m., resident #7's POA stated the resident used to read all the time and had books in her room. She stated the resident also used to have a picture of the two of them hanging in her room. The POA stated when she visited resident #7 in the facility, after the resident had her stroke and was put on hospice, she noticed the picture which used to hang in the resident's room was missing. She found the picture, in a drawer, and the frame was broken. She stated she was sad when she found the picture had been damaged and brought it home to re-frame for the resident. She stated the resident's room felt cluttered. The POA stated she was concerned because she did not feel the resident was receiving the quality of care she deserved.",2020-09-01
229,PARK PLACE TRANSITIONAL CARE AND REHABILITATION,275030,1500 32ND ST S,GREAT FALLS,MT,59405,2017-04-20,241,D,0,1,05GH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to promote dignity and quality of life by failing to assist a resident with putting away clothing after admission, and educating the resident on where his toiletries would be kept, and the resident felt he was not important due to the lack of assistance for these things, for 1 (#8) of 17 sampled residents. Findings include: Resident #8 was admitted to the facility on [DATE]. During an observation on 4/17/17 at 9:45 a.m., resident #8's clothes were in three white garbage bags, and one white plastic personal belongings bag was on the floor at the foot of the patient's bed. A pink blanket was on the floor next to his recliner. The resident was not in his room. During an interview on 4/17/17 at 9:45 a.m., staff member F stated the resident was a new admit on 4/14/17 and he could not answer how long his personal belongings were on the floor. She stated the nursing staff and the CNAs were responsible to assist resident to put away there clothing. During an interview on 4/17/17 at 9:50 a.m., staff member H stated the resident was admitted on [DATE] and could not answer when his clothes arrived. She stated it was the expectation of the nursing staff to put the clothes away as soon as possible, and no longer than one day. During an interview on 4/17/17 at 9:55 a.m., staff member L stated she was not sure when the resident's belongings were delivered. She stated it was the expectation that the resident's clothes be put away as soon as possible, in relation to how the resident wanted their belongings unpacked. During an interview on 4/17/17 at 10:30 a.m., resident #8 stated he was admitted to the facility on Friday 4/14/17, and he came only with a small belongings bag. He stated his friend brought the rest of his belongings in the white trash bags on Saturday 4/15/17. He stated he would like help from the staff to put his belongings away. Resident #8 stated he did not like it at the facility, and he felt like he was put on the back burner when the facility did not help him put his belongings away. The resident stated he did not have a place to put his toiletries in the bathroom. He stated there was only one little shelf, and the resident in the adjoining room had his belongings on the shelf. The resident stated he did not feel he had a place to put his belongings. During an interview on 4/17/17 at 12:00 p.m., staff member J stated resident #8 was admitted to the facility on Friday 4/14/17. She stated staff member F was responsible for showing the resident around and helping the resident acclimate to the facility. She stated the resident's belongings should be put away by the CNAs as soon as possible. The staff member could not recall when resident #8's belongings were delivered.",2020-09-01
230,PARK PLACE TRANSITIONAL CARE AND REHABILITATION,275030,1500 32ND ST S,GREAT FALLS,MT,59405,2017-04-20,253,E,0,1,05GH11,"Based on observation, record review, and interview, the facility failed to maintain a wheelchair and seating system in a sanitary manner for 1 (#19); failed to ensure a clean environment in a resident's room for 1 (#7) of 26 sampled and supplemental residents. The facility also failed to ensure resident rooms and bathrooms were maintained in a sanitary condition for 11 of 17 bathrooms on the 500 hall; for 3 resident rooms and bathrooms (104, 105, and 106) of 21 rooms on the hall; and for 8 resident rooms and bathrooms (106, 107, 108, 300, 301, 306, 307, 308) of 12 bathrooms on the 100/300 halls. Findings include: 1. Cleanliness concerns on the 100/300 units - WHEELCHAIR During an observation on 4/17/17 at 3:40 p.m., resident #19 was seated, in his wheelchair, near the 100 hall nurse's station. Attached to the wheelchair was a black 4-point seating system that buckled low across the waist. Dried white, tan, yellow, and brown substances were noted on the seating system which appeared to be dried food or fluid spills. Dust and loose debris that appeared to be dried food were on the frame of the wheelchair, and all four wheels had white spots and streaks, that appeared to be a spilled white liquid. There was also dirt on the wheel spokes; especially the left front wheel. During an observation on 4/18/17 at 8:00 a.m., resident #19 was seated, in his wheelchair, near the nurse's station. The seating system and wheelchair were unchanged from the previous day, and remained soiled. During an observation on 4/19/17 at 8:10 a.m., resident #19 was seated, in his wheelchair, near the nurse's station while a staff member worked on the wheelchair. The seating system remained soiled. During an interview with resident #19 on 4/19/17 at 8:10 a.m., the resident looked towards the surveyor, but made no response showing he understood. He was unable to make himself understood. Review of resident #19's MDS, with an ARD of 3/21/17, showed the resident was coded as rarely/never understood for his BIMS assessment. During an interview on 4/18/17 at 7:30 a.m., staff member H stated the night shift CNAs were responsible for cleaning wheelchairs. A review of a facility document titled, Night shift wheel chair wash list, showed that resident #19's wheelchair was scheduled to be washed every Friday. - ODOR During an observation on 4/17/17 at 9:30 a.m., during the initial tour, there was a urine odor in resident room 106, and the bathroom. The odor was stronger in the bathroom, which had a urinal dated 3/14/17. The urinal was hanging from the towel bar. The urinal lid was open and there were drops of a straw colored liquid in the bottom of the container which emanated a strong odor characteristic of urine. The bathroom floor had a dried yellow/brown substance to the left of the toilet, and in front of the toilet. This was on the baseboard to the right, and in front of the toilet. There was a used glove on the floor. In the resident room, the floor had a dried yellow/brown substance on the right side of the bed. During an observation on 4/18/17 at 7:15 a.m., an unpleasant odor, characteristic of urine, was noted on entrance to the 100 hallway. The odor increased towards the end of the hall where room 106 was located. During an observation on 4/18/17 at 8:45 a.m., there was a strong odor, characteristic of urine, in the bathroom of room 106. There was a urinal dated 3/14/17 hanging from the towel bar with the lid closed. The discolored areas on the floor and baseboard were unchanged from 4/17/17 at 9:30 a.m. During an observation on 4/19/17 at 7:30 a.m., an odor, characteristic of urine, was noted in room 106. The odor was stronger in the bathroom. A urinal dated 4/19/17 was sitting on the back of the toilet. During an interview, which was completed in room 106, on 4/19/17 at 7:33 a.m., staff member K was asked about an odor in the room and responded that the odor was not overwhelming. Upon entering the bathroom, staff member K stated the odor was stronger than in the bedroom. Upon returning to the bedroom, staff member K stated that there was a hint of a urine odor, but it's not overwhelming. During an interview on 4/18/17 at 4:30 p.m., questions were provided in writing for the resident due to his hearing deficit. The questions were about his room and how often he received a new urinal. Resident #22 showed verbally and non-verbally, through his expressions, that he could not understand. During an observation on 4/19/17 at 8:10 a.m., the window, in room 106, was observed to be open and there was an odor, characteristic of air freshener, in addition to the urine odor noted on 4/19/17 at 7:30 and 7:33 a.m. During an observation on 4/19/17 at 4:30 p.m., housekeeping staff were scrubbing the floor in room 106 with a floor cleaning machine. During an interview on 4/20/17 at 8:30 a.m., staff member H stated that urinals were changed out every day by the night shift. Staff member H withdrew the statement and said she was uncertain and would verify the information. Staff member H did not provide a clarification for when the urinals were changed. During an interview on 4/20/17 at 8:45 a.m., staff member L stated that urinals were changed weekly by the night shift and would be changed anytime if the urinal was soiled. Staff member L stated the urinal should be dated and labeled with the resident's name and room number. Staff member L said after a resident uses the urinal, the contents should be dumped in the toilet, and the urinal rinsed with water and dumped in the toilet. Staff member L stated the urinal should then be bagged and stored in the bottom drawer in the resident's room. A urinal had been used for resident #22 for 5 weeks before being replaced. It had not been rinsed and stored in a manner that would minimize odor. The floor had not been cleaned in a manner that would minimize odor until 4/19/17. There was minimal odor in the room and bathroom on 4/20/17, after the urinal was changed and the floor was cleaned. - FALL MAT/DRAPES During an observation of room 105 on 4/17/17 at 9:26 a.m., there was an alarmed fall mat on the floor with dirt and debris visible, including two raisins that were adhering to the mat. Three pest traps were on the floor. During an observation on 4/17/17 at 4:20 p.m., the raisins had not been removed from the alarmed fall mat in room 105, and several reddish brown spots were noted on the drapes. During an observation on 4/18/17 at 7:30 a.m., the raisins were observed on the alarmed fall mat in room 105 again. The drapes continued to have the spots on them, which were initially observed on 4/17/17. During an observation on 4/19/17 at 4:30 p.m., the alarmed fall mat in room 105 had been replaced, but had remained soiled for at least 48 hours. The drapes with the soiled spots had not been changed. Review of a document titled, (Housekeeping Contractor) Housekeeping In-Service, undated, had a subject: 5-Step Daily Patient Room Cleaning. The document showed the following steps: 4. Dust Mop, The entire floor must be dust mopped . and Move all furniture to dust mop. At step 5. Damp Mop, The most important area of a patient's room to disinfect is the floor. This is where most air-borne bacteria will settle and so it needs to be sanitized daily. - BATHROOMS During an observation of room 105 on 4/17/17 at 9:26 a.m., there was a basin containing food wrappers, crumbs, and used tissues on the over-bed table. In the shared bathroom, on the floor, was a bedpan, a used glove, and used tissue. During an observation on 4/17/17, the shelf in the shared bathroom for rooms 300 and 301 had chunks of a white pasty substance and white streaked areas, where a liquid had dried. There was a urinal, dated 3/14/17, hanging from the towel bar. During an observation on 4/17/17, during the initial tour, in bathroom 306 was a mug, with a dried white substance and dust in the bottom, containing toothbrushes. On the bathroom shelf was a tan sticky substance, and on top of that, a piece of dycem. There was a storage container on the floor, and on top was a soap dish with a soiled gray/brown buildup in the dish. There were two non-slip strips on the floor in front of the toilet, soiled with loose dirt and debris. Hair and lint was adhered to the strips. During an observation on 4/17/17, [RM #]/308 was noted to share a bathroom which had a dried yellow/brown substance on the baseboard and floor. Dirt was visible on the floor, and a brown matter was adhering to the inside and rim of the toilet. Review of a document titled, (Housekeeping Contractor) Housekeeping In-Service, undated, showed a heading, titled 7-Step Daily Washroom Cleaning with two of the following steps listed (not all inclusive): 3. Dust Mop Floor 7. Damp Mop Floor. 2. Review of resident #7's Significant Change MDS, with an ARD date of 3/14/17, showed the resident was severely cognitively impaired. The MDS showed the resident was an extensive two person assist with bed mobility and toileting. During an observation on 4/17/17 at 9:15 a.m., resident #7 could answer yes and no questions by shaking her head yes or no, or blinking her eyes. The resident was not able to move herself in her bed and was not able to communicate verbally. During an observation on 4/17/17 at 9:15 a.m., in resident #7's room, the bedside table and the recliner had several pink basins with toiletries and wound care supplies. The recliner had pillows and blankets piled on the seat. The red clock on the wall was set an hour behind. There was a mouse trap on the resident's window sill and dead insects and trash behind her bed. The garbage bin was half full, and there were used gloves on the floor by the garbage can as well as used, open alcohol wipes on the floor. There was a metal walker with a tray folded up and tucked beside the recliner. The two drink holders had a large amount of crumbs and a thick brown, black food and dried liquid buildup with a white fuzzy top on the dried liquid. The resident's shared bathroom had a toilet riser with the handles duct taped with a turquoise colored duct tape, and the tape was frayed and hanging off from the left handle. During an observation on 4/18/17 at 9:20 a.m., resident #7's bedside table and the recliner had several pink basins with toiletries and wound care supplies. The recliner had pillows and blankets piled on the seat. The red clock on the wall was set an hour behind. There was a mouse trap on the resident's window sill. The metal walker had two drink holders which had a large amount of crumbs and a thick brown, black food and dried liquid buildup with a white fuzzy film on top of the dried liquid. A review of the facility's Night shift Wheel Chair Wash List showed resident #7's chair and walker was to be cleaned on the first Thursday of the month. During an interview on 4/17/17 at 12:30 p.m., staff member Q stated the housekeeping was responsible for cleaning the horizontal surfaces, floors and bathrooms. He stated there was a 5-step procedure for the resident rooms and a 7 step procedure for the resident bathrooms. Staff member Q stated it was the responsibility of the aides to clean up the clutter in the resident's rooms. He stated it was the aides responsibility to wash the resident's wheelchairs and walkers when dirty. During an interview on 4/17/17 at 4:41 p.m., staff member V stated night nurses were responsible for cleaning the wheelchairs and walkers. Staff member V stated both nursing and CNAs were responsible to clean up clutter and put away items in the resident's rooms. During an interview on 4/17/17 at 10:00 a.m., staff member A stated resident #7 had not used her walker since her readmission on 3/8/17. She stated the resident had a stroke and had not been able to use the walker since returning to the facility. Staff member A stated to leave the walker dirty in the resident's room was an oversight. She stated it was the responsibility of the nursing staff to daily clear clutter and put personal hygiene items away for the residents who needed assistance. During an interview on 4/18/17 at 2:45 p.m., staff member B stated she cleaned resident #7's room. Staff member B stated she still needed to get the broom from housekeeping to sweep resident #7's room. Staff member B stated she had changed the time on the clock. This was noted after the facility was made aware of the cleanliness concerns, which the facility had not identified and corrected prior. 3. During an observation of resident bathrooms on the 100 hall on 4/17/17 at 9:45 a.m., the following was observed: - Room 108: There was a strong odor of urine. The floor had yellow staining, and a medium sized yellow spot by the toilet was sticky when stepped on. Review of the facility grievance book showed a resident had concerns on 2/13/17, with an adjoining bathroom for room 518. The grievance was about the cleanliness of the bathroom. 4. During observation of resident bathrooms on the 500 hall on 4/18/17 at 7:15 a.m., the following was observed: -Rooms 504 and 505 had a shared bathroom. There was a strong urine odor. There was a brown substance around the edges of the floor, surrounding the toilet that extended 4 up the wall. There was a blue bed pan sitting on a plastic bag, under the sink. -Rooms 511 and 512 had a shared bathroom. There was a strong, unidentifiable odor. The floor was sticky. The toilet had a brown substance on the seat and the back. The edges of the floor, in front of and behind the toilet, were soiled with a gray and brown substance. -Rooms 513 and 514 had a shared bathroom. There was a brown substance on the slip strips located in front of the toilet. The floor was stained with a gray substance around the edges and 4 up the wall. There was food debris on the fall mat, and the floor of room 514. During an observation on 4/18/17 at 9:00 a.m., resident bathrooms in 504/505, 511/512 and 513/514 remained unchanged following cleaning. During an interview on 4/19/17 at 8:35 a.m., staff member O stated a deep clean was completed on one room, daily.",2020-09-01
231,PARK PLACE TRANSITIONAL CARE AND REHABILITATION,275030,1500 32ND ST S,GREAT FALLS,MT,59405,2017-04-20,280,D,0,1,05GH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to revise care plans with resident condition changes for 3 (#s 3, 16, and 22) of 26 sampled and supplemental residents. Findings include: 1. Resident #16 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. During the initial tour of the 100 and 300 units on 4/17/17, staff member F stated resident #16 previously had a pressure ulcer which had healed prior to 4/17/17. During a record review of resident #16's, of evaluation forms titled, Weekly Pressure Ulcer BWAT Report, showed resident #16 was admitted to the facility on [DATE] with a Stage II pressure ulcer to the right buttock and the wound was documented to be resolved on 4/4/17. During an interview with staff members B and F on 4/20/17 at 10:40 a.m., staff member F stated the resident's care plan showed a current ulcer, and to her knowledge, resident #16 did not currently have a pressure ulcer. Staff member B said the ulcer reflected in the care plan was the ulcer that was present on admission and had recently resolved. Staff member B stated the care plan should have been updated to show the ulcer was resolved. 2. Resident #22 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. During an observation and interview with resident #22 on 4/18/17 at 4:30 p.m., the resident was observed to have a Foley catheter. During an interview on 4/20/17 at 9:40 a.m., staff member G stated resident #22 had both a suprapubic catheter, which was currently plugged, and a functional Foley catheter. Review of resident #22's surgical procedure report, dated 7/15/16 from (local hospital name), showed the plan for the resident was to maintain both a suprapubic and a Foley catheter. Review of resident #22's pharmacy treatment order sheet, showed an order dated 4/6/17 to change the Foley catheter. Review of resident #22's care plan showed the use of a suprapubic catheter was addressed under three focus areas: ADL deficit, Potential for skin integrity impaired, and Potential for infection. The care plan did not show the suprapubic catheter was plugged. The care plan did not show use of the Foley catheter or need for care of the catheter. During an interview on 4/20/17 at 10:40 a.m., staff member F stated she expected resident #22's care plan to show the suprapubic catheter was plugged, and the Foley was in place. She stated she could not locate the information on the care plan. 3. Resident #3 was admitted on [DATE], and had [DIAGNOSES REDACTED]. During an observation and interview on 4/18/17 at 7:30 a.m., staff member H assisted resident #3 by positioning her wheelchair at the foot of the bed as the resident sat up in preparation for a transfer. Staff member H stated the resident did not have a cushion and preferred a folded chuck in her wheelchair as padding. During an observation and interview on 4/18/17 at 2:20 p.m., a folded chuck was observed on the seat of resident #3's wheelchair. Staff member I stated the resident used this as padding, and a cushion was not used in the wheelchair. Resident #3 said she used the chuck as padding, and she didn't know anything about having a cushion. Resident #3 stated that a cushion might be more comfortable and she would try one, if offered. Review of resident #3's Care Plan, showed a focus for Potential skin integrity impaired . with an intervention of pressure reducing device: cushion to bedside chair and/or wheelchair. During an interview on 4/19/17 at 9:45 a.m., staff member F stated she relied on staff member B to inform her of which residents had wheelchair cushions. She stated she did not always confirm the information prior to completion of the MDS/CP. She said the coding was incorrect for resident #3. A review of the facility policy, titled Comprehensive Plan of Care, showed the following in the Rational section of page one: The care plan was re-evaluated and modified: - As necessary to reflect changes in care, service and treatment; - Quarterly with assessment; and - With significant change of condition assessment.",2020-09-01
232,PARK PLACE TRANSITIONAL CARE AND REHABILITATION,275030,1500 32ND ST S,GREAT FALLS,MT,59405,2017-04-20,312,E,0,1,05GH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to keep resident clothing free of food debris and urine, and failed to provide grooming and facial care for 4 (#s 7, 9, 10 and 19) of 26 sampled and supplemental residents. Findings include: 1. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of resident #7's Significant Change MDS, with an ARD date of 3/14/17, showed the resident was severely cognitively impaired. The MDS showed the resident was an extensive two person assist with bed mobility and toileting. The MDS showed the resident was incontinent all the time of bowel and bladder. During an observation on 4/17/17 at 9:15 a.m., resident #7 was laying on her back in bed. She was wearing a pink cotton shirt. The bed sheet under the resident's back was wet up to the shoulder. There was a slight odor of urine. During an observation on 4/17/17 at 4:18 p.m., resident #7 was laying on her back in bed. She was wearing the same pink cotton shirt. The bed sheet was no longer wet. There was no odor. The resident's right hand was at her side. The right hand was slightly contracted, and a strong foul odor emanated from the right hand. During an interview on 4/19/17 at 1:43 p.m., staff member B stated she did smell resident #7's right hand, and it smelled bad. She stated she cleaned the right hand with warm soap and water and moved the fingers. She stated the fingers opened without effort, and noted a small amount of stiffness in the thumb. The staff member stated there was no fingernail impressions in the palm of the hand or open skin on the palms. During an observation on 4/18/17 at 7:24 a.m., resident #7 was awake laying on her back in bed. She was wearing the same pink cotton shirt she was wearing the day before. The resident had dried drool down her right chin. She had dry and crusted eye drainage caked on the right eye, and thick creamy dark brown drainage at the corners of her mouth. During an observation on 4/18/17 at 7:28 a.m., staff member T brought the resident breakfast. She offered breakfast to the resident, and the resident shook her head no. The staff member left resident #7's room at 7:30 a.m. The staff member did not offer to wash the resident's face, hands, or change her clothes. During an observation on 4/18/17 at 8:02 a.m., staff member T returned to the resident's room, and offered the resident breakfast again. The resident shook her head no. The staff member left the resident's room, she did not offer to wash her face, hands, or change her clothes. During an observation on 4/18/17 at 8:35 a.m., staff member L cleaned the resident's face with a warm washcloth. She did not change her shirt, or wash her hands. During an observation on 4/18/17 at 9:03 a.m., the resident was laying on her back in bed. She was wearing the same pink cotton shirt from the day prior. Staff member B and staff member U changed resident #7's wet soiled brief. The wet brief had saturated the resident's bedding from below the knees to above the elbows. The bedding was changed at the same time the staff changed the resident's brief. The staff members did not change the resident's shirt and did not clean her skin after laying in wet soiled linens. During an interview on 4/18/17 at 10:00 a.m., staff member B stated she did not change the resident's shirt when she changed the urine soaked sheets. She stated it would be the expectation to change any saturated clothing, although this had not occurred. During an interview on 4/18/17 at 10:35 a.m., staff member H stated she had not been able to check on resident #7 to change her position in bed because the day was crazy. The staff member stated she had changed the resident's head of bed a couple of times from 35 degrees to 90 degrees. The staff member stated she changed resident #7's briefs, washed her face, and brushed her teeth between 7:15 a.m., to 7:30 a.m. on 4/18/17. The staff member did not mention if she cleaned the resident's hands or changed her shirt. During an interview on 4/18/17 at 11:07 a.m., staff member A stated it was the expectation of staff to change a resident's soiled clothing, and per the resident's preference, wash hands, face, and perform ADL's. During an observation on 4/18/17 at 11:30 a.m., resident #7 was lying in bed on her back wearing the same pink cotton shirt she had worn when the sheets were saturated with urine the day prior. During an observation on 4/18/17 at 12:39 p.m., resident #7 was sitting in her wheelchair, in the dining room being assisted with her lunch. She was wearing a green velvet shirt and pants. 2. Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED]. During an observation on 4/17/17 at 3:40 p.m., resident #19 was seated, in his wheelchair, near the 100 hall nursing station. The tan colored hat he was wearing was noted to have soiled streaks and spots. He was not wearing any glasses. Attached to the wheelchair was a black 4-point seating system that buckled low across the waist. During an observation on 4/18/17 at 8:00 a.m., resident #19 was seated, in his wheelchair, near the nurse's station. He was wearing the same hat with the soiled streaks and spots as seen on 4/17/17. He was not wearing any glasses. During an observation on 4/19/17 at 8:10 a.m., resident #19 was seated, in his wheelchair, near the nursing station while a staff member worked on the wheelchair. Resident #19 was wearing a long-sleeved tee shirt which had loose debris/crumbs and dried matter on it. He was wearing gray jogging pants which had loose debris/crumbs on them. He was wearing the same hat with the discolored areas and spots noted on the previous day. He was not wearing any glasses. During an observation on 4/19/17 at 2:05 p.m., resident #19 was seen with the same soiled hat and clothing as during the observation that morning. Debris/crumbs were seen on his shirt and pants, and the shirt had four discolored areas. He was not wearing any glasses. The glasses were observed on the bedside stand in the resident's room at 2:04 p.m. During an observation on 4/20/17 at 8:33 a.m., resident #19 was seated, in his wheelchair, near the nursing station. He was wearing the same soiled tan hat. His shirt had discolored spots and loose debris/crumbs on it. Loose debris/crumbs were seen on his pants. He was wearing his glasses. Discolored areas and spots were on the seating system. There was dirt on the wheelchair frame and the wheels had white spots and dirt on the spokes. The left front wheel was nearly covered with white spots and streaks. During an interview with resident #19 on 4/19/17 at 8:10 a.m., the resident looked at the surveyor but made no response showing he understood. He was unable to make himself understood. During an interview on 4/19/17 at 2:00 p.m., staff member M stated resident #19 needed staff to provide his ADL's and that he had behaviors, such as removing and twisting his glasses, and grabbing the arm of staff who were attempting to provide care. Review of resident #19's Annual MDS, with an ARD of 3/21/17, showed the need for extensive assistance of one person for dressing. The resident was coded as sometimes understood and as rarely understands. There was no cognitive score, but the assessment was coded showing the BIMS could not be conducted due to resident #19's inability to make himself understood. Review of resident #19's care plan showed a focus area of Altered ADL - Self Care Deficit, with a date of 4/25/16, which listed multiple factors contributing to the deficit. The focus showed these factors resulted in, Creating a risk for unmet needs, impaired integument (skin) and further decline. The goal showed that (resident #19) will be appropriately groomed & dressed, evidenced by neat and clean appearance; no odor. Interventions showed extensive assist of one person for dressing. 3. During an observation on 4/17/17 at 11:30 a.m., resident #10 had dried food around her mouth, and her chin was covered in facial hair. She was feeding herself with a knife. Staff did not cue her to use a fork. During an observation in the dining room on 4/17/17 at 5:00 p.m., resident #10 had dried food around her mouth. During an observation in the dining room on 4/18/17 at 7:35 a.m., resident #10 still had a chin full of whiskers, and her hair was not combed. During an observation in the dining room on 4/18/17 at 12:30 p.m., resident #10 had a dried green substance in the corner of her eyes. During an observation in the resident's room on 4/19/17 at 7:50 a.m., resident #10's clock was not set to the correct time, and her electric clock screen was flashing on and off. During an interview in 4/18/17 at 7:40 a.m., staff member J stated resident #10 could be resistive to shaving at times. 4. During an observation on 4/19/17 at 4:25 p.m., resident #9 was laying on a sheet with a large yellow-rimmed circle. The top sheet was yellowed and looked damp. He had a incontinent brief on that appeared heavily soaked. The resident stated he did not want to use his call light because They don't care. He stated all he wanted was a big towel. The room had a urine odor. Staff member N was notified of resident #9's need for a big towel. She went into the room with a towel, and immediately returned to her cart. The resident was not assisted with the soiled brief. During an observation on 4/19/17 at 5:10 p.m., resident #9 was still laying in the stained and damp-looking sheets. He had the big towel and said that it would dry things up. Staff member C was made aware of the resident's need for assistance, and said it was being taken care of. During an observation on 4/19/17 at 5:20 p.m., staff member F entered resident #9's room with a towel, and immediately came out to the hall. The sheet and soiled brief was not changed. During an interview on 4/19/17 at 5:25 p.m., staff member F stated she had asked resident #9 if he needed anything, and he stated he did not need anything. She stated she did not notice the discolored sheets or the odor.",2020-09-01
233,PARK PLACE TRANSITIONAL CARE AND REHABILITATION,275030,1500 32ND ST S,GREAT FALLS,MT,59405,2017-04-20,314,G,0,1,05GH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to prevent the development of 3 Stage II pressure ulcers, the worsening of pressure ulcers, the development of 2 Unstageable pressures ulcers, and a wound infection for 1 (#13) of 17 sampled residents. The facility failed to prevent the development of an Unstageable pressure ulcer for 1 (#6) of 17 residents. Findings include: 1. Review of the Admission MDS, with the ARD of 5/24/16, showed resident #13 came to the facility with 2 Stage II pressure ulcers. Review of the BWAT forms, dated 5/18/16, showed resident #13 had a Stage II pressure ulcer on the left gluteal fold, and 2 stage II ulcers on the left buttock. Review of the BWAT, dated 6/1/16, showed the resident's left gluteal fold ulcers had healed. Review of the BWAT, dated 6/3/16, showed the resident's new development of a Stage II ulcer to the left heel. Treatments included Rook Boots, and heel protectors. Review of the BWAT, dated 6/14/16, showed the resident's left buttock ulcer had healed. Review of resident #13's Progress Note, dated 6/16/16, showed the left heel was healing well. Review of the BWAT, dated 6/22/16, showed the heel had developed into an Unstagable pressure ulcer. The ulcer was covered with eschar. During an interview on 4/20/17 at 1:20 p.m., staff member B stated she did not know what had happened to worsen the heel pressure ulcer. She stated his heels were floated, and the strap on the back of his wheel chair was removed because it may have caused the blister. Review of resident #13's Progress Note, dated 6/28/16, showed NF2 had requested the appointment for the foot doctor on that day. Review of resident #13's Progress Note, dated 8/3/16, showed (Family member) continues to want to go to resident's podiatrist. During an interview on 4/11/17 at 1:30 p.m., NF2 stated she had to fight to get the facility to send resident #13 to the foot doctor. Review of resident #13's Progress Note, dated 8/17/16, showed out to (Podiatrist) yesterday. Continuing with [MEDICATION NAME] washes. Review of resident #13's physician order, dated 8/24/16, showed must wear boot we dispensed last week to protect heel. During an interview on 4/11/17 at 1:15 p.m., NF2 stated the boots were not on resident #13 during visits. Review of the resident's Physician Order, dated 9/2/16, showed Boot to off-weight heel to be worn at all times. Grey boot goes on L foot. Review of the resident's Progress Note, dated 10/4/16, showed Left heel has been grafted and has a non-removable dressing in place. Has specialty mattress, heel pro, and heel lift boots. Review of the resident's Progress Note, dated 12/18/16, showed the resident was sent to the ER related to a fall out of bed. Review of the resident's Hospital Notes, dated 12/19/16, showed resident #13 had Right heel has intact bullous lesion with bone palpated beneath it suggestive of suspected pressure stage 2. Left heel has dry crusted lesion with bone palpated beneath it suggestive of unstageable suspected pressure ulcer. During an interview on 4/21/16 at 1:20 p.m., staff member B stated she had not looked at resident #13's heel, since 11/8/16. She was not aware the pressure ulcer was still on the heel. 2. Review of resident #13's Progress notes showed he discharged from the facility on 7/12/16, with a UTI, and readmitted on [DATE], with a Stage II pressure ulcer on the sacrum, and an Unstageable area on the left buttocks. Review of the Progress Notes for resident #13, dated 7/27/16, showed the left buttock was now a Stage II, and the sacrum remained a Stage II. Review of the Progress Note, dated 8/10/16, showed resident #13's left buttock ulcer had healed, and the pressure ulcer to the sacrum running across both buttocks, had resolved. Has (new) abrasion to left buttock that appears to be from armrest of chair when transferred with mechanical lift. Review of the resident's Progress Note, dated 9/6/16, showed the abrasion to the left buttock continued. An abraded area was also noted to the scrotum, and some excoriation, lower down the left buttock. During an interview on 4/20/17 at 4:25 p.m., staff member B stated the open areas were identified as injuries, and not pressure ulcers. She stated the treatment would not have changed if the areas had been identified as pressure. Review of the resident's physician's orders [REDACTED]. Review of the resident's Progress Note, dated 11/1/16, showed bilateral buttocks are very macerated. Skin is white and peeling away. Believe this is from too much moisture with current treatment. Some bleeding noted. Right buttock measures 4.3 x 3.2 cm, and left buttock measures 5.9 x 3.8 cm. Will request orders for [MEDICATION NAME] q shift and to wear tape attends products to assist with moisture issues. Review of the resident's Progress Note dated, 11/8/16, showed [MEDICATION NAME] noted at 50% of wound bed. Scrotal area with new skin damage. Has appearance of being torn, maybe by adjusting of attends or pants. Scabbed over. Will continue use of antifungal powder/Vaseline mix to soften scab. Resident continues to be non-compliant with turn and repositioning. Review of resident#13's Significant Change MDS, with the ARD of 10/18/16, showed the resident required extensive assist of two people to reposition in bed. Review of the resident's Progress Note, dated 11/14/16, showed Injury to left ischium and across to scrotum covered with necrotic tissue now. Unable to use tape on this resident as his skin reacts. MD notified and that wound has progressed and is now a pressure ulcer. Have PT to debride and treatment. Airbed orders and will be delivered within 24 hours. Review of the last physician visit provided by the facility, dated 11/14/16, showed the resident had Fever above 102 several days. New decubitus of buttocks. Culture if temp. A review of resident #13's Progress Note, dated 11/15/16 showed he had a temperature of 100.2. Review of resident #13's Progress Note, dated 11/20/16, showed a new open area on the coccyx. Review of resident #13's Wound Clinic Report, dated 11/29/16, showed an Unstageable pressure ulcer of the left buttock. Review of resident #13's Progress Note, dated 12/1/16, showed he was now being treated at the wound clinic. Review of resident #13's Progress Note, dated 12/4/16, showed, Resident appetite poor @ lunch. Lethargic @ times & slow to respond to staff questions .temp decreased to 98.4 with prn Tylenol Review of resident #13's Progress Note, dated 12/5/16, showed IDT review r/t fall out of bed this past weekend. Resident is on air mattress with a low bed. This is an isolated incident. Resident was running an increased temperature and more lethargic than usual. ? (sic) infection r/t wound. Will have MD assess resident. During an interview on 4/20/17 at 2:50 p.m., staff member K stated resident #13's wound care was managed by the wound clinic, when asked about wound cultures for non-healing pressure ulcers. Review of resident #13's Wound Clinic Report, dated 12/6/16, showed the left buttock wound site was larger, with a new sacral ulcer; Stage III. Review of resident #13's IDT note, dated 12/8/16, showed injury with added pressure to sacrum to ischium. Wife continues to place an extra cushion in wheelchair under ROHO (a cushion). Education provided but she continues to direct and provide husbands care. Wound is followed by wound clinic. Wound is worsening. Resident is up for meals only. During an interview on 4/20/17 at 1:40 p.m., staff member B stated she had never personally seen the wife place the cushion on the chair. During an interview on 4/11/17 at 1:35 p.m., NF2 stated she visited resident #13 on 12/11/16, and he did not appear to be his usual self, and did not eat or speak much. Review of resident #13's Progress Note dated 12/15/16 showed the Foley catheter was blocked. New catheter inserted using sterile technique, balloon inflated with 8cc sterile water, 900 cc dark cloudy fluid return. Afebrile. During an interview on 4/18/17 at 1:00 p.m., staff member [NAME] stated she notified the physician by putting the above note in the MD book. No further documented assessment was completed for the resident's temperature, wound or urinary status. Review of resident #13's Vitals tab, in the electronic record, showed no temperature had been recorded since 12/8/16. During an interview on 4/20/17 at 8:40 a.m., staff member A stated there was nothing going on with the resident to warrant recorded temperatures. 3. Resident #13 was discharged to the hospital on [DATE], after a second fall out of bed. Review of resident #13's ER admission note, dated 12/18/16 at 1:43 a.m., showed (physical exam in the ED has revealed what I can only describe as significant neglect resulting in serious ulceration, possible perirectal fistula and even ulceration and swelling of the posterior scrotum. There was stool packed into his wounds. His urinalysis shows significant infections. Skin break down was noted on both heels, pressure sore with damage down to the fascia on the scrotum and pressure sore on coccyx with damage down to the muscle. Review of the resident's hospital notes, dated 12/25/16, showed the resident had septic shock secondary to urinary tract infection present on admission; stage IV decubitus ulcer, which was noted to have stool inside the wound at admission. A culture, dated 12/19/16, showed drainage from the penis had E. coli, and Proteus Mirabilis. The two urine cultures were contaminated with the same 2 organisms. The left ischial necrotic tissue had the same two organisms, plus Pseudomonas aeruginosa. The bone culture also had [MEDICAL CONDITION][MEDICATION NAME]. Resident #13 had surgery for [REDACTED]. He was placed on Hospice 12/28/16. The resident passed away on 12/29/16. 4. Review of resident #13's Progress Note, dated 6/22/16, showed his penis was swollen and macerated. Review of resident #13's Progress Note, dated 6/22/16, showed he had a small amount of thick green drainage from the open area on the penis. Will request orders for antibiotic ointment. During an interview on 4/19/17 at 3:00 p.m., staff member B stated she determined the open area was an injury related to the Foley catheter and resident rubbing penis back and forth. She stated it did not look like a pressure ulcer, and she determined it as an injury. Review of resident #13's Progress Note, dated 6/29/16, showed Catheter is rubbing penis and causing drainage. Review of resident #13's Physician order, dated 7/19/16, showed Apply [MEDICATION NAME] BID to open area of penis. Review of resident #13's electronic record showed the resident was discharged to the hospital on [DATE] for a urinary tract infection. Review of resident #13's physician progress notes [REDACTED]. Review of resident #13's Progress Note, dated 10/18/16, showed he continued to have an open area to foreskin. Staff report continued stimulation to area. Resident denies manipulation. Review of resident #13's Progress Note, dated 12/18/16, showed he fell out of bed on his face. He was taken to the ER. Review of the resident's Discharge summary from the hospital, prior to admit to ICU, at a second hospital, showed pus in the Foley catheter and around the urethral meatus. There was a small skin ulceration with pus at the foreskin area. During an interview on 4/20/17 at 8:45 a.m., regarding the UTI and pus, staff member A stated the facility could not be responsible for what happens at the hospital. During an interview on 4/20/17 3:40 p.m., staff member D stated resident #13 fell out of bed. She sent him to the ER. She could not remember whether he had a boot on (for wound). She thought the staff took vitals, but they were not recorded. She did not notice anything out of the ordinary. 5. Resident #6 was admitted with [DIAGNOSES REDACTED]. Review of resident #6's Quarterly MDS, with an ARD of 3/3/17, showed the resident had a BIMS of 6, showing severely impaired cognition. The Quarterly MDS showed the resident was a two-person extensive assist for bed mobility and total dependence for toilet use. The MDS showed the resident was always incontinent of bowel. The Quarterly MDS showed the resident was a high risk for pressure ulcers and had a unhealed pressure ulcer noted on the last OBR[NAME] The Quarterly MDS showed there were no current pressure ulcers for the resident. Review of resident #6's most current Braden scale showed the resident was a high risk for pressure ulcers. During an observation on 4/19/17 at 3:43 p.m., staff member L told staff member B resident #6 had a new red open area on his coccyx. During an observation on 4/19/17 at 4:49 p.m., staff member B performed wound care to resident #6's coccyx and back. The area was approximately 1 cm by 1 cm of reddened tissue with approximately 50% slough and open in center with a dark red dot in the middle. During an interview on 4/19/17 at 4:49 p.m., staff member B stated the area on the coccyx was a new pressure ulcer, and she would put the resident on pressure ulcer precautions, and get an order from the physician. Staff member B stated she was just notified of the skin change on resident #6's coccyx. Staff member B stated she had not been informed of any skin changes for resident #6 prior to this wound care. Review of resident #6's CNA Skin Observation documentation record, from 4/1/17 to 4/19/17, showed red area, documented on the following dates, but there was no indication on the CNA documentation record of where the red area was noted: - 4/8/17 - 4/9/17 - 4/10/17 - 4/11/17 - 4/14/17 - 4/15/17 - 4/16/17 - 4/17/17 - 4/19/17 Review of resident #6's Weekly Skin Check, dated 4/14/17, showed heels are clear, coccyx is reddish but CR is STAT. Turned to side with pillows placed to avoid pressure on coccyx. Skin warm and dry turgor good no tenting. This was a new area of redness and was not indicated as such on the Weekly Skin Check sheet. Review of patient #6's nursing notes did not show any further skin assessments to check the reddish area on the coccyx and the wound care nurse was not notified of the change to the resident's skin until 4/19/17. Review of resident #6's Weekly Pressure Ulcer BWAT Report, dated 4/19/17 showed, Weekly Pressure Ulcer BWAT Report Completed. Site information: Coccyx-Pressure: Length 0.5, Width 0.5, Depth, unstageable. Date of initial observation: 4/19/17. BWAT score 28.0. See progress note assessment for more details. Noted new open area to coccyx, Measurements are 0.5 x 0.5 with yellow center that covers approximately 50% of the wound. Unstageable. secondary to slough. there is no odor, no drainage, and no surrounding redness noted. Painful to touch. Will request new orders for ulcer care to area change Wednesday and Saturdays. Ulcer care placed. Will update guardian and MD in AM. Will place ROHO as soon as one available. Request pain medication prior to treatment. Refer to dietary. Turn and reposition per plan. During an interview on 4/20/17 at 11:34 a.m., staff member K stated the CNAs Skin Observation Documentation record, did not allow the CNAs to make a note to where the red area was observed. She stated it would be the expectation of the CNAs to let the floor nurse know of any new findings to the resident's skin. It would then be the nurse's responsibility to monitor the patient's skin for changes, and notify the wound nurse of any new areas of skin breakdown or ulceration. Staff member K stated it was the expectation of staff to notify the wound nurse as soon as the area was noted. The nurse would make a note in the Weekly Skin Check which would indicate the area is new and this alerts the wound nurse. Staff member K stated the weekly skin check on 4/14/17 should have been noted in the documentation as a new area, and it was not. During an interview on 4/20/17 at 12:00 p.m., staff member B stated she was not notified of the skin change to resident #6's coccyx. She stated had she been notified of the change, she would have assessed the area immediately and implemented an appropriate treatment. The staff member stated, had she not been available, there was a secondary nurse that could be notified for wound management on the weekends.",2020-09-01
234,PARK PLACE TRANSITIONAL CARE AND REHABILITATION,275030,1500 32ND ST S,GREAT FALLS,MT,59405,2017-04-20,323,G,0,1,05GH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to identify the root cause and analyze risk factors to prevent falls with injury; failed to implement interventions, monitor for effectiveness, and modify interventions as needed for 2 (#9 and #13) of 17 sampled residents. Findings include: 1. Review of resident #9's Quarterly MDS, with the ARD of 12/8/16, showed he required supervision and 1 person assist for transfers, and was cognitively intact. Review of resident #9's Care Plan, dated 5/20/14, showed he had a recent fall with fractures, was non-weight bearing, and had poor safety awareness. The interventions included: check ammonia levels if altered mental status is present; Ensure brake extensions are in place to wheelchair; Ensure fridge is stocked to decrease risk for falls; Monitor, cue as needed and minimize clutter. Review of the resident #9's Care Plan, dated 2/27/17, showed Impaired communication, cognition and impaired thought process related to exhibits poor safety awareness, impulsive actions, requires frequent verbal cues for safety and care needs, hearing impaired, forgetful, and easily confused. (Resident) inconsistently uses his call light due to cognition. Review of resident #9's Post Fall Investigations reports showed 13 unwitnessed falls from 4/16/16 through 4/17/17. The 12th fall resulted in a non-displaced trochanter fracture and right inferior pubic ramus fracture. Review of resident #9's Post Fall Investigation, dated 4/16/16, showed he slipped on the skid strips (used to prevent falls.) He stated he was using the urinal and got dizzy. He stated his pain was at a 10 and his knees gave out on him. The intervention implemented was Physical Therapy from 4/19/16 through 6/7/16. The dizziness was not addressed. Review of resident #9's Post Fall Investigation, dated 6/16/16, showed he was found in the bathroom, sitting upright. There was feces on the floor and he had poor footing while walking. Contributing causes included non-compliance. No documented interventions were implemented to prevent further falls. Review of resident #9's Post Fall Investigation, dated 7/15/16, did not describe the fall, but showed he was found in his room, laying on his back, with legs stretched outward, next to his bed. No investigation or analysis was completed regarding the cause of the fall. Review of resident #9's Post Fall Investigation, dated 8/23/16, showed he was sitting on the floor, on his bottom, with his back against the bed. He stated he dropped his medications on the floor and was bending over to pick them up. He had a red bruise/abrasion between his brows and tender to touch. No new interventions were implemented; interventions in place were not evaluated for effectiveness. Review of resident #9's Progress Note, dated 8/29/16, showed he had a fall out of bed, trying to find his cell phone. A Fall Investigation report was not provided. The new intervention was to place a call sign to remind resident to call before reaching items. During an observation on 4/18/17, 4/19/17 and 4/20/17, no sign was visible in resident #9's room to remind the resident not to reach for items without calling for assistance. Review of resident #9's Post Fall Investigation, dated 9/01/16, showed the resident was lying on his back, 5 to 7 feet away from the bed. He was reaching for a coke from the refrigerator in his room. His pain level was a nine. No further analysis was completed for a root cause for the fall, or new interventions. Documentation showed, Resident has fallen 6 times since March. Will monitor. The monitoring was not measurable, or clear enough to show what staff were to monitor for. Review of resident #9's Post Fall Investigation, dated 10/24/16, showed the resident was found in the bathroom, on the floor, with his call light on. I slipped in these socks. Review of an IDT note for resdent #9, dated 10/27/16, showed Resident reminded to either wear non-skid socks or shoes during ambulation. Although the resident did not have good recall for calling for assistance, staff continued to use the intervention to remind the resident. Review of an IDT note for resident #9, dated 12/20/16, showed review related to fall last week. Resident slid off the edge of bed while trying to get to bathroom He has non-skid strips beside bed and slippers with good soles. He was incontinent of bowel and appears to have slid in it (feces). Resident is independent with ambulation. Isolated incident. No further interventions needed. No Post Fall Investigation was provided. The facility did not address the resident's potential need for more assistance relating to bowel and bladder deficits. Review of resident #9's Post Fall Investigation, dated 12/22/16, showed the resident was found on the floor of his bathroom, and stated he lost his balance. A contributing cause was listed as non-compliance. The loss of balance was not addressed. Review of resident #9's Post Fall Investigation, dated 1/10/17, showed a CNA found him lying on the floor. He stated he was looking for stuff in the bottom of his closet and I got dizzy. Review of resident #9's IDT note, with no date, showed a review of the 12/22/16, and 1/10/17 falls: Resident is independent with ambulation in room. Does use walker. Nonskid strips beside bed and in bathroom. Room was changed to allow easy access to his fridge and other items he uses frequently. Resident has a history of balance issues which does affect him when bending down or reaching for items, causing a loss of balance, resulting in a fall. PT has worked with resident in the past with good results. Takes Meclizine for dizziness. Resident will call for assistance if not feeling well but not for simple tasks that he believes he can do on his own. Plan: therapy to review[NAME]Balance Scores from recent therapy session to see if an improvement in noted with therapy if balance remains unchanged. Will review to determine if further therapy is indicated. The IDT note, addressed factors from the 12/22/16 fall that may have prevented the fall from occurring on 1/10/17, but the IDT did not address these until after 1/10/17, which was at least 20 days after the 12/22 fall. During an interview on 4/20/16 at 8:20 a.m., staff member A stated PT was initiated for resident #9 on 1/13/17. Review of resident #9's Post Fall Investigation, dated 2/10/17, showed he was found sitting on the floor by the bed. He stated he was walking back to his bed from the bathroom. A team huddle (IDT huddle meeting and discussion) was documented after the fall, but no analysis, root cause, new interventions, or evaluation of the effectiveness of current interventions was documented in the resident's medical record. Review of resident #9's Post Fall Investigation, dated 2/19/17, showed he was found on his back, his feet toward the bathroom door, head against his hallway door, and he was incontinent of bowel and bladder. A contributing cause was listed as non-compliance. Review of resident #9's Progress note, dated 2/27/17, showed he had sustained two fractures from the fall on 2/19/17; a hip and pelvic fracture. The resident was now non-weight bearing. Review of resident #9's Significant Change MDS, with the ARD of 2/27/17, showed he now required two person extensive assist with all his ADLs except for eating. A Foley catheter was placed for bladder incontinence related to immobility. During an interview on 4/17/17 at 1:00 p.m., resident #9 stated he stayed in bed now, and did not get dressed. He said he would shower if he wanted. He said he was now afraid of falling. I fell , and I fell , and I fell . He stated he didn't use his call light because They don't care about me. During an interview on 4/20/17 at 8:40 a.m., staff members A and C stated the facility did have a fall prevention program in place, and that team huddles were conducted with each fall. The team huddle answered the 10 questions (for falls) to determine the root cause. Staff member C stated the facility did not keep this document, because it was a working tool, therefore the root cause analysis was not documented in the resident's medical record. One of 15 falls had documentation from the team huddle for resident #9's falls. Staff member C also stated the resident had the right to fall. 2. Review of resident #13's progress note, dated 5/23/16, showed a Post Fall Investigation was completed for a fall on an unidentified date. See investigation for details. No Post Fall Investigation was provided by the facility. Review of resident #13's Admission MDS, with the ARD of 5/24/16, showed he had a history of [REDACTED]. Review of resident #13's IDT note dated 5/23/16, showed a review of the falling star program (fall program). Resident is not impulsive and will call for assistance when needed. Will remove from falling star program. Review of resident #13's Post Fall Investigation, dated 12/5/16, showed he was found lying on the floor by his bed. Review of resident #13's IDT note, dated 12/5/16, showed Resident is on an air mattress with a low bed. This is an isolated incident. Resident was running an increased temperature and more lethargic than usual. ? (sic) infection related to wound. Will have MD assess resident. Review of the Physician visits for resident #13 showed no visit or assessment was completed after 11/14/16. During an interview on 4/11/17 at 1:35 p.m., NF2 stated she visited resident #13 on 12/11/16, and he did not appear to be his usual self, and did not eat or speak much. Review of resident #13's Post Fall investigation, dated 12/18/16, showed he had fallen out of bed, onto his face, and sustained a large hematoma over right eyebrow. During an interview on 4/11/17 at 1:40 p.m., NF2 said the hospital called her the night of 12/18/16, and asked Do you know how sick (resident #13) is? Review of resident #9's Progress Note, dated 12/18/16, showed he was discharged to the hospital. The resident was admitted , and the resident had an infection in the wound of the buttock. (Refer to F314) Review of resident #13's Care Plan, dated 7/19/16, showed no new interventions were implemented to prevent falls after each of the three falls. The investigations did not include the root cause analysis of the falls, monitoring, or evaluation of the resident's individualized risk factors.",2020-09-01
235,PARK PLACE TRANSITIONAL CARE AND REHABILITATION,275030,1500 32ND ST S,GREAT FALLS,MT,59405,2017-04-20,332,E,0,1,05GH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident medication error rate for the facility was not 5% or greater. Medication errors during that occurred during the observation of medication administration involved 3 (#s 2, 4, and 8) of 17 sampled residents. Findings include: 1. During an observation on 4/19/17 at 4:30 p.m., staff member R removed resident #2's [MEDICATION NAME] 70/30 mix insulin vial and drew up 22 units. The staff member did not visually inspect or gently roll the insulin to re-suspend the mixture prior to administering it to the resident. During an interview on 4/19/17 at 4:35 p.m., staff member R was not aware of the need to roll the [MEDICATION NAME] Insulin to re-suspend the mixture prior to administration. 2. During an observation on 4/19/17 at 8:02 a.m., staff member B prepared [MEDICATION NAME] 5 mg tablet and [MEDICATION NAME] 20 mg tablet with the rest of resident #4's AM medications, and administered the medications to the resident. Review of resident #4's physician orders, with a start date of 3/28/17, showed, [MEDICATION NAME] 5 mg tablet, give 30 minutes prior to [MEDICATION NAME]. During an interview on 4/19/17 at 8:20 a.m., staff member B stated she had made a medication error by administering the [MEDICATION NAME] at the same time as the [MEDICATION NAME]. The staff member could not explain the complication of administering the [MEDICATION NAME] and [MEDICATION NAME] at the same time. Staff member B stated she would notify her DON and complete a medication error form, and notify the MD and the family of the error. During an interview on 4/19/17 at 8:40 a.m., staff member B stated the interaction between [MEDICATION NAME] and [MEDICATION NAME] could reduce the efficacy of the [MEDICATION NAME] if given at the same time. 3. Resident #8 was admitted to the facility with a [DIAGNOSES REDACTED]. During an observation on 4/17/17 at 3:11 p.m., staff member P administered resident #8's bolus tube feeding. During an observation on 4/17/17 at 4:00 p.m., staff member P checked patient #8's blood sugar, and administered the appropriate dose of Humalog Insulin per the sliding scale. The Humalog was administered 45 minutes after his 3:00 p.m. tube feeding, and two hours before his 6:00 p.m. tube feeding. During an interview on 4/17/17 at 4:10 p.m., staff member P stated she would administer resident #8's next bolus tube feeding at 6:00 p.m. Staff member P stated she was not concerned about the administration times of insulin in relation to the resident's tube feeding times. During an interview on 4/19/17 at 9:00 a.m., staff member A stated the expectation of the nursing staff was to follow the physician orders [REDACTED]. Staff member A stated she was not worried about resident #4's medication error since the medication given together would only reduce the efficacy of the [MEDICATION NAME]. Staff member A stated she was not worried about resident #8's insulin administration time since the resident was not a diabetic. She stated the protocol for the administration of a rapid-acting insulin was to administer it 15 minutes before or after a meal. http://www.novo-pi.com/[MEDICATION NAME].pdf 2.2 Resuspension [MEDICATION NAME](R) Mix 70/30 is a suspension that must be visually inspected and re-suspended immediately before use. The [MEDICATION NAME](R) Mix 70/30 vial should be rolled gently in your hands in a horizontal position 10 times to mix it. The rolling procedure must be repeated until the suspension appears uniformly white and cloudy. Inject immediately. Resuspension is easier when the insulin has reached room temperature. http://pi.lilly.com/us/humalog-pen-pi.pdf INDICATIONS AND USAGE; HUMALOG is a rapid acting human insulin analog indicated to improve glycemic control in adults and children with diabetes mellitus. (1); 2.2 Route of Administration Subcutaneous Injection: HUMALOG U-100 or U-200. Administer the dose of HUMALOG U-100 or HUMALOG U-200 within fifteen minutes before a meal or immediately after a meal by injection into the subcutaneous tissue of the abdominal wall, thigh, upper arm, or buttocks. To reduce the risk of [DIAGNOSES REDACTED], rotate the injection site within the same region from one injection to the next (see Adverse Reactions (6)).",2020-09-01
236,PARK PLACE TRANSITIONAL CARE AND REHABILITATION,275030,1500 32ND ST S,GREAT FALLS,MT,59405,2017-04-20,333,E,0,1,05GH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from a significant medication error, during the administration of a rapid-acting insulin for 1 (#8) of 17 sampled residents. Findings include: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of patient #8's Progress Note from (hospital name), dated 4/13/17, showed: Plan: 2. Tube feeds per dietary recommendations. Free water boluses as well . 4. Sliding scale insulin. A review of resident #8's MAR, dated 4/01/17 - 4/30/17, showed: CBS TID, before meals for DM. A review of resident #8's MAR, dated 4/01/17 - 4/30/17, showed: Humalog Solution 100 unit/ml (Insulin [MEDICATION NAME]) Inject as per sliding scale: if 0-139 = 0 units; 140-199 = 1 unit; 200-249 = 3 units; 250-299 = 5 units; 300-249 = 7 units; 350-399 = 9 units; 400+ = call MD subcutaneously before meals for DM in addition to scheduled dose. A review of resident #8's MAR, dated 4/01/17 - 4/30/17, showed: Humalog Solution 100 unit/ml (Insulin [MEDICATION NAME]) Inject 10 units subcutaneously before meals for DM in addition to sliding scale. Review of resident #8's TAR, dated 4/01/17 - 4/30/17, showed: Enteral Feed Order five times a day Enteral Nutrition via Bolus: Full Strength [MEDICATION NAME] 2.0 at frequency: 250 mls 5 times day. Total mls/24 hours: 1250 mls. To be given at Hours of: 0500, 1000, 1500, 1800, and 2200. During an interview on 4/17/17 at 12:00 p.m., staff member J stated they were trying to coordinate resident #8's bolus feeding scheduled with his administration of insulin. Staff member J stated as the orders were, resident #8 would wait an hour between his bolus feedings and his Humalog insulin administration. Staff member J stated the resident should have food within 15 minutes of the Humalog insulin administration. During an interview on 4/17/17 at 3:10 p.m., staff member P stated the resident received tube feedings at 5:00 a.m., 10:00 a.m., 3:00 p.m., 6:00 p.m., and 10:00 p.m. The staff member stated she would administer the resident's tube feeding at 3:00 p.m., and would then check the resident's blood sugar between 4:00 p.m., and 4:30 p.m., and would then administer his insulin per the sliding scale. Staff member P stated the resident would receive the insulin around 4:00 p.m., and she would then administer his next tube feeding at 6:00 p.m. She stated the fast-acting insulin should be administered for the resident 15 minutes before or after his bolus feeding. The staff member stated it was difficult to work out the resident's insulin administration with his tube feeding because the tube feedings were five times daily, and the insulin was three times daily. She stated the resident was out of the facility during the day for [MEDICAL CONDITION] and [MEDICAL CONDITION]. During an observation on 4/17/17 at 3:11 p.m., staff member P administered resident #8's bolus tube feeding. During an observation on 4/17/17 at 4:00 p.m., staff member P checked patient #8's blood sugar, and administered the appropriate dose of Humalog Insulin per the sliding scale. The Humalog was administered 45 minutes after his 3:00 p.m. tube feeding, and 2 hours before his 6:00 p.m., tube feeding. During an interview on 4/17/17 at 4:10 p.m., staff member P stated she would administer resident #8's next bolus tube feeding at 6:00 p.m. Staff member P stated she was not concerned about the administration times of insulin in relation to the resident's tube feeding times. The staff member stated it was difficult to administer the resident's insulin dosing with his tube feeding, and manage his outings for [MEDICAL CONDITION] and [MEDICAL CONDITION]. During an interview on 4/19/17 at 9:00 a.m., staff member A stated resident #8 did not have a [DIAGNOSES REDACTED]. The staff member stated it was protocol on all new tube feedings, because the enteral nutrition was so high in calories, the body couldn't manage the sugars, so any resident on a new tube feeding would receive insulin. Staff member A stated she wrote the orders for the tube feedings and the insulin administration on the MAR and TAR. She stated she was not worried about the resident receiving the insulin an hour after his bolus tube feeding and an hour before his next tube feeding, because he was not a diabetic. The staff member stated symptoms of [DIAGNOSES REDACTED] were shakiness, confusion, diaphoresis, nausea, vomiting, and [MEDICAL CONDITION]. She stated for residents who were diabetic, and received a fast acting insulin such as Humalog, it would be the procedure to administer the insulin 15 minutes before or after a meal to avoid low blood sugars Staff member A provided a Progress Note, dated 4/19/17, which reflected, Resident has order for CBS TID with scheduled and sliding scale insulin. Does not have [DIAGNOSES REDACTED]. Need clarification on when to check CBS and administer insulin with new tube feeding schedule. A review of resident #8's Medication Discharge Summary, dated 4/15/17, showed: Humalog (Insulin [MEDICATION NAME] 100 units/ml 3 ml vial. subcutaneous three times daily with meals. A review of resident #8's Progress Note, from (hospital), dated 4/6/17, showed: Assessment and plan: Diabetes Mellitus . During an interview on 4/19/17 at 10:00 a.m., resident #8 stated he was a diabetic and had been for the past [AGE] years. The resident stated he managed his diabetes at home with the daily assistance of his hospital. The resident stated he was on a long acting insulin but was taken off the [MEDICATION NAME] in the hospital and put only on Humalog. The resident stated he had been vomiting due to the [MEDICAL CONDITION] and [MEDICAL CONDITION], and had not been feeling well since he was admitted on [DATE]. Review of the facility's procedure, titled, Duration of Effect of Various Insulins When Given by Subcutaneous Injection, showed, Rapid Acting, [MEDICATION NAME] Humalog, Administer within 15 minutes before or immediately after a meal. On 4/17/17 and 4/19/17 a facility policy and procedure on insulin administration was requested, and was not provided by the facility. http://pi.lilly.com/us/humalog-pen-pi.pdf INDICATIONS AND USAGE; HUMALOG is a rapid acting human insulin analog indicated to improve glycemic control in adults and children with diabetes mellitus. (1); 2.2 Route of Administration Subcutaneous Injection: HUMALOG U-100 or U-200. Administer the dose of HUMALOG U-100 or HUMALOG U-200 within fifteen minutes before a meal or immediately after a meal by injection into the subcutaneous tissue of the abdominal wall, thigh, upper arm, or buttocks. To reduce the risk of [DIAGNOSES REDACTED], rotate the injection site within the same region from one injection to the next (see Adverse Reactions (6)).",2020-09-01
237,PARK PLACE TRANSITIONAL CARE AND REHABILITATION,275030,1500 32ND ST S,GREAT FALLS,MT,59405,2017-04-20,431,E,0,1,05GH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to properly label a mixed product, containing two ingredients, being used for skin integrity for 2 (#3 and #7) of 17 sampled residents. Findings include: 1. Observations: a. During an observation on 4/17/17 at 4:20 p.m., in resident #3's room, a denture cup containing a thick, opaque substance was seen in a basin on a bedside stand. The substance had a texture and odor characteristic of Vaseline, and there was no name, date, content label, or other labeling on the cup. Review of resident #3's (MONTH) (YEAR) MAR indicated [REDACTED]. b. During an observation on 4/18/17 at 5:00 p.m., in resident #7's room, a denture cup containing a thick, opaque substance was observed in a basin on a bedside stand. The substance had a texture and odor characteristic of Vaseline, and there was no name, date, content label, or other labeling on the cup. During an interview on 4/19/17 at 9:00 a.m., staff member A stated that the product observed in the denture cups, in resident #7's room and the other rooms, was a mixture of Vaseline and an antifungal powder. Staff member A stated that staff member B determined which resident's needed this treatment, notified the provider, received an order, and mixed the product. Staff member A stated that staff member B had documentation regarding the practice of mixing the two products for the treatment of [REDACTED]. Staff member A stated that there was no expectation for the denture cup to be labeled because nursing staff was trained at orientation, and periodically, regarding the product and it's use. She stated that due to this training, staff would know what was in the cup, and when and how to use it. During an interview on 4/19/17 at 10:45 a.m., NF1 stated the mixed product should be stored with a minimum labeling, consisting of the resident's name, the drugs used to mix the product, the date of the mixing, and directions for use. NF1 also stated that the original containers of the drugs mixed to create the product should be maintained with the product, for information that is noted on the label. During an interview with staff members A and B on 4/20/17 at 7:25 a.m., staff member B stated there were no written instructions or guidelines related to the use of the mixed product. She stated the facility uses one container of Vaseline and one container of antifungal powder according to the verbal direction received years ago from a provider. Staff member B provided a 13 oz container labeled petroleum jelly and a 3 oz container labeled Miconozole Nitrate. Staff member B stated no knowledge of the container sizes of either product when this process began several years ago or if the container sizes had changed since the process was initiated. During this interview, staff member A reiterated from a prior interview, there was no expectation that the denture cup with the mixed product in resident #7's room would be labeled since both products in the mix are over the counter items, and the nursing staff have been trained on the use of the product.",2020-09-01
238,PARK PLACE TRANSITIONAL CARE AND REHABILITATION,275030,1500 32ND ST S,GREAT FALLS,MT,59405,2017-04-20,441,D,0,1,05GH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed medical supplies in areas where the supplies could become contaminated for 1 (#23) of 26 sampled and supplemental residents. During an observation on 4/17/17 at 12:35 p.m., of the bathroom between rooms [ROOM NUMBERS], the sink had rubber tubing, a syringe, and a plastic measuring container on top of a washcloth on the left side of the sink counter. During an observation on 4/18/17 at 7:39 a.m., tubing, a syringe, and a measuring container sat on a washcloth on the sink counter of the bathroom between rooms [ROOM NUMBERS]. Review of resident #23's medication administration record showed the resident was receiving food and medication through a feeding tube. Resident #23 resided in room [ROOM NUMBER]. Review of the resident #25's Significant Change MDS, with an ARD of 3/24/17, showed the resident was coded for being moderately impaired; a coding of 12 on the assessment. The resident resided in room [ROOM NUMBER]. During an interview on 4/18/17 at 7:55 a.m., staff member G stated the tubing, syringe and measuring container were for resident #23. The staff member agreed the items should not be left on the sink shelf, in a bathroom shared by another resident.",2020-09-01
239,PARK PLACE TRANSITIONAL CARE AND REHABILITATION,275030,1500 32ND ST S,GREAT FALLS,MT,59405,2018-06-28,600,G,0,1,STQR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent verbal abuse, resulting in psychosocial harm for 2 (#s 22 and 82) of 35 sampled and supplemental residents. Findings include: 1. During an interview on 6/26/18 at 1:31 p.m., resident #82 stated there is a staff member who is disrespectful towards him. He said it was more than being disrespectful, adding, She is just mean. Resident #82 stated the staff member scolded him when he put on his call light to use the bathroom, and yelled at him if he bumped into things while wheeling himself in the hallway. He stated the way she treated him made him feel, less than human. During the interview, resident #82 raised his voice and became agitated and tearful. During an interview on 6/27/18 at 8:17 a.m., staff member K stated staff member L had an irritated attitude when interacting with residents. She stated she heard staff member L talk to residents as if they were a burden. Staff member K stated she heard staff member L scold resident #82 for activating his call light. She stated the issue was beyond poor customer service and a lack of respect. She stated it was more like abuse. Staff member K stated she has reported staff member L's behavior in the past, but not recently. She stated she did not know why she did not report the abuse this time. Staff member K said she didn't work this hall often or work with staff member L very often. During an interview on 6/27/18 at 4:00 p.m., staff member N stated on 6/26/18, NF1 told her resident #82 had complained to him of a CNA who mistreated him. She stated NF1 reported resident #82 said she made him feel bad about needing to use the toilet. She stated when she interviewed resident #82 he told her staff member L did not treat him like a human being. During an interview on 6/28/18 at 1:17 p.m., staff member O stated the facility had no assessment to determine if a resident was at risk for abuse, but she does consider risk factors when she develops the care plan. She stated she had not considered resident #82 at risk because he was so quiet and easy to deal with. She stated he did have a whiny tone, and she may need to expand what risk factors she considers. During an interview on 6/28/18 at 1:29 p.m., staff member I stated resident #82 told her that he was being mistreated by another CN[NAME] She said he had told her that every Monday, when she comes back after her days off, for three or four weeks. Staff member I stated resident #82 said the CNA was mean to him, and said she's evil, asking why staff member L had not been fired. She stated he could not tell her what staff member L did, just that she was mean to him. Staff member I said resident #82 never said he was being physically abused, and she never saw any signs of physical abuse. She stated she had not noticed any behavior changes. During an interview on 6/28/18 at 2:09 p.m., staff member [NAME] stated about two weeks ago NF1 told her that resident #82 had told him a CNA named (alleged staff name) spoke roughly to him while she assisted him with toileting. She stated she told NF1 there was no CNA named (alleged staff name), but she would tell staff member N about the concern. Staff member [NAME] stated she had reported the concern to staff member N approximately two weeks ago, but she was uncertain of the timeframe. She stated she did not follow-up with resident #82, and she did not ask any other residents if they had been mistreated. Staff member [NAME] said she thought staff member N would conduct the investigation. She said she received abuse training in April, and the training included what should be reported, and to whom to report. Staff member [NAME] stated she would not do anything differently. She said she felt she had received adequate information from NF1, and did not feel she needed to talk to resident #82. Staff member [NAME] stated resident #38 had voiced concerns to her about the treatment of [REDACTED]. She stated resident #38 said they were not as nice as they should be when taking him to the bathroom. She stated she did not know if resident #38 reported to her before or after NF1 reported, but both reports were about two weeks ago. Review of an investigation provided by the facility, dated 6/27/18, showed the following statements by resident #82: - If I say anything to her she says I am whimpering. - She grabs ahold of me like a stick of wood. - She slams me into it, referring to the grab bar next to the toilet. - I would rather die than have her handle me. - I feel abused . Review of an investigation provided by the facility, dated 6/27/18, showed the following statements by staff member L: - Resident #82 has complained about the way she assisted him to use the toilet. - He tells me that I am trying to kill him because I am being rough with him. - She gets frustrated with resident #82 and stated he would feel like she was scolding him. - She stated she was, short and abrupt. During an interview on 6/28/18 at 1:44 p.m., staff member M stated staff member L had been terminated as a result of the allegation of abuse being substantiated. 2. During an interview on 6/25/18 at 11:20 a.m., resident #22 stated he was treated well by everyone, except for one CN[NAME] He stated she used, abusive speech when talking to him, telling him not to question her and that she would do things her way. Resident #22 stated she had a, stinking rotten attitude. He said staff member L was the CN[NAME] He stated he had discussed the issue with staff member N, and staff member L was being reassigned. During an interview on 6/25/18 at 3:25 p.m., resident #22 stated he was happy staff member L would no longer be assigned to assist him, because the way she talked to him made him feel abused. During an interview on 6/27/18 at 8:02 a.m., staff member [NAME] stated staff member L was no longer allowed to provide showers for resident #22 due to his complaints. She stated staff member L did not engage with residents, but rather just tells them what to do. She stated she felt the situation was a personality conflict. Review of a Grievance Form, dated 6/20/18, showed resident #22 was the resident voicing the concern. The forms showed resident #22 stated the following regarding staff member L: - she made him uncomfortable by using her cell phone while assisting him with toileting - she was very short with him - she made him feel bad if he asked for anything - she said he always complains - he was afraid to ask to pick out his own clothes - he was in fear of her getting angry at him During an interview on 6/27/18 at 4:00 p.m., staff member N stated there was no documentation of interviews with residents or staff regarding resident #22's complaint because she viewed it as a grievance, rather than an allegation of abuse. She stated she did not ask what his fear was or what he feared she would do. Staff member N stated when an abuse investigation is done, she asks residents if they feel safe. She said she did ask resident #22 that question, in this case. She said she did not consider the situation as abuse, so she did not question the resident in that manner. She stated resident #22 did not use the term abuse, and a full investigation was not conducted. She stated she wished she had questioned him more thoroughly. Review of an abuse investigation provided by the facility, dated 6/27/18, showed staff member L stated she has had quite a few conflicts with resident #22. Four out of five staff statements, other than staff member L, showed resident #22 had complained about treatment by staff member [MI] During an interview on 6/28/18 at 2:25 p.m., resident #22 stated he dreaded having staff member L as his CN[NAME] He said there was always a battle, and if he tried to ask for her to honor his requests a war would start. Resident #22 said she made him fee like, crap. He said his interactions with her would, suck the life out of me.",2020-09-01
240,PARK PLACE TRANSITIONAL CARE AND REHABILITATION,275030,1500 32ND ST S,GREAT FALLS,MT,59405,2018-06-28,610,G,0,1,STQR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to thoroughly investigate an allegation of abuse after it was reported resulting in 1 (#82) of the 35 sampled and supplemental residents, and being exposed to further psychosocial abuse by a staff member. Findings include: During an interview on 6/26/18 at 1:31 p.m., resident #82 stated there is a staff member who is disrespectful towards him. He said it was more than being disrespectful, adding, She is just mean. Resident #82 stated the staff member scolded him when he put on his call light to use the bathroom, and yelled at him if he bumped into things while wheeling himself in the hallway. During an interview on 6/27/18 at 8:17 a.m., staff member K stated staff member L had an irritated attitude when interacting with residents. She stated she heard staff member L talk to residents as if they were a burden. Staff member K stated she heard staff member L scold resident #82 for activating his call light. She stated the issue was beyond poor customer service and a lack of respect. She stated it was more like abuse. Staff member K stated she has reported staff member L's behavior in the past, but not recently. She stated she did not know why she did not report the abuse this time. Staff member K said she didn't work this hall often or work with staff member L very often. During an interview on 6/28/18 at 1:29 p.m., staff member I stated resident #82 told her that he was being mistreated by another CN[NAME] She said he had told her that every Monday, when she comes back after days off, for three or four weeks. Staff member I stated resident #82 said the CNA was mean to him, and said she's evil, asking why staff member L had not been fired. She stated she had not reported the allegations because she could not figure out who he was talking about. She stated he could not tell her what staff member L did, just that she was mean to him. She stated about a week ago she had figured out it was another day shift CNA, but she still did not report it because resident #38 told her he had reported the situation to the nurse. She stated she should have said something in the beginning, even without knowing who it was. Staff member I said resident #82 never said he was being physically abused, and she never saw any signs of physical abuse. She stated she had not noticed any behavior changes. Staff member I stated there are mandatory staff training twice a month which include dementia training, and abuse prevention. She said she could not say when she had last received training regarding reporting abuse. She stated she was not aware she was a mandatory abuse reporter, but said it just seemed like common sense to report. During an interview on 6/28/18 at 1:44 p.m., staff member M stated there was a culture in the facility, developed under the previous management, that discouraged reporting abuse. Staff members M and A stated they were aware of barriers to abuse reporting in the facility and had addressed the issue with a QAPI plan. Staff members M and A stated the plan included initiating Angel Rounds. They stated the Angel Rounds involved asking residents if they had any concerns. Staff member M said the rounds do not include asking the resident if they have been abused. He stated his expectation was for staff to report allegations of abuse. During an interview on 6/28/18 at 2:09 p.m., staff member [NAME] stated NF1 told her that resident #82 had told him a CNA named (alleged staff name) spoke roughly to him while she assisted him with toileting. She stated she told NF1 there was no CNA named (alleged staff name), but she would tell staff member N about the concern. Staff member [NAME] stated she had reported the concern to staff member N approximately two weeks ago, but she was uncertain of the timeframe. She stated she did not follow-up with resident #82, and she did not ask any other residents if they had been mistreated. Staff member [NAME] said she thought staff member N would conduct the investigation. She said she received abuse training in April, and the training included what should be reported, and to whom to report. Staff member [NAME] stated she would not do anything differently. She said she felt she had received adequate information from NF1, and did not feel she needed to talk to resident #82. Staff member [NAME] stated resident #38 had voiced concerns to her about the treatment of [REDACTED]. She stated resident #38 said they were not as nice as they should be when taking him to the bathroom. She stated she did not know if resident #38 reported to her before or after NF1 reported, but both reports were about two weeks ago. Review of an abuse investigation provided by the facility, dated 6/27/18, showed statements by two staff members who stated they were aware of the allegations of abuse by resident #82. One of the statements showed the allegation was reported to staff member N the previous week. During an interview on 6/28/18 at 2:40 p.m., staff member N stated she had not investigated an allegation of abuse of resident #82 prior to 6/25/18, because she had not received a report of an allegation of abuse regarding resident #82 at any time before 6/25/18, when NF1 brought the allegation to her attention. She stated she did not recall staff member [NAME] reporting anything about resident #82 to her two weeks ago, or at any other time.",2020-09-01
241,PARK PLACE TRANSITIONAL CARE AND REHABILITATION,275030,1500 32ND ST S,GREAT FALLS,MT,59405,2018-06-28,623,E,1,1,STQR11,"> Based on interview and record review, the facility failed to provide notice of transfer or discharge documentation at the time of resident transfer or discharge from the facility for 3 (#s 86, 135, and 136) of 35 sampled and supplemental residents. Findings include: During an interview on 6/28/18 at 7:55 a.m., staff member A said the facility was not providing written notice of transfer or discharge at the time of the survey. Staff member A said she was not aware of the regulation. a. Review of resident #86's medical record failed to show a transfer/discharge summary had been provided, in a timely manner, to the resident after her transfer to the hospital. b. Review of resident #135's medical record failed to show a transfer/discharge summary had been provided, in a timely manner, to the resident after her discharge to the community. c. Review of resident #136's medical record failed to show a transfer/discharge summary had been provided, in a timely manner, to the resident after her discharge to the community.",2020-09-01
242,PARK PLACE TRANSITIONAL CARE AND REHABILITATION,275030,1500 32ND ST S,GREAT FALLS,MT,59405,2018-06-28,656,D,0,1,STQR11,"Based on interview and record review, the facility failed to implement services identified and included on the plan of care for range of motion and mobility, for 2 (#s 6 and 32) of 35 sampled and supplemental residents, which could cause a decline in range of motion or ambulation ability for the residents. Findings include: 1. During an interview on 6/26/18 at 1:21 p.m., resident #6 stated she had limited mobility in her left knee and both feet. She said she was on an ambulation program, but the program was not consistently provided. Review of resident #6's care plan showed a problem or focus area of altered physical mobility, last revised 10/17/17. The care plan showed an intervention was implemented, which was to ambulate the resident 50-100 feet, three times per week. During an interview on 6/27/18 at 1:43 p.m., staff members H and I stated staff member G was responsible for completing restorative nursing tasks for resident #6. They stated staff member G had moved to another unit, but they had not been told the restorative tasks had been reassigned to any other staff. Staff member I provided care to resident #6 daily working. During an interview on 6/28/18 at 8:24 a.m., staff member G stated he used to provide ambulation service to resident #6, but he was reassigned to another unit the middle of June. He stated prior to being re-assigned, he would offer ambulation service on days he was working, and the CNAs should have offered the service on days he was not working. Staff member G stated any resident refusal should be documented and another attempt should be made to provide the service. Review of resident #6's physical therapy discharge summary, dated 5/6/18, showed the discharge instructions were for, Ambulation FLP as patient allows. During an interview on 6/28/18 at 9:45 a.m., staff member J stated she did not know what FLP meant, but the FLP referred to the form titled, Rehabilitation Referral for Nursing Programs. Review of resident #6's Rehabilitation Referral for Nursing Programs form, dated 4/27/18, showed a program for ambulation of 50-100 feet three times a week, which was reflected on the care plan. Review of resident #6's EHR P[NAME] Response History report, from 6/1/18-6/28/18, showed 11 documented days ambulation service was refused by the resident, and 17 days no ambulation service was offered, as identified on the care plan. During an interview on 6/28/18 at 10:15 a.m., resident #6 stated she was walking regularly with staff member G for awhile, but never everyday. She stated she was worse lately, due to the swelling in her legs, and she could not walk as well as she could before the swelling worsened. Resident #6 stated she was offered ambulation assistance 1-2 times per week, or less. She said she would like to be offered the service everyday, and she could decide each day if she wanted to walk or not. 2. During an interview on 6/26/18 at 9:56 a.m., resident #32 stated she had range of motion/mobility problems with her knees and feet. She stated she does not walk. She expressed she would like to receive restorative exercises, and that she had reported that in her care conference. Review of resident #32's care plan showed a problem or focus area for mobility impairments, revised 5/15/18. The care plan showed the facility identified the problem, and implemented an intervention as follows: -Sit to stand at handrail for 2-3 trials of 15-30 seconds each repetition. Complete daily. Review of resident #32's Rehabilitation Referral for Nursing Programs form, dated 3/5/18, showed a plan for resident #32 to sit-to-stand at the handrail with minimal to moderate assistance, five times per week, for 2-3 trials of 15-30 seconds each. During an interview on 6/27/18 at 1:43 p.m., staff members H and I stated staff member G was responsible for completing restorative nursing tasks for resident #32. They stated staff member G had moved to another unit, but they had not been told the restorative tasks had been reassigned to any other staff. Staff member H stated she provides care to the resident daily, when on shift. During an interview on 6/28/18 at 8:33 a.m., resident #32 stated the sit to stand exercise at the handrail was not being done by staff. She stated she would really like to have the service by staff to strengthen her arms and legs. She stated she is not able to perform the exercises without assistance. During an interview on 6/28/18 at 12:21 p.m., staff member G stated resident #32's sit-to-stand program, at the handrail, was never on his assignment. Review of resident #32's EHR P[NAME] Response History report, from 6/1/18-6/28/18, showed resident #32 received the sit-to stand exercises eight days, had never refused the exercises, and had not been offered the exercises for 20 of the days.",2020-09-01
243,PARK PLACE TRANSITIONAL CARE AND REHABILITATION,275030,1500 32ND ST S,GREAT FALLS,MT,59405,2018-06-28,761,D,0,1,STQR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to properly label an insulin pen with the open date for 1 (#45) of 35 sampled and supplemental residents, and failed to dispose of expired influenza vaccine, which had the potential to affect any resident who received the vaccine. Findings include: 1. During an observation and interview on [DATE] at 9:40 a.m., a Basaglar (insulin) Kwikpen's pharmacy label showed the name of resident #45 and a date of [DATE]. Staff member [NAME] stated [DATE] was the date the medication order was filled by the pharmacy. She stated insulin vials and pens were usually replaced after 28 days, but she would need to check to be sure for the specific type of insulin. She stated the pen had been opened and used, but did not show an open date. Staff member [NAME] stated a nurse would not know when to discard and replace the insulin pen if it was not dated with the open date. Review of the facility policy titled, Vials and [MEDICATION NAME] of Injectable Medications, showed the following: - If opening a multi-dose vial of medication for the first time, the person opening the bottle should identify the date the bottle was opened by writing the date on the label. - Use the medication in a multi-dose vial until the manufacturer's expiration date for the length of time allowed. Review of the manufacturer's instructions for a Balsagar insulin Kwikpen showed, Once you begin using your Pen, store it at room temperature up to 86 F (30 C) and throw it away after 28 days. During an interview on [DATE] at 12:20 p.m., staff member A stated the vial policy would apply to an insulin pen. 2. During an observation and interview on [DATE] at 9:55 a.m., a box of ten expired [MEDICATION NAME] influenza vaccine pre-filled syringes was found in the ,[DATE] unit medication refrigerator. The box showed an expiration date of [DATE]. Staff member F stated the vaccines expired [DATE], and should have been discarded.",2020-09-01
244,PARK PLACE TRANSITIONAL CARE AND REHABILITATION,275030,1500 32ND ST S,GREAT FALLS,MT,59405,2018-06-28,880,D,0,1,STQR11,"Based on observation and interview, the facility staff member failed to perform hand hygiene or apply gloves before administering an injection to a resident, after the injection, for 1 (#25) of 35 sampled and supplemental residents. Findings include: During an observation and interview on 6/27/18 at 12:01 p.m., staff member D prepared insulin for administration to resident #25. She entered resident #25's room and told her she had come to administer her insulin. Without performing hand hygiene or applying gloves, staff member D administered the insulin to resident #25. Without performing hand hygiene, she left the room and walked down the hall to the medication cart. Staff member D stated she did not need to wear gloves when giving an injection because, It's not an infection control issue. She stated she did not wash her hands upon entering the room because she had used hand sanitizer at the medication cart prior to going to resident #25's room. She could not state what she may have touched from when she sanitized her hands until she gave the injection. Staff member D stated she did not wash her hands after giving the insulin injection and prior to leaving resident #25's room because she did not want to set down the used syringe and pick it up again. She stated she should have washed her hands when entering and before leaving resident #25's room. During an interview on 6/27/18 at 4:20 p.m., staff member A stated the expectation was for licensed nurses to wear gloves when giving an injection, and to wash their hands before and after giving the injection. Review of a facility policy titled, Hand Hygiene/Handwashing, showed the following: - Decontaminate hands before having direct patient contact. - Decontaminate hands after contact with a patient's intact skin. - Wear gloves when contact with blood or other potentially infectious materials could occur. Review of the facility policy titled, Subcutaneous Injection, in the procedure section, step 18 showed the licensed nurse was to put on gloves prior to administering the injection.",2020-09-01
245,PARK PLACE TRANSITIONAL CARE AND REHABILITATION,275030,1500 32ND ST S,GREAT FALLS,MT,59405,2018-06-28,883,E,0,1,STQR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to determine if a resident had the Prevnar vaccine and offer the vaccine if needed, for 3 (#s 18, 22, and 68) of 35 sampled and supplemental residents. Findings include: During an interview on 6/27/18 at 4:38 p.m., staff member A stated the Prevnar was given if need was determined. She stated she had been the Director of Nursing for only six weeks, and the current process was for residents to have Prevnar vaccine status determined on admission. She stated the process also included a step for the resident to sign a form if the vaccine was offered and declined. Staff member A stated she did not know what the process involved, before she was hired, for the vaccines. A written request was made for vaccination records. The following was found during record reviews for resident #18, 22, and 68. - Resident #18's Clinical Immunizations report showed she had received the [MEDICATION NAME], but did not address the Prevnar vaccine. - Resident #22's Clinical Immunizations report showed he had received the [MEDICATION NAME], but did not address the Prevnar vaccine. - Resident #68's Clinical Immunizations report showed she had received the [MEDICATION NAME], but did not address the Prevnar vaccine. During an interview on 6/28/18 at 7:32 a.m., staff member A stated there was no evidence of the Prevnar vaccine being offered or administered for residents #18, 22, or 68. She stated the facility now addresses the vaccine status on admission, but they would need to determine the Prevnar vaccine status of all the current residents, and offer the vaccine, if indicated.",2020-09-01
246,PARK PLACE TRANSITIONAL CARE AND REHABILITATION,275030,1500 32ND ST S,GREAT FALLS,MT,59405,2019-07-23,812,F,0,1,67BZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to dispose of expired dried goods; and failed to maintain two refrigerators in the main kitchen at or below 41 degrees Fahrenheit during (MONTH) of 2019, which had the potential to result in food-borne pathogens for all residents. Findings include: [NAME] During an observation on [DATE] at 1:08 p.m., several dried seasonings were past their expiration and/or use-by date: -Lemon and pepper seasoning, exp. [DATE]; -Ground thyme, use-by [DATE]; -Taco seasoning, use-by [DATE]; -Cumin, use-by [DATE]; -Dill weed, use-by [DATE]; -Ground ginger, use-by [DATE]. During an observation and interview on [DATE] at 1:09 p.m., staff member G stated she and another kitchen staff checked expiration dates on Mondays. When the expiration and use-by dates were brought to staff member G's attention, she threw away the lemon and pepper seasoning only. Staff member G did not inspect the other seasonings at that time. During an interview on [DATE] at 1:15 p.m., staff member H stated kitchen staff checked expiration dates on delivery days, which were Tuesdays and Fridays. Review of the facility's policy titled, Refrigerators and Freezers, showed, Expiration dates on unopened food will be observed and 'use by' dates indicated once food is opened .Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. B. During an observation on [DATE] at 4:53 p.m., the refrigerator labeled Milk/dessert box had a digital temperature reading of 43 degrees Fahrenheit. The refrigerator contained a food storage shelving unit that had individual cups of chocolate pudding with marshmallows on top, along with individual plates of chef salads. During an observation on [DATE] at 5:11 p.m., the milk/dessert refrigerator's digital temperature read 44 degrees Fahrenheit. During an interview on [DATE] at 5:12 p.m., staff member F stated kitchen staff should be checking refrigeration temperatures daily. During an interview on [DATE] at 5:16 p.m., staff member H stated the temperature readings on the outside of the refrigerators are not to be trusted. Staff member H recommended using the internal thermometers. During an observation and interview on [DATE] at 5:18 p.m., the milk/dessert refrigerator digital temperature read 45 degrees Fahrenheit. Staff member F opened the refrigerator and stated she could not find the internal thermometer. During an observation on [DATE] at 5:20 p.m., another refrigerator, labeled R1, had a digital reading of 45.5 degrees Fahrenheit, and stored fresh produce, juices, yogurts, dressings, and cheeses. During an interview on [DATE] at 5:22 p.m., staff member I stated 42 degrees Fahrenheit was in the upper range for accepted refrigerator temperatures. Staff member I stated R1 had a reading of 50 degrees Fahrenheit one day in (MONTH) and kitchen staff had to throw everything away. Staff member I stated kitchen staff should notify maintenance when refrigerators are out of range and that he would contact maintenance about this issue. During an observation and interview on [DATE] at 11:04 a.m., the milk/dessert refrigerator's digital temperature read 47 degrees Fahrenheit. Staff member J stated the internal thermometer would have a more accurate reading. Staff member J looked at the internal thermometer, which read 50 degrees Fahrenheit. The same storage tray containing pudding and chef salad was observed in the milk/dessert refrigerator. Staff member J moved the storage trays to another refrigerator directly next to the milk/dessert refrigerator. Review of the facility's refrigerator/freezer temperature log for (MONTH) of 2019 showed 29 out of 39 recorded temperatures were above 41 degrees Fahrenheit on R1. The milk/dessert refrigerator temperature log had 13 out of 38 recorded temperatures above 41 degrees Fahrenheit. Review of the facility's policy titled, Refrigerators and Freezers, showed: Acceptable temperature ranges are 32 to 42 degrees Fahrenheit for refrigerators .Monthly tracking sheets will include time, temperature, initials and 'action taken.' .The supervisor will take immediate action if temperatures are out of range. Review of the facility's temperature log included instructions on the top of the page, which showed temperature guidelines should be within ,[DATE] degrees Fahrenheit for refrigerators. The temperature log also showed: If temperatures are not at appropriate levels, notify supervisor immediately and document action taken. Potentially hazardous food is to be kept at an internal temperature of 41 degrees Fahrenheit or lower. Generally air temperature of ,[DATE] degrees Fahrenheit below desired internal food temperature is appropriate (i.e. 39 degrees Fahrenheit or below) to maintain food temperatures at 41 degrees Fahrenheit or lower.",2020-09-01
247,PARK PLACE TRANSITIONAL CARE AND REHABILITATION,275030,1500 32ND ST S,GREAT FALLS,MT,59405,2019-09-25,677,D,1,0,I4CJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > 1. During an observation on 9/24/19 at 12:05 p.m., resident #2 reclined in a recliner, in his room. The resident did not respond. When spoken to, he yawned. The resident's teeth were noted to have a whitish, thick substance, caked on his upper teeth, along the gum line. During an interview on 9/24/19 at 10:10 a.m., and again at 2:30 p.m., NF1 stated staff were not assisting resident #2 with oral care. NF1 stated resident #2 was unable to do this for himself and needed help. NF1 stated the staff did not always brush resident #2's teeth. During an interview on 9/24/19 at 12:10 p.m., staff member H stated resident #2 required staff to perform all his cares as he was unable to do this for himself. The staff member stated CNAs were to brush resident #2's teeth. Staff member H stated brushing resident #2's teeth was difficult at times as he resisted. Review of resident #2's care plan, with an initiation date of 3/20/17, showed staff were to attempt to provide oral care in the AM (morning), and the HS (evening). The resident was more accepting of the oral care when sleepy. Review of the CNA Kardex report, with an admission date of [DATE], did not address the need for the CNAs to provide oral care. Review of resident #2's Interdisciplinary Team (IDT) Care Conference Summary, dated 2/11/19 and 4/22/19, showed NF1 had identified concerns that resident #2's teeth were not being brushed two times daily. There was no documentation showing the facility staff followed through with attempting to improve on brushing resident #2's teeth, twice a day. Review of resident #2's MDS, with an ARD of 6/26/19, showed resident #2 required extensive assist with all cares, including hygiene. Review of resident #2's nurse progress note, dated 7/8/19 at 1:47 a.m., showed a friend had visited resident #2, and complained to staff that the resident's teeth were not cleaned. There was no documentation that showed the facility staff had looked into the visitor's claim, updated resident #2's plan of care, and audited for compliance. Review of resident #2's Interdisciplinary Team (IDT) Care Conference Summary, dated 7/10/19, showed NF1 still had concerns about resident #2's oral hygiene. The summary showed nursing was monitoring, and the oral care was happening at least 1 (one) time daily.",2020-09-01
248,PARK PLACE TRANSITIONAL CARE AND REHABILITATION,275030,1500 32ND ST S,GREAT FALLS,MT,59405,2019-09-25,695,D,1,0,I4CJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, observation, and record review, the facility staff failed to have distilled water available for use with a [MEDICAL CONDITION] machine, and there was a physician order [REDACTED]. During an interview on 9/24/19 at 5:15 p.m., resident #4 stated, in an angry tone, he had no distilled water the past weekend and had just received some. The resident stated he had no available distilled water for his [MEDICAL CONDITION] before, and This is not the first time this has happened. Resident #4 stated he had asked the CNAs and nurses for distilled water. He never received any distilled water for the [MEDICAL CONDITION] machine. He had been told there was no distilled water available by the staff. During an interview on 9/24/19 at 6:40 p.m., staff member C stated the facility supplied distilled water to residents using [MEDICAL CONDITION] machines. The staff member stated the distilled water was generally behind the nurse station or in central supply, either of which were assessable to all staff. The staff member stated she was unaware if resident #4 did not have distilled water during the past weekend. During an interview on 9/24/19 at 6:50 p.m., staff member G stated she purchased distilled water locally and had it always on hand. The CNAs were to come and get the distilled water from central supply and give it to a resident who needed it for their [MEDICAL CONDITION] machine. The staff member stated nursing had the code to unlock the central supply room. No documentation was produced showing why the distilled water was not available for resident #4. During an interview on 9/25/19 at 10:53 a.m., staff member D stated, resident #4 had stated being out of distilled water on Thursday and through the weekend. The staff member stated resident #4 did receive distilled water, first thing this morning (Wednesday). During an interview on 9/25/19 at 10:55 a.m., staff member L said resident #4 was pretty with it (ability to understand), and did not know why resident #4 was out of distilled water for any period of time. Review of resident #4's physician orders, dated 6/17/19, showed, [MEDICAL CONDITION]@with O2 at with humidification (sic). [MEDICAL CONDITION] scheduled start at bedtime and remove in the morning. Review of resident #4's Quarterly MDS note, dated 9/23/19 at 2:30 p.m., showed resident #4 wore a [MEDICAL CONDITION] at night with two liters of oxygen. Staff member C was unable to locate the manual for resident #4's [MEDICAL CONDITION] machine in the facility but located the manual on the Internet. Review of the System One Heated Humidifier user manual, showed, Caution: Do not turn on the humidifier without the water tank install. The Humidifier setting must remain off if there is no water in the water tank. 4 .fill it (humidifier) with distilled water . Review of resident #4's care plan, with a revision date of 7/1/19, showed that his [MEDICAL CONDITION] needed cleaned per physician orders. There was no documentation on the care plan or the Kardex Report showing the nursing staff had to supply #4 with distilled water for his [MEDICAL CONDITION] machine.",2020-09-01
249,PARK PLACE TRANSITIONAL CARE AND REHABILITATION,275030,1500 32ND ST S,GREAT FALLS,MT,59405,2019-09-25,755,D,1,0,I4CJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility staff did not follow physician orders [REDACTED].#2 and 3) of 5 sampled residents. Findings include: During an interview on 9/24/19 at 10:10 a.m., NF1 stated the facility nurses were not following resident #2's physician orders [REDACTED]. a. Review of the facility nurse progress notes, dated 8/26/19 at 11:39 a.m., showed staff member H had faxed resident #2's labs to the resident's physician's nurse. The nurse, Called back with orders to hold [MEDICATION NAME] ([MEDICATION NAME] suspension) x2 days, restart on 08/28/2019 7 AM. Review of resident #2's physician orders [REDACTED]. Review of resident #2's MAR (medication administration record), for 8/1/19 through 8/31/19, showed resident #2's administration of [MEDICATION NAME] suspension had been held from 12 noon on 8/26/19 until 8/28/19 at 12 noon. No documentation was available which showed why the medication was held. During an interview on 9/25/19 at 9:53 a.m., staff member C stated the nurse who had written down the physician order, for the hold of the [MEDICATION NAME] suspension, told him she gave the order as the physician had prescribed. Staff member C said the resident did not receive the [MEDICATION NAME] suspension as ordered. Staff member C stated the nurses would receive education on taking physician orders [REDACTED]. b. Review of resident #2's MAR (medication administration record), for 8/1/19 through 8/31/19, showed resident #2 was to receive Felbamate, 11.6 ml via PEG tube at 5:00 a.m., 8:30 a.m., and 5:00 p.m. Resident #2 did not receive the administration of Felbamate suspension on 8/17/19 at 5 a.m. There was no documentation showing why the medication was not given at 5:00 a.m. Review of resident #2's nurse progress notes, dated 8/17/19 at 9:43 a.m., showed the resident did not have any Felbamate suspension in the facility, and the nurse was waiting on the medication from the pharmacy. The MAR indicated [REDACTED]. Review of resident #2's physician orders [REDACTED]. c. Review of resident #3's physician orders, dated 9/11/19, showed the physician wanted a CBC completed 9/16/19. Review of a documentation on the physician order [REDACTED].#3's CBC lab draw and entered it on the physician order [REDACTED]. Review of resident #3's physician progress notes [REDACTED].#3 was to have a CBC on 9/16/19, but the physician was unable to find the completed blood work.",2020-09-01
250,PARK PLACE TRANSITIONAL CARE AND REHABILITATION,275030,1500 32ND ST S,GREAT FALLS,MT,59405,2018-12-27,600,G,1,0,KV4V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility staff, to include multiple disciplines and shifts, failed to identify and provide necessary medical interventions for a resident who had an accident, in which the resident sustained [REDACTED]. not be repaired, therefore, the resident had all medications stopped and was receiving end of life care, for 1 (#7) of 7 sampled residents. Findings include: During an observation on 12/26/18 at 2:37 p.m., resident #7 was observed sitting in her wheelchair, with a white towel placed underneath her. She was wearing blue pants which covered her knees, but exposed the remainder of her legs. A large hematoma was observed on her left calf. Several other small bruises were observed on both of her lower legs. During an interview on 12/26/18 at 2:39 p.m., staff member H stated she was not sure why resident #7 was sitting on a white towel, but she would go and get one of her staff to determine why the towel was placed under the resident, and then assist the resident. During an observation and interview on 12/26/18 at 2:43 p.m., staff member [NAME] was observed approaching resident #7. He stated he was not sure why she had a towel placed underneath her, but he would get another staff member to help him remove it. Staff member [NAME] pushed resident #7 to the nurse's station of the 400 wing. During an observation on 12/26/18 at 2:44 p.m., staff members [NAME] and D were observed trying to lift resident #7 from her wheelchair so they could remove the white towel from her chair that was placed underneath her. Resident #7 yelled out Ouch, don't touch me! It hurts so bad! Staff member D removed the white towel, even though the resident was voicing the pain when touched/moved. During an observation and interview on 12/26/18 at 2:45 p.m., staff member D and [NAME] were observed taking resident #7 to her room. Staff member [NAME] stated resident #7 had recently been complaining about pain in her right hip and leg. He stated resident #7 had difficulty transferring recently, and he reported both the pain and transferring issues to the nursing staff. During an observation and interview on 12/26/18 at 2:46 p.m., staff member C entered resident #7's room. She stated she had not worked the last two days, and she was not aware that resident #7 had been complaining of right hip or leg pain. Staff member C instructed staff members D and [NAME] to transfer the resident to her bed. Staff member [NAME] was observed touching resident #7's right leg to lift the right foot pedal of the resident's wheelchair. Resident #7 screamed, Stop! Staff members D and [NAME] continued to prepare resident #7 for a transfer to her bed. Due to the resident's heightened pain complaints, with resident #7 observed yelling out in pain every time the staff members touched her right leg, Staff member C was asked if a nursing assessment should be done prior to resident #7 being transferred to her bed. Staff member C stated, Oh yes, and she approached resident #7 and began asking her questions about where her pain was. Resident #7 stated, to staff member C, pain was a six, on a scale of one-to-ten. The resident was observed holding the middle portion of her right upper leg with both hands, and would not let go. Resident #7's right knee was swollen, and there was an old vertical scar observed. Resident #7 could not recall how her leg was injured, and stated, Moving it causes terrible pain. Staff member C stated, Let me go call the doc. She exited resident #7's room at 3:03 p.m. During an observation on 12/26/18 at 3:07 p.m., staff member B was observed entering resident #7's bedroom. She began asking the resident questions about where her pain was, and what the source of the pain was. While completing a nursing assessment of the resident's right leg, staff member B placed her hands on the resident's right knee. Staff member B attempted to lift resident #7's pant leg up above her knee but was unable to, due to resident #7's complaints of pain. When staff member B attempted to move resident #7's right leg, resident #7 yelled out, It hurts so bad! Staff member B asked resident #7 if she would like medication to manage her pain. Resident #7 responded, I'm afraid I'm gonna go downhill (decline in health/mobility). She stated, I'm scared something is gonna happen to me, and I'm not ready to go yet. During an observation on 12/26/18 at 4:38 p.m., resident #7 had been removed from her bed, although the resident had voiced the prior complaints of pain with her hip/leg, and the resident was observed sitting in her wheelchair in her room. Resident #7 appeared groggy. When greeted, she opened her eyes, responded, then appeared to fall asleep. During an interview on 12/26/18 at 4:40 p.m., staff member B stated resident #7 had an X-ray completed of her right leg. Staff member B stated the portable X-ray tech arrived to do resident #7's x-rays and the facility was waiting for the x-rays to be read. She stated the technician who took the x-rays stated there appeared to be a right distal femur fracture. Staff member B stated resident #7's doctor had requested that she be sent to the emergency room for further evaluation, and she had arranged for a transfer. Staff member B stated the resident had been transferred from the bed, to the wheelchair, by the hoyer lift. During an interview on 12/26/18 at 8:10 p.m., staff member D stated he worked on 12/22/18 and 12/23/18 from 2 p.m. to 10 p.m. He stated resident #7 was in bed and remained in bed both days for the entirety of his shifts. Staff member D stated, She wouldn't get up. She complained of pain whenever she was repositioned. He stated he did not work on 12/24/18 or 12/25/18. Staff member D stated resident #7, Complained of a lot of pain today. During an interview on 12/26/18 at 8:15 p.m., staff member [NAME] stated resident #7 had been in bed the last three shifts he had worked. He stated resident #7 had, Complained of a lot of pain all three days. Staff member [NAME] stated he worked on 12/21/18, 12/24/18 and 12/25/18. He said he was not scheduled to work on 12/22/18 and 12/23/18. Staff member [NAME] stated he had to use the sit to stand hoyer lift for resident #7 on 12/25/18. He stated, She wouldn't bear weight, and I needed enough time to do peri care. Review of resident #7's Care Plan, last updated 12/18/18, showed she has alterations in her physical mobility. Section Interventions showed, I want to (sic) licensed unit nurse to intervene when I decline to ambulate. I want them to investigate my reasons and resolve the core issue I identify and document as appropriate .Monitor/document/report to my MD as needed signs/symptoms of immobility . During an interview on 12/26/18 at 8:30 p.m., staff member L stated she worked 6 p.m. to 6 a.m. on 12/21/18, 12/22/18, and 12/23/18. She stated that resident #7 remained in her bed the entirety of all three of her scheduled shifts. Staff member L stated she had not received any reports of resident #7 having had any falls or incidents in the last week. She stated, On the 23rd she refused her pain medications although she did complain of pain in her leg. Staff member L stated, (Resident #7) was hollering with pain and did eventually take her meds. Staff member L said she was informed that resident #7 was transferred to the hospital for a suspected fracture when she arrived for her shift. During an interview on 12/27/18 at 8:30 a.m., staff member N stated she had been told in report that morning that resident #7 had been in bed for, Four days straight. Staff member N stated to staff member G that they should, Get (resident #7) up. Staff member N said resident #7 complained of her body hurting more than usual during care. She stated resident #7 transferred from her bed into her wheelchair okay with the assistance of one staff. Staff member N stated resident #7 initially refused to transfer from her wheelchair to the toilet. She stated resident #7 eventually agreed to the transfer and stated, Ow, ow, ow, during the transfer. Staff member N stated she then went to get another CNA to assist her. Staff member N said she did not report this information to the nurse. During an interview on 12/27/18 at 8:52 a.m., staff member G stated she worked on 12/21/18. She stated around 1:00 p.m., she was asked to take resident #7 out of the dining room. Staff member G stated, I asked (resident #7) to lift up her legs. She stated when she went to move her wheelchair, resident #7 dropped her right leg, and it got caught under her wheelchair. Staff member G stated resident #7 screamed, Ouch! She stated, I grabbed her foot pedals. She stated, I lifted her left leg first, nothing. Then, I lifted her right leg and she screamed. Staff member G stated, I pushed resident #7 to the nurse's station. She stated the nurse on her wing was on break so she went to get staff member M. She stated she told staff member M exactly what happened. Staff member G said she reported that resident #7 was in extreme pain. Staff member G said that she observed staff member M looking at resident #7's right knee. She stated she was not sure if staff member M completed a nursing assessment and was not sure if staff member M gave resident #7 any pain medication. Staff member G stated staff member M told her to take resident #7 to her room and lay her down in her bed. She stated when she transferred resident #7, she Screamed and told me not to move her leg. Staff member G stated she reported the incident to staff member C around 2:00 p.m., and she reported the incident to the oncoming shift. During an interview on 12/27/18 at 9:13 a.m., staff member C stated she worked on 12/21/18, 12/22/18, and 12/23/18 from 6:00 a.m. to 6:00 p.m. She was not scheduled to work on 12/24/18 or 12/25/18. She stated when she came back from lunch on 12/21/18, staff member M told her about the incident that occurred with resident #7. She stated staff member M told her she did an assessment, the resident was in pain, and she gave the resident a PRN pain medication. Staff member C stated she did not complete an assessment of resident #7 because she was told staff member M did one. She stated staff member M should have completed a nursing assessment. Staff member C stated she did not call the doctor or the family to report the incident. She stated staff member M should have notified both parties. When asked if resident #7 received a PRN medication to treat her pain following the incident, staff member C stated, Based on the documentation on the MAR, no PRN was administered. She stated nursing staff should document on the MAR all medications that are administered. Staff member C stated she was not aware that resident #7 remained in bed for several days following the incident. She stated, She refused to get up two days for me. Staff member C stated resident #7 did not get out of bed on 12/22/18 or 12/23/18. She stated prior to the incident on 12/21/18, resident #7 had never complained of right leg pain. During an interview on 12/27/18 at 9:24 a.m., staff member M stated she worked on 12/21/18. She stated staff member G, Came to get me. She came to my office panic stricken. Staff member M stated staff member G told her resident #7's right foot got caught underneath her wheelchair. She stated staff member G told her resident #7 yelled out in pain. Staff member M stated she completed an assessment of resident #7's right leg. She stated, There was no swelling in the right leg, or in her right knee. Staff member M stated, (Resident #7) told me the pain was in her right lower leg. She stated resident #7 said she wanted pain medication and she, Gave her a [MEDICATION NAME]. Staff member M stated she did not sign the MAR when she administered the medication. She stated, I signed out the medication in the NARC book. When asked if she should have signed the MAR, staff member M stated, Yes of course I am supposed to sign the MAR. Staff member M stated she did not document her assessment of resident #7's right leg, and stated, I am supposed to. She stated she gave staff member G permission to put resident #7 in her bed. She stated she did not hear resident #7 scream out in pain when she was transferred. Staff member M stated she reported the incident to staff member C when she returned from lunch. Staff member M stated she did not report the incident to resident #7's family or doctor. She stated she was not aware that resident #7 spent several days in bed following the incident. Staff member M stated, I have heard that (resident #7) has a femur fracture. She stated, (Staff member B) told me yesterday. Staff member M stated staff are supposed to be placing a resident's feet on the foot pedals of their wheelchairs before transporting them. Review of resident #7's narcotic medication log showed staff member M removed a [MEDICATION NAME] tablet from resident #7's medication card on 12/21/18 at 1:30 p.m. Review of resident #7's Medication Administration Record for (MONTH) (YEAR), showed, no documentation that a PRN pain medication was administered to resident #7, or that a pain assessment was completed for the resident on 12/21/18 at 1:30 p.m. During an interview on 12/27/18 at 9:51 a.m., staff member B stated she was made aware of the incident that occurred on 12/21/18 with resident #7 at 5:00 p.m. the previous day (12/26/18). She stated there was no nursing assessment completed for resident #7 following the incident on the 21st, and stated, Whoever assessed the resident should have wrote an assessment. Staff member B stated, Pain assessments should be made and documented, if a PRN pain medication is given to a resident. She said when a PRN pain medication is administered, the computer system prompts staff to complete a pain assessment. Staff member B stated it is not acceptable practice for a nurse to sign out a narcotic medication and administer it to a resident without signing the residents MAR. Staff member B stated she was not aware that resident #7 had remained in bed for several days following the incident that occurred on 12/21/18. She stated she worked from 6:00 a.m. to 6:00 p.m. on 12/24/18 and resident #7 did complain of pain that day. Staff member B stated she administered a PRN Tylenol to resident #7, and the documentation could be found on her MAR. She stated resident #7 refused to get out of bed that day, but she did take all her medications. When asked if staff member G should have placed resident #7's foot pedals on her wheelchair prior to transporting her on 12/21/18, staff member B stated, I would have preferred it. Staff member B stated that all incidents involving residents in the facility should be documented. She stated nursing staff should complete a nursing note and document their assessments. She stated incidents are reviewed the following day by the IDT. Staff member B stated notifications of incidents should be reported to the doctor, the family, and she would, Prefer to be notified. She stated her phone number is posted all over the building. When asked if she had received an updated report from the hospital, staff member B stated resident #7 had a right femur fracture. She stated resident #7 was admitted to the hospital, and, We just don't know the plan yet. During an interview on 12/27/18 at 10:25 a.m., staff member F stated resident #7 told her that she was having right knee pain on 12/25/18. She stated CNA's had informed her that the resident would not bear weight well, even while using a stand up lift. Staff member F stated she documented this information in resident #7's nursing progress notes. She stated she placed a copy of the note in the doctor communication book, and staff member S read and signed the note on 12/26/18. Staff member F stated she did not notify the doctor of her findings on 12/25/18. Review of resident #7's progress notes, dated 12/25/18, showed, Resident does complain of right knee pain. Knee has continuous selling, (sic) does not seem worse today. No redness or warmth to the area. CNA's report that resident does not bear weight well even with stand up lift. The note was signed by staff member S. During an interview on 12/27/18 at 10:52 a.m., staff member A stated that he was made aware of the incident that occurred on 12/21/18 with resident #7 on the previous day (12/26/18). He stated, I learned about it yesterday afternoon. You would think that someone would have reported it (prior). During an interview on 12/27/18 at 11:10 a.m., staff member G stated she worked on 12/26/18. She stated she was informed that resident #7 had been, In bed for four days, when she got her morning report. During an interview 12/27/18 at 12:27 p.m., staff member S stated she was at the facility on 12/26/18. Staff member S stated she signed the nursing progress note that was placed in the physician communication log for resident #7 (by staff member F). She stated she did not assess resident #7 while at the facility that day, and stated she had not assessed the resident in the last week. Staff member S stated she could not provide any additional information about resident #7 or her medical status without having her chart available. She stated she would follow-up with a phone call on 12/28/18. No follow up phone call was received from staff member S regarding the resident. Review of resident #7's physician progress notes [REDACTED]. No documentation of a resident assessment was completed after that date. Review of resident #7's radiology report, dated 12/26/18, showed resident #7 was diagnosed with [REDACTED]. Findings showed, Comminuted periprosthetic [MEDICAL CONDITION] femur with half shaft width posterior displacement of the arthroplasty at the fracture line and posterior angulation approaching 90 degrees. Indications section of the report showed, Fall. Review of resident #7's pain evaluation assessment, completed on 12/13/18, showed, resident #7 did not verbalize or exhibit non-verbal symptoms of pain. Review of resident #7's Medication Administration Record for (MONTH) (YEAR), showed resident #7's pain assessments were documented, on a scale of 0-10, as follows: -12/21/18- 0; -12/22/18- 0; -12/23/18- 0; -12/24/18- 7; -12/25/18- 7; -12/26/18- 8. Review of resident #7's medical chart showed no nursing assessment was completed for the resident following the incident that occurred on 12/21/18, and the record failed to show the resident #7's right foot was caught under her wheelchair. No interventions were implemented for future prevention of similar events, to address pain, or the resident's transferring with staff. Review of resident #7's progress notes, dated 12/26/18, showed, Spoke with ER. Nurse stated res (sic) is going to be admitted to the hospital for a Tib and Fib (sic) fracture. No other information was given. During an interview on 12/27/18 at 1:58 p.m., NF1 stated resident #7 was admitted to the hospital and sustained a substantial fracture to her right femur. She stated the facility had called her the afternoon prior (12/26/18), to inform her that her mother was going to be sent to the emergency room for a suspected injury to her leg, but she had not had any communication with anyone from the facility since that time. NF1 stated she had spent her morning talking to several doctors at the hospital. She stated she was told that her mother's femoral fracture was, So severe that the bone was shattered. NF1 stated, The doctor's said that my mom is too fragile and would not be able to survive the surgery to fix her leg. She stated she and her family had made the decision to pursue hospice care for her mother due to this, and stated, We are going to take her off all of her meds. She's in so much pain. After this, all we want to do is keep her comfortable. She just wants to die. Review of the facilities Abuse and Neglect policy, revised (MONTH) (YEAR), showed, Neglect is defined as, The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Section Assessment and Recognition of the policy showed, 1. The nurse will assess the individual and document related findings. Assessment data will include: a. Injury assessment .b. Pain assessment .2. The nurse will report findings to the physician .",2020-09-01
251,PARK PLACE TRANSITIONAL CARE AND REHABILITATION,275030,1500 32ND ST S,GREAT FALLS,MT,59405,2018-12-27,658,D,1,0,KV4V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility staff failed to follow professional standards of practice for a resident who had an accident with a staff member present and the resident sustained [REDACTED].; to include failure to notify the physician and responsible party timely; or to implement interventions to prevent future accidents or injury, and ensure an accurate medical record was maintained, for 1 (#7) of 7 sampled residents. Findings include: The following evidence was gathered during the survey process, which reflected standards of practice were not followed for resident #7 for pain management, accident and hazard prevention, medical record documentation, safe transfers, resident assessments, and updating or modifying the resident's care plan: a. Care concerns and care plan During an observation on 12/26/18 at 2:44 p.m., staff members [NAME] and D were observed trying to lift resident #7 from her wheelchair so they could remove the white towel from her chair that was placed underneath her. Resident #7 yelled out Ouch, don't touch me! It hurts so bad! Staff member D removed the white towel, even though the resident was voicing pain when touched or moved, and failed to consider alternate interventions for the resident, relating to the pain and being touched. During an interview on 12/26/18 at 8:10 p.m., staff member D stated he worked on 12/22/18 and 12/23/18 from 2 p.m. to 10 p.m. He stated resident #7 was in bed and remained in bed both days for the entirety of his shifts. Staff member D stated, She wouldn't get up. She complained of pain whenever she was repositioned. Staff member D stated resident #7, Complained of a lot of pain today. The resident's care plan and medical record did not reflect the concerns identified by the staff member, to ensure future staff were aware of the concerns, and the resident's care needs and well being was addressed. During an interview on 12/26/18 at 8:15 p.m., staff member [NAME] stated resident #7 had been in bed the last three shifts he had worked. He stated resident #7 had, Complained of a lot of pain all three days. Staff member [NAME] stated he worked on 12/21/18, 12/24/18 and 12/25/18. Staff member [NAME] stated he had to use the sit to stand hoyer lift for resident #7 on 12/25/18. He stated, She wouldn't bear weight, and I needed enough time to do peri care. The resident's medical record and care plan failed to identify and address the concerns voiced by staff member E, so future staff would be aware of, and be able to provide the level of care necessary for the resident. Review of resident #7's Care Plan, last updated 12/18/18, showed she has alterations in her physical mobility. Section Interventions showed, I want to (sic) licensed unit nurse to intervene when I decline to ambulate. I want them to investigate my reasons and resolve the core issue I identify and document as appropriate .Monitor/document/report to my MD as needed signs/symptoms of immobility . b. Lack of staff communication and coordination of care During an interview on 12/26/18 at 8:30 p.m., staff member L stated she worked 6 p.m. to 6 a.m. on 12/21/18, 12/22/18, and 12/23/18. She stated that resident #7 remained in her bed the entirety of all three of her scheduled shifts. Staff member L stated she had not received any reports of resident #7 having had any falls or incidents in the last week. During an interview on 12/27/18 at 8:30 a.m., staff member N stated she had been told in report that morning that resident #7 had been in bed for, Four days straight, complained of her body hurting more than usual during care, initially refused to transfer from her wheelchair to the toilet, but eventually agreed to the transfer and stated, Ow, ow, ow, during the transfer. Staff member N said she did not report this information to the nurse. During an interview on 12/27/18 at 8:52 a.m., staff member G stated she worked on 12/21/18. She stated around 1:00 p.m., she was asked to take resident #7 out of the dining room. Staff member G stated, I asked (resident #7) to lift up her legs. She stated when she went to move her wheelchair, resident #7 dropped her right leg, and it got caught under her wheelchair. Staff member G stated resident #7 screamed, Ouch! She stated, I grabbed her foot pedals. She stated, I lifted her left leg first, nothing. Then, I lifted her right leg and she screamed. Staff member G stated she notified the nurse, who looked at the resident's right knee, then told staff member M to take her to her room and lay her down in her bed. The nurse did not not monitor or assist with the transfer. She stated when she transferred resident #7, she Screamed and told me not to move her leg. No changes were made to the resident's plan of care, related to the incident, pain, and concern relating to transferring, for resident safety, comfort, and well being. The physician was not notified of the event or resident's pain complaints. During an interview on 12/27/18 at 9:13 a.m., staff member C stated she worked on 12/21/18, 12/22/18, and 12/23/18 from 6:00 a.m. to 6:00 p.m. She stated staff member M told her she did an assessment (after the event on 12/21/18), the resident was in pain, and she gave the resident a PRN pain medication. Staff member C stated she did not complete an assessment of resident #7 because she was told staff member M did one. She stated staff member M should have completed a nursing assessment. Staff member C stated she did not call the doctor or the family to report the incident. She stated staff member M should have notified both parties. When asked if resident #7 received a PRN medication to treat her pain following the incident, staff member C stated, Based on the documentation on the MAR, no PRN was administered. She stated nursing staff should document on the MAR all medications that are administered. Staff member C stated she was not aware that resident #7 remained in bed for several days following the incident. She stated, She refused to get up two days for me. Staff member C stated resident #7 did not get out of bed on 12/22/18 or 12/23/18. She stated prior to the incident on 12/21/18, resident #7 had never complained of right leg pain. Although the resident had an accident, increased pain, and refused to get out of bed, staff member C did not take further action to review the resident's record, or assess the resident further when she would not get out of bed, to ensure the necessary action had been taken to address the resident's injury and root cause of the pain. During an interview on 12/27/18 at 9:24 a.m., staff member M stated she worked on 12/21/18. She stated staff member G, Came to get me and said resident #7's right foot got caught underneath her wheelchair. She stated staff member G told her resident #7 yelled out in pain. Staff member M stated she completed an assessment of resident #7's right leg. She stated, There was no swelling in the right leg, or in her right knee. Staff member M stated, (Resident #7) told me the pain was in her right lower leg. She stated resident #7 said she wanted pain medication and she, Gave her a [MEDICATION NAME]. Staff member M stated she did not sign the MAR when she administered the medication. She stated, I signed out the medication in the NARC book. When asked if she should have signed the MAR, staff member M stated, Yes of course I am supposed to sign the MAR. Staff member M stated she did not document her assessment of resident #7's right leg, and stated, I am supposed to. She stated she gave staff member G permission to put resident #7 in her bed. She stated she did not hear resident #7 scream out in pain when she was transferred. Staff member M stated she reported the incident to staff member C when she returned from lunch. Staff member M stated she did not report the incident to resident #7's family or doctor. She stated she was not aware that resident #7 spent several days in bed following the incident. Review of resident #7's MAR and Narcotic Medication Log showed a [MEDICATION NAME] tablet was removed on 12/21/18 at 1:30 p.m., but was not signed as given on the resident's MAR, or that a pain assessment was completed for the resident on 12/21/18 at 1:30 p.m., relating to why the medication was given. During an interview on 12/27/18 at 9:51 a.m., staff member B stated she was made aware of the incident that occurred on 12/21/18 with resident #7 at 5:00 p.m. the previous day (12/26/18). Staff member B provides oversight for nursing care at the facility. She stated there was no nursing assessment completed for resident #7 following the incident on the 21st, and stated, Whoever assessed the resident should have wrote an assessment. Staff member B stated, Pain assessments should be made and documented, if a PRN pain medication is given to a resident. She said when a PRN pain medication is administered, the computer system prompts staff to complete a pain assessment. Staff member B stated it is not acceptable practice for a nurse to sign out a narcotic medication and administer it to a resident without signing the residents MAR. Staff member B stated she was not aware that resident #7 had remained in bed for several days following the incident that occurred on 12/21/18. She stated she worked from 6:00 a.m. to 6:00 p.m. on 12/24/18 and resident #7 did complain of pain that day. Staff member B stated she administered a PRN Tylenol to resident #7, and the documentation could be found on her MAR. She stated resident #7 refused to get out of bed that day, but she did take all her medications. Staff member B stated that all incidents involving residents in the facility should be documented. She stated nursing staff should complete a nursing note and document their assessments. She stated incidents are reviewed the following day by the IDT. Staff member B stated notifications of incidents should be reported to the doctor, the family, and she would, Prefer to be notified. During an interview on 12/27/18 at 10:25 a.m., staff member F stated resident #7 told her that she was having right knee pain on 12/25/18. She stated CNA's had informed her that the resident would not bear weight well, even while using a stand up lift. Staff member F stated she documented this information in resident #7's nursing progress notes. She stated she placed a copy of the note in the doctor communication book, and staff member S read and signed the note on 12/26/18. Staff member F stated she did not notify the doctor of her findings on 12/25/18. Review of resident #7's progress notes, dated 12/25/18, showed, Resident does complain of right knee pain. Knee has continuous selling, (sic) does not seem worse today. No redness or warmth to the area. CNA's report that resident does not bear weight well even with stand up lift. The note was signed by staff member S. A medical record reviewed showed staff member S had not assess the resident on 12/26/18, relating to the inability to bear weight well, pain and redness/warmth to knee area, which was noted in the resident's nursing note on 12/25/18. Review of resident #7's radiology report, dated 12/26/18, showed resident #7 was diagnosed with [REDACTED]. Findings showed, Comminuted periprosthetic [MEDICAL CONDITION] femur with half shaft width posterior displacement of the arthroplasty at the fracture line and posterior angulation approaching 90 degrees. Indications section of the report showed, Fall. c. Medical record accuracy and lack of documentation Review of resident #7's medical chart showed no nursing assessment was completed for the resident following the incident that occurred on 12/21/18, and the record failed to show the resident #7's right foot was caught under her wheelchair, or that further assessments were attempted to determine the root cause for the resident's increase in pain, and change in transfer ability/increased pain complaints, per the staff reports. No interventions were implemented for future prevention of similar events.",2020-09-01
252,PARK PLACE TRANSITIONAL CARE AND REHABILITATION,275030,1500 32ND ST S,GREAT FALLS,MT,59405,2018-12-27,689,G,1,0,KV4V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to assess, identify, thoroughly investigate, and act on a resident's injury and medical condition timely, and the injury occurred during an accident at the facility. The failure caused a delay in treatment for [REDACTED].#7) of 7 sampled residents. Findings include: During an interview on 12/27/18 at 8:52 a.m., staff member G stated she worked on 12/21/18. She stated around 1:00 p.m., she was asked to take resident #7 out of the dining room. Staff member G stated, I asked (resident #7) to lift up her legs. She stated when she went to move her wheelchair, resident #7 dropped her right leg, and it got caught under her wheelchair. Staff member G stated resident #7 screamed, Ouch! She stated, I grabbed her foot pedals. She stated, I lifted her left leg first, nothing. Then, I lifted her right leg and she screamed. Staff member G stated, I pushed resident #7 to the nurse's station. She stated the nurse on her wing was on break so she went to get staff member M. She stated she told staff member M exactly what happened. Staff member G said she reported that resident #7 was in extreme pain. Staff member G said that she observed staff member M looking at resident #7's right knee. She stated she was not sure if staff member M completed a nursing assessment and was not sure if staff member M gave resident #7 any pain medication. Staff member G stated staff member M told her to take resident #7 to her room and lay her down in her bed. She stated when she transferred resident #7, she Screamed and told me not to move her leg. Staff member G stated she reported the incident to staff member C around 2:00 p.m., and she reported the incident to the oncoming shift. During an interview on 12/27/18 at 9:24 a.m., staff member M stated she worked on 12/21/18. She stated staff member G, Came to get me. She came to my office panic stricken. Staff member M stated staff member G told her resident #7's right foot got caught underneath her wheelchair. She stated staff member G told her resident #7 yelled out in pain. Staff member M stated she completed an assessment of resident #7's right leg. She stated, There was no swelling in the right leg, or in her right knee. Staff member M stated, (Resident #7) told me the pain was in her right lower leg. She stated resident #7 said she wanted pain medication and she, Gave her a [MEDICATION NAME]. Staff member M stated she did not sign the MAR when she administered the medication. She stated, I signed out the medication in the NARC book. When asked if she should have signed the MAR, staff member M stated, Yes of course I am supposed to sign the MAR. Staff member M stated she did not document her assessment of resident #7's right leg, and stated, I am supposed to. She stated she gave staff member G permission to put resident #7 in her bed. She stated she did not hear resident #7 scream out in pain when she was transferred. Staff member M stated she reported the incident to staff member C when she returned from lunch. Staff member M stated she did not report the incident to resident #7's family or doctor. She stated she was not aware that resident #7 spent several days in bed following the incident. Staff member M stated, I have heard that (resident #7) has a femur fracture. She stated, (Staff member B) told me yesterday. Staff member M stated staff are supposed to be placing a resident's feet on the foot pedals of their wheelchairs before transporting them. During the survey, the following was identified, showing concerns were present, but not identified and acted upon adequately, following the resident's accident: a. Care After Accident - Care Plan Modification During an observation and interview on 12/26/18 at 2:45 p.m., staff member [NAME] stated resident #7 had recently been complaining about pain in her right hip and leg. He stated resident #7 had difficulty transferring recently, and he reported both the pain and transferring issues to the nursing staff. No changes were made to address the resident's plan of care by this date. During an interview on 12/26/18 at 8:10 p.m., staff member D stated he worked on 12/22/18 and 12/23/18 from 2 p.m. to 10 p.m. He stated resident #7 was in bed and remained in bed both days for the entirety of his shifts. Staff member D stated, She wouldn't get up. She complained of pain whenever she was repositioned. He stated he did not work on 12/24/18 or 12/25/18. Staff member D stated resident #7, Complained of a lot of pain today. During an interview on 12/26/18 at 8:15 p.m., staff member [NAME] stated he had to use the sit to stand hoyer lift for resident #7 on 12/25/18. He stated, She wouldn't bear weight, and I needed enough time to do peri care. During an interview on 12/26/18 at 8:30 p.m., staff member L stated she worked 6 p.m. to 6 a.m. on 12/21/18, 12/22/18, and 12/23/18. She stated that resident #7 remained in her bed the entirety of all three of her scheduled shifts. Staff member L stated she had not received any reports of resident #7 having had any falls or incidents in the last week. She stated, On the 23rd she refused her pain medications although she did complain of pain in her leg. Staff member L stated, (Resident #7) was hollering with pain and did eventually take her meds. Staff member L said she was informed that resident #7 was transferred to the hospital for a suspected fracture when she arrived for her shift. During an interview on 12/27/18 at 8:30 a.m., staff member N stated she had been told in report that morning that resident #7 had been in bed for, Four days straight. Staff member N stated to staff member G that they should, Get (resident #7) up. Staff member N said resident #7 complained of her body hurting more than usual during care. She stated resident #7 transferred from her bed into her wheelchair okay with the assistance of one staff. Staff member N stated resident #7 initially refused to transfer from her wheelchair to the toilet. She stated resident #7 eventually agreed to the transfer and stated, Ow, ow, ow, during the transfer. Staff member N stated she then went to get another CNA to assist her. Staff member N said she did not report this information to the nurse. Review of resident #7's Medication Administration Record for (MONTH) (YEAR), showed resident #7's pain assessments from 12/21/18 - 12/23/18 were documented with 0's until 12/24/18, which is when the pain increased to a 7 or 8 out of 10. Review of resident #7's Care Plan, last updated 12/18/18, showed she has alterations in her physical mobility. Section Interventions showed, I want to (sic) licensed unit nurse to intervene when I decline to ambulate. I want them to investigate my reasons and resolve the core issue I identify and document as appropriate .Monitor/document/report to my MD as needed signs/symptoms of immobility . Review of resident #7's medical chart showed no nursing assessment was completed for the resident following the incident that occurred on 12/21/18, and the record failed to show the resident #7's right foot was caught under her wheelchair. No interventions were implemented for future prevention of similar events, to address pain, or the resident's safe transferring with staff members. b. After Surveyor Involvement, the following occurred: During an observation and interview on 12/26/18 at 2:46 p.m., staff member C was observed touching resident #7's right leg to lift the right foot pedal of the resident's wheelchair. Resident #7 screamed, Stop! Staff members D and [NAME] continued to prepare resident #7 for a transfer to her bed. Due to the resident's heightened pain complaints, with resident #7 observed yelling out in pain every time the staff members touched her right leg, Staff member C was asked if a nursing assessment should be done prior to resident #7 being transferred to her bed. Staff member C stated, Oh yes, and she approached resident #7 and began asking her questions about where her pain was. Resident #7 stated, to staff member C, pain was a six on a scale of one-to-ten. The resident was observed holding the middle portion of her right upper leg with both hands, and would not let go. Resident #7's right knee was swollen, and there was an old vertical scar observed. Resident #7 could not recall how her leg was injured, and stated, Moving it causes terrible pain. She left to notify the physician, which was now five days after the accident occurred. During an interview on 12/26/18 at 4:40 p.m., staff member B stated resident #7 had an X-ray completed of her right leg. Staff member B stated the portable X-ray tech arrived to do resident #7's x-rays and the facility was waiting for the x-rays to be read. Staff member B stated resident #7's doctor had requested that she be sent to the emergency room for further evaluation, and she had arranged for a transfer. During an interview on 12/27/18 at 9:51 a.m., staff member B stated she was made aware of the incident that occurred on 12/21/18 with resident #7 at 5:00 p.m. the previous day (12/26/18). She stated there was no nursing assessment completed for resident #7 following the incident on the 21st. Staff member B stated she was not aware that resident #7 had remained in bed for several days following the incident that occurred on 12/21/18. When asked if staff member G should have placed resident #7's foot pedals on her wheelchair prior to transporting her on 12/21/18, staff member B stated, I would have preferred it. Staff member B stated that all incidents involving residents in the facility should be documented. She stated nursing staff should complete a nursing note and document their assessments. She stated incidents are reviewed the following day by the IDT. Staff member B stated notifications of incidents should be reported to the doctor, the family, and she would, Prefer to be notified. c. Provider and Radiology During an interview on 12/27/18 at 10:25 a.m., staff member F stated resident #7 told her that she was having right knee pain on 12/25/18. She stated CNA's had informed her that the resident would not bear weight well, even while using a stand up lift. Staff member F stated she documented this information in resident #7's nursing progress notes. She stated she placed a copy of the note in the doctor communication book, and staff member S read and signed the note on 12/26/18. Staff member F stated she did not notify the doctor of her findings on 12/25/18; verbally. During an interview 12/27/18 at 12:27 p.m., staff member S stated she was at the facility on 12/26/18. Staff member S stated she signed the nursing progress note that was placed in the physician communication log for resident #7 (by staff member F). She stated she did not assess resident #7 while at the facility that day, and stated she had not assessed the resident in the last week. Review of resident #7's radiology report, dated 12/26/18, showed resident #7 was diagnosed with [REDACTED]. Findings showed, Comminuted periprosthetic [MEDICAL CONDITION] femur with half shaft width posterior displacement of the arthroplasty at the fracture line and posterior angulation approaching 90 degrees. Indications section of the report showed, Fall. During an interview on 12/27/18 at 1:58 p.m., NF1 stated resident #7 was admitted to the hospital and sustained a substantial fracture to her right femur. She stated, My mom is too fragile and would not be able to survive the surgery to fix her leg. She stated she and her family had made the decision to pursue hospice care for her mother due to this, and stated, We are going to take her off all of her meds. She's in so much pain. After this, all we want to do is keep her comfortable. She just wants to die. Refer to F600 for Neglect, F658 Professional Standards, and F697 Pain, related to this event.",2020-09-01
253,PARK PLACE TRANSITIONAL CARE AND REHABILITATION,275030,1500 32ND ST S,GREAT FALLS,MT,59405,2018-12-27,697,G,1,0,KV4V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility staff failed to sufficiently assess and provide timely and suitable interventions for a resident who had an unidentified leg fracture and the resident had a change in pain and comfort level, and staff were aware of the changes, which included increase in pain intensity, change of pain location, pain when touched, she refused to get out of bed for four days, and had a change in her transfer ability. The resident's care plan was not modified during this time period to address the pain and care related to it; and, staff did not adequately communicate the resident's ongoing pain and condition related to the pain, to ensure a comprehensive nursing assessment and ongoing monitoring occurred so the pain could be actively addressed timely with the provider, for 1 (#7) of 7 sampled residents. Findings include: a. Accident and initial assessment - Start of increased pain complaints During an interview on 12/27/18 at 8:52 a.m., staff member G stated she worked on 12/21/18. She stated around 1:00 p.m., she was asked to take resident #7 out of the dining room. Staff member G stated, I asked (resident #7) to lift up her legs. She stated when she went to move her wheelchair, resident #7 dropped her right leg, and it got caught under her wheelchair. Staff member G stated resident #7 screamed, Ouch! She stated, I grabbed her foot pedals. She stated, I lifted her left leg first, nothing. Then, I lifted her right leg and she screamed. Staff member G stated, I pushed resident #7 to the nurse's station. She stated the nurse on her wing was on break so she went to get staff member M. She stated she told staff member M exactly what happened. Staff member G said she reported that resident #7 was in extreme pain. Staff member G said that she observed staff member M looking at resident #7's right knee. She stated she was not sure if staff member M completed a nursing assessment and was not sure if staff member M gave resident #7 any pain medication. Staff member G stated staff member M told her to take resident #7 to her room and lay her down in her bed. She stated when she transferred resident #7, she Screamed and told me not to move her leg. Staff member G stated she reported the incident to staff member C around 2:00 p.m., and she reported the incident to the oncoming shift. During an interview on 12/27/18 at 9:24 a.m., staff member M stated she worked on 12/21/18. She stated staff member G, Came to get me. She came to my office panic stricken. Staff member M stated staff member G told her resident #7's right foot got caught underneath her wheelchair. She stated staff member G told her resident #7 yelled out in pain. Staff member M stated she completed an assessment of resident #7's right leg. She stated, There was no swelling in the right leg, or in her right knee. Staff member M stated, (Resident #7) told me the pain was in her right lower leg. She stated resident #7 said she wanted pain medication and she, Gave her a [MEDICATION NAME]. Staff member M stated she did not sign the MAR when she administered the medication. She stated, I signed out the medication in the NARC book. When asked if she should have signed the MAR, staff member M stated, Yes of course I am supposed to sign the MAR. Staff member M stated she did not document her assessment of resident #7's right leg, and stated, I am supposed to. She stated she gave staff member G permission to put resident #7 in her bed. She stated she did not hear resident #7 scream out in pain when she was transferred. Staff member M stated she reported the incident to staff member C when she returned from lunch. Staff member M stated she did not report the incident to resident #7's family or doctor. She stated she was not aware that resident #7 spent several days in bed following the incident. Staff member M stated, I have heard that (resident #7) has a femur fracture. She stated, (Staff member B) told me yesterday (12/26). Staff member M stated staff are supposed to be placing a resident's feet on the foot pedals of their wheelchairs before transporting them. The resident's injury/fracture was not identified after the accident and initial nursing assessment was done, and care continued with no changes to the resident's care plan. Review of resident #7's pain evaluation assessment, completed on 12/13/18, showed, resident #7 did not verbalize or exhibit non-verbal symptoms of pain. The evaluation was completed prior to the injury occurring. Review of resident #7's Medication Administration Record for (MONTH) (YEAR), showed resident #7's pain assessments were documented, on a scale of 0-10, as follows: -12/21/18- 0; Staff voiced resident had pain throughout day (content below) -12/22/18- 0; Staff voiced resident had pain throughout day (content below) -12/23/18- 0; Staff voiced resident had pain throughout day (content below) -12/24/18- 7; -12/25/18- 7; -12/26/18- 8. b. Staff awareness of pain During an observation and interview on 12/26/18 at 2:45 p.m., staff member [NAME] stated resident #7 had recently been complaining about pain in her right hip and leg. He stated resident #7 had difficulty transferring recently, and he reported both the pain and transferring issues to the nursing staff. During an interview on 12/26/18 at 8:10 p.m., staff member D stated he worked on 12/22/18 and 12/23/18 from 2 p.m. to 10 p.m. He stated resident #7 was in bed and remained in bed both days for the entirety of his shifts. Staff member D stated, She wouldn't get up. She complained of pain whenever she was repositioned. He stated he did not work on 12/24/18 or 12/25/18. Staff member D stated resident #7, Complained of a lot of pain today (12/26). During an interview on 12/26/18 at 8:15 p.m., staff member [NAME] stated resident #7 had been in bed the last three shifts he had worked. He stated resident #7 had, Complained of a lot of pain all three days. Staff member [NAME] stated he worked on 12/21/18, 12/24/18 and 12/25/18. He said he was not scheduled to work on 12/22/18 and 12/23/18. Staff member [NAME] stated he had to use the sit to stand hoyer lift for resident #7 on 12/25/18. He stated, She wouldn't bear weight, and I needed enough time to do peri care. During an interview on 12/26/18 at 8:30 p.m., staff member L stated she worked 6 p.m. to 6 a.m. on 12/21/18, 12/22/18, and 12/23/18. She stated that resident #7 remained in her bed the entirety of all three of her scheduled shifts. Staff member L stated, (Resident #7) was hollering with pain and did eventually take her meds. During an interview on 12/27/18 at 8:30 a.m., Staff member N said resident #7 complained of her body hurting more than usual during care. She stated resident #7 eventually agreed to the transfer and stated, Ow, ow, ow, during the transfer. Staff member N stated she then went to get another CNA to assist her. Staff member N said she did not report this information to the nurse. During an interview on 12/27/18 at 9:51 a.m., staff member B stated Whoever assessed the resident should have wrote an assessment. Staff member B stated, Pain assessments should be made and documented, if a PRN pain medication is given to a resident. She said when a PRN pain medication is administered, the computer system prompts staff to complete a pain assessment. Staff member B stated it is not an acceptable practice for a nurse to sign out a narcotic medication and administer it to a resident without signing the residents MAR. Staff member B stated she was not aware that resident #7 had remained in bed for several days following the incident that occurred on 12/21/18. During an interview on 12/27/18 at 10:25 a.m., staff member F stated resident #7 told her that she was having right knee pain on 12/25/18. She stated CNA's had informed her that the resident would not bear weight well, even while using a stand up lift. She stated she placed a copy of the note in the doctor communication book. Staff member F stated she did not notify the doctor of her findings on 12/25/18, which was now four days after the accident occurred. Review of resident #7's progress notes, dated 12/25/18, showed, Resident does complain of right knee pain. Knee has continuous selling, (sic) does not seem worse today. No redness or warmth to the area. CNAs report that resident does not bear weight well even with stand up lift. The note was signed by staff member S. Review of resident #7's Care Plan, last updated 12/18/18, showed she has alterations in her physical mobility. Section Interventions showed, I want to (sic) licensed unit nurse to intervene when I decline to ambulate. I want them to investigate my reasons and resolve the core issue I identify and document as appropriate .Monitor/document/report to my MD as needed signs/symptoms of immobility . c. Failure to identify root cause of pain increase and provide intervention. During an observation on 12/26/18 at 2:44 p.m., staff members [NAME] and D were observed trying to lift resident #7 from her wheelchair, and resident #7 yelled out Ouch, don't touch me! It hurts so bad! Staff member D removed a white towel from under the resident, even though the resident was voicing the pain when touched/moved. This surveyor had questioned why a towel was under the resident, and staff did not have knowledge of why the towel was placed on the chair. During an observation and interview on 12/26/18 at 2:46 p.m., staff member C entered resident #7's room. She stated she had not worked the last two days, and she was not aware that resident #7 had been complaining of right hip or leg pain. Staff member C instructed staff members D and [NAME] to transfer the resident to her bed. Staff member [NAME] was observed touching resident #7's right leg to lift the right foot pedal of the resident's wheelchair. Resident #7 screamed, Stop! Staff members D and [NAME] continued to prepare resident #7 for a transfer to her bed. Due to the resident's heightened pain complaints, with resident #7 observed yelling out in pain every time the staff members touched her right leg, Staff member C was asked if a nursing assessment should be done prior to resident #7 being transferred to her bed. Staff member C stated, Oh yes, and she approached resident #7 and began asking her questions about where her pain was. Resident #7 stated, to staff member C, pain was a six, on a scale of one-to-ten. The resident was observed holding the middle portion of her right upper leg with both hands, and would not let go. Resident #7's right knee was swollen, and there was an old vertical scar observed. Resident #7 could not recall how her leg was injured, and stated, Moving it causes terrible pain. Staff member C stated, Let me go call the doc. She exited resident #7's room at 3:03 p.m. During an observation on 12/26/18 at 3:07 p.m., staff member B was observed entering resident #7's bedroom. She began asking the resident questions about where her pain was, and what the source of the pain was. While completing a nursing assessment of the resident's right leg, staff member B placed her hands on the resident's right knee. Staff member B attempted to lift resident #7's pant leg up above her knee but was unable to, due to resident #7's complaints of pain. When staff member B attempted to move resident #7's right leg, resident #7 yelled out, It hurts so bad! Staff member B asked resident #7 if she would like medication to manage her pain. During an interview on 12/26/18 at 4:40 p.m., staff member B stated resident #7 had an X-ray completed of her right leg. Staff member B stated the portable X-ray tech arrived to do resident #7's x-rays and the facility was waiting for the x-rays to be read. She stated the technician who took the x-rays stated there appeared to be a right distal femur fracture. Staff member B stated resident #7's doctor had requested that she be sent to the emergency room for further evaluation, and she had arranged for a transfer. Staff member B stated the resident had been transferred from the bed, to the wheelchair, by the hoyer lift. During an interview 12/27/18 at 12:27 p.m., staff member S stated she was at the facility on 12/26/18. Staff member S stated she signed the nursing progress note that was placed in the physician communication log for resident #7 (by staff member F). She stated she did not assess resident #7 while at the facility that day, and stated she had not assessed the resident in the last week. Review of resident #7's radiology report, dated 12/26/18, showed resident #7 was diagnosed with [REDACTED]. Findings showed, Comminuted periprosthetic [MEDICAL CONDITION] femur with half shaft width posterior displacement of the arthroplasty at the fracture line and posterior angulation approaching 90 degrees. Indications section of the report showed, Fall. Review of resident #7's medical chart showed no nursing assessment was completed for the resident following the incident that occurred on 12/21/18, and the record failed to show the resident #7's right foot was caught under her wheelchair. No interventions were implemented for future prevention of similar events, to address pain, or the resident's transferring with staff. Review of resident #7's progress notes, dated 12/26/18, showed, Spoke with ER. Nurse stated res (sic) is going to be admitted to the hospital for a Tib and Fib (sic) fracture. No other information was given. During an interview on 12/27/18 at 1:58 p.m., NF1 stated resident #7 was admitted to the hospital and sustained a substantial fracture to her right femur. She stated the facility had called her the afternoon prior (12/26/18), to inform her that her mother was going to be sent to the emergency room for a suspected injury to her leg, but she had not had any communication with anyone from the facility since that time. NF1 stated she had spent her morning talking to several doctors at the hospital. She stated she was told that her mother's femoral fracture was, So severe that the bone was shattered. NF1 stated, The doctor's said that my mom is too fragile and would not be able to survive the surgery to fix her leg. She stated she and her family had made the decision to pursue hospice care for her mother due to this, and stated, We are going to take her off all of her meds. She's in so much pain. After this, all we want to do is keep her comfortable. She just wants to die. Review of the facilities Abuse and Neglect policy, revised (MONTH) (YEAR), showed, Neglect is defined as, The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Section Assessment and Recognition of the policy showed, 1. The nurse will assess the individual and document related findings. Assessment data will include: a. Injury assessment .b. Pain assessment .2. The nurse will report findings to the physician .",2020-09-01
254,MISSOULA HEALTH & REHABILITATION CENTER,275035,3018 RATTLESNAKE DR,MISSOULA,MT,59802,2017-03-23,164,E,0,1,ZSX511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain privacy in resident rooms, bathrooms and shower rooms for 17 of 25 rooms on two separate resident wings; and failed to provide privacy to 1 (#7) of 10 sampled residents while the resident was seated on a toilet, and while receiving care when the resident was lying in bed. Findings include: 1. Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation on 3/20/17 at 3:40 p.m., resident #7 was transferred to the common tub room in the south wing, via a sit-to-stand lift. The resident was lowered onto the toilet that sat adjacent to the room door. At 3:52 p.m., staff member J entered, then exited the tub room, and exposed the resident to the corridor while he was seated on the toilet. The tub room door was left ajar, and the resident could be visualized from the corridor. At 3:55 p.m., staff members J and L entered the tub room, exposing the resident to the corridor as he was seated on the toilet. Privacy was not provided for the resident. During an observation on 3/20/17 at 4:11 p.m., staff members J and L transferred the resident from the lift onto the bed in his room. Staff member J pulled the resident's privacy curtain to block the bedroom door, but the curtain was not long enough to extend around the bed. The resident's transfer was visible to his roommate, and privacy was not provided. During an interview on 3/20/17 at 4:13 p.m., staff members J and L stated the privacy curtain was not long enough to extend around the resident's bed. During an interview on 3/23/17 at 11:40 a.m., resident # 7 stated he was happy to know curtains had been installed to provide him privacy while seated on the toilet, and while laying in his bed. 2. During observations on 3/20/17 at 4:30 p.m., 25 resident rooms, bath rooms, and shower rooms, were inspected for privacy concerns. Eight of twenty five rooms did not have privacy curtains which could provide complete privacy in shared rooms. This was an issue in resident rooms 6, 9, 10, 12, and 14 on south wing, and 19, 23, and 24, on the north wing. Other rooms which did not have curtains installed around the shower area or toilet included: shower room on north wing, bath on north wing, and bath on south wing. During an interview on 3/21/17 at 8:30 a.m., staff member Q stated that he had discovered 17 rooms which did not have curtains around the beds for privacy, and an additional three rooms, which included shower rooms and toileting rooms which were without curtains to provide privacy. A review of the facility's Privacy policy, revised 9/2016, read, 4. During the delivery of care and services, staff remove residents from public view and provide clothing or draping to prevent unnecessary exposure of body parts.",2020-09-01
255,MISSOULA HEALTH & REHABILITATION CENTER,275035,3018 RATTLESNAKE DR,MISSOULA,MT,59802,2017-03-23,226,E,0,1,ZSX511,"Based on record review and interview, the facility failed to screen all employees prior to hire and direct patient care, by failing to complete timely backgrounds checks for staff. This had the potential to affect all residents. Findings included: Review of the following personnel files showed the background checks were not completed prior to the staff's date of hire: -Staff member H Date of hire: 3/14/15 Date of background check: 10/2/15 This staff member provided direct care for seven months prior to her back ground check. -Staff member L Date of hire: 4/4/16 Date of background check: 5/3/16 This staff member provided direct care for one month prior to her back ground check. -Staff member M Date of hire: 1/30/16 Date of background check: 5/9/16 This staff member provided direct care for four months prior to her back ground check. -Staff member O Date of hire: 4/11/16 Date of background check: 5/9/16 This staff member provided direct care for one month prior to her back ground check. During an interview on 3/23/17 at 9:00 a.m., staff member A stated the facility had issues with the human resource employee. She stated there had been a lot of turnover for that position. Record review of the facility's Abuse policy showed the following under the protection section: -The Center does not employ individuals who: (i) have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law.",2020-09-01
256,MISSOULA HEALTH & REHABILITATION CENTER,275035,3018 RATTLESNAKE DR,MISSOULA,MT,59802,2017-03-23,273,D,0,1,ZSX511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a comprehensive MDS assessment within 14 calendar days after admission for 1 (#8) out of 10 sampled residents. The findings include: Record review showed resident #8 was admitted to the facility on [DATE]. Review of resident #8's Admission MDS, with an ARD of 3/13/17, had a Z0500B date of 3/22/17. The facility did not complete the comprehensive assessment within the required timeline for the resident's admission to the facility. During an interview on 3/21/17 at 3:00 p.m., staff member W stated she did not have resident #8's MDS completed yet, but would work on it next. She stated the facility had started a new process for their MDSs last month and knew there would be some late MDSs assessments because she was still getting used to the new process.",2020-09-01
257,MISSOULA HEALTH & REHABILITATION CENTER,275035,3018 RATTLESNAKE DR,MISSOULA,MT,59802,2017-03-23,275,D,0,1,ZSX511,"Based on record review and interview, the facility failed to complete an Annual MDS assessment timely for 1 (#4) of 10 sampled residents. Findings included: Review of resident #4's Annual MDS had an ARD of 1/21/17, and a Z0500B date of 2/20/17. The ARD of the previous comprehensive assessment was dated 1/21/16. The assessment was not completed timely. During an interview on 3/21/17 at 3:00 p.m., staff member W stated the facility had started a new process for their MDSs in the last month and knew there would be some late MDSs assessments because she was still getting used to the new process.",2020-09-01
258,MISSOULA HEALTH & REHABILITATION CENTER,275035,3018 RATTLESNAKE DR,MISSOULA,MT,59802,2017-03-23,281,E,0,1,ZSX511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to document the efficacy for PRN pain, anxiety, and metered dose inhaler medications for 3 (#s 2, 3, and 7); and failed to administer a scheduled dose of [MEDICATION NAME] for 1 (#2) of 10 sampled residents. Findings include: 1. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #2's medication record reflected a physician's orders [REDACTED]. The administration record reflected the medication was scheduled to be given on 3/8/17. Recorded on the medication administration record for the date of 3/8/17, was a signature which showed the medication was given. Recorded on the medication administration record for the date of 3/12/17, was a signature which showed the medication was given. Each date reflected a different nurse's signature. During an interview on 3/20/17 at 9:30 a.m., staff member B stated the dose was given late on 3/12/17. Staff member B stated the dose that was signed as given on 3/8/17 was not given. Staff member B stated the resident had an additional as needed order for the [MEDICATION NAME]. Staff member B stated the as needed [MEDICATION NAME] could have been what was given on 3/8/17, instead of the long-acting scheduled dose of [MEDICATION NAME]. Staff member B stated she would investigate the error. On 3/24/17, a fax was received from the facility that reflected a medication error report had been completed. The report reflected the omission of the [MEDICATION NAME] injection on 3/8/17. The report reflected the physician was notified on 3/24/17 of the error. The report reflected corrective action taken was to; verify with Omnicare pharmacy which medications were sent, to discontinue the as needed [MEDICATION NAME] order, and remove it from the medication cart, and complete an AIMS assessment for the resident. 2. Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the resident's (MONTH) (YEAR) MAR showed orders for: - [MEDICATION NAME] 5mg - 325 mg, one tablet by mouth, as needed for pain, three times daily. Staff did not document efficacy, fifteen times. - [MEDICATION NAME] HFA, 2 puffs by mouth, every four hours as needed for shortness of breath. Staff did not document efficacy, twenty-one times. During an interview on 3/22/17 at 9:15 a.m., staff member H stated all PRN medications should have had efficacies documented on the MAR. 3. Resident #3 was admitted to the facility with hypertension, GERD, dementia, paranoid personality disorder, and [MEDICAL CONDITION]. Record review of resident #3's (MONTH) (YEAR) MAR showed the following medications were not documented: -3/19/17: Aspirin low dose, 81 mg tablet, delayed release, one time daily, for hypertension. -3/18/17: [MEDICATION NAME] 25 mg tablet, daily, for hypertension -3/18/17: [MEDICATION NAME] ER 25 mg tablet, extended release, daily, for hypertension -3/18/17 at 9:00 a.m.: [MEDICATION NAME] 500 mg tablet, delayed release, two times daily, for hostility -3/18/17 at 9:00 a.m.: [MEDICATION NAME] 5 mg tablet, two times daily, for hostility -3/2/17 & 3/3/17: Atrovastatin calcium F/C 10 gm tablet, daily, for [MEDICAL CONDITION] During an interview on 3/21/17 at 9:15 a.m., staff member B stated that she, and the medical records staff, both performed audits on the MARs and TARs. She stated she then educated the nursing staff to make sure to document medications. She stated her medical record staff had been filling in on shifts and she had been on vacation, so some audits may have been missed.",2020-09-01
259,MISSOULA HEALTH & REHABILITATION CENTER,275035,3018 RATTLESNAKE DR,MISSOULA,MT,59802,2017-03-23,315,D,0,1,ZSX511,"Based on observation, interview, and record review, the facility failed to provide appropriate care for a resident with a suprapubic catheter for 1 (#4) out of 10 sampled residents. Findings included: Review of resident #4's TAR, dated (MONTH) (YEAR), showed the resident was to have the following treatment, daily care of suprapubic insertion site: clean with NS and pat dry. Cover with smooth split gauze. However, documentation was not completed on three dates including the following: 3/14/17, 3/15/17, and 3/20/17. Review of resident #4's nursing notes did not show any documentation that the dressings were changed. During an observation on 3/21/17 at 2:45 p.m., staff member H provided catheter care to resident #4. Resident #4 told staff member H that her suprapubic dressing had not been changed yesterday (3/20/17). Staff member H replied to the resident, I see that. The resident stated the dressing was supposed to be changed every day. Staff member H removed the dressing, and applied a new dressing to the suprapubic site. During an interview on 3/21/17 at 2:45 p.m., staff member H stated the suprapubic dressing was supposed to be changed daily. Staff member H stated she did not know why it had not been changed yesterday (3/20/17).",2020-09-01
260,MISSOULA HEALTH & REHABILITATION CENTER,275035,3018 RATTLESNAKE DR,MISSOULA,MT,59802,2017-03-23,323,D,0,1,ZSX511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to administer medications, as ordered, with pureed textured food to 1 (#5) of 10 sampled residents with swallowing difficulties. Findings include: Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the facility's Therapy Communication to Nursing notes, dated 3/7/17, read, Take pills 1-2 at a time with yogurt/pudding. A review of Physician Telephone Orders, dated 3/7/17, and signed by the physician on 3/16/17, read, Take pills 1-2 at a time with pureed textures to increase bolus control. A review of the resident's (MONTH) (YEAR) MAR showed an order, which read, 3/7/17-Take pills 1-2 at a time with pureed textures to increase bolus control. The resident had orders for, and was administered: - Tylenol 325 mg, two tablets, by mouth, four times daily. - Vitamin D3, 1,000 units tablet, one tablet daily. - Fluoxetine 20 mg tablet, one time daily. - Lasix 40 mg tablet, one time daily. - Isosorbide mononitrate ER 30 mg tablet, one time daily. A review of the resident's Nutritional Status Interdisciplinary Care Plan, dated 3/6/17, read, 3/7/17 Administer meds per MD orders. During an observation on 3/22/17 at 8:47 a.m., staff member H administered six tablets, all at once to the resident, with approximately 4 ounces of water. During an interview on 3/22/17 at 9:00 a.m., staff member H stated she did not know there was an order for [REDACTED].",2020-09-01
261,MISSOULA HEALTH & REHABILITATION CENTER,275035,3018 RATTLESNAKE DR,MISSOULA,MT,59802,2017-03-23,441,H,0,1,ZSX511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to maintain an infection control program, which included: preventing, identifying, and controlling a communicable disease for all residents, staff, and family. The facility failed to utilize precautions correctly, notify family of the gastroenteritis, follow a policy and procedure in a timely manner, use proper hand hygiene, provide education to staff and residents, and prevent the spread of the infection through laundry. The failure affected 5 (#s 1, 4, 8, 9, and 11 ) out of 15 sampled and supplemental residents, but had the potential to affect everyone in the facility. The findings included: 1. Precautions Upon entry to the facility on [DATE] at 9:25 a.m., staff member A stated the facility had an outbreak of gastrointestinal and respiratory related concerns; nausea, vomiting, diarrhea, and coughing with and without a fever. She stated the staff were treating the gastrointestinal and respiratory symptoms with either contact, or droplet PPE precautions. The staff member stated the medical director, and the Infection Control consultant had advised not to test the residents. She stated there were no confirmed cases of influenza or Norovirus in the community. Staff member A stated the facility staff members were following precautions for those residents with gastrointestinal or respiratory symptoms to prevent the spread of symptoms. The facility did not test for the type of infection(s), in order to appropriately treat the infection(s). During an observation on 3/20/17 at 12:35 p.m., staff member G was delivering room trays. Staff member G entered resident #8's room with a lunch tray. The door had a droplet precaution sign on it. There was a cart with PPE outside the door of the resident's room. Staff member G entered the room with the room tray, and did not don PPE prior to entering the room. Staff member G left the room without washing or sanitizing her hands. During an observation on 3/20/17 at 12:45 p.m., staff member X entered resident #9's room. The door had a contact precaution sign on it. There was a cart with PPE outside the door of the adjacent room which was used by the staff member. The staff member donned a clean gown, but did not wash, or sanitize her hands, or don clean gloves prior to entering the resident's room. During an observation on 3/20/17 at 12:57 p.m., staff member X exited resident #9's room. The staff member walked up to the meal cart that contained meal trays, selected one, and went back into the resident's room. Staff member G entered the room with staff member X. Staff member G donned a clean gown, but did not wash, or sanitize her hands, or don gloves prior to entering the resident's room. During an observation and interview on 3/20/17 at 3:10 p.m., staff member J and staff member L walked into resident #4's room, which had a contact precaution sign on the door. The staff members did not put on masks, gloves, or a gown. They asked resident #4 if she would like to lay down. This surveyor asked if the room was no longer on contact precautions. The staff members stated no and walked out of the room and put on gloves. They did not put on a mask or a gown. The staff members did not follow the correct precautions. During an observation on 3/20/17 at 3:15 p.m., staff member G entered resident #4's room, which had a contact precautions sign on the door. Staff member G wore a mask and gloves, and no gown. She sat on the resident's bed, and painted her nails. The staff member did not follow the correct precautions. During an observation on 3/20/17 at 3:40 p.m., staff member L responded to a call light for residents #1 and #4. The door had a contact precaution sign on it. There was a cart with PPE outside the door of the resident's room. Staff member L entered the room, and did not don PPE. Staff member L quickly left the room without washing his hands. During an observation on 3/20/17 at 3:47 p.m., staff member G donned a gown and gloves, and entered resident #4's room. The door had a contact precaution sign on it. Staff member G sat on the resident's bed, and provided nail care. Proper precautions were not taken. During an interview on 3/21/17 at 8:45 a.m., staff member B stated they took residents off precautions after they were symptom free for 24 hours. During an interview on 3/22/17 at 12:15 p.m., staff member C stated The CDC states that precautions are not needed after 24 hours of no active symptoms. Review of the facility's Norovirus Prevention and Control policy showed the following during outbreaks, residents with Norovirus gastroenteritis are placed on Contact Precautions for a minimum of 48 hours after the resolution of symptoms. 2. Family notification During an observation and interview on 3/22/17 at 8:00 a.m., resident #11's family member was seated in his room, next to his bed, and held his hand. The family member did not have on gloves, a gown, or a mask. The room had a contact precautions sign on the door, related to recent nausea and vomiting from resident #11. Resident #11's family member then left the room to refill the resident's water pitcher. She stated she had not been informed about the recent gastroenteritis outbreak in the building. She stated that she had been sick the previous week with nausea, vomiting, and diarrhea for three days. A staff member took the water pitcher, refilled it, and gave it back to the family. She was then seen back in the resident's room without a gown, gloves, or a mask. During an interview on 3/22/17 at 12:15 p.m., staff member B stated resident #11's family member had been there the past two days. She did not know why the facility did not think to notify her about the resident's illness. Review of the facility's Norovirus Prevention and Control policy showed the following, If it is necessary to have continued visitor privileges during outbreaks, visitors with symptoms consistent with Norovirus infection are screened and excluded. All visitors comply with hand hygiene and Contact Precautions. 3. Hand hygiene During an interview on 3/21/17 at 8:45 a.m., staff member B stated that hand sanitizer was used by staff most of the time. She stated soap and water was not encouraged over hand sanitizer at any time. During an interview on 3/22/17 at 3:22 p.m., staff member J stated was not aware of any specific time to use hand soap instead of hand sanitizer, unless his hands were visibly soiled. Review of the facility's Norovirus Prevention and Control showed the following, during outbreaks, use soap and water for hand hygiene after providing care or having contact with residents suspected or confirmed with Norovirus gastroenteritis. Review of the facility's Help Prevent the Spread of Norovirus (Stomach Bug) educational handout from their infection control book, showed the following, wash your hands thoroughly with soap and water, hand sanitizers may not be effective against Norovirus. During an observation on 3/23/17 at 11:47 a.m., staff member Z wiped dining room tables with a wet towel. During an interview on 3/23/17 at 11:53 a.m., staff member Z stated the cleaner used for cleaning the dining room tables was regular table sanitizer, without bleach. 4. Staff education During an interview on 3/22/17 at 3:22 p.m., staff member J stated he was not aware of any specific time to use hand soap instead of hand sanitizer, unless his hands were visibly soiled. He stated he was sick last week with nausea, vomiting, and diarrhea. He worked the next day. 5. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #1 required total assist with all of her transfers, and activities of daily living. Resident #1 was under contact precautions for gastrointestinal symptoms. During an observation on 3/21/17 at 7:25 a.m., staff member U and V assisted the resident with dressing and perineal care. Staff member U sanitized her hands, and donned gloves. Staff member U provided perineal care, log rolled the resident, applied a clean brief, and pulled up the resident's pants. Staff member U then removed her gloves. Staff member U did not remove her gloves immediately after providing perineal care. Staff member V sanitized her hands, and donned gloves. Staff member V assist the resident with dressing, oral care, and transferring to her wheel chair from the bed. Staff member V removed her gloves, and did not sanitize her hands. During an interview on 3/21/17 at 7:40 a.m., staff member U stated she should have removed her gloves after completing the perineal care. Staff member V stated staff is taught to remove their gloves, and when working with body fluids to sanitize their hands. Staff member V stated staff was taught to sanitize when coming into a resident's room and to remove gloves, and sanitize when leaving the room. During an interview on 3/21/17 at 9:10 a.m., staff member B stated the facility staff used hand washing if hands were visibly soiled. Otherwise, staff used hand sanitizer. During an observation on 3/21/17 at 2:00 p.m., staff member V assisted resident #1 with a transfer from her wheelchair to her bed. Staff member V sanitized her hands, and donned gloves. Staff member V lowered the resident's pants, and removed her brief. Staff member V provided perineal care. Staff member V did not remove her gloves, and applied a clean brief. Staff member V continued to wear the contaminated gloves, and pulled up the resident's pants while log rolling her on the bed. Staff member V then removed her gloves, and sanitized her hands. Resident #1 was on contact precautions for a gastrointestinal illness. Staff member V left the resident's room without washing her hands. 6. Laundry During observations and interviews on 3/20/17 at 11:40 a.m., the laundry in the lower level of the facility was inspected. Staff member S was asked if the door between the soiled sorting room and the washing machine area was ever closed while sorting. She stated that she was not told to close the door. The door was being held open by a 5-gallon bucket of detergent. Also, the corridor door to the laundry room had a coat hung over the door preventing the door from closing and latching in case of an emergency. Staff member P removed the coat from the door and placed it on a pile of clean linen. He was instructed that personal clothing goes into lockers and not on clean linen. He again removed the coat and placed it in another room. During an observation on 3/20/17 at 2:30 p.m., the laundry room was again inspected. Red bags containing soiled linen were scattered on the floor directly in front of the handwash sink. The sink was not available for handwashing. The laundry chute was checked for proper latching. There were three red bags containing soiled laundry in the chute, which dumped out into a sink below. One of the bags had rips in the bag. The chute room on first floor was inspected. The room was small and a garbage can had been placed directly infront of the chute opening preventing the chute door from fully opening. The limited opening caused bags to be ripped when stuffed through the chute door. During an observation on 3/21/17 at 7:45 a.m., the laundry area was again inspected. The same coat was again placed over the corridor door to the laundry room. During an interview on 3/21/17 at 8:30 a.m., staff member Q stated that the door to the soiled sorting room would remain closed during sorting. He stated that all facility staff that work in laundry had been retrained on the afternoon of 3/20/17. He stated that the garbage can had been relocated in the chute room. 7. Activities During an interview on 3/23/17 at 9:30 a.m., staff member Y stated 25 residents, including #3, #5, and #6 had attended group activities on 3/17/17. She stated a Saint [NAME]'s Day party, and a musical activity, was held in the main dining area from 2:00 p.m. to approximately 4:30 p.m. A review of the facility's Activities Participation Form for (MONTH) (YEAR) showed residents #3, #5, #6, #12, #13, #15, and #16 attended the Saint [NAME]'s Day party on 3/17/17. A review of the facility's Skilled Nursing Room Roster showed: 3/15/17 - resident #1 had vomiting, diarrhea, and a fever. - resident #3 had respiratory symptoms. - resident #12 had diarrhea. - resident #13 had diarrhea. - resident #14 had nausea. These residents were having their symptoms and vital signs monitored. 3/16/17 - resident #7 had a fever. - resident #8 had a sore throat, and a fever. - resident #9 had diarrhea. - resident #13 still had diarrhea. - resident #14 still had nausea. These residents were having their symptoms and vital signs monitored. 3/18/17 - resident # 15 had nausea and diarrhea The residents was having his symptoms and vital signs monitored. 3/19/17 - resident # 14 had diarrhea The resident was having his symptoms and vital signs monitored. During an interview on 3/21/17 at 8:35 a.m., staff member B stated several residents had gastrointestinal complaints on 3/15/17. The staff member stated symptomatic residents should have been confined to their room, and staff should have been using PPE precautions when in contact. 8. Mechanical Lift use During an observation on 3/20/17 at 3:30 p.m., staff members J and L transfered resident #7 from his bed to his wheelchair using a sit-to-stand lift. The resident was taken to the Tub room on the south hall and lowered onto the toilet. The lift sling, and straps were left on the resident while he used the toilet. At 4:10 p.m., resident #7 was taken back to his room and transfered from his wheelchair back to his bed using the sit-to-stand lift. Staff member L wheeled the sit-to-stand lift from the south hall, and put it into a storage room on the north hall. The lift was not cleaned. During an interview on 3/20/17 at 4:16 p.m., staff member L stated the lifts were cleaned by the night shift staff. The staff member was not sure whom, or when the lifts were cleaned. A review of the facility's Standard Precautions policy, initiated 5/2015, read, 5. Resident-Care Equipment .b. Ensure that reusable equipment is not used for the care of another resident until it has been appropriatley cleaned and reprocessed and single use itmes are properly discareded. 9. Policy A policy was requested that the facility used for a gastroenteritis or Norovirus outbreak during the following times: -3/20/17 at 5:00 p.m. -3/22/17 at 5:35 p.m. During an interview on 3/21/17 at 8:45 a.m., staff member A stated she would provide the facility's Norovirus policy. During an interview on 3/21/17 at 12:15 p.m., staff member C stated the facility did not follow a policy for a gastroenteritis outbreak, but rather they called their infectious disease and control consultant. She stated she could ask the consultant to type a policy and procedure for the facility. During an interview on 3/22/17 at 5:09 p.m., NF1 stated he did not provide the facilities with policy and procedures, or the CDC guidelines. He stated his role as a consultant was to answer any questions the facility had over the phone. NF1 stated he had spoken to the facilty but did not remember exactly what was going on at the facility. During an interview on 3/23/17 at 7:55 a.m., staff member C stated NF1 never sent the policy and procedure for Norovirus outbreak. During an interview on 3/23/17 at 11:23 a.m., staff member C stated the facility's policy and procedure was on-line. She stated the facility did not print one off to follow, they looked at it on the computer. The facility did not follow any policy or procedure to help stop the spread of the infection in their facility.",2020-09-01
262,MISSOULA HEALTH & REHABILITATION CENTER,275035,3018 RATTLESNAKE DR,MISSOULA,MT,59802,2017-03-23,517,F,0,1,ZSX511,"Based on record review and interview, the facility failed to have detailed written plans to meet all potential emergencies and disasters. Specifically, the emergency plan did not have updated contact information for facility staff, regional management staff or outside agencies such as fire department, police department, backup water supply, etc. This had the potential to affect all residents, staff and visitors. Findings include: During record review on 3/20/17 at 3:30 p.m., the emergency disaster manual was reviewed for detailed contact information. The pages for facility contact information were blank. Also, the pages for local contact information for police, fire department, sewer, water, electrical, gas, heating, ventilation and air-conditioning (HVAC) were left blank. During interview on 3/23/17 at 8:30 a.m., staff member A stated that the manual was information put together by the corporation and that some of the information which could have been put together by the facility was missing or not finished.",2020-09-01
263,MISSOULA HEALTH & REHABILITATION CENTER,275035,3018 RATTLESNAKE DR,MISSOULA,MT,59802,2018-07-13,604,D,0,1,C0RL11,"Based on observation, interview, and record review, the facility failed to ensure residents were free from restraints, unless there had been a documented medical symptom, for 2 (#s 10 and 26) of 18 sampled residents. Findings include: 1. During an observation on 7/9/18 at 2:18 p.m., resident #10 had a lap buddy in place. During an interview on 7/11/18 at 12:05 p.m., staff member M stated resident #10 cannot take the lap buddy off on demand. During an interview on 7/13/18 at 3:25 p.m., staff member C stated resident #10 was blind and deaf, and the lap buddy was to keep her from leaning forward and falling out of her wheel chair. Staff member C stated the facility evaluated the ongoing need for the lap buddy at admission, quarterly, and when there was a change in condition. She stated the resident cannot see the lap buddy, and the staff would have to have shown her where it is. During an interview on 7/13/18 at 3:38 p.m., staff member B stated the lap buddy for resident #10 was to help with repositioning and prevent injury as the resident had poor safety awareness. Staff member B stated the resident had removed the lap buddy, but could not always remove it on demand. Review of resident #10's physician order, dated 5/23/17, showed the order for the lap buddy for patient safety. Review of a Device Evaluation form, dated 5/23/17, with no signature, showed dementia and falls as the medical condition or symptom for the lap buddy. The form did not show the benefits or reasons for the device. Review of resident #10's care plan for falls showed a lap buddy had been used. 2. During an observation on 7/9/18 at 2:26 p.m., resident #26 had a lap buddy in place. During an observation on 7/11/18 at 11:47 a.m., resident #26 had a lap buddy in place. During an interview on 7/11/18 at 12:03 p.m., staff member M stated resident #26 cannot remove the lap buddy. During an interview on 7/13/18 at 3:20 p.m., staff member C stated the medical symptoms for the lap buddy, for resident #26, were dementia, cognitive deterioration, hospice, and behavioral disturbances. During an interview on 7/13/18 at 3:38 p.m., staff member B stated the medical symptoms for the lap buddy, for resident #26, were positioning and safety. Staff member B stated resident #26 could not remove the lap buddy on demand. Review of resident #26's device evaluation, dated 5/9/18, showed the medical condition or symptoms for the lap buddy were impulsive disorder, decreased mobility, leans forward and worsening posture. The form showed the resident could not remove the lap buddy on request, therefore it was considered a restraint.",2020-09-01
264,MISSOULA HEALTH & REHABILITATION CENTER,275035,3018 RATTLESNAKE DR,MISSOULA,MT,59802,2018-07-13,623,D,0,1,C0RL11,"Based on interview and record review, the facility failed to provide a written notice of transfer for 1 (#31) of 18 sampled residents. Findings include: During an interview on 7/12/18 at 2:19 p.m., staff member I stated a written transfer notice could not be located in resident #31's medical record. Review of resident #31's nursing notes showed the following: -5/9/18; transferred to the hospital, from the physicians office, for a critical potassium level, -5/17/18; transferred to the hospital, from the facility, for a critical potassium level, -5/27/18; transferred to the hospital, from the facility, for weakness and inability to obtain an oxygen saturation.",2020-09-01
265,MISSOULA HEALTH & REHABILITATION CENTER,275035,3018 RATTLESNAKE DR,MISSOULA,MT,59802,2018-07-13,625,D,0,1,C0RL11,"Based on interview and record review, the facility failed to provide a written notice of bed hold for 1 (#31) of 18 sampled residents. Findings include: During an interview on 7/12/18 at 2:19 p.m., staff member I stated a written notice of bed hold could not be located in resident #31's medical record. Review of resident #31's nursing notes showed the following; -5/9/18; transferred to the hospital, from the physicians office, for a critical potassium level, -5/17/18; transferred to the hospital, from the facility, for a critical potassium level, -5/27/18; transferred to the hospital, from the facility, for weakness and inability to obtain an oxygen saturation.",2020-09-01
266,MISSOULA HEALTH & REHABILITATION CENTER,275035,3018 RATTLESNAKE DR,MISSOULA,MT,59802,2018-07-13,658,E,0,1,C0RL11,"Based on observation, record review and interview, the facility nursing staff failed to follow professional standards of practice when failing to document their own signatures when signing resident narcotics into the narcotic control book for 5 (#s 2, 4, 6, 31, and 33) of 18 sampled residents. Findings include: During an observation of the medication carts and narcotic log books, on 7/11/18 at 2:45 p.m., there were several narcotic sign in sheets in the narcotic log book that had no nursing signatures or only one signature of a licensed nurse was present, when two were required for checking the medication in. 1. Review of resident #2's narcotic log sheets showed resident #2 had two narcotic medications in which one licensed nurse signed the medications into the narcotic log book. 2. Review of resident #4's narcotic log sheets showed resident #4 had one narcotic medication in which there were no licensed nurse signatures in the narcotic log book for the medication. 3. Review of resident #6's narcotic log sheets showed resident #6 had one narcotic medication in which there were no licensed nurse signatures in the narcotic log book for the medication. 4. Review of resident #31's narcotic log sheets showed resident #31 had one narcotic medication in which there were no licensed nurses signature in the narcotic log book for the medication and one narcotic medication in which one licensed nurse signed the narcotic medication into the narcotic log book. 5. Review of resident #33's narcotic log sheets showed resident #33 had two narcotic medications in which there were no licensed nurses signatures in the narcotic log book for the medications. During an interview on 7/11/18 at 2:45 p.m., staff member N stated when the medications are delivered to the facility, two licensed nurses sign the medications in, check the delivery slip, and then each nurse signs their residents narcotic medication in on the narcotic log book by themselves.",2020-09-01
267,MISSOULA HEALTH & REHABILITATION CENTER,275035,3018 RATTLESNAKE DR,MISSOULA,MT,59802,2018-07-13,755,K,0,1,C0RL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility staff failed to ensure a malfunctioning refrigerator, which held resident medications, was monitored adequately to identify temperature concerns which had been ongoing, for the replacement or repair of the refrigerator, for stored and refrigerated medications. This failure involved medications for 12 (#s 3, 4, 6, 11, 12, 20, 22, 24, 26, 31, 33, and 35) of 24 sampled and supplemental residents, in which the medication efficacies were unable to be determined once the temperature of the refrigerator was out of range. This also had the potential to affect all other residents who received, or might receive, medications that were required to be stored in the medication refrigerator. On 7/12/18 at 5:13 p.m., the facility Director of Clinical Services, Executive Director and Director of Nursing Services were notified that an immediate jeopardy existed in the area of F755 for pharmacy services and F761 for storage of drugs and biologicals. The facility submitted an acceptable plan to remove the immediacy on 7/13/18 at 1:16 p.m. The severity and scope was identified at a level K. After the plan was accepted the severity and scope was reduced to an E. Findings include: During an observation on 7/11/18 at 3:00 p.m., the medication refrigerator had leaked water on the shelves below the freezer portion of the refrigerator where numerous resident insulin pens, insulin vials, vaccines, antibiotic wound wash, liquid anti-anxiety medications, eye drops, and the facility emergency e-kit were stored. The temperature of the medication refrigerator was documented at 32 degrees. These medications were required to be stored in the refrigerator at temperatures between 36 and 46 degrees. The medications in the refrigerator included: - Resident #3 had a 10 ml vial of Humalog insulin, and ten Humalog kwik pens, - Resident #4 had a 30 ml bottle of [MEDICATION NAME], - Resident #6 had one vial of [MEDICATION NAME] insulin, - Resident #11 had a 30 ml bottle of [MEDICATION NAME], - Resident #12 had a 30 ml bottle of [MEDICATION NAME], - Resident #20 had a 10 ml vial of [MEDICATION NAME] insulin, - Resident #22 had one Basaglar insulin kwik pen, - Resident #24 had a 30 ml bottle of [MEDICATION NAME], - Resident #26 had a 30 ml bottle of [MEDICATION NAME], - Resident #31 had a one liter bottle of Genta 80 mg/Neosp antibiotic wound wash, - Resident #33 had a 30 ml bottle of [MEDICATION NAME], - Resident #35 had a bottle of [MEDICATION NAME] 0.005% eye drops. Included in the medication refrigerator were four stock single dose vials of [MEDICAL CONDITION] vaccination, one stock bottle of influenza vaccination, eight Prevnar thirteen injections, one single dose [MEDICATION NAME] injection, and the facility e-kit. The facility e-kit contained two 10 ml vials of [MEDICATION NAME], two 10 ml vials of [MEDICATION NAME], a 2 mg vial of Alteplase, a 10 ml vial of [MEDICATION NAME], two vials of 2 mg/ml [MEDICATION NAME], one [MEDICATION NAME] 0.005% eye drops, one 10 ml vial of [MEDICATION NAME] N, four [MEDICATION NAME] 25 mg suppositories, two vials of Humalog, one vial of 10 ml [MEDICATION NAME] 70/30, one [MEDICATION NAME] 30 ml bottle, and one 10 ml vial of [MEDICATION NAME] insulin. A review of the manufacturers recommendations for the refrigerated medications showed the medications should have been stored between 36 and 46 degrees and the manufacturer was not able to account for the efficacy of the medications once the medications were stored out of the required temperature ranges. During an interview on 7/12/18 at 7:49 a.m., NF3 stated she could not attest to the efficacy of the medication stored in the refrigerator and would refer to the manufacturer's recommendations on the efficacy of the medications. Record review of the (MONTH) (YEAR) thru (MONTH) (YEAR) medication refrigerator temperatures showed the following: - In (MONTH) there were fifteen of thirty-one days the temperature of the medication refrigerator was not taken and/or was below 36 degrees. - In (MONTH) there were twenty-eight of twenty-eight days the temperature of the medication refrigerator had not been taken and/or had been below 36 degrees. - In (MONTH) there were twenty-seven of thirty-one days the temperature of the medication refrigerator had not been taken and/or had been below 36 degrees. - In (MONTH) there were nine of thirty days the temperature of the medication refrigerator had not been taken and/or had been below 36 degrees. -In (MONTH) there were twenty-five of thirty-one days the temperature of the medication refrigerator had not been taken and/or had been below 36 degrees. - In (MONTH) there were twenty-seven of thirty days the temperature of the medication refrigerator had not been taken and/or had been below 36 degrees. - In (MONTH) there were ten days out of 11 that the temperature of the medication refrigerator had not been taken and/or had been below 36 degrees. During an interview on 7/12/18 at 9:50 a.m., staff member B stated there were no maintenance work orders. She stated staff filled them out, the maintenance department fixed the problem and gave the work orders to her, she signed off on the work order, and then shredded them. Review of the policy for the consultant pharmacist, titled ORGANIZATIONAL ASPECTS IA2: CONSULTANT PHARMACIST SERVICES PROVIDER REQUIREMENTS, showed the following information under procedures: Section C. The consultant pharmacist agrees . 2) Evaluating the process of receiving and interpreting prescriber's orders; acquiring, receiving, storing . Section F . 3) Checking emergency medication supply at least monthly to ascertain that is is properly sealed and stored . Checking the medication storage areas routinely, and the medication carts routinely, for proper storage and labeling of medications . During an interview on 7/11/18 at 3:00 p.m., NF3 stated she did not check the mediation refrigerator temperatures when she comes to the facility. During an interview on 7/12/18 at 11:55 a.m., staff member [NAME] stated he had adjusted the temperature on the medication refrigerator on 7/9/18. He stated he was informed by one of the licensed staff members that the refrigerator had not been running right. He stated he turned the refrigerator down and did not return to check on the temperature of the medication refrigerator. During an interview on 7/13/18 at 11:57 a.m., staff member NF2 stated she was not sure if the improperly stored medications would affect the residents.",2020-09-01
268,MISSOULA HEALTH & REHABILITATION CENTER,275035,3018 RATTLESNAKE DR,MISSOULA,MT,59802,2018-07-13,761,K,0,1,C0RL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications that were required to be refrigerated were stored at the appropriate temperature for an extended period of time. This failure involved 12 (#s 3, 4, 6, 11, 12, 20, 22, 24, 26, 31, 33, and 35) of 24 sampled and supplemental residents, who had medications stored in the malfunctioning refrigerator, and all other residents who received or might receive medications that were required to be stored in the medication refrigerator. On 7/12/18 at 5:13 p.m., the facility Director of Clinical Services, Executive Director and Director of Nursing Services were notified that an immediate jeopardy existed in the area of F755 for pharmacy services and F761 for storage of drugs and biologicals. The facility submitted an acceptable plan to remove the immediacy on 7/13/18 at 1:16 p.m. The severity and scope was identified at a level K. After the plan was accepted the severity and scope was reduced to an E. Findings include: During an observation on 7/11/18 at 3:00 p.m., the medication refrigerator had leaked water on the shelves below the freezer portion of the refrigerator where numerous resident insulin pens, insulin vials, vaccines, antibiotic wound wash, liquid anti-anxiety medications, eye drops, and the emergency e-kit were stored. During an interview on 7/12/18 at 11:55 a.m., staff member [NAME] stated he had adjusted the temperature on the medication refrigerator on 7/9/18. He stated he was informed by one of the licensed staff members that the refrigerator had not been running right. He stated he turned the refrigerator down and did not return to check on the temperature of the medication refrigerator. Medications stored in the refrigerator included: - Resident #3 had a 10 ml vial of Humalog insulin, and ten Humalog kwik pens, - Resident #4 had a 30 ml bottle of [MEDICATION NAME], - Resident #6 one vial of [MEDICATION NAME] insulin, - Resident #11 had a 30 ml bottle of [MEDICATION NAME], - Resident #12 had a 30 ml bottle of [MEDICATION NAME], - Resident #20 had a 10 ml vial of [MEDICATION NAME] insulin, - Resident #22 had one Basaglar insulin kwik pen, - Resident #24 had a 30 ml bottle of [MEDICATION NAME], - Resident #26 had a 30 ml bottle of [MEDICATION NAME], - Resident #31 had a one liter bottle of Genta 80 mg/Neosp antibiotic wound wash, - Resident #33 had a 30 ml bottle of [MEDICATION NAME], - Resident #35 had a bottle of [MEDICATION NAME] 0.005% eye drops. Included in the medication refrigerator were four stock single dose vials of [MEDICAL CONDITION] vaccination, one stock bottle of influenza vaccination, eight Prevnar thirteen injections, one single dose [MEDICATION NAME] injection, and the facility e-kit. The facility ekit contained two 10 ml vials of [MEDICATION NAME], two 10 ml vials of [MEDICATION NAME], a 2 mg vial of Alteplase, a 10 ml vial of [MEDICATION NAME], two vials of 2 mg/ml [MEDICATION NAME], one [MEDICATION NAME] 0.005% eye drops, one 10 ml vial of [MEDICATION NAME] N, four [MEDICATION NAME] 25 mg suppository, two vials of Humalog, one vial of 10 ml [MEDICATION NAME] 70/30, one [MEDICATION NAME] 30 ml bottle, and one vial 10 ml vial of [MEDICATION NAME] insulin. The temperature of the medication refrigerator was documented at 32 degrees. These medications were required to be stored in the refrigerator at temperatures between 36 and 46 degrees. A review of the manufacturers recommendations for the refrigerated medications showed the medications should have been stored between 36 and 46 degrees and the manufacturer was unable to account for the efficacy of the medications once they had been stored out of the proper range. Record review of the (MONTH) (YEAR) thru (MONTH) (YEAR) medication refrigerator temperatures showed the following: - In (MONTH) there were fifteen of thirty-one days the temperature of the medication refrigerator was not taken and/or was below 36 degrees. - In (MONTH) there were twenty-eight of twenty-eight days the temperature of the medication refrigerator had not been taken and/or had been below 36 degrees. - In (MONTH) there were twenty-seven of thirty-one days the temperature of the medication refrigerator had not been taken and/or had been below 36 degrees. - In (MONTH) there were nine of thirty days the temperature of the medication refrigerator had not been taken and/or had been below 36 degrees. -In (MONTH) there were twenty-five of thirty-one days the temperature of the medication refrigerator had not been taken and/or had been below 36 degrees. - In (MONTH) there were twenty-seven of thirty days the temperature of the medication refrigerator had not been taken and/or had been below 36 degrees. - In (MONTH) there were ten days out of eleven that the temperature of the medication refrigerator had not been taken and/or had been below 36 degrees. A review of the temperature sheets showed the refrigerator temperatures should have been maintained between 36 and 46 degrees. During an interview on 7/12/18 at 7:15 a.m., staff member P stated she was not sure what temperature the medications should be stored at. She stated she assumed the medications should not freeze or go over 40 degrees. Staff member P had checked the refrigerator temperatures in the past. During an interview on 7/12/18 at 7:20 a.m., staff member D stated the medications should be stored at temperatures between 35 and 41 degrees. During an interview on 7/12/18 at 7:30 a.m., staff member O stated the temperatures should be above 32 degrees and not above 40 degrees. During an interview on 7/12/18 at 7:49 a.m., NF3 stated she could not attest to the efficacy of the medication stored in the refrigerator and would refer to the manufacturer's recommendations on the efficacy of the medications. During an interview on 7/12/18 at 8:35 a.m., staff member C stated if the temperatures in the medication refrigerator were out of range, the staff were to notify staff member E. Staff member C stated she conducted a random audit the week before survey and noticed one day when the temperature had been out of range and notified staff member E. Staff member C stated the night nurse checks the refrigerator temperatures. During an interview on 7/12/18 at 9:50 a.m., staff member B stated there were no maintenance work orders. She stated staff filled them out, the maintenance department fixed the problem and gave the work orders to her, she signed off on the work order, and then shredded them. During an interview on 7/12/18 at 4:27 p.m., NFI stated he was not aware the medication refrigerator temperatures had been out of the recommended range for (MONTH) through (MONTH) (YEAR). He stated this was unacceptable. He stated there should have been checks and balances in place to identify a problem like this with the temperatures. He stated he had been told the new refrigerator had been put in place but it did not address the months of inconsistencies. During an interview on 7/13/18 at 11:57 a.m., with NF2 she stated was not aware of the number of days the medication refrigerator temperatures had been out of the proper range for storing medications. She stated she did not know what the efficacy of the medications would be due to not being stored properly. During an interview on 7/13/18 at 2:49 p.m., staff member B stated the facility had not identified refrigerator temperatures as a problem.",2020-09-01
269,MISSOULA HEALTH & REHABILITATION CENTER,275035,3018 RATTLESNAKE DR,MISSOULA,MT,59802,2018-07-13,803,E,0,1,C0RL11,"Based on observation, interview, and record review, the facility failed to ensure standardized menus with standardized recipes were utilized by all staff in the kitchen when preparing pureed food. This deficiency may affect any resident receiving pureed meals from the facility. Findings include: During an observation and interview on 7/9/18 at 11:40 a.m., staff member G was preparing pureed enchiladas. She stated she used a little bit of water to make the pureed enchiladas. During an observation and interview on 7/10/18 at 8:05 a.m., staff member G was serving breakfast and stated she had used the gravy to puree the biscuits for breakfast. Review of the menu for lunch for 7/9/18 included cheese enchiladas and fiesta rice. Review of the facility recipe for cheese enchiladas showed prepare according to regular recipe, and the recipe for the rice showed use margarine and milk, prepare per recipe. Review of the menu for 7/10/18 showed biscuits and gravy for breakfast. During an interview on 7/9/18 at 12:48 p.m., staff member J stated the staff used hot water from the coffee machine to make the pureed foods. During an interview on 7/9/18 at 1:00 p.m., staff member Q stated the kitchen staff should not be using water to puree food items.",2020-09-01
270,MISSOULA HEALTH & REHABILITATION CENTER,275035,3018 RATTLESNAKE DR,MISSOULA,MT,59802,2018-07-13,812,E,0,1,C0RL11,"Based on observation, interview, and record review, the facility failed to ensure proper food storage in the kitchen, and for the food in the freezer. There were several boxes of frozen food items opened, not sealed, and not labeled with an open date. The deficient practice may affect all of the residents who received services from the kitchen. Findings include: During an observation of the kitchen freezers on 7/11/18 at 7:40 a.m., there was one box of pork steak fritters, opened, not sealed, and not dated; one box opened, not sealed, and not dated hamburger patties; one box opened, not sealed, and not dated cinnamon rolls, and one box french bread stick dough opened, not sealed and not dated. During an interview on 7/11/18 at 7:50 a.m., staff member Q stated she would get the frozen food items taken care of right away. Review of the facility policy for storage areas showed food was to be labeled and dated with the month and the year.",2020-09-01
271,MISSOULA HEALTH & REHABILITATION CENTER,275035,3018 RATTLESNAKE DR,MISSOULA,MT,59802,2018-07-13,835,E,0,1,C0RL11,"Based on observation, interview, and record review, the facility failed to provide adequate oversight for the monitoring of medication storage. The facility failed to monitor equipment to ensure it was in the proper working condition to maintain medications in an acceptable temperature range. The facility failed to educate the licensed staff for the monitoring of refrigerator temperatures. The medication storage refrigerator contained multiple medications that required temperatures between 36 and 46 degrees Fahrenheit. This failure involved the medications of 12 (#s 3, 4, 6, 11, 12, 20, 22, 24, 26, 31, 33, and 35) of 24 sampled and supplemental residents, and all other residents who received or might have received medications that were required to be stored in the medication refrigerator. Findings include: During an observation on 7/11/18 at 3:00 p.m., the medication refrigerator had leaked water on the shelves below the freezer portion of the refrigerator where medications were being stored for resident #s 3, 4, 6, 11, 12, 20, 22, 24, 26, 31, 33, and 35. The temperature of the medication refrigerator was documented at 32 degrees. These medications were required to be stored in the refrigerator at temperatures between 36 and 46 degrees. Refer to tags F755 and F761 for more detail on the deficient practices. A review of the manufacturers recommendations for the refrigerated medications showed the medications should have been stored between 36 and 46 degrees and the manufacturer could not guarantee the efficacy of the medications once they had been stored out of the proper range. During an interview on 7/11/18 at 3:00 p.m., NF3 stated she did not check the mediation refrigerator temperatures when she comes to the facility. During an interview on 7/12/18 at 7:49 a.m., NF3 stated she could not attest to the efficacy of the medication stored in the refrigerator and would refer to the manufacturer's recommendations on the efficacy of the medications. During an interview on 7/13/18 at 2:49 p.m., staff member B stated the facility had not identified refrigerator temperatures as a problem. Staff member B stated the facility had not identified the need for staff education for monitoring refrigerator temperatures. Staff member B stated the facility used a prioritization tool for identifying which concerns to address.",2020-09-01
272,MISSOULA HEALTH & REHABILITATION CENTER,275035,3018 RATTLESNAKE DR,MISSOULA,MT,59802,2018-07-13,842,E,0,1,C0RL11,"Based on observation and interview, the facility failed to safeguard medical records against loss, destruction, or unauthorized use. This had the potential to affect all residents who have medical records stored in the medical records storage room. Findings include: During an observation of the medical record storage room on 7/11/18 at 8:20 a.m., there was no door to the medical records storage room. The exit door, located at the end of the hall, was not locked. There were over 60 boxes of medical records in the medical records storage room. During an interview on 7/11/18 at 8:20 a.m., staff member K stated she did not know where the door to the medical records storage room was. She stated the exit door is unlocked during the daytime and locked after five p.m. During an interview on 7/11/18 at 8:30 a.m., staff member [NAME] stated the door to the medical records storage had been off for at least three and a half years. He stated the door for the medical records storage was in the maintenance shop. Staff member [NAME] stated the exit door was unlocked during the day and locked after five p.m.",2020-09-01
273,MISSOULA HEALTH & REHABILITATION CENTER,275035,3018 RATTLESNAKE DR,MISSOULA,MT,59802,2018-07-13,865,E,0,1,C0RL11,"Based on observation, interview, and record review, the facility Quality Assurance and Performance Improvement program failed to identify an ongoing quality deficient practice relating to the timely identification and correction of a malfunctioning refrigerator which was not maintaining adequate temperature ranges for an extended period of time, and the refrigerator was used for medication storage; and, failed to identify educational needs for the nursing staff relating to the documentation and monitoring of medication storage, and the safety of medications for 12 (#s 3, 4, 6, 11, 12, 20, 22, 24, 26, 31, 33, and 35) of 24 sampled and supplemental residents. This failure may have affected or potentially may have affected any resident who had medications stored in the refrigerator during the period of time where temperatures were not maintained adequately. Findings include: During an observation on 7/11/18 at 3:00 p.m., the medication refrigerator had leaked water on the shelves below the freezer portion of the refrigerator, compromising the integrity of the medication for numerous residents. Medications included: insulin pens, insulin vials, vaccines, antibiotic wound wash, liquid anti-anxiety medications, eye drops, and the emergency ekit were stored in the refrigerator. The temperature of the medication refrigerator was documented at 32 degrees. The medications stored in the refrigerator were not monitored, and QAPI had not identified the concern for correction. These medications were required to be stored in the refrigerator at temperatures between 36 and 46 degrees. Medications identified and stored in the refrigerator were for resident #s 3, 4, 6, 11,12, 20, 22, 24, 26, 31, 33, and 35. Refer to tags F755 and F761 for further detail on the deficient practices related to the malfunctioning refrigerator. During an interview on 7/12/18 at 4:27 p.m., NFI stated he was not aware the medication refrigerator temperatures had been out of the recommended range for (MONTH) through (MONTH) (YEAR). He stated this was unacceptable. He stated there should have been checks and balances in place to identify a problem like this with the temperatures. He stated he had been told the new refrigerator had been put in place but it did not address the months of inconsistencies. During an interview on 7/13/18 at 11:57 a.m., with NF2 she stated was not aware of the number of days the medication refrigerator temperatures had been out of the proper range for storing medications. Record review of the (MONTH) (YEAR) thru (MONTH) (YEAR) medication refrigerator temperature logs showed almost all opportunities for documentation, for all of the months, were either documented as out of range of the required temperatures, or the temperatures were not recorded at all. During an interview on 7/13/18 at 2:49 p.m., staff member B stated the facility conducts mock surveys, however had not identified refrigerator temperatures as a problem. Staff member B stated the QAPI committee meets monthly, but no less than quarterly. Staff member B stated the committee decides to work on issues by using a QAPI Prioritization Tool.",2020-09-01
274,MISSOULA HEALTH & REHABILITATION CENTER,275035,3018 RATTLESNAKE DR,MISSOULA,MT,59802,2018-07-13,908,E,0,1,C0RL11,"Based on observation, record review, and interview, the facility failed to ensure the medication refrigerator that held residents' medication, was maintained, and in working condition for 12 (#s 3, 4, 6, 11, 12, 20, 22, 24, 26, 31, 33, and 35) of 24 sampled and supplemental residents, and all other residents who received or might receive medications that were required to be stored in the medication refrigerator. Findings include: During an observation on 7/11/18 at 3:00 p.m., the medication refrigerator had leaked water on the shelves below the freezer portion of the refrigerator where numerous resident medications were stored. The temperature of the medication refrigerator was documented at 32 degrees. These medications were required to be stored in the refrigerator at temperatures between 36 and 46 degrees. During an interview on 7/12/18 at 11:55 a.m., staff member [NAME] stated he had adjusted the refrigerator on 7/9/18. He stated he was informed by one of the licensed staff members that the refrigerator was not running right. He stated he turned it down and did not return to check on the temperature of the refrigerator. Record review of the (MONTH) (YEAR) thru (MONTH) (YEAR) refrigerator temperatures showed there were one to twenty-eight days the temperatures were not recorded and/or were below 36 degrees.",2020-09-01
275,LIBBY CARE CENTER,275040,308 E THIRD ST,LIBBY,MT,59923,2017-06-15,253,D,0,1,ILXD11,"Based on observation, interview, and record review, the facility failed to clean and maintain a sanitary room and bathroom for 1 (#16) of 19 sampled and supplemental residents. Findings include: 1. During an observation on 6/13/17 at 1:30 p.m., resident room 103 was inspected. The floor was found to be sticky, with hair stuck to the floor. The room smelled of urine. The shared bathroom between rooms 103 and 104 was also inspected. The flooring in the bathroom was found to be broken, cracked, and large chunks of the flooring was missing, creating an uncleanable surface around the toilet. Review of the facility 5-Step Daily Patient Room Cleaning regimen reflected the room was to be dust mopped, damp mopped, and disinfected, daily. During an interview on 6/14/17 at 3:00 p.m., staff member [NAME] stated room 103 was an ongoing issue. He stated it was difficult to get the resident to leave the room for any length of time. Staff member [NAME] stated the floor needed to be stripped and waxed, and that would mean the resident needed to be out of the room for a couple days. In an interview on 6/15/17 at 9:50 a.m., resident #16 stated that he would be open to leaving the room for a couple days. He stated his biggest concern was his TV not coming back on. When the bathroom floor was mentioned as a concern, the facility brought in a contractor to put new floor covering in the bathroom.",2020-09-01
276,LIBBY CARE CENTER,275040,308 E THIRD ST,LIBBY,MT,59923,2017-06-15,279,D,0,1,ILXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to develop a comprehensive plan of care, including the presence and treatment of [REDACTED].#9) of 15 sampled residents. Findings include: 1. Resident # 9 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of resident #9's Admit MDS, with an ARD of 4/18/17, showed the presence of three unstageable pressure ulcers on admission. An observation on 6/12/17 at 1:45 p.m. showed one unstageable ulcer to the resident's left foot. Review of resident #9's care plan, showed a problem of risk for skin breakdown, but lacked indication of the existing three ulcers or the plan of treatment for [REDACTED]. During an interview on 6/13/17 at 10:55 a.m., staff member C stated the current ulcer to resident #9's left foot was present on admission and should have been included on the care plan. She stated the usual care plan nurse was not working at the present time and another nurse was covering. During an interview and record review on 6/15/17 at 11:15 a.m., staff member C stated resident #9's care plan had been updated and a copy of the change was provided. The care plan showed an update to the skin at risk problem area, a new problem area for the existing ulcer with treatment plan, and a history showing the resolved ulcers.",2020-09-01
277,LIBBY CARE CENTER,275040,308 E THIRD ST,LIBBY,MT,59923,2017-06-15,309,G,1,1,ILXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to provide consistent pain management following a pathological [MEDICAL CONDITION] for 1 (#1), and provide consistent bowel management for 2 (#2 and 4) of 15 sampled residents. Findings include: 1. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of resident #1's nurses note, dated 6/1/17 and a radiology report dated 6/1/17, reflected an incident where the resident suffered a possible pathological [MEDICAL CONDITION], the night of 5/31/17. Review of resident #1's nursing note, dated 6/1/17 at 2:30 a.m., reflected the resident had left hip pain, and was given PRN pain medication with no effect. She was repositioned and massaged with no effect. There was no redness or bruising at the area of complaint. Review of resident #1's nursing note, dated 6/1/17 at 10:30 a.m., reflected the resident had complained of left sided hip and back pain in the morning. The nurse assessed the area, noting there was no bruising. The nurse wrote that the resident did not fall. She gave the resident another PRN pain pill as the resident requested before going to breakfast. The note reflected the resident was able to bear weight comfortably with assist of one and was transferred to the wheelchair. The resident ambulated herself in the wheelchair to the dining room and ate breakfast. It was at this time the family came to the facility and told the nurse the resident called them at 6:30 a.m. complaining of pain. The nurse called the doctor and awaited instructions. The family became frustrated of the time it was taking to get a return call from the doctor. At 10:30 a.m., the family decided to take the resident to the ER for an X-ray. The X-rays were inconclusive for [MEDICAL CONDITION], femur, or lumbar spine. Following a complaint by the family of the facility failing to treat resident #1's pain, the facility, on 6/2/17, initiated an investigation and plan of correction. Review of witness statements from the investigation reflected the nurse, working the night of the incident, stated that resident #1 was complaining of having Charlie horse type cramps in her left hip area while sitting on the commode around 11:00 p.m. on 5/31/17. The nurse assessed the resident, as was written in the nursing note on 5/31/17 at 2:30 a.m. The resident was assisted back to bed. The nurse placed pillows from the resident's shoulder to the lumbar area of the resident's back, to alleviate pressure on the left side. The resident still had complaints of pain one hour afterward. The nurse stated she massaged the resident's hip area per the resident's request. There were no other time tables mentioned in the witness statement. In a timeline of events provided by the facility, the initial pain medication was given at 11:00 p.m. on 5/31/17. This was confirmed by the narcotic count book. Incidentally, the wrong date was written for this administration of narcotic. It was written as 6/1/17 at 11:00 p.m., not 5/31/17. During an interview on 6/13/17 at 10:45 a.m., staff member D stated the date written in the narcotic book was a mistake. Review of the Medication Administration Record [REDACTED]. During an interview, on 6/13/17 at 10:45 a.m., staff member D stated the med aides were responsible for change over of the Medication Administration Record, [REDACTED] Review of the timeline provided by the facility, reflected at 12:00 a.m. the resident was reassessed by the nurse. The area was massaged, and pillows placed for comfort. On 6/1/17 at 2:30 a.m., the resident requested more pain medication. The nurse told the resident she could not give any more because it had not been six hours since the last dose. Other staff reported the resident was initially uncomfortable at rest, and pain was more significant during routine incontinence care and repositioning. Record review showed a fax was sent to the doctor sometime between 2:30 a.m. and 6:00 a.m. on 6/1/17. The fax was not marked with the time it was sent. The fax reflected the same information as the nursing note on 6/1/17 at 2:30 a.m., but showed the resident stated she related her pain to feeling as if something was broken. During an interview, on 6/13/17 at 3:25 p.m., staff member D stated the resident told her it felt like it was broken, at the end of her shift, before she sent the fax to the doctor. During an interview, on 6/13/17 at 3:10 p.m., staff member C stated the resident should not have been left in pain, it shouldn't have happened. The staff member stated the other administrative nurses agreed staff member D should have called the doctor at 2:30 a.m. 2. Review of resident #2's Skilled Daily Nurses Notes, dated 4/6/17, showed the resident was placed on comfort care, and had [DIAGNOSES REDACTED]. The resident was discharged to a local hospital on [DATE], and was readmitted [DATE]. Review of the resident's Admit MDS, with an ARD of 4/16/17, showed the resident was cognitively impaired and unable to make her needs known. The resident required extensive assist with toileting and cares. Review of the resident's Skilled Daily Nurses Notes, dated 4/8/17, showed the resident was unable to make her needs known, and the resident had stool digitally removed from rectum, anxiety restlessness, PRN [MEDICATION NAME] and [MEDICATION NAME] given. There was no documentation on the follow up on the removal of the stool. Review of resident #2's Order Summary Report, dated 1/1/17 - 5/31/17, showed the resident had orders, dated 4/8/17, [MEDICATION NAME], 0.125 ml up to 1 ml every 1 hour as needed for pain. The resident had orders for laxative of choice qd PRN for constipation as a standing order, dated 4/3/17. Review of the facility's BM Communication Log, (MONTH) (YEAR), and the CNA - ADL Tracking form, dated 3/17, showed the resident did not have a bowel movement documented from 3/27/17 until she went to the hospital on [DATE]. Review of the facility's BM Communication Log, (MONTH) (YEAR), and the CNA - ADL Tracking form, dated 4/17, showed the resident did not have a bowel movement documented 4/23/17 until 4/28/17. Review of the facility's BM Communication Log, (MONTH) (YEAR) and (MONTH) (YEAR), and the CNA - ADL Tracking form, dated (MONTH) (YEAR) and (MONTH) (YEAR), showed the resident did not have a bowel movement documented from 5/26/17 until 6/9/17. Review of resident #2's MAR, dated 3/1/17 - 3/31/17 and 4/1/17 - 4/30/17, showed the resident had a physician prn order, dated 3/11/17, for [MEDICATION NAME] capsule 100 mg, two capsules, two times a day. Documentation showed the resident recieved the medication 32 out of 47 opportunities. The order was discontinued on 4/7/17. Review of resident #2's MAR, dated 3/1/17 - 3/31/17, 4/1/17 - 4/30/17, and 5/1/17 - 5/31/17, showed: - An order, dated 3/21/17, for [MEDICATION NAME], 5 mg, 1-2 tablets if no bowel movement in two days. - An order, dated 3/21/17 for [MEDICATION NAME], 17 gm, dissolved in 4/8 oz. of water, by mouth, if no bowel movement in three days. - If the resident had no bowel movement on the fourth day, a suppository, as needed, had been ordered, on 3/27/17, related to constipation. Review of resident #2's MAR, dated 3/1/17 - 3/31/17, showed a nurse had signed off for giving resident #2 a laxative of choice, PRN, for constipation, on 3/15/17. There was no other documentation showing the resident had received any of the ordered PRN medications in March, April, or (MONTH) (YEAR). Review of resident #2's care plan, with a date of 6/29/16, showed the problem of the resident's decreased fluid or PO intake. Approaches and interventions included to encourage fluid intake at meal times and between meals. Comfort measures included offering fluids as tolerated. Constipation concerns were identified as a problem under weight loss but there was no documentation showing approaches and interventions the facility staff should use. Review of resident #2's physician visit, dated 5/1/17, showed the resident was getting more forgetful, and less obsessed with her bowel movements than she had been. During an interview on 6/14/17 at 9:06 a.m., staff member A stated if a resident had no bowel movement in three days, she would give a laxative. The staff member stated she was made aware of a resident's bowel movements by looking at the BM sheets at the nurse station. The staff member also stated she would ask the resident if he/she had a bowel movement. During an interview on 6/14/17 at 9:53 a.m., staff member B stated she would give a resident a suppository if he/she had not had a bowel movement in three days. The staff member stated she reviewed the CNAs' BM charting, daily. 3. Review of resident #4's medical records showed the resident had a [DIAGNOSES REDACTED]. Review of the facility's BM Communication Log, (MONTH) (YEAR), and the CNA - ADL Tracking form, dated (MONTH) (YEAR), showed the resident did not have a bowel movement documented from 3/8/17 until 3/11/17. Review of the facility's BM Communication Log, (MONTH) (YEAR), and the CNA - ADL Tracking form, dated (MONTH) (YEAR), showed the resident did not have a bowel movement documented 4/5/17 until 4/8/17. There was no documentation of a concern with the resident not having regular bowel movements. Review of resident #4's physician progress notes [REDACTED]. The physician's assessment showed slow transit constipation. The treatment included: - Increase the resident's dose of [MEDICATION NAME] to 15 ml, twice a day. - Ordered an enema 7-19 GW118 ml, as directed, as needed for not having a BM in three days. - [MEDICATION NAME] powder, 48.57 percent, one dose daily. - Increase in Senna S tablet to 8.6-50 mg, two tablets, every eight hours as needed for no BM times one day. Review of the facility's BM Communication Log, dated (MONTH) (YEAR) and the CNA - ADL Tracking form, dated (MONTH) (YEAR), and (MONTH) (YEAR), showed the resident did not have a bowel movement documented from 5/7/17 until 5/12/17 and from 5/22/17 until 5/29/17. Review of the facility's CNA - ADL Tracking form, dated 6/17, showed the resident did not have a bowel movement documented from 6/1/17 until 6/13/17. The BM Communication Logs, and the CNA - ADL Tracking forms, for resident #4, were inconsistent. During an interview, on 6/14/17 at 10:30 a.m., NF1 stated the resident had a bowel problem. The physician had increased the resident's order for a laxative daily. NF1 stated she kept the resident's BM marked on a calendar, in the resident's room, and told the CNAs to mark when the resident had a BM. NF1 stated she would go tell the nurses if the resident hadn't had a BM for a while and then they give him something. Review of the Policies and Procedures form, with a subject of Bowel Movement Assessment, and an effective date of 11/30/14, showed the policy provided a format to use as a working tool to record and monitor each resident's bowel movement to prevent impactions. The procedure was for the CNAs to fill out the Bowel Movement Worksheet or the ADL sheet each shift, for each resident. The sheets were to remain at the nursing desk. The CNAs were directed not to leave a blank space and to mark either the size of the BM or that no BM occurred. When a suppository or enema was given, the nurse was to mark the space for the resident. The Nurse was to check the BM worksheet or the ADL sheet for the date of the resident's last BM and identify the need for additional interventions. If the resident does not have a BM by the third day, the nurse would give a laxative or suppository, depending upon the circumstances and physician orders.",2020-09-01
278,LIBBY CARE CENTER,275040,308 E THIRD ST,LIBBY,MT,59923,2017-06-15,323,E,0,1,ILXD11,"Based on observation, record review, and interview, the facility failed to properly and safely store potentially harmful chemicals in 1 of 2 two shower rooms in the facility. The special care unit of the facility was currently closed due to a broken water pipe. All the memory care residents were moved out of the unit and were placed in rooms throughout the facility, some near the shower room next to the south nurses' station. An unsecured door with with harmful chemicals poses a risk to these residents. Findings include: 1. During an observation on 6/14/17 at 10:30 a.m., the shower room near the south nurses' station was inspected. The door to the room was found to not be latched. It would not latch after being exercised three times. Inside the room there was a cabinet mounted to the wall for storage of chemicals, lotions, and soaps. The cabinet was unlocked, and the doors were open. In the shower area, next to a large bottle of body soap, there was a spray bottle of Quat disinfectant. Review of the facility policy on storage and handling of hazardous material reflected directive of never leaving containers of cleaning chemicals unattended and other hazardous materials unattended. The material safety data sheet for Quat disinfectant showed it was harmful if swallowed, harmful in contact with skin, and could cause serious eye damage. In an interview on 6/14/17 at 3:00 p.m., staff member F stated the door would be an easy fix, and he would get a new lock on the cabinet, in the shower room, immediately. He stated he would tell the housekeeping manager about the disinfectant being left out.",2020-09-01
279,LIBBY CARE CENTER,275040,308 E THIRD ST,LIBBY,MT,59923,2017-06-15,332,D,0,1,ILXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that medication error rates are less than 5%. 3 (#s 10, 18, and 19) of 19 sampled and supplemental residents were noted to be effected by the deficient practice. Findings include: 1. During an observation and interview on 6/13/17 at 8:20 a.m., staff member G was preparing medication for administration to resident #10. The MAR indicated [REDACTED]. After searching again in the cart, she stated she did not have the correct dose and would give the dose available and contact the doctor later. She prepared and administered the medication to resident #10. Review of resident #10's (physician's) Order Summary Report, with an MD signature date of 5/4/17, showed an order for [REDACTED].>During an interview on 6/13/17 at 10:55 a.m., staff member C stated that staff member H orders stock medications and if a medication was not available in the dose ordered, she would go out and purchase it locally. Staff member C also stated that if the medication was not available in the dose ordered, the nurse should contact the MD to ask if the alternate dose is acceptable. During an interview on 6/14/17 at 4:55 p.m., staff member C stated the correct dose of Oystercal-D was available in central supply and she did not know why the nurse had not checked there. 2. During an observation on 6/14/17 at 7:30 a.m., in the room of resident #18, staff member A handed the resident a medicated inhaler, Breo Ellipta, for him to use as she observed. The resident completed the administration, and staff member A gave resident #18 his pills and a drink of water. Staff member A did not instruct the resident to rinse his mouth following use of the inhaler. Review of the manufacturer's instructions indicate that following inhalation of Breo Ellipta, the user should rinse the mouth and spit out the water to prevent a potential adverse effect of the medication. During an interview on 6/14/17 at 11:27 a.m., staff member A stated resident #18 should have been instructed to rinse his mouth after use of the inhaler. She stated she may have forgotten due to being nervous. An email from NF2 to staff member C, dated 6/14/17, provided by staff member C, was reviewed. The email showed NF2, a pharmacy consultant, informed staff member C that the mouth should be rinsed after use of steroid inhalers, such as Breo Ellipta. 3. During an observation and interview on 6/13/17 at 12:40 p.m., staff member G prepared medication for administration to resident #19. One of the medications was [MEDICATION NAME] 0.5/2.5mg in 3ml solution, to be given four times a day, inhaled through a nebulizer machine. Staff member G picked up the nebulizer mouthpiece, with an attached medication reservoir cup, and stated the morning dose of the medication was still in the cup. She advised the resident to use the medication and left the room with the unused dose. Staff member G stated the resident usually takes the inhaled medication after breakfast but sometimes forgets and the staff check on him to monitor completion. Staff member G stated she did not know resident #19 had not completed his morning dose and had not checked for completion. She stated there was no order or assessment for resident #19 to self-administer the medication, and the nurses always set it up for him. Review of resident #19's (physician's) Order Summary Report, with an MD signature date of 5/30/17, showed an order for [REDACTED].>Review of facility policies titled, Medications-Oral Administration of and, Metered Dose Inhaler, showed instructions on both policies to observe administration and not leave medication in the resident's room unless ordered (by the physician). During an interview on 6/14/17 at 9:05 a.m., staff member C stated no residents have orders for self-administration of medication but residents are often left unattended to complete medications given by nebulizer. She stated the facility was in the process of completing self-administration of medication assessments for all residents who use nebulizers. The facility's medication error rate was calculated to be 7.3%. During an interview on 6/15/17 at 9:37 a.m., staff member C stated the facility relies on nurses to self-report in order to identify medication errors. She stated the nurse would not recognize an error to report if the nurse did not know the proper technique was not being followed. Staff member C stated the consulting pharmacy provided a review of the medication administration process quarterly, and that audits are conducted by the facility if a problem has been identified. The facility provided a medication administration review, dated 3/21/16, conducted by the pharmacy's nurse. The facility also provided an audit of one nurse, dated 7/18/16. Staff member C stated medication administration was a good thing to always be checking, but in the case provided, it was the result of a survey. No other audits, or evidence of medication administration oversight, were provided.",2020-09-01
280,LIBBY CARE CENTER,275040,308 E THIRD ST,LIBBY,MT,59923,2017-06-15,431,D,0,1,ILXD11,"Based on observation, interview, and record review, the facility failed to label medications accurately for 1 (#10) of 15 sampled residents. Findings include: 1. During an observation, interview, and record review on 6/13/17 at 8:20 a.m., staff member G prepared medication for administration to resident #10. She pulled a card from the cart labeled Divalproex DR 125mg Capsule. The label included instructions to administer two capsules every morning and one capsule every evening. The medication card was dated as dispensed by the pharmacy on 5/24/17. The order on the MAR indicated [REDACTED]. Staff member G stated a change of direction sticker should have been applied to the card. Review of resident #10's (physician's) Order Summary Report, with an MD signature date of 5/4/17, showed the same order that was on the MAR, which did not match the medication card. During an interview on 6/13/17 at 10:55 a.m., staff member C stated that when an order changes, and the medication card does not match the order, a change of direction sticker is to be applied to the card. Review of a (pharmacy) policy titled, Medication Labels showed instructions to add a change of direction sticker to the medication container if the physician's directions for use change.",2020-09-01
281,LIBBY CARE CENTER,275040,308 E THIRD ST,LIBBY,MT,59923,2017-06-15,514,D,1,1,ILXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and observation, the facility failed to accurately maintain medical records by not accurately reflecting the timing of an as-needed pain medication for 1 (#1); and failed to document presence of a pressure ulcer for 1 (#9) of 15 sampled residents. Findings include: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #1's nursing notes reflected an incident where the resident was complaining of left hip pain and was given a dose of her PRN pain medication at 11:00 p.m. on 5/31/17. Review of resident #1's MAR for (MONTH) (YEAR), reflected no medication was given at 11:00 p.m., on 5/31/17. Review of the narcotics count log book reflected resident #1 was given [MEDICATION NAME] at 11:00 p.m. on 6/1/17. In an interview on 6/13/17 at 10:45 a.m., staff member D stated the date on the narcotic distribution log was incorrect, it should have been 5/31/17. Staff member D also stated the reason the [MEDICATION NAME] was not marked on the Medication Administration Record [REDACTED]. She stated the med aides were the ones that pulled the MAR indicated [REDACTED] In an interview on 6/13/17 at 3:10 p.m., staff member C stated the MAR indicated [REDACTED] 2. Resident #9 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of resident #9's Admit MDS, with an ARD of 4/18/17, showed the presence of three unstageable pressure ulcers on admission. An observation on 6/12/17 at 1:45 p.m. showed one unstageable ulcer to the resident's left foot. During an interview on 6/13/17 at 10:55 a.m., staff member C stated the current ulcer to resident #9's left foot was present on admission, along with two additional unstageable ulcers. Review of resident #9's Daily Skilled Nurse's Notes showed a total of 19 forms completed from 4/12/17-4/28/17. The form includes a skin section with a box to check to indicate the resident has a pressure ulcer and a space for narrative charting, along with other sections. The box to indicate unstageable pressure ulcer is checked on four of the forms and blank on twelve. Of the twelve that do not indicate a pressure ulcer, two have a narrative note related to the ulcer(s). The remaining six notes do not show the presence of an ulcer(s). No Daily Skilled Nurse's Note was found for 4/25/17. During an interview on 6/14/17 at 4:55 p.m., staff member C stated the Daily Skilled Nurse's Notes should be complete and accurate and indicate the resident had unstageable pressure ulcers.",2020-09-01
282,LIBBY CARE CENTER,275040,308 E THIRD ST,LIBBY,MT,59923,2018-08-23,550,G,0,1,LOOE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a resident's right to privacy and dignity for 1 (#62) of 23 sampled residents. This caused harm to the resident and instilled fear, mistrust, increased anxiety and anger. Findings include: Resident #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an observation and interview on 8/21/18 at 10:00 a.m., resident #62 was in bed with a sheet pulled over his head. Staff member M stated resident #62 covered his head often while he was in his room. The staff member said the act must help with his nightmares and anxiety. Review of resident #62's Admission MDS, with an ARD of 8/8/18, Section C0500, showed the resident had a summary score of 15, no cognitive impairment. The resident was his own guardian During an observation and an interview on 8/22/18 at 1:09 p.m., resident #62 stated staff confiscated items of his personal belongings, which the staff took from his black backpack. He said the items taken were now locked up at the facility and now I have to keep my bag with me at all times. He stated that after the items were taken, staff members A and B came to him during therapy and told him the staff went through his bag. Resident #62 said his belongings were still locked up, so they say. If they had asked me, I would have given the items to them. During an interview on 8/23/18 at 9:30 a.m., staff member I said staff member J reminded her that she had observed a vapor device by the bed. Staff member J asked staff member K to get staff member I to go to the room to remove the items from the resident's bag. The resident was in therapy at the time and not in his room. The items were placed in a plastic bag with his name and left in the medication room. Staff member I told staff member B that she had called the family and they were on their way to the facility. Staff member I said that was the last time she saw the items. Staff member I said she did not ask the resident's permission, prior to searching and confiscation his items. Staff member I stated if it had been her, she would have been pretty upset. During an interview on 8/22/18 at 3:05 p.m., staff member I said that on 8/10/18, staff member J and staff member K had gone into the resident's room and saw a vapor device on the floor. The resident was at therapy and out of his room. The staff member said the resident's bag was on his bed, and the items were in his bag. Staff member I said the bag was searched without the resident present and without his permission. Staff member I said it would have been better to do in the resident's presence. Staff member I said the items taken out of the resident's bag were placed in a plastic bag and given to a nurse. Staff member I said she had called the family before noon on 8/10/18. Staff member I said the resident had the right to have personal belongings. Staff member I said she knew the resident had been upset. The facility had not worked with resident to store his belongings prior to this event. During an interview on 8/23/18 at 10:00 a.m., resident #62 stated I was in therapy when this occurred. I was told that one of the workers found something and they went through my bag. I was not present when they went through my bag. I did not consent to allow them to go through my bag. Now, I keep my bag with me at all times. During an observation on 8/23/18 at 10:00 a.m., resident #62 had a black backpack hanging on his wheel chair, and the resident pulled a wallet out of his pocket. Resident #62 stated I have to sleep with my wallet now as I do not trust them. During an interview on 8/22/18 at 2:48 p.m., staff member B said resident #62 had drugs without a prescription. Staff member B said the resident had signed a smoking policy which included no vaping. Staff member B said she and staff member A spoke to the resident and his family members about the resident's items taken. Staff member B stated his belongings were still here and a family member was suppose to get them and had not picked them up, yet. Staff member B did not know if there was an inventory of the items that were taken from resident #62. Staff member B stated the resident should have been present when the staff went through his personal belongings. She said staff needed to be educated on going through a resident's personal items without the resident present. Staff member B thought the event occurred on 8/10/18. She said that staff member A had the items and reviewed with the resident. Family members asked staff member B to hold them until they could be picked up by the family. Staff member B thought there were pain medications, an antipsychotic, a blood pressure medication and some oils. Staff member B said the resident did not have an order for [REDACTED].>During an interview on 8/22/18 at 3:37 p.m., staff member A said he did not know who removed the items from the resident's bag. Staff member A said all the items were given to the family. Staff member A denied giving the items to another staff member. Staff member A stated he did not know if anyone's rights were violated. Staff member A said he did not know where the items were but staff member B should have an inventory. Staff member A stated he was not sure if residents could have property removed from their room if the resident was not aware of the removal. During an interview on 8/23/18 at 7:15 a.m., staff member B stated there was no investigation completed for the incident occurring on 8/10/18, pertaining to the infringement of rights for resident #62. During an interview on 8/23/18 at 7:23 a.m., staff member A stated there was no investigation done to his knowledge for the incident occurring on 8/10/18, pertaining to the infringement of rights for resident #62. Review of resident #62's Interdisciplinary Progress Note, dated 8/10/18, by social services, showed the resident was visited by staff, and the resident was observed to be Upset by raid of his medications that were in satchel in room. The resident felt he should have the right to keep some medications in room. The resident expressed high level of frustration/sorrow with medical condition and lack of control over the events in his life. Review of resident #62's Evaluation For Self-Administration of Medications, signed and dated on 8/2/18, showed the resident was approved for self-administration of medications. Review of resident #62's Inventory of Personal Effects, dated 8/3/18, did not show a black backpack, a wallet, or a list of medications. Review of resident #62's Physician's Evaluations of Resident's Capacity to Make Health Care Decisions or Provide Informed Consent, signed and dated 8/7/18, showed the resident was deemed to have the capacity to make health care decisions. The survey team requested to observe the items taken from the residents backpack on 8/10/18, and the facility did not provide the items, prior to the end of the survey, on 8/23/18.",2020-09-01
283,LIBBY CARE CENTER,275040,308 E THIRD ST,LIBBY,MT,59923,2018-08-23,636,D,0,1,LOOE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have a current plan of care available to staff, for 1 (#3) of 23 sampled and supplemental residents. Findings include: During an interview on 8/23/18 at 9:49 a.m., staff member D stated she could not find resident #3's most current plan of care. The staff member was sure the care plan was updated and had been placed in the group care plan notebook. The care plan was not located. During the review of resident #3's medical records for [MEDICAL CONDITION] drug use, no current plan of care was located. The most current care plan was updated in (YEAR). Review of a care plan received on 8/27/18 showed the facility updated resident #3's care plan on 8/24/18.",2020-09-01
284,LIBBY CARE CENTER,275040,308 E THIRD ST,LIBBY,MT,59923,2018-08-23,657,E,0,1,LOOE11,"Based on observation, interview, and record review, the facility failed to update the care plan on fluid restrictions for 1 (#61) of 23 sampled residents. Findings include: Review of resident #61's order summary report, dated 8/1/18, showed the resident was on a fluid restriction of 1500 cc per day. The fluid restriction had an order date of 6/26/18. Review of resident #61's dehydration prevention care plan, with a target date of 11/15/18, did not show the resident was on a fluid restriction. During an interview on 8/23/18 at 9:00 a.m., staff member [NAME] was not aware resident #61's fluid restriction was not on her care plan. Staff member [NAME] was shown the resident's dehydration prevention care plan, and the blank area regarding fluid restrictions. Staff member [NAME] said the blank area should have contained the 1500 cc fluid restriction.",2020-09-01
285,LIBBY CARE CENTER,275040,308 E THIRD ST,LIBBY,MT,59923,2018-08-23,689,D,0,1,LOOE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to follow physician orders [REDACTED].#62) of 23 sampled residents. Findings include: During an interview on 8/22/18 at 11:19 a.m., resident #62 stated staff did not sit with him while he ate meals. The resident stated he fed himself. During an observation on 8/22/18 at 12:10 p.m., and again at 1:05 p.m., resident #62 was in his room, with his door closed. The resident's lunch was still in his room. At 1:05 p.m. resident #62 confirmed he always ate in his room, with the door shut. Review of resident #62's Standard Admission Physician order [REDACTED]. Review of resident #62's Clinical Health Status Evaluation, dated 8/1/18, showed resident #62 was to have one person assist with eating. Review of resident #62's Initial Nutrition Evaluation, with no signature or date, showed resident #62's nutritional [DIAGNOSES REDACTED]. The evaluation showed that the resident was eating soft foods and needed to work with a speech therapist. The resident had an unplanned weight loss related to his [DIAGNOSES REDACTED]. The resident was on the tube feeding to supplement his nutrition. Review of resident #62's physician orders, dated 8/1/18, showed resident #62 was on a regular diet with thin liquids, with supplement health-shakes via NG Tube PRN. Review of resident #62's speech therapy Evaluation and Plan of Treatment, dated 8/3/18 showed resident #62 needed precautions for aspiration. The speech therapist recommended that if the NG tube was removed, the resident should have close supervision, when eating, from a distance. There was no documentation regarding an updated speech evaluation after the removal of the NG tube. Review of resident #62's Restorative Nursing Evaluation, with no date or signature, showed resident #62 was to be supervised during meals. Review of resident #62's Nursing Progress Notes, dated 8/6/18, showed resident #62 was admitted with an NG tube. The resident removed the NG tube independently on the evening of 8/6/18. Review of resident #62's physician orders, updated on 8/7/18, showed that all medications administered by the NG tube could be taken by mouth, due to the removal of NG tube on the evening of 8/6/18. Review of resident #62's care plan, dated 8/20/18, showed no updates regarding the supervision and assistance needed with meals. During an interview, dated 8/22/18 at 10:00 a.m., staff member H stated she is working with resident #62 five times a week. The staff member stated she completed an initial swallowing evaluation, identifying that the resident had problems with swallowing, saying the resident's larynx didn't elevate as it should. Staff member H stated she worked on swallowing exercises with resident #62. Staff member H stated resident #62 did have an NG tube when admitted , and then the resident removed the tube. The tube remained out as resident agreed he would eat an adequate intake by mouth. Staff member H stated that resident #62 had no signs or symptoms of aspiration since the removal of his NG tube. He did have a weak swallow. The staff member stated the resident was to continue with ongoing treatment. The staff member stated she did not conduct another evaluation to determine his aspiration risk following the removal of his NG tube. The resident eats in his room. I believe staff monitor, and he was given an hour or more to eat. During an interview on 8/23/18 at 9:00 a.m. staff member B stated that staff member H had not told staff member B of resident #62's need to be supervised during meals due to his aspiration risk. During an interview on 8/23/18 at 9:23 a.m., staff member B presented the form Decline of Recommended Treatment, with the effective date of 8/23/18 at 9:23 a.m., showing resident #62 had signed the form and wanted to be allowed to eat independently without supervision.",2020-09-01
286,LIBBY CARE CENTER,275040,308 E THIRD ST,LIBBY,MT,59923,2018-08-23,812,F,0,1,LOOE11,"Based on observation and interview the facility staff failed to clean kitchen equipment and maintain sanitary handling practices during the meal service, which affected all residents who received food from the kitchen, due to the unsanitary practices. Findings include: During the initial tour of the kitchen on 8/20/18 at 3:10 p.m., the following observations were made: 1) The facility failed to store food safely so there was not cross contamination. A box of ready to serve luncheon meat was observed on the bottom shelf in the walk in refrigerator. The box had wet blood on the top of the box, soaking into the cardboard lid. Staff member C did not know where the blood had came from. 2) The facility failed to ensure two fan guards, located above the shelving and food, on the back wall of the walk in refrigerator, had a build-up of dirty, black, greasy dust dangling from the fan guards, blowing with the air output, were cleaned. 3) Food was uncovered. A ketchup container was sitting on a shelf, opposite the fans, The lid had an opening that wasn't covered, leaving the ketchup open to contaminants. 4) The facility failed to maintain sanitary food practices. During observations of meal service in the kitchen on 8/20/18 at 5:10 p.m., staff member F was dishing up the dinner meal. The staff member wore gloves while serving. The staff member was using gloved hands to pick up handfuls of tater tots, biscuits, and breaded seafood, placing the items on the plates for the residents. The staff member was observed, in between serving plates, going to the refrigerator, opening it by the handle, and pulling out trays of coleslaw. The staff member continued wearing the gloves she had served the food with, and without washing, sanitizing or changing her gloves, the staff member went back to serving the meal. Then, staff member F was observed moving the plate cart around, positioning it closer to her. The cart had dried food on the top, where the staff member had grabbed onto. While waiting on the staff to move trays out, staff member F would stand a clean plate on it's edge, on the steam table counter, and lean up against the plate. The staff member's shirt was resting against the plate, where the food was then placed. The staff member was observed resting her cloth, gloved hand (used to pick up the warmed plates) on top of a clean plate. Throughout the meal service, staff member F did not remove the contaminated gloves and did not wash or sanitize her hands. During an observation on 8/22/18 at 7:55 a.m., the toast and bacon were being served by staff member G with a gloved hand. In between the meal service, staff member G moved around the plate warmer, opened the refrigerator, went to the dish room, dropping off kitchenware; all with the same gloves on her hands. The staff member did not throw away the contaminated gloves, and did not wash or sanitize her hands. During an interview on 8/22/18 at 8:33 a.m., staff member C stated she was not aware either staff member F or G had served food with contaminated, gloved hands. Staff member C stated staff should use utensils to serve.",2020-09-01
287,LIBBY CARE CENTER,275040,308 E THIRD ST,LIBBY,MT,59923,2018-08-23,835,F,0,1,LOOE11,"Based on observation, interview, and record review, the facility's Administrator and Director of Nursing failed to address the lack of a comprehensive personal belongings inventory for a new resident, failed to identify, assess, follow-up, investigate, and provide staff education and training for a violation of as residents' rights incident, which occurred on 8/10/18, and resulted in psychosocial harm for 1 (#62) of 23 sampled and supplemental residents. Findings include: During an interview on 8/22/18 at 1:09 p.m., resident #62 stated that staff had entered his room when he was not there and confiscated items out of his bag. Resident #62 said that staff member A and B had come to the therapy room to tell him that they went through his black bag. Resident #62 said if staff had asked him, he would have given the items to them. Resident #62 said, now, he kept his bag with him at all times, and he slept with his wallet on him. Review of resident #62's Admission MDS, with an ARD date of 8/8/18, showed the resident had no cognitive impairment. Review of an Interdisciplinary Progress Note dated 8/10/18 by social services, showed that resident #62 was upset by the raid of his medications that were in his black bag in his room. The note showed that the resident expressed a high level of frustration/sorrow with his medical condition, and his lack of control over the events in his life. (Refer to F550 for further detail) During an interview on 8/22/18 at 2:48 p.m., staff member B said she thought this had happened on 8/10/18. Staff member B sated that after the fact, staff member A and B met with the resident and his family. Staff member B said the resident had complained of pain, it was much worse and a call had been place for an alternative on 8/22/18 to the resident's physician. During an interview on 8/22/18 at 3:27 p.m., staff member A said he did not know if any rights were violated for the removal of resident #62's belongings. Staff member A said he did not know where these items were and staff member B should have had an inventory of the items.",2020-09-01
288,LIBBY CARE CENTER,275040,308 E THIRD ST,LIBBY,MT,59923,2018-08-23,868,C,0,1,LOOE11,"Based on interview and record review, the facility failed to ensure the medical director participated in the QAPI program at least quarterly, which had the potential to affect all the residents in the facility. Findings include: During an interview on 8/23/18 at 8:30 a.m., staff member B said the medical director was sent an invitation every month for the quality assurance meeting. Staff member B said she had been attending the quality assurance meetings for the last two months and the medical director had not attended either meeting. Staff member B said she did not know of the last time the medical director had attended a quality assurance meeting. During an interview on 8/23/18 at 8:42 a.m., staff member A said he did not recall the last time the medical director had attended a quality assurance meeting. Staff member A said the medical director had only attended one or two meetings that year. Staff member A said the medical director was sent an invitation prior to the meeting. Staff member A said the medical director had said she was too busy to attend quality assurance meetings at the facility. During an interview on 8/23/18 at 8:46 a.m., staff member A said the last quality assurance meeting the medical director had attended was 5/1/18. A review of the facility's policy, Quality Assurance and Performance Improvement, showed, 2. The QAPI Committee consists of: c. A physician designated by the facility; and",2020-09-01
289,LIBBY CARE CENTER,275040,308 E THIRD ST,LIBBY,MT,59923,2018-08-23,880,D,0,1,LOOE11,"Based on observation, interview, and record review, the facility failed to protect 2 (#33 and #54) of 27 sampled and supplemental residents from bodily fluids and the possibility of contamination. Findings include: During an observation and interview on 8/20/18 at 4:33 p.m., resident #33's bathroom had a urine odor and contained two clear plastic containers which held the contents of resident #33's urine. The container marked R showed 50 cc, and the container marked L showed 100 cc. Resident #33 stated the containers held her urine. She stated she emptied her catheter bags into the plastic containers and then the nurse would come and record the amount. The resident stated the nurse would come by the end of the day to read the levels and then dump the urine into the toilet. During an observation and interview on 8/21/18 at 9:30 a.m., the plastic containers, which held urine, were draped over with a plastic garbage bag. Resident #33 stated staff sometimes covered the containers. She stated she could not get the plastic over the containers. The resident stated her roommate, and the two women occupying the room, which was attached to the bathroom, had to use the bathroom where her urine sat above the toilet. During an interview on 8/21/18 at 9:35 a.m., resident #54 stated she had often used the toilet between her room and resident #33's room and found urine on the toilet seat and the floor. Resident #54 stated she cleaned the urine up before using the toilet. She stated her room mate also used the same toilet. During an interview on 8/22/18 at 9:50 a.m., staff member L stated resident #33 drained her catheter bags herself into the containers above the toilet, and the CNAs, at the end of the day, would document and empty the containers. Sometimes during day, they would document the total and dump the containers. Record review of resident #33's cognition from the 5-Day MDS assessment showed the resident was cognitively impaired.",2020-09-01
290,LIBBY CARE CENTER,275040,308 E THIRD ST,LIBBY,MT,59923,2018-08-23,921,D,0,1,LOOE11,"Based on observation and interview, the facility failed to repair a floor in a resident's room, which made it difficult for the resident to open the bathroom door to enter the bathroom, for 1 (#43) of 23 sampled residents. Findings include: During an observation and interview on 8/20/18 at 2:20 p.m., resident #43 pointed out a gouge in the floor where the bathroom door dragged when closing or opening. Resident #43 stated the bathroom door stuck and was hard for her to open when she was inside the bathroom. During an interview on 8/23/18 at 9:04 a.m., staff member D stated he was unaware there was an issue with resident #43's bathroom door. The staff member stated he had replaced the flooring, in front of the door, at one time, because there had been a problem with that part of the floor breaking down. During the conversation, resident #43 stated she could not get the bathroom door open to get out of the bathroom. It was too heavy. Staff member D repaired the floor on 8/23/18, 9:35 a.m., making the door easier to open and close.",2020-09-01
291,LIBBY CARE CENTER,275040,308 E THIRD ST,LIBBY,MT,59923,2019-10-03,561,E,0,1,0HT011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide showers based on residents' preferences for 3 (#s 36, 40, and 42) of 25 sampled residents, and resident #36 felt dirty when showers were not provided, and resident #42 liked baths to help ease back pain. This failure had the potential to decrease residents' autonomy and negatively affect their psychosocial well being, due to feelings of uncleanliness. Findings include: 1. During an interview on 10/2/19 at 11:15 a.m., resident #36 stated she had been unable to take showers when she wanted, and in the past, she had gone more than one week without a shower. Resident #36 stated she had tried to give herself sponge baths, but it was difficult to do so in her room and maintain privacy, since staff come into her room often. During an interview on 10/2/19 at 2:57 p.m., resident #36 stated she would like to have showers daily, but staff had told her she could only have two per week. Resident #36 said she was supposed to have a shower on 9/30/19, but did not receive it. Resident #36 stated she may have to wait until 10/3/19 to have a shower. Resident #36 stated it made her feel dirty when she was unable to take showers. Resident #36 stated she had asked staff about taking showers more often, and staff had responded they were unable to give her showers more often, or, they would say, 'Yes, sure,' but it would not happen. During an interview on 10/3/19 at 9:39 a.m., resident #36 stated someone had been able to give her a bath last night. She stated, It is tough, because if someone gives her a bath, that means, No one is on the floor, because the facility does not have designated bath aides anymore. Review of resident #36's shower log for June-September 2019, showed resident #36 was scheduled to receive showers every 3-4 days (twice weekly); however resident #36 went without a shower for: --6 days from 6/29-7/5 (7/1 and 7/4 were charted as Not Applicable) --6 days from 8/2-8/8 --7 days from 8/29-9/5 (9/2 was charted as Not Applicable) Review of resident #36's care plan, dated 11/17/19, showed resident #36 required, 1 staff participation with bathing. The care plan did not show a bathing frequency preference. 2. During an interview on 10/1/19 at 3:15 p.m., NF1 and NF2 stated resident #40 was diagnosed with [REDACTED].#40 was not cognizant to ask for care when needed. NF1 and NF2 stated resident #40 received showers twice weekly. NF1 and NF2 stated daily showers were preferable for resident #40, and said showers three times per week, would be helpful. NF1 and NF2 explained the facility used to have bath aides but had since given that responsibility to CNAs. NF1 and NF2 stated they had spoken with staff member A about resident #40 receiving showers three times per week, and staff member A had told them resident #40's care plan would be updated to reflect that preference. Review of resident #40's shower log for June-September 2019, showed resident #40 was scheduled to receive showers twice weekly; however resident #40 went without a shower for: --5 days from 6/12-6/17 (6/13 and 6/15 were charted as Not Applicable) --6 days from 7/2-7/8 (7/4 was charted as Refused; 7/6 was charted as Not Applicable) --7 days from 9/12-9/19 (9/16 was charted as Refused) Review of resident #40's care plan, dated 11/19/19, showed resident #40 had the potential for urinary tract infections and skin breakdown. Resident #40's care plan did not show bathing frequency preference. Review of resident #40's Health Status Note, dated 8/5/19, showed: Resident is dependent on staff for bathing, dressing, feeding, elimination, personal hygiene, ambulation, and transfers . 3. During an interview on 10/1/19 at 11:32 a.m., resident #42 stated she could not take baths when she wanted, and that she would like to take baths to help ease her back pain. During an interview on 10/3/19 at 7:43 a.m., resident #42 stated when she was at home, she would take daily baths to help her back, and it was nice to soften her toenails so that she could cut them. Resident #42 stated she had talked to staff about more frequent baths a while back, but she had not been receiving baths more often since that conversation. Review of resident #42's shower log for June-September 2019, showed resident #42 was scheduled to receive showers twice weekly; however, resident #42 went without a shower for: --8 days from 6/10-6/18 (6/13 and 6/17 were charted as Not Applicable) --6 days from 6/18-6/24 (6/20 was charted as Not Applicable) --7 days from 7/1-7/8 (7/4 was charted as Not Applicable) --8 days from 7/29-8/6 (8/5 was charted as Refused) --7 days from 8/15-8/22 (8/19 was charted as Refused) --10 days from 8/26-9/5 (8/29 and 9/2 were charted as Refused) --7 days from 9/9-9/16 (9/12 was charted as Not Applicable) --7 days from 9/23-9/30 (9/26 was charted as Refused) Review of resident #42's care plan, dated 11/19/19, did not show resident #42's bathing frequency preference. During an interview on 10/2/19 at 11:37 a.m., staff member A stated if a resident wanted a bath every day, the facility would accommodate for that. Staff member A explained the facility's protocol was to offer two showers per week, but if residents requested additional baths it would be noted in the care plan. Staff member A stated CNAs had been trained to ask residents twice if they would like a bath before charting the resident had refused. During an interview on 10/2/19 at 5:09 p.m., staff member C stated if she were unable to offer showers to all the residents on her daily task list, she would chart Not Applicable in the bathing log. During an interview on 10/3/19 at 7:47 a.m., staff member B stated she would chart Not applicable in the bathing log if she were unable to give a resident a bath or shower during her shift due to time constraints. Staff member B stated she would ask someone on the night shift to offer a resident a bath if she had been unable to do so, or she would offer the resident a bath the next time she was on shift. If a resident were to request daily showers, staff member B stated she would not promise anything to a resident, and instead say, I'll see what I can do.",2020-09-01
292,LIBBY CARE CENTER,275040,308 E THIRD ST,LIBBY,MT,59923,2019-10-03,657,E,0,1,0HT011,"Based on interview and record review, the facility failed to update the care plan to reflect how often staff needed to check a resident for incontinence and care, for 1 (#40) resident, which had the potential to result in urinary tract infection and/or skin breakdown; and failed to update resident care plans to reflect bathing preferences for three (#s 36, 40, and 42) of 25 sampled residents. Findings include: [NAME] During an interview on 10/1/19 at 3:15 p.m., NF1 and NF2 explained staff check and change resident #40 every four hours, and because of his medication (a diuretic) and inability to ask for help, he needed to be checked and changed more frequently. NF1 and NF2 stated they had communicated to facility staff during care plan meetings that resident #40 needed to be changed more frequently, and facility staff had said they would make changes to resident #40's care plan. NF1 and NF2 stated that had not happened. NF1 and NF2 explained resident #40 had not had any skin breakdown, but they were concerned. During an interview on 10/1/19 at 3:15 p.m., NF1 stated resident #40 received showers twice weekly. NF1 and NF2 stated they would prefer daily showers and said showers three times per week would be helpful. During an interview on 10/2/19 at 8:50 a.m., staff member [NAME] stated resident #40 gets checked for incontinence every two hours. During an interview on 10/2/19 at 9:41 a.m., staff member B stated staff manage resident #40's incontinence by checking and changing him every two hours. Review of resident #40's care plan, dated 11/19/19, showed resident #40, .is at risk for skin breakdown related to nutritional status, dementia, incontinence of (bladder and bowel), decreased mobility. Resident #40's care plan did not show any information about how often he should be checked and changed, or how often he would like to be bathed. During an interview on 10/2/19 at 3:50 p.m., staff member F stated she would edit resident #40's care plan to reflect resident #40 should be checked and changed every two hours. Staff member F stated the task list for CNAs would be edited to ensure incontinence care documentation. B. During an interview on 10/1/19 at 11:32 a.m., resident #42 stated she could not take baths when she wanted, and that she would like to take baths to help ease her back pain. Review of resident #42's care plan, dated 11/19/19, did not show resident #42's shower frequency preference. C. During an interview on 10/2/19 at 11:15 a.m., resident #36 stated she had been unable to take showers when she wanted, and that in the past, she had gone more than one week without a shower. During an interview on 10/2/19 at 2:57 p.m., resident #36 stated she would like to have showers daily, but staff had told her she could only have two per week. Review of resident #36's care plan, dated 11/17/19, showed resident #36 required 1 staff participation with bathing. The care plan did not show how often resident #36 would like to have a bath. During an interview on 10/2/19 at 11:37 a.m., staff member A stated if a resident wanted a bath every day, it would be noted in the care plan.",2020-09-01
293,LIBBY CARE CENTER,275040,308 E THIRD ST,LIBBY,MT,59923,2019-10-03,660,D,0,1,0HT011,"Based on interview and record review, the facility failed to ensure a discharge plan was identified and documented in the medical record, which focused on the resident's discharge goals and included the resident as an active partner. This failure caused the resident frustration; and the facility failed to document and update the discharge plan and care plan, with the identified needs and services related to discharge, for 1 (#183) of 25 sampled residents. Findings include: During an interview on 10/1/19 at 3:21 p.m., resident #183 stated she had been at the facility for the past week, and was frustrated that she hadn't seen a doctor since she was admitted , and she didn't know how long she was going to be in the facility. Resident #183 expressed frustration in not knowing why she had not been able to see a doctor since being admitted to the facility, and to find out why she was so dizzy after her fall at home. Resident #183 stated she, wished someone would find out and let her know. Resident #183 stated she felt like she could go home. Resident #183 stated she had installed grab bars all over her house after her first stroke twenty years ago, and she was able to get around fine while at home. During an interview on 10/2/19 at 9:48 a.m. with staff members A and D, staff member A stated the facility had postponed resident #183's discharge planning, until the resident's daughter from California could attend in person. Staff member D stated the facility had completed the care conference with the resident's daughter over the phone. Staff member A stated, There is not a real good discharge plan documented in the resident's chart, but planning is underway. Staff member D stated she, would go and visit with the resident right after the meeting to discuss the resident's concerns, plans for discharge, and upcoming doctor appointment scheduled for 10/7/19. Review of resident #183's medical records and social service progress notes, dated 9/24/19 thru 10/1/19, showed the admission care conference occurred on 9/25/19 with the facility team, resident, and resident's daughter on the phone. Following the admission care conference, no discharge planning documentation was found in the resident's medical record. Review of resident #183's current care plan showed a discharge focus was initiated on 9/25/19, but failed to identify detailed intervention or task updates that included the resident's involvement in the discharge planning process.",2020-09-01
294,LIBBY CARE CENTER,275040,308 E THIRD ST,LIBBY,MT,59923,2019-10-03,837,C,0,1,0HT011,"Based on interview and record review, the facility's governing body failed to employ an Administrator that was licensed in the State of Montana. This failure had the potential to affect all residents. Findings include: During the entrance conference interview on 9/30/19 at 4:36 p.m., NF2 stated he was the Director of Operations, was licensed as an Administrator in Idaho, and was waiting for his Montana license. NF2 stated his Montana license was in the mail. Staff member A stated she was the DON and had been the acting Administrator for the past 1.5 weeks. NF2 stated he was acting as administrator until staff member A got the position. Review of the facility's Key Personnel Contact List, dated 9/25/19, did not include an Administrator name or contact information. Review of the facility's Disaster Call List, dated 10/1/19, did not show an Administrator name or contact information. Review of the State of Montana, Department of Labor and Industries online license verification, did not show a temporary or permanent Nursing Home Administrator license for NF2, as of 10/3/19.",2020-09-01
295,VILLAGE HEALTH & REHABILITATION,275043,2651 SOUTH AVE W,MISSOULA,MT,59804,2018-04-06,575,C,0,1,5IZ311,"Based on interview and observation, the facility failed to publicly post contact information for the required State agencies and advocacy groups, to include the State Survey Agency. This deficient practice has the potential to affect all residents, family members, staff, or other entities who may want or need the information, and the 9 residents identified (#s 10, 14, 21, 43, 44, 63, 66, 95 and 138) of 50 sampled and supplemental residents. Findings include: During a group meeting on 4/4/18 at 1:30 p.m., residents (#s 10, 14, 21, 43, 44, 63, 66, 95 and 138) stated they were not aware of contact information being posted for the State agencies except for the Ombudsman. During an observation on 4/4/18 at 2:00 p.m., Ombudsman contact information was posted on the wall. There was no information posted for the State Survey Agency, the State Licensure Bureau, Adult Protective Services, or the Protection/Advocacy Agencies. During an interview and observation on 4/4/18 at 2:35 p.m., staff member A stated the information had never been posted and she was not aware of any regulation that stated the posting was required. She stated the information was kept in a binder, located in a bin on the wall beside the Ombudsman posting. Observation showed the binder was kept in a plastic bin, located on the wall above a sitting bench. This was not easily accessible to all residents, especially those in wheel chairs.",2020-09-01
296,VILLAGE HEALTH & REHABILITATION,275043,2651 SOUTH AVE W,MISSOULA,MT,59804,2018-04-06,623,B,0,1,5IZ311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide, in writing, notice of transfer, to the hospital, from the facility, for 4 (#s 17, 25, 97, and 417) of 33 sampled residents. Finding include: 1. A review of resident #417's medical record showed the resident was was transferred to the hospital on [DATE], and returned to the facility on [DATE]. Review of resident #417's Quarterly MDS, with an ARD of 3/30/18, showed a BIMS score of 15; cognitively intact. Review of resident #417's Acute Care Transfer Form, showed a family member was notified on 3/15/18, of the resident's transfer to the hospital. A written request was given to the facility during the survey of the notice of transfer for resident #417. The facility did not provide documentation the resident was notified, in writing, of the transfer. During an interview on 4/5/18 at 10:20 a.m., staff member N stated residents receive the transfer form, but it is not documented in the clinical record. 2. A review of resident #97's medical record showed the resident was transferred to the hospital on [DATE], and returned to the facility on [DATE]. Review of resident #97's Quarterly MDS, with an ARD of 1/25/18, showed a BIMS score of 15; cognitively intact. Review of resident #97's Acute Care Transfer Form showed the resident's representative was notified, by phone, of the transfer. The form did not show the facility provided a written notice, for the reason of the transfer, to resident #97 or to resident #97's representative. During an interview on 4/5/18 at 11:34 a.m., staff member N stated the facility process was to provide a copy of the Acute Care Transfer Form to the resident or the resident's representative. She stated she did not know if the information was documented in the resident's record when the notice was provided. The facility offered no evidence that written notice, for the reason for the transfer, was given to the resident or the resident representative. During an interview on 4/5/18 at 10:35 a.m., resident #97 stated she had not been provided written notice, for the reason of the transfer. 3. A review of resident #17's medical record showed the resident was transferred to the hospital on [DATE], and returned to the facility on [DATE]. Review of resident #17's Quarterly MDS, with an ARD of 12/26/17, showed a BIMS score of 15; cognitively intact. Review of resident #17's Acute Care Transfer Document Checklist showed no evidence the resident or a representative was provided verbal or written notice of the reason for the transfer. The form did not show a reason for resident #17's transfer. No Acute Care Transfer Form for resident #17 was provided for review, although requested. 4. A review of resident #25's medical record showed the resident was transferred to the hospital on [DATE], and returned to the facility on [DATE]. She was admitted to the hospital on [DATE], and returned to the facility on [DATE]. Review of resident #25's Quarterly MDS, with an ARD of 12/28/17, showed a BIMS score of 15; cognitively intact. No documentation was provided to show resident #25 or a representative received verbal or written notice of the reason for transfer, although requested. During an interview on 4/5/18 at 2:15 p.m., resident #25 stated she did not recall ever receiving a written notice, of the reason for the transfer, to the hospital. During an interview on 4/6/17 at 4:10 p.m., staff member A stated she was unaware of the need to provide a written notice, of the reason for the transfer, to the resident or the resident's representative, for a hospital transfer.",2020-09-01
297,VILLAGE HEALTH & REHABILITATION,275043,2651 SOUTH AVE W,MISSOULA,MT,59804,2018-04-06,636,D,0,1,5IZ311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a Care Area Assessment for triggered MDS care areas for 1 (#49) of 33 sampled residents. Findings include: Review of resident #49's Annual MDS, with an ARD of 10/19/17, showed the assessment had triggered the following Care Area Assessments (CAAs); - CAA #5 ADL Function; - CAA #6 Urinary Incontinence and Indwelling Catheter; - CAA #11 Falls; - CAA #12 Nutritional Status; - CAA #14 Dehydration/Fluid Maintenance; - CAA #15 Dental Care; - CAA #16 Pressure Ulcer; - CAA #17 [MEDICAL CONDITION] Drug Use; and, - CAA #19 Pain The documentation, in Section V0200A, showed each triggered area had a corresponding note on the triggered CA[NAME] Review of the CAAs for sections 5, 6, 11, 14, 15, 16, and 19, showed the required elements of the CAA had not been completed. CAA number 17 showed a summary note that minimally addressed areas for section 5, 6, 12, 14, 16, 17, and 19. During an interview on 4/6/18 at 12:00 p.m., staff member O stated resident #49's CAAs were not completed according to the facility's standards. She stated the standard practice was to complete the CAA Summary, as required. She stated staff member P had signed the CAAs and staff member O did not know why they were not completed. Staff member P was not available for an interview.",2020-09-01
298,VILLAGE HEALTH & REHABILITATION,275043,2651 SOUTH AVE W,MISSOULA,MT,59804,2018-04-06,637,D,0,1,5IZ311,"Based on interview and record review, the facility failed to complete a Significant Change in Status MDS within the required 14-day timeframe for 1 (#119) of 33 sampled residents. Findings include: Review of resident #119's hospice agreement showed the start of care date for hospice services was 11/20/17. Review of resident #119's clinical note, dated 11/22/17, written by staff member P, showed resident #119 was receiving hospice services and was being evaluated for a significant change in status. Review of resident #119's Significant Change in Status MDS, with an ARD of 12/4/17, showed a completion date of 12/12/17. The ARD was set as the 14th day after hospice services were initiated. The completion date was on the 22nd day after hospice services were initiated, instead of by the 14th day, as required. During an interview on 4/6/18 at 1:30 p.m., staff member O stated she was not the person who completed the Significant Change in Status MDS for resident #119. She stated the assessment was completed by staff member P, who was not available for interview. She stated she would have to review the timeline requirement for completing an MDS when hospice was initiated. No further information or explanation was provided.",2020-09-01
299,VILLAGE HEALTH & REHABILITATION,275043,2651 SOUTH AVE W,MISSOULA,MT,59804,2018-04-06,641,E,0,1,5IZ311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately code the MDS Assessment when a resident was receiving hospice services, for 1 (#119), and for impaired function due to a limitation in ROM, for 3 (#s 7, 41 and 119) of 33 sampled residents. Findings include: Hospice 1. Review of resident #119's hospice agreement showed hospice services were initiated 11/20/17. Review of resident #119's Significant Change in Status MDS, with an ARD of 12/4/17, did not show resident #119 was receiving hospice services. During an interview on 4/6/18 at 1:30 p.m., staff member O stated she was not the person who completed the Significant Change in Status MDS for resident #119. She stated the assessment was completed by staff member P, who was not available. Staff member O stated she believed the MDS was not coded for the hospice services being received by resident #119 because staff member P was waiting for a signed physician's orders [REDACTED]. Review of resident #119's clinical note, dated 11/22/17, written by staff member P, showed resident #119 was receiving hospice services and was being evaluated for a significant change in status. During an interview on 4/6/18 at 2:00 p.m., staff member B stated resident #119 was receiving hospice services during the look-back period, and his Significant Change in Status MDS, with an ARD of 12/4/17, should have been coded to show hospice services were received. Prior to the end of the survey staff member O provided a modified Significant Change in Status MDS, with an ARD of 12/4/17, for resident #119. The modified Significant Change in Status MDS showed the resident had received hospice services during the look-back period. Range of Motion 2. a. Review of resident #7's Significant Change in Status MDS, with an ARD of 12/7/17, showed resident #7 had limitation in ROM on one of his upper extremities, and both of his lower extremities, that interfered with his daily functions or put him at risk for injury. Review of the ADL CAA did not show resident #7 had limited ROM or how the limited ROM impaired his function. Review of resident #7's Care Plan Report, effective 5/7/15-present, showed the following problems: - Requires assistance with activities of daily living due to: weakness, chronic back pain, dementia, incontinence and history of falls. - Potential for falls related to weakness, history of falls, unsteady balance, dementia and use of [MEDICAL CONDITION] medications and poor safety awareness. - At risk for declines in self care abilities in the area of dressing, grooming related to dementia, [MEDICAL CONDITION], spinal stenosis, and chronic lower extremity [MEDICAL CONDITION]. - At risk for decline in self-care ability in the area of transfers. Review of resident #7's Care Plan Report, effective 5/7/15-present, did not show an identified limitation in ROM in the problem, goal, or interventions sections. A written request was made for evidence of resident #7's impaired ROM that interfered with his daily function. No evidence was provided. During an interview and observation on 4/6/18 at 10:18 a.m., resident #7 demonstrated functional mobility in the joints of his upper and lower extremities, according to the steps in the RAI Manual. b. Review of resident #119's Significant Change in Status MDS, with an ARD of 12/4/17, showed resident #119 had limitation in ROM on one of his upper extremities, and both of his lower extremities that interfered with his daily functions or put him at risk for injury. Review of the ADL CAA did not show resident #119 had limited ROM or how the limited ROM impaired his function. Review of resident #119's Quarterly MDS, with an ARD of 3/1/18, showed resident #119 had limitation in ROM on one of his upper extremities, and both of his lower extremities that interfered with his daily functions or put him at risk for injury. Review of resident #119's Care Plan Report, effective 10/30/17-present, showed the following problems: - Self care deficit: Requires assist with ADL's due to hypertension, diabetes mellitus Type II, [MEDICAL CONDITIONS] infarction, [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], left [MEDICAL CONDITION], weakness, and impaired mobility. - Fall risk as evidenced by: hypertension, diabetes mellitus type 2, [MEDICAL CONDITIONS], left [MEDICAL CONDITION], weakness, and impaired mobility. Review of resident #119's Care Plan Report, effective 10/30/17-present, did not show an identified limitation in ROM in the problem, goal, or interventions sections. The care plan did not show how the impaired mobility was related to a limitation in ROM. A written request was made for evidence of resident #119's impaired ROM that interfered with his daily function. Resident #119's clinical note, dated 3/5/18, was provided. Review of resident #119's clinical note, dated 3/5/18, showed resident #119 had [DIAGNOSES REDACTED]. The clinical note did not show resident #119 had a limitation to his ROM, or how that limitation impaired his function. During an interview on 4/4/18 at 9:45 a.m., staff member P stated she used the resident's [DIAGNOSES REDACTED]. She stated she did not conduct a physical assessment of ROM. Staff member P stated she knew the coding instructions for the ROM item. During a continuation of the interview, a review of the RAI manual showed: 3. Coding for functional ROM limitations is a 3 step process: - Test the resident's upper and lower extremity ROM . - If the resident is noted to have limitation of upper and/or lower extremity ROM, review G0110 and/or directly observe the resident to determine if the limitation interferes with function or places the resident at risk for injury. - Code G0400 A/B as appropriate based on the above assessment. 4. Assess the resident's ROM bilaterally at the shoulder, elbow, wrist, hand, hip, knee, ankle, foot, and other joints unless contraindicated (e.g., recent fracture, joint replacement or pain). Staff member P could not find instructions to code weakness as impaired ROM. During an interview on 4/4/18 at 11:25 a.m., staff members P and O stated they conducted an informal bedside observation of the resident's function for coding the ROM item. Staff member O stated she believed the item was to be coded based on impaired functional mobility, not necessarily related to ROM. She stated she knew the coding instructions. Staff member O stated resident #119 had multiple [DIAGNOSES REDACTED]. She was not able to state or show evidence that the impaired mobility or impaired function was related to a limitation in ROM. 3. Resident #41 was admitted with [DIAGNOSES REDACTED]. Review of resident #41's Significant Change in Status MDS, with an ARD of 3/22/18, showed resident #41 required limited one person assist with his ADLs to include locomotion. Review of the Range of Motion assessment showed resident #41 had limited range of motion to his lower extremity on one side. Review of resident #41's Quarterly MDS, with an ARD of 1/11/18, showed resident #41 required supervision and set-up with his ADLs to include locomotion. Review of the Range of Motion assessment showed resident #41 had limited range of motion to his lower extremity on one side. Review of resident #41's care plan, with an effective date of 10/12/16, showed a problem area for deficits in his self-care abilities due to a history of a left fibula fracture, incontinence, and pain. There were no problems, goals or interventions listed on the care plan that addressed limited range of motion to his lower extremity. Review of resident #41's Physical Therapy discharge summary, dated 3/8/18, showed resident #41 required supervision for basic mobility and partial to moderate assistance for walking. During an interview and observation on 4/5/18 at 1:44 p.m., staff member R was assisting resident #41. Resident #41 demonstrated to staff member R that he could move all his extremities without limitations. Resident #41 was observed to move his legs, hips, knees, ankles, and feet without restriction or complaints. Resident #41 stated he did exercises every day in his wheelchair and demonstrated leg lifts. Resident #41 showed staff member R he could lift his arms above his head, move his elbows and wrists and fingers without restrictions.",2020-09-01
300,VILLAGE HEALTH & REHABILITATION,275043,2651 SOUTH AVE W,MISSOULA,MT,59804,2018-04-06,656,D,0,1,5IZ311,"Based on observation, interview, and record review, the facility failed to offer fluids, and have the fluids available, for a resident who had mobility limitations and needed assistance, as directed by the care plan, for 1 (#119) of 33 sampled residents. During observations on 4/2/18 at 11:35 a.m., 4/3/18 at 8:59 a.m., and 4/4/18 at 7:42 a.m., in resident #119's room, one or two CNAs assisted resident #119 with transfers, dressing, and personal hygiene. Throughout these observations, no fluids were offered to resident #119. See F677 for details. During an interview on 4/2/18 at 11:50 a.m., resident #119 stated he did not drink from the pitcher of thickened water in his room. He stated he preferred flavored water or juice, like he received in the dining room, with his meals. Review of resident #119's Care Plan Report, effective date, 10/30/17-present, showed a problem area of Altered Nutrition Needs. The interventions showed staff were to encourage honey thickened fluids with and between meals. (Resident #119) prefers water and fruit juices. During an interview on 4/4/18 10:38 a.m., staff member U stated she did not provide fluids to residents between meals. She said she was not aware of any residents who should receive fluids between meals. Staff member U stated there was no hydration pass during the day shift. She stated other shifts passed out the water pitchers. During observations on 4/2/18-4/6/18, including 4/3/18 at 2:35 p.m., and 4/6/18 at 9:57 a.m., resident #119 sat in the day room during the morning and afternoon, between meals. The resident was not observed being offered fluid, or having a glass of fluid while sitting in the day room. During an interview on 4/6/18 at 9:35, resident #119 stated staff did not provide fluids for him while he was in the day room.",2020-09-01
301,VILLAGE HEALTH & REHABILITATION,275043,2651 SOUTH AVE W,MISSOULA,MT,59804,2018-04-06,676,D,0,1,5IZ311,"Based on record review, observation, and interview, the facility failed to provide an interpreter as needed to assist in maintaining the highest well being for a resident who's primary language was not English, for 1 (#121) of 33 sampled residents. Findings include: Review of resident #121's physician visit, dated 2/14/18, showed the resident had Severe dementia with behavioral disturbance, compounded by language barrier. Patient participation is improved with family present at bedside. Review of resident #121's Quarterly MDS, with the ARD of 3/1/18, showed the resident wanted or needed an interpreter to communicate with the physician and health care staff. Her preferred language was Hmong. Review of resident #121's Care Plan showed impaired communication related to a language barrier and dementia. The goal was for resident #121 to understand others as evidenced by responding appropriately daily. Interventions included a louder volume, short phrases, gestures, facial expressions, refer to Common Word List, family to assist as able when staff is unable to understand, and elicit the assistance of a relative that works in the Pharmacy to interpret or speak with resident as needed, when he is available. Use Interpreter Services as needed for resident to make her needs known (contact phone number provided). Review of resident #121's Clinical Notes, dated 10/6/17, showed resident has dementia with behaviors and does not speak English as her native language. Staff are able to communicate with her by gestures, understanding basic English and family will come in to help with communication when needed. Review of resident #121's Clinical Notes, dated 10/13/17, showed yells sometimes and spit at staff. Family visited to assist feeding. Staff reported that resident complained to family that she does not want to get up early for breakfast. Review of resident #121's Clinical Notes, dated 10/28/17, showed Has hollered out once in a while. Staff try to figure out why she is hollering, but she is unable to communicate why she is yelling. Review of resident #121's Clinic Notes, dated 11/24/17, showed Resident hollering out loud this shift. Staff have offered her food/drinks, toileted her, given her attention, asked if she's having pain, and took her for a walk. She continues to holler out despite these interventions. Staff continue to try and find out what will fulfill her needs. Review of resident #121's Clinical Notes, dated 12/2/17, showed Resident was hollering loudly in her native language this shift. Staff tried to figure out what her needs were, but she just hollered louder when they tried. Review of resident #121's Clinical Notes, dated 12/22/17, showed Resident was hollering for long periods of time tonight. Staff tried to figure out why she was hollering, but she just became louder as they tried. Review of resident #121's IPR team noted, dated 3/7/18, showed Resident communicates/interacts with others by making noises, gesturing and pointing to things. Staff have a word guide and ask yes/no questions, interpretive service number, and family pharmacy employee to help aid in communication. During an interview on 4/3/18 at 10:08 a.m., staff member A stated the interpretive service and the family member were available to assist with communication for resident #121. Evidence for the use of these services, was requested, and not provided. During an interview on 4/6/18 at 10:54 a.m., staff member G stated the facility had not needed to use the interpretive services for resident #121. During an observation on 4/3/18 at 8:43 a.m., resident #121's family was attempting to feed the resident cereal. The family spoke to resident #121 in her native language, and she opened her eyes. The family declined any further interview. Resident #121 passed away during the survey.",2020-09-01
302,VILLAGE HEALTH & REHABILITATION,275043,2651 SOUTH AVE W,MISSOULA,MT,59804,2018-04-06,677,D,0,1,5IZ311,"Based on observation, interview, and record review, the facility failed to provide perineal care to a dependent resident, for 1 (#25); and provide oral care assistance for a dependent resident, for 1 (#119) of 33 sampled residents. Findings include: 1. During an interview and observation on 4/2/18 at 11:45 a.m., resident #119 stated he would like his teeth brushed more often. A thick, white, liquid substance could be seen along resident #119's gum line. He stated his teeth had not been brushed that day, and he would like for his teeth to be brushed twice a day. Resident #119 pointed towards an electric toothbrush on the counter next to the sink, and said that was his toothbrush. He stated the staff brush his teeth for him because he cannot do it himself. He said his teeth were brushed a few times a week, but definitely not everyday. A review of resident #119's Care Plan Report, effective 10/30/17-present, showed the need for staff to provide assistance for ADL's. The goal was for resident #119 to participate as much as able. The interventions did not distinguish what level of assistance resident #119 required. Oral care was not addressed on the care plan. During an observation and interview on 4/4/18 at 7:49 a.m., staff member U stated she was providing morning ADL care to resident #119. Resident #119 had been transferred into his wheelchair and assisted with dressing his upper body. The lower body was dressed prior to the transfer. Staff member U washed resident #119's face. She stated there were no other ADL tasks to provide for resident #119 and she wheeled him out of the room. Staff member U had not offered or provided oral care to resident #119. Review of an oral hygiene policy and procedure, provided by the facility, showed oral care should be done at least twice a day. The policy and procedure showed oral care included brushing the teeth, tongue, and gums. and flossing the teeth. 2. During an observation on 4/5/18 at 2:05 p.m., staff member HH prepared to complete perineal care/cleansing, and emptying of the catheter bag for resident #25. Resident #25 stated No one ever does that, referring to the perineal care/cleansing, when staff member HH positioned her in bed and explained what she was going to do. Staff member HH used ten packaged perineal wipes to clean resident #25's pubic and perineal areas, removing a dried brown substance and pasty matter. Staff member HH obtained ten more wipes and continued cleaning resident #25's pubic/perineal area, stating she had not been thoroughly cleaned the last time perineal care was provided. Resident #25 stated perineal care/cleaning was only done when she pooped. Review of a policy titled, Activities of Daily Living, with an approval date of 10/4/17, showed staff were to, provide necessary services for residents who are unable to carry out activities of daily living to maintain good nutrition, grooming, and personal and oral hygiene. The policy did not show how frequently the necessary services should be provided. Review of a policy titled, Appropriate Use of Catheters and Feeding Tubes, with an approval date of 10/4/17, showed appropriate indications for use of a urinary catheter, and other clinical considerations related to the use of a urinary catheter. The policy did not show any instructions for the provision of perineal care or other care related to the catheter. A written request was made for the facility's policy regarding provision of perineal care. No policy was provided. During an interview and record review on 4/6/18 at 10:40 a.m., staff member B stated perineal care/cleansing was not considered a part of catheter care. She stated there was no standard for how often perineal care/cleansing services were provided to a dependent resident. Staff member B stated perineal care/cleansing should be provided as needed, and there was no minimum. She stated resident #25 could not perform her own perineal care/cleansing, and was dependent on the staff to complete the task. Staff member B stated it would not be acceptable for resident #25 to receive perineal care/cleansing assistance only when she had a bowel movement, if it occurred only every two or three days. After review of resident #25's Care Plan Report, she stated the care plan did not show how often perineal care/cleansing assistance should be provided to resident #25, and she did not know how a CNA would know how often to perform the task.",2020-09-01
303,VILLAGE HEALTH & REHABILITATION,275043,2651 SOUTH AVE W,MISSOULA,MT,59804,2018-04-06,689,J,1,1,5IZ311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to identify the root causes and contributing factors related to 11 falls, one which caused a cervical fracture, and failed to monitor the resident adequately, and evaluate the effectiveness of interventions to prevent falls, and modify the interventions as falls occurred, for 1 (#75), and failed to identify root causes and contributing factors for falls, and failed to monitor residents adequately, and evaluate the effectiveness of interventions to prevent falls and modify the interventions as falls occurred, for 2 (# 25 and 146); and failed to provide adequate supervision for residents in the bathroom, when a mechanical lift was used to transfer the resident to the bathroom, and the resident's were left unattended in the bathrooms, for 2 (# 98 and 164) and 1 (#164) had an injury from the lift in the bathroom, of 50 sampled and supplemental residents. On 4/5/18 at 10:50 a.m., the survey team announced an Immediate Jeopardy which pertained to a resident (#75) residing on the dementia unit, who had multiple falls and sustained injuries, to include a cervical fracture. The regulatory area identified was F689- Accidents and Hazards, at the Severity and Scope of [NAME] Upon removal of the immediacy for the resident, the Severity and Scope would lower to a [NAME] Findings include: 1. Review of the facility report, Occurrence Type, Falls, showed resident #75 fell 11 times from 4/22/17 through 4/5/18. Review of the facility's Falling Star program, showed the residents involved in the program would have a green star on the resident's door. During an observation on 4/5/18 at 4:40 p.m., resident #75's door did not include a green star. During an interview on 4/5/18 at 1:50 p.m., staff member Z stated the falling star program meant the resident was at risk for falling, and should not be left alone in the bathroom. She stated there were two residents in the Pearl Unit that were on the program. Review of resident #75's Occurrence Reports showed: -- 4/22/17; the resident fell from her bed to the floor, landing on the fall mat. The root cause was identified as Due to resident action or internal risk factor. The recommendations included, anticipate needs as able, provide frequents check as able. Resident reeducated to call for assist. The resident's record did not show the facility identified needs staff may anticipate, or show the resident's care plan was reviewed for effectiveness of fall prevention interventions. The facility did not identify why the resident may have fell from the bed. Review of resident #75's Annual MDS, with the ARD of 1/25/18, showed the resident had severe cognitive impairment. - 6/3/17; the resident fell while ambulating with a walker. She hit her right elbow on the walker. A root cause was not identified and contributing factors were not evaluated per record review. Recommendations by the IDT included, Staff to continue frequent checks and anticipate needs. Keep in line of sight as able. The facility failed to identify the needs staff may anticipate for fall prevention, and failed to show how often or frequent checks were to be completed for resident monitoring. - 7/13/17; the resident was found on the floor in her room. She stated, I want to go home. A root cause was not identified for why or how she may have fell to the floor. Recommendations included Staff to continue frequent checks, to anticipate needs as able, reassure and redirect as needed, PT evaluation and Falling Star Program. How reassurance was a fall prevention intervention was not specified, and the purpose of the PT evaluation was not specified. Contributing factors were not shown to be reviewed or discussed by the IDT, per the resident's record. - 11/6/17; the resident was being pushed in her wheelchair, out of the dining room. She put her feet down, (promptly stopping the chair) and she fell forward, hitting her forehead on the floor. Ice pack applied to her forehead. Large amount of blood from head wounds. The root cause was Other, CNA did not use foot pedals while transporting resident. The recommendation was Foot pedals to be on wheelchair when transporting resident. Bag on back of wheelchair with foot pedals to be readily available for use. Review of a facility inservice, dated 11/7/17, showed a topic of Wheelchair foot Pedal Safety was provided for the staff, after resident #75's fall with the head injury. During an observation and interview on 4/5/18 at 2:20 p.m., staff member CC was pushing resident #75 down the hall. Foot pedals were not placed on the chair to hold the resident's fee up off the floor so they would not catch under the resident as she was pushed by the staff member. When asked about her foot pedals, staff member CC stated the resident does not use them, because she gets around with her feet on the ground. This was not reflected on the resident's care plan. - 11/20/17; the resident was found lying under the sink in another resident's room. The resident was unable to say what had happened. The root cause was No Fault. The recommendations included, Staff to continue frequent checks and anticipate needs. These interventions had shown to be ineffective from the prior four falls, but these were not modified. - 11/24/17; the resident was found lying on the floor next to her bed. She had bluish-red bruising to the left elbow, and a small superficial skin tear. She sustained an abrasion to her left cheek, and a small slit to her left lateral eye. The root cause was No Fault. Recommendations included changing the mattress to a perimeter mattress to reduce the chance of rolling out of bed. Staff to continue frequent checks and anticipate needs as able. - 11/28/17; the resident was found on the floor in between her wheelchair and another residents bed. Resident #75 was complaining of neck pain. A bump was noted to the back of her head. The root cause was No Fault. Recommendations included Staff to continue frequent checks and anticipate needs as able. Staff to keep resident in line of site in common areas as able. Falling star program. The interventions implemented were not evaluated for effectiveness relating to the resident's fall history and interventions implemented. Review of resident #75's Nursing Progress note, dated 11/29/17, showed the resident complained of back pain, and medication was provided and was effective. Woke up at 4:35 p.m., and again complained of back and neck pain. At 7:41 p.m., (resident #75) kept holding her neck. Review of resident #75's Nursing Progress note, dated 11/30/17, showed resident complaining today of pain at neck stated 'really hurting.' Review of resident #75's Nursing Progress note, dated 12/1/17, showed a computed tomography scan was completed with a finding of cervical fracture. This occurred four days after the fall with neck pain. Review of resident #75's Occurrence Reports, dated 1/14/18 and 1/22/18, showed two more falls, without injury, and a root cause of Due to resident action or internal risk factors. The facility failed to identify what actions or internal risk factors were contributing to the repeated falls. Review of resident #75's Nursing Notes, dated 4/5/18, showed the resident rolled out of bed. She also fell out of her wheelchair at 11:20 a.m., the same day. The resident was sent to the ER with hip pain. An X-ray showed no fracture and no further injury to the cervical fracture. The resident returned to the facility. Review of resident #75's falls Care Plan showed the following interventions for fall prevention: - the resident could ambulate with a front wheel walker, - had foot pedals for transport, - had a perimeter mattress, - was to be in common areas while awake as able, - was on 4 Ps rounding q shift, - was to be encouraged to use call light, - staff to keep pathways free of clutter, - staff were to encourage her to rise slowly and get balance before ambulating, - staff to encourage rest periods when ambulating, - the bed was to be in the lowest position, and - there was to be a mat on floor. During an interview on 4/5/18 at 8:30 a.m., staff member EE stated resident #75 was no longer able to ambulate. 2. Review of the facility's Occurrence Type, Falls Report, showed resident #146 fell 20 times, from the day of admission in (MONTH) to his discharge date of [DATE]. The Occurrence Reports showed: - 2/14/18; the resident was assisted to the floor by the CN[NAME] Resident was educated on waiting for CNA to remove equipment and having staff assist with positioning in bed. Falling star program and landing strip next to bed. The root cause was Due to resident action or internal risk factors. - 2/17/18; the resident stated he rolled out of bed while sleeping. The root cause was No Fault. No new interventions were implemented. The facility failed to identify the root cause or contributing factors for why the resident rolled out of the bed while sleeping. - 2/18/18; the resident rolled out of bed onto the landing strip. A perimeter mattress was applied. Consider bariatric bed due to second fall from bed due to turning over. The root cause was due to resident action or internal risk factors. The facility failed to address the resident's positioning in bed. - 2/18/18; the resident was seen slipping out of his chair. The CNA was unable to stop him from falling out and assisted the resident to the floor. The root cause was No fault. The Intervention was to add a dycem pad (non skid pad) to his wheelchair cushion. The facility failed to identify contributing factors for the fall from the chair, such as positioning, size of chair, or resident's use of the chair. - 2/19/18; the resident thought I'd go ahead and get into the chair by myself. My legs just gave out and I didn't make it and wound up on the floor. No root cause was identified, and the recommendations included anti-roll back brakes, and the Falling Star Program. The facility did not determine why the resident wanted to get up on his own, or determine if his needs could be anticipated prior to him taking action on his own. - 2/23/18; the resident slid off the bed as he was trying to get to bed from the wheelchair. The root cause was due to resident action or internal risk factors. The recommendation was Staff to continue frequent checks and anticipate needs as able. Staff to encourage call light. The facility did not identify the resident needs to be anticipated or what parameters of the frequent checks. - 3/3/18; showed the resident was on the floor next to his bed. The resident stated he had been trying to grab a pen that had fallen on the floor. The root cause was due to resident action or internal risk factors. Recommendations included Resident was educated on using call light and asking for assistance to pick items up from floor. Staff to continue frequent checks and anticipate needs as able. Staff to encourage call light use. - 3/4/18; showed the nurse was informed that the resident had fallen again. He was on the landing strip next to his bed, and reported he had just rolled out of bed trying to roll over. The root cause was due to resident action or internal risk factors. The intervention was to move the bedside table onto the landing strip to prevent future rolling out of bed. - 3/6/18; the resident was found on the floor, in the bathroom, near the sink and his wheelchair. He was trying to self transfer from the wheelchair to the toilet. The results of the fall investigation showed resident is alert and oriented and able to make his needs known. The resident has a history of involuntary movement disorder and had been seen by the physician on 3/6/18. He is being followed by neurology. The resident stated that he doesn't want to bother anyone when he gets up, and will transfer himself. He has a call light in place and demonstrates he understands how to use his call light. He stated if his chair is next to the bed, he will transfer himself. The recommendation was to keep the wheelchair away from the bed. The facility did not address how the involuntary movements may have affected the transfer, why he felt he was bothering the staff when he needed care, or how staff may anticipate the needs prior to the resident attempting to use the restroom on his own. - 3/10/18; the resident had attempted to self transfer from the wheelchair to the toilet. The root cause was due to resident action or internal risk factors. The recommendations were for PT to adjust the wheel chair and place a uno-slip pad on the wheelchair cushion, which was previously recommended after the fall on 2/18/18. - 3/11/18; the resident was in the restroom on the floor. The root cause was Due to resident action or internal risk factors. The recommendations included a tent call light, and a sign to remind the resident to call for help, and the Falling Star Program. The resident was not comprehensively assessed to determine if his fall history showed any patterns relating to the fall details, or why interventions were not successful for the prevention of falls. This was the resident's 11th fall since his admission in (MONTH) (YEAR). - 3/12/18; the resident attempted to self transfer and fell to his knees. No new interventions or root cause were identified. - 3/14/18; the resident was found lying on his stomach between his bed and the window. He stated he was moving from his wheelchair to his bed, and his tremors caused him to fall. Recommendations included a self releasing seat belt, and slide board for transfers, with red tape on the brake extensions. No root cause was identified. How the slide board transfer was a fall prevention intervention was not identified. The facility did not address the resident's desire to be independent which in turn increased his risk for falls. - 3/15/18; the resident fell in the bathroom. No root cause was identified. The recommendation was to move him to a room closer to the nurses station, for closer observation. Resident is in agreement with this, and PT is aware of resident's numerous falls, and are working with him on safety. - 3/16/18; the resident once again rolled out of bed. No root cause was identified, and no new interventions were recommended. - 3/16/18; the resident was found lying on the bathroom floor. The resident was placed in bed with a mechanical lift. The intervention was to continue to encourage call light use. - 3/18/18; the resident was found on the floor between the toilet and his wheelchair. He refuses to use his call light. He has been moved closer to the nurses station today for closer observation. The fall occurrence report for 3/15/18 showed he would be moved closer to the nurses station on that day. Review of resident #146's Occurrence Reports for 3/25/18 and 3/27/18, showed he did not lock his wheelchair brakes and fell to his knees and rolled out of bed again. The resident was discharged home on[DATE]. During an interview on 4/4/18 at 3:30 p.m., staff member D stated the resident wanted to discharge home, and PT cleared him to leave, as soon as he could get off of the floor by himself. Review of the Physical Therapy discharge summary, dated 3/26/18, did not address the frequent falls, or the resident's ability to get off the floor independently. Review of resident #146's Care Area Assessment from the Admission MDS, with the ARD of 2/19/18, showed the resident was at risk for falls, and his knees would buckle. This was not identified in the Occurrence Reports. Review of resident #146's 30 day MDS, with the ARD of 3/11/18, showed the resident used an antianxiety medication and a hypnotic, on a daily basis. These medications can contribute to the risk for falls, and were not addressed in the Occurrence Reports. During an interview on 4/5/18 at 11:38 a.m., staff member D stated falls were discussed monthly at the Quality Assurance meeting, and the facility looked at the units and halls the falls occurred on, to come up with ideas for interventions. When asked how the meeting discussions were implemented into actual fall interventions, staff member D gave an example, and for monitoring for the effectiveness of interventions, staff member D stated the facility reviews the occurrence reports daily. The frequent checks and increased supervision were not documented in the electronic records. 3. Resident #98 admitted to the facility with [DIAGNOSES REDACTED]. During an interview and observation on 4/2/18 at 4:43 p.m., resident #98 stated he fell in his bathroom, because staff did not answer his call light, and he tried to help himself. Resident #98 stated he fell on to his back. Located in the resident's bathroom was a red card (identifier for the facility fall program) on the wall behind the toilet. Review of resident #98's Annual MDS, with an ARD of 2/15/18, showed he was extensive assist of one person with all of his transfers, locomotion on and off the unit, dressing, and toilet use. The MDS showed resident #98 did not resist care. The MDS showed resident #98 was frequently incontinent of bowel and bladder. Review of resident #98's care plan, with an effective date of 3/30/11, showed a problem for falls related to history of falls, unsteady balance, and a dementia diagnosis. Interventions listed included: assist with toileting needs as needed, clip call light to clothing while up in chair, and a red card in the bathroom. Review of resident #98's occurrence report, dated 10/12/17, showed the resident attempted to self transfer and fell in the bathroom. The investigation showed the CNA placed him on the toilet then went to attend other duties. During an interview on 4/5/18 at 2:38 p.m., staff member LL stated a red card in the bathroom means the resident can not be left in the bathroom by themselves. Staff member MM stated the CNAs get the red card information and education during orientation training. Resident #98 was not supervised according to his care plan, while he was in the bathroom, resulting in a fall on 10/12/17. The occurrence report showed the root cause analysis as, other, CNA had w/c to far from the bed (sic), but this did not address the resident being left unattended. 3. Resident #164 had [DIAGNOSES REDACTED]. Review of an Occurrence Report, dated 11/29/17, showed resident #164 had a fall while sitting on a commode. The section, General Follow up Procedures, dated 12/1/17, showed the following: -Resident was placed on the commode with the use of a hoyer lift; -The hoyer lift was placed in front of the resident and to the right; -The CNA left the room; -The CNA continued to check on the resident; -Resident was found with his neck resting on the left hook of the hoyer lift and holding onto it with his hands, and his left leg was off of the commode; -The CNA lowered the resident to the ground and found that the hoyer lift had caused a wound to his neck; -The resident was sent to the ER and received stitches to the site; -There was bruising noted to the wound; -(resident's name) caused the wound when he attempted to move his left side of his body off of the commode to reposition himself after he fell forward. The CNA did not stay in the room and supervise the resident while he was hooked up to the lift and left on the commode. During an interview on 4/5/18 at 8:20 a.m., staff member B stated residents should always be supervised when in a lift. She stated the fall was unusual, and the resident was frustrated by using the lift. Staff member B stated education was provided regarding safety. The facility did not provide documentation of the education. 4. Review of a fall log provided by the facility, showed resident #25 had fallen five times since (MONTH) (YEAR). During an interview on 4/5/18 at 9:43 a.m., staff member V stated the way he knew who was on the Falling Star Program was to look for a red star on the doorway. He said if a resident was on the Falling Star Program he would check as he went by the room, looking for positioning and call light placement. He stated he regularly worked on the 200/500 unit, but he was unsure of who was currently on the Falling Star Program on the 200/500 unit because it changed frequently, and he worked other areas of the facility. During an observation and interview on 4/5/18 at 9:57 a.m., staff member B pointed out one room on the 200/500 unit which had a green star. She stated no one else was on the program, or there would have been a star on the doorway. She stated residents who have fallen in the past 30 days are included on the program, and automatically come off the program when the 30 days had passed, if no more falls had occurred. Review of resident #25's Occurrence Reports from 12/14/17 - 3/11/18, showed the following: - On 12/14/17, resident #25 was sitting in her wheelchair, and unfastened her safety belt, fell asleep, and slid out of her chair. The report showed the chair was her preferred place to sleep. - On 1/26/18, resident #25 was lying in her bed on her right side, with her head at the foot of the bed. Resident #25 said she rolled over and fell on to the floor. The interventions to prevent falls included initiating the Falling Star Program and 4Ps rounding. The root cause of the fall was identified as, Due to resident action or internal risk factors. The resident action or internal risk factors which caused the fall were not defined. - On 2/9/18, resident #25 was sitting on the foot of her bed with pillows behind her back and to her right, and with her feet dangling over the edge of the bed, fell asleep, and slid off the bed. The interventions recommended to prevent falls included continuing frequent checks, and placing a landing strip next to the bed, on the floor. The root cause of the fall was identified as, Due to resident action or internal risk factors. The resident action or internal risk factors which caused the fall were not defined. - On 2/18/18, resident #25 was dreaming, and had an incontinent bowel movement. She slipped out of her bed onto the floor. The interventions recommended to prevent falls included the Falling Star Program, 4Ps rounding, continuing frequent checks, and placing a landing strip next to the bed, on the floor. Resident #25 refused to have the landing strip on the floor next to her bed, due to the need to move her overbed table. These interventions had been previously implemented. The root cause of the fall was identified as, Due to resident action or internal risk factors. The resident action or internal risk factors which caused the fall were not defined. Staff member B stated the fall of 2/18/18, was different because resident #25 had a disturbing dream, and had an incontinent bowel movement, which was not usual for her. She stated she could not say what had been done to evaluate why resident #25 had the unusual occurrence. Staff member B stated resident #25 was transferred to the hospital the following day, 2/19/18, due to a critically elevated potassium level. She stated she could not say if the fall was related to the elevated potassium level. - On 3/11/18, resident #25 was sitting on the edge of her bed and slipped to the floor. After evaluation by the PT, it was determined resident #25's air mattress was deflating as she sat on the edge of the bed, causing her to slide off. The recommended interventions to prevent falls included replacing the air mattress, Falling Star Program, and 4Ps rounding. A different type of air mattress was provided to resident #25. The root cause of the fall was identified as equipment failure. - Resident #25 had no documented falls after the air mattress was replaced. During an interview on 4/5/18 at 9:44 a.m., staff member Q stated she would look for a red or a green star over a resident's door to determine who was on the Falling Star Program. She said the star means she was to check on the resident at least every hour for positioning and call light placement. Staff member Q stated she would set up the resident's personal items within easy reach, and be sure the call light was close, because most falls happened because the call light was not within reach. She stated she did not think there was currently anyone on the Falling Star Program on the 200/500 unit. During an interview on 4/5/18 at 2:52 p.m., staff member D stated resident #25 had a fall from her wheelchair on 10/4/17, and a fall from her bed on 10/18/17. She said the root cause of the fall from the bed was the resident kicking her legs over the edge of the bed, and falling out. She stated the bed had not been considered as a factor in the four falls from the bed between 10/18/17, and 2/18/18, because the resident rarely used her bed, and usually sat in her wheelchair. Staff member D said the bed was not identified as the common factor until the fall of 3/11/18, which was the fifth fall out of bed in five months. She stated that at the time of the falls the root cause was identified as resident #25's choice of positioning, or her movements in the bed. Staff member D stated resident #25, who resided on the 200/500 unit, was currently on the Falling Star Program. She said she had checked on Monday (4/2/18) and there was a star on the doorway at that time. Staff member D stated the effectiveness of the interventions was determined by whether a resident continued to fall. She stated continuing the interventions for frequent checks, the Falling Star Program, and 4Ps rounding had not been effective for resident #25. Staff member D stated determining the root cause, and changing the mattress had been effective and resident #25 had no falls since the mattress was changed. She stated she thought she was using the five why's of root cause analysis to establish the cause of falls, but could see that she needed to conduct a deeper investigation. No evidence was provided which indicated the use of the five why's process for any of resident #25's falls.",2020-09-01
304,VILLAGE HEALTH & REHABILITATION,275043,2651 SOUTH AVE W,MISSOULA,MT,59804,2018-04-06,725,E,1,1,5IZ311,"> Based on interview and record review, the facility failed to ensure there was sufficient staffing for residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being, by receiving their preferred twice weekly showers, for 4 (#s 6, 44, 66, 97, and 98 ) of 50 sampled and supplemental residents. Findings include: Resident Interviews and record reviews 1. a. During an interview on 4/2/18 at 4:05 p.m., resident #97 stated there were not enough CNAs to meet her needs. She stated she could not always have two showers a week because there was no shower aide available. Resident #97 stated she wanted two showers per week, every week. Review of resident #97's ADL Verification Worksheet for bathing, dated 1/1/18-4/6/18, showed six weeks in which two showers were not provided. The worksheet documentation showed a shower on 3/16/18, and the next shower on 3/30/18, a span of 14 days between showers. b. During an interview on 4/3/18 at 11:32 a.m., resident #44 stated the facility did not have enough staff, and the bath aides were pulled to the floor. He said no showers were given yesterday or today because the bath aide called off, and there was no replacement. Resident #44 stated he wanted two baths per week. He stated six or seven days between baths was too long. Review of resident #44's ADL Verification Worksheet for bathing, dated 1/1/18-4/6/18, showed five times when the span between baths was six or more days. The worksheet showed a span of 12 days, 3/16/18-3/28/18, between baths for resident #44. c. During an interview on 4/3/18 at 11:42 a.m., resident #6 stated he was scheduled for a shower twice a week, and it was not always done, due to short staffing. Resident #6 stated he wanted to be showered twice every week. Review of resident #6's ADL Verification Worksheet for bathing, dated 1/1/18-4/6/18, showed five weeks when resident #6 did not receive two showers. The worksheet documentation showed a span of 12 days between showers from 3/16/18 - 3/28/18. d. During an interview on 4/3/18 at 1:59 p.m., resident #66 stated, When an aide calls off, they take the bath aide away, and baths were not being done. She said sometimes she had gone a week without a bath. She said she was very upset by that, and wanted two baths a week. Resident #66 stated if the bath aide called off, they were not replaced, and she had to go without her bath. She said anything less than two baths per week was not enough for her. Review of resident #66's ADL Verification Worksheet for bathing, dated 1/1/18-4/6/18, showed three weeks during which resident #66 received only one bath. Staff Interviews During an interview on 4/6/18 at 9:40 a.m., staff member U stated one bath aide had called off all of her scheduled days that week, and the CNAs assigned to resident care were trying to give the showers. She stated the CNAs could not complete all of the scheduled showers, but did the best they could to make sure everyone received at least one shower (for the week). During an interview on 4/6/18 at 9:58 a.m., staff member II, who was assigned to give baths, stated she was often pulled to the floor, to cover for a call off. She stated she was pulled on Monday and could not give baths. She stated she tried to make up the missed baths on another day, but often she could not. Staff member II stated there were, definitely baths missed, and some residents who preferred twice a week baths did not get them. During an interview on 4/6/18 at 2:00 p.m., staff member B stated when the shower aide was reassigned to resident care, the CNAs were expected to check the shower schedule and provide showers to as many residents as possible. She stated the facility tried to avoid pulling the shower aide away from providing showers, but sometimes it was necessary. Staff member B said if a resident missed a scheduled shower, the CNAs were expected to try to provide an unscheduled shower later in the week to make it up. She said showers were only scheduled four days per week to allow an opportunity for making up the missed showers. 2. During an interview on 4/6/18 at 11:45 a.m., resident #98 stated he was supposed to get his baths on Tuesday and Friday of each week. Resident #98 stated when staff can not give him his bath it makes him feel terrible. He stated, I want my bath and I want them to answer my call light. Review of resident #98's Annual MDS, with an ARD of 2/15/18, showed the resident did not resist care, it was very important to choose a bath or shower, was frequently incontinent of bowel and bladder, was at risk for developing a pressure ulcer, and was extensive assistance with his bathing with the support of one person. Review of resident #98's care plan, with an effective date of 3/30/11, showed a problem for assistance with activities of daily living due to weakness and a dementia diagnosis. Interventions listed included staff observing for skin redness or breakdown, toilet and change upon rising and before/after meals, and set up for all cares. The care plan did not address what type of bath the resident preferred, or that he required assistance with his baths. Review of resident #98's ADL worksheet showed resident #98 did not receive a bath/shower as scheduled in (MONTH) of (YEAR) on 1/23/18. The (MONTH) (YEAR) bath/shower schedule showed resident #98 did not receive a bath as scheduled on 2/2/18, 2/9/18, and 2/20/18. The (MONTH) (YEAR) schedule showed resident #98 did not receive a bath as scheduled on 3/20/18 and 3/30/18. Review of the bath and shower schedule showed resident #98 did not refuse his bath for the days he did not receive a scheduled bath. During an interview on 4/4/18 at 1:20 a.m., staff member KK stated she had concerns that the bath aide was pulled to do floor work. She stated this occurred almost daily. She stated it made her feel bad for the residents when they did not get their baths. During an interview on 4/6/18 at 2:15 p.m., staff member B stated host staff are pulled first, and then the bath aide is pulled to the floor. She stated if the bath is missed on the scheduled day it is caught up the next day or two.",2020-09-01
305,VILLAGE HEALTH & REHABILITATION,275043,2651 SOUTH AVE W,MISSOULA,MT,59804,2018-04-06,758,E,0,1,5IZ311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to perform required gradual dose reductions and behavior monitoring, and failed to provide a clinical rational and appropriate diagnosis, for the use of antipsychotic medications, for 4 (#s 21, 48, 70 and 117) of 33 sampled and supplemental residents. Findings include: 1. During an interview and record review on 4/6/18 at 1:10 p.m., staff member DD's notes showed the resident had not had a gradual dose reduction. The use of the antianxiety medication had no appropriate [DIAGNOSES REDACTED]. The resident had been on the antipsychotic since 6/2017. Review of resident #21's Physician visit, dated 3/26/18, showed She has a [DIAGNOSES REDACTED]. Review of resident #21's Quarterly MDS, with the ARD of 12/28/17, showed the daily use of an antipsychotic, antianxiety medication, and an antidepressant. Review of resident #21's Fax Notification form, dated 1/12/18 showed Please consider appropriateness of dose reduction in [MEDICATION NAME], 25 mg at night, and [MEDICATION NAME], 40 mg daily. Intermittent yelling out and [MEDICATION NAME]. The physician replied Lowest dose for patient, will monitor for efficacy. The Physician did not provide a rational for why it was the lowest dose for the resident, or why the GDR would be contraindicated. No dose reduction was requested for the antianxiety medication. The facility did not provide documentation of yelling out or [MEDICATION NAME], which was requested on 4/4/18. During an interview on 4/6/18 at 1:54 p.m., staff member BB stated resident #21 continued to [MEDICATION NAME] about 40 percent of the day shift, despite the three medications. During an observation on 4/4/18 at 2:36 p.m., resident #21 had been asleep most of the day shift. Review of resident #21's Care Plan showed the resident was at risk for adverse drug effects related to the use of [MEDICAL CONDITION] medications, but did not show why the resident was on three [MEDICAL CONDITION] medications. It showed the last gradual dose reduction occurred on 1/15/18, for the antidepressant only. 2. review of resident #117's Annual MDS, with the ARD of 3/1/18, showed the daily use of an antipsychotic, antianxiety, and antidepressant medication. Review of resident #117's Fax Notification form, dated 2/26/18, showed Stable behavioral symptoms for greater than 2 years. History of significant self-abuse. Receiving [MEDICATION NAME] (antipsychotic), [MEDICATION NAME] (antianxiety), trazadone (antidepressant) and duloxetine (antidepressant). The facility requested a GDR for the duloxetine. Review of resident #117's Pharmacy note, dated 3/30/18, showed Duloxetine decreased, no mood or behavior concern recently. No signs of side effect. During an interview on 4/6/18 at 1:15 p.m., staff member DD stated the physician declined the other GDR's because of the decrease in the antidepressant, despite no behaviors in over two years. Review of resident #117's care plan did not address the [DIAGNOSES REDACTED]. 3. Review of resident #48's Quarterly MDS, with the ARD of 1/8/18, showed she received an antipsychotic and an antidepressant daily. Review of resident #48's Fax Notification form, dated 10/18/17, showed Please consider appropriateness of dose reduction in: [MEDICATION NAME] (antidepressant), and Quetiapine (antipsychotic). Timing less than ideal - [MEDICATION NAME] (antianxiety) was discontinued on 9/28/17. The physician replied due to recent med (sic) changes, not appropriate to change now, please reassess in 3- 6 months. Review of resident #48's pharmacy note, dated 11/17/17, showed GDR requested for Florentine and quetiapine. Resident recently tapered off [MEDICATION NAME], discontinued 9/28/17, no increased behavioral symptoms reported thus far, MD states dose reduction is not advised at this time due to recent changes in [MEDICAL CONDITION] medications and continued stability. During an interview on 4/6/18 at 1:25 p.m., staff member DD stated the reduction was contraindicated because of resident #48's impulsive behaviors leading to falls. 4. During an observation on 4/5/18 at 10:40 a.m., resident # 70 came to the nurses station three times in 10 minutes, worried about contacting her daughter, and forgetting each time the staff told her the daughter would be in at 6:00 p.m. that night. Review of resident #70's Quarterly MDS, with the ARD of 2/1/18, showed the resident received an antipsychotic and an antidepressant daily. The MDS's showed the antipsychotic was initiated in (MONTH) of (YEAR). Review of resident #70's fax Notification form, dated, 10/18/17, showed Quetiapine reduction failed 9/2016. Stable since move to secure unit. Occasional anxiety asking for daughters noted. The physician replied Lowest effective dose, please re-evaluate in 3-6 months. Review of resident #70's Nursing Progress notes, showing behaviors for the failure of the medication discontinuation included wheeling to several desks asking about calling daughter, restless about staying here. Very upset wheeling around facility trying find someone to help her call, getting angry about being redirected. Family wishes only one call per day. No further distress noted. And, Resident started with her usual frequent behavior of asking to call her daughter, thinking her daughter does not know she was here and saying she doesn't live here constantly. Had resident call daughter who did not answer phone. Resident became more agitated that she could not reach daughter after calling four times and each time forgot less than a minute later that she had called. The agitation and angry behavior is not resident's usual, therefore, medicated with [MEDICATION NAME] prn. Daughter called back at 7:00 p.m. During an interview on 4/6/18 at 1:30 p.m., staff member DD stated a GDR for the antipsychotic was contraindicated because of meaningful improvement with the antipsychotic, a GDR had failed to times prior, and the family's preference.",2020-09-01
306,VILLAGE HEALTH & REHABILITATION,275043,2651 SOUTH AVE W,MISSOULA,MT,59804,2018-04-06,760,D,0,1,5IZ311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors, by not following manufacturer's instructions for the timing of insulin administration for 2 (#s 35 and 144) of 50 sampled and supplemental residents. Findings include: 1. Observations and Orders Review a. During an observation on 4/4/18 at 10:21 a.m., staff member S obtained a blood glucose reading for resident #35. Resident #35's blood glucose was 163. Staff member S administered 20 units of [MEDICATION NAME] to resident #35. Review of resident #35's (MONTH) (YEAR) physician's orders [REDACTED].#35 had an order for [REDACTED].>b. During an observation on 4/4/18 at 10:27 a.m., staff member S obtained a blood glucose reading for resident #144. Resident #144's blood glucose was 136. Staff member S administered 6 units of Humalog (fast-acting) insulin. Review of resident #144's (MONTH) (YEAR) physician's orders [REDACTED].#144 had an order for [REDACTED].>2. Manufacturer's Instructions Review a. Review of the manufacturer's instruction for [MEDICATION NAME]showed the recipient was to, Eat a meal within 5 to 10 minutes after taking it. b. Review of the manufacturer's instructions for Humalog insulin showed: Fast-acting insulin (also called rapid-acting) is absorbed quickly and starts working in about 15 minutes to lower blood sugar after meals. Humalog fast-acting insulin should be taken 15 minutes before eating or right after eating a meal. 3. Interviews During an interview on 4/4/18 at 1:59 p.m., staff member B stated medications could be given up to an hour before or an hour after the scheduled administration time. She stated there were some medications that were exceptions to this rule. Staff member B stated giving residents #35 and #144 the fast-acting insulin within the one-hour timeframe was acceptable. She then clarified that she was referring to a scheduled dose of insulin, not insulin ordered as a sliding scale. She stated administration 30-40 minutes prior to a meal was acceptable for a sliding scale dose. After review of the manufacturer's administration instructions, staff member B stated it was not the expectation for the staff to give resident #35 and #144 their insulin according to the timeframe's shown in the instructions. She stated that portion of the instructions could be disregarded. During an interview on 4/4/18 at 1:51 p.m., staff member S stated [MEDICATION NAME] was a short-acting insulin, and should be given shortly before meals. She stated it was ordered to be given at 11:00 (a.m.,) and was usually given at ten something. She could not state what the manufacturer recommended for administration timing in relation to meals. She said lunch was served at 11:00 a.m. During an interview on 4/6/18 at 9:13 a.m., staff member B stated the facility provided medication administration training and conducted audits to verify competency. She stated the training and audits did not include the timing of insulin administration in relation to meals being given.",2020-09-01
307,VILLAGE HEALTH & REHABILITATION,275043,2651 SOUTH AVE W,MISSOULA,MT,59804,2018-04-06,761,E,0,1,5IZ311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility staff failed to return expired medications to the pharmacy for disposal, failed to label medication with opening dates, mislabeled medications with inaccurate dates, and failed to identify the facility pharmacy labels showed a drug expiration date different than the manufacturer's expiration date, causing confusion as to when medications required disposal. These failures had the potential to effect all the residents receiving facility pharmacy labeled medications. Findings include: During an observation on 4/4/18 at 4:10 p.m., with staff member C, of the medication storage room on the 300/500 hall, a carton of [MEDICATION NAME] purified protein derivative 5 TU/0.1 ml was found opened with the carton labeled opened on 12/20/17. The [MEDICATION NAME] medication vial inside of the carton was labeled with an open date of 3/20/18. Staff member C stated the facility policy was to dispose of medications after they had been opened for thirty days. After observing both carton and vial open dates, the staff member took the medication saying she would dispose of it. During an observation on 4/4/18 at 4:40 p.m., in the medication storage room on the 100 hall, with staff member L, an [MEDICATION NAME] Diskus of 60 blisters 250/50 was found opened and labeled with an opened date of 2/26/18. It was also labeled with use by 3/24/18. The outdated medication was taken by staff member L to go to the pharmacy for disposal. During an observation and interview on 4/4/18 at 4:40 p.m., in the medication storage room, with staff member L, on the 100 hall, a bottle of [MEDICATION NAME] solution 1 mg/ml was found. The bottle had been opened and was not labeled with an opening date. The pharmacy label, in the lower right corner, showed Exp. 3/06/19. The bottle also had a manufacturer's expiration date of Sep 2020. Staff member L said he did not know what expiration date was to be used to determine the required discard date for the bottle. He said he didn't know why the pharmacy label date was not the same date as the manufacturer's expiration date. He said he did not pay attention to the pharmacy label date and the question as to which date to use had not been brought up before. He did not know if the facility had a policy or procedure that addressed medication expiration dates. During an interview on 4/5/18 at 3:00 p.m., with staff member K was administering medication from a medication cart on the 300's hall, she said she was aware that the facility medications had two different expiration dates. She said she returned medications to the pharmacy on the expiration date shown on the facility pharmacy label. She said she did not know if the facility had a policy showing which expiration date to use. During an observation on 4/5/18 at 3:39 p.m., staff member I said he would use the earlier date of the two different medication expiration dates to decide when to discard the medication. He said he would do it that way to avoid the potential of administering an outdated medication to a resident. He said he did not know which of the two dates the facility policy showed to use to determine if a medication was outdated. During an interview on 4/4/18 at 4:50 p.m., staff member B was shown several medications with facility pharmacy labels and expiration dates different from the manufacturer's expiration date. She said she had been unaware that the facility pharmacy labels had a drug expiration date. She said the facility did not have a policy as to what expiration date to use to determine when to discard the medication. She said she would have to discuss the matter with the facility's pharmacist. During an interview on 4/5/18 at 11:40 a.m., staff member M said the expiration date in the lower right corner of the facility pharmacy labels is the one year date after the medication was dispensed from the facility pharmacy. In the past the facility policy was to discard all unused medication one year after it had been dispensed. She said the dating was computer generated and serves no purpose at this time. She said the present facility policy was to discard the medication according to the manufacturer's expiration date. She said having two different dates on the medication could be confusing especially if the person administering the medication did not realize that the bottle had two expiration dates. During an observation and interview on 4/5/18 at 3:39 p.m., of the medication storage room, on the 800 hall, with staff member I, a 50 ml vial of sterile water for injection was found among dressing supplies. It was half empty and not labeled with an opening date or a resident's name. It could not be determined if the medication had been opened for more than 30 days. Also found were two opened, half empty bottles, of acetic acid 0.25% irrigation solution. Neither bottle was labeled with a resident's name or an open date. A Pro Air HFA inhaler was found opened and labeled with a resident's name. Handwritten dating on the label showed the medication was opened on a date that had not yet occurred, and the handwritten use by date was a date that would have occurred before the open date. Staff member I said the open date had to be incorrect. If the only date noted by a staff member was a label expiration date earlier than the manufacturer's expiration date, the potential existed for the medication to be disposed of prior to it's actual outdate. If the only date noted by a staff member was a label expiration date later than the manufacturer's expiration date the potential existed for a resident to be administered a medication after it's manufacturer's expiration date.",2020-09-01
308,VILLAGE HEALTH & REHABILITATION,275043,2651 SOUTH AVE W,MISSOULA,MT,59804,2018-04-06,803,D,0,1,5IZ311,"Based on interview, observation, and record review, the facility failed to follow the menu for a resident who had a finger food diet order, which failed to maximize the resident's ability to self-feed, which contributed to a significant undesirable weight loss related to poor meal intakes, for 1 (#75) of 33 sampled residents. During an observation on 4/2/18 at 12:23 p.m., resident #75 was served beef stew in a coffee mug, and a glass of milk. Resident #75 was unable to drink or eat the stew out of the mug. Her neck hit the top of the table, interfering with her ability to self feed. The resident was observed to have difficulty raising her arm(s) to her plate of food. Review of the facility menu and spread sheet for the lunch meal on 4/2/18, showed a Finger food diet should be three ounces of beef tips, 1/2 cup of potatoes, and tomato wedges. Review of resident #75's Annual MDS, with the ARD of 1/28/18, showed she had severe cognitive impairment. Review of resident #75's diet order showed Regular, Finger food, and 1/2 portions. During an observation and interview on 4/3/18 at 8:17 a.m., resident #75 received scrambled eggs and mandarin oranges. She did not attempt to pick up the scrambled eggs with her fingers. No assistance was provided by staff for the meal. Staff member Z stated resident #75 was resistive to assistance, and would strike out. Resistiveness to care was not on resident #75's Care Plan. During an observation on 4/3/18 at 12:16 p.m., resident #75 was served sliced chicken for her entree. Her plate had a silver metal plate guard placed on it so the food would not be pushed off the side of the plate. The plate guard did not assist the resident with using her fingers while eating, but rather, it appeared to block her hands and fingers from the plate. Review of resident #75's Care Conference note, dated 2/8/18, showed the family thought the plate guard might help resident #75 eat better because she could not see well. During an observation on 4/4/18 at 12:32 p.m., resident #75 was served sliced chicken cooked in ranch seasoning. The menu called for a cut beef patty and broken spaghetti. During an observation of the dietary tray-line on 4/4/18 at 4:43 p.m., staff member AA stated she had sliced chicken prepared for the residents on the finger food diet. The menu called for chicken quesidillas. During an observation on 4/6/18 at 12:10 p.m., resident #75 received a brownie that was soaked in milk for dessert. Staff member GG exchanged the brownie for one that could be eaten with the resident's fingers. Review of resident #75's Nutrition Care Plan showed she had experienced a significant undesirable weight loss related to poor meal intakes. Interventions included, assist with meals as needed; include in food related activities; provide requested foods as able; provide nutrition supplements as ordered; provide 1/2 meal portions; assist with meals at times related to poor eyesight; offer alternative food if less than 50% of meal eaten. Review of resident #75's meal intake record showed: 4/2/18 - 50 percent intake for breakfast, 10 percent intake for lunch and dinner; 4/3/18 - 25 percent intake for breakfast, lunch and dinner; 4/5/18 - 50 percent intake for breakfast. During meal observations on 4/2/18 and 4/3/18, no alternative foods were offered to resident #75. During an interview on 4/5/18 at 8:14 a.m., staff member [NAME] stated it was the dietitian's responsibility to monitor the effectiveness of the approaches for weight loss, including evaluating likes and dislikes. During an interview on 4/4/18, staff members GG and FF stated they did not complete meal rounds for monitoring of meals. Staff member X stated she did periodic rounds to monitor for correct textures.",2020-09-01
309,VILLAGE HEALTH & REHABILITATION,275043,2651 SOUTH AVE W,MISSOULA,MT,59804,2018-04-06,867,I,0,1,5IZ311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collect measurable data, to be used during the QAPI process to identify quality deficient areas and practices, and to ensure interventions that were used to prevent falls were effective; and, failed to identify the facility staff and IDT were not identifying direct root causes for falls, for the future prevention of falls, for 5 (#s 25, 75, 98, 146, and 164) of 50 sampled and supplemental residents. Findings include: During the QAPI interview on 4/5/18 at 11:38 a.m., staff member B and D were asked for the facility process for identifying concerns, collecting data, formulating interventions, and monitoring for compliance, in regards to resident falls in the past year. Staff member D stated they had falls identified as a concern and were monitoring in QAPI. Staff member D stated falls were discussed monthly, including the times of falls, what unit, what shift, and what hall. Staff member D stated the team was coming up with ideas for interventions. She stated the team has always included falls as an identified concern in QAPI. She stated the Stop and Watch program was put into effect in (MONTH) of (YEAR). When asked what measured data the facility looked at to see if the Stop and Watch program was effective in reducing falls, staff member D stated, We don't have measured data for Stop and Watch to show it was effective. Staff member D stated the team was measuring the number of falls in a month, and the number of hospitalization s, because of the number of injuries with falls. She stated they asked for staff feed back regarding if the staff felt the interventions were working. The Falling Star Program was not mentioned, and no documentation was provided to show the Falling Star Program was monitored or implemented by the QAPI Committee. Resident concerns included: - Review of resident #25's medical record and documentation for the resident's repeated falls (four falls in less than two months), from her bed, showed the facility failed to consider the bed as a contributing factor, to include the resident's position on the bed. It was not until the resident's fourth fall that the IDT considered these factors. - Upon review of the medical records for resident #75 and #146, and fall documentation, it was identified the facility failed to identify the root cause of 31 falls, and the facility did not monitor or modify interventions to reduce the number of falls. The QAPI Committee process failed to identify individualized resident-specific fall concerns. The following was found: Review of the facility report, Occurrence Type, Falls, showed resident #75 fell 11 times from 4/22/17 through 4/5/18. Review of the facility's Falling Star program, showed the residents involved in the program would have a green star on the resident's door. Review of resident #75's medical record and Occurrence Reports, for falls, showed the resident sustained [REDACTED]. Of the falls identified, the facility failed to identify direct root causes for the repeated falls. The resident had poor cognition and recall, and put herself at risk. Interventions implemented did not correlate to the direct root causes of the falls, and individualized interventions were not monitored for effectiveness from one fall to the next. The same interventions were implemented after several falls, although the interventions were shown to be ineffective, per the medical record. During an observation on 4/5/18 at 4:40 p.m., resident #75's door did not include a green star. - Resident #146 had 20 falls from 2/14/18 to 3/27/18. Review of the Physical Therapy discharge summary, dated 3/26/18, did not address the frequent falls, or the resident's ability to get off the floor independently. Review of resident #146's Care Area Assessment from the Admission MDS, with the ARD of 2/19/18, showed the resident was at risk for falls, and his knees would buckle. This was not identified in the Occurrence Reports. Review of resident #146's 30 day MDS, with the ARD of 3/11/18, showed the resident used an antianxiety medication and a hypnotic, on a daily basis. These medications can contribute to the risk for falls, and were not addressed in the Occurrence Reports. During an interview on 4/5/18 at 11:38 a.m., staff member D stated frequent checks and increased supervision, which were documented as interventions for the residents, were not documented in the electronic records. Review of the QAPI data submitted by the facility showed falls were an identified concern. The data showed categories for: type of fall, location of fall, and the shift the fall occurred on. The information gathered under the category location showed there were 41 falls, five with an injury, in resident rooms. There was no data to show why the falls were occurring in the resident rooms on the report. Staff member D stated the falls in the rooms were looked at individually, on the occurrence reports, and then discussed. There was no trending available for review to show patterns were identified for falls in resident rooms. Review of the root cause analysis process for the falls cited during the survey showed the facility IDT did not identify true root causes of resident falls. Review of resident #98's medical record, for falls, showed the fall on 10/12/17 showed the root cause was identified to be staff not following the resident's care plan and leaving him in the bathroom without supervision. Review of the resident's Occurrence Report for the 10/12/17 fall showed the root cause analysis was, due to resident action or internal risk factors. Review of resident #164's medical record showed the staff failed to adequately supervise the resident while hooked to a lift which resulted in a fall on 11/29/17. Resident #164 sustained a laceration to his neck, which required evaluation and treatment in the ER. Review of the resident's occurrence for the 11/29/17 fall showed the root cause of the fall was due to resident action or internal risk factors. The facility failed to identify the true root cause of the fall. Documentation showed the CNA did not stay in the room and supervise the resident while he was hooked up to the lift and left on the commode, although the resident was a fall risk. During an interview on 4/5/18 at 8:20 a.m., staff member B stated residents should always be supervised when in a lift. She stated the fall was unusual, and the resident was frustrated by using the lift. Staff member B stated education was provided regarding safety. The facility did not provide documentation of the education. Review of the facility Occurrence Type, Fall report, dated 10/24/17 through 3/26/18, showed 184 residents had one or more falls in that time frame. Refer to F689 Accidents and Hazards for more detail relating to falls.",2020-09-01
310,VILLAGE HEALTH & REHABILITATION,275043,2651 SOUTH AVE W,MISSOULA,MT,59804,2018-04-06,880,E,0,1,5IZ311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a sanitary environment to help prevent the development and spread of infection, during a transfer for 1 (#112); and failed to ensure a resident had knowledge of infection control practices when managing a catheter for 1 (#49) of 50 sampled and supplemental residents; and failed to clean a lift after removing it from a room that was under precautions for [MEDICAL CONDITION] infection, which had the potential to affect any resident who had the lift used for transfers, after the lift had been used by the resident with the infection. 1. During an observation and interview on 4/3/18 at 10:15 a.m., staff member OO assisted resident #112 with a Hoyer lift transfer from her bed to her electric wheelchair. Resident #112 was on precautions for [MEDICAL CONDITION] and staff were to don a gown and gloves prior to entering the room. Staff member OO did not have her gown tied at the top. While staff member OO was assisting resident #112, and placing the sling under the resident, the staff member frequently pushed the top of her gown up with her contaminated gloved hands, touching her clothing under the gown and her hair. After, staff member OO stated she should have tied her gown at the top to prevent cross-contamination of her clothing and her hair. When resident #112 was positioned in her chair, staff member NN pushed the Hoyer lift out into the hallway and moved it down the hallway to a recessed area between two other lifts. Staff member NN did not disinfect the lift after she brought it out of the resident's room. Staff member NN stated she should have wiped the lift down after she brought it out of the resident's room to prevent cross-contamination. Disinfectant wipes were observed to be available, on the lift, at the time of the observation. 2. During an interview and observation on 4/3/18 at 1:38 p.m., resident #49 stated he emptied his own catheter bag, and completed his own toileting, including perineal care, except when he had an episode of bowel incontinence. He stated he was hospitalized for [REDACTED]. Resident #49 stated he did not use an alcohol prep pad or other disinfectant when opening the catheter port. He stated he had not been taught to do that. There were no alcohol prep pads observed in resident #49's room. Review of resident #49's hospital discharge summary, dated 10/12/17, showed the presence of a urinary tract infection. Review of resident #49's clinical note, dated 1/23/18, showed the resident experienced frequent UTI's. Review of resident #49's Physician order [REDACTED]. Review of resident #49's Care Plan Report, with an effective date of 10/19/15 - present, showed an intervention for resident #49 to complete his own catheter care, and an intervention for the facility to provide supplies for resident #49, to complete his catheter care. During an interview on 4/5/18 at 9:30 a.m., staff member T stated nurses provided the care to the catheter insertion site, and the CNAs emptied catheter bags and did perineal care. During an interview on 4/5/18 at 9:35 a.m., staff member B stated perineal care and the emptying of the catheter bag was done by CNAs, and catheter insertion site care was done by the nurses. During an interview on 4/6/18 at 11:30 a.m., staff member R stated resident #49 provided his own perineal care and emptied his own catheter bag. She stated she was routinely assigned to care for resident #49 and he did not need toileting assistance from staff except when he had an incontinent bowel movement. A written request was made for evidence that resident #49 had been educated regarding infection control techniques to utilize when emptying his catheter bag, and evidence of monitoring of his performance of the infection control techniques. The evidence provided was a statement that resident #49's catheter care was signed, on the TAR, as being completed by a nurse, and the (MONTH) (YEAR) TAR which showed a treatment for [REDACTED].",2020-09-01
311,VILLAGE HEALTH & REHABILITATION,275043,2651 SOUTH AVE W,MISSOULA,MT,59804,2018-04-06,919,D,1,1,5IZ311,"> Based on observation and interview, the facility failed to ensure access to the call light system for 1 (#119) of 33 sampled residents. Findings include: During an observation and interview on 4/2/18 at 11:35 a.m., resident #119's call light was clipped to the blanket, near the foot of his bed. Resident #119 stated, They put it there all the time. He stated he could not reach it. Resident #119 stated if he needed anything he just had to wait for someone to come along. There was an observed two-foot gap from the foot of the bed to the wall. During an observation on 4/3/18 at 8:59 a.m., resident #119's bed had the same gap between the foot of the bed and the wall, as observed on 4/2/18. The call light cord could not reach far enough to be used by the resident in the position it was observed in. During an observation on 4/4/18 at 7:42 a.m., staff members U and JJ transferred resident #119 from his bed to his wheelchair. His call light was clipped to the blanket, near the foot of his bed. The same gap was noted between the foot of the bed and the wall. At 7:51 a.m., staff member JJ pinned the call light to the blanket approximately 2/3 down the length of the bed. The call light cord was stretched tight. Staff member U stated it was not the usual placement for the call light, saying, No, it's usually here. As she spoke, she touched a spot over 1/3 the way down the length of the bed. She was unable to demonstrate the usual placement because the cord would not reach the spot she had touched. She then proceeded to push the foot of the bed close to the wall, moving it over two feet. The call light then reached the position the CNA had touched. In this position, the call light could be reached if the resident was in some positions in the bed, but not if he was lying on his left side. During an interview on 4/5/18 at 9:44 a.m., staff member Q stated resident #119's call light cord was not long enough. She stated if the cord was pulled as far as possible, he could reach it from some positions in his bed. Staff member Q stated she had not reported the need for a new cord, and was not sure why she had not. She stated staff member C would probably be the person she reported her concern to. During an interview on 4/6/18 at 1:20 p.m., staff member C, stated she was not aware of the issue with resident #119's call light, but she would take care of it. During an interview on 4/6/18 at 2:00 p.m., staff member B stated resident #119 should have had his call light within reach. She stated if a call light cord was too short, the room configuration should have been changed or a maintenance slip should have been completed to get a longer call light cord, which was available at the time. During an interview on 4/6/18 at 3:10 p.m., staff member C stated she had replaced resident #119's call light with a longer cord, and he could now reach the call light, while in any position in his bed.",2020-09-01
312,VILLAGE HEALTH & REHABILITATION,275043,2651 SOUTH AVE W,MISSOULA,MT,59804,2019-05-16,558,D,0,1,30M611,"Based on observation, interview, and record review, the facility failed to allow 1 (#3) of 42 sampled residents the choice of arranging her/his room. Findings include: During an observation and interview on 5/13/19 at 2:21 p.m., resident #3 stated she did not have enough room. The resident pointed out the roommate's head board was pushing up against the privacy curtain, encroaching into resident #3's portion of the room. The privacy curtain was raised and ruffled, due to the roommate's frame of the bed being pushed into the curtain. Resident #3 wanted the curtain to fall nicely, not bunched up due to the roommates furniture. Resident #3 stated staff would enter into her portion of the room to shut off the call light when the roommate turned on the call light. The staff could not reach the switch for the call light from her roommate's side of the room, due to the fact the roommate's headboard was in the way. The resident stated she should not be interrupted when she had not used the call light. She felt staff did not need to enter her part of the room if she did not call for them. Resident #3 showed two plastic tubs, filled with various items, she had on the floor against the wall. The tubs were next to her dresser and the divider curtain. The resident stated she had trouble reaching the tubs and she used the items in the tub. She wanted to move her bed and dresser so there would be more room to get to her things. She stated she had a difficult time bending over, reaching for the items on the floor. Resident #3 had talked to a staff member about moving around her portion of the room to make it more convenient and private on her side. Per the resident, the staff member, she had spoken to, stated she/he would talk to someone about moving her side of the room around. Resident #3 stated, someone was to come in and discuss her idea, but no one came. The resident stated she had asked some time ago and felt the staff should have taken care of her concern by now. During an interview on 5/15/19 at 8:30 a.m., staff member A stated, residents had the right to move their portion of the room around if by doing so did not endanger the resident or roommate. Review of the policy, Accommodation of Needs, showed the facility should evaluate and make reasonable accommodations for the individual needs and preferences. The facility would try to make accommodations to individualize the physical environment including their bedroom and bathroom. The facility staff would make efforts to accommodate the needs and preferences of the resident and would assist in, maintaining or achieving independent functioning, dignity, and well being to the extent possible.",2020-09-01
313,VILLAGE HEALTH & REHABILITATION,275043,2651 SOUTH AVE W,MISSOULA,MT,59804,2019-05-16,656,D,0,1,30M611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to identify a care need, and then carry over the concern to the resident's comprehensive care plan, and implement a plan to address the problem, goals, or approaches staff may use to assist the resident with pain management, for 1 (#70) of 42 sampled residents. Findings include: During an interview on 5/13/19 at 2:56 p.m., resident #70 complained of left arm pain. During an interview on 5/16/19 at 8:14 a.m., staff member P stated resident #70 asked for a [MEDICATION NAME], daily, for pain, and the resident was on scheduled [MEDICATION NAME] for pain as well. During an observation and interview on 5/16/19 at 8:05 a.m., resident #70 was eating breakfast in bed, rubbing his left arm in discomfort. Resident #70 stated he was in pain, but not as bad as it was yesterday. Resident #70 stated the day prior on 5/15/19, he had experienced extreme pain located in his arm, shoulder, back, and hips. Resident #70 had asked four different CNAs for pain medication. All CNAs responded saying there was not a nurse to administer his pain medication. Resident #70 reports he had to wait approximately two hours and forty-five minutes to receive his pain medication. Review of resident #70's MDS, with an ARD of 3/27/19 and also on 12/13/18 showed resident #70's rated his pain level at a 7/10 and the pain limited his day to day activities due to the pain. Review of resident #70's Medication Administration Record [REDACTED] -[MEDICATION NAME] extended release 15 mg once a day at bedtime, -[MEDICATION NAME] extended release 30 mg every eight hours, -[MEDICATION NAME] 10-325 mg two tablets every four hours as needed. Review of resident #70's Care Plan, dated 6/5/18-present, showed no problems, goals, or approaches for the resident's pain management. Refer to F697 related to the failure to address the resident's pain adequately.",2020-09-01
314,VILLAGE HEALTH & REHABILITATION,275043,2651 SOUTH AVE W,MISSOULA,MT,59804,2019-05-16,660,D,0,1,30M611,"Based on interview and record review, the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals for 1 (#70) of 42 sampled residents. Findings include: During an interview on 5/13/19 at 3:03 p.m., resident #70 expressed he wanted to move out, but no one would help him. During an interview on 5/16/19 at 7:57 a.m., staff member N stated resident #70 wanted to leave the facility to possibly go to an assisted living facility. Staff member N stated resident #70, and his power of attorney, do not get along, and resident #70 is indecisive. Staff member N stated that a discharge plan would be discussed and then documented during care conferences and placed in the notes. During an interview on 5/16/19 at 9:22 a.m., resident #70 explained he had not wanted to return to the same assisted living that he had resided in prior to admission. Resident #70 stated he would have liked to have gone to another assisted living. The staff transport driver had told him there were about 42 assisted living options around Missoula. He stated he had discussed with social services the desire to discharge about six months ago. Recently he had left messages to speak with social services about his options, but had not seen anyone from social services in a couple of months. Review of resident #70's MDS, with an ARD of 3/27/19, showed a Brief Interview of Mental Status score of 15, showing the resident was cognitively intact, and able to make his own decisions. Review of resident #70's Care Plan, dated 6/5/18-present, showed an identified problem for resident #70, which was the resident wanting to look at alternative living options in the future, and a goal of the resident and family being assisted with discharge planning. The goal date was 3/22/19. Review of resident #70's Care Conference notes, from 9/06/18, 1/08/19, and 3/04/19, showed the following: -On 9/06/18 there was a plan in place for resident #70 to discharge back to an assisted living, -On 1/08/19 it showed resident #70 transitioned to long term care and may want to look into alternative living options in the future, -On 3/04/19 it showed that resident #70 (MONTH) want to look into alternative options in the future. Review of resident #70's Care Plan dated 6/5/18-present showed that the social service director was responsible for the following: -Discharge planning assessment, -(Resident #70) will actively participate in making choices and decisions for care, -Educating resident and family/power of attorney of who to contact for support after discharge -Educate on community resources and placement options, -Educate on services provided from the community, -Make referrals appropriate to needs and requests. Review of residents Clinical Note, dated 4/12/19, showed social services was notified that resident #70, and the power of attorney ,that the resident's Medicare A therapy would be ending on 4/15/19. There was no documentation for a plan for discharge in the note. Review of the resident #70's Care Conference notes showed the resident had been discharged from the rehabilitation unit, to long term care, on 1/08/19. There was no documentation showing the facility staff had discussed discharge plans with resident #70.",2020-09-01
315,VILLAGE HEALTH & REHABILITATION,275043,2651 SOUTH AVE W,MISSOULA,MT,59804,2019-05-16,677,D,0,1,30M611,"Based on observation, interview, and record review, the facility failed to provide the necessary ADL assistance for a resident who required assistance with bowel and bladder care, which caused the resident to be incontinent for 1 (#104) out of 42 sampled residents. Findings include: During an observation and interview on 5/14/19 at 11:01 a.m., resident # 140's call light had been ringing since 10:21 a.m. The resident stated she had put her call light on at 10:14 a.m. to use the commode. Resident #140 had documented the time she turned on the call light, which was 10:14 a.m., in a spiral note book on her side table. Resident #140 stated, I can only last so long holding myself before I just start peeing. Resident #140 stated staff member R came into the room to answer the resident's call light but requested him to find a female caregiver to assist her to the commode. Resident #140 stated staff member R stated he would go and try to find somebody to help the resident to the commode. Resident #140 stated, He (staff member R), never came back to let resident #140 know if he had found anyone to take her to the commode. Staff member F came into the room during the interview with resident #140 and asked resident #140 if she needed help. Resident #140 did not answer right away. Staff member F returned a few minutes later with staff member G, who also asked resident #140 if she could help her. The resident stated, I have been waiting for help to get to the commode. Staff member G stated that she could help her, and resident #140 stated she had been waiting so long that she already wet her pants. Resident #140 began raising her voice towards the staff in frustration. Staff member F stated they could help her get cleaned up, and resident #140 stated Just go find me (staff member R). Both staff member F and G left the resident's room neither returned, nor did staff member R, to inform resident #140 if he had found someone to help her to the commode. Resident #140 stated, It makes me feel uncomfortable when I have to wait so long, and that I hope the staff hurry up and come. Resident #140 stated she would be continent if the staff would answer her light faster. Resident #140 stated, It's disgusting to have to sit in your own filth, especially when I have had a bowel movement in my panty. Refer to F600 for neglect of care related to this event. During an observation on 5/14/19 at 11:24 a.m., no staff had returned to toilet resident #140, and she sat in a soiled attend through her lunch. Review of resident #140's Care Plan, dated 8/8/16-present showed the (resident #140) requires assistance with activities of daily living due to previous right foot fracture, chronic pain, obesity, history of falls, weakness, obstructive sleep apnea, and limited mobility. The facility did not address the extent of the resident's needs related to her ADL care for bowel and bladder assistance and preferences. A review of the facility's policy titled, Accessible Call Lights, dated 10/30/18, showed under the heading .Compliance guidelines .The facility's physical environment and staff behaviors should be directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity, and well-being to the extent possible in accordance with the resident's own needs and preferences.",2020-09-01
316,VILLAGE HEALTH & REHABILITATION,275043,2651 SOUTH AVE W,MISSOULA,MT,59804,2019-05-16,697,D,0,1,30M611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to treat, monitor, and manage the resident's pain to the extent possible in accordance with the comprehensive assessment, current professional standards of practice, and the resident's goals and preferences for 1 (#70) of 42 sampled residents. Findings include: During an interview on 5/13/19 at 2:56 p.m., resident #70 complained of left arm pain. During an interview on 5/16/19 at 8:14 a.m., staff member P stated resident #70 asked for a [MEDICATION NAME] for pain daily and was on scheduled [MEDICATION NAME] for pain as well. During an observation and interview on 5/16/19 at 8:05 a.m., resident #70 was eating breakfast in bed, rubbing his left arm in discomfort. Resident #70 stated he was in pain, but not as bad as it was yesterday. Resident #70 stated the day prior on 5/15/19, he had experienced extreme pain located in his arm, shoulder, back, and hips. Resident #70 had asked four different CNAs for pain medication. All CAN's responded saying there was not a nurse to administer his pain medication. Resident #70 reports he had to wait approximately two hours and forty-five minutes to receive his pain medication. Review of resident #70's MDS reference date of 3/27/19 and 12/13/18 showed resident #70's rated his pain level at a 7/10 and limited his day to day activity because of pain. Review of resident #70's Medication Administration Record [REDACTED] -[MEDICATION NAME] extended release 15 mg once a day at bedtime, -[MEDICATION NAME] extended release 30 mg every eight hours, -[MEDICATION NAME] 10-325 mg two tablets every four hours as needed. Review of (MONTH) 2019 Medication Administration Record [REDACTED]. On 6 out of 15 days there are several non-pharmacological interventions listed including: repositioning, dim light, quiet, and distraction, relaxation, and music/TV. Review of resident #70's Medication Administration Record [REDACTED]. The [MEDICATION NAME] is administered more frequently in the morning from 7 a.m. and 10 a.m. and in the afternoon from 2 p.m. and 6 p.m. Review of resident #70's Medication Administration Record [REDACTED]. [MEDICATION NAME] was administered at 7:39 a.m. for left shoulder pain. Two hours later at 9:39 a.m., the results were noted to be a pain level of 5/10, but had not sufficiently dropped the resident's pain level. Later that afternoon, resident #70's pain level was rated at a 7/10 at 1:43 p.m. and the non-pharmacological interventions showed dim light. Results at 3:43 p.m. showed the interventions were effective. No pain scale was documented to show the resident had stated the medication or the intervention of the dim lights was effective to decrease the pain. Review of resident #70's Medication Administration Record [REDACTED]. [MEDICATION NAME] 2 tablets were administered at 6:52 am. At 8:52 am it was noted the resident experienced no relief and the non-pharmacological pain intervention was listed as quiet. Review of (MONTH) 2019 Treatment Record, Resident #70 reported 7 out of 30 days his pain level was at or below a 5/10 and 4 out 30 days he reported his pain level at a 0/10. The other 23 days resident #70 rated his pain above a 5/10, showing his pain was not managed with the current pain medication regimen. Review of (MONTH) 2019 Medication Administration Record [REDACTED]. The facility had not identified the trending/patterns for which the resident was using the [MEDICATION NAME] more frequently, to include an alternate pain medication option, or change the current medication regimen, to assist with alleviating the resident's pain. Review of resident #70's Care Plan dated 6/5/18-present, showed no problems, goals, or approaches for pain management. Refer to F656 related to the failure to have a comprehensive care plan to address resident #70's pain.",2020-09-01
317,VILLAGE HEALTH & REHABILITATION,275043,2651 SOUTH AVE W,MISSOULA,MT,59804,2019-05-16,812,E,0,1,30M611,"Based on observation, interview, and record review, the facility failed to clean and maintain the kitchen to ensure sanitation in the kitchen areas, creating a potential for food-borne illness for all residents living at the facility. Findings include: 1. During observation and interview on 5/13/19 at 2:25 p.m., at the initial tour of the kitchen, areas of concern were: - The metal poles supporting the large exhaust fan, which was located above the ovens, grill, steamer, had greasy, black dust blowing from kitchen fan. - The plate warmer had food crumbs and splatters of whitish spots. Clean plates were upright in the warmer and the metal surface of the warmer was hot. A plate, sitting on top of the warmer, had a dried, dark greenish wrinkled leaf on it. - The dry storage room thermometer read beyond 80 degrees, which was the highest marking on the thermometer. The room air was hot. Staff member B stated the room was generally not hot. He was not sure why the room was so hot today. - The refrigerator fan vents and piping, located above the reach in refrigerator and across from the steam table, had long dark, greasy dust attached. There was no guard across the front to prevent from contamination of foods pulled out of the refrigerator or foods on the stream table. - Drops of clear oily, grease were on the side of the overhead exhaust fan, above the grill. - Black greasy dust and buildup was on the back of the convection oven. The back of the convection oven was next to and above the large heated soup vat. The large vat's sides were spotted with a build up of food splatter. -The manual can opener, attached to the back preparation table, had a build up of food and metal shavings. - There was a buildup of ice droplets on the ceiling of the walk-in freezer. Frozen drops of ice were located on the fan guards, and large 3/4 inch thick ice patches were scattered on the freezer's floor walk area. The freezer showed 25 degrees when entered and within four minutes from entering the thermometer on the outside of the freezer door read, 95 degrees, on exit. - The convection oven had dried food on the top of the oven. Large, burnt, bubbled up blobs of cooked food and food spills were on the inside bottom of the Vulcan oven. The Blodgett oven had greasy food particles and a thin layer of oil on the inside bottom. - There were no light guards on a three light fixture, above the juice and coffee stations. - A black tub completely filled with dingy, murky water was located on the floor under the clean portion of the dish machine line. Staff member B stated the dish washer counter was warped, so a hole was drilled to release stagnant water. The water dropped to the floor prior to the black tub. The black tub was placed to catch the stagnant water sitting on the floor. The staff member B stated the tub should be emptied daily. 2. During a kitchen observation and interview on 5/14/19 at 7:46 a.m., the pressure pipes, attached to the steamers, located in front of a preparation table, had visible white dried, flaked deposits and food particles over the hoses and gauges. During an observation on 5/14/19 at 7:55 a.m., the dish machine's final rinse was observed at 164 degrees. The dish machine was observed running the cycle twice, prior to checking the final rinse temperature. The dish machine was being used to wash room water pitchers. The next final rinse showed the temperature to be at 172 degrees. Staff members D and [NAME] did not know what temperature the rinse cycle needed to be at in order to sanitize the dishes. The staff members did not know how to test the dishes, to see if the dishes were being sanitized. Staff member C stated and showed staff members D and [NAME] how to use the facility's protocol for checking the sanitization of the dish machine. The final rinse showed 187 degrees and the strip placed on a baking sheet came out black, the appropriate color. 3. During observation and interview in the main dining room: - 5/13/19 12:15 p.m. the salad cart was left unattended, unsupervised, uncovered, and in the line of residents exiting the dining room. - 5/14/19 at 10:58 a.m., staff member J was observed dishing up salad plates at the salad bar cart. The staff member had medium length hair and a thick groomed beard. The staff member was not wearing a hair net or beard guard. - 5/14/19 at 11:05 a.m. staff member L came to assist serving salads from the salad bar on the food cart. The staff member was not wearing a hair net. - 5/14/19 11:00 a.m. the salad cart was left unattended, unsupervised, uncovered, and in the line of residents exiting the dining room. During an interview on 5/14/19 at 11:10 a.m., staff member B stated the staff serving at the salad cart did not have to wear hair nets and beard guards. After a moment, the staff member stated they should wear hair nets and a beard guard if they have a beard. Review of the facility's procedure, titled General Food Preparations and Handling, showed dietary staff must wear hair restraints. Examples including hairnet, hat, and/or beard restraint to prevent hair from contacting food. Review of the Dietitian job description showed the position was to ensure that dietary service work areas, food storage rooms, preparation areas, etc. are maintained in a clean and sanitary manner. Review of the Director of Dining Services job description showed ensuring the cleanliness of the dining work areas, food storage rooms, preparation areas etc. are maintained in a clean and sanitary manner. Review of the Cook job description showed the position's purpose was to prepare food in accordance with current federal standards along with overseeing overall supervision of the kitchen and the sanitation of the kitchen. Review of cleaning schedules, dated 5/1/19-5/14/19 showed: - The plate holders were to be cleaned daily. Documentation showed the plate holder cart was cleaned three days out of 14 days, - The can opener was to be cleaned daily. Documentation showed the can opener was cleaned three out of 14 days, - The soup vat was to be cleaned daily. Documentation showed the vat was cleaned three of 14 days, - Behind the steamers/ floor and oven were to be cleaned daily. Documentation showed the floor and oven had been cleaned four of 14 days. The cleaning schedules did not show: -if the freezer was being monitored -if fan guards were being cleaned, -if walk-in refrigerator and the hood vent were being washed above the grill, -if/or when staff were checking for proper sanitization of dishes. There was lack of documentation of the dirty items being cleaned on a regular basis. During an interview on 5/14/19 at 8:06 a.m., staff member B stated he had just now started a weekly cleaning and store room cleaning list. The staff member stated leaving the freezer door open on 4/13/19, while the food delivery person hauled frozen goods into the freezer. The staff member stated that must have caused the water droplets to form and freeze in the walk in freezer.",2020-09-01
318,VILLAGE HEALTH & REHABILITATION,275043,2651 SOUTH AVE W,MISSOULA,MT,59804,2019-05-16,880,E,0,1,30M611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to minimize the spread of infection, by ensuring oxygen tubing was placed or secured in a manner to prevent the spread of infection, and not laying on the floor, for 3 (#s 44, 104, and 155); failed to provide appropriate treatment and services to prevent urinary tract infections for 1 (#70) of 42 sampled and supplemental residents. Findings include: 1. a. During an observation on 5/13/19 at 11:38 a.m., resident #104's oxygen tubing was on floor under the bed, and the concentrator was still running. b. During an observation on 5/13/19 at 2:21 p.m., resident #44's oxygen tubing was on the floor under the bed, with the concentrator still running. c. During an observation and interview on 5/14/19 at 10:34 a.m., resident #155's oxygen saturation was 88% on room air, and the oxygen tubing was on the floor. Staff Member S stated, Oh your tubing is on the floor, I need to get an alcohol wipe to clean it off. The staff member was asked into the hall before she placed the contaminated oxygen tubing back in resident #155's nares. Staff member S stated, In the hospital, we would just wipe it off. I am brand new here, so I don't know what the policy is. Staff member S walked to the nursing station to find the policy on the care for the oxygen tubing that had been laying on the floor. Staff member S stated, I am not sure where the policy is. Staff member S went and asked staff member T what she should do when the oxygen tubing is on the floor. Staff member A stated, Staff member T stated our policy is to replace the tubing when it falls on the floor. During an interview on 5/14/19 at 10:41 a.m., staff member T stated, I told her (staff member A), that if the oxygen tubing falls on the floor we replace it with new tubing. During an observation on 5/16/19 at 7:35 a.m., resident #104's oxygen tubing was on the floor under the bed, with the concentrator still running. 2. During an interview on 5/13/19 at 2:54 p.m., resident #70 stated his catheter was not emptied every shift like it should be. During an interview on 5/16/19 at 8:38 a.m., staff member P performed daily oversight of care by telling the CAN's what to do. On catheter care, she would have reminded the CNAs to wipe down the catheter spout, before emptying, and after draining of the catheter bag, with alcohol swabs. Staff P stated the staff should have been draining the bag into a urinal and then pouring it out into the toilet bowl. Resident #70's catheter should have been emptied every four hours and as needed. During an interview on 5/16/19 at 8:54 a.m., staff member Q explained proper catheter care is taught in the CAN's training course; it is reviewed annually in the facility, and at in-services as needed. CNAs were checked off on a skills check list which includes catheter care. The staff should have been using the proper catheter care as outlined in the CAN's training course, which includes using an alcohol swab to sanitize the spout, and a urinal to drain urine without touching the spout to the rim of the urinal. During an interview on 5/16/19 at 8:26 a.m., staff member O stated resident #70's catheter should be drained two times, once in the morning, and once in the evening. When asked about resident #70's catheter bag today, she stated, The bag was about to explode so it was immeasurable, and stated she did not use an alcohol swab to sanitize the spout. During an observation on 5/16/19 at 8:05 a.m., resident #70's catheter bag was full of amber colored urine and was reading well above the 2000 ml mark on the bag itself. The catheter tubing was also filled with amber colored urine. During an observation on 5/16/19 at 8:25 a.m., staff member O was observed emptying resident #70's catheter, with spout and hose lying submerged in urine, in a small white garbage can. Staff did not sanitize the spout, before or after draining the catheter bag, with an alcohol swab. Staff then dumped the garbage can of urine into the toilet and put it to the left of the toilet in the bathroom. Review of resident #70's physician order [REDACTED]. Review of resident #70's Nurse's Notes, showed the catheter was placed on 2/21/19, and the physician was notified. Review of resident #70's Medication Administration Record [REDACTED].",2020-09-01
319,VILLAGE HEALTH & REHABILITATION,275043,2651 SOUTH AVE W,MISSOULA,MT,59804,2016-12-01,241,E,0,1,L3OL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to identify and address urine odors which originated in a resident room, and emanated into the hallway, in order to enhance the resident's quality of life, for 2 (#s 10 and 11) of 24 sampled residents. The facility also failed to provide a bath for 1 (#9) of 24 sampled residents. Findings include: 1. Resident #10 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #11 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation on 11/28/16 at 2:20 p.m., resident room [ROOM NUMBER] was observed. There were no residents in the room. The room had a very strong odor of old urine. The smell was emanating into the hall. There was a used urinal hanging on the side of the garbage can. It appeared to have been dumped but not washed as it had some signs of partially dry urine in the container. During an interview on 11/29/16 at 9:17 a.m., staff member D stated room [ROOM NUMBER] was always quite smelly. The staff member stated they changed the sheets whenever they were wet. During an observation on 11/29/16 at 9:28 a.m., resident room [ROOM NUMBER] had a strong odor of stale urine. During an interview on 11/29/16 at 9:28 a.m., staff member [NAME] stated the floors were mopped everyday, and spray that removed odors was used on the privacy curtains everyday. During an observation on 11/29/16 at 1:39 p.m., the room continued to smell of old urine but evident of chemicals being applied in the room, and the floor had just been mopped. During an observation on 11/29/16 at 1:55 p.m., resident #10 was wheeling himself toward the nurses station, there was no distinguishable odor emanating from the resident as he passed by in the hall. At 4:36 p.m., resident #10 was observed going into the bathroom independently. During an observation on 11/30/16 at 7:40 a.m., room [ROOM NUMBER] had a very strong odor of stale urine. Both residents were in the room. In an interview on 11/30/16 at 9:15 a.m., staff member F stated resident #10 could not hold his urine and was incontinent at times. Most of the time the resident was said to go to the bathroom on his own. In an interview on 12/1/16 at 8:45 a.m., staff member G stated room [ROOM NUMBER] was deep cleaned about two months ago. In an interview on 12/1/16 at 9:10 a.m., staff member H stated the mattress would be changed today, as well as resident #10's wheel chair and any cushion he had in the wheelchair. During an observation on 12/1/16 at 12:30 p.m., resident room [ROOM NUMBER] was markedly improved, and the smell of stale urine was barely distinguishable. 2. Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. During an interview on 11/29/16 at 9:30 a.m., resident #9 stated that she did not like showers, and that the CNA who had given her showers told her that the showers would be easier to take, although resident #9 stated that she did not want to take showers because she liked to have more baths. During an interview on 11/28/16 at 1:45 p.m., staff member I stated that she had not been aware of a bath safety concern for resident #9. Staff member I stated that she had replaced a staff member who may have known about this issue, and that she would put in a recommendation for physical therapy to see the resident right away. During an interview on 11/29/16 at 10:05 a.m., staff member C stated resident #9 used to take a bath until the resident lost her leg function. Staff member C stated the resident would get a shower now due to resident safety issues from the loss of function. Staff member C stated she had told a resident care coordinator (no longer working at the facility) about the safety concerns of resident #9 taking a bath. Review of resident #9's Nurse/Physician Communication form, on 11/30/16 at 7:50 a.m., showed no updates or recommendations for physical therapy had been made to evaluate the safety of the resident for bathing. During an interview on 11/30/16 at 8:15 a.m., staff member J stated that the progress notes for resident #9 did not show that the resident was not a candidate for a whirl pool bath due to the resident's safety concerns from her loss of functioning. During an interview on 12/1/16 at 8:10 a.m., staff member J stated he had received an order to evaluate resident #9 for bath safety, and the outcome of the evaluation was that staff would use a bath sheet to help keep resident #9 from sliding around on the bath chair. Staff member J stated that the resident would have been safe to have had a bath prior to the evaluation as well.",2020-09-01
320,VILLAGE HEALTH & REHABILITATION,275043,2651 SOUTH AVE W,MISSOULA,MT,59804,2016-12-01,278,D,0,1,L3OL11,"Based on record review and interview, the facility failed to ensure the MDS assessment accurately reflected the resident's status in regards to bathing for 1 (#1) of 24 sampled residents. Findings include: Review of resident #1's record showed a MDS completed for the following ARDs: - Annual dated 10/14/16 - Quarterly dated 7/14/16 - admitted d 10/26/15 Review of section G of the MDS, for each of the assessments, showed an 8 had been coded, showing a bath had not occurred. In an interview on 11/30/16 at 4:30 p.m., staff member B said she reviewed the ADL Verification Worksheet. She stated this was where the CNAs documented at the Kiosk. She stated the ADL was coded as an 8 because staff member A did not do baths with resident #1. In an interview on 12/1/16 at 8:15 a.m., staff member C said she did baths with resident #1 in (MONTH) (YEAR), and documented this on the bath sheets. Resident #1 was scheduled for baths on Mondays and Thursdays. Resident #1 had refused a bath on Monday the 3rd, but there was no documentation showing the resident had a bath on 10/4/16. The resident also refused on 10/5/16 and 10/6/16. He did not want his bath on 10/10/16, but rather on 10/11/16. The resident received a bath on 10/19/16, 10/24/16, and 10/27/16. In an interview on 12/1/16 at 11:15 a.m., staff member B said they decided yesterday (11/30/16) that staff member A should to go ask the bath aide for the completion of the MDS to see if the resident got a bath, instead of recording that the bath did not happen.",2020-09-01
321,VILLAGE HEALTH & REHABILITATION,275043,2651 SOUTH AVE W,MISSOULA,MT,59804,2016-12-01,279,D,0,1,L3OL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately assess a resident's pain frequency, intensity, effects on function, and pain rating, for the completion of two consecutive MDS assessments, including one Annual assessment, for 1 (#12) of 24 sampled residents. Findings include: Resident #12 was admitted to the facility with [DIAGNOSES REDACTED]. During an review of resident #12's 5/19/16 Annual MDS assessment, the resident was coded on section C500 with a BIMS score of 15, cognitively intact. Review of the pain management section, in section J, showed the sections coded for pain presence, frequency, effect on function, and intensity, were all not completed. Review of resident #12's 8/18/16 Quarterly MDS assessment reflected a BIMS of 15, cognitively intact, for section C500. Review of the pain management section reflected the sections coded for pain presence, frequency, effect on function, and intensity were not completed. Review of resident #12's nursing notes reflected the resident was able to identify and rate her pain. On 11/28/16, the resident rated her pain at an 8 out of 10, and it reflected the resident pain was always present. A nursing note on 11/26/16 reflected the resident complained of constant pain that reached an 8/10, at its highest. In an interview on 11/29/16 at 11:20 a.m., staff member B stated the resident interview should have been completed, and that the MDS Coordinator was on vacation, so she had no answer for why the pain interview was not done. In an interview on 11/29/16 at 2:00 p.m., resident #12 stated she went out of the facility to see a pain doctor, and the facility addressed her pain.",2020-09-01
322,VILLAGE HEALTH & REHABILITATION,275043,2651 SOUTH AVE W,MISSOULA,MT,59804,2016-12-01,280,D,0,1,L3OL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and observations the facility failed to update a Care Plan for 2 (#s 9 and 14) of 24 sampled residents. Findings include: 1. Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #9's Care Plan, dated 2/19/16, showed that the resident would have no signs of a bladder infection. Review of resident #9's Physician and Nurse Communication form, dated 11/19/16, showed that a physician order [REDACTED]. Review of resident #9's Clinical Notes Report, dated 11/22/16, showed U/A results back and res (sic) is positive for a UTI. On 11/26/16, the clinical notes report showed ABT is taken daily for prevention of UTI's due to frequent catheterization. During an interview on 11/29/16 at 2:00 p.m., staff member O stated that resident #9 had been treated with an antibiotic for a UTI the previous week. The resident's care plan was not updated for the infection. 2. Review of Resident #14's fall record showed she had 8 falls since her admission, one with major injury. Review of resident #14's care plan showed the resident had the following active interventions for fall prevention: - TAB's monitor on when up in chair or when in bed. - Bed in lowest position when in use. - Floor monitor at bedside when occupied. During an observation on 11/28/16, resident #14's side of the room did not have a bed. There was a recliner that staff member B stated the resident slept in. During an interview on 11/28/16 at 04:00 p.m., staff member I stated that the bed was removed from resident #14's room on 9/27/16. The resident's care plan did not show the bed was removed, or replaced with the use of a recliner, although the interventions remained in place.",2020-09-01
323,VILLAGE HEALTH & REHABILITATION,275043,2651 SOUTH AVE W,MISSOULA,MT,59804,2016-12-01,281,D,0,1,L3OL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to meet professional standards of quality by not following a physician ordered diet for 1 (#18); and failed to follow a physician order [REDACTED]. 1. Resident #28 was admitted to the facility with a [DIAGNOSES REDACTED]. During an observation of medication pass on 11/30/16 at 8:00 a.m., staff member K had prepared medications for resident #28, which had included [MEDICATION NAME] 225 mcg. During an interview on 11/30/16 at 8:00 a.m., staff member K stated that the medication that had been prepared for resident #28 had been given at this time rather than before breakfast. This was due to the residents' family requesting the resident not to be woke up for medication pass. Staff member K stated that there was a physician order [REDACTED]. During an observation of a medication administration on 11/30/16 at 8:00 a.m., staff member K had administered [MEDICATION NAME] 225 mcg to resident #28. Resident #28 was in his room and had just finished eating his breakfast. During an interview on 11/30/16 at 9:55, staff member L stated the normal time for the medication [MEDICATION NAME] to be given would be at 6:30 a.m. She also stated there was not a physician order [REDACTED].#28 could be given at 7:00 a.m. The staff member stated there does not need to be a physician order [REDACTED]. This would be indicated on the MAR, and had to be a half an hour prior to the resident eating breakfast. Review of resident #28's Skilled Nursing Facility Transfer Orders, dated 11/1/2016, showed [MEDICATION NAME] 200 mcg with an additional tablet of [MEDICATION NAME] 25 mcg. This was a total dose of 225 mcg, to be given by mouth, every morning, before breakfast. Review of resident #28's Medication Administration History, dated 11/29/16 - 11/30/16, showed [MEDICATION NAME] 200 mcg and [MEDICATION NAME] 25 mcg had been administered at 7:00 a.m. The document also showed a note that stated, Per family request give scheduled [MEDICAL CONDITION] at 7:00 to allow resident to sleep longer. Review of the facilities Medication Administration-SNF Policy and Procedure, showed specific times were needed for the following medications: [REDACTED] - Order a specific time by the physician - Order on a empty stomach 2. Resident #18 was admitted to the facility with a [DIAGNOSES REDACTED]. Review of resident #18's Physician order [REDACTED]. Review of resident #18's Quarterly MDS assessment, with an ARD of 6/23/16, showed the resident's weight was recorded as 190 lbs. Review of resident #18's Annual MDS, with an ARD of 9/22/16, showed the resident's weight was recorded as 195 lbs. Review of resident #18's Care Plan, dated 11/1/16 to 11/30/16, showed that the goal for the resident was to minimize weight gain as able with an intervention of 1/2 meal portions to aid in weight control. Review of resident #18's meal ticket, dated 12/1/16, showed that the resident was to receive a 1/2 portion, mechanical diet. Review of the facility's 1/2 portion diet, ordered by the RD and Physician, dated 6/1/12, showed that bread portions were to be cut in half. During an observation on 12/1/16 at 8:20 a.m., resident #18 had been served a bowl of oatmeal with brown sugar, and 2 whole biscuits with a meat gravy over the top of the biscuits. The resident had eaten 100 percent of the meal. The biscuit, or bread serving, was not cut in half per the diet. During an interview on 12/1/16 at 9:10 a.m., staff member M stated it had been the first time she had ever fed resident #18, because she was from a traveling agency. She also stated that she had no idea what diet resident #18 had been ordered. She thought it was a regular diet based on the type of food the resident had been served. During an interview on 12/1/16 at 10:15 a.m., staff member N stated that a 1/2 portion mechanical diet for a resident being served a biscuit, should have been cut in half. She also stated that the biscuits should have been approximately two inches thick.",2020-09-01
324,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2019-02-21,561,D,0,1,ZR9X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to honor a resident's right of choice and self-determination, related to a snack request denial by a staff member, for 1 (#8) of 18 sampled residents. This caused emotional distress for the resident and the resident felt bad, humiliated, and he was tearful from the event, and these feelings did ease shortly after. Findings include: During an observation and interview on 2/19/19 at 5:24 p.m., resident #8 was denied ice cream by staff member M. Staff member M stated if the food item being requested was not on the menu, it would not be served. Resident #8 began to cry, and stated that the situation made him feel bad. Resident #8 stated he did not like staff member M. During an interview on 2/19/19 at 5:33 p.m., staff member M stated, Normally we try to accommodate preferences if the food is available. Staff member M stated he did not know if the facility had ice cream available. During an interview on 2/19/19 at 5:37 p.m., staff member [NAME] stated there was ice cream in the facility, and if a resident had requested a specific item from the kitchen, and the kitchen could accommodate the request and it was within the resident's prescribed diet, the kitchen would get the requested item. Staff member [NAME] was informed resident #8 had been denied ice cream by staff member M before the dinner meal. The surveyor stated the denial had caused resident #8 to become very distraught and tearful. Staff member [NAME] entered the dining room and saw resident #8 crying and stated, I will run and grab it right now. Resident #8 continued to cry and be visibly upset with the denial of his food request. During an interview on 2/20/19 at 10:23 a.m., resident #8 stated he did not like staff member M, because he made him cry, and caused him to be upset when he said he could not have ice cream. During an interview on 2/20/19 at 10:27 a.m., resident #8 stated he felt humiliated that he was crying in front of everyone in the dining room. During an observation on 2/20/19 at 2:02 p.m., the main kitchen for the facility was on the main floor. Staff would have to go to the main level kitchen to retrieve frozen food items such as ice cream. During an interview on 2/20/19 at 2:02 p.m., staff member [NAME] stated she was responsible for completing the food preferences for the residents. Staff member [NAME] stated that the kitchen closed between 8:30-9:00 p.m. The facility had purchased a larger refrigerator for the long-term care unit downstairs to be able to keep more food and snacks available for the long term care residents. During an interview on 2/21/19 at 9:54 a.m., staff member I stated the residents did have food preferences. If the resident wanted something different and it was a last-minute change, there was not a lot the kitchen could do about honoring the resident's preference(s). Staff member I stated if a food item a resident wanted was available Yes, we can go get it. Staff member I stated staff have to go upstairs for pretty much everything, if it is anything but sandwiches and crackers, we have to go upstairs. She stated the facility kept the kitchen locked after hours, but the kitchen did keep the small refrigerator in the employee break room stocked with snacks and food. Staff member I stated the small refrigerator could not hold any frozen food items because the refrigerator did not have a freezer in it. Review of resident #8's Dietary Food Preference form, dated 2/12/18, showed a diet order of mechanical soft, no food allergies [REDACTED]. Review of resident #8's Dietary Food Preference form, dated 2/12/18, showed multiple dislike lists, but lacked any food preferences or food likes.",2020-09-01
325,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2019-02-21,600,D,1,1,ZR9X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to identify and implement interventions for a resident who was unable to communicate her needs, and there was documented behaviors of excessive crying, and the failure resulted in the resident being placed in her room by staff and secluded, with the door shut; even though the resident would frequently continue to cry, and further interventions were not provided, for 1 (#19) of 18 sampled residents. Findings include: During an interview on 2/19/19 at 2:48 p.m., resident #11 stated (resident #19) was taken to her room and left there when she cried. Resident #11 stated, I saw staff member S take (resident #19) into her room and close the door. You could hear her screaming. During an interview on 2/20/19 at 7:11 a.m., staff member U stated resident #19 did not like to be alone, so staff would place her where there were other people. During an interview on 2/20/19 at 8:22 a.m., staff member EE stated resident #19 had crying episodes out of the blue. Staff member EE stated sometimes you can console her and sometimes you can't. Staff member EE stated, We try to talk to her, if she continues to cry, we put her in her room and put on a movie. Staff member EE stated that she leaves the resident for maybe five minutes. Staff member EE stated she has heard in report that other staff have seen resident #19 left in her room for longer periods, in the evening. Staff member EE stated there was no medication to give the resident to help the behavior. Staff member EE stated, We monitor her behavior. Staff member EE stated resident #19 was prescribed [MEDICATION NAME] (an antidepressant), which she was given in the morning, for depression. During an interview on 2/20/19 at 9:30 a.m., NF2 stated the staffing was horrible. When discussing resident #19 NF2 stated, They take her to her room and leave her there when she is crying. During an interview on 2/20/19 at 4:30 p.m., staff member L stated When she cries (resident #19), I put her in her room and check on her. Staff member L stated, If she's mad at you, stay out of her room and let her cool off. Eventually, the nurse goes in. Staff member L stated, I don't know what the care plan says. They (facility) haven't talked to us about her (#19's) care plan. Staff member L stated, I don't know where the care plans are? During an interview on 2/20/19 at 4:45 p.m., staff member D stated, When she cries, I try to console her. Staff member D stated resident #19 did not like her door closed. During an interview on 2/21/19 at 3:30 p.m., staff member C stated there has been no formal behavior training for staff (on how to manage resident behaviors). Staff member C stated staff have reviewed a few topics, in general, during the monthly CNA meeting. The annual abuse training was done, but nothing specific was included for the management of behaviors. Record review of resident #19's physician's orders [REDACTED]. Medications included [MEDICATION NAME] and [MEDICATION NAME] for depression. The orders also included that monitoring should occur for uncontrolled crying, yelling out, agitation/aggression, and for signs and symptoms of anxiety, every shift. Review of resident #19's (MONTH) 2019 behavior monitoring showed fourteen days where monitoring did not occur and this included two evening shifts where the resident's behavior was documented. Review of resident #19's Care Plan showed a Focus of The use of antidepressant medications and the risk of side effects a goal showed I want to have decreased episodes of crying and hollering out, and agitation through next review with a revised date of 1/20/19. Interventions were: - Monitor for behaviors such as uncontrolled crying, hollering out, aggression/agitation as indicated. Notify MD of new or increased behaviors. - Resident becomes frustrated when she can not verbalize her needs, staff needs to spend time with and allow her time to come up with word or words to allow her to convey to meet her needs. - Resident enjoys sitting in her recliner, napping or watching TV this calms her and can at times decrease her feeling of frustration. - Staff to monitor for adverse side effects such as dry mouth, [MEDICAL CONDITION], dizziness, constipation, increased lethargy, and changes in mood/behaviors - notify MD as needed. The facility failed to thoroughly assess and identify interventions for the resident's exhibited behavior's which would benefit the resident during times when she was upset or crying out; and the facility did not ensure training was provided to the staff on management for the resident's behavior's to ensure the resident was not restricted or secluded. During an interview on 2/20/19 at 9:20 a.m., staff member G stated she felt the residents had been neglected when the facility was short-staffed, because We are busy answering call lights, and can't get to residents that don't, or can't, speak up. It feels like they are getting neglected. Staff member G stated last Tuesday and Wednesday there were only two staff members for the provision of resident care on the long term care unit on the day shift. Staff member H stated there had been 4 to 5 times in the last month where there were only two staff members on the day shift for the long term care unit. Staff member G stated when We are short-staffed like that, men don't get shaved, meals are served late and cold, residents do not get fed on time, residents don't get showered, and residents sit in soiled briefs for extended periods of time. (Refer to F677 and F725 for resident care concerns related to staffing)",2020-09-01
326,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2019-02-21,609,D,1,1,ZR9X11,"**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 agencies, which may 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 of the missing medications. Findings include: Review of the written statement from staff member B, dated 11/3/18, showed Pharmacy delivered shipment @ 0130 am Sat. 11/3/18 after he left I went thru the blue tote there was 30 [MEDICATION NAME] 5/325 and 30 [MEDICATION NAME] for (name of resident). I left the [MEDICATION NAME] wrapped in the plastic and sealed tote up with red ties to send [MEDICATION NAME] and [MEDICATION NAME] back to pharmacy. When i came back to work Saturday evening and went to put my belongings in the Medroom, I noticed that the tote was opened and the only thing in there was the [MEDICATION NAME], I then let staff member GG know. (sic) Review of a written investigation statement from staff member HH and II showed no information about the missing [MEDICATION NAME]. Review of the facility policy, titled ABUSE PREVENTION PLAN (MT) showed: Section [NAME] Reporting/Response . 1) All alleged violations involving abuse, .and misappropriation of resident property, are reported immediately, .State of Montana agencies within the Department of Public Health and Human Services .are required to be contacted when abuse, neglect, or exploitation has occurred. The agencies are as follows: (a) Certification Bureau (b) Adult Protective Services (c) State or Local Ombudsman . During an interview on 2/21/19 at 7:23 a.m., staff member N stated the DON has to report missing narcotics up the chain of command, and she was notified of the missing [MEDICATION NAME]. She stated she believed the nurse sent the card of [MEDICATION NAME] for resident #00 back to the pharmacy. The facility could not show the card of [MEDICATION NAME] for resident #00 was sent back to the pharmacy. During an interview on 2/21/19 at 10:10 a.m., with staff member N, Q, and O, staff member O stated he instructed the facility to contact the DOJ (Department of Justice) about the missing [MEDICATION NAME] and asked if this was the right place (to report missing narcotics to). He stated he was assured this was the right place to report. Staff member O stated he always lets the DOJ investigate as he does not know where the investigation is going to lead. He stated if the facility suspected something they would report to the S[NAME] Staff member O stated the facility reports everything to the SA that is on the brochure (abuse reporting brochure). The brochure was not provided for reference. He stated if the facility Pharmacist would have informed them there was drug diversion, he would have reported to S[NAME] The SA system did not have a record of the missing [MEDICATION NAME]. There was no information provided that the Ombudsman was notified of the missing [MEDICATION NAME].",2020-09-01
327,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2019-02-21,610,D,1,1,ZR9X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to thoroughly investigate thirty missing [MEDICATION NAME] tablets. This had the potential to affect residents in the facility receiving controlled narcotics. Findings include: 1. Review of the written statement from staff member B dated 11/3/18, showed Pharmacy delivered shipment @ 0130 am Sat. 11/3/18 after he left I went thru the blue tote there was 30 [MEDICATION NAME] 5/325 and 30 [MEDICATION NAME] for (name of resident), I left the [MEDICATION NAME] wrapped in the plastic and sealed tote up with red ties to send [MEDICATION NAME] and [MEDICATION NAME] back to pharmacy. When i came back to work Saturday evening and went to put my belongings in the Medroom, I noticed that the tote was opened and the only thing in there was the [MEDICATION NAME], I then let (staff member GG) know. (sic) Review of a written statement from staff member HH and II showed no information about the missing [MEDICATION NAME]. Review of the facility policy titled ABUSE PREVENTION PLAN (MT) showed: Section [NAME] The facility will take all necessary corrective actions depending on the results of the investigation and complete and send a final investigative report to the State Agency within 5 business days . During an interview on 2/21/19 at 7:23 a.m., staff member N stated, the DON has to report missing narcotics up the chain of command and she was notified. The facility could not show the card of [MEDICATION NAME] for resident #00 was sent back to the pharmacy. During an interview on 2/21/19 at 10:10 a.m., with staff member N, Q, and O, staff member Q stated she performed an investigation of the missing [MEDICATION NAME]. Staff member Q and N stated they thought the nurse had sent the medication back to the pharmacy. There was no documentation provided from the pharmacy that the [MEDICATION NAME] was sent back. The SA system did not have a record of missing [MEDICATION NAME] reported and investigated (refer to F609).",2020-09-01
328,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2019-02-21,657,D,0,1,ZR9X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to make the necessary revisions to the resident's care plan for urinary track infections (UTIs) and antibiotic use, to reflect changing care needs, including a focus area, goals, and interventions, for 1 (#19) of 31 sampled and supplemental residents. Findings include: During an interview on 2/20/19 at 9:30 a.m., NF2 stated resident #19 had problems with urinary tract infections. Review of resident #19's physician's orders [REDACTED]. The orders included [MEDICATION NAME] Tablet, 0.5 mg, by mouth, one time a day, related to urinary tract infection, and a cranberry tablet, one capsule, by mouth, one time a day, for urinary health. Review of resident #19's list of antibiotics, used in the last six months, and provided by staff member N, showed treatments for a urinary tract infection on 9/22/18 ([MEDICATION NAME]-antibiotic) and another treatment on 12/10/18 (Keflex-antibiotic). The resident's care plan did not show any changes or interventions related to the infections or medications. During an interview on 2/20/19 at 9:30 a.m., NF2 stated resident #19 had problems with her toes, requiring physician visits and antibiotics. During an observation and interview, on 2/20/19 at 6:24 a.m., staff member S was assisting resident #19 out of bed to get ready for breakfast. Staff member S stated she wasn't sure if resident #19 was supposed to wear both slippers as she had problems with her toe. Staff member S put both slippers on resident #19 and took her out to the lobby. When staff member S took the resident out to the lobby, another staff member stated resident #19 was not to wear a slipper on her right foot, due to the infection and pain. Review of resident #19's physician's orders [REDACTED]. apply triple antibiotic ointment and cover w/band aid every day shift. Review of resident #19's Care Plan, dated 1/9/19, did not show a focus area, goals, or interventions for these problem areas for resident #19.",2020-09-01
329,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2019-02-21,677,G,1,1,ZR9X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, a facility staff member failed to help a resident with grooming and oral care, for 1 (#14); failed to apply compression wraps, per the physician order, to a resident's [MEDICAL CONDITION] legs, for 1 (#16); failed to bathe and provide adequate peri care and brief changes for a resident that emanated an odor, for 1 (#29); failed to provide a resident with clean sheets, warm food, towels, and respond to the resident's call light timely, for 1 (#348), failed to respond to a resident who was calling out for help, for 1 (#11); failed to assist a resident with incontinent care and toileting, for 1 (#19), failed to assist residents with oral hygiene, for 2 (#23 and 37), and, failed to provide bathing assistance, and baths/showers, for 5 (#s 2, 12, 15, 17, and 37), and resident #2 felt unwanted and considered leaving the facility, and was not assisted adequately with peri care after elimination; resident #12 was upset, started to cry, and felt smelly and dirty, due to the lack of assistance with hygiene care, and the resident had a skin concern which had the potential to worsen with poor hygiene care, and resident #15 was taken to the dining room with unkept and unclean hair, out of 31 sampled and supplemental residents. 1. During an observation and interview, on 2/20/19 at 7:03 a.m., staff member K assisted resident #14 with getting out of bed and getting ready to go to the breakfast meal in the dining room. Staff member K assisted resident #14 to the sink, in her bathroom, to wash her face and hands and brush her teeth. Resident #14 was sitting in the bathroom in front of the sink, and did not wash her face and hands, or brush her teeth. Hanging on the wall next to the sink was a decorative container that contained resident #14's hair brush and oral care items. Resident #14 stated she could not reach the container. Staff member K left resident #14's room after she finished making her bed. Resident #14 remained sitting in her bathroom until staff member K came back to assist her to the dining room. Staff member K took resident #14 to the dining room without asking or offering to assist her with oral care, or brushing her hair. Resident #14 went to the dining room with her hair sticking up on one side of her head. During an observation and interview on 02/21/19 at 7:38 a.m., staff member G assisted resident #14 to transfer out of bed and toilet. Staff member G stated resident #14 required assistance with her hygiene and grooming needs. After resident #14 was finished with toileting, staff member G assisted her with a transfer to her wheelchair. Staff member G placed toothpaste on resident #14's toothbrush and offered it to her. Resident #14 was able to brush her teeth at the bathroom sink. After resident #14 was done brushing her teeth, staff member G put away her toothbrush, in the container hanging on the wall. Staff member G obtained a brush, from the container hanging on the wall, and handed it to resident #14. Resident #14 was able to brush her hair independently. Resident #14 stated she was not able to see herself in her mirror in her bathroom. She stated it would be nice if she was able to see herself in her mirror. She stated everything is so high in here I can't reach things unless I stand up, and I can't stand up by myself. She stated if things were lower she could do things more for herself. Staff member G stated resident #14 did not do anything independently for herself. Staff member G stated resident #14 could wheel herself into the bathroom sometimes but was pretty limited. Review of resident #14's Annual MDS, with an ARD of 9/7/18, under Functional Status, showed the resident required extensive assistance with transfers and toileting, and limited assistance with personal hygiene. The Cognitive Status assessment showed resident #14's cognitive functioning was severely impaired. Review of resident #14's Care Plan, with a last review date of 1/4/19, showed she needed physical help with personal hygiene and oral care. 2. During an observation and interview, on 2/19/19 at 2:30 p.m., resident #16 stated he was concerned about the nurses not applying compression wraps to his legs everyday. Resident #16 explained he had [MEDICAL CONDITION] in both of his legs. He stated his doctor ordered his legs to be wrapped every day, before he got up, and then the nurses were supposed to remove the wraps when he went to bed. Resident #16 stated the nurses were not doing this everyday. He stated when his legs did not get wrapped, it caused increased swelling and pain, due to the increased swelling. Resident #16 pulled up his pant legs and showed both of his legs. Both legs were [MEDICAL CONDITION], the the left shin had a dry yellowish caking discharge on it. The resident's legs did not have compression wraps on them. Review of resident #16's physician orders [REDACTED].>two times a day, for [MEDICAL CONDITION], on in a.m., off at h.s., with an active date of 1/17/18. Review of resident #16's Care Plan, with the last review date of 12/19/18, showed a focus area for bilateral lower extremity [MEDICAL CONDITION]. Interventions listed included: staff to monitor for any signs and symptoms of infection, worsening ulcers, and wraps to bilateral lower extremities, daily, per the MD order. Review of resident #16's Treatment Administration Record showed on 2/19/19, under compression wraps daily, a check mark showing the wraps had been applied. Record review of the resident's nurse's notes, on 2/19/19, showed no documentation that the wraps had been removed that day, or include documentation on why the wraps were not on resident #16's legs when observed during the time period of his interview at 2:30 p.m. 3. During an interview, on 2/20/19 at 11:26 a.m., resident #13 stated if she wanted her teeth brushed she had to do it herself. She reported that her bath days were Wednesdays and Saturdays, and stated, Sometimes they skip my baths. During an observation and interview, on 2/20/19 at 3:10 p.m., staff member M stated when there are only two staff members working on the evening shift for the entire long term care unit, showers are over looked. During an observation and interview, on 2/20/19 at 3:34 p.m., staff member J stated that she had to shower resident #13 that evening because it was her bath day, but I probably won't get it done. She stated the resident is female care only for peri-care and showers. The only other available evening shift staff member was male. Staff member J stated it took approximately 30 minutes to complete resident #13's shower. With only two staff members for the unit, the nurse would have to stop her duties and cover the floor. Staff member J was tearful and upset during the interview due to the concerns brought forth. Review of Resident #13's bathing record, dated 12/23/18 - 2/21/19, showed the resident received one bath, which was on 1/23/19. Review of resident #13's Care Plan, dated 12/15/14, showed the resident's need for extensive assistance with dressing, grooming, and bathing. 4. During an observation on 2/19/19 at 12:12 p.m., a strong smell of vomit was present on resident #29, but visually, vomit was not observed. The resident was slumped over to her left side and was on the edge of her wheelchair seat. The resident stated she had been in her wheelchair since 8:00 a.m. The resident stated she did use attends for her incontinence. Her hands were visibly soiled with an unidentifiable yellow-brown crusty substance. The resident had a brownish colored material caked underneath her fingernails, and she was observed eating a banana during the lunch meal, with her soiled hands. During an observation on 2/20/19 at 7:44 a.m., resident #29 was being assisted up for the day. Resident #29 had a strong yeasty smell in her room. After resident #29 had used the bed pan, staff cleaned her with a cleansing wipe, but chose to not change the resident's brief, which she had on throughout the entire night. The staff stated the brief was not soiled. The brief, which the staff had chose to leave on the resident, was permeated with a yeast odor, which was emanated from the brief. Review of resident #29's bathing record, dated 12/23/18 - 2/21/19, showed one bath was provided on 1/5/19. The resident's documented bathing performance showed the resident was total dependence. Review of resident #29's Care Plan, revised 10/29/18, showed the resident's need for extensive assistance of 1-2 staff with dressing, grooming, and bathing. During an interview on 2/20/19 at 9:20 a.m., staff member G stated she felt the residents had been neglected when the facility was short-staffed, because We are busy answering call lights, and can't get to residents that don't, or can't, speak up. It feels like they are getting neglected. Staff member G stated last Tuesday and Wednesday there were only two staff members for the provision of resident care on the long term care unit on the day shift. Staff member H stated there had been 4 to 5 times in the last month where there were only two staff members on the day shift for the long term care unit. Staff member G stated when We are short-staffed like that, men don't get shaved, meals are served late and cold, residents do not get fed on time, residents don't get showered, and residents sit in soiled briefs for extended periods of time. 5. Lack of Staff Assistance and Care During an interview, on 2/19/19 at 11:50 a.m., resident #348 stated I have to wait a long time for someone to answer my call light, maybe 20 minutes or maybe an hour and a half. Resident #348 stated My sheets haven't been changed for a week, we have to ask, I don't get clean towels, I have to ask, they don't bring my tray in a timely manner. During an interview, on 2/19/19 at 2:48 p.m., resident #11 stated it depended on when a resident needed care, and On weekends and nights it's not good. Resident #11 stated, I saw a CNA on her phone (personal cell phone) when a resident was asking for help. During an interview on 2/20/19 at 5:34 a.m., staff member P stated the staffing is good and sometimes it's not. There was one CNA on this floor and sometime I have to go downstairs to help out. It's been that way for a long time. Staff member P stated, It's very rushed when I have to do upstairs and downstairs both. I like to get the cares I have to do done and not be rushed. We bring it up at staff meetings, and I have approached administration about it. During an interview on 2/20/19 at 6:00 a.m., staff member AA stated ,If the census is below 16, then there is only one CN[NAME] I'm not able to get my care done when there is only one CN[NAME] I have approached (staff Q) and told We can do it. During an interview, on 2/20/19 at 9:30 a.m., NF2 stated, The staffing is horrible. Staff don't toilet (resident #19) every two hours on the weekend. She doesn't get great care, she sits in a wet attend. They (staff) sit (use) on their phones. They don't check on her. I've seen staff sit at the desk with three lights going off and just sit there. Record review of resident #19's physician's orders [REDACTED]. Review of resident #19's Care Plan dated 3/18/18, showed the resident needed extensive assist of one staff with dressing, grooming and bathing, extensive assistance of one staff for toileting. Review of resident #19's toileting record ,for (MONTH) (YEAR), and January/February 2019, showed toileting assistance did not occur on the following shifts: - day shift: 2/4/19 - evening shift: 12/25/18, 12/27/18, 12/28/18, 12/29/18, 1/1/19, 1/3/19, 1/4/19, 1/10/19, 1/11/19, 1/15/19, 1/16/19, 1/17/19, 1/22/19, 1/29/19, 1/30/19, 1/31/19, 2/6/19, 2/7/19 - entire day: 1/15/19, 1/12/19, 1/20/19, 1/26/19, 2/1/19, 2/2/19, 2/8/19, 2/12/19, 2/15/19 6. During an interview, on 2/20/19 at 10:09 a.m., resident #17 stated I don't get to choose when I take my shower. When I ask the CNA's when I can get my shower they say they don't have time. Resident #17 stated I sometimes go two weeks without a shower. Review of resident #17's bathing documentation, for the period of 12/26/18 - 2/20/19, showed a one shower on 12/26/18, a refusal of a shower documented on 1/6/19, and no further documentation was noted for any other showers after that. Review of resident #17's Care Plan, dated 10/15/18, showed resident #17 needed supervision for bathing. 7. During an interview on 2/20/19 at 10:09 a.m., resident #37 stated We don't get enough showers. Review of resident #37's bathing record, for the past three months, showed documentation of one bath, which was on 1/17/19. Review of resident #37's Care Plan, with a revision date of 8/13/18, showed under the interventions for bathing, I need extensive assist of one staff with bathing, twice a week. During an interview on 2/21/19 at 8:22 a.m., staff member R stated most residents on the unit, which was the top level of the facility, can tell if they are not getting the help they need. Staff member R stated she assisted the residents, if needed. Staff member R stated, I see that care is not getting done. Staff member R stated the CNAs report bathing isn't done, especially downstairs. 8. During an interview on 2/21/19 at 12:54 p.m., resident #2 stated When I don't get my bath when it's scheduled it makes me feel like I'm not really wanted, and I'm thinking about finding another place to live. Resident #2 stated We're lucky if we have two aides. It's good while surveyors are here, but after you leave we go back to the way it was. Review of resident #2's bathing record, for the last three months, showed bathing occurred two times weekly on only three of the eight weeks. Toileting showed numerous days without documentation for the resident's assistance, which required cleansing following elimination 9. During an interview on 2/21/19 at 1:07 p.m., resident #12 stated When I don't get my bath when I need it, it makes me feel dirty and smelly. I sweat a lot. Resident #12 stated I get upset and it makes me want to cry. Review of resident #12's bathing record, for the period of 12/27/18 - 2/20/19 showed resident #12 received one bath between 12/27/18 and 1/17/19; and one bath between 2/11/19 and 2/19/19. Review of resident #12's Care Plan, revised 8/13/18, showed the need for resident supervision during bathing, and limited assistance of one with toileting. Further review showed a skin issue, Moisture Associated skin damage located in my groin, under my breasts, and in other skin folds, with an intervention of treatment as ordered. Review of the facility's ADL Assistance Provided per Care Plan Policy, Number NS0798, with an effective date of 11/2016, showed, To assure ADL assistance is provided to all residents based upon assessment and Care Plan and the Procedure showed Based upon resident/resident representative desires, assessment, and care plan, ADL assistance will be provided to any residents (sic) deemed necessary. Some examples were: - Shaving and hair grooming as needed. - Bathing/showering. - Incontinent residents shall be checked according to Care Plan and peri-care provided between changes. - Assistance as needed with oral hygiene to keep the mouth, teeth or denture clean. - Fingernails and toenails shall be clean and trimmed. - Bed linen shall be changed weekly or more often as needed. 10. During an observation on 2/19/19 at 2:40 p.m., resident #15 was observed laying in bed watching T.V. Resident #15 had a white, dried on substance coating the right side of her hairline, and her hair appeared dirty. Resident #15 was non-verbal due to a persistent vegetative state. During an interview, on 2/19/19 at 3:30 p.m., staff member L observed the white substance in resident #15's hair. Staff member L stated, I don't know what it is. I've been gone for four days, so I don't know when her last bath was. A review of resident #15's Care Plan, initiated 11/12/14, showed, I need a total assist of 2 staff with my bath. I take a tub bath twice weekly. A review of resident #15's bath record showed the last entry for Bathing: Support Provided was on 1/29/19 at 4 p.m. 11. During an observation on 2/20/19 at 7:30 a.m., Staff member I assisted resident #23 and #37 up for breakfast. Staff member I assisted resident #23 into the bathroom, then gave her a wet wash cloth for her face. Resident #23 did not brush her teeth. Staff member I assisted resident #37 by giving her a wash cloth for her face. Resident #37 did not brush her teeth. Staff member I did not assist either resident #23 or #37 with their oral hygiene needs. During an interview on 2/21/19 at 7:33 a.m., staff member I stated some of the residents may brush their teeth after breakfast, referring to resident #23 and #37, But if we dont get to it before breakfast, it usually doesn't get done. Staff member I stated. It sounds bad, but we are so busy and short staffed.",2020-09-01
330,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2019-02-21,684,G,1,1,ZR9X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to ensure quality of care was provided for a resident who had multiple skin injuries, was at risk for further injuries and falls, and the resident required monitoring and staff assistance, for 1 (#7) of 18 sampled residents. This failure caused resident #7 to receive skin injuries and be at risk for future injuries, have tearful episodes, and the failure made the resident feel as though no one would listen to him. Findings include: Dignity and Privacy During an observation on 2/19/19 at 2:43 p.m., resident #7 was on the floor on a fall mat in his room, scooting around in a brief and a T-shirt, near the dresser. During an observation on 2/19/19 at 2:45 p.m., staff member X walked by resident #7's room and did not look in or assist the resident. During an observation on 2/19/19 at 2:47 p.m., staff member M walked by resident #7's room, looked in, mumbled something, then walked away without assisting the resident. During an observation on 2/19/19 at 2:59 p.m., resident #7 remained on the floor near the dresser, but he was on the opposite end of the room from the call light. He was on the carpet. During an observation on 2/19/19 at 3:13 p.m., resident #7 was back on his floor mat, on the floor. During an observation on 2/19/19 at 3:45 p.m., resident #7 was laying on the floor mat, with his brief off, and was exposed. The resident's door was open, and the length of the privacy curtain did not reach the floor, so the resident was visible to anyone who walked by the room. During an observation on 2/20/19 at 6:24 a.m., resident #7's fall mat was noted to be significantly soiled with several large brown stained areas. Resident #7 was observed to be crawling on the soiled fall mat. During an observation on 2/20/19 at 6:29 a.m., resident #7 had a pad call light for ease of use, but could not reach it from where he was in the room. During an interview on 2/20/19 at 6:36 a.m., resident #7 stated that he had not felt like staff had treated him with respect and dignity, and stated, no one listens to me. During an interview on 2/21/19 at 7:16 a.m., staff member Y stated she did not think it was a dignity issue for resident #7 to be on the floor, because the resident liked it. Staff member Y stated she had never personally asked the resident if he liked being on the floor, but stated I have known the resident a long time. Staff member Y stated she thought the CNAs asked the resident if he wanted to be on the floor. Staff member Y stated that would be a dignity issue missed by staff, regarding the situation when the resident was observed on the floor, and he had ripped his brief off, and was on the floor mat, in just a T-shirt. Skin Injuries During an interview on 2/20/19 at 6:32 a.m., resident #7 stated he does not like to crawl around on the floor. The resident stated when he was crawling around it was because he needed something or was looking for something. The resident stated crawling around on the floor hurts my knees and takes all the hide (skin) off. Review of resident #7's Care Plan, dated 9/3/18, showed, I like to sit/lay/crawl on the floor in my room when I choose to do so. During an observation on 2/20/19 at 6:32 a.m., resident #7 had multiple scabs and abrasions to his bilateral lower extremities, and his bilateral elbows, in various stages of healing. During an interview on 2/21/19 at 7:16 a.m., staff member Y did not know if resident #7 currently had any skin issues. Staff member Y stated skin issues were documented under assessments, orders, or progress notes on the computer. Staff member Y stated, The CNAs are good at reporting skin issues to the nurses, otherwise we do skin checks weekly. Staff member Y was providing care for resident #7 on this day. Review of resident #7's TAR, dated 2/1/19-2/28/19, lacked monitoring and treatment for [REDACTED]. Review of resident #7's TAR, dated 2/1/19-2/28/19, showed one completed skin check had been done on 2/19/19. During an interview on 2/21/19 at 12:35 p.m., staff member Z stated resident #7 had multiple abrasions from falls and crawling around on the floor that were all over his legs and arms. Staff members X and Z stated the intervention in place to prevent further skin issues was trying to keep resident #7 dressed. Review of resident #7's Care Plan dated, 7/29/18, showed Staff to allow resident to sit/lay or crawl on the floor if he chooses. Please just ensure call light is within reach and encourage of the same so he may have assistance up. During an interview on 2/20/19 at 6:44 a.m., resident #7 stated he had to holler to get help and more food, especially when he was on the floor, and sometimes I have to holler a long time, but sometimes they come quick. Resident #7 stated the resident across the hall would tell him to shut up when he was yelling out for help. Care Plan During an interview on 2/19/19 at 3:01 p.m., staff member X stated resident #7 had a [DIAGNOSES REDACTED]. Staff member X stated the resident was a high fall risk, and as an intervention for fall prevention, the resident was care planned to be allowed to crawl around on the floor. Staff member X stated staff placed a flat call light underneath the resident to notify staff when he was moving. During an interview on 2/21/19 at 7:16 a.m., staff member Y stated resident #7 received his new wheelchair approximately one month ago. Staff member Y stated there were many modifications made to the old wheelchair before the new wheelchair was purchased. Staff member Y stated the new wheelchair was to assist with fall prevention. Staff member Y stated resident #7's floor mats have been in place for about two months, because all the other interventions were not working to prevent falls for the resident, such as close supervision, activities, and a pancake call light. Review of resident #7's Care Plan, dated 8/31/18, showed encourage resident to spend time in the common area around nurses for more direct supervision. The care plan did not sufficiently address the resident's individual needs related to being on the floor to ensure the resident was protected from repeated skin injuries, and to ensure the provision of adequate monitoring, for necessary staff assistance.",2020-09-01
331,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2019-02-21,689,D,0,1,ZR9X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two staff members were present when a resident was transferred in a manner which was unsafe, per the resident's care plan, for 1(#39); and failed to ensure a mechanical lift was used on a resident who was assessed as needing a mechanical lift, in order to prevent accidents, for 1 (#28) of 18 sampled residents. Findings include: 1. During an observation on 2/20/19 at 7:00 a.m., staff member I and NF1 transferred resident #28 from the bed to the wheelchair. Staff member I and NF1 grasped the resident under the arms and by the resident's sweat pants, and lifted him from the bed to the wheelchair, without the use of a gait belt or other assistive device. Resident #28 had a [DIAGNOSES REDACTED]. During an observation and interview, on 2/20/19 at 1:44 p.m., resident #39 had been sitting in his wheel chair, and was transferred onto his bed. Staff member G was coming out of the resident's room by herself with the mechanical lift after transferring the resident. Staff member G stated, We are supposed to have two people (staff assisting for the mechanical lift transfer), but if you waited for someone to help, you would be here until 3:30. 2. During an interview on 2/20/19 at 1:51 p.m., staff member H stated We are supposed to have two people to use the Hoyer (lift), and I think the Sit to Stand (lift) but it doesn't always happen. During an interview on 2/21/19 at 7:33 a.m., staff member I stated she does not typically use the care plan to determine what to do for the the resident. Staff member I stated I trained by the resident and what their needs are. A review of resident #28's Care Plan, with an initiated date of 10/29/14, showed, Two person assist with gait belt for all transfers. A review of resident #28's Transfer Assessment, dated 1/4/19, showed a check mark for question 6 d., which read If no to any of the questions in 6, Use a Full Transfer Lift . During an interview on 2/21/19 at 8:30 a.m., staff member H stated, Resident #28 should be a lift, he doesn't like the gait belt.",2020-09-01
332,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2019-02-21,692,G,1,1,ZR9X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility staff failed to provide and assist residents with meals, snacks, and water, for those residents who needed the assistance, and there were weight concerns. The staff failed to document the amount of the meals consumed, and monitor the intake records for accuracy and completion, to allow the facility to identify if weight concerns were an outcome of poor intake, for 3 (#s 6, 7, and 13), and one, (#7) had a documented significant loss of weight, and resident #6 had a weight loss. These failures caused outcomes such as hunger and thirst due to the missed meals, snacks, and lack of fluids, and emotional distress due to the lack of food and fluid intake and staff assistance, out of 18 sampled and supplemental residents. Findings include: 1. During an observation and interview on 2/20/19 at 11:03 a.m., resident #13 requested fresh water with ice, and drank 300 cc of water at once. The resident asked staff member W several times not to take the water away from her mouth. The resident stated she was very thirsty. During an observation on 2/20/19 at 11:06 a.m., resident #13 was taken out of the dining room just before lunch was served. There was no lunch tray at the table in front of the resident. There was a small sandwich bag with a sandwich in it, tucked beside resident #13 in her wheel chair seat as she left the dining room. During an interview on 2/20/19 at 11:27 a.m., resident #13 stated the food was okay, and sometimes staff offer meal substitutions. The resident stated staff does not offer snacks to her often because They have to stay in my room and help me. She stated the staff tell her They don't have time to help her with snacks. The resident stated if she is sleeping, staff do not come in and wake her for meals. After 10:00 p.m., she stated she could not get anything to eat because the kitchen was locked, and staff could not get in to get food. During an interview on 2/20/19 at 3:04 p.m., resident #13 stated she did not get an early tray for lunch that day, before she went to her doctor's appointment, and she only received a half sandwich in place of the lunch she had missed. She stated she was hungry that afternoon, but did get a snack, which was not substantial enough. Resident #13 stated she needed help to eat her meals, and stated the staff was not helping her enough to consume her meals. The resident reported the staff tell her they don't have the time to sit there with her to help her eat. The resident stated her pain had affected her meal intake, as she was in too much pain to get out of bed and go the dining room. During an interview on 2/20/19 at 3:08 p.m., staff member W stated she was familiar with resident #13's care, and stated the resident did require assistance with eating. Staff member W stated resident #13 would occasionally refuse to get up for meals because she was In too much pain, or too tired. Staff member W stated resident #13 was a choking risk, and if the resident refused to get up, staff would offer to assist her to eat her meal in her room. Staff member W stated the CNAs would tell the resident that if she did not want to get up, then staff member W would give resident #13 a Boost supplement instead of her meal. Staff member W stated resident #13's refusal to get up for meals may be due to pain. During an interview on 2/20/19 at 3:10 p.m., staff member M stated he was familiar with resident #13's care. Staff member M stated the resident used to come down to the dining room, but over the last year resident #13 wanted to stay in her room more often. Staff member M stated there was not enough staff to stay in the room with resident #13 to assist her with meals, and staff member M did not feel like resident #13 was getting half as much food as she should, due to staffing and having to stay in her room to be assisted with her meals. Staff member M stated resident #13 was Full assistance, as of lately, for feeding. The staff member assisted resident #13 with meals by cuing, and stated the resident should receive finger foods, but if the resident did not want to eat, She took a boost (supplement). Staff member M stated he was not sure what they were doing with the meal intakes (documentation of intake) for the residents. He stated there was a clipboard in the dining room to chart a resident's meal intake. Staff member M stated he was unsure who was responsible for putting the meal intake amounts into the computer, but .maybe night shift? Staff member M stated it looked like resident #13 had lost weight. Staff member M stated that reporting changes for concerns or weight changes to a nurse was necessary, and the staff member would follow that. The employee believed resident #13 was weighed weekly, and on Saturday, Sunday, and Monday, there were only two staff members for evening shift, for both long term care hallways. Staff member M stated when they facility was short-staffed, resident showers were overlooked, and residents that were in their rooms for meals, were unable to be fed by the staff. Staff member M stated there had to be one staff member in the dining room during the meal and one staff member to pass hall trays and answer call lights. During an interview on 2/20/19 at 3:34 p.m., staff member J stated If there are only two staff members for both hallways during the evening shift, the only person who gets fed on the hall is (resident #10). There is not enough staff to assist with anyone else to eat in their rooms. Staff member J stated (Resident #13) is at risk for choking, and staff try to get her up at least once a day, for one meal. Staff member J stated on Saturday, Sunday, and Monday, (resident #13) did not get offered a dinner tray, due to no staffing. Staff member J stated, I did try to make sure she at least got a snack and a peanut butter and jelly sandwich. Staff member J stated, Nobody will help in the dining room, we just can't do it all. During an interview on 2/21/19 at 10:51 a.m., staff member T stated it was herself, the physician, and the interdisciplinary team, that were responsible for identifying residents at risk for weight loss. Staff member T stated a resident that was at risk for weight loss would be added to the Nutrition at Risk program. Staff member T stated that resident #13 was not at risk for impaired nutrition, and the resident will just cut back on what she eats, because she doesn't want to gain weight. Staff member T stated resident #13's nutritional status was reviewed 12/7/18, with her Annual MDS assessment. Staff member T stated resident #13 was receiving Boost, twice daily, as a supplement. Staff member T stated she had seen resident #13 eat on 12/7/18, when she evaluated her. Staff member T stated resident #13 usually eats all of the meals. Staff member T stated, All the supplement and meal intakes, and the resident's eating abilities, are documented in PCC (electronic health record program). Staff member T could not identify what resident not available meant on the meal intake record. Staff member T stated resident #13, did at times, refuse meals, but stated, that's when she takes her supplements. Staff member T, and the surveyor, reviewed the intake records for resident #13, and the staff member stated, This is interesting, I see that she has been refusing all meals. This is kind of new for her. Staff member T stated resident #13 was to be weighed monthly. When the surveyor and staff member T reviewed the current physician's orders [REDACTED].#13, staff member T stated she did not know that an order for [REDACTED].#13. When staff member T was asked when she had stopped monitoring weekly weights for resident #13, she stated, probably once she stabilized; I have to look back at my notes, hold on . then stated, It (the notes) doesn't say anything about discontinuing weekly weights. Review of resident #13's physician orders, dated 3/3/18, showed an active order for weekly weights one time a day, every seven days. Review of resident #13's Weights and Vitals Summary, dated 12/1/18 - 2/1/19, showed three weights listed, which were on 12/1/18, and the resident's weight was 201.4 pounds (wheelchair); 1/8/19, the resident's weight was 208.8 pounds; and, 2/2/19, the resident's weight was 208 pounds (wheelchair). Review of resident #13's MAR, for (MONTH) (YEAR), and January/February 2019, showed nursing staff documented the task of weighing the resident weekly, however, the CNAs were obtaining only monthly weights, as reflected on the Weights and Vital Summary. 2. During an interview on 2/20/19 at 6:49 a.m., resident #7 reported he was hungry all the time, and reported staff would not let him eat in his room. The resident reported he had lost weight, about 60 pounds. Review of resident #7's dietary progress note, dated 1/29/19, showed the resident needed assistance and cuing at meals in the dining room. Resident #7's weight was documented as 140 pounds, overall significant loss. The dietary progress note showed resident #7 consumed 75-100% of health shakes TID plus Boost pudding. Review of Resident #7's (MONTH) 2019 MAR, and the meal consumption report, did not show the amount of the Boost pudding supplement the resident had consumed. Review of resident #7's Care Plan, dated 1/29/19, showed encourage >50% of Health Shakes and pudding. During an observation on 2/20/19 at 10:50 a.m., resident #7 did not receive Boost pudding during his breakfast meal. Review of resident #7's (MONTH) 2019 MAR, showed nursing staff had administered Boost pudding at every meal. During an interview on 2/21/19 at 11:15 a.m., staff member T (who was not at the facility on a daily basis) stated resident #7 was to receive Boost pudding TID with meals. Staff member T stated, I know he gets it every day. During an interview on 2/21/19 at 11:54 a.m., staff member [NAME] stated she did not place physician ordered supplements on resident meal trays because it was the nursing staff's responsibility to make sure the resident received the supplement. Staff member [NAME] stated she needed to have a dietary communication slip from nursing, if the resident was placed on a supplement, that was to be given with meals. Staff member [NAME] stated she would put the supplement on the resident's dietary slip as a reminder, to help ensure staff got the supplement for the resident. Review of Resident #7's dietary slip showed no documentation for the Boost pudding supplement, as listed for breakfast, lunch, or dinner. Review of resident #7's physician's orders [REDACTED]. Review of resident #7's Care Plan, dated 9/3/18, showed staff to encourage po >50% at meals. Review of resident #7's Meal Intake report, dated 12/23/18 - 2/20/19, showed resident #7 ate During an observation on 2/20/19 at 6:51 a.m., there was no water pitcher at resident #7's bedside. During an interview on 2/20/19 at 8:50 a.m., staff member Z stated that she did not know how long resident #7's food had been sitting on the table. During an observation and interview on 2/20/19 at 10:50 a.m., resident #7 reported his food was cold. The resident was brought into the dining room when all meal trays had been passed and the staff were available to assist him. Resident #7's breakfast plate had been sitting on the table since the begin of meal service at 8:00 a.m. Staff did not offer to re-warm the resident's food, even after the resident verbalized the food was cold. Resident #7 was drinking his oatmeal through a straw from a bowl, no staff were available to assist him. During an interview on 2/21/19 at 12:33 p.m., staff member V stated everybody should have a water pitcher at the bedside. During an observation on 2/21/19 at 12:34 p.m., there was no water pitcher in resident #7's room. Review of resident #7's Care Plan, dated 1/11/19, showed maintain weight/hydration status. 3. During an interview on 2/19/19 at 12:55 p.m., staff member DD stated she did not take resident #6 to lunch as he was asleep and wiped out from his bed bath this morning. She stated that if the resident had swallowing precautions, We can't leave the (meal) tray (in the resident's room). Staff member DD stated We will bring him something when he wakes up. During an interview on 2/19/19 at 2:40 p.m., staff member B stated she wasn't sure if resident #6 had anything brought to him for lunch, and she wasn't sure where they charted it. A peanut butter and jelly sandwich was given to staff member DD by staff member B, but she was unsure if resident #6 ate the sandwich. Meal Intake Documentation Concerns: During an interview on 2/19/19 at 2:40 p.m., staff member U reported the meal charting for resident #6's lunch, on 2/19/19, showed not applicable. During an interview on 2/21/19 at 11:13 a.m., staff member AA stated the documentation una on the daily meal intake means the resident was in bed and didn't come to the meal. Staff member AA stated the missing documentation for supper percentages had been a problem for a long time. Review of resident #6's meal charting for the lunch meal, on 2/19/19, showed, amount eaten a percentage was not documented, and not applicable was marked. Review of resident #6's meal charting for amount eaten from 1/20/19 through 2/20/19 showed resident not available on three occasions, not applicable on one occasion, and twenty seven times where there was no documentation at all for meal percentage. Review of resident #6's Care Plan, with a revised date of 11/3/18, showed Needs cueing at meals in room or dining room; staff to provide set up and assist as needed. Mechanically altered diet related to chewing and swallowing difficulties. Review of resident #6's weight records showed a weight of 147 pounds on 10/30/19, and a weight of 137 pounds on 2/21/19, which reflected a 6.8 percent loss, in less than four months.",2020-09-01
333,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2019-02-21,697,G,0,1,ZR9X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify, treat, and manage the pain for 1 (#13), which resulted in the inability of the resident to get up for meals, decreased meal intake and missed meals, and uncontrolled pain. The facility failed to treat and manage pain for 1 (#7) of 18 sampled residents, which caused increased anxiety, agitation, and tearful episodes. Findings include: 1. During an observation and interview on 2/20/19 at 9:52 a.m., staff member H was finishing resident #13's restorative exercises, and stated she was not able to complete the lower extremity exercises due to the pain the resident was having. Resident #13 stated she was in so much pain she was unable to get up, and had refused her breakfast tray. Staff member H stated she would report the resident's pain to the nurse when she completed resident #13's restorative exercises. During an interview on 2/20/19 at 11:06 a.m., resident #13 stated resident #13 stated her pain affected how she was eating, and her ability to get up for meals. During an interview on 2/20/19 at 3:08 p.m., staff member W stated resident #13 did require assistance with meals, and the resident did refuse to get up, because she was in pain or too tired. Staff member W thought resident #13's pain was affecting her ability to get out of bed for meals. Staff member W stated resident #13 did not have any scheduled pain medication, but stated it could be helpful in managing the resident's pain. She stated The resident had been on [MEDICATION NAME], which seemed to have worked well for the resident, but (the physician) won't prescribe it. Staff member W stated she had not talked with the physician currently responsible for the resident's care, to tell her what had worked to manage the resident's pain in the past. Staff member W stated she was unaware of the facility's policy for pain monitoring. Review of resident #13's Meal Intake report, for (MONTH) and (MONTH) 2019, showed concerns related to the resident's lack of intake and lack of attendance at meals. Refer to F692 for further detail. During an interview on 2/20/19 at 11:00 a.m., resident #13 stated her pain had not been managed well. She stated her pain was rated a 9 out of 10; 10 being the worst, in her feet that morning. She stated she had [MEDICAL CONDITION], and her pain had been worsened over the last couple of weeks. Review of resident #13's MAR, for (MONTH) (YEAR) and (MONTH) 2019, showed no pain monitoring documentation for each shift. Review of resident #13's MAR, for (MONTH) 2019, showed the resident received 20 doses of PRN [MEDICATION NAME] 500 mg. The resident had rated her pain at a six or greater for fifteen of those doses. The resident also received seventeen doses of Tylenol 650 mg. The resident rated her pain at a six or greater for fourteen of those doses. Review of resident #13's MAR, for (MONTH) 2019, showed Pain Monitoring: Monitor for pain every shift either verbal or non-verbal signs. Every shift Please use the PAINAD scale if the resident is unable to verbalize pain. **Must document intervention if resident is having pain.** Start date 2/20/19 at 6:00 p.m. Review of resident #13's MAR, for (MONTH) 2019, showed the resident received seventeen doses of [MEDICATION NAME] 500 mg. The resident rated her pain at a six or greater for thirteen of the doses of [MEDICATION NAME]. The resident also received eleven doses of Tylenol 650 mg. The resident rated her pain at a six or greater for seven of those doses. Review of resident #13's Weights and Vitals Summary dated, 1/1/19-2/20/19, showed the resident rated her pain at a six or greater (10 being the worst) sixty-one times. Review of resident #13's Care Plan, dated 9/27/18, showed I have pain/discomfort related to lower back pain and diabetic [MEDICAL CONDITION]. I experience mild pain frequently and have indicated that my pain makes it difficult for me to sleep at night and limits my day-to-day activities. I want to keep my pain level at the lowest possible level. During an interview on 2/20/19 at 3:34 p.m., staff member J stated resident #13 Had been frequently complaining about the pain in her feet, and stated the resident told her she is always in pain. Staff member J stated she did report the pain to the nurse every time the resident was in pain. 2. During an observation and interview on 2/21/19 at 7:34 a.m., resident #7 stated his pain was at a 7 out of 10; 10 being the worst, in his lower back. Resident #7 was very tearful and restless in his wheelchair when he was interviewed. During an interview on 2/20/19 at 6:57 a.m., resident #7 stated he had constant pain in his knees, shoulders and back. He stated on an average day his pain was at a 7 out of 10, and on bad days he stated his pain was at a 9 out of 10. The resident stated he did report pain, and the nurse would bring him pain medicine. He stated the pain medication was not very effective, It just makes me dopey. During an observation and interview on 2/20/19 at 6:32 a.m., resident #7 stated crawling around on the floor Hurts my knees and takes all the hide (skin) off. There were multiple scabs and abrasions observed on the resident's lower extremities and elbows, which were in various stages of the healing process. During an observation and interview on 2/21/19 at 7:37 a.m., staff member V stated the facility had used the PAINAD scale to assess residents, and The assessment tool was very subjective. Staff member V demonstrated the PAINAD tool for resident #7, which generated a pain level of 2 out of 10. Staff member V stated she would go talk with the resident and ask him if he had pain. Staff member V stated other staff should also be using the PAINAD assessment for pain. Staff member V stated she did try to anticipate the resident's pain by knowing the resident's routine, and medicate the resident before and after activities, as needed. Staff member V stated when a resident had received an as needed medication for pain, The MAR indicated [REDACTED]. During an observation and interview on 2/21/19 at 8:24 a.m., staff member V administered resident #7's morning medications. Staff member V stated she did not include any as needed pain medication with resident #7's morning medications. Staff member V stated she did not give pain medication with morning medications and stated He is fine. Staff member V stated when she asked if resident #7 was in pain that morning, he told her He was living in a nightmare that he can't wake up from, and began to cry. Staff member V did not investigate further why the resident was crying. Review of resident #7's Care Plan, dated 9/3/18, showed I want to keep my pain between a pain score of 1-4. A review of the facility policy, titled Pain Assessment and Management, with a revised date of (MONTH) (YEAR), showed under the heading of Policy The purpose of this procedure are (sic) to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. Under the heading, Recognizing Pain was listed Possible Behavioral Signs of Pain: a. Verbal expressions such as groaning, crying, screaming; . d. Behavior such as resisting care, irritability, depression, decreased participation in usual activities; e. Limitations in his or her level of activity due to the presence of pain; . g. Difficulty eating and loss of appetite; h. [MEDICAL CONDITION]; and, i. Evidence of depression, anxiety, fear or hopelessness .",2020-09-01
334,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2019-02-21,698,D,0,1,ZR9X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the resident necessary services for [MEDICAL TREATMENT], by properly monitoring and assessing the resident's [MEDICAL TREATMENT] port site; failed to sufficiently educate and train nursing staff for residents receiving [MEDICAL TREATMENT] care; and failed to document and complete the [MEDICAL TREATMENT] Communication form, for 1 (#29) of 18 sampled residents. This failure increased the risk for resident complications related to [MEDICAL TREATMENT] care and services. Findings include: During an interview on 2/21/19 at 8:49 a.m., staff member V stated she had not received any formal training or education on the care and management, from the facility, for residents receiving [MEDICAL TREATMENT]. Staff member V stated she would care for a [MEDICAL TREATMENT] port by looking at the port site, and stated She probably still has her dressing on from yesterday. Staff member V stated resident #29 is receiving regular [MEDICAL TREATMENT]. Staff member V stated vital signs are to be completed before and after [MEDICAL TREATMENT], and the [MEDICAL TREATMENT] center weighs the resident. Staff member V is unaware of any food or fluid restrictions, and stated She makes us crazy, eating all those Cup-a-Soups that are high in salt. Staff member V stated sometimes resident #29 had refused to go to [MEDICAL TREATMENT] because she could not tolerate it, and had a history of [REDACTED]. Staff member V stated she was unaware of [MEDICAL TREATMENT] related complications, other than resident #29 coming back early from her [MEDICAL TREATMENT] appointments, She is just really depressed. Staff member V stated There is no communication to the [MEDICAL TREATMENT] clinic, only weights and vitals. Staff member V stated she had [MEDICAL TREATMENT] education from a previous employer, but did not know if any of the other facility staff had received [MEDICAL TREATMENT] education. During an interview on 2/21/19 at 9:15 a.m., staff member W stated she had received no training from the facility on the care and management of a resident receiving [MEDICAL TREATMENT] and she did not know what type of [MEDICAL TREATMENT] resident #29 was receiving. Staff member W stated No I don't know how to care for the (port) site. We just have whatever the communication form from the [MEDICAL TREATMENT] clinic says. Staff member W stated vital signs were completed before and after the resident goes to [MEDICAL TREATMENT], and a weight was completed after the resident comes back from [MEDICAL TREATMENT]. Staff member W stated resident #29 had no food or fluid restrictions that she knew of. Staff member W stated resident #29 occasionally comes back early because of pain, but she makes it up the next day. Staff member W stated she was unaware of any [MEDICAL TREATMENT]-related complications, Nothing has been reported to me. Staff member W stated she had noted an increase in resident #29's flat affect. She stated she communicated with the [MEDICAL TREATMENT] clinic by phone, faxed orders, and the daily sheets that were sent to the [MEDICAL TREATMENT] clinic. Review of resident #29's Care Plan, dated 5/22/18, showed the resident was receiving [MEDICAL TREATMENT]. Review of resident #29's MAR and TAR, dated 2/1/19-2/28/19, lacked documentation for monitoring of the shunt access site for infection and thrills or bruits. Review of resident #29's [MEDICAL TREATMENT] Communication with Long Term Care Center form, dated 12/28/18-2/15/19, showed twelve incomplete forms the facility was responsible for completing before resident #29 left the facility to the [MEDICAL TREATMENT] center. Review of resident #29's physician's orders, from the [MEDICAL TREATMENT] center, dated 4/11/18, showed a fluid restriction of 1.5 Liters/day. The order was a verbal order from (resident's [MEDICAL TREATMENT] provider) to the facility. Documented on the left side of the order was a handwritten note that showed the order had been faxed to the facility, and noted as called to the facility, from the [MEDICAL TREATMENT] center. The order did not specify who the nurse was that received the call at the facility. During an interview on 2/21/19 at 11:40 a.m., NF4, from the [MEDICAL TREATMENT] center, stated there was a standard fluid restriction of 1.5 liters per day for anyone receiving [MEDICAL TREATMENT]. NF4 stated there have been several times resident #29 had been unable to complete her 4.5-hour [MEDICAL TREATMENT] treatment, and stated it was because the resident just couldn't sit anymore, and she is difficult for us to reposition. Review of resident #29's [MEDICAL TREATMENT] Communication with Long Term Care Center form, dated 12/28/18, showed, under the heading of incidents/new acute problems/[MEDICAL TREATMENT] occurrences (fever, chills, hypertension, [MEDICAL CONDITION], prolonged bleeding, increased weakness, ect.:) showed bottom sacral area painful-difficulty sitting-skin assessment? The top portion of the [MEDICAL TREATMENT] Communication form the facility was responsible for completing was marked with zeros for the listed concerns. Review of resident #29's TAR for (MONTH) (YEAR) (MONTH) 2019, showed no documentation that a weekly skin check was completed. Review of resident #29's TAR for (MONTH) 2019, showed the skin check was to be completed every night shift on Tuesday for skin assessment. The weekly skin check monitoring was initiated on 2/19/19 at 6:00 p.m. A skin check was documented on 2/19/19, but did not indicate any skin issues. During an interview on 2/21/19 at 10:51 a.m., staff member T was questioned about a fluid restriction for resident #29 due to her receiving [MEDICAL TREATMENT]. Staff member T stated, I believe so, I am looking up, I guess not. Review of resident #29's [MEDICAL TREATMENT] Communication with Long Term Care Center form, dated 1/2/19, showed under the section Changes ([MEDICAL TREATMENT] time increased or decreased, change in target weight, diet, medication etc.): showed the pt. was very fluid overloaded. Documentation on the form showed 4.5 liters of fluid was removed from resident #29. A review of the facility policy, titled [MEDICAL TREATMENT] showed, under the heading of Purpose, The purpose was to provide quality of care and treatment services to the resident who requires [MEDICAL TREATMENT].7. comprehensive care plan will be developed for each resident receiving [MEDICAL TREATMENT] services to include: .f. If fluid restrictions apply, specify order, including ml/ccs. .k. monitoring of a shunt or access site for thrill/signs of infection at least once daily. i. Report any concerns noted to MD and [MEDICAL TREATMENT] unit. Section ii. Access site will be covered and kept dry during showering/bathing. iii. Monitor site for redness, warmth, swelling. .m. Staff to remove the dressing on the [MEDICAL TREATMENT] port 4(four) hours after treatment. Or as directed by the [MEDICAL TREATMENT] unit.",2020-09-01
335,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2019-02-21,725,E,1,1,ZR9X11,"> Based on observation, interview, and record review, the facility failed to ensure adequate staff were available for the provision of resident care and services, to include specifically during nights and weekends; and, -failed to provide a resident (#7) with assistance with rewarming his meal(s), and assistance with meals; - failed to ensure a resident (#14) had assistance with hair and oral care, and the resident was taken to the dining room with messy hair; - failed to ensure a resident was transferred safely with a mechanical lift, for 1 (#39); - failed to ensure a resident's call light was responded to timely, for 1 (#348); - failed to ensure a resident received a warm/palatable meal, and ensured the resident was provided and assisted with a meal, when the resident required assistance to consume the meal in her room and she was at risk for choking, for 1 (#13); - failed to assist a resident who was hollering for help (#13); and, - failed to ensure assistance was provided for bathing/showering for 3 residents, and resident (#2) felt unwanted and considered moving out of the facility due to the lack of care, and a resident (#12) felt dirty and smelly due to the lack of bathing and assistance, and began to cry and was upset when discussing the lack of care, and staff failed to assist a resident (#29) with bathing assistance, and the resident went without bathing/showering. These failures had the potential to affect any resident who needed staffing assistance related to ADL care, meals assistance, or assistance in their room or during the day, and increased the risk of resident declines due to the lack of bathing, provision of meals, and resident oversight with daily care, out of 31 sampled and supplemental residents. Findings include: During an interview on 2/21/19 at 11:11 a.m., staff member C stated When we don't have three CNAs for nights we post open shifts in advance for staff to sign up for. If we have short notice that we will not have enough staff, we call people and try to get someone to come in. If we are unable to get staff through calling our own staff, we call the Pool (staffing agency) that we contract staff through. If we are short two staff we attempt to get two filled, if we are only able to get one staff instead of the two, we staff one upstairs and one down. The CNA upstairs helps the staff downstairs, at 1 a.m., 3 a.m. and 5 a.m., to do the rounds. If we are not able to get sufficient staff through calling and using pool staff, managers have to come in and help. Staff member C stated the staffing matrix required the facility to staff five CNAs on day shift, five CNAs on evening shift, and three CNAs on the night shift. Record review of the facility CNA schedule for (MONTH) 2019, evening shift, showed fourteen days out of the month the facility had 4.5 or less CNA staff working, of the five required CNA staff. Out of the fourteen days, ten of the staff were carried over to the night shift, from the evening shift, to fill the required three CNAs for the night shift. The day of the week most affected by the lower number of staff working was Sunday. Record review of the facility CNA schedule for (MONTH) 2019, night shift, showed seven nights out of the month the facility had two CNAs, of the three required, for the shift. Out of the seven night shifts, six staff were carried over from the evening shift, to fill the required three CNAs for the night shift. The day of the week most affected by the lower number of working staff was Sunday. Record review of the facility CNA schedule for (MONTH) 2019, evening shift, showed twelve days out of the month the facility had 4.5 or less, of the five required scheduled CNA staff. Out of the twelve evening shifts, eleven CNA staff were carried over to work the night shift. The day of the week most affected by the lower number of staff working was Sunday. Record review of the facility CNA schedule for (MONTH) 2019, night shift, showed three days out of the month the facility had two CNAs working, of the three scheduled for that shift. The days affected by the lower number of staff working included Friday, Sunday, and Monday. During an interview on 2/21/19 at 7:21 a.m., staff member V stated Sundays were usually the days they were low on CNA staff. She stated one day, she came to work and had only one CNA, on a Sunday. She stated she gets behind on her task of administering medications when they are low on CNA staff. She stated there were several medications to administer in the morning, and she was usually done by 9:30 a.m., when she had the required amount of staff. If this happened, she would not be interrupted as much with having to help with resident care when the floor did not have the required number of staff working. She stated, We have two CNAs show up, and with residents calling for help, assisting with meals, and giving baths, it causes residents to not get their baths. Staff member V stated We have a problem when we only have two CNAs, because we have to stay with the resident that eats in her room. She is a choking risk, and we have to watch her eat. So, this means one CNA is doing it all (helping all residents on the unit) during the time we have to be in with that resident. I am responsible for the residents. They should have another CNA on this floor instead of just two. A review of the Facility assessment, originally submitted to the survey team, showed the area of the General Staffing Plan had not been completed. During an interview on 2/20/19 at 2:29 p.m., staff member N and O stated the Facility Assessment submitted to the survey team was worked on by the previous administrator and was a working copy. Staff member N stated the facility assessment would be completed and resubmitted to the survey team with the current and accurate information. a. During an observation on 2/20/19 at 7:03 a.m., staff member K assisted resident #14 with getting out of bed and getting ready to go to the breakfast meal in the dining room. Staff member K assisted resident #14 to the sink, in her bathroom, to wash her face and hands and brush her teeth. Resident #14 sat in front of the sink and did not wash her face and hands or brush her teeth. Staff member K did not offer to assist resident #14 with her grooming. Resident #14 remained sitting in her bathroom until staff member K came back to assist her to the dining room. Staff member K failed to offer assistance with the resident's oral care or brushing her hair. Resident #14 went to the dining room with her hair standing up on one side of her head. Review of resident #14's Annual MDS, with an ARD of 9/7/18, under Functional Status, showed the resident required extensive assistance with transfers and toilet use, and limited assistance with personal hygiene. The Cognitive Status assessment showed resident #14's cognitive functioning was severely impaired. Review of resident #14's Care Plan, with a last review date of 1/4/19, showed she needed physical help with personal hygiene and oral care. b. During an observation and interview, on 2/20/19 at 1:44 p.m., resident #39 had been sitting in his wheel chair and was transferred into his bed. Staff member G was coming out of the resident's room by herself with the mechanical lift after transferring the resident. Staff member G stated We are supposed to have two people (for conducting the transfer with the mechanical lift), but if you waited for someone to help, you would be here until 3:30 (p.m.). During an interview on 2/20/19 at 1:51 p.m., staff member H stated staff were supposed to have two people to transfer with a Hoyer lift, and I think with the Sit to Stand lift, but that does not always happen. Staff member H stated, We just don't have enough staff. People call off, or we just don't have them, I just need to be honest. During an interview on 2/19/19 at 3:00 p.m., staff member D stated there is usually one CNA on the 200 hall. During an interview on 2/19/19 at 3:15 p.m., staff member D stated it was really busy after dinner. She stated sometimes the resident may have to wait thirty to forty five minutes before they were assisted to bed for the evening. c. During an interview on 2/19/19 at 11:50 a.m., resident #348 stated she waited a long time for her call light to be answered, twenty minutes to an hour and a half, staff do not bring her meal tray in a timely manner. During an interview on 2/20/19 at 5:29 a.m., staff member EE stated there was one CNA working on the upper floor during the night. During an interview on 2/20/19 at 5:34 a.m., staff member P stated sometimes the staffing was good and sometimes it was not. Staff member P stated there was only one CNA working on the floor and sometimes staff member P had to go downstairs to help out. It could be very rushed when the employee had to work both upstairs and downstairs. The employee stated, We bring it up at staff meetings, and I have approached administration about it (staffing concern). During an interview on 2/20/19 at 5:40 a.m., staff member AA stated if the resident census was below 16, then there was only one CN[NAME] Staff member AA was not able to get the assigned resident care done if this happened. Staff member AA stated I have approached (staff member Q) and told We can do it. During an interview on 2/20/19 at 9:30 a.m., NF2 stated the staffing was horrible. NF2 felt the resident care needs were neglected, especially on the weekends. Baths/Showers d. During the group interview, on 2/20/19 at 10:09 a.m., residents stated they waited thirty minutes or more for someone to answer the call light. The call lights just keep going on and on. The group stated resident #13 hollered help me, help me, and no one comes to assist them. The group stated they do not get sufficient baths or showers, and when they ask about their baths or showers, the CNAs state they do not have time, so they are not provided. e. During an interview on 2/21/19 at 12:54 p.m., resident #2 stated when she doesn't get her baths as scheduled It makes me feel like I'm not wanted, and I'm thinking about finding another place to live. Resident #2 stated, We're lucky if we have two aides, when discussing concerns related to staffing. Resident #2 stated It's good while surveyors are here, but after you leave, we go back to the way it was. f. During an interview on 2/21/19 at 1:07 p.m., resident #12 stated It makes me feel dirty and smelly when I don't get my showers. I get upset and it makes me want to cry. During an interview on 2/20/19 at 9:20 a.m., staff member H stated she felt the residents were neglected when the facility was short-staffed, because We are busy answering call lights, and can't get to residents that , or can't, speak up. It feels like they (the residents) are getting neglected. Staff member H stated that last Tuesday and Wednesday there were only two staff members for the long term care unit. Staff member H stated this had occurred 4-5 times in the last month, when there had only been 2 staff members, on the day shift, for the long term care unit. Staff member H stated when the facility is short-staffed like that men don't get shaved, meals are served late and cold, resident's do not get fed on time, residents don't get showered, and residents are in soiled briefs for extended periods of time. h. During an observation and interview on 2/20/19 at 3:34 p.m., staff member K stated that she had to shower resident #13 that evening because it was her bath day, but I probably won't get it done. She stated the resident was female care only for peri-care and showers, and the only other available evening shift staff member was male. Staff member K stated it took approximately 30 minutes to complete resident #13's shower, and with only two staff members for the unit, the nurse would have to stop what she was doing and assist with the resident care and covering the floor. Staff member K was tearful and upset during the interview when discussing the staffing and resident care concerns. i. Review of resident #29's bathing record for 2/21/19, showed from 12/23/18 - 2/21/19, one bath occurred on 1/5/19. The resident's bathing performance was total dependence. Review of resident #29's care plan dated 3/31/18, showed the resident's need for extensive assistance of 1-2 staff with bathing. j. During an observation and interview on 2/20/19 at 10:50 a.m., resident #7 reported his food was cold. The resident was brought into the dining room when all trays had been passed, and staff were available to assist him with the meal. During the observation, it was noted resident #7's breakfast plate had been sitting on the table for sometime. Staff did not offer to re-warm the resident's food, even after the resident verbalized the food was cold. Resident #7 was drinking his oatmeal through a straw from a bowel, no staff were available to assist him. k. During an interview on 2/20/19 at 3:34 p.m., staff member K stated If there are only two staff members for both hallways during the evening shift, the only person who gets fed on the hall is resident #10. There is not enough staff to assist with anyone else to eat in their rooms. Staff member L stated Resident #13 is at risk for choking, and staff try to get her up at least once a day, for one meal. Staff member L stated on Saturday, Sunday, and Monday, resident #13 did not get offered a dinner tray due to no staffing. Staff member K stated I did try to make sure she at least got a snack and peanut butter and jelly sandwich. Staff member K stated nobody will help in the dining room, we just can't do it all.",2020-09-01
336,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2019-02-21,755,D,1,1,ZR9X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to ensure procedures were established that assured the accurate acquiring, receiving, dispensing, and administering of all controlled medications to meet the needs of each resident and maintain an accurate Narcotic Log Record, per pharmacy and facility procedures, which reflected an inaccurate medication count of controlled medications for 3 (#s 00, 27, and 39) of 31 sampled and supplemental residents. Findings include: 1. During an interview on 2/20/19 at 5:35 a.m., staff member FF stated two nurses count the narcotics at shift change, and if there was an inaccurate count, the nurses would contact the DON. The medications were delivered at night, and in a container. There was paperwork delivered with the container, to show what medications were in the box. The paperwork copies that were made from the original documents that the driver had. Staff member FF stated when a medication was missing they would call DON or the pharmacy. She stated when the nurse signed for the medication delivery he/she had to sign the form on a clipboard showing the medication tote was delivered. The tote was not checked for the contents, by the night nurse, who checked the tote in. Staff member FF stated a few months back the facility had an investigation. At that time, the medication delivery procedure changed to have the day shift sign in the medication totes and check them instead of night shift checking the contents inside. She stated if she had to get into the tote she would have to get the other nurse, pull out just get the medication she needed, and then lock the medication tote back up. She stated she did not know the outcome of the investigation mentioned prior. Staff member FF stated the medications delivered have always been put in the medication room. The tote was only checked in by a nurse, not a CN[NAME] She stated the day nurse takes the tote, and the paperwork, for what was inside the tote, and checked it in. If there was a narcotic in the tote, two nurses signed the narcotic in, by using the narcotic log book. Staff member FF stated the Omni Cell, a medication dispensing machine, required the nurse to put in a password and a code. These were required of each nurse. Staff member FF stated if the nurse was getting a narcotic out of the machine, the nurse had to have a second nurse to sign off for the narcotic and put their password/code in the machine. Staff FF stated if the nurse did not have another nurse available, the narcotic could not be dispensed. The only way the nurse could get the narcotic, was if another nurse provided the password and code. She stated the system would not allow the nurse to try and put the same password and code in as the first and second nurse, required for the dispensing. The medication container that was delivered on the night of 2/19/19 into 2/20/19 a.m., was observed in the medication room, and the medication tote was sitting on the counter top, and the tote had one zip tie. The zip tie on the container did not have a number, for tracking. The zip tie was a plan black zip tie. Staff member C could not explain why there was only a black zip tie on the tote, and why tracking numbers were not on the zip tie. 2. A note was observed on 2/19/19 at 5:45 a.m., at the nurses station. The noted was dated 10/18/18, and showed For administering all MS liquid Two nurses to be present when signing out and when adm. to resident. Thank you and the note was signed by staff member Q. 3. During an interview on 2/20/19 at 9:58 a.m., with staff members C and W, they stated that sometimes there were numbers on the zip tie which locked the totes. Both stated the pharmacy delivered the totes with either the black zip tie or tags with numbers. If the nurse opened the tote, the nurse would then put the numbered tag on that they had in the medication room. The staff stated before the policy change, if the pharmacy delivered the tote, the nurse would open the medication tote with the pharmacy driver, and scan the medications, because the paperwork showing what medications were delivered was inside the tote. After the change, the nurse now had the paperwork delivered outside of the tote, so the tote did not need opened. Therefore, it was opened on the day shift. Staff member C stated if there was missing medication upon opening the tote, there would be an investigation started. 4. Record review of resident #39's [MEDICATION NAME] documentation showed twenty-eight and a half milliliters on 2/3/19. The record showed twenty-seven milliliters on 2/7/19, with a nurse documenting corrected dose and two signatures were included. Staff member C did not know who the two signatures were on the narcotic log. Staff member C stated the signatures should be a manager, or the DON, that would do the adjustment on any narcotic medication, which was to be done with another nurse. She stated the adjustment may have been needed due to the medication absorption. 5. Record review of resident #27's narcotic log book showed on 10/18/18 at 8:45 a.m., one milliliter of [MEDICATION NAME] was given by staff member V, leaving fourteen on the bottle. The record showed on 10/19/18, fourteen milliliters was destroyed. During an interview with staff member V on 2/21/19 at 11:35 a.m., she stated when she pulled the [MEDICATION NAME] Solution up on 10/18/18, it appeared to look like water. She stated previous to that it was pink in color. She stated she notified the DON and Administrator. She stated she looked at another bottle of [MEDICATION NAME] Solution and it was pink in color. She stated she believed that after that they were to have two nurses pull up any [MEDICATION NAME] Solution for a resident. During an interview on 2/21/19 at 11:50 a.m., staff member Y stated she had not been instructed to use two nurses to pull up [MEDICATION NAME] Solution. 6. During an interview on 2/21/19 at 8:06 a.m., staff member EE stated the facility had not instructed her to have another nurse with her to pull up [MEDICATION NAME] Solution. She stated she does it by herself since she is the only nurse on the floor, and there is nobody to ask. Staff member EE stated there was a board in the medication room to sign when they opened the tote, and then if sealed back up, they put new zip ties on it. During an interview on 2/21/19 at 8:22 a.m., staff member Q stated that sometimes in (MONTH) of (YEAR) the totes had numbers on them and sometimes the totes did not. 7. Review of the SHIFT TAG CHECK NARCOTIC E-KIT logs for November, (MONTH) (YEAR), (MONTH) 2019, and (MONTH) 2019, showed there were thirty dates without numbered tags on the tote. There were forty two dates that were left blank on the form. The form for (MONTH) was for the 1st to the 15th of (MONTH) (YEAR). Review of missing narcotic investigations showed there were two [MEDICATION NAME] tablets missing for an unknown resident that came from the pharmacy, in a bag, with two different labels, and a card of [MEDICATION NAME] for resident #00, who did not enter the facility. Staff member FF gave a written statement that when she opened the tote on 11/13/18, the bag with the [MEDICATION NAME] tablets was heat sealed and was for the Omni Cell replacement. She placed the medication manifest, and the heat sealed bag, in the medication cart. She said when she returned on 11/14/18 the bag and manifest were still in the cart. Around 3 a.m., when she was putting narcotics away she noted that the [MEDICATION NAME] was no longer in a sealed bag. She said they were in a Ziploc bag with the manifest around it. There were two [MEDICATION NAME] missing. She called the day nurse, and she said she had not touched them. Staff member FF said she then called the DON. Review of the written statement from staff member B dated 11/3/18, showed Pharmacy delivered shipment @ 0130 am Sat. 11/3/18 after he left I went thru the blue tote there was 30 [MEDICATION NAME] 5/325 and 30 [MEDICATION NAME] for (resident name}, I left the [MEDICATION NAME] wrapped in the plastic and sealed tote up with red ties to send [MEDICATION NAME] and [MEDICATION NAME] back to pharmacy. When i came back to work Saturday evening and went to put my belongings in the Med room, I noticed that the tote was opened and the only thing in there was the [MEDICATION NAME], I then let (staff member GG) know. Review of a written statement from staff member HH and II showed the label for the two [MEDICATION NAME] was erroneous, and an error on the pharmacy's part, and there was no clear evidence the [MEDICATION NAME] was altered. The facility destroyed the [MEDICATION NAME] and replaced the medication. The statement showed the policies relating to delivery, restock into Omnicell, administration and disposition of medications were discussed with staff member Q. There was no information in the statement about the missing [MEDICATION NAME]. A note dated 11/14/18 titled Process of checking in the Pharmacy Tote showed the following: Only, if a medication is needed from the tote during the night shift two nurses will check the count and only that medication will be put in the Omnicell by two nurses during the night . Two nurses on Day shift will open the tote together, check the narcotic count is correct and will be put in the Omnicelle preferably before stand up or by 9:30 a.m. Make sure the green or red tags are intact. Put tag numbers on the Shift Tag Check Narcotic E-Kit form on clip board . I have read and understand the above information. Signature. There were no licensed staff signatures on the paper, under the Signature line. A review of the facility policy, titled Delivery, Receipt, Storage, and Inventory of Medication and Products, section 5.1 . Procedure 1. The Pharmacy will deliver medications to the Community. A Community authorized recipient should sign the delivery receipt indicating all medications have been received. 2. recipient should verify all continents of the delivery . Any discrepancies or omissions noted on the delivery packing slip or log should be promptly faxed to the Pharmacy . Review of the facility policy, titled Medication: Storage of, showed . 10. All controlled drugs are stored under double-lock and key. 8. During a phone interview with staff member HH and II on 2/20/19 at 4:35 p.m., they stated the totes come to the building sealed from the pharmacy with the zip ties on them. Staff member HH stated he had looked at the information staff member Q had regarding the [MEDICATION NAME], and the changes put in place. Staff member II stated the DEA would only be notified if the missing medication belonged to the pharmacy, and that notification was completed for the [MEDICATION NAME]. 9. During an interview on 2/21/19 at 7:23 a.m., staff member N stated the log for the tote has different names, sometimes the log shows E-Kit, but the staff use that for the tote. She stated the DON has to report missing narcotics up the chain of command and she was notified of both. She stated the facility believes the one [MEDICATION NAME], for unknown resident, is resolved as there were two labels on the bag. She stated she believed the nurse sent the card of [MEDICATION NAME] for resident #00 was sent back to the pharmacy. The facility could not show the card of [MEDICATION NAME] for resident #00 was sent back to the pharmacy.",2020-09-01
337,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2019-02-21,761,D,1,1,ZR9X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to dispose of expired medical supplies, and failed to date insulin with an open date. This deficient practice had the potential to affect all residents who utilized the facility's medical supplies storage, and insulin for 1 residents (#351), who received insulin. Findings include: 1. During an observation of the 200 hall medication room on [DATE] at 4:09 p.m., there was an un-opened package of thirty purple top vacutainer's with an expiration date of [DATE]. During an interview on [DATE] at 4:09 p.m., staff member B stated she thought the local hospital had just delivered the tubes to the facility. She stated that herself and staff member C check the medication room one time a month for outdated medications and supplies. 2. During an observation, and interview, on [DATE] at 10:29 a.m., the inspection of a medication cart showed opened [MEDICATION NAME] and Humalog insulin pens without dates for resident #351. Staff member EE stated those should have been labeled with an open date. A review of the facility policy, titled Delivery, Receipt, Storage and Inventory of Medication and Products under section 5.3 Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, showed: . Procedure . 4. The Community should ensure that medications and biologicals: 4.1 Have an expiration date on the label; 4.2 Have not been retained longer than recommended by the manufacturer or supplier guidelines . 5. Once any drug or biological is opened, the Community should follow manufacturer/supplier guidelines with respect to expiration date for opened medications .",2020-09-01
338,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2019-02-21,800,D,0,1,ZR9X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview, the facility failed to identify residents who had food preferences or needs related to nutrition, which were not met, and the residents would not eat some of the meals served due to these preferences or needs. The facility also failed to consistently serve meals which were not delayed, and this caused food to be cold at times or not of a palatable temperature, for 2 (#s 8, and 13) of 31 sampled residents. Findings include: During an interview on 2/19/19 at 2:50 p.m., resident #13 reported having 1/2 of a peanut butter and jelly sandwich for lunch, which was not enough to satisfy the resident for the meal. During an interview on 2/20/19 at 10:29 a.m., resident #8 stated the food did not taste good, and it was sometimes cold. During an interview and observation, on 2/21/19 at 8:15 a.m., staff member JJ stated the breakfast for the lower level of the facility was supposed to start at 8:00 a.m., but she was observed gathering residents to take to the dining room [ROOM NUMBER] minutes after this time. Staff member JJ stated residents are typically finished eating by 8:30 a.m., and residents eating in their rooms were finished by 8:45 a.m. Staff member JJ stated this is a policy (the meal time(s), and this is what they (staff) are expected to follow. She stated the dietary aide prepares the meal from the steam table, and then the CNA takes the meal to the resident waiting in the dining room. During an observation and interview on 2/21/19 at 8:17 a.m., breakfast was prepared and maintained on the steam table, next to the dining room. Staff member CC uncovered the oatmeal and English muffins, in preparation of serving the meal. Staff member CC then started dishing up food plates, placing them on a rolling cart, which was next to the steam table. Staff member CC waited for facility staff to come take and deliver the plates, but the staff did not arrive in a timely manner. Staff member JJ, and other staff, were observed standing in the dining room talking to one another. The administrator, and two other staff, were pouring fluids or helping residents. The meal service continued to be delayed due to the lack of staff assisting. Staff member CC stated she always had to wait for the staff to come serve the meals. The meals, which had been dished up already, remained on the cart, uncovered, and without a thermal warmer under the plate to keep the food at a palatable temperature. When the nursing staff started to assist with taking the meal plates to the residents, there were frequent times when plates sat on the cart for 2 to 3 minutes before being delivered to a resident. All meals were served in the lower level dining room by 8:47 a.m. Alternates were not requested by the staff during the meal. Staff member CC started dishing up and preparing the plates for the resident in their rooms. The food on the steam table remained uncovered (oatmeal/English muffins) or partially uncovered (eggs/ham), throughout the entire meal service, and as the room trays were prepared. The food warming cart was taken to the hall, and the CNA started passing the breakfast trays at 9:07 a.m.; almost an hour after the meal began. Immediately after the meal, it was noted many residents had not eaten large portions of their meal. Refer to F802, 805, and F806, for concerns related to the breakfast meal and service.",2020-09-01
339,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2019-02-21,802,D,0,1,ZR9X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, staff failed to provide the necessary assistance during meal service and when residents needed assistance to prepare, set up, or eat meals or snacks, for 2 (#s 13 and 24) out of 31 sampled and supplemental residents. Findings include: During an interview on 2/20/19 at 11:27 a.m., resident #13 stated she was not offered snacks because the staff need to assist her to eat the snacks. Therefore, staff did not give snacks to her due to time constraints. The resident wanted to receive the snacks. A review of a Root Cause Analysis Worksheet, provided by the facility, and dated 1/17/19, showed the facility had a concern with Snacks not being offered to residents, residents have to ask the CNAs for them. The goal of the problem was to pass snacks, twice daily, at 2:00 p.m. and 8:00 p.m. During an observation and interview on 2/21/19 at 9:07 a.m., resident #24 was served a breakfast tray. The CNA entered the resident's room with the tray and immediately exited the room without the tray. Upon entering the room, the resident was observed to be flat on the bed, with the side table pushed up directly over her chest area. The resident was visibly trying to scoot herself up in the bed. The head of the bed was at approximately a 10-degree angle. The long edge of the side table was located within a few inches of the resident's face, and this made it difficult for her to push herself up, as her face almost hit the table several times. She stated she was, just trying to get herself up to eat. The resident was physically struggling to maneuver herself up to have her head above the tray's level. The resident stated the staff member had not assisted with her position or food prior to leaving the room, and it probably would have helped. The resident's meal had not been prepped by the CNA prior to leaving the room. At 9:25 a.m., the resident's tray had been removed from her room. The resident stated she did not eat, and the food did not look good to her. The meal tray had been placed back on the warming cart, and when checked, the resident had eaten only a few bites of oatmeal. The slice of ham, English muffin, and the eggs, were untouched. The resident only drank an 8 oz glass of juice. A review of the resident #24's meal intake record for 2/21/19 showed two meals were documented 2/21/19. Data points were defined as 0 = 0% to 25% or 1 = 25% to 50%. These were: - 12:58 p.m. - (breakfast) - 0, 300, -97 (amount consumed, fluid intake, not applicable) - 12:59 p.m. - (lunch) - 1, 140, -97 (amount consumed, fluid intake, not applicable) A review of resident #24's care plan, as of 2/21/19, showed an intervention for nutrition, and staff to provide set-up and assist as needed and record meal/fluid intake at all meals. The plan also showed the resident had weakness, immobility, and [MEDICAL CONDITION] and was in a restorative program for bilateral upper extremity exercises. The resident's dental care plan showed she had no natural teeth and she did not wear her dentures, and staff were to monitor difficulty with chewing food. The meal she was served for breakfast on 2/21/19 was a slice of ham, and an English muffin with cooked crisp edges. The resident had only consumed a few bites of the soft oatmeal and had not been offered an alternative to the meal. A review of the resident #24's (MONTH) 2019 meal intake record showed of the 16 days documented, seven days had no documentation for any meal consumed; 6 of 15 meals were documented as a 0 intake (0-25%); and 6 of 15 meals were documented as a 1 (26-50%). The documentation failed to show enough information for others to be able to identify intake concerns related to the resident's intake. For resident #24, facility staff failed to provide resident #24 the necessary assistance that day with her meal set up and positioning in bed, and the staff did not document her meal intake for all meals to ensure an up-to-date accurate medical record was maintained. During an observation and interview on 2/21/19 at 9:14 a.m., resident #18 received her breakfast tray. At 9:30 a.m., the resident had still not eaten her breakfast. When asked about her meal, she picked up her whole slice of ham, which had visible bite marks on one edge. The ham had not been cut up for the resident prior to the staff leaving the room. Resident #18 stated it would be nice if she had assistance with her food preparation, but the Staff never help me. They don't cut up my food. The resident voiced she would like, and at times needed, staff assistance. The resident had eaten only 1/4, of 1 half, of the 2 slices of the English muffin. The eggs were untouched, as well as the oatmeal. A review of resident #18's comprehensive care plan, as of 2/21/19, showed staff to provide set up and assist as needed and record meal/fluid intake at meals. A review of resident #18's meal intake records, dated 2/6/19 to 2/21/19, showed only 4 of 16 days had documented meals, with two of these having two meals documented, and the other two having only one meal documented. Eleven of the 16 days had no documentation to show the resident had eaten any meals. Six of the 7 meals showed the resident had consumed less than 50% of the meals. For resident #18, staff failed to assist the resident with her food preparation and meal set up and did not documented the resident's intake sufficiently, for the monitoring and identification of intake or weight concerns.",2020-09-01
340,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2019-02-21,803,E,0,1,ZR9X11,"Based on interview and observation, the facility contracted staff failed to ensure the resident food & meals, were prepared and served in a consistent manner, to ensure recommended dietary needs were met. This failure had the potential to affect any resident receiving food from the kitchen and staff who failed to utilize and follow recommended meal portions, who prepared pre-portioned food, or served meals. Findings include: During an interview on 2/19/19 at 11:47 a.m., staff member F stated he would eyeball the meat portions for the mechanically altered textures. During an observation and interview on 2/21/19 at 8:33 a.m., staff member CC was asked if the English muffins were considered a mechanical soft food, since they were observed to be whole and some had crisp brown edges. She responded, I don't know, is it? This writer then asked again if staff member CC knew if the muffin was considered a mechanical soft food item, as she was observed to have just served an English muffin to a resident, who had a mechanical soft diet noted on the tray card, and he was given a full unaltered English muffin. Staff member CC asked staff member KK about the muffin, and she responded the English muffin was considered a mechanical soft food item, if it was cooked lightly. At that time, this writer pointed to the English muffins on the steam table, which were cooked, and some had visible crisp brown edges. This writer relayed that the muffins did not appear to be lightly cooked. No changes were made to any resident meals during the rest of the dining session for the English muffins. A review of the facility At-A-Glance menu, for mechanically altered diets, showed the English muffin, but the menu did not show the muffin was to be lightly cooked. During an observation and interview on 2/21/19 at 8:30 a.m., ham was placed on resident meal plates, and maintained in the pan on the steam table. The ham slices were inconsistently precut. Some of the slices had large thick edges, up to approximately 1/2 inch, while the other side of the slice was thin or cut completely off. Each piece was a different thickness and oval size. Staff member KK was observing the meal service, and was asked about the weight of the ham slice, which was displayed on the tray cards. She verified the ham was to be a 1 oz. serving. She stated, The ham looks good. Staff member KK had not noted the inconsistent meat portion sizes. The facility was not staff member KK's typical work location. During the same observation, the serving size for the eggs was to be 1/4 cup. When placed on the plates, staff member CC would heap the eggs on the scoop, therefore, the 1/4 cup of eggs resulted in a portion closer to 1/2 cup. This occurred for residents who were only to receive 1/4 cup documented on the tray card. The same staff member scooped the oatmeal into the bowls in the same manner. A review of the facility At-A-Glance menu, for mechanical soft diets, showed for the breakfast the eggs provided were to be measured at 1/4 cup, and the oatmeal 3/4 cup. A review of staff member CC's educational trainings, completed in (YEAR), showed the employee attended trainings to include Plate Presentation, Time and Temperature Control, Texture Modification, Service and Line Procedures, and Weights and Measures.",2020-09-01
341,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2019-02-21,805,E,0,1,ZR9X11,"Based on observation, interview, and record review, the facility staff failed to serve resident meals that were cooked and prepared in a manner in which the resident could eat the meal/food, for 3 (#s 10, 12, and 29) of 31 sampled and supplemental residents. Findings include: During an observation and interview, on 2/21/19 at 9:16 a.m., resident #12 had eaten all of her meal, except the two sides of the English muffin, with jelly, which remained on the plate. She stated the muffin was tough and she could not eat it. The muffin had edges that were cooked, and brown to dark brown in color and crispy. A review of resident #12's current care plan, as of 2/21/19, showed, staff to provide set up and assist as needed. The plan did not address the resident's inability to chew some of her food. During an observation on 2/21/19 at 9:16 a.m., resident #10 was sitting next to resident #12. Resident #10 had not eaten any of her breakfast. She had a full slice of ham, all the oatmeal, 2 slices of the English Muffin, and her yogurt left. There was a banana skin next to the plate, which had been given to her by the Administrator. The resident stated she did not want the food. She stated staff had not offered her other food options for the breakfast. A review of resident #10's meal intake record, for 2/6/19 to 2/21/19, showed 11 of 16 days had no documentation for meal intake. Three of the five days documented, showed only one meal had been eaten, but for these, only two days showed the resident's intake was over 51%. A review of resident #10's current care plan, as of 2/21/19, showed the resident had chewing difficulties, and she needed upper and lower dentures. Staff were required to provide assistance, as needed, but the plan did not specifically show what level or type of assistance was necessary due to her inability to chew food served. During an observation and interview, on 2/21/19 at 9:23 a.m., resident #29's English muffin remained on her food plate, untouched. She stated the muffin was too tough to eat, and she did not have enough teeth to break bites off. The muffin was observed to be cooked, and it had brown crispy edges. The resident was not provided a bread which was prepared and served in a manner in which she could chew or eat it. A review of resident #29's current care plan, as of 2/21/19, showed staff were too honor her food preferences, and staff were too provide set up assistance, as needed. Neither the care plan problem for the resident's weight concerns, nor the remaining portions of the care plan, included information related to the resident's inability to eat some foods due to her dentition.",2020-09-01
342,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2019-02-21,806,E,0,1,ZR9X11,"Based on interview and observation, the facility staff failed to identify residents that had not eaten served food, and staff did not offer alternatives for the items or meals not eaten, either due to resident preference, or the inability to consume the food due to the way it was prepared, for 4 (#s 8, 12, 13 & 29) of 31 sampled and supplemental residents. Findings include: During an interview on 2/20/19 at 10:29 a.m., resident #8 stated a substitution was not always offered by staff if the meal on the menu was not liked by the resident. During an interview on 2/20/19 at 11:27 a.m., resident #13 stated she was offered meal substitutions, some of the time, but this did not occur consistently. She stated after 10 p.m., she was unable to get anything to eat if she was hungry, because the kitchen was closed. During an observation and interview on 2/21/19 at 9:16 a.m., resident #12 had not eaten her English muffin. She stated the meal was not appealing, and she stated staff had not offered an alternative for the English muffin served with the meal but would have liked that. During an observation and interview on 2/21/19 at 9:23 a.m., resident #29's English muffin remained on her food plate, untouched, because it was too tough to eat. The resident was not provided an alternative option for the English muffin. During an observation on 2/21/19, beginning at 8:17 a.m. and going until 8:47 a.m., staff did not make any requests that alternates be provided for the residents, for those who did not like or were able to eat the food. Staff member CC had provided a resident a cold cereal, which was not on the menu for the day, but she had prior knowledge the resident wanted the cold cereal. During an interview on 2/21/19 at 9:40 a.m., staff member N and O discussed the implementation of a new system for serving meals in the lower level dining area. They stated changes had taken place recently with the meal service and delivery. Staff member O had observed the meal service since starting to work at the facility a few weeks prior, and felt things had improved, but work and change still needed to occur.",2020-09-01
343,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2019-02-21,812,E,0,1,ZR9X11,"Based on observation, interview, and record review, the facility failed to label food with an expiration date, and discard food beyond the expiration date, in accordance with professional standards for food service safety. This had the potential to affect any resident consuming the unlabeled food, at the facility. Findings include: During an observation and interview on 2/19/19 at 11:47 a.m., the walk in cooler in the kitchen, two 5-pound containers of sour cream, and four 32-ounce cartons of thickened dairy drink, were found stored in the cooler and the items had not been dates. Staff member F stated the items must have been missed when food was dated. During an observation and interview on 2/21/19 at 7:26 a.m., the two 5-pound containers of sour cream, and three of the 32-ounce cartons of thickened dairy drink, remained in the walk in cooler, and continued to be undated. Staff member [NAME] stated she would date the items. A record review of the facility policy, titled, Food Storage: Cold Foods, revised 9/17 showed All food will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. During an observation of the resident refrigerator, on 2/19/19 at 4:35 p.m., the following was observed: - one, four ounce yogurt with a use by date of 2/18/19 - one, white bread sandwich with a use by date of 2/12/19 - 2/15/19, and - three, eight ounce glasses of milk, with use by dates of 2/16/19, 2/17/19, and 2/19/19. During an interview on 2/19/19 at 4:35 p.m., staff member A stated the CNA staff were supposed to check the refrigerator, but she has been completing the checks, and she had just checked it a few days ago and threw out some outdated food.",2020-09-01
344,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2019-02-21,835,D,1,1,ZR9X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, facility administration failed to provide adequate oversight to ensure narcotic medications were monitored, documented, and accounted for accurately, and failed to ensure nursing staff were educated on new protocols for the management of narcotic medication after there were concerns with missing narcotics and a new process was implemented. The failure had the ability to affect any resident in the facility receiving, or who had stored, narcotic medications. Findings include: Record review of resident #39's [MEDICATION NAME], showed twenty-eight and a half milliliters on 2/3/19. The record showed twenty-seven milliliters on 2/7/19, with the information corrected dose and two signatures. Staff member C did not know who the signatures were on the narcotic log. Staff member C stated it should be a manager, or the DON, that would complete an adjustment for the amount of any narcotic medication, and this would be done with another nurse. She stated the adjustment may have been needed due to the medication's absorption. Record review of resident #27's narcotic log book showed, 10/18/18 at 8:45 a.m., one milliliter of [MEDICATION NAME] was given by staff member V, leaving fourteen in the bottle. The record showed on 10/19/18, fourteen milliliters were destroyed. During an interview with staff member V on 2/21/19 at 11:35 a.m., she stated when she pulled the [MEDICATION NAME] Solution up on 10/18/18, it appeared to look like water. She stated previous to that it was pink in color. She stated she notified the DON and Administrator. She stated she looked at another bottle of [MEDICATION NAME] Solution and it was pink in color. She stated she believed after that occurred, the process changed, and the nurses were required to have two nurses pull up any [MEDICATION NAME] Solution for a resident. During an interview on 2/21/19 at 11:50 a.m., staff member Y stated she had not been instructed to use two nurses to pull up [MEDICATION NAME] Solution. Review of missing narcotic investigations showed there were two [MEDICATION NAME] tablets missing for an unknown resident that came from the pharmacy, stored in a bag, with two different labels. A card of [MEDICATION NAME] for resident #00, who did not enter the facility, was included. Staff member FF gave a written statement that when she opened the medication tote on 11/13/18, the bag with the [MEDICATION NAME] tablets was heat sealed and was for the Omnicell (medication dispensing machine) replacement. She placed the medication manifest, and the heat sealed bag, in the medication cart. She stated when she returned on 11/14/18 the bag and manifest were still in the cart. She stated around 3 a.m., when she was putting narcotics away, she noted the [MEDICATION NAME] was no longer in a sealed bag. She stated there were two [MEDICATION NAME] missing. She called the day nurse, and she said she had not touched the medications. Staff member FF said she then called the DON. Review of a written statement from staff member HH and II showed the label for the two [MEDICATION NAME] was erroneous, and an error on the pharmacy part, and there was no clear evidence the [MEDICATION NAME] was altered. There was no information in the statement about the missing [MEDICATION NAME]. Facility staff and administration failed to show a clear path of documentation related to the medication. A note, dated 11/14/18, and titled Process of checking in the Pharmacy Tote showed the following: Only if a medication is needed from the tote during the night shift two nurses will check the count and only that medication will be put in the Omnicell by two nurses during the night . Two nurses on Day shift will open the tote together, check the narcotic count is correct and will be put in the Omnicell preferably before stand up or by 9:30 a.m. Make sure the green or red tags are intact. Put tag numbers on the Shift Tag Check Narcotic E-Kit form on clip board . I have read and understand the above information. Signature. The facility administration failed to show the licensed staff were educated on the new process of checking in the medication totes.",2020-09-01
345,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2019-02-21,838,D,0,1,ZR9X11,"Based on interview and record review, the facility failed to ensure they had reviewed and maintained an up to date Facility Assessment, to ensure resources were available for the care and services of the residents, based on the acuity of the resident population, which had the potential to affect any resident at the facility who required services, which the facility had not identified necessary, and did not fulfill. Findings include: A review of the Facility assessment, originally submitted to the survey team showed the area for the General Staffing Plan had not been completed. During an interview, on 02/20/19 at 2:29 p.m., staff members N and O stated the Facility Assessment submitted to the survey team was worked on by the previous administrator and was a working copy. Staff member N stated the facility assessment would be completed and resubmitted to the survey team, with the current and accurate information. The facility had not updated or maintained the plan, based on the resident needs and acuity. Refer to F677 and F725 for deficient practices identified and related to concerns with staffing, and the provision of resident care.",2020-09-01
346,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2019-02-21,865,D,1,1,ZR9X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility Quality Assurance and Performance Improvement (QAPI) program failed to identify an ongoing quality deficient practice relating to missing narcotics, reporting of missing narcotics, and thorough investigations of missing narcotics. This had the potential to affect all residents receiving, or having narcotics stored, at the facility. Findings include: Narcotic Concerns: Record review of resident #39's [MEDICATION NAME] showed the medication had been adjusted on 2/7/19, which decreased the medication quantity. An investigation on the change of the medication quantity, was not investigated by the facility. Record review of resident #27's narcotic log book showed on 10/18/18 at 8:45 a.m., one milliliter of [MEDICATION NAME] was given by staff member V, leaving fourteen in the bottle. The record showed on 10/19/18, fourteen milliliters were destroyed. During an interview on 2/21/19 at 11:35 a.m., staff member V stated when she pulled the [MEDICATION NAME] Solution up on 10/18/18, it appeared to look like water. She stated she notified the DON and Administrator. After that, staff member V stated the process changed for how [MEDICATION NAME] Solution was handled by the nursing staff, and required two nurses, rather than one. Further investigation identified not all nursing staff were aware of the new process implemented for the management of the narcotic medication (refer to F835). Staff member FF gave a written statement that when she opened the medication tote on 11/13/18, the bag with [MEDICATION NAME] tablets was heat sealed. She placed the manifest, and the heat sealed bag in the medication cart. Around 3 a.m., when she was putting narcotics away, she noted that the [MEDICATION NAME] was no longer in a sealed bag. She said the medications were in a Ziploc bag, with the manifest around it. There were two [MEDICATION NAME] tablets missing. Staff member FF reported the concern to the DON. Review of the written statement, from staff member B, dated 11/3/18, showed Pharmacy delivered shipment @ 0130 am Sat. 11/3/18 after he left I went thru the blue tote there was 30 [MEDICATION NAME] 5/325 and 30 [MEDICATION NAME] for (resident name}, I left the [MEDICATION NAME] wrapped in the plastic and sealed tote up with red ties to send [MEDICATION NAME] and [MEDICATION NAME] back to pharmacy. When i came back to work Saturday evening and went to put my belongings in the Medroom, I noticed that the tote was opened and the only thing in there was the [MEDICATION NAME], I then let staff member GG know. The [MEDICATION NAME] was not longer accounted for. Review of a written statement from staff member HH and II showed the label for the two [MEDICATION NAME] was erroneous and an error on the pharmacy part and there was no clear evidence the [MEDICATION NAME] was altered. The facility destroyed the [MEDICATION NAME] and replaced the medication. The statement said the policies relating to delivery, restock into Omnicell, administration and disposition of medications, were discussed with staff member Q. There was no information in the statement about the missing [MEDICATION NAME]. A note dated 11/14/18 titled Process of checking in the Pharmacy Tote showed the facility implemented a new process for narcotic medications, requiring two staff signatures and management of two staff. The facility failed to ensure all nurses were educated on the new process for the narcotic medications. During an interview on 2/20/19 at 2:29 p.m., staff member C stated she looked through the QAPI meeting book and could not find where the facility QAPI committee had talked about the issues with narcotic medications, although the concerns had been ongoing. The facility failed to ensure monitoring and identification of medication concerns were addressed timely and effectively, through the QAPI system, and monitored for compliance after corrections were made, to ensure the issue of missing narcotics did not continue to happen.",2020-09-01
347,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2018-05-24,554,D,1,0,FXNT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility staff failed to ensure 2 (#s 17 and 18) of 20 sampled residents who had medications in their room, was stored safely, securely, had physician orders to self administer medications; and the facility failed to assess 2 (#s 17 and 18) of 20 sampled residents for self administration of medications. Findings include: 1. Resident #17 was admitted with [DIAGNOSES REDACTED]. During an observation and interview on 5/23/18 at 1:50 p.m., resident #17 had a bottle of Calcium 600 mg, a bottle of Vitamin B Complex, and a bottle of One A Day Vitamins sitting on her dresser, under her television. Resident #17 stated the medications on her dresser were hers, and she takes them herself and does not keep them locked. During an observation on 5/24/18 at 7:35 a.m., resident #17 had a bottle of Calcium 600 mg, a bottle of Vitamin B Complex, and a bottle of One A Day Vitamins sitting on her dresser under her television. During an observation on 5/24/18 at 10:40 a.m., resident #17 had a bottle of Calcium 600 mg, a bottle of Vitamin B Complex, a bottle of One A Day Vitamins, and a jar of [MEDICATION NAME] sitting on her dresser under her television. A review of resident #17's medical record showed there was no self administration of medication assessment and no physician order for [REDACTED].>2. Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an observation and interview on 5/23/18 2:10 p.m., resident #18 had a [MEDICATION NAME] inhaler, Symbacort inhaler, and Flucitasone spray sitting on his bedside table. Resident #18 stated they left them there, They leave them sometimes, when speaking of his medications on the bedside table. During an observation and interview on 5/24/18 10:50 a.m., there was a Proair HFC inhaler sitting on the bedside table. Resident #18 stated to look in the top drawer in the brown bag. In the drawer, inside the brown bag, was a Symbacort inhaler, a Proair HFC inhaler, [MEDICATION NAME] spray, and a [MEDICATION NAME] inhaler. Resident #18 stated he keeps them .just in case they don't get to me in time. A review of resident #18's medical record showed there was no self administration of medication assessment and no physician order for [REDACTED].>Review of the facility policy titled Self Administration of Medications, showed . that if the resident is deemed capable to self-administer medications then the drugs will be stored in a locked box in the resident's room, unless otherwise deemed by the interdisciplinary team. Nursing to get an order from the physician for self-administration of medication .",2020-09-01
348,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2018-05-24,600,G,1,0,FXNT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, and record review, facility failed to protect 1 (#1) of 20 sampled residents from neglect of care causing harm while smoking. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was admitted to Hospice services on 5/8/18 and passed away the morning of 5/24/18. Resident #1 had been seen by staff smoking in the building on 3/2/18, 3/11/18 two times, and again on 5/1/18 when she was on fire and received second [MEDICAL CONDITION] her face. (Refer to F689) Review of resident #1's Interdisciplinary progress notes showed the following information: Review of resident #1 Progress Note dated 5/1/18 - Staff report resident got burned. Upon arrival resident yelling repeatedly he told me it was off, why would he tell me it was off. Noted circumoral burns/blackened areas extending upward on the face. Burns/blackened areas noted to L hand -primarily around index, middle and ring fingers. Resident reportedly was smoking and did not remove her oxygen tubing from her face. Resident angry and lashing out at staff, calling them names, accusing them of letting her get burned, stating 'I will own this building.' 911 called, ambulance arrived on scene and transported resident to ER for eval and treatment and to r/o [MEDICAL CONDITION] airway. Check of oxygen tank on residents wheelchair at this time-oxygen tank had been turned off prior to this writer arrival at resident. W/C and oxygen tank were still sitting on patio. Tubing was melted up to approx. 6' from oxygen tank. No further remains of tubing noted at that time. Overall resident upset and angry but stable.(sic) Review of resident #1's ER report dated 5/1/8 at 4:02 p.m., showed resident #1 received [MEDICAL CONDITION] on her usual liters of oxygen. Resident #1 reported to the ER physician she was not smoking but took a drag from another resident's cigarette when her oxygen ignited. She [MEDICAL CONDITION] her upper left lip and nares. During an interview on 5/22/18 at 10:20 a.m., resident #4 stated resident #1 was out on the patio by herself, on fire. He stated it took about ten minutes to get someone to her and to call EMS to get her to the hospital. He stated sometimes there wasn't any staff out there when the residents were smoking. He stated there was a code on the door so no one escapes. During an interview on 5/22/18 at 1:30 p.m., staff member A stated prior to the incident with resident #1 on 5/1/18 the residents were allowed to smoke independently. She stated resident #1 was let outside by a therapist. Staff member A stated she was aware of the incident on 5/1/18 with resident #1. During an interview on 5/23/18 at 10:55 a.m., staff member [NAME] stated he was alerted by a staff member that resident #1 needed help into the facility and was on fire. He stated he was by the nurses desk and when he got to the smoking door resident #1 was on fire at her shoulder area. He stated resident #1 probably could not have used the code and gotten outside by herself. He stated staff member F ran outside and doused the flame and made sure the oxygen tank was off. Staff member [NAME] stated part of the resident's w/c was smoking around the arm rest area. He stated resident #1 was hollering out. During an interview on 5/22/18 at 2:42 p.m., staff member P stated the facility had the smoking aprons for some time now. She stated the management staff knew the smoking aprons were at the facility, and she was told by staff member D to put the aprons out on 5/22/18. During an interview on 5/22/18 at 9:30 a.m., staff member A stated she met weekly with staff memebr B to go over things. She stated she had access to look things up in the computer system to see things like incident reports, census, admits, and discharges, therefore, staff member A was aware of resident #1's incident on 5/1/18.",2020-09-01
349,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2018-05-24,609,G,1,0,FXNT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, and interview, the facility failed to report and investigate the event with a resident smoking with oxygen, without supervision, who received second degree burns, for 1 (#1) of 20 sampled residents. This had the potential to affect other residents who smoked that were on oxygen. Findings include: Resident #1 had been seen by staff smoking on 5/1/18 when she was on fire and received second [MEDICAL CONDITION] her face. Review of resident #1's Interdisciplinary progress notes in the medical record showed the following information: Review of resident #1 Progress Note dated 5/1/18 - Staff report resident got burned. Upon arrival resident yelling repeated he told me it was off, why would he tell me it was off. Noted circumoral burns/blackened areas extending upward on the face. Burns/blackened areas noted to L hand -primarily around index, middle and ring fingers. Resident reportedly was smoking and did not remove her oxygen tubing from her face. (Refer to F689) Review of resident #1's ER report dated 5/1/8 at 4:02 p.m., showed resident #1 received [MEDICAL CONDITION] on her usual liters of oxygen. (Refer to F689) During an interview on 5/22/18 at 12:55 p.m., staff member A stated the facility did not report the incident on 5/1/18 regarding resident #1. No investigation was provided before the exit.",2020-09-01
350,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2018-05-24,656,D,1,0,FXNT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review, and interview, the facility failed to develop a comprehensive care plan to address self administration of medications for 2 (#s 17 and 18) of 20 sampled residents. findings include: 1. Resident #17 was admitted with [DIAGNOSES REDACTED]. During an observation and interview on 5/23/18 at 1:50 p.m., resident #17 had a bottle of Calcium 600 mg, a bottle of Vitamin B Complex, and a bottle of One A Day Vitamins sitting on her dresser under her television. Resident #17 stated the medications on her dresser were hers and she takes them herself and does not keep them locked up. During an observation on 5/24/18 at 7:35 a.m., resident #17 had a bottle of Calcium 600 mg, a bottle of Vitamin B Complex, and a bottle of One A Day Vitamins sitting on her dresser under her television. During an observation on 5/24/18 at 10:40 a.m., resident #17 had a bottle of Calcium 600 mg, a bottle of Vitamin B Complex, a bottle of One A Day Vitamins, and a jar of [MEDICATION NAME] sitting on her dresser under her television. A review of resident #17's medical record did not show a comprehensive care plan to address self administration of medications. 2. Resident # 18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an observation and interview on 5/23/18 2:10 p.m., resident #18 had a [MEDICATION NAME] inhaler, Symbacort inhaler, and Flucitasone spray sitting on his bedside table. Resident #18 stated they left them here. They leave them sometimes, when speaking of his medications on the bedside table. During an observation and interview on 5/24/18 10:50 a.m., there was a Proair HFC inhaler sitting on the bedside table. Resident #18 stated look in my top drawer in the brown bag. In the drawer, inside the brown bag, was a Symbacort inhaler, a Proair HFC inhaler, [MEDICATION NAME] spray, and a [MEDICATION NAME] inhaler. Resident #18 stated he keeps them just in case they don't get to me in time. A review of resident #18's medical record did not show a comprehensive care plan to address self administration of medications.",2020-09-01
351,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2018-05-24,689,J,1,0,FXNT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews, and interviews, the facility failed to ensure residents who smoke were safe when smoking for 4 (#s 1, 2, 3, and 5) of 20 sampled residents. On 5/23/18 at 11:59 a.m., the facility Administrator, Administrator in Training, and the Director of Clinical Services were notified that an Immediate Jeopardy situation was identified for the areas of deficient practice, which included F689 Accidents and Hazards, and F835 Administration. The Severity and Scope was identified at the level of J, and upon the removal of the immediacy for the deficient practices, the severity and scope would be lowered to a [NAME] Findings Include: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was admitted to Hospice services on 5/8/18 and passed away the morning of 5/24/18. Review of resident #1's Interdisciplinary progress notes in the medical record showed the following information: Progress Note 3/2/18 at 5:12 a.m.- . CNA had caught this patient smoking in her room the night before when the CNA smelled cigarette smoke . Progress Note dated 3/11/18 at 1:45 p.m. - Resident went down stair to bum a cig from female resident a lighter and went outside by resident letting her out the door and was smoking with 02 tank on nasal cannula draped on the handle of w/c. Talked with resident and was told smoking revoked due to incident yesterday and not safe to smoke reuses to follow smoking rules. very angry confiscated cigs from her. explained will need to talk with administrator in am on 3/12/18.(sic) Progress Note dated 3/11/18 at 9:23 a.m. - Resident smoking rights were revoked due to smoking in the dining room on 3/10/18 with oxygen on and placing other resident in harm. Nurse confiscated cigarettes and lighter on 3/10/18, explained no smoking until talked with administrator and DON on 3/12/18.(sic) Progress Note dated 5/1/18 - Staff report resident got burned. Upon arrival resident yelling repeated he told me it was off, why would he tell me it was off. Noted circumoral burns/blackened areas extending upward on the face. Burns/blackened areas noted to L hand -primarily around index, middle and ring fingers. Resident reportedly was smoking and did not remove her oxygen tubing from her face. Resident alert, follows commands, tracks individuals speaking. Noted pupillary response within norm. Nail beds of R hand pale but blanchable and radial pulse rapid and strong regular-resident with good circulation. Oxygen saturation 83% on R[NAME] Oxygen applied and titrated up to 10L/min raising saturations to 93%- gas exchange adequate for vital function with supplemental 02 in place. Face mask blow-by held approx. 1 from residents face to prevent further trauma/pain if fully applied due to location of burns. Cool compress applied both face and hands to slow burning process. Unable to determine severity [MEDICAL CONDITION] to blackened color of skin. No sloughing of skin noted. Resident angry and lashing out at staff, calling them names, accusing them of letting her get burned, stating 'I will own this building.' Resident prompted several times that she needed to calm and focus on taking deep breaths to promote oxygenation and stop yelling. Resident complied. 911 called, ambulance arrived on scene and transported resident to ER for eval and treatment and to r/o [MEDICAL CONDITION] airway. Check of oxygen tank on residents wheelchair at this time-oxygen tank had been turned off prior to this writer arrival at resident. W/C and oxygen tank were still sitting on patio. Tubing was melted up to approx. 6' from oxygen tank. No further remains of tubing noted at that time. Overall resident upset and angry but stable.(sic) Review of resident #1's ER report dated 5/1/8 at 4:02 p.m., showed resident #1 received [MEDICAL CONDITION] on her usual liters of oxygen. Resident #1 reported to the ER physician she was not smoking but took a drag from another resident's cigarette when her oxygen ignited. She [MEDICAL CONDITION] her upper left lip and nares. The ER report said resident #1 singed hair over bilateral eyebrows and eyelashes. Soot on the left cheek, upper lips, and some singed mucosa in the left nares but not in the right, slight burn on the left upper lip but nothing intraoral. Soot and burn between second and third MCPJ on the left. The ER physician referred resident #1 to the plastic surgeon. Resident #1 was seen by the plastic surgeon on 5/3/18. A review of the surgeon's progress note showed .second [MEDICAL CONDITION] left nasal tip and asa (sic), left upper lip, and left cheek lateral to oral commissure. She documented there was soot present on upper lip and left nasal mucosa, moderate swelling of left cheek. There was a small superficial burn on dorsum of left index finger and soot on left upper lateral arm. Review of resident #1's smoking assessment dated [DATE] showed the resident had a vision deficit, and the facility needed to store the lighter and cigarettes, she needed assistance outside the door and was able to get in the building again. It showed the plan of care was used to assure resident was safe while smoking. Review of resident #1's smoking assessment, dated 5/2/18, showed the resident had vision and dexterity deficits, needed the facility to store her cigarettes and lighter, and the plan of care was not used to assure resident was safe while smoking. Review of resident #1's undated plan of care showed resident #1's cigarettes are to be stored in a locked container and distributed to her during assigned smoking times. Review of resident #1's plan of care initiated on 5/1/18 showed resident #1 has chosen not to smoke at this time. Review of resident #1's copy of the facility smoking policy was signed by the resident on 3/1/18 and 5/2/18. Both signed policies included information that residents are not allowed to possess cigarettes and lighters in the facility, and independent smokers will store lighter/matches in the lock box in the Goldrush nurses med room. During an interview on 5/22/18 at 10:20 a.m., resident #4 stated resident #1 was out on the patio by herself, on fire. He stated it took about ten minutes to get someone to her and to call EMS to get her to the hospital. He stated sometimes there wasn't any staff out there when the residents were smoking. He stated there was a code on the door so no one escapes. Observations: Resident #1 was observed on 5/22/18 at 8:45 a.m., lying in bed. Resident #1 had blackened areas to the left side of her face/cheek and mouth. Resident #1 had her oxygen on at 4.5 liters per nasal cannula. Resident #1 was calling for help, and stated she was in pain. The surveyor notified staff member E. Resident #1 continued to call out for help at 8:51 a.m., staff member F told the resident he would be right there. At 8:55 a.m. staff member F took resident #1 pain medication. Resident #1's oxygen tubing was not on, and staff member F placed the cannula on resident #1's face. Resident #1 was observed in her room sitting on the edge of her bed on 5/22/18 at 1:00 p.m. She was hunched over and moaning. Resident #1 stated she remembered burning her face. She stated There was a gal on the deck who gave them to me, when speaking of her cigarette. Resident #1 said it was another resident who gave the cigarette to her. Resident #1 stated she was not able to punch the code for the door, to get out of the smoking area. Resident #1 was observed on 5/23/18 at 6:00 a.m. She was moaning and groaning for help. Resident #1's blackened areas remained on her face. Two staff members went in the room at 6:10 a.m. to help her. During an observation of the smoking area on 5/22/18 at 9:40 a.m., there was a sign posted next to the door leading to the smoking area. The smoking area was located down stairs right outside of the dining room. The sign showed, one staff member from either floor to be out with residents. Staff will hand out one cigarette to each resident for each session. Staff make sure no lighter, matches, cigarettes are with residents. Return lock box to Gold Rush. There was a key pad next to the door that needed a code entered before you could open the door and go out to the smoking area. There was no fire extinguisher or fire blanket readily accessible in the smoking area. There was a no oxygen sign posted in the dining room just by the door of the smoking area. The sign on the wall read smoking times were 6:30 a.m., 9:30 a.m., 1:30 p.m., 4:30 p.m., and 8:30 p.m. During an observation on 5/24/18 at 10:35 a.m., two residents were observed sitting in the smoking area. Both stated they knew the code to get out of the building to the smoking area. During an observation on 5/24/18 at 1:30 p.m., eight residents were observed in the smoking area with one staff member. None of the residents wore a smoking apron. During an interview on 5/22/18 at 10:00 a.m., staff member G stated resident #1 had been caught smoking in her room before by staff, and staff member B told her that there was no safe discharge plan in place, and the resident would be allowed to continue to smoke, but staff would keep the cigarettes and lighter. She stated the resident was found after that smoking again, and the resident was once again given a warning. Resident #1 was then moved down stairs. Staff member G stated the resident was caught on three different occasions smoking and was still allowed to smoke. During an interview on 5/22/18 at 12:00 p.m., staff member M stated that she was not at the facility at the time of the incident with resident #1 but the nurses are supposed to keep the smoking materials and do not enforce it. She stated the management staff knew the nurses were not enforcing the locking up of the smoking materials. During an interview on 5/22/18 at 12:07 p.m., staff member I stated all the materials are locked up. He stated there are no smoking aprons for the residents to wear. He stated he had heard resident #1 got the cigarette from someone else but did not know who. During an interview on 5/22/18 at 1:30 p.m., staff member A stated prior to the incident with resident #1 the residents were allowed to smoke independently. She stated resident #1 was let outside by a therapist. She stated the residents were allowed to keep their materials in their room. She stated prior to the incident with resident #1, the residents were not required to sign the smoking policy. Staff member A stated she was aware of the incident on 5/1/18 with resident #1. During an interview on 5/22/18 at 2:42 p.m., staff member P stated the facility had the smoking aprons for some time now. She stated the management staff knew the smoking aprons were at the facility, and she was told by staff member D to put the aprons out on 5/22/18. During an interview on 5/23/18 at 6:15 a.m., resident #10 stated he .used to be able to keep his cigarettes and lighter and everything until resident #1 blew herself up . He stated the staff kept everything now and he does not like wearing the aprons when smoking. During an interview on 5/23/18 at 7:00 a.m., staff member L stated resident #1 has had numerous problems with breaking the smoking policy. She stated the resident was caught smoking in the dining room and in her room. She stated staff member D was notified of these instances. Staff member L said the staff would take the resident's cigarettes and lighters away, and the management would come in and say the resident could smoke and it was her right. During an interview on 5/23/18 at 7:00 a.m., staff member L stated resident #2 was smoking in her bathroom on the night of 5/21/18. She stated there was smoke in the bathroom, and the staff found the lighter on the shelf. She stated there were ashes on the toilet seat and a cigarette in the resident's hand. She stated they could see the smoke when they went in the bathroom. Staff member L said she reported the incident to staff member D. Staff member L said that as of about two weeks ago the staff were to go out with the residents when they smoked, prior to that, the staff did not go out with them. She stated there were no smoking aprons available currently. During an interview with staff member B on 5/23/18 at 7:29 a.m., he stated when resident #1 broke the policy he spoke with her about it and had resident #1 sign a smoking policy on 3/1/18. Staff member B stated he did not think he had documented the conversation with resident #1 on 3/1/18. During an interview on 5/23/18 at 10:55 a.m., staff member [NAME] stated he was alerted by a staff member that resident #1 needed help into the facility and was on fire. He stated he was by the nurses desk and when he got to the smoking door resident #1 was on fire at her shoulder area. He stated resident #1 probably could not have used the code and gotten outside by herself. He stated staff member F ran outside and doused the flame and made sure the oxygen tank was off. Staff member [NAME] stated part of the resident's w/c was smoking around the arm rest area. He stated resident #1 was hollering out. He stated he did not ask her if she had cigarettes and a lighter, and he did not check. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Interdisciplinary progress notes in resident #2's medical record showed the following information: Progress note dated 5/8/18 at 10:04 a.m. - While I was in my morning meeting, a CNA came in asked that someone come and speak to the resident because she was outside smoking . Progress note dated 5/21/18 at 6:30 p.m. - CNA caught resident smoking in her bathroom. CNA took lighter that was lying on the shelf. Rsdt denied having any more cigarettes. This writer spoke w/ rsdt and reminded her of the smoking rules. Rsdt voiced understanding and said it would not happen again. Room check done when rsdt downstairs. 0 cigarettes or lighter found.(sic) A review of resident #2's undated plan of care showed the resident's cigarettes and lighter are to be stored in a locked container and distributed to be during assigned smoking times. A review resident #2's plan of care dated, 5/4/18, showed the residents cigarettes and lighter are to be stored in a locked container and distributed during assigned smoking times. A review of resident #2's smoking assessment dated , 5/2/18, showed the resident had cognitive and vision deficits. The facility needed to store the lighter and cigarettes for the resident, and the plan of care was used to assure the resident was safe while smoking. A review of a signed smoking policy for resident #2, dated 5/2/18, included residents are not allowed to possess cigarettes and lighters in the facility, and independent smokers will store lighter/matches in the lock box in the Goldrush nurses med room. During an observation on 5/22/18 at 7:30 a.m., there were no smoke detectors in the resident rooms or bathrooms. During an observation on 5/23/18 at 1:20 p.m., resident #2 was ambulating in the hall, wearing a purple gown with small burn holes, which appeared to be cigarette burns, in the front. 3. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #3 was oxygen dependent. Review of Interdisciplinary progress notes in resident #3's medical record showed the following information: Review of a smoking assessment dated [DATE] showed the resident had a vision deficit, needed the facility to store the cigarettes and lighter, and the plan of care was used to assure resident was safe while smoking. Review of a signed smoking policy, without a date, included residents were not allowed to possess cigarettes and lighters in the facility, and independent smokers will store lighter/matches in the lock box in the Goldrush nurses med room. Review resident #3's careplan, dated 5/2/18, showed her cigarettes and lighter were to be in a locked container, and would be distributed to her by staff during assigned smoking times. Review of the facility policy, titled Smoking Policy Residents updated Nov (YEAR), included, . Designated smoking areas include: . smoking aprons, or devices to assist residents in smoking . any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the resident's individual care plan. The care plan will indicate how the smoking materials will be stored, i.e. secure/locked cabinets for residents deemed to be safe to smoke independently, allowing independent residents to maintain their smoking material on their own person, maintence of all smoking material at a secure designated area of another system as indicated to meet the residents need and within the ability of the facility . During an interview on 5/22/18 at 9:30 a.m., staff member A stated she met weekly with staff member B to go over things. She stated she had access to look things up in the computer system to see things like incident reports, census, admits, and discharges, therefore, staff member A was aware of resident events. During an interview on 5/22/18 at 1:40 p.m. resident #5 stated there was an accident with a lady with oxygen so now there was new procedures that everyone wears aprons, and the staff keep cigarettes and lighters locked up. During an interview on 5/22/18 at 2:42 p.m., staff member P stated the facility had the smoking aprons for some time now. She stated the management staff knew the smoking aprons were at the facility, and she was told by staff member D to put the aprons out on 5/22/18. A review of the packing slip for the aprons was dated 5/26/17. During an interview on 5/23/18 at 6:20 a.m., staff member N stated when staff members B and D were hired and started their administrative oversight for the facility, the smoking materials were not locked up. She stated she has smelled cigarette smoke in the building before but it could be from the outside. She stated there have been no smoking aprons available for the past year. During an interview on 5/24/18 at 2:30 p.m., staff member O stated resident #2 is the only person that is required to wear an apron now.",2020-09-01
352,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2018-05-24,835,J,1,0,FXNT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and observation, facility administration failed to provide adequate oversight for the safety of residents, while smoking, which affected 3 (#s 1, 2, and 3) of 20 sampled residents. Resident #1 had actual harm from second [MEDICAL CONDITION] while smoking with oxygen. Resident #1 had three incidents of smoking in inappropriate places, times, and with oxygen in place. The facility failed to asses the smoking area for safety, perform smoking assessments, care plan, follow through with the smoking policy, provide smoking aprons and equipment as needed for residents, monitor and supervise residents while smoking, and provide for the safety of others. Findings include: On 5/23/18 at 11:59 a.m., the facility Administrator, Administrator in Training, and the Director of Clinical Services, were notified that an Immediate Jeopardy situation was identified for the areas of deficient practice, which included F689 Accidents and Hazards, and F835 Administration. The Severity and Scope was identified at the level of J, and upon the removal of the immediacy for the deficient practices, the severity and scope would be lowered to a [NAME] 1. Resident #1 had been seen by staff smoking in the building on 3/2/18, 3/11/18 two times, and again on 5/1/18 when she was on fire and received second [MEDICAL CONDITION] her face.(Refer to F689) Staff members B and D were notified each time resident #1 was smoking where she should not have been either by phone or in person. A review of the facility smoking assessment for resident #1 showed the facility needed to store the lighter and cigarettes for resident #1 so she would not have access to cigarettes and lighters. Resident #1's smoking assessment revealed she was independent with smoking. During an interview on 5/22/18 at 1:30 p.m., staff member A stated prior to the incident with resident #1, the residents were allowed to smoke independently. She stated resident #1 was let outside by a therapist. She stated the residents were allowed to keep their materials in their room. She stated prior to the incident with resident #1, the residents were not required to sign the smoking policy. Staff member A stated she was aware of the incident on 5/1/18 with resident #1. During an interview on 5/23/18 at 7:00 a.m., staff member L stated resident #1 had numerous problems with breaking the smoking policy. She stated the resident was caught smoking in the dining room, and in her room. She stated staff member D was notified of these instances. Staff member L said the staff would take the resident's cigarettes and lighters away, and the management would come in and say the resident could smoke, it was her right. During an interview on 5/23/18 at 7:29 a.m., staff member B stated he spoke with resident #1 on 3/1/18 about the smoking incident in the dining room with her oxygen on and in place. He stated he educated her on the policy and resident #1 signed the smoking policy. He stated he did not think he documented the education. He stated a resident would only need to use a smoking apron if deemed so through the smoking assessment. During an interview on 5/23/18 at 6:15 a.m., resident #10 stated he .used to be able to keep his cigarettes and lighter and everything until resident #1 blew herself up . He stated the staff kept everything now, and he does not like wearing the aprons when smoking. During an interview on 5/22/18 at 10:00 a.m., staff member G stated resident #1 had been caught smoking in her room before by staff, and staff member B told her that there was no safe discharge plan in place, and the resident would be allowed to continue to smoke, but staff would keep the cigarettes and lighter. She stated the resident was found after that smoking again, and the resident was once again given a warning. Resident #1 was then moved down stairs. Staff member G stated the resident was caught on three different occasions smoking and was still allowed to smoke. 2. Resident #2 had been caught smoking in the building, and not during smoking times, on 5/8/18 and again on 5/21/18. During an observation on 5/23/18 at 1:20 p.m., resident #2 was wearing a purple gown with small burn holes, in the front of the gown, which appeared to be cigarette burns. During an interview on 5/23/18 at 7:00 a.m., staff member L stated resident #2 was smoking in her bathroom on the night of 5/21/18. Staff member L said she reported the incident to staff member D. Staff member L said that, as of about two weeks ago, the staff were to go out with the residents when they smoke. Prior to that the staff did not go out with them. She stated there were no smoking aprons available currently. 3. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #3 wore oxygen at all times. During an observation on 5/24/18 at 1:30 p.m., eight residents were observed in the smoking area with one staff member. None of the residents wore a smoking apron. During an interview on 5/22/18 at 2:42 p.m., staff member P stated the facility had the smoking aprons for some time now. She stated the management staff knew the smoking aprons were at the facility. A review of the packing slip for the aprons was dated 5/26/17. Review of resident #3's smoking assessment dated [DATE] showed the facility needed to store the cigarettes and lighter. The smoking assessment showed resident #3 had a vision deficit. Review of the facility policy, titled Smoking Policy Residents updated Nov (YEAR) included, . Designated smoking areas include: . smoking aprons, or devices to assist residents in smoking . any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the resident's individual care plan. The care plan will indicate how the smoking materials will be stored, i.e. secure/locked cabinets for residents deemed to be safe to smoke independently, allowing independent residents to maintain their smoking material on their own person, maintenance of all smoking material at a secure designated area of another system as indicated to meet the residents need and within the ability of the facility During an interview on 5/22/18 at 9:30 a.m., staff member A stated she met weekly with staff member B to go over things. She stated she had access to look things up in the computer system to see things like incident reports, census, admits, and discharges. During an interview on 5/23/18 at 6:20 a.m., staff member N stated when staff members B and D were hired and started their administrative oversight of the facility, the smoking materials were not locked up. She stated she has smelled cigarette smoke in the building before. She stated there have been no smoking aprons available for the past year. During an observation on 5/22/18 at 7:30 a.m., there were no smoke detectors in the resident rooms or bathrooms. During an observation of the smoking area on 5/22/18 at 9:40 a.m., there was no fire extinguisher or fire blanket readily accessible in the smoking area.",2020-09-01
353,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2019-06-07,580,D,1,0,5WFT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, facility staff failed to notify the physician of a change in condition, the increased need for PRN nebulizer treatments after smoking cigarettes, for 1 (#1) of 8 residents. Findings include: During an interview on 6/6/19 at 9:25 a.m., staff member B stated resident #1 had a PRN order for nicotine [MEDICATION NAME]. The staff member stated resident #1 had not requested any [MEDICATION NAME] because the resident went outside to smoke every 30 minutes to 1 hour. Staff member B stated resident #1 would frequently request a nebulizer treatment when he returned to the facility after smoking. Staff member B stated the increase in smoking and nebulizer treatments began several months ago, and the physician had not been informed. Review of resident #1's (MONTH) 2019 MAR indicated [REDACTED]. The start date was 11/28/18. Staff documented PRN nebulization treatments were administered on 5/8/19, 5/13/19, 5/15/19, 5/16/19, 5/18/19, 5/19/19, 5/20/19, 5/22/19, 5/26/19, and 5/27/19. Review of resident #1's (MONTH) 2019 MAR indicated [REDACTED]. Staff documented PRN nebulization treatments were administered on 6/3/19 and 6/4/19. Review of resident #1's Nurse's Notes showed the following: - 5/12/19 at 11:58 p.m., .he had to wait 5 minutes for a breathing treatment and then went out to smoke as soon as he finished it. Upsetting rsdts around him because he comes out and stands out in the hall and dry heaves very loudly . - 5/13/19 at 10:52 p.m., .Rsdt came in from smoking and requesting a nebulizer treatment ASAP. - 5/15/19 at 11:31 p.m., Earlier in the evening rsdt came in from smoking and up to me and asked for a breathing treatment. He spoke like he needed it right away. Rsdt did breathing treatment and went back out to smoke. A few hours later he was seen in his room using his inhaler and right after he went out to smoke. - 5/17/19 at 1:49 a.m., res c/o SOB .res was given 2000 meds and neb tx . - 5/21/19 at 1:26 a.m., .Earlier in the shift rsdt was in room using [MEDICATION NAME] inhaler and asked this writer to set up [MEDICATION NAME] nebulizer. Rsdt went outside to smoke and came back in and used nebulizer. During an interview on 6/17/19 at 2:09 p.m., staff member J stated she had not been informed by facility staff of resident #1 required increase in PRN nebulization treatments after smoking. Staff member J stated she spoke with resident #1 on 6/12/19 about the resident's smoking preferences. The staff member stated resident #1 had been offered several smoking cessation options, but resident #1 was new to her care.",2020-09-01
354,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2019-06-07,600,D,1,0,5WFT11,"> Based on observation, interview, and record review, facility staff failed to monitor, supervise, and implement safety goals for 1 (#1) of 8 sampled residents when the resident left the facility, going to a busy adjacent street, to smoke cigarettes. Findings include: During an observation on 6/5/19 at 8:47 a.m., resident #1 exited the facility in a motorized wheelchair, drove to the end of the facility driveway, exited the facility property, and parked on the street next to the curb. Resident #1 began smoking a cigarette. Several vehicles drove past the resident and even came to a stop when two vehicles were passing resident #1 at the same time. The resident was not wearing reflective gear and did not have any safety accessories visible. There was no sidewalk between the facility and the street. The resident was unsupervised. During an interview on 6/5/19 at 10:33 a.m., staff member D stated resident #1 did not require assistance from the facility staff, with oxygen, when the resident exited the facility to smoke. She stated resident #1 should not be wearing an oxygen tank on his wheelchair when going to the street to smoke. The staff member stated it was, Not safe. Staff member D stated resident #1 was often gruff and difficult to approch. She stated resident #1 was independent and could be verbally abusive to the staff if he was questioned about his smoking activities. During an interview on 6/5/19 at 2:26 p.m., staff member [NAME] stated resident #1 was constantly outside, on the street, smoking, including at night. Staff member [NAME] stated resident #1 often wore his oxygen tubing while smoking. Staff member [NAME] stated when approaching resident #1 to assist with removing, or turning off the oxygen, resident #1 would say, I will do it myself. During an observation on 6/6/19 at 10:00 a.m., resident #1 went outside, to the street, with an oxygen tank attached to the wheelchair. The resident's oxygen tubing was coiled up and under the seat of the wheelchair. Resident #1 began smoking a cigarette. The resident was unsupervised. During an observation on 6/6/19 at 10:28 a.m., resident #1 went outside, to the street, with an oxygen tank attached to the wheelchair. The resident's oxygen tubing was coiled up and under the seat of the wheelchair. Resident #1 began smoking a cigarette. The resident was unsupervised. A review of Nurse's Notes dated 5/4/19 through 6/5/19 lacked documentation showing staff had monitored and supervised resident #1 when he left the facility premises to smoke cigarettes on an adjacent street or when he was away from the facility. A review of the facility's policy, Non-Smoking Compliance, effective 5/23/18, read, .5. All new admissions will be informed of facility non-smoking policy . A review of the facility's policy, Non-Smoking Compliance effective 5/23/18, was signed by resident #1 and witnessed on 11/29/18. A review of the facility policy, Resident Leave of Absence (LOA) Sign-Out, read, It is the intent that staff of this facility are aware of the location of residents while outside of the building .6. If the resident is mentally and physically able to be away from the building but can't write to sign out, the nursing staff is to sign out and in for the resident.",2020-09-01
355,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2019-06-07,657,D,1,0,5WFT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, facility staff failed to update, implement safety goals, and revise the care plan for 1 (#1) of 8 sampled residents when the resident started smoking cigarettes on a busy street adjacent to the facility. Findings include: During an observation on 6/5/19 at 8:47 a.m., resident #1 drove to the end of the facility driveway in a motorized wheelchair, exited the facility property, and parked on the street next to the curb. Resident #1 began smoking a cigarette. The resident was not wearing reflective gear and did not have any safety accessories visible. There was no sidewalk between the facility and the street. Resident #1 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. An admission MDS, with an ARD of 2/11/19, showed the resident had a BIMS of 15; cognitively intact. Review of resident #1's Smoking Assessment, dated and signed by resident #1 on 11/28/18, read, .smoker up to the time of admit .(Facility name) policy is NO SMOKING UNLESS admitted [DATE] OR BEFORE. we are beyond that time. no smoking, and patient is receptive to cessation. (sic) During an interview and record review on 6/5/19 at 9:29 a.m., staff member A stated resident #1's care plan lacked documentation showing a focused area for smoking (cigarettes) which included goals and interventions. A copy of resident #1's care plan was provided and reviewed. Staff member A stated the previous DON was responsible for updating care plans, but she was no long employed by the facility; the facility was in the process of hiring a new DON. During an interview on 6/5/19 at 8:56 a.m., staff member A stated resident #1 was independent and was the only active smoker at the facility. Staff member A stated resident #1 had been assessed for smoking, which should have included updating his care plan, and required the resident to sign out each time he went outside to smoke. During an interview and record review on 6/6/19 at 9:33 a.m., staff member A stated the Care Plan for resident #1 had been updated to include smoking. The focus area of the care plan, updated 6/6/19, read, I have recently started smoking cigarettes. The goal area read, I will be as safe as I can when choosing to smoke against facility policy and nursing advise. The interventions area read, I have agreed to apply reflectors and a flag on my wheelchair to increase my visibility when off property smoking. at (sic) this time, I only have reflectors. I have been educated on turning my oxygen off before going out to smoke. my oxygen tank is affixed to my electric wheelchair. I have signed a risk vs benefit in regard to smoking against policy and nursing advise. I will keep all of my smoking paraphernalia (sic) in a secured lock box that I have a key to. I will park my wheelchair in a safe area off of property when I am smoking. I will sign out each time I go out of building/off property to smoke. A review of the facility policy, Comprehensive Care Plans, effective 4/23/19, read, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.",2020-09-01
356,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2019-06-07,689,J,1,0,5WFT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to ensure 1 (#1) resident was safe, had visible safety accessories on his wheelchair, when leaving the premises to smoke cigarettes on a nearby busy street used by hospital patrons and an ambulatory surgical center, requiring cars to stop or swerve to avoid hitting the resident parked on the roadway; and failed to ensure 1 (#1) of 8 sampled residents was not smoking near oxygen equipment affixed to the wheelchair. Findings include: On 6/6/19 at 1:08 p.m., the facility Administrator in Training, was notified that an Immediate Jeopardy situation had been identified in the areas of deficient practice 483.25; F 689 Accidents and Hazards which affected 1 (#1) of 8 sampled residents. The severity and Scope was identified at the level of J, and upon the removal of the immediacy for the deficient practices, the severity and scope would be lowered to a D. Findings include: During an observation on 6/5/19 at 8:47 a.m., resident #1 exited the facility in a motorized wheelchair. A small oxygen cylinder, with tubing, was attached to the back of the resident's wheelchair. Resident #1 drove to the end of the facility driveway, exited the facility property, and parked on the street next to the curb. Resident #1 began smoking a cigarette. Several vehicles drove past the resident and even came to a stop when two vehicles were passing resident #1 at the same time. The resident was not wearing reflective gear and did not have any safety accessories visible. There was no sidewalk between the facility and the street. Resident #1 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The resident was oxygen-dependent and used 3 liters per minute, continuously, with a nasal cannula. An Admission MDS, with an ARD of 2/11/19, showed the resident had a BIMS of 15; cognitively intact. Review of resident #1's Smoking Assessment, dated 11/28/18, read, .smoker up to the time of admit .(Facility name) policy is NO SMOKING UNLESS admitted [DATE] OR BEFORE. we are beyond that time. no smoking, and patient is receptive to cessation. (sic) During an interview on 6/5/19 at 8:56 a.m., staff member A stated resident #1 was independent and was the only active smoker at the facility. Staff member A stated resident #1 had been assessed for smoking, which included updating his care plan, and the resident was required to sign out each time he went outside to smoke. During an interview and record review on 6/5/19 at 9:29 a.m., staff member A stated resident #1's care plan lacked documentation showing a focused area for smoking (cigarettes) with goals and interventions had been initiated. A copy of resident #1's care plan was provided and reviewed. During an interview on 6/5/19 at 10:33 a.m., staff member D stated resident #1 did not require assistance from the facility staff, with oxygen, when the resident exited the facility to smoke. Staff member D stated resident #1 should not be wearing an oxygen tank on his wheelchair when going to the street to smoke. Staff member D stated it was, Not safe. The staff member stated resident #1 was required to leave the facility premises because it was a no smoking facility. During an interview on 6/5/19 at 1:05 p.m., staff member I stated resident #1 often went out to the street to smoke because the facility was non-smoking. Staff member I stated she had heard of concerns with resident #1 being out in the road, but nobody approached the resident because he was off the facility premises. Staff member I stated it was concerning to her that resident #1 would be in the street and smoking with an oxygen tank attached to his wheelchair. Staff member I stated it was known throughout the facility that resident #1 would exit the facility, go to the street, and smoke cigarettes. During an interview on 6/5/19 at 2:15 p.m., staff member F stated resident #1 had begun going outside several times an hour, around the clock, to the street to smoke cigarettes. Staff member F stated resident #1 had a BIMS of 15 and he was cognitively intact. Staff member F stated other staff members did not approach or attempt to redirect resident #1 when on the street smoking, for fear of the resident becoming angry with staff. During an interview on 6/5/19 at 2:26 p.m., staff member [NAME] stated resident #1 was constantly outside, on the street, smoking, including at night. Staff member [NAME] stated resident #1 often wore his oxygen tubing while smoking. Staff member [NAME] stated when approaching resident #1 to assist with removing, or turning off the oxygen, resident #1 would say, I will do it myself. During an observation and interview on 6/5/19 at 3:10 p.m., resident #1 was smoking a cigarette while parked out on the shoulder of a busy street. Resident #1 stated he was not allowed to smoke on the facility premises and that was why he would drive onto the shoulder of the street with his motorized wheelchair. Resident #1 stated he used to smoke in the drive way of the facility but was told that vehicles entering and exiting the facility had to go around him. He stated he had no fears about being on the street and that vehicles often, crossed the middle line to avoid hitting him. Resident #1 stated some vehicles would stop, and passengers would ask if he were ok, when they saw him on the shoulder of the street. Resident #1 stated he was required to smoke on the street, in the parking lane, because there was no sidewalk in front of the facility for him to use. The oxygen tank on the back of the wheelchair was on, set to 3 liters per minute, and had 1700 PSI of oxygen remained in the tank. Resident #1 stated he kept his smoking paraphernalia with him at all times but had a lock box in his room. He pulled a lighter out of the top pocket of his shirt and a box of cigarettes from behind an unopened button of his shirt. During an interview on 6/5/19 at 3:40 p.m., staff member C stated she was afraid resident #1 would get hit by a car. Staff member C stated the street used by resident #1 to smoke on, was very busy. Staff member C stated resident #1 went outside after dark with a small light attached to his wheelchair, which illuminated the ground next to the wheelchair tire, and not the resident. Staff member C stated resident #1 was not visible until, Headlights were on him, but it might be too late by then. Staff member C stated she feared resident #1 would be hit by a car and killed. During an interview on 6/5/19 at 4:00 p.m., staff member A stated the facility had tried to initiate a transfer to another local facility where smoking was allowed, but resident #1 and his family refused to be transferred. Staff member A stated she was not sure if resident #1 fit the five-criteria for a transfer to another facility. A review of resident #1's (MONTH) 2019 Order Summary Report, signed by the physician on 4/29/19, showed the resident was to have 3 liters of oxygen continuously. A review of resident #1's (MONTH) and (MONTH) 2019 Medication Administration Order showed orders for PRN Nicotine [MEDICATION NAME] 2 mg every 1 hours (sic) as needed for Health maintenance every 1-2 hours with a start date of 12/11/18 at 1:30 a.m. No [MEDICATION NAME] had been administered. A review of resident #1's Nurse's Notes, showed the following: - 5/4/19 at 6:31 a.m., .While exiting the facility, this nurse noted that this resident was out, in front of facility, on side of street, in his w/c, smoking with his O2 in place per NC. An oncoming car needed to swerve around him while passing him. I called facility to inform of this situation. - 5/4/19 at 8:19 p.m., .He had cigarettes in his pocket that were visible. Rsdt will not give cigarettes or lighter to staff. - 5/5/19 at 12:53 a.m., Rsdt is going in and out of the building. He has been reminded x2 that he has to sign out each time, but he doesn't. He stated it's just a way for us to control him. - 5/6/19 at 3:22 a.m., Rsdt continued to go outside w/o signing out all evening and into the night, until approx. 0100. He still has cigarettes and lighter on his person. Stated what he does is between him and God. - 5/8/19 at 4:42 a.m., Rsdt continues to refuse to sign out when going outside. He goes outside and off the property at all hours of the night. Rsdt has cigarettes and lighter on his person. Rsdt says he always turns off his O2 and sits on the tubing when he goes out to smoke. - 5/12/19 at 11:58 p.m., .As soon as his need is met he is back outside smoking. - 5/13/19 at 10:52 p.m., Rsdt has been out to smoke at least 8 times since (staff member arrived for shift) at 6 p.m. He will not sign out. Rsdt does not pay attention to traffic coming in and out of parking lot and is driving his chair fast out onto the street. I witnessed him not even seeing me when I pulled into parking lot and driving right out in front of me .Rsdt came in from smoking and requesting a nebulizer treatment ASAP. As soon as he finished treatment he was back outside smoking. - 5/14/19 at 10:53 p.m., Rsdt continues to go out onto the street to smoke w/o signing out . - 5/15/19 at 11:47 a.m., Received a call this morning from a neighboring business to inform us that there was a gentleman in an electric wheelchair wandering down the street. Informed her that we do have a resident that does that and that I would check on him. Resident continues to be unsafe when going outside to smoke and has been driving in the middle of the road. - 5/15/19 at 11:31 p.m., Earlier in the evening rsdt came in from smoking and up to me and asked for a breathing treatment. He spoke like he needed it right away. Rsdt did breathing treatment and went back out to smoke. A few hours later he was seen in his room using his inhaler and right after he went out to smoke. - 5/16/19 at 5:22 a.m., Rsdt has been up all night. Going outside on average of every 30 minutes. Continues to not sign out when leaving. Administration is aware. - 5/17/19 at 4:57 a.m., .Res also has cigarettes and lighter on his person and cont. to go outside with only a flash light no reflectors noted on W/C all night to smoke with oxygen on electric W/C. - 5/19/19 at 8:19 a.m., Another resident's family reported that (resident name) was in the middle of the street (name), with his oxygen on and smoking a cigerette. (sic) Resident did not sign out to go outside today and was noted by staff to go outside 12 times between 0600 and 1200. Resident verbalized understanding that he has to sign himself out to go outside but did not sign out at all today. - 5/20/19 at 12:28 a.m., .He has been outside smoking >10 times since 1800 (6:00 p.m.) . - 5/20/19 at 3:58 a.m., Rsdt has been awake all night drinking coffee and going out to smoke aprox (sic) every 30 min. Rsdt does not sign out. Rsdt has not been going off of the property every time. He was smoking outside near the front doors. - 5/21/19 at 1:26 a.m., N[NAME] CNA reported that rsdt was sitting outside in front building, right next to the no smoking sign smoking when she came in. Rsdt is weel (sic) aware that rsdts cannot smoke on property. Earlier in the shift rsdt was in room using [MEDICATION NAME] inhaler and asked this writer to set up (medication) nebulizer. Rsdt went outside to smoke and came back in and used nebulizer. - 5/22/19 at 3:45 a.m., Rsdt found outside next to building smoking. Rsdt was told again that he can't smoke on facility property. Rsdt stated he would go out to the street, but the cold wet weather was really getting to him. Rsdt contues (sic) to not sign out when leaving the building. - 5/23/19 at 6:25 p.m., .Resident went out with family, and went out to smoke every 15 minutes this shift with no signs of pain when he was outside. - 5/27/19 at 11:50 p.m., .Rsdt has been up in electric chair and outside smoking many times. - 5/28/19 at 9:00 a.m., Received phone call from a nurse across the street concerned about this resident being outside smoking with his oxygen on . - 5/28/19 at 9:16 a.m., Phone call received from a concerned nurse from the Dr.'s offices across the street stating, 'You have one of your patients outside smoking in the street with his oxygen on.' CNA then went outside to check on resident, resident came back inside upset and stating 'I wish everyone would relax about this and mind their own business.' Will continue to monitor. - 5/29/19 at 4:44 a.m., Rsdt continues to go outside and smoke at all hours of the day and night. He does not sign out. - 5/30/19 at 7:30 a.m., Left building to smoke on way out the door attempted to get him to come back and sign out, however he kept moving in his scooter and said he was 'fine'. Reinforced with him again that he needed to sign out if he was going off property for an reason. He stated, 'I have my rights.' - 6/5/19 at 5:32 a.m., Rsdt continues to go out to the street to smoke. He refuses to sign out before leaving the property. During an observation on 6/6/19 at 9:30 a.m., resident #1 exited the facility, drove to the street, with an oxygen tank attached to the back of his motorized wheelchair. The resident's oxygen tubing was coiled up and under the seat of the wheelchair. Resident #1 began smoking a cigarette. During an interview on 6/6/19 at 9:50 a.m., staff member [NAME] stated resident #1 had been admitted to the facility in the Fall of (YEAR) and was on a nicotine supplement. Staff member [NAME] stated the facility was a non-smoking facility and resident #1 was not allowed to smoke on the premises. The staff member stated resident #1's son had put small (0.5 inch by 1.5 inch) reflectors on the motorized wheelchair wheels used by the resident. Staff member [NAME] stated resident #1 did not use a wheelchair safety flag when he was on the street smoking. Staff member [NAME] stated resident #1 was not allowed to use the public easement area used by staff for smoking because the resident's wheelchair could not climb the curb. During observations on 6/6/19 at 10:00 a.m. and 10:28 a.m., resident #1 exited the facility, drove to the street, with an oxygen tank attached to the back of his motorized wheelchair. The resident's oxygen tubing was coiled up and under the seat of the wheelchair. Resident #1 began smoking a cigarette. During an observation on 6/6/19 at 10:40 a.m., resident #1 entered the facility, approached the nurse's station, and requested the oxygen tank on his wheelchair be replaced with a full tank. Staff member D replaced the tank, asked resident #1 if he wanted the tank regulator turned on, to which the resident replied, yes. Staff member D turned the tank on and the resident left the nurses station. During an observation on 6/6/18 at 11:18 a.m., resident #1 exited the facility, drove to the street, with an oxygen tank attached to his wheelchair. The resident drove up the street and took a left onto another street. Resident #1 drove approximately 3/4 of a mile, turned around, and went back to the facility. The resident was smoking a cigarette until he returned to the facility. During an interview on 6/6/19 at 1:00 p.m., NF2 stated, There was a resident outside, parked in the street, smoking a cigarette, and has an oxygen tank attached to his wheelchair. NF2 stated she had informed a facility staff member, but remained concerned, because nobody appeared to be assisting the resident. A review of resident #1's Smoking Assessment, dated 6/6/19 at 8:18 a.m., read, .10. Comments: resident signed the smoking policy on admission. he has since started smoking in the last couple months. he chose not to relinquish his smoking material and opted to keep them in a lock box that only he has a key to. he is independent and uses an electric wheelchair to go off property to smoke. he was provided and signed a risk vs benefit. he is non compliant with smoking policy. (sic) A review of a facsimile, dated 6/7/19 at 10:59 a.m., showed orders signed by resident #1's physician for, Nicotine gum and nicotine [MEDICATION NAME] as directed as tolerated. A review of the facility policy, Non-Smoking Compliance effective: 5/23/18, read, 1. Staff will be aware of facility non-smoking policy and will report any violations to the Administrator or Director of Nursing. 2. Daily Quality Conference will include any non-smoking issues. 3. Monthly QAPI Meetings will address any non-smoking compliance issues. 4. Non-Smoking signs will be posted at entrances. 5. All new admissions will be informed of facility non-smoking policy. 6. Residents are not allowed to have any smoking material on their person or in their possession. Smoking materials include but are not limited to: cigarettes, pipes, cigars, tobacco, cigarette paper, matches, lighters, butane, e-cigarettes .7. Facility will not hold in their possession any resident smoking material. 8. Non-compliance with non-smoking policy will result in a written warning for the first violation. A review of the Oxygen Regulator's manufactures instructions, page 3, read, .Smoking near oxygen equipment is strictly prohibited. Keep cigarettes, matches, burning tobacco and open flames, such as lighted candles, away from the area where the system is being stored or operated. Avoid creation of any spark, such as static electricity caused by any type of friction, near oxygen equipment . A review of the facility's policy, Non-Smoking Compliance effective 5/23/18, was signed by resident #1 and witnessed on 11/29/18.",2020-09-01
357,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2019-06-07,835,D,1,0,5WFT11,"> Based on observation, interview, and record review, the facility administration failed to provide adequate oversight for the safety of a resident, while smoking on a busy street adjacent to the facility, including the lack of monitoring and supervision for 1 (#1); and failed to perform a smoking assessments, implement a smoking care plan with goal and interventions, and follow through with the smoking policy for 1 (#1) of 8 sampled residents. Findings include: During an observation on 6/5/19 at 8:47 a.m., resident #1 exited the facility in a motorized wheelchair. A small oxygen cylinder, with tubing, was attached to the back of the resident's wheelchair. Resident #1 drove to the end of the facility driveway, exited the facility property, and parked on the street next to the curb. Resident #1 began smoking a cigarette. Several vehicles drove past the resident and even came to a stop when two vehicles were passing resident #1 at the same time. The resident was not wearing reflective gear and did not have any safety accessories visible. There was no sidewalk between the facility and the street. During an interview on 6/5/19 at 8:56 a.m., staff member A stated resident #1 was independent and was the only active smoker at the facility. Staff member A stated resident #1 had been assessed for smoking, which included updating his care plan, and the resident was required to sign out each time he went outside to smoke. During an interview and record review on 6/5/19 at 9:29 a.m., staff member A stated resident #1's care plan lacked documentation showing a focused area for smoking (cigarettes) with goals and interventions had been initiated. Staff member A stated the previous DON was responsible for updating and initiating a resident's care plan. Review of the facility's Release of Responsibility for Leave of Abscence lacked documentation showing resident #1 was signing out when leaving the facility to smoke cigarettes on a busy street. During an interview on 6/5/19 at 4:00 p.m., staff member A stated the facility had tried to initiate a transfer to another local facility where smoking was allowed, but resident #1 and his family refused to be transferred. Staff member A stated she was not sure if resident #1 fit the five-criteria for a transfer to another facility. During observations on 6/6/19 at 9:30 a.m., 10:00 a.m., and 10:40 a.m., resident #1 exited the facility, drove to the street in his electric wheelchair, with an oxygen tank attached to the back of the seat, and smoked several cigarettes. The resident's oxygen tubing was coiled up and under the seat of the wheelchair. When the resident finished smoking, he would briefly go back into the facility, then he would return to the street and began smoking again. A review of the facility policy, Non-Smoking Compliance effective: 5/23/18, read, 1. Staff will be aware of facility non-smoking policy and will report any violations to the Administrator or Director of Nursing. 2. Daily Quality Conference will include any non-smoking issues. 3. Monthly QAPI Meetings will address any non-smoking compliance issues. 4. Non-Smoking signs will be posted at entrances. 5. All new admissions will be informed of facility non-smoking policy. 6. Residents are not allowed to have any smoking material on their person or in their possession. Smoking materials include but are not limited to: cigarettes, pipes, cigars, tobacco, cigarette paper, matches, lighters, butane, e-cigarettes .7. Facility will not hold in their possession any resident smoking material. 8. Non-compliance with non-smoking policy will result in a written warning for the first violation. 9. Residents whom smoke that have resided in the facility prior to 5/23/18, are grandfathered in to the previous resident smoking policy. Those residents have signed smoking policies in their record and will be subject to having smoking privileges revoked for violating the smoking and or non-smoking policy. A review of the facility's policy, Non-Smoking Compliance effective 5/23/18, was signed by resident #1 and witnessed on 11/29/18.",2020-09-01
358,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2019-06-07,865,E,1,0,5WFT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, facility staff failed to ensure an ongoing QAPI (Quality Assurance and Performance Improvement) program which tracked and measured the performances, goals, and systematically identified quality deficiencies for smoking concerns previously identified for 1 (#1) of 8 sampled residents. Findings include: During an observation on 6/5/19 at 8:47 a.m., resident #1 exited the facility in a motorized wheelchair, drove to the end of the facility driveway, exited the facility property, and parked on the street next to the curb. Resident #1 began smoking a cigarette. Several vehicles drove past the resident and even came to a stop when two vehicles were passing resident #1 at the same time. The resident was not wearing reflective gear and did not have any safety accessories visible. There was no sidewalk between the facility and the street. A small oxygen cylinder was attached to the back of the wheelchair. Resident #1 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. An Admission MDS, with an ARD of 2/11/19, showed the resident had a BIMS of 15; cognitively intact. During an interview on 6/5/19 at 8:56 a.m., staff member A stated resident #1 was independent and was the only active smoker at the facility. Staff member A stated resident #1 had been assessed for smoking, which included updating his care plan, and the resident was required to sign out each time he went outside to smoke. During an observation and interview on 6/5/19 at 3:10 p.m., resident #1 was smoking a cigarette while parked out on the shoulder of a busy street. Resident #1 stated he was not allowed to smoke on the facility premises and that was why he would drive onto the shoulder of the street with his motorized wheelchair. Resident #1 stated he used to smoke in the drive way of the facility but was told that vehicles entering and exiting the facility had to go around him. He stated he had no fears about being on the street and that vehicles often, crossed the middle line to avoid hitting him. Resident #1 stated some vehicles would stop, and passengers would ask if he were ok, when they saw him on the shoulder of the street. Resident #1 stated he was required to smoke on the street, in the parking lane, because there was no sidewalk in front of the facility for him to use. The oxygen tank on the back of the wheelchair was on, set to 3 liters per minute, and had 1700 PSI of oxygen remained in the tank. Resident #1 stated he kept his smoking paraphernalia with him at all times but had a lock box in his room. He pulled a lighter out of the top pocket of his shirt and a box of cigarettes from behind an unopened button of his shirt. A review of Nurse's Notes from 5/4/19 to 6/5/19 showed resident #1 was going outside, to an adjacent street, to smoke cigarettes. Staff documented on numerous occasions concerned citizens driving past the facility, concerned staff members leaving or entering the facility, and concerned family members visiting the facility worried resident #1 would be hit by a passing vehicle or be injured by smoking and having an oxygen tank attached to his motorized wheelchair. During an observation on 6/6/19 at 9:30 a.m., resident #1 went outside, to the street, with an oxygen tank attached to the wheelchair. The resident's oxygen tubing was coiled up and under the seat of the wheelchair. Resident #1 began smoking a cigarette. During an interview on 6/6/19 at 9:50 a.m., staff member [NAME] stated resident #1 had been admitted to the facility in the Fall of (YEAR) and was on a nicotine supplement. Staff member [NAME] stated the facility was a non-smoking facility and resident #1 was not allowed to smoke on the premises. The staff member stated resident #1's son had put small (0.5 inch by 1.5 inch) reflectors on the motorized wheelchair wheels used by the resident. Staff member [NAME] stated resident #1 did not use a wheelchair safety flag when he was on the street smoking. Staff member [NAME] stated resident #1 was not allowed to use the public easement area used by staff for smoking because the resident's wheelchair could not climb the curb. During an observation on 6/6/19 at 10:00 a.m., resident #1 went outside, to the street, with an oxygen tank attached to the wheelchair. The resident's oxygen tubing was coiled up and under the seat of the wheelchair. Resident #1 began smoking a cigarette. During an observation on 6/6/19 at 10:28 a.m., resident #1 went outside, to the street, with an oxygen tank attached to the wheelchair. The resident's oxygen tubing was coiled up and under the seat of the wheelchair. Resident #1 began smoking a cigarette. During an observation on 6/6/19 at 10:40 a.m., resident #1 entered the facility, approached the nurse's station, and requested the oxygen tank on his wheelchair be replaced with a full tank. Staff member D replaced the tank, asked resident #1 if he wanted the tank regulator turned on, to which the resident replied, yes. Staff member D turned the tank on and the resident left the nurses station. During an interview on 6/6/19 at 1:00 p.m., NF2 stated, There was a resident outside, parked in the street, smoking a cigarette, and has an oxygen tank attached to his wheelchair. NF2 stated she had informed a facility staff member, but remained concerned, because nobody appeared to be assisting the resident. A review of resident #1's Smoking Assessment, dated 6/6/19 at 8:18 a.m., read, .10. Comments: resident signed the smoking policy on admission. he has since started smoking in the last couple months. he chose not to relinquish his smoking material and opted to keep them in a lock box that only he has a key to. he is independent and uses an electric wheelchair to go off property to smoke. he was provided and signed a risk vs benefit. he is non compliant with smoking policy. (sic) A review of the facility policy, Non-Smoking Compliance effective: 5/23/18, read, .3. Monthly QAPI Meetings will address any non-smoking compliance issues. A review of QAPI meeting agenda notes provided by the facility, from 12/19/18 through 4/5/19, lacked documentation showing activities for tracking and trending residents at the facility that smoked were reviewed or monitored. During an interview on 6/5/19 at 5:00 p.m., staff member A stated the facility QAPI program no longer tracked and trending residents that smoked because the facility was a Non-smoking facility.",2020-09-01
359,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2019-09-11,677,E,1,0,YENF11,"> Based on observation, interview, and record review, the facility staff failed to assist in shaving facial hair for 1 (# 13) and failed to assist with oral care for 2 (#s 12 and 13) of 14 sampled residents. Findings include: 1. During an observation and an interview, on 9/10/19 at 7:51 a.m., resident #12's teeth had a collection of white colored substance caked to just below the gum line on his upper teeth. Resident #12 stated he could not brush his own teeth and he had to depend on staff to brush them. Resident #12 stated staff, often, did not brush his teeth throughout the day. Review of resident #12's Quarterly MDS, with an ARD of 5/22/19, showed the resident required extensive assist with his hygiene needs. Review of the resident #12's care plan, with revision date of 7/17/19, showed resident #12 was to receive assistance with brushing his teeth. During an interview on 9/10/19 at 7:20 a.m., NF3 said she was concerned with resident #12's daily hygiene. She said she was usually in to visit the resident at least weekly if not more. She said she had noticed the resident had his teeth always had food stuck in them. NF3 said resident #12 was pretty much dependent on staff for all his cares due to his disease process. 2. During an observation and interview on 9/10/19 at 12:10 p.m., resident #13 had facial hair which was a fourth of an inch long. Resident #13 said that he did not like facial hair, but he hadn't been shaved recently. The resident stated he needed staff assistance and was to be shaved daily. Resident #13 showed his teeth, saying he needed assist with brushing his teeth. The resident's teeth had a brownish stain on all of them. Resident #13 stated it was hit or miss with his cares from staff. During an interview on 9/10/19 at 12:45 p.m., staff member P stated the CNAs was to shave facial hair when the resident had a shower. The staff member stated that when she assisted with showers she would shave the resident if she noticed facial hair on the resident. Review of resident #13's Functional Abilities form, dated 7/3/19, showed the resident required assistance with his oral cares. Review of resident #13's care plan, with a target date of 10/25/19, showed the resident needed extensive staff assistance of 1-2 with grooming. Review of the facility's Facility Assessment Tool showed: - General Care; Activities of daily living, - Specific Care or Practices; Bathing, showers, oral/denture care, dressing .",2020-09-01
360,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2019-09-11,688,D,1,0,YENF11,"> Based on interview and record review, the facility failed to provide restorative nursing services, which caused a physical decline for 1 (#8) of 14 sampled residents. Findings include: 1. During an interview on 8/26/19 at 8:15 p.m., resident #8 said she was supposed to be on a restorative nursing program but said she had not seen the restorative aide in quite some time. During an interview on 9/11/19 at 10:02 a.m., resident #8 said she felt her physical capabilities (ADL) had declined since she had not received restorative nursing for several months. The resident said staff member M would either be doing resident transports to medical appointments or she would be pulled to the floor to work as a CN[NAME] Resident #8 said she looked forward to receiving restorative care. Review of resident #8's Admission MDS, with an ARD of 10/17/18, Section G, showed: - transfer was with the extensive physical assistance of 2 people, - walk in room happened once or twice with physical assistance of one person, - walk in corridor happened once or twice with physical assistance of one person, - locomotion on unit was with the extensive assistance of one person, - locomotion off the unit happened once or twice the extensive assistance of one person, - toileting was with the extensive physical assistance of two people. Review of resident #8's Quarterly MDS, with an ARD of 7/20/19, Section G, showed: - transfer only happened once or twice with the physical assistance of 2 people, - walk in room did not happen, - walk in corridor did not happen, - locomotion on unit only happened once or twice with the physical assistance of one person, - locomotion off the unit only happened once or twice with the physical assistance of one person, - toileting was total dependence with the physical assistance of two people. Review of resident #2's care plan showed, I am on a Nursing Restorative Program, I have decreased mobility. The date initiated was 1/15/19 with a target date of 11/6/19. Review of the facility's Daily Nursing Staff Postings from 7/1/19 to 8/29/19 showed a restorative aide was assigned for 6 of 58 days. During an interview on 8/27/19 at 8:42 a.m., staff member D said he knew nothing about the restorative program or what the restorative aide was doing every day. The staff member said, I don't worry about staffing levels, I come to work and do my job. During an interview on 8/27/19 at 1:22 p.m., staff member J said she was the only CNA on the Alpine unit. She said she not did not have time to do restorative care for any of the residents on her floor. Staff member J said she currently had 16 residents to take care of, and she did not have time for extras. She said the CNA who did restorative care was usually downstairs working the floor. During an interview on 8/27/19 at 1:40 p.m., staff member K said, I don't do any restorative, not my job. During an interview on 8/27/19 at 1:42 p.m., staff member L said none of the floor aides were trained to do restorative care. She said, It (restorative care) does not happen very often down here (lower level of facility). During an interview on 8/27/19 at 1:44 p.m., staff member M said she was always being pulled to work the floor. Staff member M was aware of the restorative services, and had been employed many years at the facility. During an interview on 8/27/19 at 3:25 p.m., staff member B said she did not know a restorative aide had only been scheduled to work six of the last 58 days per the Daily Nursing Staff Postings. Staff member C said they were aware this was a problem and they were working on it. Staff member B said the director of nursing was new and she had not had time to address the restorative nursing program yet. Staff member C said the facility had been authorized to get another contract staff so the restorative aide could start doing restorative care again. During an interview on 8/27/19 at 4:35 p.m., staff member B provided an untitled document that showed staff member M was to have worked as a restorative aide 16 days for (MONTH) of 2019 and six days for (MONTH) of 2019. Staff member B was requested to provide supporting restorative documentation of the days staff member M was to have provided restorative care. The facility was given until 8/28/19 at 12:00 p.m. to provide the documentation. The facility failed to provide any further documentation related to the restorative program. Review of the facility's Facility Assessment Tool showed: Part 2: Services and Care We Offer Based on our Resident's Needs: - Specific Care or Practices; Transfers, ambulation, restorative nursing, contracture prevention/care; .",2020-09-01
361,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2019-09-11,689,D,1,0,YENF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed on admission to document the events surrounding the possession of a knife, or knives, that belonged to 1 (#1) resident, and confiscate the item(s) for ongoing resident(s) safety, which caused fear for 1 (#12) resident, of 14 sampled residents. Findings include: 1. a. During an interview on 9/11/19 at 8:14 a.m., resident #12 stated he was fearful of another resident who had a knife in his possession. Resident #12 was sure the other resident still had a knife. Review of resident #12's care plan, with a revision date of 7/3/19, showed the resident was at risk for abuse because he was unable, at times, to communicate his needs and staff were to monitor any signs of abuse or neglect. b. During an interview on 9/10/19 at 8:45 a.m., resident #1 stated he had brought his knife into the facility when he was admitted to the facility. He said he had always carried a knife around prior to entering the facility. He stated he had the knife with him in the facility but staff had recently, just recently taken his knife away and they locked it up. During an interview on 9/11/19 at 8:30 a.m., staff member N said the facility was told resident #1 had a knife. Staff member N said resident #1's room was searched by herself and staff member B. They failed to find any knives in the resident's room. Staff member N said staff member B was notified on 8/10/19 that resident #1 had a knife, in a sheath, attached to his belt. The staff member said resident #1's room was searched on 8/10/19 and knives were found and confiscated. Staff member B said the knives were put in the facility safe. Review of resident #1's records showed the resident was admitted to the facility on [DATE]. There was no personal inventory lists for resident #1 located, which should have identified whether the resident had a knife or knives when he entered the facility, or if the facility staff were aware of the resident having knives. Review of resident #1's progress notes, dated 8/10/19 at 6:15 a.m., showed that resident #1 has pocket knives on his dresser and a fixed-blade knife, he's wearing on his belt in a sheath. The following note revealed the writer had notified the on-call nurse manager, who talked to the administrator and was told that this is his personal property. The knife was not taken from the resident at that time. Review of the facility Weapons Policy, with a revision date of 3/2019, showed the facility did not allow weapons and this would be communicated to residents or their representatives prior to admission. If a resident did bring a weapon on the facility's premises, the weapon would be removed from the premises or locked in the facility safe until the resident was discharged . Weapons included any item reasonably recognized as such, including, but not limited to, guns, knives, etc .",2020-09-01
362,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2019-09-11,697,G,1,0,YENF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to control a resident's pain due to a lack of pain medication for 1 (#7) of 14 sampled residents. Findings include: During an interview on 8/26/19 at 8:29 p.m., staff member G said resident #9 had fallen several days ago. She said the resident was sent to the emergency room several days after her fall and returned to the facility wearing a splint on her right arm. The staff member said she had heard the resident crying earlier that night. She said she went to the resident's room to see what was wrong. Staff member G said resident #9 told the staff member her arm hurt. Staff member G said she told the floor nurse the resident was in pain and crying. During an observation on 8/26/19 at 9:03 p.m., resident #9 was in bed. Her right lower arm was covered with a splint and was elevated on a pillow. During an interview on 9/11/19 at 9:02 a.m., NF1 said the facility did not manage resident #9's pain appropriately after her fall on 8/16/19. She said resident #9 had called NF2 several days after her fall, and was crying and told NF2 her arm hurt so bad. NF1 said NF2 called her, and NF1 called the facility. She spoke with the nurse, asking the nurse to check on resident #9. The nurse told NF1 she had given the resident a pain pill about an hour before and she was fine. NF1 said she told the nurse the resident had just called NF2 and was crying because her arm hurt so bad. NF1 said she got a phone call from the nurse a short time later to tell her the resident was being sent to the emergency room . NF1 said she went to the hospital to be with resident #9. NF1 said the resident was taken to X-ray. When the resident returned to the room, the doctor told the resident and NF1 the resident had a fracture just above the wrist. NF1 said the resident was placed in a splint, given some pain medicine, and sent back to the facility. During an interview on 9/11/19 at 11:53 a.m., NF2 said resident #9 called her on 8/19/19. She said the resident was crying and saying her arm hurt. NF2 said she called NF1 and told her of the phone call. NF2 said NF1 told her she would take care of it. Review of resident #9's physician orders [REDACTED]. - 2/19/18, [MEDICATION NAME] HCI Tablet 50 mg, Give 1 tablet by mouth every 4 hours as needed for pain. - 1/9/19, [MEDICATION NAME] HCI Tablet 50 mg, Give 50 mg by mouth at bedtime for pain related to displaced intertrochanteric fracture . Review of resident #9's nursing progress notes dated 8/27/19 to 8/29/19 showed: - 8/27/19 C/O pain 6/10 scale at hs. Is out of [MEDICATION NAME] as needs a new script, so gave 650 mg APAP of c/o pain. Later pain decreased to 4/10 scale. - 8/28/19 1830 writer phoned (Pharmacy Name) to see if they had received script from MD for residents [MEDICATION NAME], (pharmacy name) (pharmacy tech) states they have not received a script and that the pharmacy has also faxed MD to get script for the [MEDICATION NAME] but they have not received it as of this time. 2046 since resident is out of [MEDICATION NAME], Tylenol 650 mg given . - 8/29/19 [MEDICATION NAME] has not arrived from pharmacy at this time, given Tylenol 650 mg instead . Review of resident #9's Medication Administration Record [REDACTED] - [MEDICATION NAME] HCI 50 mg by mouth at bedtime for pain . The resident did not receive the scheduled doses on 8/26/19, 8/27/19, and 8/28/19. It was noted the medication was unavailable. - [MEDICATION NAME] tablet give 500 mg by mouth every 6 hours as needed for pain . The resident received this medication on 8/26/19 with a noted pain level of 7, and she received another dose on 8/27/19 with a noted pain level of 6. - [MEDICATION NAME] HCI 50 mg Give 1 tablet by mouth every 4 hours as needed for pain. The dates for 8/26/19, 8/27/19, and 8/28/19 were blank. Review of resident #9's care plan with a print date of 9/11/19 showed: - Focus: Comfort/Pain: I have pain/discomfort related to hx of knee pain and abdominal pain. - Goal: I want to keep my pain between a pain score of 1-4. - Interventions: Please provide me with pain medications as ordered. During an interview on 9/11/19 at 11:05 a.m., staff member N said the facility had been having problems with the pharmacy providing medications in a timely manner. She said she talked to the pharmacist on or about 8/28/19 regarding the [MEDICATION NAME] for resident #9. The pharmacist told her the pharmacy had not received a script from the physician's office for the [MEDICATION NAME]. Staff member N said she went back and forth with the doctor's office and the pharmacy on this issue. The doctor's office told staff member N the script had been faxed to the pharmacy several times over several days. Staff member N said the matter was finally taken care of but resident #9 did not receive her scheduled or PRN [MEDICATION NAME] for several days.",2020-09-01
363,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2019-09-11,732,B,1,0,YENF11,"> Based on interview and record review, the facility failed to complete daily nursing staff posting sheets for 4 of 58 days. Findings include: During an interview on 8/27/19 at 4:35 p.m., with staff member B and C, staff member B stated she was not aware of the process for ensuring the accurate completion of the Daily Nursing Staff Posting forms used by the facility. Staff member C explained to staff member B how the total number of staff for each shift and the total number of hours for each shift had to be written in. Review of the facility's Daily Nursing Staff Posting forms showed: - 8/12/19, total number of staff for the day shift and evening shift; RN, LPN, CNA, were blank, as were the total hours for each shift. - 8/19/19, total number of staff for the day shift and evening shift; RN, LPN, CNA, were blank, as were the total hours for each shift. - 8/20/19, total number of staff for the day shift and evening shift; RN, LPN, CNA, were blank, as were the total hours for each shift. - 8/27/19, total number of staff for the day shift and evening shift; RN, LPN, CNA, were blank, as were the total hours for each shift.",2020-09-01
364,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2018-09-13,919,D,1,0,0C3J11,"> Based on observation, interview, and record review, the facility failed to ensure access to the call light system for 1 (#1) of 3 sampled residents. Findings include: During an observation on 9/13/18 at 9:35 a.m., resident #1 was lying in her bed watching TV. Her call light was fastened to her privacy curtain behind her head. During an interview on 9/13/18 at 9:40 p.m., resident #1 stated she would not be able to use her call light if she needed it because it was fastened to the privacy curtain behind her head. Resident #1 stated the night staff usually fastened the call light on the curtain and would pull the curtain so she could reach it. She stated the day shift staff often forgot to un-fasten the call light from the privacy curtain before they pulled it back so she did not have access to it. During an interview on 9/13/18 at 10:50 a.m., staff member A stated staff usually take the call light off the privacy curtain and fasten it to the resident or on the bed so they have access to it. Night shift usually fastened it on the privacy curtain. Review of resident #1's Care Plan, with an initiation date of 10/26/16, showed, keep call light within reach at all times.",2020-09-01
365,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2017-12-11,550,D,0,1,P6JV11,"Based on observation, interview, and record review, the facility failed to assist with shaving facial hair for 1 (#52), and turned off a call light without asking the problem for 1 (#417) of 17 sampled residents. Findings include: 1. During an observation on 12/5/17 at 9:09 a.m., 12/6/17 at 10:55 a.m., and 11:21 a.m., resident #52 was in the Gold Rush day room. The resident had 1/4 inch long hairs, covering her chin. During an interview on 12/6/17 at 10:46 a.m., NF1 stated resident #52 was unable to shave her own facial hair, and had requested staff do the task during her showers. NF1 stated he usually would shaved her chin, as staff had not. He had not seen staff shave the resident for a long time. Review of the resident #52's Multidisciplinary Care Conference Summary Update, with a date of 3/1/17, showed resident #52's facial hairs were to be shaved when she had showers. During an interview on 12/6/17 at 11:10 a.m., staff member K stated resident #52 was to have her facial hair shaved by staff. It was to be on shower days. 2. During an interview on 12/4/17 at 11:59 a.m., resident #417 said there were two CNAs who did not treat him with respect and dignity. He stated one was really snotty, but he did not know her name and could not describe her. He provided a description of another CNA, later confirmed to be staff member G, and stated that the CNA would respond to his call light, but then not address his needs before leaving the room. He said he would have to put on the call light again for another staff member to come to assist him. He said his needs were eventually met by other staff, but not by staff member [NAME] During an interview on 12/6/17 at 4:00 p.m., staff member J stated she had worked many times with staff member [NAME] She said she had answered call lights, and was told by the residents that staff member G answered the light but did not address the resident's needs. Staff member J stated the residents told her staff member G said she would return to meet the resident's needs but did not return. During an interview on 12/7/17 at 2:29 p.m., staff member G stated she would not turn off a call light without meeting a resident's needs unless the resident was sleeping when she entered the room. She stated she would softly say the resident's name to determine if the resident was awake. She stated resident #417 has asked her to speak up, and to slow down, when talking to him, so he could understand her. She stated she was aware resident #417 had a hearing impairment.",2020-09-01
366,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2017-12-11,610,D,0,1,P6JV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to investigate missing personal property for 2 (#s 49 and 407) of 17 sampled residents. Findings include: Concerns with lack of investigation: a. During an interview on 12/4/17 at 2:45 p.m., resident #49 stated she had a pair of shoes in her closet, in a bag, and tried to put them on one day, but they were too tight. She said the following Friday she had an appointment and wanted to try on the shoes again. Resident #49 stated she asked a staff member to get out the shoes for her, and the staff member told her they were not in the closet. Resident #49 stated she also looked for the shoes and could not find them. She said she told a CNA about the missing shoes and nothing happened, as far as anyone else asking about the shoes, or searching for them. Resident #49 said she did not know the names of the staff member who searched for the shoes or the CNA she had reported to about the missing shoes. b. During an interview and observation on 12/5/17 at 8:06 a.m., resident #407 stated her left hearing aid had been lost since her admission to the facility on [DATE]. She stated a staff member pushed her across the street, in her wheelchair, to a doctor's appointment last Monday, and she was wearing the hearing aid when she left the facility. She said after the appointment a staff member wheeled her back to the facility. Resident #407 stated after she returned to the facility she noticed she did not have the hearing aid, and reported the missing hearing aid to a staff member who helped her search for the hearing aid. She stated the hearing aid was not found and her daughter was checking into getting her a new one. She stated no one had questioned her about the missing hearing aid, or assisted her to search for it, other than the staff member she had reported to after returning from her appointment. Resident #407 pointed to her left ear, and upon observation, there was no hearing aid in her ear. There was a hearing aid in the right ear. During an interview on 12/6/17 at 11:56 a.m., staff member V stated she brought resident #407 back from her appointment on 11/27/17, but she was not aware of a missing hearing aid. During an interview on 12/6/17 at 3:00 p.m., staff members A and D stated they were not aware of the missing shoes or the missing hearing aid. Staff member A stated there was no report or investigation completed because he was not aware of the missing property. He said the facility procedure was for staff to notify administration of reports of missing property. Upon receiving the report, he would open a grievance and complete an investigation. Staff member A stated he would check the personal inventory list and hope it had been done and kept up. He stated he would contact the resident's family to determine if the item had been taken home. He said the facility would try to replace the item, if reasonable. Specifically, regarding resident #s 49 and 407, staff member A said he would open a grievance and investigation. He said he, or a designee, would contact the doctor's office to see if the hearing aid was found there. Staff member D stated the Admission Agreement indicated valuables were the responsibility of the resident. A verbal request was made for the grievance and investigation results for residents #49 and #407. A review of the resident #49's and #407's EHR and paper charts showed no personal inventory list. On 12/7/17, a request was made for the personal inventory lists for residents #49 and 407. On 12/7/17, a copy of the request list was provided to the surveyor with the words, not available, written next to the request. On 12/11/17 at 8:15 a.m., a written request was made for the grievance reports for the missing items for residents #49 and #407. No reports were provided. During an interview on 12/11/17 at 12:20 p.m., staff member A stated resident #49 had reported missing pants, as well as the missing shoes, when questioned, and the facility would replace both items. He stated resident #407 had both of her hearing aids. He said he was informed last Friday the resident had not had both hearing aids in the facility, and the daughter had recently brought one to the facility. He stated the grievance reports and investigations would be sent to the State Survey Agency. During an interview on 12/11/17 at 12:23 p.m., staff member A asked resident #407 if she had both of her hearing aids. Resident #407 stated she did and pointed to both ears. Staff member A stated he was told one hearing aid was never at the facility, and the resident's daughter had brought it to her. She said her daughter had brought the new hearing aid that had been ordered to replace the one that had been lost while she was in the facility. Resident #407 said her insurance covered the replacement hearing aid after the $250.00 deductible was paid by the resident/representative. The grievance reports and investigation findings for the missing property were not received by the State Survey Agency by the close of business on 12/11/17.",2020-09-01
367,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2017-12-11,636,E,0,1,P6JV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete MDS assessments within the required timeframe of 14 days from the assessment reference date to the completion date, for 4 (#s 3, 48, 49, and 312), and failed to comprehensively assess triggered care areas for 1 (# 49) of 25 sampled and supplemental residents. Findings include: 1. A record review of resident #3's MDS assessments showed the Annual MDS, with an ARD of 10/30/17, was not completed as of 12/6/17. This was a span of 36 days. During an interview and record review on 12/6/17 at 10:00 a.m., staff member C stated the facility was behind on MDS assessment completion. The MDS staff had been required to fill in for other nursing oversight tasks when the facility lacked a DON. She said the facility was aware of the issue, and had an ad hoc meeting to correct the problem. Staff member C said the plan for the MDS staff was to complete current MDS's timely and chip away at the past due assessments until they were caught up. She said resident #3's Annual MDS was one of the assessments that was behind. 2. a. Review of resident #49's Significant Change in Status MDS, with an ARD of 10/8/17, showed a completion date of 11/8/17. This was a span of 31 days. b. During an interview and observation on 12/7/17 at 11:37 a.m., resident #49 stated she had impaired ROM, due to arthritis, in her right hand. Resident #49 stated the impaired mobility interfered with her performance of some of the tasks of daily living. She held up her right hand and demonstrated that she did not have full ROM. A review of resident #49's [DIAGNOSES REDACTED]. A review of her Progress Notes showed the CAA for ADL Function was completed on 11/8/17. The CAA did not address the impaired mobility to resident #49's right hand. During an interview on 12/06/17 at 10:10 a.m., staff member B stated the facility had recently identified multiple areas of concern, and conducted a QAPI meeting to address the concerns. Staff member B said MDS and CAA completion were among the areas of concern. She said the first two steps towards correction had been completed, which included her assignment as interim DON, and the return of the MDS staff to their routine duties. 3. Resident #312 was admitted to the facility on [DATE], and the primary [DIAGNOSES REDACTED]. Record review showed resident #312 did not have an Admission MDS. Review of the EHR for resident #312 showed the Resident Assessment Instrument (RAI) was not used, in accordance with specified format and timeframe's, in conducting comprehensive assessments as part of an ongoing process where the resident's functional and mental health, goals, and care needs, were identified with further assessments. Resident #312's EHR lacked the CAAs. The CAAs were documented in the EHR on 12/7/17. During an interview on 12/6/17 at 8:50 a.m., staff member C stated the MDS was completed 12/5/17. She stated this was the only MDS assessment completed for the resident since his admission to the facility. She stated the resident was admitted on [DATE], and then placed on hospice on 11/17/17, then a Significant Change MDS was initiated. The EHR showed only one comprehensive MDS, completed on 12/5/17. The resident should have had an Admission MDS assessment for his admission. 4. Resident #48 was admitted to the facility on [DATE]. Record review showed resident #48's Admission MDS had an ARD of 10/13/17. The Admission MDS was not completed until 11/9/17 During an interview on 12/11/17 at 7:29 a.m., staff member C said resident #48's Admission MDS, with an ARD of 10/13/17, was not completed in a timely manner.",2020-09-01
368,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2017-12-11,656,E,0,1,P6JV11,"Based on observation, interview, and record review, the facility failed to develop a care plan for individualized restorative programs for 4 (#s 8, 14, 37, and 52); and failed to identify a functional limitation in ROM and the need for ADL assistance for 1 (#49) of 17 sampled residents. Findings include: 1. During an interview on 12/4/17 at 2:29 p.m., resident #8 stated she should be receiving the restorative program for strengthening her legs. The resident stated she did not always receive restorative, due to the CNAs being short staffed. Review of resident #8's care plan, with a review date of 3/24/17, which had not been updated quarterly, showed a lack of restorative services as one of the focused care areas. 2. During an observation on 12/7/17 at 10:56 a.m., resident #37 was in a wheel chair, close to the Gold Rush nurses' station. The resident was positioned on the edge of the seat, his legs stretched out in front. He stated he wanted to walk. He said he was supposed to walk two times a day, and that hadn't been happening. Staff member F told the resident she would help him walk to and from lunch, if she had time. The resident stated he was worried about getting enough walking distance in. Review of resident #37's care plan, dated 9/4/17, showed no documentation the resident had received individualized care, related to a restorative program. 3. During an observation on 12/04/17 at 2:47 p.m., resident #52 was in a wheel chair, in the Gold Rush day room. The resident was leaning over the right side of the wheel chair. The resident's head was almost touching the arm of the wheel chair. The resident's right hand was contracted and up against her stomach. During an observation on 12/6/17 at 11:21 a.m., resident #52 was in the Gold Rush day room. The resident was sleeping in a wheel chair. The resident's head hung to the right of her neck. The resident's right hand was contracted, facing up, while resting on the lower part of her abdomen. The resident had no hand brace, and no type of head rest. The right arm of the wheel chair had a cushioned arm rest. The arm rest was lifted up and off the back of the wheel chair arm. Neither the resident's arm nor head rested on a cushioned surface. Review of a progress note, dated 5/18/17, and labeled significant change, showed resident #52 had been discharged from hospice, and would be working with PT/OT/ST. During an interview on 12/5/17 at 3:29 p.m., staff member M stated the facility had not had a functioning restorative program for about a year. The staff member stated a program had just been developed. The staff member provided a Restorative Schedule. The staff member stated physical therapy was reassessing residents from the Restorative Schedule. Review of resident #52's care plan showed the care plan had not been updated since 5/18/17. No documentation was available showing the resident's comprehensive care plan was addressing the resident being discharged from hospice or change in care needs, relating to the goals, focus areas, or interventions used by staff. 4. During an interview on 12/5/17 at 1:27 p.m., resident #14 said she was concerned she would become weaker without restorative care. She said she may get more physical therapy in the future to help with strengthening. She had heard the facility was hiring more staff to help with providing physical therapy care to the residents. Resident #14 said she could get up from her recliner, to her walker, from a seated position. She could ambulate to and from the bathroom, and transfer to the toilet, by herself. She said she needed assistance with pericare. Resident #14 said she used to walk more often, in the hallways, when she had more assistance available. She said she infrequently walks in the halls now. Review of resident #14's PT - Therapist Progress & Discharge Summary, dated 11/6/17, showed discharge instructions of, PT to d/c to restorative nursing program with goal to continue ambulation and strengthening consistently. Review of resident #14's Resident Restorative Plan, dated 11/8/17, showed she would receive care for, Ambulation as able rolling walker - CGA - w/c follow (sic), and There ex (sic) - please focus on ambulation as pt works on her exercises on her own as well. Otherwise- general LE there ex. (sic). Review of resident #14's care plan lacked evidence restorative services were planned or implemented. 5. During an interview and observation on 12/7/17 at 11:37 a.m., resident #49 stated she had impaired ROM, due to arthritis, in her right hand. Resident #49 stated the impaired mobility interfered with her performance of some of the tasks of daily living. She held up her right hand and demonstrated that she did not have full ROM. Review of resident #49's Admission MDS, with an ARD of 7/27/17, showed the resident received limited to extensive assistance to complete ADLs, except she received supervision for eating. Review of resident #49's Significant Change in Status MDS, with an ARD of 10/5/17, showed the resident received limited to extensive assistance to complete ADLs. Review of resident #49's care plan, which showed resolved and current focus areas, did not show the limitation to ROM of resident #49's right hand, or the need for ADL assistance.",2020-09-01
369,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2017-12-11,657,D,0,1,P6JV11,"Based on observation, interview, and record review, the facility failed to revise resident care plans to show the need for restorative services for 1 (#49); and a change in weight-bearing status for 1 (11) of 17 sampled residents. Findings include: 1. During an interview and observation on 12/7/17 at 11:37 a.m., resident #49 stated she had impaired ROM, due to arthritis, in her right hand. Resident #49 stated the impaired mobility interfered with her performance of some of the tasks of daily living. She held up her right hand and demonstrated that she did not have full ROM. Resident #49 stated she had been receiving therapy to her right arm and hand, but the therapy had recently ended. She said she was told by a therapist that she would be receiving restorative services, but none had been provided. During an interview and record review on 12/7/17 at 11:45 a.m., staff member P provided a copy of resident #49's Restorative Plan, dated 12/1/17. The copy was made from a document kept in the therapy office, and was not available to the nursing staff. No copy was found in the book used by the restorative aides. The plan showed three restorative program recommendations. Review of resident #49's care plan did not show the need for restorative services or the restorative treatment plan. 2. Resident #11 was admitted to the facility with non-weight bearing status due an ankle fracture. Review of a physical therapy discharge summary, dated 11/11/17, showed resident #11 was able to walk 50 feet with partial to moderate assistance using a front wheeled walker. Review of resident #11's current care plan showed under the Fall Prevention that she was non-weight bearing. Staff were to ensure I adhere to my NWB order for my affected LE. The care plan showed the last revision to this section was done on 7/17/17. During an interview on 12/11/17 at 7:29 a.m., staff member C said resident #11's care plan should have been revised and updated. Staff member C said the facility had been short on staff and she had been working on the floor.",2020-09-01
370,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2017-12-11,661,D,0,1,P6JV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a discharge summary for 2 (#s 59 and 357) of 17 sampled residents. Findings include: 1. Review of resident #59's progress note, dated 8/30/17, showed the writer started a discharge summary for resident #59, from the facility. Review of resident #59's care plan, dated 9/6/17, showed the resident was a short stay resident, with an admit of 8/18/17. The facility staff had planned to start arranging for discharge 72 hours prior to the discharge. Review of resident #59's nursing progress note, dated 9/7/17, showed resident #59 discharged [DATE]. Review of the Discharge Summary (Interdisciplinary), with the effective date of 9/7/17, showed the therapy summary, the drug therapy required, the physical functional status, and special treatments or procedures, for the discharge, had not been completed. During an interview on 12/7/17 at 12:29 p.m., staff member N stated she was not at the facility when resident #59 was discharged . The writer no longer worked at the facility. During an interview on 12/7/17 at 1:00 p.m., staff member B stated she had just started working at the facility, and was unaware of the discharge summary for resident #59. 2. Resident #357 was admitted on [DATE], and discharged on [DATE]. Review of the discharge record for resident #357 showed that the Admission MDS, with an ARD of 11/22/17, was not completed by 12/7/17 at 10:36 a.m. A form titled, Discharge Instructions, in the EHR, was not completed, and a Discharge Summary was not found. During an interview on 12/7/17 at 12:27 p.m., staff member L stated that they are behind with a lot of our MDSs. Staff member L said that for resident #357, the Admission MDS should have been completed on 11/28/17. Staff member L said the Discharge Instructions were completed in the resident's paper chart. A copy of the completed Discharge Instructions was requested but not received by the survey exit date; 12/11/17. During an interview on 12/11/17 at 7:36 a.m., staff member Q stated social services was in charge of getting the physician's signature for the discharge summary. During an interview on 12/11/17 at 7:44 a.m., staff member N said she helped the residents with their discharge plans. Staff member N said the discharge summary was completed by her or nursing. She stated she would fax the physician for a signature. A completed plan with a physician's signature was reviewed. She also stated that someone would have to scroll through all the notes to see how the resident was from admission to discharge. Staff member N could not provide a completed Discharge Summary addressing resident #357's recapitulation of the resident's stay. Review of resident #357's faxed note to the physician dated 12/4/17, showed an anticipated discharge date of [DATE], The physician authorized the discharge.",2020-09-01
371,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2017-12-11,677,D,1,1,P6JV11,"> Based on observation, interview, and record review, the facility failed to assist with dressing, grooming, and cleaning around the opening of a tracheotomy for 1 (#24); and with removing facial hair for 1 (#52) of 17 sampled residents. Findings include: 1. During an observation on 12/7/17 at 8:00 a.m., resident #24 was in bed. She was wearing a night shirt and a brief. The resident had a brownish green, dried liquid, coming from the tracheotomy site. The dried liquid was also on the resident's lower chin. The resident's eyes had a dried discharge around her eyes from eye drainage. During an observation on 12/7/17 at 10:41 a.m., resident #24 was still in bed, wearing the night shirt, and brief. The resident's hair was tussled from the night, in bed. The resident had a brownish green, dried liquid, coming from the tracheotomy site, around the site, and on the resident's lower chin. The resident's eyes still had the dried discharge, which had drained out and dried around her eyes. During an interview on 12/7/17 at 10:54 a.m., staff member F stated the resident generally was assisted with ADLs earlier in the morning, but a nursing staff member did not show up for work and so they were behind, and unable to get resident #24 up earlier. Review of the Annual MDS, with an ARD of 9/8/17, showed the resident required total assist for all cares. 2. During observations on 12/5/17 at 9:09 a.m., 12/6/17 at 10:55 a.m., and 11:21 a.m., resident #52 was in the Gold Rush day room. The resident had prominent chin hairs. Review of resident #52's Multidisciplinary Care Conference Summary Update, with a date of 3/1/17, showed resident #52's facial hairs were to be shaved by staff when she had showers. Review of resident #52's current care plan, dated 5/18/17, showed resident #52 needed extensive assist with ADLs, including hygiene and grooming. During an interview on 12/6/17 at 10:46 a.m., NF1 stated resident #52 was unable to shave her own facial hair and had requested staff do the task during her showers. NF1 stated he generally shaved her chin. He had not seen staff shave it for a long time. During an interview on 12/6/17 at 11:10 a.m., staff member K stated resident #52 was to have her facial hair shaved by staff. It was usually done on shower days.",2020-09-01
372,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2017-12-11,686,D,0,1,P6JV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to adequately identify and document pressure ulcers to the thigh and penis, and failed to adequately assess and document the condition and healing status of the wounds during the resident's stay, for 1 (#417) of 17 sampled residents. Findings include: Resident #417 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of resident #417's Initial Nursing Evaluation and Vitals form, dated 11/16/17, and signed as completed on 11/29/17, showed no evidence of impaired skin integrity. The form showed no specified area to document impaired skin integrity. Review of resident #417's Initial Weekly Wound Documentation Form, dated 12/1/17, showed the document was in progress, and had no completion date. The form showed the following: -instructions to document one wound per form, and, This initial wound sheet is to be completed when a wound is first discovered. Weekly wound sheet done each week thereafter until healed. The form showed present on admission, but does not distinguish which wound(s) were present on admission. -Section 1.a. and b. Type of wound: form showed mixed, with an explanation of, Some pressure, 1 abrasion. Three wounds were listed, including one Stage II pressure ulcer to the coccyx, one Stage II pressure ulcer to the right gluteal fold, and one abrasion to the left gluteal fold. -Section 1.c. Description of the wound base was blank. -Section 1.d. and e. Drainage amount and type were blank. An option for none was available but was not marked. -Section 1.g. and h. Undermining/tunneling, and wound edges, were blank. -Section 1.i. Wound treatment and pain was not marked to indicate pain. -The form was signed by staff member I. During an observation and interview on 12/6/17 at 12:27 p.m., staff member I completed a treatment to the resident's penis, skin folds, and scrotum. There was adherent black eschar to the tip of the penis, adjacent to the meatus. Adjacent to the eschar, there was a reddened area that visually appeared to be similar in size to the eschar. Staff member I stated these wounds were from the chronic indwelling catheter, and were present on admission. She said the scab had been much larger but had been falling off. No measurements were obtained and none were found in resident #417's wound documentation. No wound assessments were found for the penis wound. Review of resident #417's (MONTH) (YEAR) MAR indicated [REDACTED]. During an observation and interview on 12/11/17 at 8:27 a.m., staff member I positioned resident #417 for skin and wound care to his penis, scrotum, and left inner thigh. Staff member J was present to assist staff member I. When the sheet was removed, exposing resident #417's groin area, there was an indwelling catheter with the tubing secured to the right inner thigh. There was enough slack in the tubing that a portion was pressed into the left inner thigh. When the tubing was removed from resident #417's left thigh, there was a concave indentation in the skin, the size and shape of the catheter. The skin was deep red, and the redness did not resolve after 15 minutes. Staff member J stated the wound was a pressure ulcer. Both staff member I and staff member J stated the wound was not new, but could not say how long it had been there. Both staff member I and staff member J stated the wound was caused by the catheter. Staff member I applied A&D ointment to the site. No measurements were taken and none were found in resident #417's wound documentation. No assessments of the thigh wound were found. No evidence was found that the thigh wound was present on admission. Review of resident #417's Skilled Status Assessments, from 11/25/17-12/6/17, showed a Stage II pressure ulcer to the sacral region/coccyx, excoriation to buttocks, and excoriation to scrotum. The assessments did not show the presence of the penis wound or the thigh wound. Review of a facility policy titled, Skin Program, revision date (MONTH) (YEAR), showed a comprehensive wound assessment would be completed: -When a skin ulcer is identified. The assessment will include site, stage, size, appearance of the wound bed, undermining, depth, drainage, and status of peri-wound tissue. -Reassess the wound at least weekly.",2020-09-01
373,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2017-12-11,688,E,0,1,P6JV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide restorative nursing services for 7 (#s 8, 11, 14, 34, 37, 49, and 52) of 17 sampled residents. Findings include: 1. Resident #34 was admitted with [MEDICAL CONDITION] in (MONTH) of (YEAR). During an observation on 12/5/17 at 3:30 p.m., two CNAs transferred resident #34 from the bed to the wheelchair, using a lift with a sling. Staff member G told resident #34 what they would do. After supplies were gathered, a soiled brief was changed, and skin care was provided. A sling was placed under the resident, by rolling him from side to side. The resident was transferred to the wheelchair safely. The resident was able to use his arms during the transfer but not his lower extremities. During an interview on 12/6/17 at 9:30 a.m., resident #34 stated he had contractures of his legs, which were present on admission. He stated that he felt he would have benefited from continued ROM, and thought he had PT when he was admitted . Review of resident #34's Occupational Therapy Log for (MONTH) and (MONTH) (YEAR) reflected the resident received OT from 6/14/17-7/11/17. Review of a form titled, Restorative Schedule, showed resident #34 was on the list to receive restorative care, with the days of the week blank, showing nothing was documented. 2. During an interview and observation on 12/7/17 at 11:37 a.m., resident #49 stated she had impaired ROM, due to arthritis, in her right hand. Resident #49 stated the impaired mobility interfere with her performance of some of the tasks of daily living. She held up her right hand and demonstrated that she did not have full ROM. Resident #49 stated she had been receiving therapy to her right arm and hand, but the therapy had recently ended. She said she was told by the therapist that she would be receiving restorative services, but none had been provided. Review of resident #49's Occupational Therapy Discharge Summary showed discharge instructions for a restorative nursing program. No evidence was found that the resident received the restorative services recommended on the Occupational Therapy Discharge Summary. During an interview and record review on 12/7/17 at 11:45 a.m., staff member P provided a copy of resident #49's Restorative Plan, dated 12/1/17. The copy was made from a document kept in the therapy office and was not available to the nursing staff. No copy was found in the book used by the restorative aides. The plan showed three program recommendations which were not provided for the resident. 3. During an interview on 12/5/17 at 1:27 p.m., resident #14 said she was concerned she would become weaker without restorative care. She said she may get more physical therapy in the future to help with strengthening. She had heard the facility was hiring more staff to help with providing physical therapy care to the residents. Resident #14 said she could get up from her recliner, to her walker, from a seated position. She could ambulate to and from the bathroom, and transfer to the toilet by herself. She said she needed assistance with pericare. Resident #14 said she used to walk more often in the hallways when she had more assistance available. She said now she infrequently walks in the halls. Review of resident #14's PT - Therapist Progress & Discharge Summary, dated 11/6/17, showed discharge instructions of, PT to d/c to restorative nursing program with goal to continue ambulation and strengthening consistently. Review of resident #14's Resident Restorative Plan, dated 11/8/17, showed she would receive care for, Ambulation as able rolling walker - CGA - w/c follow (sic), and There ex - please focus on ambulation as pt works on her exercises on her own as well. Otherwise- general LE there ex. (sic). Review of resident #14's care plan lacked evidence restorative services were planned or implemented. During an interview and request for information, on 12/6/17 at 4:25 p.m., staff member B said the facility did not have documentation of services following the PT/OT discharge and recommendation that restorative care be provided for resident #14. She said the facility recently did not have a restorative aide. She said the facility had identified the problem and had been working to put restorative services back in place. Staff member B said restorative services had not been provided to the residents for a while, and she did not know for certain how long that had been, since she had only been at the facility since the end of November. 4. Resident #52 was admitted [DATE] with a [DIAGNOSES REDACTED]. During an observation on 12/4/17 at 2:47 p.m., resident #52 was in a wheel chair, in the Gold Rush day room. The resident was leaning over the right side of the wheel chair. The resident's head hung to the right, against the shoulder, and almost touching the arm of the wheel chair. The resident's right hand was contracted and resting against her stomach. During an observation on 12/6/17 at 11:21 a.m., resident #52 was in the Gold Rush day room. The resident was sleeping in a wheel chair. The resident's head was hanging down, and against the right shoulder. The resident's right hand was contracted, facing up on the lower part of her abdomen. The resident had no hand splint on the contracted hand and no type of head rest. The right arm of the wheel chair had a cushioned, arm rest. The cushioned arm rest had worked up and off the back of the wheel chair arm. Neither the resident's arm nor head did rested on the cushioned arm rest. Review of resident #52's progress note, dated 5/18/17, and labeled significant change, showed resident #52 had been discharged from hospice, and would be working with PT/OT/ST. During an interview on 12/6/17 at 3:21 p.m., staff member W stated she had worked with resident #52 in (MONTH) (YEAR). She was to assess the resident's right hand as she had bad contractures. Because of the pain the resident had not been wearing a brace. Recently, the staff member was working with the resident to find a splint which would dry the moisture in the contracted hand, which did not cause pain to the resident. The staff member stated the facility policy directed therapies would assess, treat, and then make plans for restorative services. The staff member stated she had not followed up on the progress of resident #52 as the restorative program was a nursing responsibility. The staff member stated she had not worked with the resident, prior to (MONTH) (YEAR), due to to the resident being on hospice. Review of resident #52's care plan showed the care plan had not been updated since 5/18/17. No documentation was available showing the resident had an updated care plan since being discharged from hospice. The resident's care plan did not show what the resident's updated focus, goals, and interventions, were. Review of OT Daily Treatment notes, with a start of care date of 11/22/17, showed the reason for the treatment as contracture of the right hand. During an interview on 12/6/17 at 10:40 a.m., NF1 stated the facility had waited for the okay from insurance for resident #52 to receive therapies. He stated the resident used to lean to the side, so therapies had placed the right arm pad. Recently, the arm pad really was not as useful as it had been. He stated OT had worked with the resident recently to try a hand brace on her right hand. He and a CNA had put the brace on but the resident took it off later, saying it hurt. He was unaware of restorative staff working with the resident. During an interview on 12/6/17 at 11:10 a.m., staff member K stated resident #52's husband had placed the brace on the resident's right hand but the resident took it off. The staff member stated the resident did not have range of motion exercises completed by the restorative aides. During an interview on 12/5/17 at 3:29 p.m., staff member M stated that resident #52 would be a good candidate for the current restorative program. 5. During an observation on 12/7/17 at 10:56 a.m., resident #37 stated he wanted to walk. He said he was supposed to walk two times a day, and he had not being assisted to do that. Staff member F stated to the resident he could walk to and from lunch, if she had time. The resident was worried about walking an adequate distance. Review of resident #37's occupational therapy plan of care, with a start of care dated 9/8/17, and end of care dated 10/26/17, showed that OT was to see the resident 12 times in four weeks. From 10/26/17 through 11/22/17, resident #37 received no skilled or restorative services for ambulation. Review of resident #37's Resident Restorative Plan, dated 11/8/17 showed the resident program recommendations were for ambulation, using a front wheeled walker and in a lower extremity strengthening program with use of weights and bands if able. Goals were to maintain or improve his ambulatory status and maintain strength. The plan was signed by a physical therapist. During an interview on 12/7/17 at 11:00 am, staff member F stated she had started restorative a month ago. She said if she was unable to get her restorative work completed, during a shift, she would sometimes stay and complete it after 2:00 p.m., when the shift ended. The staff member stated it depended on CNA staffing if she could work with restorative program residents. I am suppose to be restorative, but like today, a no show (staff did not arrive to work as scheduled), so I need to be on floor (working). If short (low on staff), I don't always get restorative completed. 6. During an interview on 12/4/17 at 2:29 p.m., resident #8 stated she should be receiving the restorative program for strengthening her legs. The resident stated she did not always receive restorative and that was due to the CNAs being short staffed. Review of resident #8's Resident Restorative Plan, dated 11/8/17, showed the resident program recommendations were for ambulation, using the rolling walker and in a lower extremity strengthening program. Goals were to maintain or improve her ambulatory status. The plan was signed by a physical therapist. During an interview on 12/4/17 at 10:15 a.m., staff member B stated the restorative program had not been up and running prior to her recently coming to the facility. The staff member stated she was working on getting the program up and running. The staff member stated there was no one overseeing the restorative program before. During an interview on 12/5/17 at 3:15 p.m., staff member B stated the facility had started following the facility's restorative policy and procedure. The staff member stated administrative staff had identified a problem with restorative programming around 11/22/17. The staff member stated they took the restorative concern to QAPI on 11/27/17 at 12:00 p.m. There, they overhauled the restorative program. The staff member stated the facility had not been doing restorative for about a year. There was a schedule for the restorative program, but it was very inconsistent as the restorative aide had been working on the floor as a CN[NAME] The staff member stated restorative staff would meet 12/11/17 for the first time since the new program was implemented. The physical therapy department would continue to assess and make changes to the list of residents requiring services. During an interview on 12/5/17 at 3:29 p.m., staff member M stated the facility had not had a functioning restorative program for about a year. The staff member stated a program had just been developed. The staff member provided a Restorative Schedule with resident names. The staff member stated physical therapy was reassessing residents from the Restorative Schedule. During an interview on 12/5/17 at 3:40 p.m staff member M stated she had designed the restorative schedule page, but there was no documentation showing residents were attending restorative. During an interview on 12/6/17 at 11:25 a.m., staff member P stated he would receive physician orders [REDACTED]. Once completed, he recommended restorative services for the resident. The staff member stated he did not follow up with the resident once he recommended to the restorative program as the program was a nursing program. The staff member stated there wasn't much of a restorative program. The last DON oversaw the program but had heard from the residents that the restorative program wasn't working with them and that they missed opportunities to work with restorative staff. The staff member stated he was looking forward to the restorative program to get up and running. Review of resident #52's care plan, with a review date of 5/18/17 showed a focus of the resident having contractures of the neck, back, hip, and right arm. Interventions included PT/OT for improved mobility. A more current care plan was not available. The care plan showed no evidence that resident #52 was in a continuous, ongoing, or individualized restorative program, since she had been admitted . During an interview on 12/7/17 at 8:21 a.m., staff member A stated that as far as he knew, the restorative program was currently available. The staff member reviewed the staffing schedule and stated all restorative staff were off. Review of the Restorative Nursing Program facility policy, with a revision date of 1/14/14, showed the program was to be nursing interventions that promoted the resident's ability to adapt and adjust to living as independently and safely as possible. The policy showed that when a resident was discharged from formalized physical, occupational, or speech therapy, the therapist would evaluate the resident for restorative services. Each resident would be evaluated for restorative needs upon admission, at the time of an annual assessment, or when a significant change in function occurred. The restorative program would be supervised by the licensed nursing personnel. Each resident participating in the program would have an individualized program with individualized goals. Documentation of the resident's progress would be assessed and documented quarterly by the manager, in the progress notes. No documentation was found showing residents were continually working with restorative staff or receiving restorative services, for the past eight plus months 7. Resident #11 was discharged from physical and occupational therapy on 11/11/17. Review of resident #11's discharge summary from occupational therapy, dated 11/11/17, showed the resident was to start restorative nursing. Review of resident #11's MDS discharge summary, with an ARD of 11/27/17, showed resident #11 had not received restorative nursing. During an interview on 12/5/17 at 2:58 p.m., staff member B said the restorative nursing program had been identified as a problem during the facility's mock survey. Staff member B said they were working on getting the restorative program back up and running. During an interview on 12/6/17 at 4:11 p.m., resident #11 said no one from the facility had talked to her about starting a restorative nursing program. Resident #11 said she would like to have restorative nursing so she would not lose all the gains she had made in therapy.",2020-09-01
374,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2017-12-11,690,G,0,1,P6JV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to adequately assess a Foley catheter for 1 (#11) resident, who had not received adequate pericare, and who was found to have a urinary tract infection, of 17 sampled residents. Findings include: Resident #11 was admitted to the facility with a Foley catheter in place. During an interview on 12/6/17 at 11:10 a.m., resident #11 said she knew she was getting a UTI again, before she went to the hospital this last time. Resident #11 said she asked a nurse to check out her vaginal area and the catheter placement. The nurse told her she had dried feces crusted around the catheter where it was going into her bladder. Resident #11 said she thought staff member B was the nurse who had examined her. Resident #11 said she was not surprised to have another UTI because the CNAs wipe her from back to front most of the time. Review of resident #11's physician's history and physical from a hospital, dated 9/6/17, showed resident #11 had a Foley catheter placed (MONTH) of (YEAR) due to her non-weight bearing status. The history and physical also showed the resident had no history of [MEDICAL CONDITION] bladder, retention, or other issues. Review of resident #11's physician discharge summary from a hospital, dated 9/13/17, showed resident #11 had a right ankle fracture in (MONTH) of (YEAR), and was treated with an ORIF by an orthopaedic surgeon. Resident #11 had the surgical hardware removed in (MONTH) of (YEAR), by an orthopaedic surgeon. The note showed resident #11 was to be minimal weight-bearing on her right leg. The note showed resident #11 resided in a skilled nursing facility because of her minimal weight-bearing status, and that problem is what necessitated her indwelling Foley catheter. Review of resident #11's physician history and physical from a hospital, dated 11/27/17, showed resident #11 had a chronic indwelling Foley catheter. The history and physical also showed, The patient has a history of recurrent urinary tract infections and has recently been on [MEDICATION NAME]. Most recent organisms grown were from 11/16/17, Klebiella pneumoniae resistant to [MEDICATION NAME] and Escherichia coli resistant to [MEDICATION NAME], sulbactam, [MEDICATION NAME], intermediate to [MEDICATION NAME] and [MEDICATION NAME]; both were ESBL negative. The patient has grown same organisms in (MONTH) (YEAR) and E. coli in (MONTH) (YEAR). She has had urine cultures demonstrated to be negative. Review of a physician's history and physical from a hospital, dated 11/27/17, showed under Assessment and Plan; 4. Urinary tract infection, not altogether clear why the patient needs ongoing Foley catheter drainage. This may be something to look at over time. She will be treated with IV [MEDICATION NAME] as opposed to previously selected third generation cephalosporin and the reason this is being done as it is an agent that is less likely to induce broad spectrum cephalosporins when compared to [MEDICATION NAME]. The patient's [MEDICATION NAME] will be stopped. It is not likely that [MEDICATION NAME] is going to have any effect on preventing urinary tract infections, and in fact, the only way to prevent UTIs in somebody with an indwelling Foley catheter is to remove it. During an interview on 12/6/17 at 1:39 p.m., staff member B said the facility had not done an assessment for resident #11's Foley catheter. A record review showed Resident #11 had a Bladder and Bowel Assessment Combined (YEAR) in her EHR, and the assessment was dated 5/17/17, but was not completed. Review of resident #11's care plan showed in her focus area for her catheter I have a history of UTI's (sic) and am susceptible to same. A request for information was submitted to the facility on [DATE] at 7:34 a.m., which included, the resident's physician orders, diagnosis, and an assessment for resident #11's Foley catheter. The facility did provide a physician's orders [REDACTED]. The medical record had not contained this information prior to this. The facility provided a copy of another physician's orders [REDACTED].",2020-09-01
375,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2017-12-11,697,G,0,1,P6JV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility nursing staff failed to assess and manage a resident's pain, and proceeded with the provision of care when the resident voiced pain, was guarding, wincing, and showing other indicators of pain, to include calling out and in pain, during the care, for 1 (#417) of 17 sampled residents. Findings include: During an observation and interview on 12/6/17 at 12:27 p.m., staff member I positioned resident #417 for a treatment. She lowered the head of resident #417's bed and he winced and said, Ow. Staff member I proceeded to lift resident #417's right leg with one hand under his upper leg and one under his lower leg. Resident #417 called out in pain, grimaced, and guarded the hip area. Staff member I stated, can you hear that cracking in his hip? She proceeded to reposition the resident by abducting the right hip, and placing a pillow under his right leg. Throughout the process, the resident intermittently called out, Ow, grimaced, winced, and guarded the right hip by drawing it in, as staff member I attempted to abduct it. Staff member I completed a treatment to the resident's penis, skin folds, and scrotum. He continued to call out and display nonverbal pain indicators. After the treatment, staff member I attempted to reposition resident #417 again in preparation for the sacral wound care and dressing change. Resident #417 called out, and grimaced, and verbalized he had pain to his right hip, tailbone, and wound area. Staff member I continued to attempt repositioning, and resident #417 withdrew his right leg, and called out, that hurts. Staff member I did not ask resident #417 what level of pain he was experiencing. She did not ask him if he needed pain medication. She stated resident #417 received scheduled [MEDICATION NAME] twice a day and she did not know when he received his last dose of pain medication. Resident #417 stated he might have had a pain pill at 12:00 (noon), but was still hurting a lot. At this point in the observation, 12:50 p.m., the surveyor asked the nurse if she would like to stop, assess resident #417's pain, provide appropriate treatment, and continue the wound care later. Staff member I stated she would. Staff member I told resident #417 she would check to see if he could have a pain pill. After a few minutes, staff member I returned with staff member [NAME] Staff member J stated resident #417 had his scheduled pain medication at 10:18 a.m., and she would give him his prn [MEDICATION NAME] (pain medication). Staff member J gave the pain medication at 12:57 p.m. Staff member J stated the staff would give the prn pain medication more frequently, within the parameters of the order. Review of resident #417's MAR for 12/6/17 showed the [MEDICATION NAME] was given at 12:30 p.m. and the results of the effectiveness were unknown. During an observation on 12/6/17 at 4:47 p.m., staff member I stated, to resident #417, she was going to do the wound care and dressing change. Resident #417 stated he had a lot of pain to his wound area. Staff member I stated NF8 would be in to see the resident tomorrow and would address his pain. Resident #417 stated he had a lot of pain. Staff member I asked resident #417 if he wanted to wait until tomorrow to have his dressing changed, and he said yes. During an interview and record review on 12/6/17 at 4:53 p.m., staff member B stated comfort was the priority for resident #417. She stated she had spoken to NF8 regarding the resident's pain and the instruction was to continue the scheduled pain medications and to offer the prn pain medication as ordered. Staff member B provided a progress note showing the information regarding the conversation she had with NF8. Review of resident #417's (MONTH) (YEAR) MAR indicated [REDACTED]. The MAR indicated [REDACTED] -12/6/17 at 4:28 p.m., for a pain level of 9. Results showed as effective. -12/7/17 at 7:53 a.m., for a pain level of 7. Results showed as unknown. -12/7/17 at 7:17 p.m., for a pain level of 7. Results showed as effective. -12/8/17 at 8:03 a.m., for a pain level of 9. Results showed as unknown. -12/9/17 at 10:48 p.m., for a pain level of 8. Results showed as effective. -12/10/17 at 3:08 a.m., for a pain level of 7. Results showed as effective. -12/10/17 at 1:02 p.m., for a pain level of 9. Results showed as ineffective. -12/11/17 at 12:44 a.m., for a pain level of 6. Results showed as effective. -12/11/17 at 6:40 a.m., for a pain level of 8. Results were not recorded at 8:20 a.m., the time of the record review. The MAR indicated [REDACTED]. Resident #417 received one dose on 12/10/17 at 10:08 a.m., for a pain level of 8. Results showed as ineffective. The MAR indicated [REDACTED]. One order showed the nurse was to complete a functional pain assessment and indicate functional pain score of 0-5. The second order showed the nurse was to monitor for pain and document yes if pain was monitored and no pain was observed or verbalized, or document no if pain was monitored and was observed or verbalized. The order showed directions to choose the code Other/See Nurse Notes and enter findings in appropriate progress note, including the pain level on a scale of 1-10. Review of resident #417's EHR showed no evidence resident #417's pain was monitored every four hours and prn pain medication was offered every four hours. Documentation of resident #417's pain was consistently rated 6-9 when it was documented, and there were gaps of 12 hours or more between doses of prn pain medication. During an observation on 12/11/17 at 8:27 a.m., staff member I and staff member R positioned resident #417 for a treatment, sacral wound care, and dressing change. Resident #417 winced and grimaced when his right leg was moved or head of his bed was lowered or raised. Staff member I stated resident #417 had a pain medication due at 10:00 a.m. and they would give it to him early, after the treatment, and sacral wound care and dressing change, were done. Staff member J was resident #417's nurse at the time, and she was in attendance in the room. As staff member I did the treatment, resident #417 winced, withdrew, and put his right hand in the air, and made a motion as if pushing staff member I away. Staff member I completed the treatment and stated the sacral wound care and dressing change would not be done at that time due to resident #417's pain. During an interview and record review on 12/11/17 at 9:30 a.m., staff member B stated the facility charted only by exception. She stated pain would be an exception that should be charted. Staff member B stated the pain monitor order, on the (MONTH) (YEAR) MAR, did not have the correct monitors to show if resident #417 had pain. She stated she had been correcting erroneously written orders but had focused on medication orders, and had not gotten to all the monitors. Staff member B stated there should be documentation if prn pain meds were offered and refused. She stated the signatures on the order to monitor pain every shift (twice a day), and the administration of prn pain medication, was the only evidence that resident #417 had been monitored for pain. There was no evidence in resident #417's record the provider had been contacted for further instruction regarding management of the resident's pain. Review of a facility policy titled, Pain Assessment and Management, revised (MONTH) (YEAR), showed, If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated.",2020-09-01
376,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2017-12-11,725,E,1,1,P6JV11,"> Based on observation, interview, and record review, the facility failed to provide adequate staffing to assist with resident care needs, in relation to, answering call lights in a timely manner for 1 (#11) to include several residents who attended the group meeting who voiced similar concerns relating to the call lights; and failed to offer restorative services for 2 (#s 37 and 49) of 17 sampled residents. The facility also failed to serve meals, snacks, and fluids, at the scheduled time, which had the potential to affect any resident receiving meals, snacks, or fluids at the facility. Findings include: Call Light Response 1. Resident #11 was admitted to the facility with non-weight bearing status due to an ankle fracture. During an interview on 12/06/17 at 11:10 a.m., resident #11 said direct care staff would come in to her room, shut off her call light, tell resident #11 they had other residents to take care of first and they would be back. Resident #11 said the staff did not come back, and she had to put on her call light again and wait for another staff to answer it. Resident #11 said she heard the CNAs in the hallway laughing and joking but when they came into her room, that's all gone. Resident #11 said she was a happy person, and she tried to keep a positive outlook on life, but things like that make it pretty obvious that staff don't want to help you. Resident #11 said she had recently self-transferred to the toilet, at least three times, because staff did not answer the call light. Resident #11 said she had pooped her pants, once, due to the delay of the staff answering her call light, and she refused to do that again. Resident #11 said it could take a half hour to 45 minutes for staff to answer a call light. Resident #11 said this happened mainly on the evening shift. 2. During a group interview on 12/05/17 10:57 a.m., four out of four residents stated staff answering call lights in a timely manner was a concern. One resident stated she had to wait 10-20 minutes for staff to answer her call light. The three others stated having to wait sometimes longer than 30 minutes for staff to answer their call lights. All residents stated staff took longer to answer their call lights in the evening. Restorative Nursing Program 1. During an interview and observation on 12/7/17 at 11:37 a.m., resident #49 held up her right hand and demonstrated that she did not have full ROM. Resident #49 stated she had been receiving therapy to her right arm and hand, but the therapy had recently ended. She said she was told by the therapist that she would be receiving restorative services, but none had been provided as yet. Review of resident #49's Occupational Therapy Discharge Summary showed discharge instructions for a restorative nursing program. No evidence was found that the resident was receiving the services recommended for restorative. During an interview and record review on 12/7/17 at 11:45 a.m., staff member P provided a copy of resident #49's Restorative Plan, dated 12/1/17. The copy was made from a document kept in the therapy office and was not available to the nursing staff. A copy of the plan was not available for the restorative aides, but it did include three program recommendations. 2. During an interview on 12/5/17 at 3:15 p.m., staff member B stated the facility had not been doing restorative for about a year. There was a schedule for the restorative program but it was very inconsistent as the restorative aide had been working on the floor as a CN[NAME] During an observation on 12/7/17 at 10:56 a.m., resident #37 told staff member F he wanted to walk. The resident stated he was supposed to walk two times a day. He said he had not been walking two times a day. The staff member stated she would walk him to lunch, if she had time. The resident was worried the distance he walked to the dining room would not be enough for what he needed. During an interview on 12/7/17 at 11:00 a.m., staff member F stated her ability to work as a restorative aide depended on the floor staffing numbers, and whether she worked as a restorative aide or a CN[NAME] I am suppose to be on restorative, but like today, a no show and so I needed to be on floor. If short, I don't always get to do the restorative program. I can usually get restorative done after 2:00 p.m., when day shift ends. Meal Times and Snacks 1. During an observation, on 12/4/17, the breakfast meal in the Gold Rush dining room started at 8:24 a.m During an interview on 12/4/17 at 8:24 a.m., NF5 stated breakfast meal service was to start at 8:00 a.m., but that usually didn't happen, as staff were either not ready (kitchen staff), or the CNAs were not ready. 2. During a group meeting on 12/5/17 at 11:00 a.m., three of four residents stated the staff never offered evening snacks to the residents. Review of a Grievance/Concern Report Form, dated 8/31/17, showed residents had reported that snacks and hydration rounds were not being performed in the facility. Snacks and water was available but not being offered. The form showed the residents reported this had been going on for the past few weeks. During an interview on 12/06/17 at 11:52 a.m., staff member NF2 stated dietary supplied evening snacks for the residents but that the CNAs were to pass them.",2020-09-01
377,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2017-12-11,755,D,0,1,P6JV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide ordered medications for 2 (#s 11 and 315) of 25 sampled and supplemental residents. Findings include: 1. During an observation and interview on 12/6/17 at 7:42 a.m., staff member O prepared medications for administration to resident #315. She stated the [MEDICATION NAME] 25 mg was not available and she would see if the medication had been ordered from the pharmacy. Resident #315 was given his other scheduled medications, but not the [MEDICATION NAME] 25 mg. Review of resident #315's physician's orders [REDACTED].>2. During an observation and interview on 12/6/17 at 8:19 a.m., staff member J prepared medication for administration to resident #11. She stated resident #11's [MEDICATION NAME] and [MEDICATION NAME] 6 mg were not available for administration, and she would order the [MEDICATION NAME] from the pharmacy. Staff member J stated the [MEDICATION NAME] was a stock item but the facility had not had the 6 mg dose for about a week. She stated she would notify the central supply office to obtain the needed dosage. Resident #11 was given her other scheduled medications, but not the [MEDICATION NAME] or [MEDICATION NAME]. Review of resident #11's physician's orders [REDACTED]. Review of resident #11's (MONTH) (YEAR) MAR indicated [REDACTED]. During an interview on 12/6/17 at 10:35 a.m., staff member stated that a nurse was assigned to check the medication cart weekly and reorder medications that had a low supply. She said when medications were ordered they were sent from a pharmacy out of state. Staff member B stated if the medications arrive after the scheduled administration time, the missed dose was given, if appropriate. She stated that medication administration had been identified as an area of concern and a corrective action plan had been developed. Review of the plan, dated 11/27/17 showed the need to educate licensed nurses, and audit medication and treatment administration documentation, but it did not address the availability of medications in the facility.",2020-09-01
378,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2017-12-11,756,E,0,1,P6JV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow the recommendations made by the pharmacy consultant after the monthly drug regimen review for 2 (#s 17 and 41) of 25 sampled and supplemental residents. Findings include: 1. Review of resident #41's (MONTH) (YEAR) drug regimen review recommendations, dated 11/8/17, showed the pharmacist had recommended a BMP and TSH (labs) be obtained due to potential adverse effects of resident #41's medications. Review of resident #41's paper chart, in the lab section, showed no results for the labs recommended. A written request was made, on 12/11/17, for the lab results or any evidence the physician had denied the request. The facility provided lab results, dated 12/1/17, for different labs tests. None of the results provided were for a TSH test. No evidence was provided that the physician had denied the pharmacy recommendation. During an interview on 12/6/17 at 4:50 p.m., staff member B stated the facility had recently started working on the most current drug regimen recommendations. She said she had identified the recommendations were not being completed by the prior DON. Staff member B stated she could not say how long the recommendations had not been done because she had been unable to locate the pharmacy reports. She said she had obtained copies of the reports and was following up to determine which recommendations still required follow-up. 2. Review of resident #17's Consultation Report, from the pharmacist to the physician, showed the pharmacist recommended an involuntary movements assessment for tardive dyskinesia be conducted. The same recommendation was made in the months of (MONTH) and (MONTH) of (YEAR). The pharmacist also recommended, for the medications [MEDICATION NAME] and [MEDICATION NAME], behavioral monitoring be initiated during the month of October, (YEAR), as there was no behavior monitoring documented in the resident's record. During an interview on 12/6/17 4:50 p.m., staff member B said she had just started working to address the pharmacy review recommendations for (MONTH) (2017), as she had just recently started as Interim DON. She could not speak to the follow ups for the drug regimen review done for the months of (MONTH) and (MONTH) (YEAR), and was unable to provide documentation that would suggest follow up actions were taken. She did not know for sure what the prior DON had done to address the pharmacist recommendations for (MONTH) and (MONTH) of (YEAR). Although she was working on the (MONTH) recommendations, she had not completed the follow up for resident #17.",2020-09-01
379,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2017-12-11,758,D,0,1,P6JV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to identify and monitor resident specific behaviors related to the use of anti-psychotic and [MEDICAL CONDITION] medications for 1 (#23) of 17 sampled residents. Findings include: A review of resident #23's clinical record showed he had [DIAGNOSES REDACTED]. For these diagnoses, he was administered [MEDICATION NAME] 3 mg bid, [MEDICATION NAME] 1 mg q 4 prn for anxiety, and Trazadone 50 mg for depression. A review of resident #23's Consultation Report from the pharmacist to the physician, dated 10/16/17, showed the [MEDICATION NAME] was not to be decreased or discontinued due to the behavior of aggression. During an interview on 12/5/17 at 5:00 p.m., staff member B said for behavior monitoring, The CNAs just indicated if they observed a behavior. She said the CNAs did not indicate what the specific behavior was that had been witnessed, and did not write narrative documentation regarding the behavior. The CNAs would indicate if a behavior (in general) had been witnessed. The CNAs then reported the behavior to the nurse. The nurse then documented the behavior in a narrative Progress Note. Staff member B said when she became the interim DON, she changed the documentation parameters in the electronic records software. She said the parameters had to be changed because the nurses could not comply with the instructions provided by the software program. The program required the nurse to document and indicate Y when they had monitored behaviors and had not seen any aberrant behaviors, or to check N when the behaviors were observed. Prior to the change in the parameters of the software program, the nurses could have only place a check mark by behaviors, and would not have been able to indicate if behaviors had been witnessed, only that they had been monitored. She said that now the software program would lead the nurse to a narrative note, if the monitoring indicated there had been a witnessed behavior. Review of resident #23's MAR, showed on 11/27/17 the parameters of the behavior documentation were changed. A review of resident #23's CNA documentation for the dates of 9/19/17 through 12/5/17, showed there were eight entries' where the CNAs documented they had witnessed an unusual behavior from resident #23. The questions asked were not individualized to the resident, but rather global, and included: Does the resident: Seem different; talk or communicate less; overall needs more help; participated in activities less; ate less (appetite); drank less; has a weight change; is agitated or more nervous; tired, weak, confused, delirious or drowsy; has a change in skin color or condition (ulcers, significant skin tear, rashes); needs more help with walking, transferring or toileting; than usual. IF THESE OR ANY CHANGES ARE NOTED, TELL THE NURSE. The behaviors were not specific to resident #17's behaviors. A review of the corresponding dates in the nursing Progress Notes, did not include evidence the nurses had been notified of the behaviors, and the nurses did not document regarding reported behaviors. A review of resident #23's nursing Progress Notes between 9/19/17 and 12/5/17 showed resident #23 had fallen, or placed himself on the floor, on several occasions. During these occasions resident #23 would appear to be unarousable until a sternal rub was applied. Resident #23 would generally be sent to the ER for an evaluation after an event. The nursing Progress Notes lacked evidence of resident #23 being aggressive. During an interview on 12/5/17 at 5:00 p.m., staff member B said she did not know what the identified specific behaviors were that were being monitored for resident #23, how the goals were to be measured, or what identified interventions were in place. A review resident #23's Care Plan showed that specific behaviors to be monitored had been added on 12/5/17, with a goal of My behaviors will decrease. The care plan did not describe how the behaviors would be measured. A tele-psych eval was also added to the Care Plan for resident #23.",2020-09-01
380,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2017-12-11,761,E,0,1,P6JV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to label a time sensitive medication with the opening date for 2 (#s 32 and 417) of 25 sampled and supplemental residents. The facility also failed to store urine specimens away from medications. Findings include: Insulin Observations 1. During an observation and interview on 12/6/17 at 8:35, a [MEDICATION NAME] (insulin) pen, labeled with the name of resident #32 showed no open date on the pen or the packaging. Staff member O stated the date was not there. She stated she did not look for the date prior to administering. She stated insulin may be kept for 28 days after opening, and then should be discarded. 2. During an observation and interview on 12/7/17 at 1:56 p.m., a [MEDICATION NAME] (insulin), labeled with the name of resident #417, showed no open date on the pen or packaging. Staff member H stated the [MEDICATION NAME] was used and should have been dated when first used (opened). She stated the insulin was supposed to be discarded 28 days after opening. Review of a facility policy, titled, medications: [REDACTED]. The policy showed the solutions were to be dated when opened. Medication Room 3. During an observation of the medication room on 12/6/17 at 7:05 a.m., the locked refrigerator that held insulins, liquid [MEDICATION NAME] and other medications, also had a urine specimen stored between two boxed medications. During an interview on 12/6/17 at 7:05 a.m., staff member S stated that specimens should not be in the refrigerator with the medications. Staff member B entered the medication room to visually check where the specimen was placed in the refrigerator. Staff member B also said, on her way out the door, that it could have had a costly outcome.",2020-09-01
381,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2017-12-11,801,F,0,1,P6JV11,"Based on interview and observation, the facility failed to ensure the dietary manager completed a certification program approved by a national certifying body; or had an associate's or higher degree in food service management or in hospitality from an accredited institution of higher learning. Findings include: During the kitchen observation, on 12/5/17 starting at 3:06 p.m., concerns with kitchen staff practices, staffing, and poor sanitary conditions were identified in the kitchen (See F802 and F812 for more information). During an interview on 12/06/17 at 3:31 p.m., NF2 said he had not taken part in a ServSafe training course. The course focused on training of food service employees in required sanitary practices in food service management establishments, including health care facilities. During an interview on 12/7/17 at 10:40 a.m., staff member NF2 stated he was granted a promotion on 8/28/17 to be the dietary manager in the facility. He stated he was not a certified dietary manager, but his employer was planning on having him complete a program for a certified dietary manager. He stated previous to this position he worked as a kitchen staff member. During an interview on 12/7/17 at 10:45 a.m., staff member NF3 stated they were waiting for the consulting RD to sign off on the preceptor agreement. A signed copy of the preceptor agreement was provided on 12/7/17 and it was dated 12/7/17. During an interview on 12/7/17 11:10 a.m., staff member D stated he would have to check with the corporate headquarters to get the clarification on this issue. Staff member D stated he felt that they met the expectation by receiving the services of the consulting RD once weekly instead of once monthly.",2020-09-01
382,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2017-12-11,802,E,0,1,P6JV11,"Based on observation and interview, the facility failed to ensure dietary services were adequately staffed. The facility also failed to ensure an adequate program was in place for identifying resident food preferences, and ensure these preferences were granted, as able, which had the potential to affect any resident who had specific preferences relating to food. Findings include: 1. During an interview on 12/05/17 at 3:41 p.m., both staff members NF2 and NF4 stated they were short staffed in the kitchen. Staff member NF2 stated they were short three staff members that day. Staff member NF4 stated they were so short that the current staff did not have time to clean (See F812 for more information). During an interview on 12/7/17 9:16 a.m., staff member NF4 stated to ask the dietary manager for staffing. She stated three people quit and there were no replacements yet for them. During an interview on 12/7/17 10:40 a.m., staff member NF2 stated they were short staffed by three persons, compared to the past. This had occurred since a new company took over the management of the kitchen and the kitchen staff. He stated total of five staff had quit their jobs. He stated since the new company took over they had one cook and one DA in the morning; and one cook at night. He said they had the 8-4 DA shift which would not change. He said the new company took over mid (MONTH) this year. He stated he had two DAs in the morning and two DAs in the evening, prior to the new company. He stated they had two dining rooms, 68 residents. He stated they had to transport all of the food, the steam table, and the dishes, downstairs, with each meal. During an interview on 12/7/17 at 11:30 a.m., staff member NF9 stated she thought 2-3 staff worked for the morning shift, or four staff, plus the DM, but she was not sure. She said staff member NF2 and staff member A were responsible for kitchen staffing. She stated she was not aware that the kitchen was short staffed. She stated she had not completed the kitchen inspection for (MONTH) (YEAR). She said she was told about the dirty kitchen. She stated she provided the copy of her inspections to the dietary manager and the administrator monthly. 2. During an observation on 12/4/17 the breakfast meal in the Gold Rush dining room started at 8:24 a.m. During an interview on 12/4/17 at 8:24 a.m., NF5 stated breakfast meal service was to start at 8:00 a.m., but that usually didn't happen as either the kitchen staff were not ready, or the CNAs were not ready, for the meal. During an interview on 12/6/17 at 11:52 a.m. staff member NF2 stated the dietary department was short of staff, related to the staff quitting their positions.",2020-09-01
383,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2017-12-11,806,E,0,1,P6JV11,"Based on interview and observation, the facility failed to offer choices and honor preferences for meals for 1 (#37) of 17 sampled residents. Findings include: During an observation, on 12/6/17 at 9:25 a.m., resident #37 wheeled himself to the steam table outside the Gold Rush dining room. The resident was angry as he yelled to the staff serving meals. The resident wanted pancakes, bacon, and scrambled eggs. He stated he couldn't eat fried eggs or corn muffins. Staff members R and NF5 both stated there were no substitutions. The resident yelled that he always received the same breakfast and why not today. Staff member NF5 stated the facility had a new company in the kitchen, and they were not to serve anything but what was on the menu. There were not substitutions. During an interview on 12/6/17 at 11:52 a.m., staff member NF2 stated a new computer system, for meals, was in place since the middle of November. When the residents names, diets, and preferences were added into the program, the program didn't switch the residents' preferences. The staff member stated he was unable to get the residents' preferences into the system as the dietary department had a shortage of staff related to staff quitting. The staff member stated resident #37 would receive his preference for breakfast from then on.",2020-09-01
384,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2017-12-11,812,E,0,1,P6JV11,"Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the kitchen and in other food and beverage service areas. This deficiency had the potential to affect all residents who received food from the kitchen or food and beverage service areas. Findings include: 1. During an observation on 12/5/17 starting at 3:01 p.m., the floor, in the coffee machine room located in the downstairs dining room, had a heavy accumulation of black colored film/matter along the edges of the baseboards, the door jams on both sides, and the door threshold. There was a dark colored stain on the floor under the heat register that measured approximately 3 inches by 12 inches in size. One could scrape off the film type matter in these described areas with a tip of a pen or a nail. Debris was embedded in the black matter in these described areas, showing the areas had not been cleaned and maintained in a sanitary manner. Some of the walls in the room had splash marks from beverages, which caused staining, and the walls were not cleaned. 2. During the observation on 12/5/17 at 3:04 p.m., the upstairs ice machine room floor had a heavy accumulation of black colored dirt, debris, and stains, along the baseboards and behind the ice machine. 3. During the observations on 12/5/17 at 3:09 p.m. ,in the main kitchen, the following concerns were documented in the company of staff member NF3: - The dish room floor had a heavy accumulation of dirt and debris under the dish counter and the dish machine, along the baseboards (hard to reach areas), on both dirty and clean sides of the room. The grout between the tiles in the dish room were blackened and the dirt could be scraped off with a tip of pen. The base board, measuring approximately 2 to 2.5 feet, was separated from the wall under the dirty dish counter. Staff member NF3 stated they were in the process of developing cleaning schedules and currently there was not one for review. He stated the damaged baseboard would be repaired. - The legs of the dish counters had dried food splatter which had not been cleaned, and stains. - The walls and pipes under the dish room counters were soiled and stained. - The dish machine was had a layer of food debris and hard water build up which had not been cleaned. - The surfaces of the range top burners were covered in burned food and splattered with other food debris. The surfaces, and the handle of the oven, had dried food debris which had not been cleaned, and stains. The pipes and connections behind the range also had a build up of a black colored greasy substance on them, which had not been cleaned. - The knobs and exterior surfaces of the convection oven had a greasy substance and marks on them from lack of cleaning. The floor behind the cook's line, along with the baseboard, was covered with a black matter which could be scraped with a tip of a pen. The floor in this area also had dirt and debris which had collected in the area. - The kitchen staff could not locate the chemical strips for the testing of the sanitary solution for holding and rinsing the dish towels, and the cleaning of the kitchen, as needed. There was no sani-solution bucket set up for soaking kitchen towels when the towels were in between use. - The floor behind the reach in coolers was black in color, and observed to be soiled showing it had not been maintained in a sanitary manner. - The floor under the air gap (for the 3-sink compartment), measuring approximately 10 inches by 18 inches, was covered in black colored matter, that could be scraped off with a tip of a pen. The tiles were not visible due to the dirt cover. The air gap was covered with black matter. The grease trap was covered with dirt and dried stains. - The lids of all the baking bins were gritty and sticky to the touch, with crusty substance on them. - The baseboard was separated from the wall under behind the bleach containers near the 3-sink compartment, and it was filled with debris and dirt. - The floor space behind the reach in coolers were covered in a black matter, the tiles could not be seen. - A Ziploc bag of personal items and a newspaper of staff member NF4 were stored with canned soups and clean dishes in storage. Staff member NF4 announced the paper and the Ziploc bag belonged to her and removed them from the area. - The cooking pots, which were hanging, were facing up, creating the potential for dust collection inside them. - The hand wash sink, located in the storage room, was covered in dirt and stains and had black colored human hair. The base and edges of the faucet to this sink had crusty matter. - The surfaces to the handles of the reach in coolers had crusty food matter. - Two of the whipped cream topping containers, located in the reach-in cooler, were opened and the caps were missing, exposing the tips to the elements. The rubber gasket to the reach-in cooler was torn and separated, creating the potential for unsanitary conditions and ineffective cooling temperatures. - There was a water leak behind the Hobart mixer (drips from a pipe was visible with pooled water on the floor), the tile floor here was dirty and blackened in color. - The laminate, behind and under the coffee maker, located in the upstairs dining room, was damaged (separated from the wood splash board), and dirty. There was a large brown stain under the coffee maker. The floor behind counter was blackened in color. - The metal racks, above the tray of hamburgers, in the walk-in cooler, had dried red colored food matter. Other racks in the cooler had stains and dried food matter on them. Staff member NF3 stated these would be added to the cleaning schedule. - Staff member NF5 was listening to music and he was using ear-buds for hearing the music. When he was addressed by staff member NF3, he removed his left ear-bud. He then continued with his task of cleaning the meat slicer without washing his hands first. During an interview on 12/5/17 at 3:44 p.m., staff member NF3 stated the kitchen showed there was a long term cleaning concern for sanitation and cleanliness. He showed the new dietary policy and procedures, and the QAPI program binders, and stated all of the kitchen staff would be retrained. He also stated staff member NF5 would be instructed not to use ear buds (listening to music) during food preparation. During an interview on 12/06/17 at 3:31 p.m., NF2 said he had not taken part in a ServSafe training course. NF2 said none of his staff had taken part in a Servsafe training course. NF2 said he would like to receive this training for himself and for his staff. Review of the cleaning schedules, established on 12/7/17, showed the daily cleaning schedule was a list and it did not identify the responsible staff cleaning the specific areas in the kitchen. Review of the registered dietitian's monthly Food Safety and Sanitation Audits for June-October (YEAR) lacked review of the non-food contact areas and repair needs, i.e., walls, floors, surfaces of the equipment, tops of the equipment, hood filters, recipe books etc. The registered dietitian's monthly reviews lacked monthly monitoring and evaluation of the previous month's violations in the kitchen.",2020-09-01
385,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2017-12-11,849,D,0,1,P6JV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure effective care coordination with a hospice agency for 1 (#312) of 17 sampled residents. Findings include: Resident #312 was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. The EHR showed hospice was ordered on [DATE]. During an interview on 12/4/17 at 3:36 p.m., resident #312 stated he was receiving hospice services. He was not sure who came from (represented) the hospice agency and who was the facility staff were involved in his care. Review of resident #312's EHR and the paper chart showed a lack of care coordination with the delineation of care services between the facility and the hospice agency. Review of resident #312's EHR showed the facility's social service worker made an entry on 11/13/17, during the time of the resident's admission to the facility, but there were no other documentation as to the initiation of the end of life care. During an interview on 12/7/17 at 7:10 a.m., staff member B stated let me see what I can find when she was asked about the communication between the facility and the hospice agency for resident #312. At 8:40 a.m., staff member B looked at the resident's paper chart and stated she could not find anything, but she said she wanted to check with staff member U, because that staff member was supposed to copy the hospice documents. Staff member U stated there was nothing in the resident's chart and the hospice agency was notified. Staff member U stated the hospice agency promised to hand deliver the resident's visitation notes, the consents, and the hospice care plan. Staff member B stated I now confirm we don't have it about the lack of the evidence to show hospice care coordination. During an interview on 12/7/17 at 10:10 a.m., staff member NF7 stated resident #312 was admitted to Hospice on 11/28/17. NF7 stated she came to the facility previous to 11/28/17, but the resident refused hospice at the time. She stated the resident called them on the 28th and requested hospice services to be initiated. She stated that typically the orders were written in the patient's chart, and she faxed the consents and the plan of care to the facility. The physician's certification of the hospice services was not sent to the facility until the physician authorized the service. She stated she talked to the facility's social worker and the nurse who cared for the resident last week after a visit, but she said this was not a documented conversation. She stated she visited the resident three times during the first week, per the hospice P[NAME] and physician's orders [REDACTED]. She stated the resident also received one visit from the chaplain, one from the hospice aide and one visit from the MSW. She said the interdisciplinary group notes were also provided to the facility as those meetings took place. Review of resident #312's care plan showed the hospice plan was initiated on 12/6/17. The P[NAME] showed I am receiving Hospice care and I am in need a coordinated care efforts by the hospice and the nursing facility to assure all my care needs are met and the risks are addressed in a timely fashion. The P[NAME] lacked the delineation of the nursing and aide services between the two entities (the nursing facility and the hospice agency). During an interview on 12/4/17 at 3:40 p.m., the resident stated he had stomach pain, and [MEDICAL CONDITION]. He said sometimes he would not sleep for five nights. He said he had a poor appetite. He said he would like to smoke after 8:30 p.m., but he could not, because the doors were locked. He said not being able to smoke was worse because he could not sleep at night. Review of #312's facility care plan lacked the [MEDICAL CONDITION] and smoking issues as focus areas. The resident's EHR lacked the evidence to show coordinated care efforts between the facility and the hospice agency. On 12/07/17 at 9:50 a.m., copies of two electronic hospice nursing visit notes, a P[NAME] dated 11/28/17, and the copy of the hospice contract was provided. Review of the Hospice Certification and Plan of Care showed the resident had shortness of breath with minimal exertion, and hospice was to assure the caregivers' understanding of the symptom scale, how to manage symptoms, how to notify hospice when changes occurred, and the caregivers' understanding of a lack of appetite and dehydration in the dying patient. According to the hospice P[NAME], the hospice social worker had already visited the patient during the week of 11/28/17, however, there was no evidence in the medical record of the coordination efforts between the hospice MSW and the facility staff. Also, according to the hospice P[NAME], the hospice chaplain visited the resident during the week of 11/28/17, however the medical record lacked evidence of this visit. During an interview 12/7/17 at 11:07 a.m., staff member B stated This is definitely an issue. She stated it would be revisited with the agency and the facility staff involved.",2020-09-01
386,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2017-12-11,880,E,0,1,P6JV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain infection control parameters relating to catheter use, for 2 (#s 11 and 417) of 17 sampled residents. Findings include: 1. During an observation on 12/7/17 at 9:02 a.m., resident #11 was being pushed from the dining room by staff member T. Resident #11's catheter tubing was dragging on the floor. Staff member T pushed resident #11 through the foyer of the main entrance of the facility, past the nursing station, and down the hallway to the resident's room. Resident #11's catheter bag was attached to the side of her wheelchair by the left wheel. During an interview on 12/07/17 at 2:30 p.m., staff member T said resident #11's catheter tubing should not be dragged on the floor. Staff member T said she did not notice the tubing was dragging on the floor when she wheeled the resident back to her room after breakfast. Staff member T said the catheter bag should be in the middle, underneath the wheelchair. Staff member T said it should not be hanging from anywhere else on the wheelchair because there was a higher likelihood of the catheter tubing being drug on the floor. 2. a. During an observation and interview on 12/6/17 at 5:00 p.m., staff member L emptied resident #417's urinary drainage bag. She placed the graduate container directly on the floor next to the bed, without a barrier under the container. Staff member L opened the urinary drainage bag port, without cleansing the port with alcohol, and drained the urine into the container. She closed the port and disposed of the urine. She did not clean the drainage port with alcohol after draining the urine. Staff member L stated she was trained to use a barrier under a urine collection container, but did not do it because it is not an expectation in this facility. She stated she was trained to use an alcohol swab to clean the drainage bag port, but there were never any available in the rooms, so she did not do it. b. During an observation and interview on 12/11/17 at 8:27 a.m., staff member I prepared supplies to do a dressing change and treatment for [REDACTED]. She removed all the items from the resident's overbed table. There were visible crumbs and shiny, dried, rings which were left from a drinking glass, and other smears of an unknown substance on the table. Staff member I opened a sterile package and laid a barrier on the table. The barrier covered less than 25% of the table. She opened a sterile package that contained a sacral dressing which was approximately 7 x 7 inches. She laid the dressing on the portion of the table not covered by the barrier. She removed a pair of scissors from a basin on the resident's dresser. The basin contained a used package of disposable peri wipes, opened packages of gauze and unopened packages of dressing supplies. She laid the scissors on a portion of the table not covered by the barrier. After laying gauze pads on the barrier, she used the scissors to cut the sacral dressing. She did not clean the scissors prior to use. After completing a treatment for [REDACTED].#417's verbal and non-verbal signs of pain. As staff member I prepared to leave the room, she stated she did not clean the overbed table because there were no purple-top wipes (disinfectant wipes in a canister with a purple lid) in the room. She stated she did not clean the scissors because she had cleaned them prior to putting them in the basin, and did not think she needed to clean them after laying them on the uncleaned table. Staff member I said the sacral dressing was not on the barrier, but it still had the plastic attached that covered the adhesive. After making that statement, staff member I threw the sacral dressing in the trash can.",2020-09-01
387,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2016-12-14,202,E,0,1,FR2P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete, or had inadequately completed, documentation for the multidisciplinary discharge summary for resident's who were discharging from the facility, showing why the facility no longer met the resident's needs for 9 (#s 13, 16, 19, 20, 21, 22 ,23, 24, and 25) of 28 sampled and supplemental residents. Findings include: 1. A review of resident #19's medical record showed the resident was discharged to the hospital on [DATE]. The resident did not return to the facility from the hospital. Documentation for the resident's discharge summary was not evident in the medical record. During an interview on 12/14/16 at 1:35 p.m., staff member B stated the facility had not documented discharge summary information for resident #19. 2. A review of the medical record for resident #21 showed a lack of evidence for discharge summary information, relating to the resident's discharge on 11/12/16. During an interview on 12/14/16 at 1:38 p.m., staff member B stated the facility staff had a partially completed discharge summary only, for the resident. 3. A review of the medical record for resident #22 showed a lack of evidence relating to discharge summary information for the resident's discharge on 11/16/16. During an interview on 12/14/16 at 1:38 p.m., staff member B stated the facility had a partially completed discharge summary for resident #22. Staff member B said that none of the discharge summaries had been signed by the physician. During an interview on 12/14/16 at 12:50 p.m., staff member G said she provided a list of all discharged residents to the various departments and she would tell them a discharge summary would need to be completed for those residents. She stated she did not check the medical record to ensure the discharge summary had been completed. 4. A record review for resident #23 showed the resident was discharged to home on 11/17/16. A review of the resident's record showed a lack of evidence for a discharge summary relating to the resident's stay. During an interview on 12/14/16 at 9:00 a.m., staff member B stated she reviewed the resident's medical record and did not find documentation relating to a discharge summary. 5. A review of resident #25's medical record showed the resident was discharged on [DATE], to an acute care facility. The resident did not return to the facility. Further review of the resident's medical record, showed a lack of evidence for discharge summary information. During an interview on 12/14/16 at 9:00 a.m., staff member B stated she had reviewed the resident's record and found no documentation for a discharge summary. 6. A review of the medical record's for resident #'s 13, 16, 20, and 24, showed the following: - Resident #13 discharged the facility on 11/15/16. - Resident #16 discharged to home on 11/29/16. - Resident #20 discharged to home on 12/8/16. - Resident #24 discharged to home on 10/25/16. The medical records for resident #'s 13, 16, 20, and 24, showed a lack of evidence relating to discharge summary information. During an interview on 12/14/16 at 1:40 p.m., staff member B stated the facility did not have discharge summaries for resident #'s 13, 16, 20, and 24.",2020-09-01
388,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2016-12-14,226,D,0,1,FR2P11,"Based on interview and record review, the facility failed to obtain a completed background check on an employee hired prior to the employee providing direct patient care, for 1 of 5 new employees; and failed to educate and document the education for abuse prevention training for new employees, prior to allowing direct resident care, for 2 of 5 new employees hired by the facility. These failures had the potential to affect all 53 residents at the facility, relating to abuse. Findings include: 1. During a review of new hire employee records, it was found the employee file for staff member Q showed he was hired on 11/4/16. A review of the background screening results for staff member Q, showed background searches and the dates the searches were completed. Dates ranged between 11/2/16 and 11/8/16. No records were found to indicate a history of prior abuse for any of the searches completed. The background check was completed on 11/8/16. The record showed it had been viewed and printed on 11/9/16 at 1:38 p.m. During an interview on 12/13/16 at 11:20 a.m., staff member A stated staff member Q was hired on 11/4/16, and started working that same day with the residents at the facility. He stated staff member Q worked for three days, and did not return to work on the 4th day. He stated staff member Q did not contact the facility after that, and the employee/employer relationship on the last day of the month. 2. During a review of new hire employee records, they showed staff member Q was hired on 11/4/16. Documentation showed the dates staff member Q was to have received orientation training, which included the abuse training. The form had not been completed, and all entry areas for needed documentation were left blank. During an interview on 12/13/16 at 11:20 a.m., staff member A stated he was unable to substantiate whether or not abuse training had been received by staff member Q prior to his provision of direct care for the residents on 11/4/16. 3. During a review of new hire employee records, staff member R's employment file showed that she was hired on 10/5/16. The record showed staff member R's orientation training records were marked with checks for abuse, fire safety, and disaster preparedness, but the sections were not dated or signed to show the acknowledgement of the training, and that it had actually occurred. During an interview on 12/13/16 at 4:40 p.m., staff member B stated she could not find documentation of education on any abuse training received by staff member R, and provided documentation regarding this.",2020-09-01
389,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2016-12-14,279,D,0,1,FR2P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a comprehensive care plan for 1 (#9) out of 14 sampled residents. Findings include: Review of resident #9's Admission MDS showed the following CAAs were triggered: - 5. ADL function/rehab potential - 6. Urinary incontinence/CATH -11. Falls -14. Dehydration-fluid maintenance -16. Pressure ulcers -17. [MEDICAL CONDITION] drug use Review of resident #9's Care Plan showed only two focus areas: anticipated weight loss, and quality of life. During an interview on 12/12/16 at 11:15 a.m., staff member H and staff member D stated that they knew something had been forgotten. They did not have a reason why resident #9's Care Plan did not address the residents needs in the areas triggered by the resident's admission MDS.",2020-09-01
390,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2016-12-14,281,E,0,1,FR2P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to follow current standards of practice for the care and treatment of [REDACTED].#13); and failed to notify a physician when 2 residents (#s 26 & 27) had finger stick blood sugar levels, for their diabetes, that exceeded the doctors' ordered sliding scale, and did not provide the resident's insulin in a timely manner for the evening scheduled meals, out of 28 sampled and supplemental residents. Findings include: 1. A review of the facility's Physician Recapitulation orders from 11/4/16 for resident #13, showed a dysphagia advanced diet was ordered on admission (11/4/16). A review of the facility's Dietary Communication Form showed a regular dysphagia advanced diet was communicated by the nursing staff, to the food and nutrition department, three days after the resident's admission which was on 11/7/16. During an interview on 12/12/16 at 3:00 p.m. staff member [NAME] stated that nursing staff received the physician ordered diets and entered them into the electronic health record. The nursing staff then filled out a Dietary Communication Form and physically brought the form to the food and nutrition department, and left the form in a box. Staff member [NAME] then entered the diet into the dietary computer system, and the resident's diet was printed each day from the dietary computer system. Staff member [NAME] stated he had not received resident #13's correct Dietary Communication Form until 11/7/16. The facility failed to provide resident #13 with the correct physician ordered diet from 11/4/16-11/7/16. 2. A listing of resident #26's blood sugar reading for the evening meal was provided on 12/13/16. A review of the resident's evening blood sugar, insulin given, and the time of the evening meal on 12/13/16 was showing: -Blood sugar check: 439 at 6:05 p.m. -[MEDICATION NAME] (insulin) administered: 15 units at 6:10 p.m. -Evening meal provided at 6:44 p.m. The facility did not administer the resident's insulin within 15 minutes of the meal.4 Review of resident #26's MAR indicated [REDACTED] -blood sugar: 400 -1800: 10 units provided The nurse on duty documented the resident's blood sugar reading to be 400, when prior documentation provided to the surveyor for the blood sugar check showed the reading was 439. The facility failed to notify the physician for the reading of 439 to ensure further action was not needed to address the high blood sugar reading. Review of the resident's Weights and Vitals record for (MONTH) (YEAR), showed the resident's blood sugars were over 300 for the previous 12 blood sugar checks. Review of the physician ordered sliding scale for (MONTH) (YEAR), showed the following: [MEDICATION NAME] solution injection as per sliding scale if 151-200 = 2 units 201-250 = 4 units 251-300 = 6 units 301-350 = 8 units 351-400 = 10 units The physician's order failed to address what nursing staff should do when the resident's blood sugars were out of the ordered parameters, and the facility had not attempted to obtain orders to address the blood sugars which were out of the ordered parameters. 2. Review of the listing provided by the facility, for resident #27's evening blood sugar, insulin, and time of meal, on 12/13/16, showed the following: -Blood sugar: 515 at 5:45 p.m. -[MEDICATION NAME] administrated: 10 units at 5:50 p.m. -Evening meal provided at 6:45 p.m. (55 minutes after the resident received her insulin). The facility had not administered the resident's insulin within 15 minutes of the meal.4 Review of resident #27's MAR indicated [REDACTED]. A review of the resident's medical record showed a lack of evidence for whether or not the facility had notified the physician of the high blood sugar reading. Review of the resident's physician ordered sliding scale for (MONTH) (YEAR), showed: [MEDICATION NAME] solution inject as per sliding scale if 150-199 = 2 200-250 = 3 251-300 = 4 301-350 = 5 351-400 = 6 401-450 = 7 451-500 = 8 501-9999 = 10 subcutaneous four times a day The order failed to address what nursing staff should do when the resident's blood sugars were outside of the parameters ordered. During an observation on 12/13/16 at 6:43 p.m., resident #27 was sitting at the table. She stood and started to walk. Two CNA's ran over from across the dining room, and assisted the resident back into her chair. Resident #27 was newly admitted to the facility. The resident appeared to have advanced dementia. Review of resident #27's Weights and Vitals record for (MONTH) (YEAR), showed resident's blood sugars were greater than 300 for 9 out of 19 times. Review of the [MEDICAL CONDITION] policy, revised 7/2013, defined the onset of [MEDICAL CONDITION] as gradual. The policy showed the MD needed to be notified after standing orders for [MEDICAL CONDITION] were followed, and the resident did not respond. The policy failed to address specific parameters for when to contact the physician. During an interview on 12/14/16 at 11:00 a.m., staff member B stated there were no standing orders for [MEDICAL CONDITION]. She stated the nursing staff had been educated to use clinical judgment when blood sugars were out of range. She stated they were not educated to call the physician. During an interview on 12/14/16 at 1:00 p.m., staff member H and staff member K stated if a resident's blood sugar was greater than the physician ordered sliding scale, or greater than 400, they would call and notify the physician. During an interview on 12/14/16 at 1:15 p.m., staff member N stated if a resident's blood sugar was greater than the physician ordered sliding scale, or greater than 400, he would call and notify the physician. During an interview on 12/14/16 at 2:30 p.m., staff member B stated she did not expect the nursing staff to contact the physician's when the resident's are in a hyperglycemic state. During an interview on 12/19/16 at 4:19 p.m., staff member O stated it was the expectation that the nursing staff notify him when the resident's blood sugars are greater than 400, to determine if further action was necessary. References: As stated in The Art & Science of DSME by [NAME] Mensing, the following was noted: -Very high glucose levels are acute and serious and can evolve from chronic [MEDICAL CONDITION]. -Diabetic ketoacidosis occurs when there is so little insulin available to transport glucose into cells that glucose accumulates in the blood, raising levels to 250 mg/DL or greater. Diabetic ketoacidosis can evolve quickly (within 24 hours), causing dehydration and ketosis and electrolyte imbalance and acidosis. This condition requires immediate treatment. -Although the symptoms of poorly controlled diabetes may be present for several days, the metabolic alterations typical of ketoacidosis usually occur within a short time frame (typically less than 24 hours). Occasionally, DKA may develop more acutely with no prior signs or symptoms. Persistent [MEDICAL CONDITION] increases the risk of dehydration, electrolyte abnormalities, urinary incontinence, dizziness, falls, and hyperglycemic hyperosmolar syndrome. The 2012 ADA consensus report states that goals that minimize severe [MEDICAL CONDITION] are indicated for all patients. Thus, glycemic goals for patients in LTC are guided by preventing [DIAGNOSES REDACTED] while avoiding extreme [MEDICAL CONDITION]. Simplified treatment of [REDACTED]. M. M. (February (YEAR)). Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association. Diabetes Care, 39, 308-318 Call as soon as possible: b) glucose values greater than 250mg/dl within a 24-h period c) glucose values greater than 300mg/dl within 2 consecutive days d) when any reading is too high. Cefalu, W. T., MD (Ed.). (January (YEAR)). American Diabetes Association Standards of Medical Care in Diabetes-2017. The Journal of Clinical and Applied Research and Education, 40, 599-604. 4With [MEDICATION NAME], you must start eating within 5-10 minutes after injection. Turkoski, B. B., RN, PhD, Lance, B. R., RN, MSN, & Bonfiglio, M. F., BS, PharmD, RPh. (n.d.). Drug Information Handbook for Nursing (10th ed.). 2008: Lexi-Comp.",2020-09-01
391,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2016-12-14,309,E,0,1,FR2P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure there was an exchange of information between the [MEDICAL TREATMENT] clinic and the facility, pre and post treatment; and did not ensure ongoing resident monitoring and assessment after [MEDICAL TREATMENT] treatment and the resident's return to the facility, for 1 (#25) out of 2 residents requiring [MEDICAL TREATMENT]. The facility also failed to offer residents water at snack time; and at meal time failed to offer and pour water for those residents unable to pour the water on their own, or ask for the water. This had the potential to effect all residents in the facility who could not assist themselves or request assistance with the water for hydration. This failure affected 1 (#8) out of 28 sampled and supplemental residents. Findings include: 1. Resident #25 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. He had previously undergone a right [MEDICAL CONDITION]. A review of a Patient Visit Summary, dated 9/22/16, showed physician orders [REDACTED]. It showed to continue [MEDICAL TREATMENT] . A review of a facsimile cover sheet, dated 9/24/16, showed physician orders [REDACTED]. A review of resident #25's progress notes dated 11/2/16 to 12/8/16, did not provide any information as to any of the actual dates the resident received [MEDICAL TREATMENT] treatment. No information was given regarding the resident's transportation to the [MEDICAL TREATMENT] clinic, and whether he missed any scheduled treatments. No information was documented as to the patency of the resident's [MEDICAL TREATMENT] fistula. No information was documented indicating the resident was assessed upon his return to the facility after [MEDICAL TREATMENT] treatment. No documentation concerning the residents vital signs, pre and post treatment weights, and lab values post treatment, was found. During an interview on 12/12/16 at 3:30 p.m., staff member C stated the facility staff usually obtained a pre-[MEDICAL TREATMENT] resident weight and sent the results with the resident to the [MEDICAL TREATMENT] clinic. She stated that residents returning to the facility come back with a weight slip providing the resident's post [MEDICAL TREATMENT] weight, as completed by the [MEDICAL TREATMENT] clinic just prior to leaving the clinic. She reported that vital signs were not routinely obtained following a resident's return to the facility from [MEDICAL TREATMENT] procedures. The weights were completed according to the resident's usual weight schedule. Post [MEDICAL TREATMENT] vital signs, post [MEDICAL TREATMENT] lab results, fluid exchange volumes, and medications administered to the resident during [MEDICAL TREATMENT], were not provided by the [MEDICAL TREATMENT] clinic, and they were not being requested by the facility following the completed [MEDICAL TREATMENT] procedures. A review of a Telefax message, documented on 11/9/16 at 2:30 p.m., in resident #25's closed medical record, showed the physician following the resident at the [MEDICAL TREATMENT] center ordered the resident to be restricted to one liter of fluid intake per day. A review of resident #25's TARs for (MONTH) and (MONTH) (YEAR), showed, starting 11/9/16, staff members signed each shift acknowledging the resident was on fluid restrictions. Fluid intake volumes were not recorded on the TARs for evaluation. The TAR form boxes were blocked out. A review of resident #25's progress notes, dated 11/2/16 to 12/8/16. did not show an analysis of fluid volume consumption or mention of the resident's response to the fluid restriction. A review of resident #25's TAR for (MONTH) and (MONTH) of (YEAR) showed the resident was scheduled to receive two treatments as follows: a. Starting 11/9/16, the facility was ordered, per the resident's [MEDICAL TREATMENT] physician, to remove coban from the resident's ([MEDICAL TREATMENT]) fistula dressing every night shift after [MEDICAL TREATMENT] on Mondays, Wednesdays, and Fridays. Of the 13 Mondays, Wednesdays, and Fridays in (MONTH) and (MONTH) (YEAR), only 3 showed e-signatures on the resident's MARs indicating the coban was being removed from the resident's fistula, a per physician's orders [REDACTED]. b. Starting on 11/10/16, the facility was ordered, per the resident's [MEDICAL TREATMENT] physician, to remove the pressure dressing from the resident's ([MEDICAL TREATMENT]) fistula on the day following [MEDICAL TREATMENT] on Tuesdays, Thursdays, and Saturdays, for wound care. Of the 13 Tuesdays, Thursdays, and Saturdays in (MONTH) and (MONTH) (YEAR), 9 of the days showed e-signatures on the TAR indicating wound care was given per physician's orders [REDACTED]. During an interview on 12/14/16 at 9:00 a.m., staff member B was shown resident #25's TARs for (MONTH) and (MONTH) (YEAR). She stated she could not explain why the procedures were not completed as ordered. She said usually overview of the residents treatments was the responsibility of the facility's director of nursing. A review of the facility's policy, Care of Resident with End Stage [MEDICAL CONDITION], dated (MONTH) 2014, showed Residents with [MEDICAL CONDITIONS] will be cared for according to currently recognized standards of care. 2. During the following observations in the dining room, water was not poured or offered at meals to those residents (8-10 per meal) who were unable to request or pour water, including resident #8. -12/11/16: Lunch -12/12/16: Breakfast -12/12/16: Lunch -12/13/16: Dinner During an interview on 12/12/16 at 8:30 a.m., staff member [NAME] stated the nursing staff had not been passing snacks or water at 3 p.m. or 9:30 p.m. He stated the CNA's were responsible for pouring water from the water pitchers at meals. During an interview on 12/12/16 at 8:34 a.m., staff member P stated the CNA's were responsible for pouring water at meal time, but only poured water for residents when they asked for the water. Record review of resident #8's progress notes dated 12/16/16 showed the resident was on [MEDICATION NAME] for a UTI. Record review of resident #8's I and O's showed the resident averaged 532 mL per day over the past 11 days. Review of the recommended fluid needs from the facility's registered dietitian showed resident #8 needed 1200-1500mL of fluid per day. A review of facility signs, posted at the nursing station, showed snacks must be passed/offered at 3:30 p.m. and 9:00 p.m.; Fresh water must be passed/offered 3:30 p.m. and 9:00 p.m. The facility failed to offer water for over 24 hours. Staff member [NAME] stated they had just started to offer the 9:00 p.m. snack, and planned to start offering the 3:30 p.m. snack in the future. A review of the facility's Resident Hydration and Dehydration Prevention policy, last revised on (MONTH) 2014, showed: 4. The Dietitian will include resident preference in distribution of allowed fluid. 7. Nurses' Aides will provide and encourage intake of bedside, snack and meal fluids on a daily and routine basis as part of daily care. Water pass will be completed on each shift and as requested. Intake will be documented in the medical records, if ordered/recommended.",2020-09-01
392,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2016-12-14,371,E,0,1,FR2P11,"Based on observation, record review, and interview, the facility failed to ensure food was served and stored in a sanitary manner, and non-food contact surfaces were kept clean in the main kitchen. Cleaning schedules developed for the kitchen were not comprehensive, and did not include all of the areas that required regular cleaning. This deficiency had the potential to affect all residents receiving food from the kitchen. Findings included: During the following observations on 12/11/16 at 7:25 a.m. and 12/14/16 at 8:30 a.m., the following concerns were observed in the main kitchen: -The last temperatures recorded on the walk-in cooler and freezer were dated 12/7/16. There were no temperatures recorded for 12/8/16, 12/9/16, or 12/10/16. -In the dish room, sealant was present, which had a black substance build up, which was also on the walls above, and below the dishwasher. The substance was removable when touched or scraped with the finger. -There was a layer of dust that was sticky and removable to the touch on the top of the refrigerators. -The fan in the walk-in cooler was covered in dust and a fuzzy substance. -The fan in the dry storage room was covered in thick dust. Food was stored below the dusty fan. -Duct tape had been placed along the bottom of the walk-in freezer door, holding together a broken piece of the door at the base. This was an uncleanable surface. During the following interviews on 12/11/16 at 7:30 a.m., and 12/14/16 at 8:00 a.m., staff member L stated they obtained temperatures twice per day on the cooler and walk-in freezer. He had noticed that staff had not obtained the temperatures for the last couple days. Staff member L stated the kitchen was short on staff. He stated the black substance in the dish room, was deep cleaned eight months ago. During an interview on 12/14/16 at 9:24 a.m., staff [NAME] stated that he was aware of the black substance in the dish room. He stated that it was sprayed nightly with bleach, and deep cleaned every 3-4 months. He stated the kitchen cleaning was distributed throughout the job descriptions. The kitchen aides and cooks were responsible for certain daily cleaning tasks. Staff member [NAME] stated that he created deep cleaning list on a weekly basis, based on what he felt needed to be cleaned. This list was provided to a staff member on Sunday. The lists provided for review did not include a consistent schedule of all areas that required routine deep cleaning in the kitchen. Review of the cleaning lists provided from 11/27/16, 12/4/16, and 12/11/16, did not address the cleaning concerns for the dish room, the fans, and the top of the kitchen refrigerators. Review of the daily task assignment for the cooks and dietary aides had not addressed the dish room, the fans, or the top of the kitchen refrigerators. Review of temperature logs for the coolers or freezers in the kitchen did not show documentation of the temperatures obtained for: December (YEAR): -Roll-in Fridge: 8 missed times -Freezer: 8 missed times -Walk-in: 6 days missed -Reach-In: 8 missed times November (YEAR): -Roll-in Fridge: 10 missed times -Freezer: 8 missed times -Walk-in: 8 days missed -Reach-In: 10 missed times The documents for the temperatures obtained for the coolers and freezers were provided to the surveyor on 12/14/16. The following dates had been filled in: 12/8/16, 12/9/16, and 12/10/16. As stated above, these dates were blank during an observation on 12/11/16 at 8:30 a.m.",2020-09-01
393,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2016-12-14,431,E,0,1,FR2P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to correctly label a resident's medication with updated administration instructions to assure administration according to the resident's physician's orders [REDACTED]. This occurred with the potential result of repetitive significant medication administration errors and/or subsequent harm for one resident (#28) out of 28 sample and supplemental residents. Findings include: A review of the resident's medical record showed the resident had been in the facility since 11/25/16. During a medication pass observation for resident #28 on 12/12/16 at 8:05 a.m., staff member S poured and administered the resident's medications. The resident's MAR indicated [REDACTED]. The medication was scheduled to be given at 8:00 a.m. A review of the resident's prednisone dose card, found by staff member S on the medication cart, was labeled, prednisone (10 mg per tablet). The instructions showed: Give 3 tablets (30 mg) orally once a day x 7 days, 2 tablets (20 mg) orally daily x 7 days, then decrease to 15 mg daily. The label showed the prednisone order date was 11/18/16 but did not show when the medication was initially administered. During the observation, staff member S delayed the pouring and administration of resident #28's prednisone, stating that she wanted to clarify the dosage to be given. A review of a patient visit summary for resident #28, e-signed by the resident's discharging physician on 11/30/16, showed that prednisone (5 mg per tablet) 15 mg orally once daily was ordered on that date as a new prescription. In a list labeled Stop taking these Medications was prednisone (10 mg per tablet) with the instructions Give 3 tablets (30 mg) orally once a day x 7 days, 2 tablets (20 mg) orally daily x 7 days, then decrease to 15 mg daily. In an interview on 12/12/16 at 11:00 a.m., staff member S stated she had requested the facility's pharmacy to send a new prednisone medication dose card with the updated dosage, and with the updated administration, as per the new prednisone order of 11/30/16. She stated, Nursing should have sent for a different drug card long before now. A review of resident #28's MAR, which was on the drug cart computer on 12/12/16 at 11:00 a.m., showed e-signatures indicating that prednisone (5 mg per tablet), in the dose of 15 mg, was given for the daily 8:00 a.m. doses prior to 12/12/16. Actual doses of prednisone given for the daily 8:00 a.m. dose was not recorded, and could not be determined from the resident's MAR's.",2020-09-01
394,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2016-12-14,456,D,0,1,FR2P11,"Based on interview and observations, the facility failed to maintain a mechanical lift, used for resident transfers, which had torn knee pads, and the foot pads were peeling back. This failure had the potential to affect all residents requiring the use of the lift. Findings include: During an observation on 12/12/16 at 2:00 p.m., a sit to stand mechanical lift was sitting in the south hallway. The gray leather knee pad on the lift was torn on the outside corner, exposing the material inside the pad. The beige colored soft foam pad wrapped around the gray leather knee pads, was not covered with a cleanable surface. The footpad had a worn and peeled black surface. During an interview on 12/12/16 at 3:20 p.m., staff member F, stated the Sit to Stand lifts were serviced once a month, and the batteries were replaced every two years. The knee pads were replaced as needed. The Sit to Stand lift was probably the oldest lift, purchased in 2002. During an observation on 12/13/16 at 7:20 a.m., the same Sit to Stand lift, in the same condition as observed on 12/12/16, was sitting in the north hallway, between rooms 106 and 108. The lift had not been removed from service, or repaired.",2020-09-01
395,BIG SKY CARE CENTER,275044,2475 WINNE AVE,HELENA,MT,59601,2016-12-14,514,E,0,1,FR2P11,"Based on record review and interview, the facility failed to maintain complete and accurate medical records relating to the discharge documentation for 7 (#s 17, 18, 19, 21, 22, 23, and 25) of 28 sampled and supplemental residents. Findings include: A review of the discharge documentation for the following resident's: 17, 18, 19, 21, 22, 23, and 25, showed a lack of evidence relating to the resident's discharge. This included the interdisciplinary plan for the resident's discharge, showing the resident's status at the time of the discharge, and the services provided to the resident during the stay. The documentation did not show how the facility no longer met the resident's needs, to include information for the resident's future discharge goals. Refer to F202 for more detail. During an interview on 12/14/16 at 12:50 p.m., staff member G said she provided a list of all discharged residents to the various facility departments and she would tell them a discharge summary would need to be completed for those residents. Staff member G said she did not check the medical record to ensure the discharge summary had been completed. Staff member G said the discharge summary was a document found in the EMR system, which was what the facility was using for all it's documentation needs.",2020-09-01
396,LIVINGSTON HEALTH & REHABILITATION CENTER,275047,510 S 14TH ST,LIVINGSTON,MT,59047,2017-03-09,155,E,0,1,ENFZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to comply with the requirements for Advance Directives for 4 (#s 4, 5, 7, and 8) of 15 sampled residents. Findings include: A review of resident #7's physician's orders [REDACTED]. A medical record review for resident #s 4, 5, and 8, showed concerns relating to documentation being incomplete or the advance directives not being signed by the physician for the following: - Resident #8's Advance Directive showed the form was stamped with the resident's name, and under the Directive to Physicians and Caregivers resuscitate was marked. It also showed a handwritten entry, No CPR per patient - patient wants everything but chest compressions. The resident also had checked to be given a tube feeding if the resident couldn't swallow, intravenous fluids, oxygen therapy, transfer to a hospital if medically indicated by a physician, and restrictions to medication/treatment with no CPR, was printed on the line. The resident's signature and date were absent. The physician had signed and dated the document as of [DATE]. A Montana physician's orders [REDACTED].#8's chart and was also incomplete. Resident #8's name was placed on the form, after a copy of the document was requested. The resident's date of birth was missing, and the gender of the resident was not checked. Section A was completed, and the DNR box checked. Sections B, C, and D, had no boxes checked. These boxes contained whether or not the resident wanted intravenous fluids, oxygen, tube feedings, and other medical treatment. The POLST contained the resident's signature, and the signature of the physician, but a date and time, or the physician's phone number was not included. - Resident #5's record showed a Directive to Physicians and Caregivers, dated [DATE], signed by an Adult Protective Services, to resuscitate the resident. Review of Resident #5's medical record showed a letter, dated [DATE], from Adult Protective Services, showing the agency had been dismissed as a Permanent Limited Co-Guardian for the resident. The physician's orders [REDACTED].#5 as their client. - Resident #4's medical record showed on [DATE] at 3:00 p.m., that the physician's orders [REDACTED]. During an interview on [DATE] at 11:00 a.m., staff member C stated that an audit of Advance Directives were completed in (MONTH) (YEAR). Staff member C said most residents are admitted from the hospital and that she contacted the hospital personnel to have the physician's orders [REDACTED]. Staff member C stated that the reason resident #7's guardian had not signed, was because once the physician had signed, staff member C thought it was complete and placed it back in the medical record.",2020-09-01
397,LIVINGSTON HEALTH & REHABILITATION CENTER,275047,510 S 14TH ST,LIVINGSTON,MT,59047,2017-03-09,241,D,0,1,ENFZ11,"Based on observation and interview, the facility failed to provide nail care for 1 (#10) of 15 sampled residents. Findings include: During an observation on 3/9/17 at 7:25 a.m., resident #10 was sitting at the [NAME] wing nurses station in her wheelchair, with no shoes or socks on. The resident's toe nails were long. A staff member went and retrieved some socks and shoes, and the resident allowed her to put on the shoes and socks on. During an interview on 3/9/17, at 8:45 a.m., staff member I stated the resident was generally compliant with her toe nail care, and the toe nail care was completed during bath times. Staff member I was unable to identify a reason for the resident's nails being so long. She stated she did not document nail care because there was nowhere to document the care.",2020-09-01
398,LIVINGSTON HEALTH & REHABILITATION CENTER,275047,510 S 14TH ST,LIVINGSTON,MT,59047,2017-03-09,244,E,0,1,ENFZ11,"Based on interview and record review, the facility failed to respond to resident council concerns and the grievances from those concerns. This practice had the potential to affect all those residents who attended the resident council meeting, or who were aware of the concerns brought forth at the meeting. Findings included: Review of the Resident Council minutes showed concerns were identified in (MONTH) (YEAR) about the following: -Cleanliness of the facility van. -Folding chairs not being used for residents. -Cold temperatures in the building, and windows getting left open. -Hallways still a mess-need staff education. The facility failed to provide follow-up documentation for the (MONTH) (YEAR) resident concerns. Review of the Resident Council minutes showed concerns were identified in (MONTH) (YEAR) about the following: -Coffee being served sooner. -Talk to administration about getting a new VCR/DVD player. The facility failed to provide follow-up documentation for the (MONTH) (YEAR) resident concerns. Review of the Resident Council minutes showed concerns were identified in (MONTH) (YEAR) about the following: -Enough help? related to not having enough staff available. -Bagels available for alternates. The facility failed to provide follow-up documentation for the (MONTH) (YEAR) resident concerns. During the group interview with the resident's, on 3/8/17 at 9:00 a.m., some of the following concerns were brought up by the residents, and discussed: - Towels not soft, like drying with sand paper. - There was never enough aides, residents felt their basic needs were not met. - The residents felt they had voiced concerns about the facility, and the food, but it felt like a broken record because things did not get fixed. - The residents wished the coffee would be served at 6:30 a.m., and they felt the staff did not understand how important coffee was to the them. - They have asked for a new VCR or DVD, but the facility had not replaced the items, or addressed the concern with the residents. The resident's had tons movies they wished they could watch. - Showers were not being given, related to the lack of available staff. A record review of the facility's Grievance Forms showed 15 grievances, since (MONTH) (YEAR), were not adequately followed-up on or resolved. The following were some examples of the grievances reviewed: - 1/7/17, showed the following, lights in the dining room need lights, please. The facility did not compete the rest of the form and did not provide any resolution to the above grievance. - 2/2/17 - Six residents had filed a grievance related to showers not being given for up to 9 days apart. The facility took the following action on the concern, per the form: Staffing is being resolved with better weather conditions. - 2/23/17 - A resident was upset about the facility running out of lettuce. The facility took the following actions, per the form: Jacob is working on these. The facility did not provide any resolution for this grievance, or show if lettuce would be available. A record review of the facility's Food Committee Meeting Minutes, showed no minutes for the month of February. During an interview on 3/9/17 at 3:04 p.m., staff member J stated the facility encouraged residents to fill out grievance forms from the resident council meetings, with any concerns. He stated that there was no official follow-up from the resident's concerns addressed at resident council. During an interview on 3/9/17 at 3:20 p.m., staff member D stated she encouraged the residents to fill out a grievance form with any concerns from the group meeting. Otherwise, the facility did not follow-up on any concerns that were on a grievance form. She stated there was no official follow-up form from the meetings and no documentation of follow-up.",2020-09-01
399,LIVINGSTON HEALTH & REHABILITATION CENTER,275047,510 S 14TH ST,LIVINGSTON,MT,59047,2017-03-09,250,E,0,1,ENFZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During observation, interview, and record review, the facility failed to provide medically related social services to develop, evaluate, and monitor interventions that were individualized for residents with signs and symptoms of depression and other mental illnesses for 3 (#s 1, 2, and 6) of 15 sampled residents. Findings included: Review of the job description for the Social Service Director, dated (MONTH) (YEAR), showed the following expectations for the director: 1. Organize, assess, and maintain the existence of the social service program designed to meet the individual physical, mental, and psychosocial needs of the residents. 2. Assumes additional responsibilities that provide for the well-being of the residents. 3. Identification of needs, and coordination of services, so that bio-psychosocial needs of each resident is met. 4. Assisting residents and responsible parties in locating mental health or community resources. 5. Provide individual, group, and family services focused on the eminence or enhancement of the resident's bio-psychosocial functioning's and understanding their health status. 6. Coordinate and/or provide health and mental health social work services to residents to assist with attaining or maintaining the highest practical mental and psychosocial well-being, while helping residents receive appropriate treatment and services. 7. Providing education and resource support to staff participating in behavioral interventions for residents. 8. Demonstrate skill in guidance and counseling. 1. Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #6's Social Service Evaluation, dated 5/14/14, showed resident #6 had poor safety awareness, poor decision making, and violent tendencies towards staff. The evaluation showed he avoided activities. He required cues, and preferred to be left alone to watch television. The evaluation showed he had a [DIAGNOSES REDACTED]. He had a history of [REDACTED]. The evaluation showed the resident should be given space, to not approach him when he was acting out, and remove others from area, and observe. Additional notes were documented on the back of the Social Service Evaluation and showed the following: - 3/9/16: Improved mood, not as short, continues to be stable. - 8/10/16: Mood is pleasant and no behaviors. - 9/19/16: Resident asked a peer to get out of his way. Peer hollered back, they were removed from each other's presence. - 9/23/16: No behaviors noted. - 12/4/16: Continues to do good on medication, no behaviors, and pleasant to converse with. - 1/15/17: Altercation with another resident, report filed. - 1/16/17: No further issues in regards to altercation. - 1/19/17: No continued behavioral concerns. Review of the nursing notes for the resident showed there had not been any documentation on the resident's behaviors since 1/14/17. The note dated 1/14/17, showed resident #6 had an altercation with another resident over a TV remote. Both of the resident's were hitting each other with fists. During an interview on 3/7/17 at 2:40 p.m., staff member C stated resident #6 had not had any behaviors, and therefore did not think a PRN (as needed medication intervention) for behaviors was needed. She stated he had only been on Sertraline. She stated the resident did not have any behaviors since (MONTH) (YEAR). Resident #6 was only defending himself in (MONTH) (YEAR) she stated, and did not start a fight with his peer. Staff member C stated the resident was doing very well, and preferred to be in his room watching television, but did come out for meals. She stated the facility kept all the interventions on the care plan because the resident had a history of [REDACTED]. Review of resident #6's care plan showed a note attached the care plan that showed if resident #6 appeared angry, started yelling, or made threatening gestures, to not approach him. The note showed staff was to remove any other residents that may be in the area, and allow resident #6 time to calm down. The note showed that if resident #6 approached anyone, make sure an exit away from him was available and not to get within an arm's reach from him, and Always stay between him and a door so you can get out. The note was dated 7/17/14 and had a reviewed signature on 1/5/17. During an interview on 3/8/17 at 11:15 a.m., Staff member A stated there were closet care plan located at the nurse's station for the staff to use as a reference for residents who had behavioral issues. Review of the Care Directive sheet, dated 3/1/16, showed the resident could be physically aggressive, may respond better to men, to refocus him, change the subject, and see the behavior sheet. The behavior sheet was not located in the binder at the nursing station. Review of the Care Directive Form, dated 6/8/16, showed the resident could be combative if he did not understand something, because he hadn't heard or did not agree to the plan. During an interview on 3/8/17 at 3:10 p.m., staff member O stated that he was a contracted employee, and was not aware of any care plan directives or closet care plans located at the nursing station. He stated resident #6 had displayed behaviors in his time working at the facility, but he had not received any training for the resident's individual behaviors. During an interview on 3/8/17 at 3:30 p.m., staff member N stated he was put in charge of training new staff and it was difficult. He stated that he recalled the resident acting out around (MONTH) 13, (YEAR), and (MONTH) 22, (YEAR). He stated he did not recall what triggered the resident, but did mention the resident preferred male caregivers over female caregivers. He stated that the resident had a lot of behavioral issues. He stated that he tried to communicate with the Social Services personnel, and the supervisors, but the communication notes tended to disappear. He stated he also tried to document notes about the residents, including resident #6, to his co-workers, but stated the notes also disappeared. He stated that he has made suggestions to the supervisors of personalized interventions for the care plans, but that his suggestions were not placed on the resident(s) care plans, and there are many staff members who are unaware of interventions that work for various residents. 2. Resident #1 was admitted with MS and depression. Review of a significant change MDS with an ARD date of 12/20/16, showed a BIMS of 15, cognitively intact. The resident was observed in his room, in his bed, during the following times: -3/6/17 at 4:10 p.m. -3/7/17 at 7:25 a.m. -3/8/17 at 8:30 a.m. -3/9/17 at 9:05 a.m. Review of resident #1's Depression Care Plan, last reviewed 1/3/17, showed the resident had suicidal thought/comments. The care plan did not provide interventions for staff to follow when the resident experienced suicidal thoughts or made comments. It also did not provide individualized activities or interventions for the resident while he was isolating himself to his room. The care plan did not address the resident's risk for self-isolation. During an interview on 3/8/17 at 9:52 a.m., staff member C stated resident #1 used to be active, would hike daily, and participated in back country rescues. She stated if the resident was suicidal she would put Bob Marley (musician) on, and visit with him. She stated the resident became very needy, and just needed attention, but he loved to visit about Yellowstone. The resident would get upset when his son visited because he would tell the resident he could not go home. She did not know why there wasn't any individualized interventions on his care plan for these concerns. During an interview on 3/8/17 at 2:45 p.m., staff member K stated she was unsure about the resident's care plans, although she provided ADL care to the residents. During an interview on 3/8/17 at 3:00 p.m., staff member B stated they used a book, for the care plans, for the CNAs. She stated she did write special notes for residents, for the CNA's to read on a piece of paper, and she would put the notes in the front of the binder. She stated if things were highlighted on the care plans, that meant the issue had been discontinued. However, she stated staff often forgot to highlight interventions that may have been discontinued. 3. Record review of resident #2's Social Service History showed the following was documented by staff member C: When I attempted to go visit with resident #2, I merely got out the words (MONTH) I visit with you for a bit. She stated that if I'm here to snoop and ask questions about her life she is not interested. I did not attempt any further. During an interview 3/9/17 at 1:55 p.m., staff member C stated that the residents had the right to refuse their initial assessments. She stated she did not feel feel their history about how many children they had, or what high school they went to, was very important to their care at the facility. She stated she did not gain rapport with the residents during their initial assessment, but rather during their day-to-day visits. Staff member C did not document the day-to-day visits. She stated if she was to document every visit she would not have any time for all of the residents.",2020-09-01
400,LIVINGSTON HEALTH & REHABILITATION CENTER,275047,510 S 14TH ST,LIVINGSTON,MT,59047,2017-03-09,252,D,0,1,ENFZ11,"Based on interview and observation, the facility failed to provide a homelike environment, for 1 (#14) out of 15 residents. Findings include: During an interview and observation on 3/9/17 at 1:25 p.m., resident #14's room was cluttered with storage stacked on the resident's recliner chair. The resident stated my room is a mess, the rocking chair needs to go, they just store stuff on it. During an interview on 3/9/17 at 1:39 p.m., staff member B stated resident #14's rocking chair was used a storage. Staff member B provided oversight for resident care services.",2020-09-01
401,LIVINGSTON HEALTH & REHABILITATION CENTER,275047,510 S 14TH ST,LIVINGSTON,MT,59047,2017-03-09,253,B,0,1,ENFZ11,"Based on observation, interview, and record review, the facility failed to provide a clean environment for 1 (#2) out of 15 sampled residents. Findings include: A review of the resident's medical record showed she was on isolation precautions related to diarrhea. During an observation on 3/7/17 at 1:00 p.m., resident #2's dresser was visibly dusty. The dresser had been dusted, but dust was present around the cards and pictures on the dresser. The items on the dresser had not been moved, so that the dust could be removed, when the dresser was cleaned. During an interview and observation on 3/9/17 at 2:00 p.m., staff member J looked at the dust on resident #2's dresser, which had been present since the observation on 3/7/17. Staff member J stated it possibly was not dusted due to the resident's religious preference. However, staff member J stated the facility only had one resident in the building, which the specific religious preference she was referring to, and this was not resident #2. A review of the facility's Housekeeping Job Routine, A&B Hall, from the contracted housekeeping vendor, showed the following: - From 8:20 a.m. - 9:50 a.m., Clean resident rooms 102-113 using the 5&7 step cleaning method and A hall nurses station (vacuuming, garbage, and light dusting.).",2020-09-01
402,LIVINGSTON HEALTH & REHABILITATION CENTER,275047,510 S 14TH ST,LIVINGSTON,MT,59047,2017-03-09,280,E,0,1,ENFZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to identify and document individualized interventions on the care plans for resident's diagnosed with [REDACTED].#s 1, 4, and 6) of 15 sampled residents, to include the failure to identify and revise the care plan for 1 (#1) resident who had suicidal ideation's. Findings include: 1. Resident #6 was admitted to the facility with [MEDICAL CONDITION] Disorder and [MEDICAL CONDITION]. Review of resident #6's care plan showed a note attached to the care plan that showed if resident #6 appeared angry, started yelling, or making threatening gestures, to not approach him. The documentation showed that staff were to remove any other residents that may be in the area and allow resident #6 time to calm down. The documentation showed if resident #6 approached anyone to make sure an exit away from him was available and not to get within an arm's reach from him, to include Always stay between him and a door so you can get out. This note was dated on 7/17/14 and had a review date, and signature of 1/5/17. Review of resident #6's care plan interventions for the depression and aggressive behaviors, reviewed 1/7/17, showed the facility documented that the resident had the following problems and interventions: Problems: 1. Lack of energy and fatigue 2. Difficulty making decisions 3. Social withdrawal 4. Increased complaints of pain 5. Behavior problems such as cussing, striking, punching 6. Changes taking place in the brain 7. Impaired cognition 8. Physical discomfort 9. Impaired vision or hearing 10. Resident to Resident (interactions) Interventions included: 1. Medications per physician 2. Limit environmental noise 3. Small group activities 4. Complete and perform task when person is less fatigued 5. Assist with problem solving, decision making 6. Don't rush tasks 7. Praise the person frequently. 8. Assess pain when agitated 9. Redirect 10. Process through feelings 11. Be aware of warning signs 12. Try to reduce demands on person 13. Eliminate possible cause of distress 14. Provide unrushed and consistent routine and keep physical environment consistent 15. Provide person exercise and participation in activities (take for a walk, look at magazines) 16. Check for comfort 17. Meds per MD order 18. Maintain person's safety and the safety of others 19. Assess for pain and watch for agitation report to the charge nurse 20. Redirect, remove from situation, and know he refuses cares Review of resident #6's MAR, dated (MONTH) and (MONTH) (YEAR), showed he had the following medications: [REDACTED] 1. [MEDICATION NAME] HCL, 100 mg tablets, oral, for depression. 2. [MEDICATION NAME], 5 mg-[MEDICATION NAME] 325 mg, oral, two times per day, for pain 3. [MEDICATION NAME], 325 mg tablets, as needed, every four hours. This medication was not administered at all during the month of (MONTH) (YEAR), or in (MONTH) up to the time of the survey. Review of resident #6's Social Service Evaluation, dated 5/14/14, showed resident #6 had poor safety awareness, poor decision making, and violent tendencies towards staff. The evaluation showed he avoided activities, required cues, and preferred to be left alone to watch television. The evaluation showed he had a [DIAGNOSES REDACTED]. He also had an explosive behavior, and had a history of [REDACTED]. The evaluation showed he should have been given space, and to not approach him when he was acting out. The evaluation showed the staff would need to remove others from area if problem occurred, and observe for future behaviors. Additional notes were written on the back of the Social Service Evaluation and showed the following: - 3/9/16: Improved mood, not as short, continues to be stable. - 8/10/16: Mood is pleasant and no behaviors. - 9/19/16: Resident asked a peer to get out of his way. Peer hollered back, they were removed from each other's presence. - 9/23/16: No behaviors noted. - 12/4/16: Continues to do good on medication, no behaviors, and pleasant to converse with. - 1/15/17: Altercation with another resident, report filed. - 1/16/17: No further issues in regards to altercation. - 1/19/17: No continued behavioral concerns. Review of the nursing notes for the resident showed there had not been any documentation on the resident's behaviors since 1/14/17. The note dated 1/14/17, showed resident #6 had an altercation with another resident over a TV remote. Both of the resident's were hitting each other with fists. Review of the Quarterly MDS, with ARD of 12/22/16, showed the following: -C0500: BIMS score of 11, moderately impaired. -D0300: Depression score of 3, indicating minimal depression. -E0200: No behaviors exhibited for Physical, Verbal, or any other behavioral disturbances. -E0800: No rejections of cares. During an interview on 3/7/17 at 2:40 p.m., staff member C stated resident #6 had not had any behaviors and therefore did not need a PRN (as needed medication intervention). She stated he had only been on [MEDICATION NAME], and the resident has not had any behaviors since (MONTH) (YEAR), and what had happened in (MONTH) (YEAR), resident #6 was only defending himself. Staff member C stated the resident was doing very well, preferred to be in his room watching television, but did come out for meals. Staff member C stated they keep all the interventions on the care plan because the resident had the history of behaviors. Staff member C did not respond to why there was no personalized interventions for the staff to help redirect or calm the resident down. The following observations were made of resident #6: - 3/6/17 at 10:30 a.m., Resident was in bed, without the television on. There was a walker by his bedside that had a boot on it. The resident was laying on his side, and the curtains were closed. - 3/6/17 at 2:30 p.m., Resident was laying on the bed in his room without the television on. The walker was still by his bedside with a boot on it. It appeared there was no change in environment noted from the 10:30 a.m. observation. - 3/7/17 at 7:17 a.m., Resident was laying on his side in his room, no television on. - 3/8/17 at 8:00 a.m., Resident was brought to the dining room by staff. His hair was unkempt. He was placed at the table with two other residents. Resident #6 had a glass of water sitting in front of him, and he attempted to pour it into the water pitcher, resulting in the water spilling all over the table and saturating the table cloth. There were no staff available to intervene or offer the resident support. The water was dripping on the floor, and the kitchen staff came over and started to clean the water up. The staff did not address resident #6 or ask him if he needed help. Review of the Care Directive sheet, dated 3/1/16, showed the resident could be physically aggressive, may respond better to men, refocus or change the subject, and to see the behavior sheet. The behavior sheet was not located in the binder at the nursing station. Review of the resident's Care Directive Form, dated 6/8/16, showed the resident could be combative if he did not understand because he did not hear or did not agree to the plan. During an interview on 3/8/17 at 3:10 p.m., staff member O stated that he was a contracted employee, and was not aware of any care plan directives, or closet care plans located at the nursing station. He stated resident #6 had displayed behaviors in the time he had worked at the facility, but he had not received any training for the resident's individual behaviors. 2. Resident #4 was admitted to the facility with a [DIAGNOSES REDACTED]. During observations at the facility, the following was observed: - 3/6/17 at 10:30 a.m., Resident was placed in the Geri chair at the nursing station on [NAME] wing. She was lying back and appeared relaxed. - 3/6/17 at 2:15 p.m., The resident's door was closed. There was no sound coming out of the room. - 3/7/17 at 7:15 a.m., The resident was sitting at the nursing station in her wheelchair. - 3/8/17 at 7:45 a.m., Resident was in her wheelchair on the [NAME] wing hallway. She was self-propelling down the hall, and the alarm sounded. A staff member approached the resident and reminded the resident not to take off the seat belt on the wheelchair because she could fall out of her wheel chair. The resident appeared to be falling out of the wheel chair when the staff had approached her. The staff member took the resident down to the nursing station, and after sitting by the nursing station, the resident started to slip down out of her wheelchair again. Review of the residents Annual MDS, with an ARD of 12/8/16, showed the following: -E0200: no behaviors (physical, verbal, other) exhibited. -E0800: no behaviors exhibited with rejection of cares. -E1100: no change in behavior symptoms. Review of the nursing notes showed the following: - 11/8/16: No evidence that room change has affected resident. - 11/10/16: No changes in behaviors. - 12/21/16 at 2:40 p.m., which was the next consecutive note recorded in the resident's progress notes, showed no attempt to self-transfer, and Geri chair not warranted at this time. - 12/25/16: Yelling out phrases that made little sense, [MEDICATION NAME] given, and parked at nurse's station in wheel chair, able to calm, and taken back to bed. - 1/2/17: Resident was yelling out. - 1/4/17: Resident was having loose stools. - 1/5/17 at 1:30 p.m., Resident was given [MEDICATION NAME] in early morning and at noon. - 1/5/17 at 11:30 p.m., Resident was yelling out - 1/6/17 at 1:30 p.m., Resident was anxious and yelling out random words, and restless in the chair - 1/7/17 at 1:30 p.m., Resident was yelling out at lunchtime, [MEDICATION NAME] given. - 1/13/17 at 5:00 p.m., Resident very agitated after getting up, yelling out loudly, attempted to give resident a stuffed animal and the resident was uninterested in the toy. [MEDICATION NAME] given, ate lunch and dinner with minimal problems. Became agitated again later in the afternoon, and started yelling which resulted in other residents becoming agitated. - 1/14/17: Restless and yelling out after dinner - 1/18/17: Taking off seatbelt, given 1:1 time, interventions were not effective, PRN given at 11:30 p.m., and it was effective. - 1/20/17: Yelling out after dinner. -3/3/17 at 2:30 p.m., this was the next consecutive note recorded after the 1/20/17 documentation entry, Resident had been sleeping, difficult to arouse. Review of the Device Evaluation Review sheet, dated 12/21/16, showed the resident was to have the Geri chair because it was effective for anxiety and/or agitation reduction, and also good for posture or pressure reduction. The review showed the chair was not a restraint because the resident was unable to self-transfer or propel. Review of the resident's Anxiety Care Plan, reviewed on 2/14/17, did not list any personalized interventions relating to the use of the Geri chair to reduce anxiety. The Geri chair was listed on the Fall Risk Care Plan, with a review date of 12/21/16 and showed the Geri chair was used for comfort, was pressure alleviating, and for body alignment. During an interview on 3/8/17 at 11:15 a.m., staff member A stated resident #4 had been using the Geri chair for a long time. The Geri chair used to be on the care plan for anxiety, but was not on there anymore. The staff member also stated the charting on the resident's behaviors lessened due to the monotonous routine. He stated that maybe the personalized interventions for the resident were located on the Care Plan Directives located at the nursing station. Review of the Care Directive Sheet, updated 12/13/15, showed staff was to remove the resident from the situation where she may be frustrated with other residents, and to see the behavior sheet. There was no behavior sheet available with the Care Directive Sheet that was located in the binder at the nursing station. The sheet also showed that the Geri chair may help reduce anxious behaviors of the resident, in addition to providing comfort. The Care Directive sheet also showed that putting soothing music on, while the resident was in bed, may help with agitation. During an interview on 3/8/17 at 3:30 p.m., staff member N stated resident #4 struggled in her wheelchair, and would become escalated (anxious) when sitting at the nursing station due to the noise of the call lights and by the other residents that were being parked there in their wheelchairs by the staff. The staff member stated the resident will become agitated and scream, and one way to calm her down was to take her to her room and place her in her bed. He stated if staff played some relaxing music, the resident calmed quickly. Staff member N stated he had relayed this information to his supervisors and also to social services, but felts nobody listened to him or the other CNA's that made suggestions for personalized interventions for the resident(s). 3. Resident #1 was admitted with MS and depression. Review of a Significant Change MDS, with an ARD of 12/20/16, showed a BIMS of 15, cognitively intact. The resident was observed in his room, in his bed, during the following times: -3/6/17 at 4:10 p.m. -3/7/17 at 7:25 a.m. -3/8/17 at 8:30 a.m. -3/9/17 at 9:05 a.m. Review of resident #1's Depression Care Plan last reviewed 1/3/17, showed the resident had suicidal thought/comments. It did not provide any interventions for staff to follow when the resident experienced suicidal thoughts or comments. The plan did not provide any individualized activities or interventions for the resident while he was isolated in his room. The care plan did not address his risk for self-isolation. During an interview on 3/8/17 at 9:52 a.m., staff member C stated resident #1 use to be active, hiked daily, and was a part of back country rescues. She stated if he is suicidal she will put Bob Marley on and visit with him. She stated the resident would become very needy, and he loved to visit about Yellowstone. He would get upset when his son came to visit because he told the resident he could not go home. She did not know why there was no individualized interventions on his care plan for these concerns.",2020-09-01
403,LIVINGSTON HEALTH & REHABILITATION CENTER,275047,510 S 14TH ST,LIVINGSTON,MT,59047,2017-03-09,281,E,0,1,ENFZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility's nursing staff failed to document medications and treatments ordered by the physician for 4 (#s 1, 2, 6, & 7) of 15 sampled residents. Findings include: 1. Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #7's (MONTH) (YEAR) MAR (Medication Administration Record), showed there was an order which had not been signed off by a nurse on 3/2/17. Resident #7 was to receive [MEDICATION NAME], 20 units, subcutaneous, three times a day, plus additional insulin per sliding scale to help control his elevated blood sugars. A nurse's signature, the blood sugar level, the site the insulin was given, and how many units of insulin were given, were blank for the 5:30 p.m. medication administration. Review of resident #7's (MONTH) (YEAR) MAR, showed there were three orders not signed off by a nurse on 2/28/17, which was for: a) [MEDICATION NAME] 100 mg capsule, to be given twice a day, to help control resident #7's chronic pain. The entry was missing a nurse's signature for the 8:00 a.m. medication administration. b) Resident #7 also had an order to wear a brace three times a day, no brace to right lower extremity when the resident's shoes were off. A nurse's signature was missing for the evening shift. c) Compression stockings were to be applied to the resident on both lower extremities in the morning, and removed at hour of sleep. A nurse's signature was missing on the day shift. During an interview on 3/7/17 at 1:40 p.m., staff member M stated there was no back up system to check that medications and treatments were signed off after being administered. She also stated that the night shift, in the past, checked the MARs for missing signatures, and let the nurse who had been on shift previously know they missed signing a medication or treatment. Staff member M stated that she realized that if a medication or treatment is not signed off, it was not done. A review of the facility's Medication Administration Guide showed that The nurse signs for the medication/treatment after administration. The nurse double checks the MAR or TAR for needed signature/initials and follow up documentation at the end of each medication pass and prior to leaving their shift. Also it showed, the nurse documents medications and treatments at the time they are administered, not at the end of their shift or on the next shift. 2. Resident #6 was admitted to the facility with Bi-Polar Disorder, Diabetes Mellitus II, and Heart Failure. Review of the resident's (MONTH) (YEAR) physician order [REDACTED].>- Facility was to document adverse reactions or the resident's medication, [MEDICATION NAME] HCL, 100 mg: Sedation, dry mouth, blurred vision, constipation, postural hypertension, [MEDICAL CONDITIONS] muscle tremors, agitation, headache, skin rash, photo sensitivity, excessive weight gain, and possible of suicidal ideation and behavior. Staff were required to mark a + or - depending on current symptoms, starting 9/25/15. - The facility had orders from a physician to assess pain each shift using the pain index which started 10/30/14. - The facility was to monitor oxygen saturations, and document findings on the MARs, two times per day. - The facility was to provide diabetic nail care by a licensed nurse, per week, starting 9/29/16. Review of the residents MARs and TARs for (MONTH) and (MONTH) of (YEAR), showed: - No documentation for symptom monitoring for 2/14/17 and 3/5/17. - No documentation for the resident's pain assessments for 2/13, 2/14, 2/15, 2/17, and 2/18/2017 - No documentation was evident for oxygen saturations for 2/15, 2/17, or 2/18/17. - No documentation completed for diabetic nail care by licensed nurse, for the weeks of 2/11/17, 2/18/17, or 2/25/17. - No documentation completed for the treatments for the resident's left hip abrasion that was listed on the TAR for 2/14, 2/15, 2/17, 2/18/17. The directions showed to clean and observe for the scope and severity of the infection daily, until healed. - No documentation evident for the site of the [MEDICATION NAME] medication which was to be given subcutaneously, 1 time per day, for Diabetes, on 2/13/17. During an interview on 3/6/17 at 3:35 p.m., staff member B stated she worked the floor sometimes and did not always sign the MARs and TARs as needed. She stated that sometimes after working so many hours, she just wasn't on her A game. 3. Record review of resident #2's MAR or TAR showed the following medications and treatments were not documented as provided: - 2/17/17: Coccyx wound cleanse with wound spray - 2/25/17: [MEDICATION NAME], 300 mg, PO, every HS - 2/16/17: Senna, 8.6 mg tablet, one time daily During an interview on 3/8/17 at 1:38 p.m., staff member B was referring to the missed wound treatment, and stated the staff missed one day so they skipped to the bottom of the MAR to start their tracking over. She was not sure why some days were signed accurately, and some were missed. 4. Record review of resident #1's MAR showed the following medications were missed: - 2/8/17: [MEDICATION NAME], 60 mg, delayed release, one time daily - 2/17/17: [MEDICATION NAME] sodium, 112 mcg tablet, orally, one time daily - 2/22/17: [MEDICATION NAME], 10 mg tablet, 3 tablets orally, one time daily REFERENCE Ann Perry and [NAME] Potter, Clinical Nursing Skills and Techniques, 5th ed., Mosby, Inc., St. Louis-Missouri, 2002, pg. 449. Postadministration Activities. 1. After administering a drug, record the following information on the MARs or other appropriate form (e.g., nurses' notes) required by the institution: -Drug name -Dose -Route of administration -Time of administration -Any unexpected client responses (see evaluation) -Pertinent data or assessment collected at time of administration -Signature and title of nurse administering drug. 2. If the client refuses a medication, document the reason for refusal in the nurses' notes. The MAR may require a special symbol that indicates that the client refused the medication.",2020-09-01
404,LIVINGSTON HEALTH & REHABILITATION CENTER,275047,510 S 14TH ST,LIVINGSTON,MT,59047,2017-03-09,312,D,0,1,ENFZ11,"Based on observation and interview, the facility failed to provide hygiene care and assistance with changing soiled clothing for a resident who had a visibly soiled mouth, and clothing, for 1 (#16) of 16 sampled and supplemental residents. Findings include: During an observation and interview on 3/7/17 at 12:56 p.m., resident #16 was observed exiting the dining room with a red food substance surrounding his lips. The resident was wearing a dark blue shirt, and the food was present on his shirt as well. During the interview, the resident stated staff did not always assist with cleaning up after meals. During an observation on 6/8/17 at 7:15 a.m., resident #16 was wearing the soiled blue shirt that he had on during the observation made on 3/7/17 at 12:56 p.m.",2020-09-01
405,LIVINGSTON HEALTH & REHABILITATION CENTER,275047,510 S 14TH ST,LIVINGSTON,MT,59047,2017-03-09,371,E,0,1,ENFZ11,"Based on observation, record review, and interview, the facility failed to ensure portions of the kitchen, and equipment in the kitchen, to include storage shelving in the cooler, was kept clean, or that cleaning schedules were adequately developed and maintained for the cleanliness of the food serving, storage, and preparation areas in the kitchen. This deficiency had the potential to affect all residents receiving food from the kitchen. Findings include: The following observations were made on 3/7/17 at 7:45 a.m.: -There was a thick build-up of dust, that was black, which appeared at the bottom of the baseboards throughout the kitchen and dining room. -The garbage can in the kitchen was dirty with food and stains on the side. -The side of the stove, next to the oven, was covered with old dried food. There was a small opening, between the oven and the stove, which was filled with old dried food. The back of the stove was also soiled with the old dried food. -Shelves in the walk-in cooler had observable food debris and soiled areas, and an orange coating, appearing to be rust, on the shelving. During an interview on 3/7/17 at 9:00 a.m., staff member [NAME] provided a copy of the cleaning schedule, and stated he would talk to the staff about the cleaning not being completed. This would include the importance of the deep cleaning. A review of the facility's Deep Cleaning Schedule, for the cook, dated for the week of 2/27/17-3/5/17, showed 4 out of 14 cleaning tasks were completed. This was the only Deep Cleaning Schedule completed for the previous weeks.",2020-09-01
406,LIVINGSTON HEALTH & REHABILITATION CENTER,275047,510 S 14TH ST,LIVINGSTON,MT,59047,2017-03-09,465,D,0,1,ENFZ11,"Based on observation, record reviev, and interview, the facility failed to maintain a sanitary environment in the dining room. This failure had the potential to affect all residents who received meals in the dining room, or who went into the area. Findings include: During an observation on 3/7/17 at 7:45 a.m., the following was found: - The fans above the tables, where residents ate their food, in the dining room had a thick layer of dust. - A buildup of dust, in black clumps, was on the ceiling in the dining room, which was above where the residents ate their meals. - The walls in the dining room had food spilled down the sides, above the baseboards. A review of the facility's Housekeeping Job Routine, A and B Hall, for the contracted housekeeping vendor, showed the dining room would be cleaned between 10:00 a.m. to 11:55 a.m. During an interview on 3/7/17 at 9:00 a.m., staff member [NAME] stated he would talk to the staff about the cleaning not being completed.",2020-09-01
407,LIVINGSTON HEALTH & REHABILITATION CENTER,275047,510 S 14TH ST,LIVINGSTON,MT,59047,2018-05-31,583,D,0,1,CIM911,"Based on observation and interview, a resident's dignity was not respected or maintained when wound care was provided in the dining room, for 1 (#12) of 20 sampled residents. Findings include: During an observation on 5/29/18 at 11:47 a.m., NF1 took off resident #12's shoes and socks, rolled up her pant legs, and inspected the resident's legs. This resident had a BIMS score of 99. At this time, other residents were sitting down in the dining room waiting for lunch to be served. Review of resident #12's Quarterly MDS, with an ARD of 4/3/18, showed that resident #12 had a BIMS score of 99. During an interview on 5/29/18 at 11:49 a.m., NF1 stated that she probably should not provide wound care in the dining room and she usually would not, however, they were running late and had to get it done. During an interview on 5/29/18 at 2:20 p.m., staff member B stated that the facility had a dedicated room to provide wound care in, and that she did not know why wound care was provided in the dining room. Staff member B stated that she was concerned that it had occurred. Staff member B stated NF1 was provided education to not do wound care in the dining room.",2020-09-01
408,LIVINGSTON HEALTH & REHABILITATION CENTER,275047,510 S 14TH ST,LIVINGSTON,MT,59047,2018-05-31,600,G,0,1,CIM911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 1 (#20) of 20 sampled residents, and all other residents who came in contact with resident #47, or were in his presence when angry, was free from abuse and fear of abuse. Resident #20 sustained a fractured finger during a resident to resident altercation with resident #47, and 6 (#s 6, 7, 10, 26, 28 and 32) filed a Grievance for fear of their safety relating to resident #47. Findings include: Resident #47 was readmitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. During an observation and interview on 5/29/18 at 11:45 a.m., resident #20 stated he was attacked by another resident and had his finger broken. The resident's left ring finger appeared swollen and deformed. The resident was unable to bend his finger. Review of a report filed with the State Survey Agency, dated 4/28/18, showed resident #47 left his table and went over to the table where resident #20 was sitting, grabbed his finger, and bent it which resulted in an injury to resident #20's left ring finger. Review of resident #20's Orthopedic Comprehensive Exam, Final Report, dated 4/30/18, showed a closed, displaced [MEDICAL CONDITION] ring finger. Review of a Grievance Form, dated 5/3/18, showed six residents (#s 6, 7, 10, 26, 28 and 32), filed a grievance which showed they feel it is an unsafe environment in the dining room and hallways, especially at night due to the behaviors of resident #47. Under the investigation and findings, the document showed resident #47 would be, .served his meals in his room if possible, staff nurse to call MD and request DC for safety to psych, 1:1 observation, resident to ER. Review of resident #47's Multi-disciplinary Progress Notes, dated 4/6/18 through 5/7/18 showed the following: -4/6/18; Foul language in dining room, cussing at other residents and staff, threw cup of orange juice across the room. The resident was directed back to his room. -4/7/18 at 6:30 a.m.; The resident ate dinner in his room the previous evening. Was verbally aggressive toward CNAs. -4/7/18 at 3:20 p.m.; The resident was agitated toward CNAs today. He yelled and cussed at the aides. -4/7/18 at 11:00 p.m.; The resident became very agitated at PM meal and threw a heavy glass plate across the floor. -4/9/18 at 11:15 a.m.; The resident was highly agitated in the AM, targeting staff, seeking them out and yelling/cussing at them, threatened violence and attempted to strike them. The resident was poorly redirectable. -4/9/18 at 11:30 a.m.; The resident threw a mug, and was repeatedly yelling/cursing. Multiple staff attempted to redirect and calm, but were ineffective. [MEDICATION NAME] (an antipsychotic) 100 mg given orally. Soon after medication was given the resident began chasing after other staff, cursing and threatening them. -4/9/18 at 5:05 p.m.; [MEDICATION NAME] (an antipsychotic) increased to 100 mg at bedtime. -4/10/18 at 2:30 a.m.; The resident was still cussing and shooing everybody out of his room. -4/10/18 at 6:00 p.m.; The resident was very agitated this AM, throwing cups in the dining room. Backed the nurse up in a corner and kicked her three times. Refused all medications and cares by staff. -4/11/18; Staff avoid the resident to avoid physical or verbal altercations. The resident was verbally or physically aggressive towards staff. Was observed talking to himself. Paperwork was started to send the resident out for evaluation. -4/12/18; Additional paperwork faxed to receiving facility. -4/13/18; The resident refused to allow staff to get him up and change soiled clothing. Reapproached later and allowed staff to assist in changing soiled clothing. The resident cussed at a CNA, at lunch. -4/14/18; The resident was in the dining room at lunch, and was yelling and throwing cups. -4/15/18; The resident was still calling some staff names and was still verbally abusive to staff. -4/16/18; The resident had a moment of verbal exchange with another resident about getting seconds. -4/17/18; The resident was vulgar towards a female CN[NAME] -4/18/18; CNAs report the resident continues to be vulgar towards them. -4/19/18; The resident was cooperative. Refused to allow staff to turn bathroom call light off. -4/21/18; Cooperative with cares. Would not let staff turn off bathroom call light. The resident told staff to get out of his room and called them names. -4/22/18; The resident yelled at the CN[NAME] -4/23/18; Cooperative with cares. -4/24/18; The resident was yelling in dining room at dinner and tossed food and threw a plastic cup at another resident. Resident removed from dining room to his room to finish dinner. -4/25/18; The resident was agitated after lunch, yelling and cursing at people and wandering around the unit. -4/26/18; Cooperative and calm. -4/28/18 at 2:00 a.m.; Threw dinner on floor at dinner time. -4/28/18; Heard loud yelling in dining room and ran down to find that (resident 47) had wheeled over to another resident and attempted to grab him (resident #20) and injured the resident's left ring finger. (Resident #47) was cursing loudly and staff had to pull the resident in wheel chair away from the other resident. The resident was swinging arms and attempting to hit anyone near him. Was able to get the resident out of the dining room and away from the other resident. The resident then attempted to punch staff. [MEDICATION NAME] (an antipsychotic) increased to 150 mg two times daily. The resident sat quietly in room for the rest of the day. -4/29/18; Cooperative. -4/30/18; Non-compliant with cares, refused medications. Refused to let staff turn bathroom call light off. The resident sat in his room with his hands down his pants. Attempted to shut door, but the resident would yell and re-open the door. Staff was finally able to get door closed for privacy. -5/1/18; The resident was agitated at breakfast and threw plate and bowl onto floor and cursed at staff. -5/2/18; The resident refused cares. Appeared heavily soiled. Received new order to increase [MEDICATION NAME] (an antipsychotic), decrease [MEDICATION NAME] (an antidepressant) and add [MEDICATION NAME] (an antidepressant). Becomes aggressive with attempts to turn bathroom call light off. -5/3/18; The staff attempted to draw blood for ordered blood work and the resident became verbally and physically aggressive. 1:1 supervision continues. 1:1 supervision initiated for other residents and staff safety. The resident was sitting in his urine and feces because he was not allowing staff to change him. An order was received for [MEDICATION NAME] (an antipsychotic) 2 mg IM, however staff could not get close enough to administer without getting injured. Resident screaming and throwing things around room at 2:15 p.m. Resident sent to ER for evaluation at 3:00 p.m. Returned from ER at 4:30 p.m. -5/4/18; The resident is on 1:1 care due to danger to staff, self, and other residents. The resident was refusing to eat, drink, or be cared for. Resident in room screaming vulgar language, sticking his hand down his pants, and throwing things around the room. -5/4/18; Order to send out for evaluation. Unable to obtain required lab work. -5/5/18 at 2:30 a.m.; 1:1 supervision when possible. -5/5/18 at 4:00 p.m.; 1:1 staff with resident at all times. -5/7/18 at 10:48 a.m.; The resident was in the hallway, yelling. The resident was observed to be hitting and pulling on staff clothing. The resident was screaming cuss words and attempting to go into other resident's rooms. Staff attempted to get the resident out of other resident rooms, but the resident became angry and started hitting staff again. -5/7/18 at 4:40 p.m.; The resident was yelling, cussing, swinging and hitting staff members. The resident was screaming in the hallways and attempted to go into other resident's rooms. All doors were shut. Police were called. The resident was yelling at the police and swung his hands at the police officer and tried to grab the officer's arm and was cussing at him. Review of resident #47's Quarterly MDS, with an ARD of 3/2/18 showed a BIMS score of 3, which reflected severe cognitive impairment. Review of resident #47's care plan showed the following interventions: -Initiated on 2/19/18; assess and anticipate resident's needs, provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated, give the resident as many choices as possible about care and activities, monitor and document behavior and attempted interventions in behavior log, notify MD with increased behaviors, and monitor/document/report PRN any signs or symptoms of resident posing danger to self and others. When the resident becomes agitated intervene before agitation escalates, guide away from source of distress, engage calmly in conversation; if response is aggressive, staff to walk calmly away and approach later. -Initiated on 4/30/18; administer medications as ordered, assist the resident to develop more appropriate methods of coping and interacting as able, encourage the resident to express feeling appropriately, caregivers to provide opportunity for positive interaction, attention, stop and talk with him/her as passing by, educate on successful coping and interaction strategies as able, explain all procedures to the resident, discuss behaviors, if reasonable, and intervene as necessary, minimize potential for the resident's disruptive behaviors by offering tasks which divert attention such as playing music in room, and offering food. Monitor behavior episodes and attempt to determine underlying cause. Praise any indication of the resident's progress/improvement in behavior. Provide a program of activities that is of interest and accommodates resident's status. As the resident continued behaviors of aggression, and medications were modified, interventions on the care plan were not evaluated or revised to show steps the facility took steps to further prevent or protect the residents who were either in direct contact with resident #47 or those who had been in his presence, relating to abuse, and for those residents who may have had fear from abuse due to the resident's aggression and behavior, between 2/19/18 and 4/30/18. During an interview on 5/31/18 at 1:45 p.m., staff member B stated she could not recall when resident #47 went on 1:1 monitoring. Staff member B stated when 1:1 was discontinued, staff were to watch the resident closely. Staff member B stated interventions, for resident #47, prior to resident #20's injury included; watching him, contacting the MD, and removing him from the situation. Staff member B stated interventions were ongoing, and included re-directing, and medication adjustment. Staff member B stated when resident #47 was throwing dishes, the facility switched to Styrofoam. Staff member B stated resident #47 would de-escalate, following medication adjustment, for a short time.",2020-09-01
409,LIVINGSTON HEALTH & REHABILITATION CENTER,275047,510 S 14TH ST,LIVINGSTON,MT,59047,2018-05-31,638,E,0,1,CIM911,"Based on interview and record review, the facility failed to complete the MDS assessments for 6 (#s 9, 12, 13, 20, 21, and 36) of 20 sampled residents. Findings include: During an interview on 5/31/18 at 11:24 a.m., staff member D stated she started her position in November, (YEAR), and there were big gaps in the dates of the MDS assessments. Staff member D stated she went through all the assessments and rescheduled all of the residents. Staff member D stated there were significant periods of time when there was no staff to complete the MDS assessments. 1. Review of resident #9's Quarterly MDS showed an ARD of 9/27/17. Review of the resident's Significant change MDS showed an ARD of 1/4/18. There were no MDS assessments completed between 9/27/17 and 1/4/18. 2. Review of resident #12's Quarterly MDS showed an ARD of 7/19/17. Review of the resident's Significant change MDS showed an ARD of 1/8/18. There were no MDS assessments completed between 7/19/17 and 1/8/18. 3. Review of resident #13's Quarterly MDS showed an ARD of 6/2/17. Review of the resident's Significant change MDS showed an ARD of 1/9/18. There were no MDS assessments completed between 6/2/17 and 1/9/18. 4. Review of resident #20's Annual MDS showed an ARD of 7/24/17. Review of the resident's Significant change MDS showed an ARD of 1/12/18. There were no MDS assessments completed between 7/24/17 and 1/12/18. 5. Review of resident #21's Quarterly MDS showed an ARD of 5/30/17. Review of the resident's Significant change MDS showed an ARD of 1/9/18. There were no MDS assessments completed between 5/30/17 and 1/9/18. 6. Review of resident #36's Quarterly MDS showed an ARD of 6/1/17. Review of the resident's Significant change MDS showed an ARD of 1/2/18. There were no MDS assessments completed between 6/1/17 and 1/2/18.",2020-09-01
410,LIVINGSTON HEALTH & REHABILITATION CENTER,275047,510 S 14TH ST,LIVINGSTON,MT,59047,2018-05-31,656,D,0,1,CIM911,"Based on observation, interview, and record review, the facility failed to implement the Comprehensive Care Plan for a resident who had cognitive deficits and needed assistance for oral care, for 1 (#9) of 20 sampled residents. Findings include: During an observation on 5/29/18 at 11:00 a.m., resident #9 was in the bathroom brushing his teeth by himself, while in his wheel chair. He had toothpaste running down the sides of his mouth over his chin. The resident was struggling to rinse his tooth brush and dropped it in the sink two times. During an interview on 5/31/18 at 9:00 a.m., staff member H stated resident #9 liked to do everything himself and staff do not help him unless he asks for help. Review of resident #9's Comprehensive Care Plan showed: Problem - Resident #9 had an ADL self-care performance deficit r/t Dementia, Impaired balance, Limited mobility. Interventions/ Tasks - ORAL CARE ROUTINE (AM, HS and PRN): Staff assistance to brush teeth, rinse mouth with wash. - PERSONAL HYGIENE: The resident requires extensive assist x 1 staff with personal hygiene and oral care. Review of resident #9's Quarterly MDS, with an ARD of 3/27/18, showed: Self-Performance: -Extensive assistance - resident involved in activity, staff provide weight - bearing support. Support: - One person physical assist. The facility failed to update resident #9's care plan based on resident #9's ability to perform oral care on his own, while maintaining his independence.",2020-09-01
411,LIVINGSTON HEALTH & REHABILITATION CENTER,275047,510 S 14TH ST,LIVINGSTON,MT,59047,2018-05-31,658,D,0,1,CIM911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility allowed 1 (#40) out of 20 sample residents to use oxygen by nasal cannula without a physician's orders [REDACTED].>During an observation on 5/30/18 at 9:43 a.m., resident #40 was in her room sitting up in bed. She was noted to be wearing an oxygen cannula connected to an oxygen concentrator. It was turned on to provide oxygen at 2 L/M. She was also noted to have an oxygen tank with nasal cannula and oxygen tubing connected to her wheelchair at her bedside. The oxygen tank was turned off. During an interview on 5/30/18 at 9:44 a.m., Resident #40 said she had been using an oxygen cannula since her admission to the facility. A review of resident #40's admission orders [REDACTED]. A review of resident #40's care plan showed on 1/10/18 the resident was on oxygen therapy for [MEDICAL CONDITION], OSA, [MEDICAL CONDITION] and [MEDICAL CONDITION]. The care plan showed O2 via nasal cannula as ordered, Monitor SATS as ordered, and Notify MD as ordered. The resident's care plan had been last revised on 1/10/18 and emphasized proper resident positioning to allow full lung ventilation. A review of resident #40's most recent physician's recapitulation record, dated 4/1/18 through 5/31/18, did not show that the resident was ordered to receive oxygen. There were no orders for oxygen flow rates. A review of resident #40's (MONTH) (YEAR) MARS, did not show the resident had an order to receive oxygen. A review of resident #40's (MONTH) (YEAR) TARS, did not show the resident had an order to receive oxygen. The TARS did not show monitoring or documentation of resident #40's oxygen saturation levels. During an interview on 5/30/18 at 4:30 p.m., staff member B said that she was aware resident #40 was continuing to use oxygen. She did not know that the resident did not have orders for her to continue its use. She said she would have to look into the matter.",2020-09-01
412,LIVINGSTON HEALTH & REHABILITATION CENTER,275047,510 S 14TH ST,LIVINGSTON,MT,59047,2018-05-31,698,D,0,1,CIM911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have a written agreement between the facility and the [MEDICAL TREATMENT] center. This had the potential to affect all residents receiving [MEDICAL TREATMENT]. Findings include: During an observation on 5/29/18 at 11:45 a.m., resident #36 returned from [MEDICAL TREATMENT], to the facility, via stretcher accompanied by EMTs. During an interview on 5/31/18 at 2:20 p.m., staff member A stated a written agreement between the facility and the [MEDICAL TREATMENT] center could not be located. Review of the policy titled [MEDICAL TREATMENT], item number five showed the center would maintain a current written agreement with each [MEDICAL TREATMENT] center responsible for the management and care of each resident undergoing [MEDICAL TREATMENT]. The agreement delineates the functions, responsibilities, and services of both the [MEDICAL TREATMENT] center and the center.",2020-09-01
413,LIVINGSTON HEALTH & REHABILITATION CENTER,275047,510 S 14TH ST,LIVINGSTON,MT,59047,2018-05-31,804,D,0,1,CIM911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent 1 (#23) of 20 sampled residents from sustaining 2nd [MEDICAL CONDITION] the upper thighs from hot coffee. Findings include: During an observation on 5/31/18 at 12:05 p.m., the temperature of the coffee was tested at 147 degrees Fahrenheit. During an interview on 5/29/18 at 3:34 p.m., NF5 stated resident #23 dumped hot coffee into his lap which resulted [MEDICAL CONDITION] his upper legs (his right leg was red and his left leg had two small blisters, fingertip sized). She stated she had on more than one occasion said to staff that the coffee was hot. She stated the nurse was not aware of the incident until the resident was preparing for a shower. She stated the resident said his leg hurt, but was unable to state what had happened. During an interview on 05/31/18 at 2:18 p.m., Staff member B stated the resident had poor safety awareness. She stated the facility had not had any complaints of the coffee being too hot. She stated the resident was evaluated for adaptive equipment such as a mug with a lid, following the incident. Review of resident #23's Significant Change MDS, with an ARD of 4/13/18, showed the resident was severely cognitively impaired. Review of resident #23's Multidisciplinary Progress Notes showed the following: -5/10/18; alert and oriented to self and family. Able to make basic needs known. No safety awareness. -5/11/18; continues with poor safety awareness. Resident had spilled hot coffee on his lap during lunch and received first [MEDICAL CONDITION] bilateral inner thighs, left inner thigh measured 5.2 cm x 2.4 cm and the right inner thigh measured 0.8 cm x 1.2 cm. -5/13/18; area on left inner thigh blistered. -5/14/18; dressing applied to right inner thigh where burn is. -5/15/18; small blister noted to left thigh in addition to right thigh, no s/s of infection, tender during dressing change. Review of resident #23's event report sent to the State Survey Agency, dated 5/11/18, showed the resident was sitting in the dining room, drinking a cup of coffee. As the resident was bringing the cup to his mouth he dropped the cup on his lap resulting in first [MEDICAL CONDITION] his upper left and right thighs. [MEDICAL CONDITION] from first [MEDICAL CONDITION] second degree burns. Review of resident #23's care plan showed the following: -Initiated on 3/6/18, with revision on 4/24/18: Eating; the resident required limited assist of one staff for meals. (MONTH) have required more/less assistance at times. -Initiated on 3/6/18: Monitor/document/report PRN s/s or complications related to arthritis. -Initiated on 3/6/18: Assistance needed to be provided by staff to ensure adequate intake of meal/fluids. -Initiated on 3/6/18, with revision on 5/29/18: Offer liquids (including thick liquids) between meals and provide a cup with a lid for hot liquids. -Initiated on 3/6/18: Occupational therapy to screen and provide adaptive equipment for feeding as needed. Review of resident #23's Hot Beverage Evaluation, completed on 5/15/18, four days following the incident on 5/11/18, showed the resident demonstrated impaired orientation, had a [DIAGNOSES REDACTED].",2020-09-01
414,LIVINGSTON HEALTH & REHABILITATION CENTER,275047,510 S 14TH ST,LIVINGSTON,MT,59047,2018-05-31,812,E,0,1,CIM911,"Based on observation, interview, and record review, the facility failed to discard moldy food items and date foods in the communal resident refrigerator. This failure had the potential to affect all residents who consumed food from the kitchen or kept food in the communal resident refrigerator. Findings include: During an observation on 5/29/18 at 10:02 a.m., a box of moldy romaine lettuce, a box of moldy green peppers, and two moldy red peppers, were found in the walk-in refrigerator. During an interview at 5/29/18 at 10:15 a.m., staff member G stated kitchen staff clean out the fridge daily. Staff member G stated she knew that the lettuce in the fridge was starting to turn and would clean it out. During an observation on 5/29/18 at 10:21 a.m., there was an un-sealed bag with half of a sandwich, dated 4/23, in the communal resident fridge. During an interview on 5/31/18 at 1:30 p.m., staff member F stated staff get rid of food that has not been eaten after seven days. Review of the record titled Safe Handling for Foods from Visitors showed, Ensure that foods are in a sealed container to prevent cross contamination. and, Daily monitoring for refrigerated storage duration and discard of any food items that have been stored for less than or equal to 7 days. During an observation on 5/31/18 at 1:30 p.m., the following items did not have a received by date: - Tropicana orange juice - Chocolate snack pudding - Italian dressing - Braunschweiger meat - Ready whip - Strawberries During an interview on 5/31/18 at 1:30 p.m., staff member F stated food that is put in the communal resident refrigerator was supposed to be labeled with the date it was put in the resident fridge. Review of the record titled Safe Handling for Foods from Visitors showed, Label foods with the resident name and the current date.",2020-09-01
415,LIVINGSTON HEALTH & REHABILITATION CENTER,275047,510 S 14TH ST,LIVINGSTON,MT,59047,2018-05-31,839,D,0,1,CIM911,"Based on interview and record review, the facility failed to follow Montana State law when it allowed a newly hired employee to provide direct resident nursing care without a Montana State nursing license. This had the potential to affect all of the residents, to who the new employee gave direct care, during the days she worked without a current State nursing license. Findings include: Review of a facility incident report sent to the State Survey Agency, alleged an LPN practiced without a valid Montana license for eight shifts, from 7/4/17 - 7/16/17. The facility's investigation outcome substantiated the incident. During an interview on 5/30/18 at 5:30 p.m., Staff member C said NF2 was from out of state and held a nursing license from a State that did not have a compact agreement with the State of Montana. He said the facility corporation had hired her and paid to bring her to Montana. Staff member C said that he was assisting in a corporate mock survey when a review of staff licenses showed NF2 did not have a Montana State Nursing License. When this was determined, NF2, NF3, and NF4, were immediately suspended until an investigation was completed. Staff member C said that all three were eventually terminated. NF2 had worked several night shifts doing direct resident care prior to being suspended. Staff member C said the facility did notify the Montana Board of Nursing of the incident. He said NF2 had previously applied for her Montana nursing license. It was issued on 7/18/17. Staff member C said the facility's human resources department had been told by the facility's administrator that the new hire was orienting and was working under supervision. Staff member C said NH2 had been working the night shifts on a consistent basis. He said the facility's investigation did not find NH2 under supervision on the dates she had worked. The investigation had determined that NF3 and NF4 were aware that NF2 did not have a Montana nursing license. During an interview on 5/31/18 at 11:00 a.m., staff member [NAME] said she was on vacation the week NF2 started work at the facility. She had come to work to do payroll so people would get paid on time. She said she saw NF2 working and had not seen her before and she asked who she was. She was told she was working night shift as a nurse under someone's supervision. After that, she left and finished her vacation. She said during the mock survey a review of nursing licensing records were reviewed and it was found that NF2 did not have a Montana nursing license. She said usually, because of her position, she is informed of perspective employees long before they are hired, so she can initiate the required background checks and check for proper licensing. She said ordinarily new hires would not be allowed to be at work in the building until they had been determined to have the proper license and their background check was done and free of problems. A review of the facility's Abuse Screening Policy updated in (MONTH) (YEAR) showed, The Center conducts license checks before hire, annually, and more frequent as required by state law and regulation.",2020-09-01
416,LIVINGSTON HEALTH & REHABILITATION CENTER,275047,510 S 14TH ST,LIVINGSTON,MT,59047,2019-07-25,584,E,0,1,PJ7G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure housekeeping and maintenance services were provided to maintain a clean and sanitary environment for 4 (#s 24, 26, 27, and 37) of 26 sampled residents, and 5 ( #s 406, 409, 410, 413, and 415) resident rooms. Findings include: During an observation on 7/22/19 at 11:16 a.m., room [ROOM NUMBER] had a sealed bag with soiled undergarments sitting on the floor, next to the garbage can. In room [ROOM NUMBER], the clothes closet had dust bunnies and black dirt adhered to the floor. There was a two by two inch hole in the sheetrock, in the bathroom, next to the right grab bar. During an observation and interview on 7/22/19 at 11:22 a.m., room [ROOM NUMBER], which was occupied by two residents (#s 24 and 26), was very cluttered with personal items. The floor had dried food particles next to the furniture and personal items. Several areas on the floor had stained circles with adhered, dark brown dirt. The baseboard heater in the bathroom was dirty with an accumulation of dust and hair. Resident #24 stated, It (the room) hasn't been wet mopped in a long time. During an observation on 7/22/19 at 11:35 a.m., room [ROOM NUMBER] had stains on the floor, under the baseboard heater in the bathroom. The stains had dark brown dirt adhered to them. During an observation on 7/22/19 at 2:10 p.m., room [ROOM NUMBER], which was occupied by resident #27, had a pair of used gloves on the floor, next to the garbage can. The baseboard heater behind the bed, next to the window, was dirty with black dirt, and grease stuck to it. The outside wall, next to the window, had a four inch by four inch area with peeling paint and the yellow undercoat of paint was visible. During an observation on 7/23/19 at 8:42 a.m., room [ROOM NUMBER] had a partially eaten food tray, with food spills, sitting on resident #37's bedside table. The baseboard heater, under the window, was broken with the metal guard lying on the floor. The same baseboard heater was dirty with dried, dark brown spills that had dirt adhered to it. The toilet had a light brown liquid in it and had not been flushed. The bathroom sink had a used bath towel lying in it. The fan on the dresser was coated with dark brown dirt, especially on the stand and the back grill, blowing air throughout the room. The privacy curtain was stained with a dried liquid substance. The clothes closet floor had dirt adhered to a previous liquid spill. The floor next to resident #37's bed, had dried pink droplets from a previous spill. The wall next to the door had brown, spilled liquid that had ran down the wall and dried. The back wall baseboard heater and wall was covered in dried grime. During an interview on 7/23/19 at 10:42 a.m., staff member G stated he cleans the rooms that he is assigned to clean. Staff member G stated his cleaning regimen included sanitizing the bathroom, sweeping and mopping the floor, emptying the garbage, dusting and wiping down surfaces, restocking the soap, hand sanitizer, toilet paper, and paper towels. Staff member G stated, I don't clean the bedside table every day, just when it looks dirty. Staff member G stated, I wet mop every room, every day. Staff member G was working on 400 and 500 hallways on Thursday. During an interview on 7/24/19 at 11:43 a.m., staff member H stated the expectation of housekeeping in each room is to clean the entire room. Staff member H stated she cleans, counter clockwise, top to bottom, and mop floors every day, including closets. Staff member H stated, We have a deep cleaning schedule for one room a day. During an interview on 7/24/19 at 2:43 p.m., staff member I stated, The new manager for housekeeping just took over on 7/22/19. The facility was without a manager for (MONTH) 2019. Staff member I stated, New hire housekeeping staff are trained in numerous areas listed on the New Hire Employee Personnel File Checklist. Each housekeeper has a daily work routine check off list, with times for duties to complete in detail. During an interview on 7/24/19 at 3:32 p.m., staff member I stated, Housekeeping assignments on a hall is consistent. The assignments are the same employees. During an interview on 7/25/19 at 7:42 a.m., staff member J stated he had worked for the facility for two years. Staff member J stated his routine for cleaning involved, I empty trash, pick up laundry on the floor and bag it up. I go into the bathroom and restock everything. I clean the toilet, sinks, clean the mirror, dust off the medicine cabinet, wipe off the light switches, handrails, then I sweep and mop the floors. Staff member J stated, Sometimes I have to scrape the floor in the bathroom, sweep and mop under the bed, chairs, furniture, and pick up trash. Staff member J stated, Deep cleaning is done as needed, otherwise you are just wasting your time. Staff member J stated, Many times I am the only housekeeper because of people calling off or quitting. During a record review on 7/24/19 at 3:50 p.m., the Deep Cleaning Calendar showed the rooms were deep cleaned the last time on: -room [ROOM NUMBER] on 7/8/19, -room [ROOM NUMBER] on 7/11/19, -room [ROOM NUMBER] on 6/13/19, -room [ROOM NUMBER] on 7/16/19, -room [ROOM NUMBER] on 7/18/19.",2020-09-01
417,LIVINGSTON HEALTH & REHABILITATION CENTER,275047,510 S 14TH ST,LIVINGSTON,MT,59047,2019-07-25,622,D,0,1,PJ7G11,"Based on interview and record review, the facility failed to ensure the necessary transfer or discharge documentation was communicated to the receiving facility for 2 (#s 41 and 42) of 26 sampled residents. Findings include: During an interview on 7/23/19 at 2:25 p.m., staff member B stated the facility sent copies of the facesheet, POLST, and MAR, to the recieving facility, for all residents tranferred out of the facility. Staff member B stated the facesheet contained contact information for the resident representative and the physician responsible for the care of the resident. The POLST provided the code status for the resident. The MAR indicated [REDACTED]. Staff member B stated no other documentation was sent, and this was all the hospital wanted. Staff member B stated this was the facility's practice, regardless of which hospital the resident was transferred to. Staff member B stated she had never sent the provider progress notes, or the care plan information. Staff member B stated there was no written procedure or protocol describing the tasks and documents expected to be completed when a resident is transferred out of the facility. She stated the nurse on duty was expected to call and provide a verbal report to the receiving facility. During an interview on 7/24/19 at 8:05 p.m., staff member C stated when a resident was transferred to the emergency room , the provider, and the resident representative, were notified by telephone. Staff member C also stated the only paperwork sent was a facesheet, a copy of the POLST, and a copy of the MAR. She stated no other documentation was routinely sent. Staff member C stated she wrote a note in the medical record identifying who the resident went with, i.e. ambulance or private vehicle, and what time the resident left. Staff member C stated that if the resident was admitted , no additional paperwork was sent to the receiving facility. [NAME] Review of resident #41's medical record showed an admission to the hospital from 4/1/19 to 4/5/19. No physician documentation regarding the resident's condition, unmet medical needs on 4/1/19, or the basis for transfer, and subsequent admission to the hospital, was found in the medical record. Physician documentation for resident #41, related to the reason for the transfer, and his condition at the time of transfer, was requested. No documentation of the transfer was received prior to the end of the survey. B. Review of resident #42's medical record showed an admission to the hospital from 6/24/19 to 6/25/19. No physician documentation regarding the resident's condition, unmet medical needs on 6/24/19, or the basis for the transfer and subsequent admission to hospital, was found in the medical record. Physician documentation for resident #41, related to the reason for the transfer and his condition at the time of transfer, was requested. No documentation of the transfer was received prior to the end of the survey. The policy for transfers was requested from the DON, and was not provided prior to the end of the survey.",2020-09-01
418,LIVINGSTON HEALTH & REHABILITATION CENTER,275047,510 S 14TH ST,LIVINGSTON,MT,59047,2019-07-25,623,E,0,1,PJ7G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide to the resident or resident's representative, a written notice of transfer with the reasons for the transfer; and failed to notify the ombudsman of facility initiated transfers and discharges, for 5 (#s 15, 39, 41, 42, and 150) of 26 sampled residents. Findings include: [NAME] During an interview on 7/23/19 at 2:25 p.m., staff member B stated the process of the written transfer notification was evolving. Staff member B stated the resident's representative was usually not in the facility during the transfer, and was therefore unable to receive the written transfer notification prior to the transfer being completed. Staff member B stated most of the transfer notifications were done by phone, and then should have been mailed to the resident representative. Staff member B stated the previous administrator was responsible for sending facility initiated transfer and discharge notifications to the ombudsman via email. 1. During an interview on 7/23/19 at 12:59 p.m., NF1 stated she agreed to resident #41's transfer and subsequent hospital admission on 4/1/19. She does not remember receiving any written paperwork related to the reason for the transfer. During an interview on 7/23/19 at 4:45 p.m., staff member B stated no written transfer notification form existed for resident #41's transfer and hospital admission from 4/1/19 to 4/5/19. Documentation of the email notifying the ombudsman of the transfer for resident #41 was requested from DON on 7/24/19. No documentation was received prior to the end of the survey. 2. During an observation and interview on 7/22/19 at 2:53 p.m., resident #42 stated she had gone to the hospital several times since being admitted in (MONTH) of 2019. She did not remember the specific details of the visits, or receiving any written paperwork regarding the reasons for her hospital visits. Resident #42 did admit to some memory issues, but could not produce any paperwork related to the transfers discussed. Review of resident #42's nursing notes, dated 6/24/19 at 1:00 a.m., showed the resident was complaining of left sided numbness. The note does not identify if any treatment was provided, or what time the transfer occurred. Resident #42's nursing notes, dated 6/25/19, showed the resident returned to the facility, [MEDICAL CONDITION] occurred. Documentation of the required written transfer notification was requested from the DON on 7/23/19. No documentation was provided prior to the end of the survey. Documentation of the email notifying the ombudsman of the transfer for resident #41 was requested from the DON on 7/24/19. No documentation was received prior to the end of the survey. B. During an interview on 7/25/19 at 7:38 a.m., staff member F stated when a resident gets transferred to the hospital, the facility nurse would call the family, but did not have any documentation for the transfer (notice information and reason), and nothing was signed by the resident or resident representative. Review of resident #15's discharge summary showed resident #15 was hosptalized on [DATE]. Review of resident #15's chart showed a transfer notification and information had not been provided to the resident or resident representative, in writing, for the most recent hospitalization of 4/7/19. A request was turned into staff member R on 7/24/19 at 1:30 p.m. for copies of the transfer notification information, and documentation for resident #15 was not provided by the facility. C. During an interview on 7/23/19 at 4:36 p.m., staff member B stated transfer notifications had been a struggle (to complete) due to residents families living out of state. Review of resident #150's Resident Notice of Transfer or discharge date d 5/6/19, showed only a, verbal 5/13/19 to (Resident Representative) was provided or documented. D. During an interview on 7/23/19 at 2:03 p.m., resident #39 stated she went to the hospital two times since January. Resident #39 stated, I was sick and came back on antibiotics. During an interview on 7/24/19 at 8:18 p.m., staff member A stated she, supposed that they (facility) would do a notice of transfer (information and reason) or a bed hold for a discharge. I have never done one, so I don't know. During an interview on 7/25/19 at 7:39 a.m., staff member B stated, I'm trying to provide it (notice of transfer), but it is a revolving process, most of it is verbal. Staff member B stated, The information for the ombudsman was going to the old administrator. Staff member B stated the ombudsman was not notified of resident #39's hospitalization s. Record review of resident #39's medical records from the hospital, showed the resident was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Record review of resident #39's medical records from the hospital, showed the resident was transferred to the hospital on [DATE] and returned to the facility on [DATE].",2020-09-01
419,LIVINGSTON HEALTH & REHABILITATION CENTER,275047,510 S 14TH ST,LIVINGSTON,MT,59047,2019-07-25,625,D,0,1,PJ7G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written information for a bed hold, when transferred, for 5 (#s 15, 39, 41, 42, and 150) of 26 sampled residents. Findings include: [NAME] During an interview on 7/23/19 at 2:25 p.m., staff member B stated the written notice of bed hold was not currently being done. Staff member B stated the process had been to have the resident or resident representative sign the bed hold form on admission. This was the only time this issue was discussed with the resident or resident representative. During an interview on 7/24/19 at 8:05 p.m., staff member C stated she verbally notified the resident or family that the bed would be there, at the facility, when the resident was ready to return. She stated no written notification or information for the bed hold had been provided (at the transfer). Staff member C stated she had not received any education regarding a change in the bed hold process. 1. During an interview on 7/23/19 at 12:59 p.m., NF1 stated she was notified by phone, when resident #41, her spouse, was tranferred to the emergency room or hospital. NF1 stated she does not remember receiving information regarding a bed hold at the time of these transfers. Review of resident #41's medical record showed no documentation of information for a bed hold was provided to resident #41 or his representative, when he was transferred to the hospital on [DATE]. 2. During an interview on 7/23/19 at 2:25 p.m., resident #42 stated she had been to the hospital several times since her admission in (MONTH) of 2019. Resident #42 stated she did not remember receiving any written paperwork related to information for a bed hold or policy. Review of resident #42's medical record showed no documentation of information for a bed hold was provided when she was transferred to the hospital on [DATE]. B. During an interview on 7/24/19 at 7:40 a.m., staff member B stated bed hold policies were signed on admission. Review of resident #15's discharge summary showed resident #15 was hosptalized on [DATE]. Review of resident #15's chart showed bed hold information had not been provided to the resident or resident's representative for resident #15's most recent hospitalization on [DATE]. A request was turned into staff member R on 7/24/19 at 1:30 p.m., for resident #15's bed hold information when transferred to the hospital; the documentation was not provided by the facility. C. During an interview on 7/23/19 at 4:36 p.m., staff member B stated there was no bed hold information provided for resident #150's most recent hospitalization of 5/13/19. During an interview on 7/24/19 at 7:40 a.m., staff member B stated resident #150 was expected to return to the facility. During an interview on 7/24/19 at 7:50 a.m., staff member [NAME] stated the facility recently started using transfer and bed hold notifications. Review of resident #150's chart showed no bed hold information was provided when the resident was transferred. A request was turned into staff member R on 7/24/19 at 1:30 p.m. for resident #150's bed hold information provided on transfer; but the documentation was not provided by the facility. D. During an interview on 7/24/19 at 8:18 p.m., staff member A stated she, supposed that they (facility) would do a notice of transfer or a bed hold for a discharge. I have never done one, so I don't know. During an interview on 7/25/19 at 7:39 a.m., staff member B stated, The representative signs the bed hold policy upon admission. The bed hold policy is mentioned when the notice of transfer is done verbally. Review of resident #39's nursing notes showed the following: -5/24/19 the resident was transferred from the facility, to the hospital, for possible urinary tract infection, -6/12/19 the resident was transferred from the facility, to the hospital, for possible urinary tract infection with recent hospitalization for urosepsis. Review of the facility's policy for bed holds, updated (MONTH) 2019, showed: - The resident or resident representative is informed of this policy in writing upon admission, transfer, or leave of absence. - If nursing is unable to provide . the Social Services Director or designee contacts . to obtain a decision. The notification is documented.",2020-09-01
420,LIVINGSTON HEALTH & REHABILITATION CENTER,275047,510 S 14TH ST,LIVINGSTON,MT,59047,2019-07-25,761,D,0,1,PJ7G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the disposal of expired stock medications and medical supplies. This deficient practice had the potential to affect all residents receiving stock medications or medical supplies. Findings include: During an observation on 7/25/19 at 9:34 a.m., the Front medication storage room had the following expired items: - one unopened bottle of [MEDICATION NAME] packing, expired 4/19, - one open box of 0.9% normal saline, single use, disposable ampoules, expired 7/21/19, - one Foley catheter, size 16 french, 2 way, expired 6/19. During an observation on 7/25/19 at 10:30 a.m., the Front medication cart had one opened box of [MEDICATION NAME] 600 mg unit dose tablets, expired 4/19. During an interview on 7/25/19 at 9:34 a.m., staff member B stated there were a number of ways that expired medications were identified. Staff member B stated that she did random checks of the medication storage rooms. Staff member B stated the corporate nurse consultants came to the facility two to three times per month and checked for expired medications and supplies. Staff member B stated the night nurses also checked for expired medications. Staff member B stated no specific responsibility for this task was assigned, and that all staff were responsible for ensuring that expired medications and supplies were not available for use.",2020-09-01
421,LIVINGSTON HEALTH & REHABILITATION CENTER,275047,510 S 14TH ST,LIVINGSTON,MT,59047,2019-07-25,812,F,0,1,PJ7G11,"Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the kitchen. The deficient practice had the potential to affect all residents who received food from the kitchen. Findings include: During an observation on 7/22/19 at 11:02 a.m. the following was identified related to unsanitary conditions: 1. Main kitchen area- floor had accumulation of dried food particles, underneath thshelving, against the stove, and the oven 2. Coffee maker - the maker was leaking coffee onto the floor, leaving a dark brown, round, wet spot. 3. Range burners/stove - dried, burnt on food particles were adhered to the range burners, - dried food crumbs were scattered sporadically on the range top, - rust brown drips were burnt onto the left side of the range stove. 4. Shelving to the left of range stove - brown dirt adhered to the shelf, where clean containers were placed upside down for storage. 5. Dry food storage - the fan attached to the refrigerator unit, drip plate and rubber hosing, were caked with thick dust. 6.Freezers - the floor was dirty with black, dried dirt adhered to it from previous spills, - dried food particles and paper scraps were uncleaned on the bottom shelves. 7. Ice machine - A large puddle of water underneath the machine, and there was a puddle of water in front of the machine, running toward the exit door, - hard water streaks ran down the front and side of the machine. During an observation on 7/23/19 at 7:22 a.m.: 1. Coffee maker - the coffee maker continued to drip coffee onto the floor, leaving a wet area. 2. Convection oven - burnt food adhered to the bottom and the oven racks. 3. Shelving to the left of the range stove - dirt adhered to the shelf, and you could see where boxes had been sitting, and the shelf was not wiped down or cleaned. 4. Range stove - black grease residue remained on the burners. 5. Dry food storage - the fan attached to the refrigerator unit, drip plate, and rubber hosing, continued to have dust. 6. Freezers/freezer room - there was dried food and paper particles on the bottom shelf, - there were dried spills on the floor that had not been cleaned or mopped up for the spills, - dried dirt adhered to old liquid spills on the floor, - the rug had dirt and gravel in the grooves which had built up, - the wall, closest to the light switch, had streaks running down the wall where liquid was spilled and not cleaned, 7. Ice machine - A large puddle of water under the machine continued to be present; hard water streaks remained down the side and front of the equipment, - hard water streaks down the front and side of the machine. During an observation on 7/24/19 at 10:31 a.m.: 1. Dry storage room - dust remained on the fan attached to the refrigerator unit and the rubber hosing, - the fan was dripping a dark brown liquid residue from the drip plate, onto the floor, in two areas, - dried food particles remained on the bottom shelves. 2. Shelving to the left of the range stove - dirt continued to be present and adhered to the surface. 3. Top convection oven - charred food on the bottom. During an observation on 7/24/19 at 8:06 p.m., staff member K was observed placing dirty dinner trays in the dry storage room, next to the kitchen. During an observation on 7/24/19 at 8:15 p.m., two puddles of water were under the ice machine, and had not been cleaned up. During an interview on 7/24/19 at 10:43 a.m., staff member N stated, The dietary aide on duty is assigned to specific deep cleaning duties daily. For an example, today is cleaning the walls and pipes. The aides follow the AM and PM job routine that is posted on the wall. During an interview on 7/24/19 at 10:50 a.m., staff member L stated, Oven cleaning is done on off hours, like 9:00 p.m. The oven needs to be cool. They are running the oven from 6:00 a.m. to 7:30 p.m. We use degreaser and other oven cleaner, then rinse with warm water and rinse agent. Staff member L stated, Deep clean on the stove is done once a month, the freezers, everything. Last time a deep clean was done was on 6/6/19. We literally clean from one end to the other. During an interview on 7/24/19 at 2:14 p.m., staff member M stated he cleans the fans in the kitchen monthly. During an interview on 7/24/19 at 2:30 p.m., staff member P stated deep cleaning is done weekly, along with other tasks. During an observation on 7/25/19 at 8:16 a.m.: 1. Range stove - spilled, burnt meat adhered to the top and inside of the stove burner. 2. Coffee maker - there was coffee dripping onto the floor, leaving a puddle, - there were coffee grounds burnt to the warming burner. 3. Floor of main kitchen area - dried food particles remained under the stove. 4. Top convection oven - burnt food adhered to the bottom. 5. Dry storage room - dust remained on the rubber hosing, next to the fan attached to the refrigerator unit. 6. Steam table - hard water stains and rust colored puddles of water were under the table, on the floor. 7. Juice dispenser - splatters stuck to the front of the machine, which had not been cleaned. 8. Freezer room - the floor remained stained with dried liquid and dirt, - underneath the freezer, closest to the dining room, there was a large area where brown liquid was spilled, not cleaned up, and now the liquid was dried with black dirt adhered to the area. 9. Ice machine - large puddle of water was under the ice machine. During an interview on 7/25/19 at 8:16 a.m., staff member L stated the area under the stove is cleaned daily. Staff member L stated, The freezers are cleaned on every Monday, everything is pulled out and rotated anyway. During an interview on 7/25/19 at 8:20 a.m., staff member O stated, Coffee always drips on the floor. A review of the facility's job description for Dining Services District Manager and Dining Services Director/Account Manager showed, Ensures that established sanitation and safety standards are maintained. A review of the facility's job description for Cook and Dietary Aide showed, Follows posted cleaning schedules utilizing proper sanitation and cleaning methods. A review of the facility's Deep Cleaning Schedule showed, all tasks were signed and dated that the tasks were completed.",2020-09-01
422,POLSON HEALTH & REHABILITATION CENTER,275049,9 14TH AVE W,POLSON,MT,59860,2017-07-26,225,D,0,1,1F7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report possible abuse to the State Agency no later than 24 hours after the discovery of an injury of unknown source, where the source of the injury was not observed by anyone, nor could it be explained by the resident, and it was extensive enough to warrant a physician order [REDACTED]. 1. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #9's nursing notes, dated 11/23/16, reflected the resident had an abrasion from an unwitnessed fall on 11/22/16. The nursing note on 11/22/16 reflected the resident was checked from head to toe and had no apparent injury. The facility provided a 24 hour report reflecting a burn to the left thigh, dated 11/23/16, and a subsequent telephone order, dated 11/23/16, for wound treatments to the left thigh. Review of resident #9's medical record showed no documentation of an investigation into the source of the burn, and there was no indication in the nursing notes that staff asked the resident how the injury occurred. Review of the resident #9's annual MDS, dated [DATE], reflected a staff assessment that the resident makes self understood, and understands verbal content. During an interview on 7/26/17 at 11:15 a.m., staff member B stated they could not find any investigation into the incident. She stated she could not remember the cause of the burn or the circumstances surrounding the burn. She said she thought it was a coffee burn. She stated she asked the nurse that was working that shift and she did not remember the source of the burn either. During an interview on 7/26/17 at 1:40 p.m., staff member A stated they will open an investigation into the incident.",2020-09-01
423,POLSON HEALTH & REHABILITATION CENTER,275049,9 14TH AVE W,POLSON,MT,59860,2017-07-26,278,E,0,1,1F7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately reflect the mood, cognition, and pain status for 5 (#s 1, 3, 4, 7, and 8); a significant weight loss for 1 (#3); a fall with a [MEDICAL CONDITION] for 1 (#1); and an ostomy coded in error for 1 (#5) of 11 sampled residents. Findings include: 1. Review of resident #1's Quarterly MDS, with the ARD of 5/18/17, showed the resident was always understood, and always understands. The Brief Interview for Mental Status and the Mood interview showed the resident was rarely or never understood, and were completed by staff, not the resident. Review of resident #1's Quarterly MDS, with the ARD of 5/18/17, showed the resident had no falls. Review of the facility Fall Log showed he fell on [DATE] and sustained a [MEDICAL CONDITION]. During an interview on 7/25/17 at 9:45 a.m., staff member C stated she had missed the fall with a fracture, and would modify the MDS. 2. Review of resident #3's Quarterly MDS, with the ARD of 4/30/17, showed the resident was always understood, and always understands. The Brief Interview for Mental Status and the Mood interview showed the resident was rarely or never understood, and were completed by staff, not the resident. Review of resident #3's Quarterly MDS, with the ARD of 4/30/17, showed the resident had experienced a physician ordered significant weight loss. During an interview on 7/26/17 at 2:20 p.m., staff member C stated this was a coding error, and the MDS would be modified to show a Not physician prescribed weight loss. She also stated resident #3 would not talk to her, so she did not complete the interviews. 3. Review of resident #8's Quarterly MDS, with the ARD of 7/14/17, showed the resident was always understood and always understands. Review of the Pain Management section showed the resident was rarely or never understood, and the pain interview was not completed with the resident. During an interview on 7/26/17 at 10:05 a.m., staff member C stated she did not think the pain interview would be accurate, so she completed a staff interview. 4. Review of resident #4's Quarterly MDS, with an ARD of 4/26/17, showed, in Section B, the resident was always understood. The Brief Interview for Mental Status showed resident #4 was rarely or never understood, and was completed as a staff interview instead of being completed with the resident. Review of resident #4's Significant Change in Status MDS, with an ARD of 1/31/17, showed, in Section B, the resident was usually understood. The pain interview showed resident #4 was rarely or never understood and was completed as a staff interview instead of being completed with the resident. 5. Review of resident #5's Admission MDS, with an ARD of 2/14/17, showed, in Section H, the resident had an ostomy. Review of resident #5's medical record showed no diagnosis, or other indication of an ostomy. During an observation and interview on 7/26/27 at 9:35 a.m., staff member D provided catheter care to resident #5. No ostomy site was observed. Staff member D stated he had been taking care of resident #5 on and off since the resident's admission and did not remember the resident having an ostomy. During an interview on 7/26/17 at 1:52 p.m., staff member C stated the coding of an ostomy was an error. She stated she had not realized it was coded incorrectly so she had not corrected it. Staff member C stated the facility did not have a method to ensure MDS accuracy, other than each person who completes a section, checking their own work. Staff member C stated the IDT wanted to have a process to check for accuracy, but had not had time to develop one. 6. Review of resident #7's significant change MDS, with an ARD of 9/9/16, showed, in Section B, the resident was usually understood. The Brief Interview for Mental Status showed resident #7 was rarely or never understood, and was completed by staff instead of being completed with the resident. Review of resident #7's quarterly MDS, with an ARD of 5/10/17, showed, in Section B, the resident was understood. The Brief Interview for Mental Status showed resident #7 was rarely or never understood, and was completed by staff instead of being completed with the resident. The pain interview showed resident #7 was rarely or never understood and was completed by staff instead of being completed with the resident.",2020-09-01
424,POLSON HEALTH & REHABILITATION CENTER,275049,9 14TH AVE W,POLSON,MT,59860,2017-07-26,280,D,0,1,1F7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to update a resident care plan following an accidental injury which required medical treatment for 1 (#9) of 11 sampled residents. Findings include: 1. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #9's medical record reflected the discovery of a burn to the left thigh which needed treatment. Resident #9's medical record reflected a physician telephone order dated 11/23/16 for wound care to the left thigh. Review of resident #9's skin integrity care plan reflected a review on 11/15/16 and again on 2/10/17. There was no revision, update, or mention of the new wound on the left thigh on or around 11/23/16.",2020-09-01
425,POLSON HEALTH & REHABILITATION CENTER,275049,9 14TH AVE W,POLSON,MT,59860,2017-07-26,281,E,0,1,1F7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to meet professional standards by not conducting neurological exams for 72 hours after falls with a potential head injury, for 3 (#s 4, 5, and 6) of 11 sampled residents; and by leaving medications with a resident, without an order, for 1 (#13) of 19 sampled and supplemental residents. Findings include: 1. Review of resident #4's Licensed Nurses Progress Notes from [DATE]-[DATE], showed the resident had unwitnessed falls on [DATE] and [DATE]. Review of resident #4's Licensed Nurses Progress Notes, untimed and dated [DATE], showed resident #4 was found lying on floor at the end of 300 hall and there was a large raised ecchymotic area to forehead. Review of resident #4's Neurological Evaluation flow sheet showed an initiation date and time of [DATE] at 4:15 p.m. The flow sheet showed the last entry was [DATE] at 4:00 p.m. This represents a total neurological evaluation cycle of 23 hours and 45 minutes. The flow sheet showed 13 timed entries. The flow sheet showed guidelines for the timing of the neurological checks, with a full cycle of 24 hours being completed with 13 neurological checks. Review of resident #4's Licensed Nurses Progress Notes, untimed and dated [DATE], showed the note was a late entry for [DATE]. The note showed the resident was noted to be on the floor in the middle of 300 hall. Fall was unwitnessed. Review of resident #4's Neurological Evaluation flow sheet showed the initiation date and time was [DATE] at 11:30 a.m. The flow sheet showed the last entry was undated and timed 12:45 p.m. The flow sheet showed 14 timed entries. The flow sheet showed guidelines for the timing of the neurological checks, with a full cycle of 24 hours being completed with 13 neurological checks. 2. Review of resident #5's IDT Fall review notes, dated [DATE], [DATE], and [DATE] showed the resident had falls on [DATE], [DATE], and [DATE], and neurological checks were initiated after each fall. During an interview on [DATE] at 2:10 a.m., staff member B stated the Neurological Evaluation flow sheets were not in the chart and she would locate them. She said resident #5 would have had neurological checks for a 24-hour cycle. The Neurological Evaluation flowsheets, for the [DATE], [DATE], and [DATE] falls, were not provided. 3. Review of resident #6's Licensed Nurses Progress Notes, untimed and dated [DATE], showed the resident was found on floor lying flat on back, and stated she hit the back of her head on floor. Review of resident #6's Neurological Evaluation flow sheet showed the initiation date and time was [DATE] at 5:45 a.m. The flow sheet showed the last entry was [DATE] at 6:30 a.m. This represents a total cycle of 24 hours and 45 minutes. The flow sheet showed 12 timed entries. The flow sheet showed guidelines for the timing of the neurological checks, with a full cycle of 24 hours being completed with 13 neurological checks. During an interview on [DATE] at 2:10 p.m., staff member B stated neurological checks are completed after an unwitnessed fall, and after a witnessed fall if the resident hit his/her head. She stated the facility policy was to conduct neurological evaluations on a set schedule for 24 hours. She said the neurological evaluations would be continued beyond 24 hours, if clinically indicated. 4. During an observation and interview on [DATE] at 7:45 a.m., staff member J was preparing medication for administration to resident #13. She stated two inhalers scheduled for administration were not available on the medication cart, and may be in the resident's room. The two inhalers were noted on resident #13's overbed table. One inhaler was [MEDICATION NAME] and the other was [MEDICATION NAME]. Staff member J stated the inhalers were not ordered for self-administration and should not have been left at the bedside. Review of resident #13's Skilled Nursing Facility Transfer Orders, dated [DATE], showed administration orders for the [MEDICATION NAME] and the [MEDICATION NAME], but not orders for the inhalers to be kept at bedside for self-administration. Review of a facility policy titled, Medication Administration Quick Reference Guide, showed that During the medication pass . 4. Medications are not left at bedside for residents to take later. Assess the resident for changes in level of consciousness, which is a cardinal sign of untoward pathology. Assess the resident immediately after the fall, then frequently throughout the shift. Assessment should continue for a minimum of 72 hours. Observe the resident for obvious injuries to the scalp, including lacerations, bruises, or contusions; confusion; memory loss; difficulty speaking; gait or balance problems; pupils of unequal size or reactions; headache; vomiting; visual disturbances; or periods of coherence alternating with periods of confusion or lethargy. Monitoring must continue for a minimum of 72 hours (or until the resident is asymptomatic for a specified period of time). Perform frequent neurologic assessments every: 15 minutes for two hours 30 minutes for two hours 60 minutes for four hours Eight hours for 16 hours Eight hours until at least 72 hours have elapsed and resident is stable Neurological checks for head injuries, LTC Clinical Pearls: Powered by HCPro's Long-Term Care Nursing Library, (MONTH) 8, 2013 According to Kozier and Erb's, the standard of practice for medication administration requires the licensed nurse to remain with the resident until all medications have been swallowed. Bermin, [NAME], Snyder, S., Kozier, B., & Erb, [NAME] (2002). Kozier & Erb's techniques in clinical nursing (5th ed.) New Jersey: Pearson Education.",2020-09-01
426,POLSON HEALTH & REHABILITATION CENTER,275049,9 14TH AVE W,POLSON,MT,59860,2017-07-26,323,D,0,1,1F7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident's environment was safe as possible, and received adequate supervision to prevent accidents by not investigating a burn which required treatment for 1 (#9) of 11 sampled residents. Findings include: 1. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #9's medical record reflected a nursing note on 11/23/16 describing a small abrasion secondary to a fall on 11/22/16. It described the wound to be 4 cm X 1.5 cm with eschar and slightly erythemic, with a dressing placed on the left thigh. The facility provided a 24 hour report for resident #9 with a burn on the left thigh, on 11/23/16, as well as a physician's telephone order for wound care to the left thigh. Review of resident #9's medical record reflected no nursing notes describing the incident or investigation by the nurse once the wound was determined to be a burn and not an abrasion from a fall. Review of resident #9's nursing notes, dated 11/28/16, reflected a burn to resident #9's thigh, healing per resident report. The dressing and the burn were also noted on 11/30/16 and 12/1/16, with no pain or discomfort. Review of resident #9's nursing notes, dated 12/7/16, reflected a nursing note describing the left inner thigh burn appearing to have a scab over entire wound and the resident has no complaints of pain. Review of resident #9's nursing notes, dated 12/9/16, reflected the resident removed the dressing to the left thigh. This was the last mention or description of the wound from the burn in the medical record. In an interview on 7/25/17 at 4:30 p.m., staff member B stated she did not remember the cause of the burn. She stated it may have been coffee. Staff member B also stated she asked the nurse on duty on that date and she did not remember how it happened. At the same interview time, staff member O stated she thought it was coffee. During an interview on 7/26/17 at 11:15 a.m., staff member B stated there is no documentation of an investigation, and there was no assessment such as a hot beverage assessment in the medical record for resident #9. She also stated the care plan had an update for cups with lids and straws, but there was no date next to the update to know if it was done before or after the injury. There was no other care plan updates for resident #9 regarding keeping her safe from accidental burns. During an interview on 7/26/17 at 1:40 p.m., staff member A stated the facility was opening an investigation in the incident.",2020-09-01
427,POLSON HEALTH & REHABILITATION CENTER,275049,9 14TH AVE W,POLSON,MT,59860,2017-07-26,325,D,0,1,1F7Z11,"Based on observation, record review, and interview, the facility failed to provide the altered texture diet, as prescribed by the physician, for 2 (#8 and 16) of 19 sampled residents. Findings include: During an observation on 7/25/17 at 8:20 a.m., resident #16 received 1/2 piece of whole sausage. Her physician-prescribed diet order was for a mechanical soft texture. The diet spreadsheet specified the sausage should have been ground. During an observation on 7/25/17 at 12:25 p.m., resident #8 was served diced, fresh cantaloupe. Review of her diet card showed a soft diet, and the physician-prescribed diet order showed a soft texture. The resident gummed the cantaloupe for 20 minutes. Review of the diet spreadsheet showed soft diets should receive 1/2 banana. During an interview on 7/26/17 at 1:15 p.m., staff member G stated the facility would be using the diet spreadsheet, and providing a consistent soft diet.",2020-09-01
428,POLSON HEALTH & REHABILITATION CENTER,275049,9 14TH AVE W,POLSON,MT,59860,2017-07-26,329,D,0,1,1F7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess a change in condition and provided an antibiotic that was without adequate indication for use for 1 (#1) of 11 sampled residents. Findings include: Review of resident #1's Licensed Nursing Progress Notes, dated 6/3/17 showed the resident had become combative and attempted to barricade himself in his room. Review of resident #1's Physician orders, dated 6/3/17, showed Bactrim DS po BID X 10 days. DX UTI [MEDICATION NAME]. During an interview on 7/26/17 at 2:45 p.m., staff member N stated the staff should have done a dip and follow-up lab work to confirm a [DIAGNOSES REDACTED]. Review of resident #1's Resident Infection Report Form showed new increase in urgency and frequency. There was no identified change in the characteristic of the urine or a fever. These changes did not meet the criteria for treatment of [REDACTED]. Review of resident #1's Licensed Nursing Progress Notes, dated 6/6/17, showed the resident was agitated and combative. Review of resident #1's Licensed Nursing Progress Notes, dated 6/7/17, showed the resident was anxious and agitated before breakfast. Anti-anxiety medication was provided, and the resident had a decrease in anxiety. Review of resident #1's Licensed Nursing Progress Notes, dated 6/11/17, showed the resident was agitated and refusing help when needed. Anti-anxiety medication was provided, and agitation appeared to decrease. Review of resident #1's Licensed Nursing Progress Notes, dated 6/13/17, showed the resident was agitated before breakfast. During an interview on 7/26/17 at 9:50 a.m., staff member B stated the facility should have done some follow-up on resident #1's behaviors and possible UTI.",2020-09-01
429,POLSON HEALTH & REHABILITATION CENTER,275049,9 14TH AVE W,POLSON,MT,59860,2017-07-26,332,D,0,1,1F7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the manufacturer's instructions were followed during medication administration for 3 (#s 10, 13 and 17) of 19 sampled and supplemental residents. The facility medication error rate was calculated at 9.67%. Findings include: 1. During an observation on 7/25/17 at 4:25 p.m., staff member L completed a blood glucose check for resident #10. The blood glucose level was 350 mg/dl. Review of resident #10's (MONTH) (YEAR) MAR indicated [REDACTED]. During an observation and interview on 7/25/17 at 4:30 p.m., staff member L stated resident #10's physician's orders [REDACTED]. She dialed four units on the Humalog insulin administration pen. Staff member L stated she would also administer the four units of insulin scheduled to be administered at 5:30 p.m. She adjusted the dial on the Humalog insulin administration pen to eight units. Staff member L signed the MAR for the 4:00 p.m. sliding scale administration and the 5:30 p.m. scheduled dose administration. Staff member L went into resident #10's room and administered the insulin into the resident's upper arm. Staff member L stated Humalog should be given within 30 minutes of a meal and resident #10 would be eating in about 30 minutes. During an observation on 7/25/17 at 5:00 p.m., dinner had not been served. During an interview on 7/26/17 at 2:20 p.m., staff member B stated resident #10 has a sliding scale dose of Humalog insulin and a mealtime dose of Humalog insulin. She said there is a one hour leeway on each side of the ordered administration time for this medication, just like there is for all other medications. Review of the Humalog's manufacturer's instructions for use showed the following: HUMALOG is a rapid-acting insulin. Take HUMALOG within 15 minutes before eating or right after eating a meal. Resident #10 received four units for the sliding scale coverage instead of eight units that was ordered by the physician. The dose scheduled to be given with a meal was administered at least 30 minutes prior to a meal. See F-333 for significant risks associated with administration. 2. During an observation and interview on 7/27/17 at 7:45 a.m., staff member J was administering medication to resident #13. Staff member J set up a Spireva hand held inhaler for the resident to use. The resident completed the inhaled medication and staff member J encouraged resident #13 to rinse her mouth. Resident #13 took a drink of water and proceeded to inhale on a second inhaler, [MEDICATION NAME], staff member J had handed to her. The resident took a puff and within 10 seconds, took a second puff. Staff member J stated the resident had used these inhalers at home, prior to admission, and liked to use them the way she did at home. Resident # 13 did not rinse her mouth without swallowing and staff member J did not instruct her to do so. During an interview on 7/25/17 at 9:25 a.m., staff member J stated she should have waited for a few minutes between the two inhalers. 3. During an observation on 7/25/17 at 9:27 a.m., staff member J handed a Breo inhaler to resident #17. The resident completed the inhalation and returned the inhaler to staff member J, who encouraged him to take a drink of water. Resident #17 took a drink of water and swallowed. During an interview on 7/26/17 at 9:30 a.m., staff member J stated she was not aware of any administration instructions for [MEDICATION NAME] or Breo, except to shake the inhaler and to give an inhaled steroid after other inhalers. Review of [MEDICATION NAME]'s manufacturer's instruction showed, [MEDICATION NAME] may cause serious side effects, including: fungal infection in your mouth or throat (thrush). Rinse your mouth with water after using [MEDICATION NAME] to help reduce your chance of getting thrush Review of Breo's manufacturer's instructions showed, BREO can cause serious side effects, including: fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using BREO to help reduce your chance of getting thrush. During an interview on 7/26/17 at 2:25 p.m., staff member B stated she was the facility educator for the licensed nurses and monitored for medication errors by auditing the MARs at the end of each month and by utilizing an audit tool to observe the nurses during medication administration. A blank audit form was provided. No completed audits were provided by the end of the survey.",2020-09-01
430,POLSON HEALTH & REHABILITATION CENTER,275049,9 14TH AVE W,POLSON,MT,59860,2017-07-26,333,D,0,1,1F7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent a significant medication error by giving rapid-acting insulin more than 15 minutes before a meal, for 1 (#10) of 11 sampled residents. Findings include: 1. Resident # 10 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. During an observation on 7/25/17 at 4:25 p.m., staff member L completed a blood glucose check for resident #10. The blood glucose level was 350 mg/dl. Review of resident #10's (MONTH) (YEAR) MAR indicated [REDACTED]. During an observation and interview on 7/25/17 at 4:30 p.m., staff member L stated the physician's orders [REDACTED]. She dialed four units on the Humalog insulin administration pen. Staff member L stated she would also administer the four units of insulin scheduled to be administered at 5:30 p.m. She adjusted the dial on the Humalog insulin administration pen to eight units. Staff member L signed the MAR for the 4:00 p.m. sliding scale administration and the 5:30 p.m. scheduled dose administration. Staff member L went into resident #10's room and administered the insulin into the resident's upper arm. Staff member L stated Humalog should be given within 30 minutes of a meal and resident #10 would be eating in about 30 minutes. During an observation on 7/25/17 at 5:00 p.m., dinner had not been served. During an interview on 7/26/17 at 2:20 p.m., staff member B stated resident #10 has a sliding scale dose of Humalog insulin and a mealtime dose of Humalog insulin. She said there is a one hour leeway on each side of the ordered administration time for this medication, just like there is for all other medications. Review of the Humalog's manufacturer's instructions for use showed the following: HUMALOG is a rapid-acting insulin. Take HUMALOG within 15 minutes before eating or right after eating a meal. Inject HUMALOG under your skin (subcutaneously). HUMALOG may cause serious side effects that can lead to death, including: low blood sugar ([DIAGNOSES REDACTED]). Signs and symptoms of low blood sugar may include: dizziness or lightheadedness, sweating, confusion, headache, blurred vision, slurred speech, shakiness, fast heartbeat, anxiety, irritability or mood changes, hunger. Resident #10 received four units for the sliding scale coverage instead of eight units that was ordered by the physician. The dose scheduled to be given with a meal was administered at least 30 minutes prior to a meal. Administration of a rapid-acting insulin prior to 15 minutes before eating or not immediately after a meal could lead to [DIAGNOSES REDACTED].",2020-09-01
431,POLSON HEALTH & REHABILITATION CENTER,275049,9 14TH AVE W,POLSON,MT,59860,2017-07-26,363,F,0,1,1F7Z11,"Based on observation, interview and record review, the facility failed to use recipes, and follow a diet spreadsheet for serving sizes, which had the potential to affect all residents who eat meals in the facility. Findings include: During an observation on 7/24/17 at 7:50 a.m., the breakfast tray line did not include ground sausage, or a diet spreadsheet, showing the portion sizes for breakfast. During an interview on 7/25/17 at 4:45 p.m., staff member I stated he did not have a diet spreadsheet, at the moment, and did not have a recipe. He stated he used five pounds of hamburger, because that is the usual amount for ground meat meals. Five pounds of ground meat was also used for spaghetti sauce, without a recipe. This amount of ground beef provided less than two ounces of protein, per resident. The diet spreadsheet specified two ounces of meat. During observations on 7/24/17 and 7/26/17, during lunch service, the plated food included a roll on top of the food. During an interview on 7/26/17 at 1:15 p.m., staff member G stated the dietary department made the same meals over and over, so quit looking at the recipes. He stated there was no problem with staffing in the dietary department, and recipes and spreadsheets would be followed.",2020-09-01
432,POLSON HEALTH & REHABILITATION CENTER,275049,9 14TH AVE W,POLSON,MT,59860,2017-07-26,369,D,0,1,1F7Z11,"Based on record review, interview, and observation, the facility failed to provide adaptive equipment to increase the ability to feed self for 1 (#8) of 11 sampled residents. Review of resident #1's physician diet order showed a soft diet with a Sippy Cup. Review of resident #1's diet card showed a scoop plate and built up spoon were to be provided each meal. During observations of breakfast on 7/24/17, 7/25/17, and 7/26/17, resident #1 had no Sippy Cup, or built up utensil. She did not feed herself. During an interview on 7/26/17 at 1:15, staff member G stated the dietary staff made the mistake, and adaptive equipment would be highlighted in some fashion to prevent errors.",2020-09-01
433,POLSON HEALTH & REHABILITATION CENTER,275049,9 14TH AVE W,POLSON,MT,59860,2017-07-26,441,E,0,1,1F7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain an infection control program that prevents the spread of infection by not properly cleaning and storing glucometers for 3 (#s10, 14, and 15); and by not performing appropriate hand hygiene for 5 (#s 5, 14, 15, 18, and 19) of 19 sampled and supplemental residents. Findings include: Hand Hygiene 1. During an observation and interview on 7/26/17 at 9:35 a.m., staff member D prepared to provide catheter care to resident #5. He stated catheter care included cleaning resident #5's perineal area, cleaning the catheter, and emptying the urinary drainage bag. Staff member D entered the room and stated that he had already prepared resident #5 for the procedure. Resident #5 was sitting in his recliner, with his legs extended. His pants and disposable pull-up briefs were pulled down below his calves and a towel was draped across his lap. Staff member D put on gloves, without performing hand hygiene. He removed the towel, used a disposable wipe to cleanse resident #5's left groin skin fold and discarded the wipe in the trash can. He then used his gloved hand to grab the rim of the trash can and pull it closer to his work area. His gloved fingers were on the inside of the trash can. Staff member D continued cleaning the resident's groin areas, scrotum, and outer surface of the penis. There was an adherent white substance on all of the surfaces being cleansed and staff member D was required to use multiple cloths to remove the substance. Staff member D stated the night shift must have put [MEDICATION NAME] on resident #5's skin. Staff member D retracted the penis foreskin and wiped away more of the adherent white substance. He then resumed cleaning resident #5's scrotum. Staff member D used an alcohol swab to wipe the catheter from the insertion point and away from the resident. He repeated this step two more times. Staff member D then used his gloved hand to turn on the water faucet, wet a washcloth, and resumed cleaning the adherent substance from the resident's skin. Staff member D placed the washcloth in a trash bag, wet a second washcloth, and turned off the faucet with his gloved hand. He continued cleaning the resident, then placed the washcloth in the trash bag. Staff member D covered resident #5's lap with the towel he had removed earlier. Staff member D removed and discarded his gloves, picked up the bag of trash and bag of soiled linens, and left the room at 9:47 a.m. Staff member D returned at 9:52 a.m., and stated that he had discussed resident #5's skin care with the nurse and the DON would be in to assess the skin. Staff member D put on gloves without performing hand hygiene. He removed the adhesive-backed holder for the catheter tubing that was attached to the resident's leg. He cleansed the residual adhesive from the resident's skin, applied a new tubing holder and attached the tubing. Staff member D adjusted the positioning of the urinary drainage bag and removed the resident's pants and pull-up brief. He discarded the used brief in the trash can and obtained a clean brief from the resident's dresser. He then laid the brief and the resident's pants on the wheelchair, and lowered the foot rest of the recliner. Staff member D opened an alcohol prep pad, drained the urine from the drainage bag into a graduated container, and cleaned the drainage port with the alcohol prep pad. He adjusted the position of the drainage bag and the straps that secure the bag in place. Staff member D emptied and rinsed the graduated container. Wearing the same gloves, staff member D put resident #5's clean pull-up brief and pants on, up to the calves. He placed a gait belt on resident #5 and put the resident's walker in place. Staff member D made two unsuccessful attempts to assist the resident to stand, by holding onto the gait belt and guiding the resident's hand on the walker. Staff member D removed his gloves and went into the hallway, just beyond the door to the resident's room. After looking up and down the hall for a few seconds, staff member D returned to the room, washed his hands and left the room. Staff member D returned with staff member K. Staff members D and K washed their hands and put on gloves. They assisted the resident to stand, pulled up his brief and pants, and assisted him to sit into the recliner. Staff member D stated he did not wash his hands in the room at the start of the observation because he had washed before he came into the room. He stated he had not washed his hands when he returned to the room at 9:52 a.m. Staff member D stated he had changed gloves five times and he didn't know if there were any times he should have changed and did not. Staff member D ended the interview stating that he was late for a personal matter and had to leave. Glucometer Disinfecting 2. During an observation and interview on 7/25/17 at 4:25 p.m., staff member L completed a blood glucose check for resident #10. She removed a glucometer from the top left drawer of the medication cart. The glucometer was not in a container, case, or wrapping. She stated the glucometer was supposed to be disinfected after each use, but there was no way to be certain. She stated the glucometer was used for multiple residents. Staff member L completed the blood glucose check and then disinfected the glucometer. Glucometer Disinfecting and Hand Hygiene 3. During an observation on 7/25/17 at 4:40 p.m., staff member N prepared to administer medication and obtain a blood glucose check for resident #14. After preparing the medications, staff member N performed hand hygiene. She removed a glucometer from the top left drawer of the medication cart. The glucometer was not in a container, case, or wrapping. Staff member N placed the glucometer on the medication cart with no barrier underneath. She laid an unwrapped gauze pad on the cart with no barrier underneath. She opened an alcohol prep pad, removed a portion of the wrapper and exposed the pad. Staff member N laid the alcohol prep pad on the cart without a barrier underneath. She then put gloves on both hands, picked up the supplies and medication cup, and proceeded to resident #14's room. Staff member N knocked on the door with a gloved hand and entered. She performed a blood glucose check on the resident using the alcohol prep to cleanse the skin and the gauze pad to wipe the puncture site. Wearing the gloves that were put on in the hallway, staff member N then assisted resident #14 to consume her medication. Staff member N touched the bed control buttons, the bedding, and the bed handrail, and then held the end of the straw between her gloved fingers while resident #14 drank from her water glass. Staff member N discarded her gloves and washed her hands. She returned to the medication cart and laid the glucometer on top, without a barrier underneath it. She then disinfected the glucometer and laid it back in the same spot to dry. She handled the glucometer prior to disinfecting it and after disinfecting it without performing hand hygiene. 4. During an observation on 7/25/17 at 4:53 p.m., staff member N prepared to complete a blood glucose check on resident #15. She placed an unwrapped gauze pad and an opened alcohol prep pad on the cart without a barrier. Staff member N then sanitized her hands and put on gloves. She knocked on resident #15's door and opened the door with her gloved hand. She performed a blood glucose check on the resident using the alcohol prep to cleanse the skin and the gauze pad to wipe the puncture site. After completing the blood glucose check, staff member N returned to the medication cart, wearing the gloves she put on before the procedure. She removed and discarded the gloves at the medication cart. Without performing hand hygiene, staff member N disinfected the glucometer and laid it back onto the same area of the cart that she had each previous time, without a barrier underneath it. During an interview on 7/25/17 at 4:55 p.m., staff member N stated she had not received education regarding placing a barrier underneath the glucometer or supplies. She said she should have performed hand hygiene after removing gloves. She stated she was not aware of any policy regarding putting on gloves in the hallway. 5. During an observation and interview on 7/24/17 at 1:05 p.m., staff member J prepared medication for administration to resident #18. After performing hand hygiene, staff member J put a glove on her right hand. She then picked up the medication cart keys, in her gloved right hand, and unlocked the cart. Staff member J pulled a medication card from the cart, with her gloved hand, popped a pill, from the card, into her gloved hand, and then placed the pill in a medication cup. She opened the narcotic sign-out book, took a pen from her pocket, and signed out a medication, using the gloved hand for each task. Staff member J opened the drawer to the medication cart, with the gloved hand, pulled out a medication card, and popped a pill, into the gloved hand, and then placed the pill in the medication cup. Staff member J stated she uses the glove because it is easier to pop the pill into her hand than into the cup. She said she uses the glove to keep the pills from being contaminated by her hands. She administered the medications to resident #18. 6. During an observation on 7/24/17 at 1:42 p.m., staff member J prepared medication for administration to resident #19. After performing hand hygiene, staff member J put a glove on her right hand. She then picked up the medication cart keys, in her gloved right hand, and unlocked the cart. Staff member J pulled two cards from the medication cart, with the gloved hand. She popped a pill, into her gloved hand, and then placed the pill into a medication cup. Staff member J picked up a pen, with her gloved hand, opened, and signed the narcotic book. She then picked up the second card, popped a pill into the gloved hand, and placed the pill into a medication cup. She administered the medication to resident #19. Review of a policy titled, Disinfecting Glucometer and PT/INR Machine, updated (MONTH) (YEAR), showed the meter was to be disinfected with a barrier between the glucometer and any surface the machine is placed upon. Review of a policy titled, Handwashing/Hand Hygiene, updated (MONTH) (YEAR), showed hand hygiene would be performed in the following situations: - before and after direct contact with residents, - before preparing or handling medications, - before and after handling an invasive device, such as a urinary catheter, - before moving from a contaminated body site to a clean body site, - after contact with blood or body fluids, - after removing gloves.",2020-09-01
434,POLSON HEALTH & REHABILITATION CENTER,275049,9 14TH AVE W,POLSON,MT,59860,2017-07-26,514,E,0,1,1F7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to keep medical records which are complete, readily accessible, and systematically organized for 6 (#2, 4, 5, 6, 8, and 9) of 11 sampled residents. Findings include: 1. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of IDT Fall review forms and nursing notes for resident #9 reflected the resident had seven falls since 1/10/17. Only one of the IDT Fall review forms was in the resident chart. During an interview on 7/25/17 at 4:00 p.m., staff member B stated the rest of them were probably in her office, she would have to look. Upon receiving and reviewing the IDT fall investigations, three of the falls were on 3/25/17, 3/29/17, and 4/8/17. There were no nursing notes regarding any of these incidents. There were no nursing notes from 1/10/17 through 5/8/17. During an interview on 7/26/17 at 1:38 p.m., staff member B stated, We chart by exception. During an interview on 7/25/17 at 11:15 a.m., staff member B was asked for documentation of wound assessments, and for the MAR indicated [REDACTED]. The facility failed to produce the MAR for December. During an interview on 7/26/17 at 1:50 p.m., staff member F stated they recognize there is an issue with documentation in the resident charts. 2. Review of resident #2 and 8's Weight Record showed the last recorded weights were for May, (YEAR). During an interview on 7/25/17 at 2:50 p.m., staff member B stated the facility was behind in filing paperwork. 3. Review of resident #4's Licensed Nurses Progress Notes from 1/2/17-2/2/17, showed five notes that included the date and time, and seven notes that included the date and a shift designation. The notes labeled as nocs did not indicate if the date showed the start of the shift or the end of the shift. Nine of the notes included a date, but no reference to the time of the note. Review of resident #4's Licensed Nurses Progress Notes from 1/2/17-2/2/17, showed the resident had unwitnessed falls on 1/2/17 and on 1/7/17 and neurological checks were initiated after each fall. Review of resident #4's Neurological Evaluation flow sheet, dated 1/2/17, showed that 13 neurological checks were done on 1/2/17 and 1/3/17. The following evaluation points were blank on the flow sheet: - level of consciousness, for two evaluations - pupil response, for four evaluations - hand grasps, for two evaluations - motor function, for twelve evaluations - pain response, for ten evaluations - evaluator's initials, for seven evaluations Review of resident #4's Neurological Evaluation flow sheet, dated 1/7/17, showed that 14 evaluation were done. The initial evaluation was dated 1/7/17 at 11:30 a.m. The remaining evaluations had a time, but were not dated. The pupil response section had three evaluations coded with a symbol that was not included on the coding legend. The evaluator's initials section showed no initials for nine of the evaluations. 4. Review of resident #5's IDT Fall review notes, dated 3/25/17, 3/29/17, and 4/8/17 showed the resident had falls on 3/25/17, 3/29/17, and 4/8/17, and neurological checks were initiated after each fall. During an interview on 7/24/17 at 2:10 a.m., staff member B stated the Neurological Evaluation flow sheets were not in the chart and she would locate them. She said resident #5 would have had neurological checks for a 24-hour cycle. The Neurological Evaluation flowsheets, for the 3/25/17, 3/29/17, and 4/8/17 falls, were not provided. 5. Review of resident #6's Licensed Nurses Progress Notes, dated 4/12/17-5/19/17, showed seven notes that included the date and time, one note that included the date and a shift designation, and twenty-one notes that included a date, but had no reference to the time of the note. Review of resident #6's Licensed Nurses Progress Notes, untimed and dated 4/28/17, showed the resident was found on floor lying flat on back, and neurological checks were initiated. Review of resident #6's Neurological Evaluation flow sheet showed the initiation date and time was 4/28/17 at 5:45 a.m. The flow sheet showed 12 timed entries. Nine of the entries do not include the evaluator's initials. During an interview on 7/24/17 at 4:45 p.m., staff member B stated there were resident records in the DON office and the Medical Records office that have been thinned, pulled for review, or needed to be filed. She stated that the documentation was an issue and she was hoping the transition to electronic medical records would help with the mess.",2020-09-01
435,POLSON HEALTH & REHABILITATION CENTER,275049,9 14TH AVE W,POLSON,MT,59860,2018-10-18,583,E,0,1,LXPM11,"Based on observation, interview, and record review, the facility failed to ensure residents' protected health information (PHI) was kept secure and confidential, which had the potential to affect all residents in the facility. Findings include: During an observation of medication pass on 10/16/18 at 7:40 a.m., staff member G left the MAR/TAR (medication administration record/treatment administration record) open to PHI when she left the medication cart. During observations on 10/16/18, the following was observed: - 10:23 a.m., the 100/200 hall MAR/TAR was left open to PHI. There was no staff in the area. - 10:35 a.m., the 100/200 hall MAR/TAR was left open with PHI available for others to see. No staff in the area. - 10/16/18 at 10:35 a.m., the face sheets for three residents were laying on top of the nursing station desk. There was one resident standing at the desk and no staff in the area. - 12:55 p.m., the facility appointment book was left open to resident appointments for the day at the nurses' station. One resident was standing at the desk. During observations on 10/17/18, the following was observed: - 7:45 a.m., one resident was standing at the nursing station. There was PHI paperwork on a clipboard at the nursing station next to the resident. - 8:08 a.m., there was two packets with PHI laying on the nursing station with the face sheets showing resident diagnoses. - 11:45 a.m., staff member A was observed leaving the MAR/TAR book open to PHI when she walked down the hall to the copy machine room. The MAR/TAR was unattended and in the hall way where residents, staff, and visitors walked by on their way to the dining room. During an interview on 10/18/18 at 9:55 a.m., staff member J stated PHI should be covered or flipped over so it is not visible to others. During an interview on 10/18/18 at 10:00 a.m., staff member L stated staff are to always fold over the report sheet so PHI is not visible and do not leave the MAR/TAR open to PHI. During an interview on 10/18/18 at 10:15 a.m., staff member C stated the facility had produced laminated paper to cover the resident PHI for the MAR/TARs and other PHI. Review of the facility's policy, Privacy of Protected Health Information, showed . shall maintain the privacy of patients' health information consistent with the requirements of the Health Insurance Portability and Accountability Act .",2020-09-01
436,POLSON HEALTH & REHABILITATION CENTER,275049,9 14TH AVE W,POLSON,MT,59860,2018-10-18,622,D,0,1,LXPM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written documentation for transfer to the hospital for 1 (#30) of 13 sampled residents. Findings include: Review of resident #30's medical record showed the resident had been admitted to the hospital on [DATE], 9/3/18, 7/26/18, and again on 4/20/18. There was no transfer paperwork in the medical record for the hospitalization on [DATE]. During an interview on 10/17/18 at 12:25 p.m., staff member M, stated the facility was not providing the information to the residents or the representative for transfer/discharge prior to (MONTH) of (YEAR).",2020-09-01
437,POLSON HEALTH & REHABILITATION CENTER,275049,9 14TH AVE W,POLSON,MT,59860,2018-10-18,623,D,0,1,LXPM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide, in writing, notice of transfer/discharge from the facility for 1 (#30) of 13 sampled residents, to a representative of the Office of the State Long-Term Care Ombudsman. Finding include: Review of resident #30's medical record showed the resident had been admitted to the hospital on [DATE], 9/3/18, 7/26/18, and again on 4/20/18. There was no transfer paperwork in the medical record for the hospitalization on [DATE]. During an interview on 10/17/18 at 12:25 p.m., staff member M, stated the facility was not providing the information to the Ombudsman for transfer/discharge prior to (MONTH) of (YEAR).",2020-09-01
438,POLSON HEALTH & REHABILITATION CENTER,275049,9 14TH AVE W,POLSON,MT,59860,2018-10-18,625,D,0,1,LXPM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a bed-hold notice when the resident was transferred to the hospital for 1 (#30) of 13 sampled residents. Findings include: Review of resident #30's medical record showed the resident had been admitted to the hospital on [DATE], 9/3/18, 7/26/18, and again on 4/20/18. There was no transfer paperwork in the medical record for the hospitalization on [DATE]. During an interview on 10/17/18 at 12:25 p.m., staff member M, stated the facility was not providing the information for the bed hold prior to (MONTH) of (YEAR).",2020-09-01
439,POLSON HEALTH & REHABILITATION CENTER,275049,9 14TH AVE W,POLSON,MT,59860,2018-10-18,657,D,0,1,LXPM11,"Based on observation, interview, and record review, the facility failed to revise a care plan, for a resident who directed his care, including the risks of self directed care, for 1 (#29) of 21 sampled and supplemental residents. Findings include: During an observation on 10/17/18 at 4:20 p.m., resident #29's catheter bag and tubing was on the floor under his wheelchair. During an interview on 10/17/18 at 4:22 p.m., staff member A said the catheter bag and tubing for resident #29 should not be on the floor. Staff member A said resident #29 frequently self-directed his care and he could have told the CNA staff to leave it that way. Review of resident #29's current care plan failed to show the resident frequently directed his own care. The care plan failed to show the resident had been informed of the risks of leaving the catheter bag and tubing on the floor.",2020-09-01
440,POLSON HEALTH & REHABILITATION CENTER,275049,9 14TH AVE W,POLSON,MT,59860,2018-10-18,880,E,0,1,LXPM11,"Based on observation, interview, and record review, the facility staff failed to perform proper hand hygiene after removing their gloves and in between clean and dirty tasks for 4 (#s 12, 16, 27, and 39 ) of 21 sampled and supplemental residents; and failed to place a urinary catheter properly to minimize risk of infection for 1 (#29) of 21 sampled and supplemental residents. Findings include: 1. During an observation on 10/16/18 at 3:40 p.m., staff member K changed the dressing to resident #16's right foot. Staff member K washed her hands when she entered the room. Staff member K obtained the supplies from the dresser drawer and places them on the bedside table. Staff member K applied a pair of gloves and stated I use double gloves while she put on a second pair of gloves. Staff member K placed a blue pad under resident #16's feet and removed the dressing. Staff member K removed her gloves and opened the dresser drawer to obtain an absorbent pad. Staff member K then put on a pair of gloves, cleansed the heel area, removed her gloves, and put on a clean pair of gloves. Staff member K dried the right foot and heel, removed her gloves, opened the calcium alginate, absorbent pad package, and the put on a clean pair of gloves. Staff member K applied skin prep around the wound and removed her gloves. She put on a new pair of gloves, placed the calcium alginate on the heel, wrapped the heel with Kerlix, and secured with tape. Staff member K removed her gloves, placed the unused supplies back in the top drawer of the dresser, raised the bed for resident #16, removed the garbage, washed her hands, and left the room. 2. During on observation on 10/17/18 at 7:30 a.m., staff member [NAME] provided morning cares for resident #39. Staff member [NAME] washed her hands and put on a pair of gloves. She spoke to the resident, assisted resident #39 to sit on the side of her bed, she placed pants and socks on the resident, and assisted the resident to ambulate to the bathroom. Staff member [NAME] assisted the resident with her bra and shirt while she was on the toilet. Staff member [NAME] removed the soiled incontinent brief, and placed it in the garbage. Staff member [NAME] asked the resident to stand, provided peri care. The resident sat back down on the toilet, staff member [NAME] placed a clean incontinent brief around resident #39's legs. Resident #39 then stood up and tried to pull her brief and pants up while staff member [NAME] assisted her. Staff member [NAME] assisted resident #39 to ambulate to the sink, removed her gloves, removed the garbage, and washed her hands. 3. During an observation on 10/17/18 at 9:30 a.m., staff member F provided peri care for resident #27. Staff member F washed her hands and put on a pair of gloves. Staff member F assisted resident #27 to bed, removed her pants, and unfastened her soiled incontinent brief. Staff member F provided peri care for resident #27. Staff member F rolled resident #27 to her left side and provided peri care to her back side, removed the soiled brief, and placed a clean brief under resident #27. Staff member F rolled resident #27 onto her back, adjusted and fastened the brief. Staff member F removed her gloves, moved resident #27 up in the bed, covered her up, gave her the call light, lowered the bed, turned her light out, and washed her hands. 4. During an observation on 10/17/18 at 11:45 a.m., staff member A changed a dressing to resident #12's right heel. Staff member A washed her hands, put on a pair of gloves, cleaned her scissors, and placed a blue pad on top of the bedside table. Staff member A obtained the dressing supplies from the night stand drawer. Staff member A removed her gloves and put on a new pair of gloves. Staff member A removed the dressing, removed her gloves, and sanitized her hands. Staff member A donned a pair of gloves, cleansed the heel, removed her gloves, and sanitized her hands. She then put on a clean pair of gloves, measured the wound, and applied a dressing to cover the heel and foot. Staff member A removed her gloves, sanitized, placed a new pair of gloves on, secured the dressing with tape, removed her gloves, pulled on her pants, and put on a clean pair of gloves. Staff member A then put the unused supplies back in the top drawer of the night stand, removed her gloves, and the garbage bag from the garbage can, and washed her hands. During an interview on 10/18/18 at 7:34 a.m., staff member A stated staff should wash or sanitize their hands between clean and dirty tasks and changing gloves. During an interview on 10/18/18 at 7:35 a.m., staff member F stated you should wash or sanitize your hands after you finish cares and when you change your gloves you should wash or sanitize your hands. During an interview on 10/18/18 at 7:37 a.m., staff member [NAME] stated you should wash or sanitize your hands after glove use or between clean and dirty tasks. During an interview on 10/18/18 at 7:38 a.m., staff member I stated you should wash or sanitize your hands when entering a room and between gloves use. Review of an in-service conducted on 9/10/18 by staff member A included catheter care and hand hygiene. 5. During an observation on 10/17/18 at 4:20 p.m., resident # 29's catheter bag and tubing was on the floor under his wheelchair. During an interview on 10/17/18 at 4:22 p.m., staff member B said the catheter bag and tubing, for resident #29, should not be on the floor. Staff member B said resident #29 frequently self-directed his care and he could have told the CNA (certified nurse aide) staff to leave it that way. Review of resident #29's current care plan failed to show the resident frequently directed his own care.",2020-09-01
441,POLSON HEALTH & REHABILITATION CENTER,275049,9 14TH AVE W,POLSON,MT,59860,2018-10-18,926,D,0,1,LXPM11,"Based on observation, record review and interview, the facilty failed to implement the smoking policy by allowing one resident (#150) of 21 sampled and supplement residents, to smoke on facility property. Findings include: During an observation and interview on 10/17/18 at 9:53 a.m., resident #150 was walking into the facility from a back door. He smelled like smoke, and said he goes out back for a few puffs. He would not say where he kept his cigarettes or cigars. Review of the facility smoking policy, dated (MONTH) (YEAR), showed Smoking is prohibited for everyone on the property owned and operated by the Center, including residents, employees and visitors. During an interview on 10/17/18 at 12:06 p.m., staff member D stated there were several residents who went out the back door to smoke. She said she was aware the building was smoke-free. During an interview on 10/17/18 at 4:40 p.m., staff member A stated she was not aware resident #150 was smoking on the facility grounds.",2020-09-01
442,POLSON HEALTH & REHABILITATION CENTER,275049,9 14TH AVE W,POLSON,MT,59860,2019-11-14,640,D,0,1,Y2L311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the required Minimum Data Set (MDS) discharge documentation, was correctly encoded and transmitted for 1 (#1) of 25 sampled residents, when the resident was discharged from the facility. Findings include: During an interview on 11/14/19 at 8:11 a.m., staff member D stated she had worked at the facility since (MONTH) of 2009. Staff member D had been doing assessments for the past five years, and was the only staff that currently worked with assessments at the facility. Staff member D stated she had done resident #1's end of Medicare discharge when the resident discharged on [DATE], but did not do a discharge and was not seeing a record. Staff member D stated she usually does both when residents leave the facility, but sometimes things slip through. Staff member D stated maybe she had submitted the MDS discharge on the wrong form. Review of the MDS 3.0 Kardex in the electronic medical record showed: Modification of End of PPS Part A Stay, dated 7/9/2019, with an accepted status. Review of the (MONTH) 2019 Centers for Medicare and Medicaid Services 'Long Term Care Facility Resident Assessment Instrument (RAI) Version 3.0 User's Manual,' shows Discharge Assessment-Return Not Anticipated assessments. Must be completed when the resident is discharged from the facility and the resident is not expected to return to the facility within 30 days . Must be completed . within 14 days after the discharge date . Must be submitted within 14 days after the MDS completion date.",2020-09-01
443,POLSON HEALTH & REHABILITATION CENTER,275049,9 14TH AVE W,POLSON,MT,59860,2019-11-14,812,F,0,1,Y2L311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility: failed to ensure sanitary conditions were maintained in the kitchen and dishwashing areas, failed to maintain inventory of unexpired food items, and failed to correctly label food items. These deficiencies had the potential to affect all residents who received food from the kitchen and food storage areas. Findings include: 1. During an observation in the facility kitchen on [DATE] at 3:54 p.m., the two ceiling vents located in the center of the kitchen had black greasy lint material on the vents and on the ceiling around the vents. During an observation in the facility's dishwashing room on [DATE] at 4:44 p.m., the fan vents located near the top of the window on the right side were covered with an accumulation of black greasy lint material. Staff member F stated the fan grates were for the swamp cooler mounted in the window. During an interview on [DATE] at 7:50 a.m., staff member F stated the facility's maintenance department cleans the kitchen area fans and vents. The stove fans and vents were cleaned by an outside contractor. During an interview on [DATE] at 8:30 a.m., staff member F stated he wasn't sure when the kitchen vents and filters were last cleaned, his best guess was at the beginning of last summer when the swamp cooler was repaired. During an interview on [DATE] at 10:07 a.m., staff member [NAME] stated he thought it was a couple months or so since the kitchen vents were cleaned, one in the dishwasher and the two vent covers in the kitchen. Staff member [NAME] stated he tries to bounce back between cleaning the light and vent covers. Review of the facility's Evaporative Coolers PM Task Sheet, showed monthly inspections for 2019, with the last filter cleaning and/or change, marked with a Y on (MONTH) of 2019. No other filter cleanings were noted for 2019. 2. During an observation in the facility food storage area on [DATE] at 4:10 p.m., the following food item was found: - One opened bag of chopped pecans, secured with a twist tie, no opened date on bag During an observation in the facility food storage area on [DATE] at 2:30 p.m., the following expired food items were found: - One 16 oz. bag of large lima beans, best by Sep 19 2019 - One opened 16 oz. bag of large lima beans, best by Sep 19 2019, no opened date on bag - One 12 pack bag of flour tortillas, Mfg [DATE], In ,[DATE] written on bag - Five bags of 16 oz. miniature marshmallows, Best by [DATE] - One opened bag of 16 oz. miniature marshmallows, Best by [DATE], no opened date on bag During an interview on [DATE] at 8:30 a.m., staff member F stated he and his staff labeled and dated the food inventory items as they were put away, on a daily basis. Staff member F stated he had just hired additional kitchen staff to assist with kitchen duties, to include cleaning, checking dates, and checking labels. Review of the facility's EmpRes Food and Nutrition Services Comprehensive Summary dated [DATE] and [DATE], showed, .Some items not labeled and dated in refrigerators, item in refrigerator was outdated . 3. During an observation in the facility food storage area on [DATE] at 4:10 p.m., dates to indicate when food items were added to the inventory were written on some of the food items packaging in the storage area, written as, In mm/dd. Open dates written on food packaging contained only month and day. Review of the facility policy, Food Labeling Reference Guide, showed, . Date stock upon arrival to the Center with month/year, Use by dates are written on the item once the item is opened, Use by dates on opened products should not exceed the manufacturer's expiration date .",2020-09-01
444,CEDAR WOOD VILLA,275053,1 S OAKS,RED LODGE,MT,59068,2019-06-13,609,D,1,0,7KJF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to ensure an alleged report of neglect of care for 1 (#2) of 6 sampled residents was investigated. The facility failed to act upon the reported alleged neglect to include a thorough investigation and corrective action. Findings include: During an observation on 6/12/19 at 3:51 p.m., resident #2 was chanting, in phrases, things she was noticing or hearing in the environment. Resident #2 was not interviewable. Review of resident #2's Quarterly MDS, with an ARD of 4/26/19, showed resident #2 had a cognitive impairment, made poor decisions, and required cues and supervision with her daily decision making. Section G Functional Status showed resident #2 required extensive assistance of two staff for bed mobility to turn side to side and position her body while in bed. Functional Limitation in Range of Motion showed resident #2 had impairment of both upper and lower extremities on both sides. Section M Skin Conditions showed resident #2 was at risk for pressure ulcers, and had two Stage III pressure ulcers, and two venous and arterial ulcers. During an interview on 6/13/19 at 12:22 p.m., staff member A was asked for the initial documentation for resident #2's pressure ulcer to her right ankle and foot. Staff member A stated she reported the pressure ulcer on resident #2's right ankle and foot as neglect to the DON approximately six months ago. Staff member A stated she told the DON that staff member D had failed to reposition resident #2 and caused the pressure ulcers to her right foot. Staff member A stated the DON responded by saying it did not happen due to the resident not being turned. Staff member A stated she had told the DON multiple times that staff member D was failing to check and change people. She stated she reported her concerns about staff member D and another CNA to staff member B today. During an interview on 6/13/19 at 1:22 p.m., staff member C stated in the past she was working on the hall with staff member D, who was responsible for resident #2's care. She stated staff member D was supposed to rotate and change resident #2 every two hours. Staff member C stated she kept seeing resident #2 in the same position, so she decided to check on resident #2 and rotate her. Staff member C stated when she repositioned resident #2, she noticed redness in a circle shape, and fluid leaking from resident #2's right foot and ankle. Staff member C stated staff member D had days she was on it and other days lazy. Staff member C stated she had brought concerns to the DON written on the facility Concern Form, but staff member D continued not to do her job. Staff member C stated, The DON would tell me, 'I'll talk to them'. Staff member C stated approximately six months ago, after the DON had returned from vacation, they had a staff meeting, and the DON told them a lot of their Concern Forms were petty and they needed to act like adults. Review of staff member D's employee file, signed on 11/30/18, showed an investigation for failure to provide care and services to residents. The investigation showed staff member D failed to ensure a resident was not left in a soaked and soiled brief resulting in the resident having bright red skin around the buttocks area on 11/20/18; failed to assist with a resident's transfer on 11/21/18; and failed to change resident #2's clothing on 11/22/18. The investigation showed staff member D violated the following facility policies: Free From Abuse and Neglect, Resident's Rights, and Must Promote Care . The investigation showed staff member D was given a verbal warning. The investigation showed staff member D was expected to provide the necessary care to incontinent residents and those needing assistance with ADLs. The investigation showed staff member D was educated on Resident Abuse and Staff treatment of [REDACTED]. Review of the facility policy and procedure titled Abuse Prevention Plan, revised (MONTH) (YEAR), showed The Administrator is ultimately in charge of the Abuse Prohibition plan and must be informed of all alleged or substantiated incidents of abuse, neglect, or maltreatment immediately/no less than 24 hours.The State Agency must also be notified immediately.B. Neglect is the failure of the facility, its employees or service providers to provided goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.D. Identification: 1. Facility will identify events that may constitute maltreatment such as abuse, neglect . E. 1. Facility will investigate all incidences . for abuse, neglect . [NAME] Reporting/Response: 1) Report all alleged violations and substantiated incidents to the State Agency immediately, but not later than 2 hours after forming the suspicion . The facility will take all necessary corrective actions depending on the results of the investigation and complete and send a final investigative report to the State Agency within 5 business days.Reportable Incidents Potential or confirmed abuse, neglect, exploitation, mistreatment by injury caused by not following care plan or frank disregard for resident safety .",2020-09-01
445,CEDAR WOOD VILLA,275053,1 S OAKS,RED LODGE,MT,59068,2019-06-13,688,G,1,0,7KJF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to provide services and assistance needed to maintain mobility, to include reassessment of need or progress, resulting in a decline in physical functioning for 1 (#1) of 6 sampled residents. Findings include: During an interview on 6/12/19 at 7:49 a.m., NF1 stated resident #1 experienced an improvement in mobility after moving to the new assisted living facility on 1/15/19. NF1 stated resident #1 was able to walk short distances with assistance. During an interview on 6/12/19 at 8:30 a.m., NF2 stated resident #1 had been able to increase his mobility for a time. Review of resident #1's care plan, dated 11/8/18, showed Please encourage me to ambulate with walker and assist to meals as a goal related to mobility. No documentation of restorative services or physical therapy was found on the care plan. Documentation of ambulation for resident #1 was requested, and no information was received prior to the exit of the survey. Review of resident #1's Admission MDS, with an ARD of 11/13/18, showed the resident required limited assistance of one staff for bed mobility, transfers, personal hygiene, and toileting. Ambulation did not occur, and supervision was necessary for wheelchair mobility and eating. Review of resident #1's Discharge MDS, with an ARD of 1/15/19, showed bed mobility, transfers, personal hygiene, toileting, locomotion on the unit, dressing, eating, and personal hygiene occurred only one or two times during the assessment period. Ambulation and wheelchair locomotion off the unit did not occur. The level of support was blank. Review of resident #1's physician's orders [REDACTED]. Review of resident #1's Physical Therapy Maintenance Program, dated 12/19/18, showed poor judgement, impaired cognition, and a high fall risk without supervision. Goals were to decrease the fall risk, increase lower extremity strength, and improve balance. The treatment plan showed balance and strength exercises, walking, and stair walking three times a week for 52 weeks. Review of resident #1's therapy note, dated 12/20/18, showed resident S: .Unable to comply with directives presented. A: Restorative program in place. P: No further PT interventions planned. Discharge from service. Review of resident #1's Charting Record for Restorative services, dated (MONTH) 2019, showed; ORDER TEXT Parallel bar exercises -Front Knee -Back Knee -Toe Raises -Side Kicks -Back Kicks -Front Kicks Walking with Walker The above exercises were documented to be done three times per week. For (MONTH) of 2019, the services were provided four times from 1/1/19 through 1/15/19. Review of resident #1's Progress Notes, dated 1/1/19 through1/15/19, did not include documentation showing that resident #1 had been assisted with ambulation as per the Restorative Program plan. Review of resident #1's Admission Note from the assisted living facility, dated 1/15/19, showed resident . is currently a 2 person transfer due to weakness. Review of resident #1's New Resident Evaluation from the assisted living facility, dated 1/15/19, showed assist of two for transfers, very weak, and unable to bear weight. Review of resident #1's care note from the assisted living facility, dated 1/17/19, showed Still difficult to transfer, used slide board. Review of resident #1's care note, from the assisted living facility, dated 1/19/19, showed Standing + (sic) pivoting pretty good. He even walked (with a lot of assistance) from his chair to his bed! Review of resident #1's care note, from the assisted living facility, dated 1/31/19, showed Walked out almost all the way down the hall. He is sitting in the living room now. Review of facility policy titled Restorative Nursing Program Policy, effective date of (MONTH) (YEAR), showed Restorative Nursing Program refers to nursing interventions that promote . living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental and psychosocial functioning. The Procedure section of this policy shows that these services can be implemented . at any time the services are indicated. and are to be . supervised by licensed nursing personnel. No documentation of licensed nursing staff supervision of restorative services could be found in resident #1's medical record.",2020-09-01
446,CEDAR WOOD VILLA,275053,1 S OAKS,RED LODGE,MT,59068,2019-06-13,690,D,1,0,7KJF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to provide services and assistance in order to maintain bladder and bowel continence for 1 (#1) of 6 sampled residents. Findings include: During an interview on 6/12/19 at 7:49 a.m., NF1 stated resident #1, had been able to take care of his own bodily needs before entering (facility name). NF1 stated resident #1 did not wear attends or have issues with incontinence prior to admission to (facility name). Review of resident #1's Admission MDS, with an ARD of 11/13/18, showed occasional bladder incontinence and always continent of bowel. No documentation of bladder training or voiding schedule was noted on the MDS. Cognitive Patterns showed resident #1 was severely impaired and was not able to make his own decisions. Review of resident #1's Care Plan, dated 11/8/18, showed goals of I want to be clean and odor free. and I want to participate in my toileting. Interventions, dated 11/8/18, showed toileting every two hours and assistance of one for toileting. There were no revisions documented on the Care Plan related to the new onset of bowel incontinence from the time of his admission on 11/6/18 until discharge on [DATE]. There were no revisions related to the progression of occasional bladder incontinence to always incontinent on the Care Plan. Documentation of attempts to restore resident #1's previous level of continence were requested. No documentation was provided prior to the end of the survey. Review of resident #1's Discharge MDS, with an ARD of 1/15/19, showed always incontinent of bladder and bowel. No documentation of attempts to maintain or restore resident #1's level of continence were noted on the MDS or in the medical record. Cognitive Patterns showed resident #1 was moderately impaired, and required cues and supervision for decision making. Review of resident #1's medical record failed to contain documentation that showed the facility provided services and care to maintain or restore his bowel and bladder continence from his admission to his discharge. Review of the facility policy titled Bowel and Bladder Retraining, with the effective date of (MONTH) (YEAR), showed the resident must be able to make decisions and have a desire to participate in bowel or bladder retraining. The policy did not address residents who were cognitively impaired. No other facility policies for maintaining continence of cognitively impaired residents were submitted.",2020-09-01
447,CEDAR WOOD VILLA,275053,1 S OAKS,RED LODGE,MT,59068,2017-08-10,241,D,0,1,PWLL11,"Based on observation, interview and record review, the facility failed to provide foods and an environment to promote independence and dignity for 2 (#s 6 and 8); failed to engage residents during assisted dining for 1 (#6) of 13 sampled residents. Findings include: 1. Review of resident #8's Care Plan, with no initiation date, showed I use a divided plate because I do not like my food to touch each other. I also enjoy to eat with my fingers, and to be offered finger food. An intervention included She will be offered finger food as much as possible. During an observation on 8/8/17 at 7:30 a.m., resident #8 was using her fingers to eat her breakfast. She ate a bowl of dry rice krispees. During an observation on 8/8/17 at 12:43 p.m., resident #8 was eating cut up beef in gravy and peas with her fingers. Her fingers were covered in gravy. During an observation on 8/9/17 at 7:50 a.m., resident #8 was using her fingers to eat her rice krispees. She did not pick up a utensil. Review of resident #8s most recent dietary note, dated 6/20/17, did not document the need for finger foods. Review of the dietary spread sheet did not include a finger food diet. During an interview on 8/9/17 at 3:00 p.m., staff member A stated the kitchen tried to provide finger foods for resident #8. She stated the facility would add a finger food diet to the spread sheet. Review of resident #8's Quarterly MD, with the ARD of 5/24/17, showed resident #8 had severe cognitive impairment. 2. During an observation and interview on 8/8/17 at 7:33 a.m., staff member O stated loudly, across a portion of the dining room, and towards the kitchen, You can bring the feeders. She stated she meant she was ready for the breakfast plates, for the residents who sat at a designated table, and who required assistance to eat. 3. During an observation on 8/8/17 from 7:33 a.m. to 8:10 a.m., resident #6 consumed a four-ounce glass of milk, that was on the table when she arrived to the dining room. A glass of water and an overturned coffee cup were also on the table at resident #6's space. Over the course of the observation, resident #6 tapped her milk glass against the table in a repetitive motion. Staff member P, who was seated to the right of resident #6, went to the drink dispenser at 7:38 a.m., and poured the resident a glass of enhanced water that was a pinkish-purple color. On two or more occasions resident #6 picked up the empty milk glass and tilted her head back trying to get the drops of milk at the bottom of the glass. Staff member P was sitting to the right of resident #6, and did not respond to the resident's attempts to drink from the empty glass. When resident #6 tapped her milk glass on the table, staff member P pushed the enhanced water, or the water, towards the resident and encouraged her to drink. Resident #6 took sips of the enhanced water, or drinks of the water, after some of the attempts to encourage her. She continued to reach for the milk glass until staff member P pushed it to towards the center of the table, out of resident #6's reach. During the observation, resident #6 responded to direct questions at times, but did not speak otherwise. Her responses were simple phrases of yes, no, or a few words. Throughout the observation above, staff members O and P were conversing directly to each other, regarding personal matters, while assisting resident #6 and two un-sampled residents to eat breakfast. The residents were periodically encouraged to eat or drink, but were not engaged in conversation. Staff members O and P remarked negatively about the appearance of the pureed toast, served to resident #6 and the un-sampled resident, sitting to the left of staff member O. Staff member O, on more than one occasion, referred to the pureed food as, this stuff, when offering the resident a bite of food. During the observation, staff members O and P mentioned resident #17, by name, stating she had been, so crabby, the previous day. During an interview on 8/8/17 at 8:10 a.m., staff member P stated the overturned coffee cup was for resident #6's hot cocoa. She stated she did not know why no one had offered to make resident #6's hot cocoa. Staff member P then asked the resident if she wanted a cup of hot cocoa, and resident #6 said no. Staff member P stated she did not know why she had not offered resident #6 another glass of milk. Staff member O stated the CNAs do not have direct access to the milk and would have to ask for it, from the dietary staff. She stated she did not want to say the milk was limited, but (the dietary manager) and her staff must account for the milk that was served. During an interview on 8/8/17 at 2:05 p.m., staff member A stated staff members O and P should have offered resident #6 more milk. She stated resident #6 had a weight loss and needed to consume calories and protein. Staff member A stated resident #6 could not drink what was not given to her. During an interview on 8/9/17 at 10:40 a.m., staff member P stated a definition of neglect could be, not talking to a resident at the table. During an interview on 8/9/17 at 11:45 a.m., staff member F stated resident #6 had been losing weight and, for a time, would not eat anything. She stated the resident would drink what was put in front of her. Staff member G stated there was no limitation on the amount of milk resident #6 could be served and she should have what she wanted.",2020-09-01
448,CEDAR WOOD VILLA,275053,1 S OAKS,RED LODGE,MT,59068,2017-08-10,248,D,0,1,PWLL11,"Based on record review, observation, and interview, the facility failed to provide adequate and meaningful activities on a consistent basis for 1 (#2) of 13 sampled residents. Findings include: Review of resident #2's Care Plan, initiated on 1/30/17, showed I want to be able to listen to music, in a peaceful area. The intervention was Have (resident) listen to comforting music and maintain a peaceful area for him. Review of resident #2's Quality of Life Care Plan, initiated on 4/12/17, showed I did the following activities prior to admission and they are important to me: Rock hunting, collage art of natural items, wood carving, writing poems, fishing and backpacking. The interventions included I would like activities to continue to provide me with my therapeutic items box. I also have stuffed animals that I like to hold that calm me. I would like activities to do 1:1 activities with me 3X a week in a quiet and soothing environment. Please visit me about my past work experience as a postal worker. I would also like activities to offer me a snack and beverage during these 1:1 times. I would like staff to play calming music for me when I am up in my chair. During observations on 8/7/17, 8/8/17, and 8/9/17, through out the day, no music was played while the resident was up in his chair. During an interview on 8/9/17 at 1:20 p.m., staff member M stated she would play the music during his 1:1 visits, which were 3 three times per week for ten minutes. The majority of visits were documented as talking about his job as a postal worker, for ten minutes. She stated she was not comfortable giving him food or water, because of his dementia. Review of resident #2's activity calendar for July, (YEAR) showed four 1:1 visits which included one visit to the patio, one walk, and one music event. During an interview on 8/8/17 at 1:07 p.m., staff member M stated the activity department had staffing issues during July, (YEAR), and resident #2 did not receive adequate 1:1 visits.",2020-09-01
449,CEDAR WOOD VILLA,275053,1 S OAKS,RED LODGE,MT,59068,2017-08-10,253,E,0,1,PWLL11,"Based on observation and interview, the facility failed to reduce urine odors in the hallway for 24 of 24 South Hall residents, and family and visitors of South Hall residents. Findings include: During an observation on 8/7/17 at 7:15 a.m., South Hall had a strong, overpowering, urine smell noted throughout. Further examination showed the smell was permeating from room S13. Room S13 was observed to have a pungent smell of urine, the floor tile was darkened with wheel chair tracks, and the floor was sticky and gritty. The hall outside the door, of room S13, was soiled by grime. During an interview on 8/7/17 at 7:15 a.m., resident #17, who lived on South Hall, stated the urine smell was related to staff member [NAME] not cleaning well. During an interview, on 8/7/17 at 7:15 a.m., staff member C stated the resident, occupying room S13, was resistant to cares, and staff had a difficult time getting in to clean the resident's room. During an interview, on 8/7/17 at 10:02 a.m., staff member [NAME] stated she was trying everything to rid room S13 of the smell but did not give examples other than mopping S13 and the bathroom. Staff member [NAME] had finished mopping S13 and cleaning the bathroom. An odor of urine continued to linger but less noticeable. During an observation on 8/7/17 at 11:45 a.m., staff member N was observed cleaning the carpet in front of room S13. During an interview on 8/10/17 at 8:55 a.m., NF2 stated she frequently noticed a foul smell from room S13 and it was an ongoing issue. She stated she had complained about the smell to the administrator and when she attended care plan meetings.",2020-09-01
450,CEDAR WOOD VILLA,275053,1 S OAKS,RED LODGE,MT,59068,2017-08-10,272,D,0,1,PWLL11,"Based on interview and record review, the facility failed to complete a comprehensive assessment within 14 days of the ARD for 1 (#5) of 13 sampled residents. Findings include: 1. Review of resident # 5's Annual MDS, with an ARD of 10/5/16, showed a completion date of 10/26/16, for a total of 22 days from ARD to completion. During an interview on 8/9/17 at 3:25 p.m., staff member C stated she was aware of late assessments through her own tracking process. She stated there were two staff members job sharing as well as the need for her to work as a floor nurse on occasion, and she had fallen behind.",2020-09-01
451,CEDAR WOOD VILLA,275053,1 S OAKS,RED LODGE,MT,59068,2017-08-10,276,D,0,1,PWLL11,"Based on interview and record review, the facility failed to complete Quarterly MDSs within the required timelines for 3 (#s 1, 2 and 16) of 18 sampled and supplemental residents. Findings include: 1. Review of resident #1's Quarterly MDS, with the ARD if 4/26/17, showed it was completed on 5/24/17. The MDS should have been completed by 5/9/17. 2. Review of resident #2's Quarterly MDS, with the ARD of 5/10/17, showed it was completed on 5/31/17. The MDS should have been completed by 5/24/17. 3. Review of resident #16's Quarterly MDS, with the ARD of 4/26/17, showed it was completed on 5/24/17. The MDS should have been completed by 5/9/17. During an interview on 7/7/17 at 3:20 p.m., staff member C stated the facility was aware of the late MDSs, and it was due to a change in schedules and job sharing. She stated she had a plan of correction ready.",2020-09-01
452,CEDAR WOOD VILLA,275053,1 S OAKS,RED LODGE,MT,59068,2017-08-10,278,D,0,1,PWLL11,"Based on record review and interview, the facility failed to accurately code vaccinations, an indwelling catheter, and height for 1 (#10) of 13 sampled residents. Findings include: a. Review of resident #10's admission records showed he was admitted with an indwelling urinary catheter. Review of resident #10's Admission MDS, with an ARD of 4/7/17, showed the MDS was not coded for the use of the catheter. b. Review of resident #10's Admission MDS, with an ARD of 4/7/17, showed the resident's pneumococcal vaccine status was not up to date. Review of resident #10's Quarterly MDS, with an ARD of 7/5/17, showed the resident's pneumococcal vaccine status was not assessed. Review of resident #10's physician's admission orders [REDACTED]. During an interview on 8/9/17 at 3:45 p.m., staff member C stated she did not know how to code the MDS when there was not an order to administer the vaccine. She stated she was certain the reason the MD had not given an order to administer was because resident #10 had already received the vaccine. Staff member C stated she believed resident #10 had the vaccine when his brother had it, but there had been no follow up with the MD. c. Review of resident #10's Admission MDS, with an ARD of 4/7/17, showed resident #10's height was coded as 00 inches on the MDS. During an interview on 8/9/17 at 3:45 p.m., staff member C stated she could not explain the coding mistakes for resident #10's catheter and height.",2020-09-01
453,CEDAR WOOD VILLA,275053,1 S OAKS,RED LODGE,MT,59068,2017-08-10,280,E,0,1,PWLL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to care plan the risks for elopement for 2 (#7 and 12), care plan restorative nursing for 3 (#s 5, 10, and 11), and care plan a pressure ulcer for 1 (#2) of 13 sampled residents. Findings include: 1. Review of resident #11's physician orders, dated 5/5/17, showed occupational therapy was to end and restorative to begin on 5/5/17. Resident #11 was to work with restorative two times a week. During an interview on 8/9/17 at 5:00 p.m., resident #11 stated she was unable to get around as well, as before, because of her decreased strength and pain in her shoulders and back. Review of the facility Charting Record, dated with a penciled (MONTH) and August, and no year, showed resident #11 received restorative in five and a half weeks. Review of resident #11's care plan, with a target date of 9/14/17, did not address the need for restorative care. 2. During an observation on 8/9/17 at 10:35 a.m., in the activity room, resident #7 was at the door, going out to the patio. Resident #7 had set off the alarm by trying to get out the door. Staff member M went over and helped resident #7 back in the door. During an interview on 8/9/17 at 10:35 a.m., staff member M stated resident #7 was doing much better at not trying to leave the facility, then he had previously. Review of resident #7's nursing notes, dated 4/23/17 at 1:30 p.m., late entry, showed resident #7 exit seeking at front door around 10 am. resident exit seeking at activity door a few minutes later. Review of resident #7's nursing notes, dated 5/1/17 at 8:34 a.m., showed the nurse was to ensure the gate was locked out in the patio, three times a day. Review of resident #7's nursing notes, dated 6/1/17 at 2:20 p.m., showed the resident was redirected from the porch, had went outside without assistance, and set off the alarm. Review of the current Elopement Book, used if a resident left the facility, showed resident #7 was an elopement risk. Review of resident #7's nursing notes, with an effective date of 4/4/17, showed the Annual MDS, dated [DATE], had identified resident #7 as an elopement risk, in the CAAs (care area assessments). Contributing factors included the resident's history of a [MEDICAL CONDITION], cognitive deficits, and independence with a wheel chair. The author, of the progress note, decided to proceed to the care plan, in an effort to minimize risk factors, related to the elopement risk. Review of resident #7's care plan, with a print date of 8/7/17, showed no documentation that the interdisciplinary team had care planned the risk of elopement for resident #7. 3. Review of resident #12's current EMRs (electronic medical records) showed his [DIAGNOSES REDACTED]. Review of the facility's current Elopement Book, used for information when a resident left the facility and the facility was unable to locate the resident, showed resident #12 was an elopement risk. Review of resident #12's care plan, with a print date of 8/9/17, showed no documentation that the interdisciplinary team had care planned the risk of elopement for resident #12. During an interview on 8/9/17 at 4:04 p.m., staff member F stated an elopement assessment had not been completed on resident #12, even though resident #12 had eloped prior to his admit. Resident #12 was also in a locked unit before entering the facility. Staff member F stated resident #12's care plan did not include the risk for elopement. The staff member stated elopement risks should be care planned. 4. Review of resident #5's weight record showed a 10% weight loss over six months was calculated on 7/5/17. Review of resident #5's nutrition assessment, completed by the registered dietician on 7/18/17, showed the supplement shakes for resident #5 were to be increased from once a day to three times a day. During an interview on 8/8/17 at 2:00 p.m., staff member A stated resident #5 had a weight loss and was receiving a (commercial) supplement shake three times a day and was offered a high-calorie smoothie, made by the kitchen, once a day. She said a portion of the supplement was added to resident #5's coffee so she would drink it. Staff member A stated the smoothies would not be on the care plan because they were not ordered by the physician. Review of resident #5's care plan did not show resident #5 had experienced a 10% weight loss. The care plan did not show resident #5 was supposed to be given supplements with her meals or a smoothie once a day. The care plan showed resident #5 would have coffee with creamer at each meal and with activities. 5. Review of resident #10's physician's orders [REDACTED]. The order showed the goal for the program was for the resident to stand for transfers, or walk. Review of resident #10's restorative charting record showed restorative services were provided, beginning in (MONTH) (YEAR). Review of resident #10's care plan showed no restorative nursing program, no treatment plan for the program, and no goals for the program. 6. Review of resident #2's weekly Wound Documentation, dated 5/18/17, showed the resident had an open area on the left iliac crest. Review of resident #2's Weekly Wound Documentation, dated 6/5/17, showed the area was wider. Review of resident #2's Weekly Wound Documentation, dated 7/17/17, showed the resident had a stage II pressure ulcer to the coccyx. Review of resident #2's Care Plan, initiated 1/30/17, showed I am at risk for skin breakdown due to falls, incontinence, weight loss. I do not currently have a wound. During an interview on 8/9/17 at 11:45 a.m., staff member F stated the interdisciplinary team meets weekly to review residents with weight loss and other clinical changes of condition. She stated it is her responsibility to update the care plan after the meeting. Staff member G stated they may change the process so the care plan is reviewed and updated during the meeting.",2020-09-01
454,CEDAR WOOD VILLA,275053,1 S OAKS,RED LODGE,MT,59068,2017-08-10,284,D,0,1,PWLL11,"Based on record review and interview, the facility failed to set up home health, after the resident discharged home, for 1 (#13) of 13 sampled residents. Findings include: Review of resident #13's Transfer/Discharge Summary, dated 5/28/17, showed resident #13 was to have occupational therapy when she discharged home. The physician had ordered the discharge home, with home health PT/OT, to follow up in one week, and medications to continue. Review of resident #13's initial MDS, with an ARD of 12/29/16, showed Resident #13 had a BIMS of 15, no cognition concerns. Resident #13 required assistance with transfers, ambulating, dressing, and bathing. Review of resident #13's nursing notes, dated 5/28/17 at 11:39 a.m., showed resident #13 was to discharge home at 12:00 p.m. with medications, a portable oxygen tank, and all belongings. Review of resident #13's nursing notes, dated 6/1/17 at 8:13 a.m., late entry, showed resident #13 called the facility, saying she thought she was to have home care services, and said she had not heard from anyone. Resident #13 told the writer she was upset. During an interview on 8/9/17 at 3:31 p.m., staff member B stated staff member G had wanted her to set up the home health for resident #13 but she did not set home health up. She was not sure who had or if resident #13 received home health services. During an interview on 8/9/17 at 5:46 p.m., staff member B stated resident #13 was not in good shape to go home. Staff member B stated she encouraged resident #13 to stay at the facility. Staff member B stated she had not put much effort into Resident #13's discharge. the staff member stated she did not set up home health for resident #13. The staff member stated she did not tell resident #13 options for community assistance, such as home health agencies available. Review of the facility's job description for the social service director, with a date of (MONTH) 1, 2013, showed duties and responsibilities to include referring residents to appropriate community resources as necessary and to assist with discharge planning services such as arranging in home care services. During an interview on 8/10/17 at 8:50 a.m., NF1 had completed a home safety evaluation prior to discharge. NF1 stated he had recommended resident #13 for home health, but then he went on vacation for a month. NF1 thought another coworker did the follow up and would do the therapy. There was no documentation showing resident #13 had been set up for home health or had received the therapy through a home health agency.",2020-09-01
455,CEDAR WOOD VILLA,275053,1 S OAKS,RED LODGE,MT,59068,2017-08-10,318,E,0,1,PWLL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to have a restorative program that could meet individual needs for 4 (#s 2, 7, 11, and 10) of 13 sampled residents. Findings include: 1. Review of resident #11's physician orders, dated 5/5/17, showed occupational therapy was to end and restorative to begin. Resident #11 was to work with restorative two times a week. Review of resident #11's Charting Record, dated (MONTH) and August, with no year, showed resident #11 was not receiving restorative two times a week. The record showed that out of five and a half weeks, resident #11 only worked, with the restorative person, four days, 7/15/17, 7/18/17, 7/29/17, and 8/8/17. Resident #11 should have been offered restorative 11 times in the time period. Resident #11's Charting Record also showed resident #11 had refused two days, 7/11/17 and 7/25/17, in the reviewed time period. There was no documentation showing that staff had offered the resident other options on the times, when she refused. During an interview on 8/9/17 at 5:00 p.m., resident #11 was sitting on her walker seat. She was observed to be short of breath and slumped over. Resident #11 stated she was unable to get around as well as she could before, related to her decreased strength and pain in her shoulders. Review of resident #11's care plan, with a target date of 9/14/17, did not address the need for restorative care. 2. Review of resident #7's [DIAGNOSES REDACTED]. Review of resident #7's care plan, with a focus area on risk for falls, related to a fall on 5/28/17, showed Resident #7 was to walk daily with restorative therapy. Review resident #7's Charting Record for (MONTH) (YEAR) and (MONTH) (YEAR), showed a restorative start date of 3/19/13. Resident #7 was to be ambulated with a gait belt, using a platform walker, assisted by two staff, while another staff member pushed the wheel chair behind the resident. The order showed resident #7 was to walk with restorative Monday through Friday. During an observation on 8/9/17, resident #7 was observed walking with staff member D and two CNAs. Review of resident #7's (MONTH) and (MONTH) (YEAR) Charting Records showed resident #7 had 43 opportunities to walk. Resident #7 refused one opportunity to work with restorative per the charting. Resident #7 was unable to work with restorative for nine opportunities, related to no restorative staff available. Eight days missed did not show documentation of why those days were missed. Resident #7 missed 16 out of 43 opportunities to walk with restorative in 61 days. During an interview on 8/7/17 at 2:33 p.m., staff member D stated she was to work with resident #7 Monday through Friday. She stated working with resident #7 once a week if the resident wanted to work with her. 3. Review of resident #10's physician's orders [REDACTED]. Review of resident #10's restorative nursing flowsheets showed the first service documented was 8/8/17. During an interview on 8/10/17 at 8:02 a.m., staff member F stated there were no restorative services for resident #10 prior to (MONTH) (YEAR). She said the service had, just started. During an interview on 8/10/17 at 8:30 a.m., staff member C stated resident #10 was a hospice patient, and the hospice staff did not want the resident to receive the restorative nursing program. She said, because of this conflict, no therapist was willing to come to the facility to evaluate the resident and write a restorative nursing program. Staff member C stated she was aware a restorative nursing program did not require a therapist's input, and a nurse could evaluate the resident and initiate the program. Staff member C stated using a therapist for evaluation was how the facility initiated restorative nursing programs. Review of resident #10's care plan did not show the resident was receiving a restorative nursing program, the indication for the program, the goal for the program, or the plan for the program. During an interview on 8/7/17 at 2:33 p.m., staff member D stated if the facility was short CNA staff, restorative would often be pulled to the floor. Staff member D stated if she worked on the floor, she tried to squeeze in the restorative work but did not always get the work done. Staff member D stated being pulled to the floor, as a CNA, in the month of July, (YEAR). If the restorative staff missed a resident, on the restorative program, for any reason, finding time to fit the resident in at another day and time did not usually work, related to the number of residents on restorative. Staff member D did not know who oversaw the restorative program. Staff member D stated she would go to the PT and sometimes the DON for direction. Staff member D stated turning in resident charting notes to the medical records person and never again seeing the charting. Review of the facility's Restorative Nursing Program, with a revision date of 1/14/2014, showed the restorative nursing program was supervised by licensed nursing personnel and: -Each resident who participated in the restorative nursing program would have an individual program with individual goals. -A licensed nurse must supervise the activities in a restorative nursing program. Review of the job description for restorative nursing showed the restorative person was to report and be supervised by the nursing department. Functions of the restorative staff member included the ongoing communication with the Registered Therapist and nursing staff regarding resident status. During an interview on 8/8/17 at 7:05 a.m. and again 8/10/17 at 8:41 a.m., staff member F stated she did do an overview of the restorative program. Staff member F stated restorative flow sheets were reviewed, but nothing was documented. Staff member F stated restorative was pulled to work the floor, to help the CNAs, at times for call offs. If the practice occurred, restorative staff would help through breakfast. Staff member F felt the services were completed as no restorative staff said differently. 4. During an interview on 8/8/17 at 1:45 p.m., NF3 stated she had requested the facility to walk resident #2, who was admitted in January, (YEAR). NF3 stated the walking was not being done, so she requested a calendar be signed by staff to show when resident #2 was walked. During an interview on 8/9/17 at 7:40 a.m., staff member G stated the walking had not been done consistently, so for the month of August, (YEAR), going forward, resident #2 would receive a restorative walking program, one time per day.",2020-09-01
456,CEDAR WOOD VILLA,275053,1 S OAKS,RED LODGE,MT,59068,2017-08-10,323,D,0,1,PWLL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify appropriate root causes for falls, and monitor and modify interventions to prevent falls, for 2 (#s 1 and 9) of 13 sampled residents. Findings include: 1. Review of the facility Incidents by Incident Type Report showed resident #1 had 18 falls from 12/28/16 through 8/8/17. Review of resident #1's Care Plan showed he was a high risk for falls, and had a history of [REDACTED]. Six Falls occurred after 2/2/17, and 10 falls occurred after 4/12/17. No other interventions were documented to prevent or reduce further falls on the care plan. Review of resident #1's Fall Scene Investigation Reports included the following root causes: a. Weak and unable to support weight. b. Lost balance. c. Himself. d. Unsteady, lost balance. e. Himself. f. Cognition and level of function. g. Very unsteady. Review of resident #1's Fall Scene Investigation Reports included the following interventions: a. 1:1 until vitals are back to baseline. b. Resident will be checked often through the day and night as he does not use his call light for assistance. c. Anticipate needs. Work with mood of the moment. d. Labs; Foot pedals to wheelchair? e. Interventions in place, continue with frequent checks. f. Check labs. (3/29/17) fell twice. Review of resident #1's Fall Report, showed he fell four times on 12/31/16. Review of resident #1's Fall Reports included the following injuries: a. Goose egg to forehead. b. Hematoma to top of scalp. c. Skin tear to right elbow with three plus edema underneath. d. Fractured clavicle. The facility was unable to provide documentation which showed interventions related to the root cause, and modification of those interventions, which were not effective, and resulted in 18 falls. 2. Review of resident #9's Care Plan, dated 1/7/2015, showed the resident was at risk for falls related to a [DIAGNOSES REDACTED]. a. Educate resident on proper use of walker brakes. b. Educate resident on vertigo. c. Encourage resident to wear non-slick footwear that fits. d. Ensure resident has proper footwear on after showers before transferring. Review of resident #9's Quarterly MDS, with the ARD of 6/21/17, showed the resident had severe cognitive impairment. Review of the facility Incidents By Incident Type Report, showed resident #9 had seven falls from 11/27/16 through 8/8/17. Review of resident #9's Care Plan showed one new intervention, dated 5/8/17; Keep light on in room to allow for proper visualization of surroundings. Review of resident #9's fall report, dated 11/27/16, showed the resident was wearing improper footwear. The resident had a hematoma to the back of her head, as a result of the fall. Review of resident #9's Fall Scene Investigation Report, dated 3/13/17, showed the root cause of the fall as urine on bathroom floor. Interventions included encourage resident to use call light, and night light in room. During an observation on 8/9/17 at 4:40 p.m., the resident's room did not include a night light. Review of resident #9's Fall Scene Investigation Report, dated 5/27/17, showed the root cause of the fall was the resident not using her FWW. Interventions included remind resident to use her walker at all times and use the call light. Review of resident #9's Fall Scene Investigation Report, dated 8/3/17, showed the root cause was wearing shoes that had no tread. The resident hit her mouth on the floor and broke her partial denture. The intervention included change to shoes with tread. During an observation on 8/9/17 at 1:15 p.m., resident #9 walked without assistance from the dining room to the next room to get her FWW. During an interview on 8/9/17 at 5:10 p.m., staff member J stated resident #9 was wearing the same shoes as the treadless shoes worn during the fall on 8/3/17. During an interview on 8/10/17 at 3:45 p.m., staff member F stated the facility had identified falls as a concern to work on, through the quality assurance quarterly meeting. Review of the facility Fall Prevention Policy showed the facility should revise the care plans as required, based on the residents' needs, and communicate the plan with staff. During an interview on 8/10/17 at 8:30 a.m., staff member G stated the FSI report was an internal document and not available to floor staff.",2020-09-01
457,CEDAR WOOD VILLA,275053,1 S OAKS,RED LODGE,MT,59068,2017-08-10,329,E,0,1,PWLL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor residents utilizing psychoactive medications for continued need, efficacy, and appropriate non-pharmacological interventions for 4 (#s 4, 5, 6, and 10); and monitoring for adverse side effects for 3 (#s 5, 6, and 10) of 13 sampled residents. Findings include: 1. Review of resident #6's admission orders [REDACTED]. The admission orders [REDACTED]. Review of resident #6's (MONTH) (YEAR) MAR showed orders for [MEDICATION NAME], with doses of 7.5 mg in the morning, and 5 mg in the afternoon. The MAR showed an order to monitor behaviors and document in the progress notes, twice a day. Review of resident #6's physician's orders [REDACTED]. Review of resident #6's progress notes, from 4/10/17-5/24/17, showed there was no documentation of inappropriate behaviors. Review of resident #6's progress notes from 5/26/17-6/14/17 showed 15 entries describing inappropriate behaviors of the resident trying to sit down on another resident's lap, slapping another resident, asking repetitive questions, repeatedly attempting to stand when unsteady, and general restlessness with agitation. The notes showed the interventions attempted were redirection (unspecified) and verbal requests to sit down. Review of resident #6's progress notes from 6/7/17-6/14/17 showed the resident was prescribed an antibiotic, for a UTI, due to her increased confusion and agitation. Review of resident #6's progress notes from 6/15/17-8/2/17 showed no documentation of inappropriate behaviors. Review of resident #6's assessments, in the EHR, showed an assessment titled, Antipsychotic use for residents with dementia, was in progress. The assessment was dated 10/9/16, and had many blank areas. There was no evidence a new assessment was initiated, after completion of the antibiotic, to monitor for the continued need of the increased dose of the [MEDICATION NAME]. During an interview on 8/9/17 at 11:45 a.m., staff member F stated there was no assessment for use of the anti-psychotic medication for resident #6. She stated the assessments were part of the EHR and there were no paper assessments in use. Staff member F stated the facility did not have regular meetings to review use of psychoactive medications and there was no established process for monitoring use. Monitoring for adverse side effects Review of resident #6's (MONTH) (YEAR) MAR showed there was no monitoring for adverse side effects related to the use of [MEDICATION NAME]. Review of the facility fall log showed resident #6 had falls on 4/5/17, 5/15/17, 6/5/17, 6/27/17, 7/14/17, and 7/19/17. Review of resident #6's progress notes from 4/10/17-6/7/17, showed there was no documentation of monitoring for ASE from the use of [MEDICATION NAME]. None of the notes showed consideration of the [MEDICATION NAME] being a contributing factor to the three falls that occurred during that period. Review of resident #6's progress notes from 6/8/17-7/13/17 showed multiple entries of no adverse side effects related to the use of [MEDICATION NAME]. None of the notes showed consideration of the [MEDICATION NAME] being a contributing factor to the two falls that occurred during that period. Review of resident #6's progress notes from 7/14/17-8/2/17 showed general notes with no documentation indicating monitoring of ASE related to the use of [MEDICATION NAME]. None of the notes showed consideration of the [MEDICATION NAME] being a contributing factor to the fall that occurred during that period. Review of resident #6's fall investigation reports for the falls of 4/5/17, 5/15/17, 6/5/17, 6/27/17, 7/14/17, and 7/19/17 showed no consideration of the [MEDICATION NAME] being a contributing factor to the falls. The [MEDICATION NAME]'s manufacturer's guidelines showed the following: [MEDICATION NAME] may cause somnolence, postural [MEDICAL CONDITION], motor and sensory instability, which may lead to falls and, consequently, fractures or other injuries. 2. Review of resident #4's (MONTH) (YEAR) MAR showed an order for [REDACTED]. Review of resident #4's assessments, in the EHR, showed a Psychopharmacological Drug Assessment, dated 9/15/15, marked as completed, with blank areas on the assessment. A Psychopharmacological Drug Assessment, dated 12/16/15, marked as, in progress, had many blank areas. During an interview on 8/9/17 at 6:00 p.m., staff member F stated the facility did not have a Psychopharmacological Drug Assessment for resident #4 and this process needed to be added. 3. Review of resident #5's (MONTH) (YEAR) MAR showed an order for [REDACTED]. The MAR did not show monitoring for anxiety, ASE, use of any non-pharmacological interventions, or effectiveness of the interventions. Review of resident #5's assessments, in the EHR, showed a Psychopharmacological Drug Assessment, dated 7/16/15, marked, in progress, and containing many blank areas. Review of resident #5's chart, in the assessments tab, showed no consent for the use of [MEDICATION NAME], or other documentation showing the resident or responsible party had been informed of the potential side effects related to the use of [MEDICATION NAME]. During an interview on 8/9/17 at 6:00 p.m., staff member F stated the facility did not have a Psychopharmacological Drug Assessment for resident #4. 4. Review of resident #10's (MONTH) (YEAR) MAR showed an order for [REDACTED]. Review of resident #10's assessments, in the EHR, showed no assessment related to the use of the [MEDICATION NAME]. Review of resident #10's chart, in the assessments tab, showed no consent for the use of [MEDICATION NAME], or other documentation the resident or responsible party had been informed of the potential side effects related to the use of [MEDICATION NAME]. During an interview on 8/9/17 at 6:00 p.m., staff member C stated the facility had missed the behavior monitoring and ASE monitoring for resident #10. She stated the monitoring should be on the MAR and it will need to be added. During an interview on 8/10/17 at 8:27 a.m., staff member C stated she was unable to locate a consent for use of the [MEDICATION NAME] for resident #10. During an interview on 8/10/17 at 8:43 a.m., staff member F stated the facility had no psychoactive assessments, or other evidence of monitoring, to provide for residents #4, 5, 6, and 10. Review of a facility policy titled, Psychopharmacologic Medication Assessment and Review, with a revision date of (MONTH) (YEAR), showed that all psychopharmacologic medications are to be reviewed for effectiveness, minimal effective dose, potential side effects, potential drug interactions, goals for use, and need for a gradual dose reduction. The policy showed it applied to all [MEDICAL CONDITION] medications. Points of the policy plan included the following: - Each resident receiving any of the specified medications would have an assessment prior to a medication being initiated, upon admission, quarterly, annually, and with a change of condition - An assessment would be completed if a resident with dementia is on an anti-psychotic medication at the time of admission and does not have an approved (unspecified) diagnosis. This assessment would be completed quarterly and annually thereafter. - The resident-specific reason for use will be monitored - Side effects monitoring would be done for each type of psychopharmacological medication being used by the individual resident - Behavior meetings would be held at least quarterly.",2020-09-01
458,CEDAR WOOD VILLA,275053,1 S OAKS,RED LODGE,MT,59068,2017-08-10,332,D,0,1,PWLL11,"**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 not greater than 5%. The facility's medication error rate was 6.8%, with errors noted for 2 (#s 15 and 16) of 18 sampled and supplemental residents. Findings include: 1. Review of resident #16's physician's orders [REDACTED]. During an observation on 8/9/17 at 4:22 p.m., staff member J prepared [MEDICATION NAME]to administer to resident #16. Staff member J had tested resident #16's blood glucose and determined the dose to administer was 12 units. She administered the insulin into resident #10's abdomen. During an interview on 8/9/17 at 4:57 p.m., staff member J stated she was not aware of any specific instructions related to the timing of [MEDICATION NAME] administration, other than to give it before dinner. She said [MEDICATION NAME] could be given up to an hour before dinner, but if resident #10's blood glucose was low, she would wait until just before the meal. Review of the [MEDICATION NAME] manufacturer's guidelines showed a warning to inject ([MEDICATION NAME]) subcutaneously within 5-10 minutes before a meal into the abdominal area, thigh, buttocks or upper arm. Review of a facility policy titled, Insulin Administration, revised (MONTH) 2014, showed the following points: - The type of insulin, dosage requirements, time to be administered, strength, and method of administration must be verified before administration, to assure it corresponds with the order on the medication sheet and the physician's orders [REDACTED].>-The nursing staff will have access to specific instructions (from the manufacturer, if appropriate) on all forms of insulin delivery systems prior to their use. - Rapid-acting insulins have an onset of action in 10-15 minutes with a peak of action in 0.5-3 hours. The policy notes these times vary by manufacturer and referred the user to see package inserts. During an observation on 8/9/17 at 5:30 p.m., dinner had not been served. 2. During an observation on 8/8/17 at 7:15 a.m., staff member I assisted resident #15 with administration of an [MEDICATION NAME] Diskus Inhaler. He prepared the inhaler and handed it to resident #15. She completed the inhalation and returned the inhaler to staff member I. Staff member I encouraged the resident to rinse her mouth with a drink of water. Resident #15 took a drink of water and swallowed. Staff member I did not instruct resident #15 to spit out the water instead of swallowing it. During an interview on 8/8/17 at 8:30 a.m., staff member I stated the instructions for [MEDICATION NAME] include to rinse (the mouth) and spit out the water. He stated he had not instructed resident #15 to spit out the water. Review of the manufacturer's guidelines for the [MEDICATION NAME] Diskus Inhaler administration showed, [MEDICATION NAME] can cause serious side effects, including: - fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using [MEDICATION NAME] to help reduce your chance of getting thrush. During an interview on 8/10/17 at 8:10 a.m., staff member F stated the facility conducted audits to ensure the facility medication error rates were less than 5%. During an interview on 8/10/17 at 8:43 a.m., staff member F stated she was not able to locate audits or training to show what steps the facility took to ensure medication error rates were less than 5%.",2020-09-01
459,CEDAR WOOD VILLA,275053,1 S OAKS,RED LODGE,MT,59068,2017-08-10,333,D,0,1,PWLL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents were free from significant medication errors, by administering [MEDICATION NAME]outside the manufacturer's instructed timeline, for 1 (#16) of 18 sampled and supplemental residents. Findings include: 1. Review of resident #16's physician's orders [REDACTED]. During an observation on 8/9/17 at 4:22 p.m., staff member J prepared [MEDICATION NAME]to administer to resident #16. Staff member J had tested resident #16's blood glucose and determined the dose to administer was 12 units. She administered the insulin into resident #10's abdomen. During an interview on 8/9/17 at 4:57 p.m., staff member J stated she was not aware of any specific instructions related to the timing of [MEDICATION NAME] administration, other than to give it before dinner. She said [MEDICATION NAME] could be given up to an hour before dinner, but if resident #10's blood glucose was low, she would wait until just before the meal. Review of the [MEDICATION NAME] manufacturer's guidelines showed a warning to inject ([MEDICATION NAME]) subcutaneously within 5-10 minutes before a meal into the abdominal area, thigh, buttocks or upper arm. The guideline showed: - [DIAGNOSES REDACTED] is the most common adverse effect of all insulin therapies, including [MEDICATION NAME](R). Severe [DIAGNOSES REDACTED] can cause [MEDICAL CONDITION], may lead to unconsciousness may be life threatening or cause death. [DIAGNOSES REDACTED] can impair concentration ability and reaction time; this may place an individual and others at risk in situations where these abilities are important (e.g. driving or operating other machinery). [DIAGNOSES REDACTED] can happen suddenly and symptoms may differ in each individual and change over time in the same individual. Symptomatic awareness of [DIAGNOSES REDACTED] may be less pronounced in patients with longstanding diabetes in patients with diabetic nerve disease, in patients using medications that block the sympathetic nervous system (e.g., betablockers) (see Drug Interactions (7)), or in patients who experience recurrent [DIAGNOSES REDACTED]. - Risk Factors for [DIAGNOSES REDACTED]: The risk of [DIAGNOSES REDACTED] after an injection is related to the duration of action of the insulin and, in general, is highest when the glucose lowering effect of the insulin is maximal. As with all insulin preparations, the glucose lowering effect time course of [MEDICATION NAME](R) may vary in different individuals or at different times in the same individual and depends on many conditions, including the area of injection as well as the injection site blood supply and temperature (see Clinical Pharmacology (12.2)). Other factors which may increase the risk of [DIAGNOSES REDACTED] include changes in meal pattern (e.g., macronutrient content or timing of meals), changes in level of physical activity, or changes to co-administered medication Review of a facility policy titled, Insulin Administration, revised (MONTH) 2014, showed the following points: - The type of insulin, dosage requirements, time to be administered, strength, and method of administration must be verified before administration, to assure it corresponds with the order on the medication sheet and the physician's orders [REDACTED].>-The nursing staff would have access to specific instructions (from the manufacturer, if appropriate) on all forms of insulin delivery systems prior to their use. - Rapid-acting insulins have an onset of action in 10-15 minutes with a peak of action in 0.5-3 hours. The policy noted these times vary by manufacturer and referred the user to see package inserts.",2020-09-01
460,CEDAR WOOD VILLA,275053,1 S OAKS,RED LODGE,MT,59068,2017-08-10,361,F,0,1,PWLL11,"Based on interview, record review, and observation, the facility failed to ensure the dietary department worked collaboratively with a qualified dietitian. A registered dietitian did not provide training, education, and oversite for a new dietary manager, and the staff working at the facility, and food was served incorrectly. This deficient practice affected all residents who who had meals served from the kitchen. Findings include: During an observation on 8/7/17 during lunch, chicken and stuffing were served. The menu specified Tilapia, dill sauce, pasta and summer squash. During an observation on 8/7/17 during dinner, a beef and cabbage casserole was served, with a tossed salad. The menu called for a pork loin, red bliss potatoes, and a Capri vegetable blend. During an observation on 8/8/17 during lunch, the resident's whom received the Mechanical Soft diet were served steak fries, instead of mashed potatoes, which were specified on the lunch spread sheet. The ground beef brisket appeared to be a pureed reddish substance, and resident #10 stated it was horrible and not edible. During an interview on 8/8/17 at 1:15 p.m., staff member L stated he got confused, and ground the meat with gravy. Staff member A stated the meat looked like cat food. During an observation on 8/8/17 during dinner preparation, staff member L was serving frozen fish, corn and french fries. The menu specified a cheese quesadilla, fiesta rice, and beans. The fish menu was identified as the alternate menu. Upon review of the menu spreadsheet, the residents on a Mechanical Soft diet should have received parsly potatoes and carrots, but rather they received corn and onion rings. During an observation on 8/9/17 during lunch service, residents on Mechanical Soft diets received ground chicken, with no sauce. The meal appeared dry. During an interview on 8/9/17 at 1:20 p.m., staff member L stated the spread sheet confused him. It showed sauce of choice so he thought the residents would choose a condiment at the table. He stated he had not received much training, and had no training from the registered dietitian. Review of the dinner spread sheet for 8/9/17, showed the residents were to have soup, sandwich, bean salad, and a relish plate. During an interview on 8/9/17 at 5:30 p.m., staff member A stated she had not seen the bean salad on the menu, and she thought the relish plate was shredded lettuce. The relish plate recipe included tomatoes, onions, and pickles. During an interview on 8/9/17 at 3:10 p.m., staff member A stated she had no formal training, and learned how to order food from other employees. She stated she was out of her element and had no kitchen experience. She stated she used the alternate menu at times, because the residents did not like the food. She stated staffing and the budget were not the reason for the menu changes. She stated the registered dietitian did not communicate with her, other than a monthly audit. The menu and spread sheets were not signed by the registered dietitian. During an interview on 8/9/17 at 2:50 p.m., staff member G stated the dietitian did not consult with the dietary manager, other than the monthly audit. She stated the dietitian was only at the facility once a month, and was not involved in care planning for the residents, and staff member A had received guidance for care planning from staff member F.",2020-09-01
461,CEDAR WOOD VILLA,275053,1 S OAKS,RED LODGE,MT,59068,2017-08-10,406,D,0,1,PWLL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and observation, the facility failed to provide a necessary service to assist with the maintaining the ability to chew and swallow for 1 (#2) of 13 sampled residents. Findings include Review of resident #2's Physician orders [REDACTED]. During an interview on 8/8/17 at 3:10 p.m., staff member F stated the order had gotten missed, and the swallow evaluation had not been completed. During an observation on 8/8/17 at 8:40 a.m., resident #2 was holding yogurt in his mouth, and would not swallow. Staff member H stated she would not feed him any more food. She stated he would also pocket his food. Review of resident #2's Physician-prescribed diet showed a regular texture.",2020-09-01
462,CEDAR WOOD VILLA,275053,1 S OAKS,RED LODGE,MT,59068,2017-08-10,441,D,0,1,PWLL11,"Based on observation, interview, and record review, the facility failed to appropriately manage the use and cleaning of glucometers to prevent the spread of infection for 2 (#s 16 and 17) of 18 sampled and supplemental residents. Findings include: 1. During an observation and interview on 8/8/17 at 5:02 p.m., staff member K prepared to perform a blood glucose test on resident #16. She entered resident #16's room and laid the glucometer (blood glucose monitor), without a barrier, on a dresser. After completing the blood glucose test, staff member K returned to the medication cart, and laid the glucometer on top of the cart, without a barrier. She wiped the glucometer with a MicroKill+ disinfectant wipe for four seconds and placed the glucometer in it's case. Staff member K stated that the glucometer does not have to be disinfected after each use because each resident had a dedicated glucometer. She said she did not know how often the glucometers needed to be cleaned. Staff member K stated the required disinfecting time for the MicroKill+ wipe was one minute. She said she had not cleaned the glucometer for one minute due to being nervous, and just trying to get done. Staff member K stated she did not think the facility policy addressed using a barrier under the glucometer. She said she had not been trained on using a barrier. During an observation on 8/9/17 at 4:17 p.m., staff member J prepared to perform a blood glucose test on resident #16. She laid the glucometer on the medication cart, without a barrier. Staff member J entered resident #16's room and laid the glucometer on the dresser, without a barrier. After completing resident #16's blood glucose test, staff member J returned the glucometer to the case and placed it in the medication cart. She did not clean the glucometer after testing resident #16's blood glucose. During an interview on 8/9/17 at 4:57 p.m., staff member J stated she had not cleaned the glucometer before or after it was used to test resident #16's blood glucose. She said sometimes she cleans the glucometer at the end of her shift. Staff member J stated she did not know how often the glucometer should be cleaned. She said she had not been trained to use a barrier under the glucometer, and was not aware of that being in the facility policy. 2. During an observation on 8/7/17 at 11:25 a.m., staff member I prepared to perform a blood glucose test on resident #17. He removed the glucometer from the case and disinfected the glucometer using a MicroKill+ disinfectant wipe. He laid the glucometer on the medication cart without a barrier. He had not cleaned the top of the cart during the observation. Staff member I took the glucometer to resident #17's room and laid it on her overbed table, without a barrier. After completing resident #17's blood glucose test, staff member I laid the glucometer on the overbed table, without a barrier. Review of a facility policy titled, Blood Glucose Monitor Disinfection, with a revision date of (MONTH) (YEAR), showed blood glucose monitors would be cleaned and disinfected following use on each resident when monitors are shared by multiple residents. The policy did not show when to clean and disinfect the blood glucose monitor when each resident has a dedicated glucometer. In the procedure section, the policy showed: - to place the equipment on bedside table, or overbed table, and use a towel/paper towels as a barrier between the table and the equipment prior to placing the equipment on the table - disinfect the monitor by continually wiping, or wrapping the monitor with a second wipe, to ensure contact time of one minute. - the disinfected monitor will be placed on a towel/paper towel.",2020-09-01
463,CEDAR WOOD VILLA,275053,1 S OAKS,RED LODGE,MT,59068,2018-11-15,582,B,0,1,DTN811,"Based on interview and record review, the facility failed to provide evidence that SNF ABN, form CMS- was provided for 1 (#203) of 27 sampled and supplemental residents. Findings include: During an interview on 11/14/18 at 8:50 a.m., staff member [NAME] stated two staff members, A and D, provided the CMS- form to resident #203 when his Medicare Part A Service Termination/Discharge was voluntary. However the staff members were unable to locate the form. Review of resident #203 medical chart showed no evidence of the CMS- form completed and the form was not provided.",2020-09-01
464,CEDAR WOOD VILLA,275053,1 S OAKS,RED LODGE,MT,59068,2018-11-15,657,D,0,1,DTN811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete and revise a comprehensive care plan to show non-pharmacological interventions regarding pain, and the resident was having pain, for 1 (#21), and failed to show alternative interventions related to the provision of ADL care, requiring male assistance, for 1 (#40) of 26 sampled residents. Findings include: 1. During an observation and interview, on 11/14/18 at 10:15 a.m., resident #21 was in her room, seated in her wheel chair, with a grimacing look on her face. She stated she had a lot of pain, almost all the time, in her neck. She stated she wore a [MEDICATION NAME] and had other pain medications as well. During an interview on 11/14/18 at 3:38 p.m., staff member B stated we apply ice packs for her neck, and have tried different pillows, and we just got a support in for her wheelchair. The [MEDICATION NAME] is the latest intervention. Review of resident #21's Care Plan did not show the non-pharmacological pain interventions were identified or added to the plan as revisions, such as ice packs and pillows, to relieve resident #21's pain. 2. During an observation on 11/14/18 at 9:52 a.m., resident #40 was visibly wet in his groin area and smelled of urine. The resident's fingernails were long and had visible dirt underneath the nails. During an interview on 11/14/18 at 10:22 a.m., staff member G stated male staff usually provide cares for resident #40, as he refused care from females. During an interview on 11/14/18 at 10:27 a.m., staff member H stated, The resident refuses to get a bath from me. He refuses a female every time. During an interview on 11/14/18 at 4:33 p.m., staff member I stated, He refuses females providing care most of the time. A lot of times there is nothing you can do for him. Review of resident #40's care plan had documented interventions dated 6/10/14 and 10/4/18, which reflected staff would provide male assistance for bathing, and the resident would not allow female staff to observe his skin during bathing. The plan showed an intervention was to provide male staff for assistance for the resident. The care plan also had a goal, which was dated 8/23/18, for the resident being odor free, with an intervention dated 5/23/14, for providing assistance with completing two showers/baths per week. The care plan did not include alternative interventions for when a male caregiver was unavailable, and only female staff were available to assist the resident, in the event the resident refused the female care. Review of facility documents, titled Daily Bath Record, showed from 10/2/18 - 11/14/18, resident #40 had five separate occurrences documented where there were no male staff available to assist the resident during the provision of ADL care.",2020-09-01
465,CEDAR WOOD VILLA,275053,1 S OAKS,RED LODGE,MT,59068,2018-11-15,658,D,0,1,DTN811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure diabetic nail care was performed by a licensed caregiver for 1 (#31), failed to observe medication ingestion for 1 (#35), and did not perform CPR for a resident that was full code for 1 (#52) out of 26 sampled residents. Findings include: 1. During an observation and interview on [DATE] at 3:24 p.m., staff member H performed a bath on resident #31 in the facility bath house. After completion of the bath, staff member H proceeded to trim the resident's toe nails and fingernails. Staff member H was asked about the practice of trimming nails on diabetic residents and stated I don't think he's a diabetic, nurses do those resident's. Staff member was not a licensed nurse. During an interview on [DATE] at 4:29 p.m., staff member I stated either nursing or a podiatrist was responsible for trimming a diabetic resident's nails. Review of resident #31's face sheet had a [DIAGNOSES REDACTED]. Review of the facility policy, Diabetic Foot Care, revised (MONTH) (YEAR) read, Nail care on Resident's with Diabetes or other diseases that affect resident's skin integrity should be performed by a licensed nurse or Podiatrist. A review of the facility form, titled, South Unit Nurse Aid (sic) Assignment Sheets, showed resident #31 was assist of two people for ADLs, without mention of the resident's diabetic status. 2. During an observation on [DATE] at 8:15 a.m., staff member I placed liquid [MEDICATION NAME] into resident #35's coffee. Staff member I stated the resident did not like the taste of the medication. Staff member I stated she would observe resident #35 drink his coffee, which contained his medication, while continuing to administer medication to other residents in the dining room. During observation, and interview on [DATE] at 8:34 a.m., it was noted that resident #35 had a full cup of coffee. Resident #35 was asked if he drank any of the coffee, and said not a drop. Staff member I was no longer in the dining area at this time. During an interview on [DATE] at 9:00 a.m., staff member I was asked if resident #35 drank his coffee containing the [MEDICATION NAME]. Staff member I stated she should have gone back to check, but did not. Staff member I stated I will have to mark it as refused. A review of the facility policy, Combining/Crushing Oral Medications, effective (MONTH) (YEAR), read there needs to be a plan to administer medications should the resident not consume the crushed/combined medications once incorporated into food. 3. During an interview on [DATE] at 10:32 a.m., staff member B stated resident #52 was a full code at the time of his passing on [DATE] because his family would not change his POLST to a DNR. Staff member B stated, The family came down and got me and told me that he had passed, I went down to the room, I listened for heart and lung sounds, and he had started to mottle prior to that. Staff member B stated she wrote the progress note regarding his death in his chart on [DATE]. Staff member B stated she did not perform CPR on resident #52 because, He was already in the dying process. Staff member B stated, The doctor tried to convince them (family) to change the POLST (from a Full Code to a DNR) but the family denied; I do not feel like CPR should have been performed. Staff member B stated she would normally perform CPR on a resident as long as they were not in the dying process. During an interview on [DATE] at 11:00 a.m., staff member A stated staff member B was aware of the CPR (Cardiopulmonary Resuscitation) / AED (Automated External Defibrillator) policy and procedure and there was not education provided on the policy after the death of resident #52. Staff member A stated it was not an identified concern that CPR was not performed on resident #52, and the resident was a full code. Review of the facility policy and procedure CPR (Cardiopulmonary Resuscitation) / AED (Automated External Defibrillator showed, CPR (Cardiopulmonary Resuscitation) will be provided to residents/patients experiencing a respiratory or [MEDICAL CONDITION] if they have chosen CPR status. Review of resident #52's Montana Provider Orders For Life-Sustaining Treatment (POLST), dated [DATE], showed Section A Treatment Options, Attempt Resuscitation (CPR). During an interview on [DATE] at 11:31 a.m., staff member B stated the facility did not ever receive a verbal or a written order for resident #52 to be a DNR.",2020-09-01
466,CEDAR WOOD VILLA,275053,1 S OAKS,RED LODGE,MT,59068,2018-11-15,678,D,0,1,DTN811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide CPR on a resident, when the resident was found unresponsive and designated as a full code status, for 1 #(52)of 26 sampled residents. Findings include: During an interview on [DATE] at 10:32 a.m., staff member B stated resident #52 was a full code at the time of his passing on [DATE] because his family would not change his POLST to a DNR. Staff member B stated, The family came down and got me and told me that he had passed, I went down to the room, I listened for heart and lung sounds and he had started to mottle prior to that. Staff member B stated she wrote the progress note in his chart on [DATE]. Staff member B stated she did not perform CPR to resident #52 because He was already in the dying process. Staff member B stated, The doctor tried to convince them (family) to change the POLST to a DNR, but the family denied and she stated, I do not feel like CPR should of been preformed. Staff member B stated she would normally perform CPR on a resident as long as they were not in the dying process. Review of resident #52's progress note, dated [DATE] at 8:01 a.m., showed: - Type: Death Note without CPR - Time of Assessment: 0600 - Does Resident have a DNR order?: Full Code - Nurse Assessment .: no pulse, no respirations, pale cool skin - Was the B/P observable or audible?: No BP - Were there any apparent respirations?: no respirations - Resident's response to external Stimuli .: non responsive to touch and verbal - Is there rigor mortis?: no rigor mortis yet - Was there mottling?: mottling in feet up to knees, and on buttocks During an interview on [DATE] at 11:00 a.m., staff member A stated staff member B was aware of the CPR (Cardiopulmonary Resuscitation)/ AED (Automated External Defibrillator) Policy and Procedure and there was not education preformed on the policy after the death of resident #52. Staff member A stated it was not an identified concern that CPR was not preformed on resident #52 who was a full code. Resident #52's wife was his Medical Power of Attorney. Review of the facility policy and procedure CPR (Cardiopulmonary Resuscitation) / AED (Automated External Defibrillator, showed CPR (Cardiopulmonary Resuscitation) will be provided to residents/patients experiencing a respiratory or [MEDICAL CONDITION] if they have chosen CPR status. Review of resident #52's Montana Provider Orders For Life-Sustaining Treatment (POLST) dated [DATE], showed Section A Treatment Options, Attempt Resuscitation (CPR). During an interview on [DATE] at 11:31 a.m., staff member B stated the facility did not ever receive a verbal or a written order for resident #52 to be a DNR.",2020-09-01
467,CEDAR WOOD VILLA,275053,1 S OAKS,RED LODGE,MT,59068,2018-11-15,689,G,0,1,DTN811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to adequately assess a resident after a fall; failed to complete neurological exams adequately after a head injury; failed to notify the physician of the resident's change of status related to complaints of hip pain following a fall, and to ensure timely treatment was provided, and the resident had sustained a [MEDICAL CONDITION] during a fall, for 1 (#46) of 26 sampled residents. Findings include: During an observation on 11/13/18 at 2:01 p.m., resident #46 had a large, circular bruise to her right temple. During an interview on 11/15/18 at 10:00 a.m., staff member C stated the process for falls was to do an assessment (for the fall). If there were no injuries to the resident then staff would place the resident in bed, obtain vital signs, and (the nurse would) fill out an incident report. Staff member C stated the resident's emergency contact and physician were also contacted. Staff member C stated if the resident hit their head then neurological checks would be started. Staff member C stated the schedule for neurological checks was every 15 minutes for one hour, every 30 minutes for two hours, every hour for two hours, then every shift for 72 hours. Staff member C stated resident #46 had dropped something on 10/31/18, and she had attempted to pick it up and toppled out of her wheel chair. Review of resident #46's incident report, dated 10/31/18, showed resident #46 had a witnessed fall out of her wheel chair in which she hit her head, which caused a bump on the resident's right forehead. The report showed the family was contacted via phone and the physician was contacted via fax. During an interview on 11/15/18 at 10:35 a.m., staff member B stated when a resident fell staff were to call for assistance. Staff member B stated the nurse was to assess the resident, and move the resident if able to move the person safely, and do a body and skin assessment. Staff member B stated if a fall was unwitnessed or if the resident hit their head, the nurse was to initiate neurological checks. Staff member B stated the physician was to be notified via fax if there was no injury, and by phone if there was an injury. Staff member B stated staff were to fill out the risk management (QA document) in the computer and also a hard copy incident report. Staff member B stated the Interdisciplinary team reviewed the fall the next day to determine the root cause and update the care plan, if needed. Review of resident #46's Neurological Evaluation Flow Sheet showed the resident had sluggish pupil response for the first one and one half hours following the fall, in which she had a bump to the right forehead. The flow sheet was incomplete. Documentation in the medical record failed to show the physician was notified of the resident's pupil response or bump to the head. Review of resident #46's medical record, showed a document with no title, dated 10/31/18, and the resident fell out of her chair, in the dining room, and landed on her left hip. Review of resident #46's medical record document, no title, dated 11/1/18, showed the resident initially complained of left hip pain after the fall. The physician was not notified timely of the resident's complaint of hip pain, but rather the notification was delayed until 11/2/18. Review of resident #46's nursing note, dated 11/1/18, showed the resident had two falls on the previous day. Fall documentation showed one fall on 10/31/18. Review of resident #46's nursing note, dated 11/2/18, showed the resident complained of increased hip and leg pain. A call was placed to the resident's physician. Review of resident #46's progress note, dated 11/2/18 showed the resident was transported to the physician's office at 1:00 p.m., and was later transferred to the hospital via ambulance from the physician's office. Review of resident #46's care plan showed the resident had a surgical incision to her left hip with staples in place, with an initiation date of 11/8/18. The care plan was not updated with interventions to include the recent fall with [MEDICAL CONDITION], or change in care due to the [MEDICAL CONDITION] sustained during a fall.",2020-09-01
468,CEDAR WOOD VILLA,275053,1 S OAKS,RED LODGE,MT,59068,2018-11-15,758,D,0,1,DTN811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor a resident sufficiently for showing the use of an antipsychotic medication was beneficial, based on the resident's routine and behavior's exhibited, for 1 (#42) out of 26 sampled residents. Findings include: During an observation on 11/13/18 at 5:44 p.m., resident #42 was falling asleep at the dinner table and only ate a few bites of her food. The resident was unable to stay awake enough to consume the meal. Review of resident #42's admission orders [REDACTED]. Review of resident #42's Facsimile Transmittal Sheet, from the doctor, dated 11/1/18, showed Resident has continued agitation and aggression to staff and other residents, also is not sleeping much, sometimes up for over 24 hrs. Increase [MEDICATION NAME] to 50 mg PO QHS. The resident's record did not show adequate documentation for behavior monitoring to support the increase in agitation and aggression. During an interview on 11/14/18 at 3:30 p.m., staff member B stated resident #42 is on [MEDICATION NAME] .because she has had a behavioral illness prior to her coming here, she has behaviors, and tries to get herself up and falls, she also refused medications. Staff member B stated the [DIAGNOSES REDACTED]. Staff member B stated it is expected that staff monitor behaviors every shift for residents on antipsychotic medication. It looks like she does not have behavior monitoring in her chart. Staff member B stated the reason [MEDICATION NAME] was increased from 25 mg to 50 mg was because She got very agitated and she was exit seeking. The record did not reflect an ongoing pattern of increased agitation/exit seeking. Review of resident #42's medical chart showed no evidence of behavior monitoring being completed.",2020-09-01
469,CEDAR WOOD VILLA,275053,1 S OAKS,RED LODGE,MT,59068,2018-11-15,812,F,0,1,DTN811,"Based on observation, interview, and record review, the facility failed to maintain a clean kitchen and show an affective system was in place for the cleaning, which had the potential to affect all residents. Findings include: During an observation on 11/13/18 at 1:10 p.m., the kitchen floor appeared dirty with food particles under the preparation table, and the floor was sticky around the refrigerator area. The outside of the microwave appeared greasy, and the handles of the refridgerators appeared to have dirty greasy hand prints on them. During an interview on 11/13/18 at 1:30 p.m., staff member F stated there was a cleaning chart that was to be filled out by the employees, however it did not always get done. He stated it was over on the bulletin board During an observation on 11/13/18 at 1:35 p.m., there were two sheets of paper titled, Closing Checklist posted on the bulletin board in the kitchen, that were blank. During an observation on 11/14/18 at 11:58 a.m., the dishwashing area appeared unclean, the floor in the dishwash room was discolored from dirt, the back splash had dried food particles on it, and there was food particles under the dishwasher which had not been cleaned. The floor under the preparation table had food particles built up, and the shelving area under the preparation table had dust on it due to not cleaned. Review of the facility document, undated, with a title of, Weekly Deep Clean, showed none of the following items were signed off: - Mop and Sanitize the walk in - Clean coffee machine and cocoa machines - Clean ovens-inside, outside, and racks - Clean top gas burner inserts - Clean and organize freezers - Remove and clean hood inserts - Wipe down outside and the inside of the hood vent - Wipe down and clean room carts During an interview on 11/15/18 at 11:00 a.m., staff member [NAME] stated the dietary staff do not sign off on a sheet when they complete a cleaning task and did not have any documentation to show when the cleaning of the kitchen was done.",2020-09-01
470,CEDAR WOOD VILLA,275053,1 S OAKS,RED LODGE,MT,59068,2018-11-15,881,E,0,1,DTN811,"Based on interview and record review, the facility failed to implement a facility-wide antibiotic stewardship program. This failure had the potential to affect all residents receiving antibiotics. Findings include: During an interview on 11/15/18 at 9:41 a.m., staff member B stated prior to 11/14/18 she did not use mapping for antibiotic use. She stated she kept track of the antibiotics on the computer and would take the information to the monthly QAPI (Quality Assurance Performance Improvement) meeting. She provided a copy of the computer printout for the antibiotic program which listed the resident name, date of infection, site, diagnosis, culture, x-ray, organism, antibiotic ordered, isolation, and if the infection was healthcare acquired. Staff member B stated the physician's need training on the antibiotic stewardship program. She stated the facility Medical Director was starting to help with the antibiotic stewardship program. The facility policy titled Antibiotic Stewardship Program (ASP) was reviewed. Documented in the policy under section 2. v. Include a separate report for the number of residents on antibiotics that did not meet criteria for active infection . This report was not provided.",2020-09-01
471,CEDAR WOOD VILLA,275053,1 S OAKS,RED LODGE,MT,59068,2019-11-27,623,D,0,1,L3PD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident and resident representative, in writing, of the reason for a transfer to the hospital for 2 (#s 12 and 43) of 22 sampled residents. Findings include: 1. During an interview on 11/25/19 at 2:40 p.m., resident #43 stated she had gone to the hospital over the past year, but was unable to remember the dates of the transfer. Resident #43 stated she did not know if she received a written notice of the transfer when she went to the hospital. Review of resident #43's Discharge MDS Assessments, dated 6/13/19, 6/21/19, 7/1/19, 7/8/19, and 7/29/19, showed resident #43 had discharged from the facility on those dates. During an interview on 11/27/19 at 10:12 a.m., staff member F stated when a resident was transferred to the hospital, the staff would send the face sheet, medication sheet, vitals, a report sheet on the reason for sending the resident to the hospital, and a call to the hospital to let them know the resident was being transported. During an interview on 11/27/19 at 10:20 a.m., staff member A stated the policy titled, Bedhold Policy was both the bed hold and transfer policy combined. A review of the facility policy titled, Bedhold Policy, dated (MONTH) 2019, showed no information that the resident, and the resident's representative, would be notified in writing of a transfer or discharge. A written request was made on 11/27/19 at 8:30 a.m. for resident #43's transfer form related to multiple hospitalization s. No transfer forms were provided. 2. During an interview on 11/27/19 at 9:50 a.m., staff member A stated the nursing staff were supposed to send the resident's medication list and an e-Interact form, generated from the EHR, with the resident when the resident was transferred out of the facility, but this had not been getting done consistently. Review of resident #12's progress notes showed the resident was transferred to the hospital for [MEDICAL CONDITION] activity on 11/11/19, and was readmitted to the facility on [DATE]. The resident's clinical record did not show a transfer form was provided to the resident, or the resident's representative.",2020-09-01
472,CEDAR WOOD VILLA,275053,1 S OAKS,RED LODGE,MT,59068,2019-11-27,625,D,0,1,L3PD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a bed hold notice when residents were transferred to the hospital for 2 (#s 12 and 43) of 22 sampled residents. Findings include: 1. During an interview on 11/25/19 at 2:40 p.m., resident #43 stated she was in the hospital over the last year. Resident #43 did not know any information about a bed hold notice. A review of resident #43's Discharge MDS and Entry Tracking Records showed: -ARD of 6/13/19, the resident was discharged on [DATE] and re-entered the facility, from the hospital, on 6/17/19. -ARD of 6/21/19, the resident was discharged on [DATE] and re-entered the facility, from the hospital, on 6/24/19. -ARD of 7/1/19, the resident was discharged on [DATE] and re-entered the facility, from the hospital, on 7/7/19. -ARD of 7/29/19, the resident was discharged on [DATE] and re-entered the facility, from the hospital, on 8/1/19. During an interview on 11/27/19 at 10:12 a.m., staff member F stated when a resident transferred to the hospital the staff would send the face sheet, medication sheet, vitals, a report sheet on the reason for sending the resident to the hospital, and a call to the hospital to let them know the resident was being transported. A written request was made on 11/27/19 at 8:30 a.m. for resident #43's bed hold notice related to multiple hospitalization s. No bed hold notice was provided. A review of the facility policy titled, Bedhold Policy, dated (MONTH) 2019, under the section Procedure showed: -If a resident has a temporary absence from the facility for medical treatment, the Facility will ask the resident/resident representative/legal representative if they wish to hold the bed. This and the response will be documented in the medical record. Upon request of the resident/resident representative/legal representative, the Facility shall hold the bed . 2. During an interview on 11/27/19 at 9:50 a.m., staff member A stated the bed hold policy was part of the admission packet. Staff member A stated a bed hold policy form was to be sent with the resident upon transfer out of the facility, but this had not been getting completed. Staff member A stated forms would be placed at the nurse's station for the nursing staff to fill out and send with the resident upon transfer out of the facility. Review of resident #12's progress notes showed the resident was transferred to the hospital on [DATE] and returned on 11/14/19. The medical record did not show bed hold information was provided to the resident and the resident representative.",2020-09-01
473,CEDAR WOOD VILLA,275053,1 S OAKS,RED LODGE,MT,59068,2019-11-27,758,D,0,1,L3PD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure as needed orders for [MEDICAL CONDITION] medications were limited to 14 days for 1 (#42) of 24 sampled and supplemental residents. Findings include: During an interview on 11/27/19 at 8:05 a.m., staff member C stated (contract pharmacy) did monthly medication reviews to monitor for any irregularities or unnecessary medications. Staff member C stated there was no one person specifically assigned to monitor for unnecessary prn [MEDICAL CONDITION] medications. She stated the Director of Nursing monitored the dashboard report daily for prn medications not used for more than 30 days. Staff member C stated this report did not capture the prn [MEDICAL CONDITION] medications which needed to either be discontinued by the physician after 14 days, or have documentation, by the physician, of the rationale for continuing a prn [MEDICAL CONDITION] medication beyond 14 days. Review of resident #42's medical record showed he had been readmitted to the facility on [DATE], after an extended stay at another facility. Review of resident #42's physician orders, dated 10/30/19, showed [MEDICATION NAME] 0.5 mg po TID prn for anxiety, with no end date. Review of resident #42's Consultation Report, dated 11/1/19, showed, .the resident's medication regimen contained no new irregularities. The report failed to show the new order for prn [MEDICATION NAME]. During a telephone interview on 11/27/19 at 4:23 p.m., staff member [NAME] stated he had done the monthly review for resident #42 on 11/1/19, and had not seen any irregularities. Staff member [NAME] stated he had not planned to contact the provider until the next monthly medication review in (MONTH) to discuss discontinuing the prn [MEDICAL CONDITION] for resident #42. Staff member [NAME] stated, Maybe the nursing staff has reached out to the provider? Staff member [NAME] stated he was aware of the regulation related to the 14 day limit for prn [MEDICAL CONDITION] medications, and could not explain why resident #42 still had an active order after 27 days.",2020-09-01
474,CEDAR WOOD VILLA,275053,1 S OAKS,RED LODGE,MT,59068,2019-11-27,761,D,0,1,L3PD11,"Based on observation, interview, and record review, the facility failed to ensure all drugs and biological's were maintained in locked compartments when unattended. Findings include: During an observation on 11/25/19 at 4:54 p.m., staff member H was preparing insulin for a resident. The medication cart was parked on the south hall, against the wall, near room S10. Staff member H left the cart in the hall, unlocked and unattended, while she administered insulin to a resident in his room across the hall. Upon return to the cart, staff member H did not comment on the unlocked cart, and continued to pass medications as if nothing untoward had occurred. During an observation on 11/26/19 at 8:03 a.m., staff member F prepared medications for administration on the south hall, near room S12. Staff member F left the medication cart in the hall, unlocked and unattended. Staff member F entered room S12, gave the medications and returned to the medication cart. When asked what the facility policy was for locking the medication cart, staff member F stated, The cart should always be locked when unattended. Review of facility's policy, Medication Pass, dated (MONTH) 2019, showed, Medication cart should never be left unattended when unlocked.",2020-09-01
475,CEDAR WOOD VILLA,275053,1 S OAKS,RED LODGE,MT,59068,2019-11-27,812,D,0,1,L3PD11,"Based on observation and interview, the facility failed to ensure the kitchen maintained sanitary practices for the storage of food items; which had the potential to affect residents eating food, using these food items, prepared by the kitchen. Findings include: During an observation on 11/25/19 at 12:50 p.m., in the facility's dry storage area of the kitchen, a 25 pound bag of powdered sugar, and a 25 pound bag of bread crumbs, had been opened. The tops of the bags were not sealed, increasing a potential for foreign objects to fall into either bag. The two bags were on a wire shelving unit. During an observation on 11/27/19 at 7:26 a.m., the bag of powdered sugar, and the bag of bread crumbs, were sitting on the wire shelf in the dry storage room. Neither bag had been sealed. During an interview on 11/27/19 at 7:27 a.m., staff member D said the powdered sugar, and the bread crumbs, should have been stored in plastic containers.",2020-09-01
476,CEDAR WOOD VILLA,275053,1 S OAKS,RED LODGE,MT,59068,2019-11-27,842,E,0,1,L3PD11,"Based on interview and record review, the facility failed to ensure the electronic medication administration records were complete, related to resident monitoring for various concerns, for 6 (#s 9, 14, 18, 35, 37, and 43) of 24 sampled and supplemental residents. Findings include: During an interview on 11/26/19 at 2:28 p.m., staff member F stated documentation for pain and behavior monitoring was the same as documentation for medication administration (meaning it should be documented). Staff member F stated if you do not initial the box for the date and time of a medication or monitoring order on the MAR, the color of the box in the electronic health record changes to red on the MAR, which showed you did not finish the documentation. During an interview on 11/26/19 at 2:50 p.m., staff member B stated documenting a medication was given, and documenting that a monitoring task was completed, is the same on the MAR. During an interview on 11/27/19 at 9:35 a.m., staff member G stated the monitoring, such as pain and behavior, are assessments. Staff member G stated, Assessments need to be completed by the nurse. A review of resident #9's (MONTH) 2019 MAR, dated 11/12/19, 11/15/19, 11/20/19, and 11/22/19, showed the following areas were not documented: -Anticoagulant medication monitoring, -Antidepressant medication monitoring, -Behavior monitoring, -Pain monitoring. A review of resident #14's (MONTH) 2019 MAR, dated 11/1/19, 11/7/19, 11/12/19, 11/15/19, 11/20/19, and 11/23/19, showed the following areas were not documented: -Antidepressant medication monitoring, -Behavior monitoring, -Pain monitoring, -weekly skin checks. A review of resident #18's (MONTH) 2019 MAR, showed the weekly skin checks were not documented on 11/7/19. A review of resident #35's (MONTH) 2019 MAR, dated 11/12/19, 11/15/19, 11/20/19, and 11/21/19, showed the following areas were not documented: -Antidepressant medication monitoring, -Antipsychotic medication monitoring, -Pain monitoring,-Behavior monitoring, -wander guard placement and an active signal, -weekly skin checks. A review of resident #37's (MONTH) 2019 MAR, dated 11/12/19, 11/15/19, and 11/20/19, showed pain monitoring was not documented. A review of resident #43's (MONTH) 2019 MAR, dated 11/5/19, showed pain monitoring was not documented. During an interview on 11/27/19 at 8:04 a.m., staff member A said the facility looked for systemic concerns using PIPs, comparisons, CASPERs, and charting in the residents' electronic health record. Staff member A said she reviewed nursing notes, and medication pass documentation on a daily basis. She said the failure of documenting MARs for all types of monitoring had not been identified as a concern. Staff member A said she, the director of nursing, and the assistant director of nursing focused on routine and PRN medication documentation when reviewing resident MARS.",2020-09-01
477,ELKHORN HEALTHCARE & REHABILITATION,275056,474 HWY 282,CLANCY,MT,59634,2019-01-24,584,E,1,1,S5DR11,"> Based on observation and interview, the facility failed to repair, clean, or maintain the South Hall bath house, which had damaged walls, trim, drywall, grout, and soiled surfaces. The failure of maintaining the safe and clean environment, had the potential to affect any resident using the bath house, increase the risk of accidents, and the spread of pathogens, due to uncleanable surfaces. Findings include: During an observation on 1/23/19 at 3:12 p.m., the following uncleanable surfaces were observed: - several sections of drywall were broken and missing above the wall, baseboard trim, - a six inch section of ceramic tiles, above the baseboard trim, was bulged out, and grout was missing from between the tiles, and - the separating wall, between the tub and the toilet, was missing ceramic tile and pieces of drywall. During an observation on 1/23/19 at 3:20 p.m., the control panel of the tub was dripping water onto the floor. The floor at the front of the tub was covered in standing water. During an observation on 1/23/19 at 3:25 p.m., the following dirty surfaces were observed: - The front, underside of the tub had a calcium build up, - the far corners of the South Hall tub room had a build up of unidentified substances, and - the two horizontal leg supports for the tub had caked on dust and grime. During an interview on 1/24/19 at 10:11 a.m., staff member A said the tub needed to be replaced. Staff member A said he was aware of the condition of the ceramic tiles, walls, and baseboards of the bath house. He said the tub and lift were not being used at that time. During an interview on 1/24/19 at 10:23 a.m., staff member C said she was aware of the dirt in the corners of the South Hall tub room, and the grime build-up on the support legs of the tub. She said it was hard to get the tub room cleaned up with the tub leaking water, and water always standing on the floor. During an observation and interview on 1/24/19 at 10:29 a.m., staff member D was in the South Hall bath house giving a resident a bath in the tub. She said no one had told her she could not give residents a bath in the tub.",2020-09-01
478,ELKHORN HEALTHCARE & REHABILITATION,275056,474 HWY 282,CLANCY,MT,59634,2019-01-24,690,D,0,1,S5DR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide on-going daily care and monitoring of indwelling urinary catheters, which increased the risk of medical concerns, related to the use of the catheters, for 2 (#214 and #215) of 17 sampled residents. Findings include: 1. During an observation and interview on 1/23/19 at 4:45 p.m., resident #214 was asked if the facility helped him keep his indwelling catheter clean. Resident #214 stated, They don't touch my catheter, I think they're afraid. I try to clean it with a Kleenex every other day, and try to get that gunk that builds up off of there. A review of resident #214's MDS, dated [DATE], showed the resident was coded as a 3-2, meaning the resident needed extensive assistance of one person physical assist for personal hygiene. During an observation and interview on 1/24/19 at 9:05 a.m., staff member F was asked to perform catheter care on resident #214. Staff member F pulled back the covers and noted a wash cloth underneath part of the resident's scrotum and penis. The washcloth was stuck onto the tip of resident #214's penis from what appeared to be dried drainage. The resident pulled the wash cloth loose, and stated he put it there after he went to the bathroom to keep any stool from getting on it. Staff member F cleansed the resident's meatus and catheter with wipes, removing a brownish gel-like discharge, that was pooled in the meatus which had leaked onto resident #214's leg and dried. Staff member F failed to pull back the foreskin on resident #214 to cleanse the area. When asked about the procedure for catheter care, staff member F stated I didn't know I was supposed to do that. Staff member F then pulled back the foreskin and exposed a thick, white/gray substance, which dried onto the shaft of the resident's penis. Staff member F stated that the nurse inserts a new catheter, but for residents with a catheter already in place, the CNA's are supposed to clean them, daily. Staff member F stated she did not document anything when she performed catheter care. Review of resident #215's Baseline Care Plan showed [MEDICAL CONDITION] and Foley Catheter under the Bowel and Bladder section. There was not documentation to address care guidelines or interventions for staff to use for the resident's catheter care. Review of the facility document titled, Catheter Care - Indwelling (no date), showed Nursing personnel will provide indwelling catheter care at least twice daily. 2. During an observation and interview on 1/22/19 at 8:58 a.m., resident #215 stated, I've had it about a month (the catheter). I don't know, they (staff) empty it. When asked if the staff helped him clean the catheter around his penis, he stated I don't know if they get that far. He explained I couldn't stand up to urinate. During an interview on 1/23/19 at 2:26 p.m., resident #215 stated, She (NF1), cleaned it (area where catheter was inserted into penis). I made sure of it. She told me it was a mess. I told her 'ya' it hasn't been done (area where catheter exits penis) since I've been here. During an interview on 1/24/19 at 10:06 a.m., staff member [NAME] described how to empty a catheter bag. When discussing catheter care, she stated, You do that often (clean tip of penis where catheter was inserted), at least every time you do peri care. If a resident refused catheter care, she stated, I would usually tell the nurse. I understand (resident #215's) catheter was pretty nasty yesterday. During an interview on 1/24/19 at 11:40 a.m., NF1 stated she had given resident #215 a bed bath on 1/23/19. NF1 stated that when she unfastened the resident's brief, she noted that the resident's pubic hair was matted on the right side where the resident's catheter laid. She placed a moist wash cloth over the resident's pubic hair to soften the hair. NF1 stated she thoroughly washed up and around the resident's pubic area (to include the penal area where catheter exited the body). Review of the document titled Montana Department Of Public Health and Human Services Nurse Aid Skill Competency Checklist, revised 1/2015, showed for peri care, .Female Pericare, Male Pericare .Catheter care: proper handeling, emptying, changing catheter bags . The Competency Checklist list did not include uncircumcised perineal care. Review of resident #214's Baseline Care Plan showed under Bowel and Bladder, continent. There was no documentation for the indwelling catheter, care guidelines, or interventions staff would use or follow on the care plan.",2020-09-01
479,ELKHORN HEALTHCARE & REHABILITATION,275056,474 HWY 282,CLANCY,MT,59634,2019-01-24,880,D,0,1,S5DR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff properly washed or sanitized hands and change gloves between dirty to clean surfaces and ADL care procedures for 2 (#214 and #215) of 17 sampled resident. Findings include: 1. During an observation and interview on 1/24/19 at 9:05 a.m., staff member F was asked to perform catheter care on resident #214. Staff member F cleansed the the meatus, and catheter with wipes, removing a brownish gel-like discharge that was pooled in the meatus, leaked onto resident #214's leg, and had dried. Staff member F went back to the package of wipes multiple times to pull out more wipes, touching the package with the same gloves that were in contact with the resident's perineal area. Staff member F was asked about hand hygiene and glove change practice at the facility. She stated, You are supposed to wash your hands after you remove gloves, but we usually take off our gloves, and take the garbage out, then wash our hands. After the provision of care, staff member F was informed of the cross contamination that occurred from the soiled to clean items and areas during the provision of the ADL care, which she had not noticed during the care process. 2. During an observation and interview on 1/23/19 at 2:26 p.m., staff members G and H performed multiple dressing changes on resident #215. Staff members G and H washed their hands and donned gloves. Staff member G wiped down the bedside table and covered it with a blue pad. She poured Dakins solution into a med cup and prepared the rest of the supplies. Staff member G removed the old dressing from resident #215's ankle and discarded it. Staff member G removed her gloves, sanitized her hands, and donned clean gloves. Staff member G placed a clean dressing on resident #215's ankle, removed her gloves, sanitized her hands, and donned clean gloves. Staff member G removed multiple dressings from resident #215's buttocks, as the edges of the dressing's had overlapped. Staff member G opened a package of gauze pads, moistened them with normal saline, and used a separate piece of gauze for each new area cleansed for resident #215's wounds. Staff G did not sanitize hands or change gloves between the different wounds on the resident. Staff member G then removed her gloves, sanitized her hands, and donned clean gloves. Staff member G moistened gauze with Dakins solution, inserted the gauze into another wound, and staff member H covered the area with a dressing. Staff member G and H removed their gloves, sanitized their hands, and donned clean gloves. Staff member G opened three tongue depressors, and applied [MEDICATION NAME] cream to each wound, with a different tongue depressor, while staff member H went behind her and applied a dressing over each wound. Staff members G and H did not change gloves between each wound when completing these tasks to ensure the spread of pathogens did not occur. When discussing the wound care process and infection control measures taken during the care, both staff members G and H were aware tasks, without sanitizing or changing gloves with each wound, could potentially spread pathogens. Review of the facility policy, titled Precaution Guidelines (no date), showed under Components of Standard Precautions: Handwashing .It may be necessary to wash hands between tasks and procedures on the same patient to prevent cross-contamination of different body sites .Gloves .Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms.",2020-09-01
480,ELKHORN HEALTHCARE & REHABILITATION,275056,474 HWY 282,CLANCY,MT,59634,2019-01-24,908,E,1,1,S5DR11,"> Based on observation and interview, the facility failed to repair or replace a bathing tub, that was cracked, and the but had water leaking from areas of the tub or components of the tub, onto the floor. This failure had the potential to affect any resident using the bath house or the damaged tub, and increased the risk of accidents, or the spread of pathogens, due to uncleanable and damaged surfaces. Findings include: During an observation on 1/23/19 at 3:12 p.m., the bathing tub in the South Hall bath house was noted to have the following: - The tub had pieces broken off the back of the tub, - deep scratches on the inside rim on the right side of the tub, - the electrical control panel cover was cracked, and clear tape had been applied over the top of the crack, - a section of the blue tub trim was broken off, - the tub lift casing was cracked, and covered with white tape, - another section of the lift casing was cracked and not covered. During an observation on 1/23/19 at 3:20 p.m., the control panel of the tub was dripping water onto the floor. The floor at the front of the tub was covered in standing water. During an interview on 1/24/19 at 10:11 a.m., staff member A said he was aware the South Hall bath house was in bad shape. Staff member A said the tub was outdated and parts could no longer be found for repairs. He said the tub needed to be replaced. During an observation and interview on 1/24/19 at 10:29 a.m., staff member D was in the South Hall bath house giving a resident a bath in the tub. She said no one had told her she could not give residents a bath in the tub. Staff member D said she was told it was Okay to use the tub, because the hot water for the tub had been fixed yesterday.",2020-09-01
481,ELKHORN HEALTHCARE & REHABILITATION,275056,474 HWY 282,CLANCY,MT,59634,2017-10-26,167,C,0,1,7LYF11,"Based on observation and interview, the facility failed to have the most recent state survey results and plan of correction readily available and accessible for residents, staff, visitors, and the general public. Findings include: During an observation and interview on 10/23/17 at 8:00 a.m., an observation of the front lobby and around the nurses' desk window was conducted, with no obvious posting or survey results available for review. Staff member D stated a copy was in a notebook in the resident's computer room, which was a small open room off the lobby hallway. The survey results were located in this room, amongst several other books, under a table that was covered by a long table cloth. It was not in a prominent location, or easily accessible. During an interview on 10/23/17 at 8:10 a.m., staff member B brought another survey notebook and placed it on a table next to the front lobby nurses' desk window. She said that was normally where a copy of the most recent survey and plan of correction was kept for the residents' and visitor's use. She said the survey notebook had recently been taken from the table.",2020-09-01
482,ELKHORN HEALTHCARE & REHABILITATION,275056,474 HWY 282,CLANCY,MT,59634,2017-10-26,241,E,0,1,7LYF11,"Based on record review, interview and observation, the facility failed to provide adequately grooming assistance with ADL care when resident hair was unkept and whiskers were not trimmed for 6 (#s 10, 16, 17, 18, 19, and 20) of 20 sampled and supplemental residents; and failed to attempt to assess the continued use of a onsie (one piece outfit) for 1 (#1) of 15 sampled residents. Findings include: During observations the following concerns were identified: 1a. During an observation on 10/24/17 at 7:30 a.m., resident #19 was eating breakfast in the dining room with hair that had not been combed, and long curly whiskers on her chin. During an interview on 10/24/17 at 2:00 p.m., staff member K stated resident #19 did not always want her chin hairs removed. Review of resident #19's current Care Plan did not show she did not want her whiskers trimmed or hair uncombed. b. During an interview and observation on 10/24/17 at 10:45 a.m., resident #20 had hair smashed to the back of her head which caused the hair to be flattened. Staff member M stated she did not know why the resident's hair was not groomed, but she would take resident #20 to her room and brush her hair. During an observation on 10/25/17 at 7:40 a.m., resident #20 continued to have uncombed hair, which was flattened to the back of her head. c. During an observation on 10/24/17 at 10:50 a.m., resident #18 had hair flattened, messy, and uncombed, on the back of his head. Review of resident #18's Quarterly MDS, with the ARD of 8/2/17, showed the resident required encouragement and cueing for grooming needs. The care plan did not show the resident preferred to have his hair uncombed. d. During an observation and interview on 10/25/17 at 8:15 a.m., resident #17 was in the dining for breakfast. His shirt had dandruff scattered on it, and his hair was not combed and was sticking up in all directions. Staff member G stated she did not know if the resident was resistive to care, or if he was usually groomed by the staff. e. During an observation on 10/25/17 at 12:00 p.m., resident #16 was in the dining room for lunch. Her hair was smashed and laying flat down to the back of her head. f. During an observation and interview on 10/25/17 at 12:10 p.m., resident #10 was eating lunch in the dining room. His hair was uncombed and disheveled. Staff member I stated it could be difficult for staff to get his hair brushed, because he was in a hurry. During an interview on 10/26/17 at 9:10 a.m., staff member A stated the facility did deal with a population of residents who are resistive to grooming. 2. Review of resident #1's hand-written Care Plan, dated 6/25/14 showed One piece adaptive clothing to be worn. Review of resident #1's Social Service note, dated 11/20/16, showed (Resident) continues to wear adaptive clothing to preserve his dignity as he will undress/urinate in inappropriate places. Review of resident #1's medical record showed no assessment had been completed during the past three years for the use of the onsie, which was restricting access to the resident's body. During an observation and interview on 10/23/17 at 11:20 a.m., staff members G and H provided care to resident #1. His shirt and pants were sewn together, and zipped in the back. Resident #1 had no access to his body. Staff member H stated the suit was used for resident #1's dignity, to prevent him from exposing himself. During an interview on 10/24/17 at 4:20 p.m., staff member D stated it appeared the facility had not done a trial discontinuation for resident #1's onsie, after three years of use. He definitely is not the same person as he was three years ago, she stated. During an observation on 10/25/17 at 9:30 a.m., resident #1 had on pants with a belt, and a button-up shirt. Staff reported no inappropriate incidents had occurred by 1:30 p.m., which showed a period of time passed without the resident exhibiting the inappropriate behavior of exposing himself.",2020-09-01
483,ELKHORN HEALTHCARE & REHABILITATION,275056,474 HWY 282,CLANCY,MT,59634,2017-10-26,278,E,0,1,7LYF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately complete MDSs according to the established RAI time frames for 4 (#s 1, 3, 7, and 13), and accurately reflect the physical and mental status for 1 (#2) of 15 sampled residents. Findings include: A review of the Long Term Care Facility Resident Assessment Instrument User's Manual, Version 3.0, showed a table (page 2-15 and 2-16) which included MDS timeline requirements for the completion of MDS assessments, which were: - Admission MDS - The admitted plus 13 days. - Quarterly MDS - The ARD plus 14 days. - Significant Change MDS - Determination date plus 14 days. A review of the MDSs for resident #1, 3, 7, and 13 showed: 1. Review of resident #1's Significant Change MDS, with the ARD of 9/8/17, showed the MDS had been completed early, on 9/8/17. A valid MDS must be completed after the ARD date of 9/8/17, according to the Resident Assessment Instrument. 2. Review of resident #3's Quarterly MDS, with the ARD of 2/10/17, showed the MDS was completed late, on 5/26/17. Review of resident #3's Quarterly MDS, with the ARD of 8/13/17, showed the MDS was completed late, on 10/3/17. 3. Review of resident #2's Quarterly MDS, with the ARD of 9/4/17, showed the resident was on a mechanically altered therapeutic diet. Review of resident #2's current Diet Order showed she was on a Regular diet. During an interview on 10/25/17 at 3:30 p.m., staff member D stated she did not know why the diet was coded incorrectly for resident #2. She stated she was new to the MDS position and learning on the job. 4. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #7's Admission MDS, with an ARD of 8/9/17, showed the completion date of 10/2/17 which is past the 14 days for the MDS required timeline. 5. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #13's Admission MDS, with an ARD of 9/4/17, showed the completion date of 9/4/17. During an interview on 10/26/17 at 9:00 a.m., staff member A stated the facility was aware of the MDS issues, and staff member D started the position with incomplete MDSs. The Quality Assurance meeting was addressing the concerns.",2020-09-01
484,ELKHORN HEALTHCARE & REHABILITATION,275056,474 HWY 282,CLANCY,MT,59634,2017-10-26,281,E,0,1,7LYF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility nursing staff failed to maintain professional standards by failing to assess and accurately document the effectiveness of administered PRN pain medications for 4 (#s 6, 7, 8, and 13) ; and failed to obtain physician signatures on physician medication recapitulation forms, to renew resident medication orders, and medications were provided to 6 ( #s 4, 5, 7, 8, 12, and 15) without signed orders, of 15 sampled residents. Findings include: 1. Resident #6 was admitted to the facility with a [DIAGNOSES REDACTED]. She had a neosplasm of the uterus secondary to metastasis with abdominal pelvic pain. A review of resident #6's (MONTH) (YEAR) Physician's Medication Recapitulation orders showed the resident to have been ordered to receive [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME] with [MEDICATION NAME]) 10-325 mg, one tab by mouth, every four hours, PRN, for pain. A review of resident #6's (MONTH) (YEAR) MARS showed that over a period of 21 days, between the dates of 10/1/17 and 10/21/17, resident #6 received [MEDICATION NAME]-[MEDICATION NAME] 32 times. A review of resident #6's (MONTH) (YEAR) PRN Medication Record showed, during the period of 10/1/17 and 10/21/17, efficacies for [MEDICATION NAME]-[MEDICATION NAME] given were recorded 15 times or 47% of the pain medication doses given had recorded efficacies. A review of resident #6's (MONTH) (YEAR) Physician's Medication Recapitulation orders showed the resident was ordered to receive [MEDICATION NAME] sulfate 108 (90 Base) MCG/ACT Aerosol Powder Breath Activated Inhalation, 2 puffs, every four hours, PRN, for [MEDICAL CONDITION]. A review of resident #6's (MONTH) (YEAR) MARS showed that over a period of 21 days, between the dates of 10/1/17 and 10/21/17, resident #6 received [MEDICATION NAME] sulfate per inhaler 14 times. A review of resident #6's (MONTH) (YEAR) PRN Record showed, during the period of 10/1/17 and 10/21/17, efficacies for [MEDICATION NAME] sulfate, per the inhaler, were recorded five times or 36% of the [MEDICATION NAME] sulfate doses given had recorded efficacies. 2. A review of physician medication recapitulation orders for three residents (#s 4, 5, and 15) showed they were not signed and dated by each resident's physician. A review of (MONTH) (YEAR) Physician's Recapitulation MEDICATION ORDERS FOR [REDACTED]. a. Resident #4 was diagnosed with [REDACTED]. b. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. She had Type II Diabetes and an uncontrolled, alcoholic induced amnestic disorder coupled with alcohol dependence and anxiety states. c Resident #15 was admitted with [MEDICAL CONDITION], diverticulitis with [MEDICATION NAME] due to [MEDICAL CONDITION] and unspecified dementia without behavioral disturbances. A review of the MARs for residents #s 4, 5, and 15, showed each resident had been receiving medications from 10/1/17 to 10/23/17, based on the unsigned printed physicians recapitulation orders. During an interview on 10/25/17 at 4:30 p.m., staff member B was shown the unsigned (MONTH) (YEAR) physician medication recapitulation records for residents #s 4, 5, and 15. She stated she had not known they were unsigned by the residents' physicians. She said she would have to look into the matter. During an interview, on 10/25/17 at 9:05 a.m., staff member A said the facility did not have a policy on obtaining monthly physician medication recapitulation orders. She went on to say that ordinarily one of the facility's drivers delivered printed copies of each resident's recapitulation orders to each resident's ordering physician's office, towards the end of each month. The physician's office would call the facility driver after the recap records were signed, and he would pick them up. Usually he collected them all, and they were returned to each perspective resident's chart before the first day of the next month. She said the facility driver had not worked for several days during the last month and had recently stopped working for the facility. Not all of the physician signed recapitulation records for the month of (MONTH) had been returned to the facility yet. 3. Resident #7 was readmitted to the facility with [DIAGNOSES REDACTED]. Review of resident #7's Physician order [REDACTED]. Medications for resident #7 continued to be administered. [MEDICATION NAME]-[MEDICATION NAME], a narcotic, used to help manage pain, was ordered to be given: one table twice daily for pain. Resident #7 also had a PRN narcotic for pain not controlled by the scheduled narcotic. Review of resident #7's (MONTH) (YEAR) Medication Administration sheet showed the [MEDICATION NAME]-[MEDICATION NAME] was scheduled for 8:00 a.m. and 5:00 p.m. Review of resident #7's Narcotic tracking sheet showed a mix of scheduled narcotics. The PRN narcotics were signed for on the same sheet. Upon further review, the resident received a PRN [MEDICATION NAME]-[MEDICATION NAME] on 10/1/17, 10/4/17, 10/5/17, 10/19/17 and 10/22/17, without follow up documented. The Narcotic tracking sheet showed the PRN narcotic being signed for on 10/1/17 at 11:00 p.m., and it was not documented on the resident's MARs. On 10/3/17 at 12:30 p.m. one PRN narcotic tablet was signed out and not documented on the resident's MARs. Review of resident #7's PRN Record for (MONTH) (YEAR) showed two entries for milk of magnesia, but no prn pain medication follow up was charted. 4. Resident #13 was admitted to the facility on for rehabilitation of right femur fracture with surgical repair. Review of resident #13's physician orders [REDACTED]. The PRN narcotic was ordered to take a half to one tablet by mouth every four hours as needed for breakthrough pain. A PRN non-narcotic ([MEDICATION NAME]) was ordered as 1 tablet every 4 hours for moderate or severe pain. The scheduled antianxiety was ordered as 0.5 ml by mouth twice a day. Review of resident #13's MARs for (MONTH) (YEAR) showed [MEDICATION NAME], the PRN narcotic was given a total of 7 times and effectiveness charted three times. Review of resident #13's MARs for (MONTH) (YEAR) showed the PRN [MEDICATION NAME] was given 12 times but only four times was the effectiveness charted. The PRN [MEDICATION NAME] was given a total of 13 times and the effectivenes charted one time for September. During a review of Resident #13's fax, dated 10/19/17, from hospice to the physician, showed the resident was admitted to hospice on 10/18/17. A new request for scheduled [MEDICATION NAME] 5 mg by mouth 4 times a day was started 10/20/17. Hospice orders, dated 10/18/17, showed [MEDICATION NAME] 20 mg/ml: give 5-20 mg (0.25-1 ml) by mouth/under tongue every 1-2 hours as needed for pain or shortness of breath. Review of resident #13's October's MARs showed the entry to be written as Roxanal (sic) MS 20/1 [MEDICATION NAME]: give 0.5-2 mg po sublingual hourly prn pain/SOB. One dose of 1 ml was given on 10/22/17 and two doses of 0.5 was given on 10/23/17. The PRN effectiveness was charted for 10/23/17 on two different sheets, one entry on the PRN Record for (MONTH) (YEAR) and the other sheet was blank, except for the resident's name, date, no time, the PRN medication, and its effectiveness. Review of resident #13's sign out sheet for the PRN [MEDICATION NAME] showed it was given 15 times in (MONTH) (YEAR), documented 13 times, and effectiveness charted one time. In (MONTH) (YEAR), the scheduled [MEDICATION NAME] was given at the scheduled times, sometimes as a PRN, and sometimes later than the scheduled dose or earlier than the scheduled dose. The PRN [MEDICATION NAME] was signed out 14 times, documented 12 times, and effectiveness charted once. 5. Resident #8 was admitted to the facility on [DATE]. During a review of resident #8's Physician Recapitulation Orders for (MONTH) (YEAR), [MEDICATION NAME] 5 mg was to be given every six hours for PRN pain and was started on 10/4/17. Review of the resident's (MONTH) (YEAR) MARs showed the entry was written as [MEDICATION NAME] 5 mg, one tablet by mouth every six hours. It was scheduled at 8:00 a.m., 2:00 p.m., 8:00 p.m., and 2:00 a.m. It was not used as a PRN (as needed) medication, per physician orders. Review of resident #8's Physician's Recapitulation Orders for (MONTH) (YEAR) showed no physician signatures or sign off date. 6. Resident #12 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #12's Physician Recapitulation Orders for (MONTH) (YEAR) showed no physician signatures or sign off date. A review of the facility's policy and procedure titled As Needed PRN Medications showed the following: Document on the PRN D[NAME]UMENTATION form in the MAR indicated [REDACTED] - Date - Time - Initial - Drug-Dose - Route - Reason - Result- 1 hour after the administration of the drug, document if the medication was effective. If not, note in medical record what steps you took to further address the issue . Accurate and consistent documentation is extremely important for many reasons, including: decreased chance of medication errors, tracking the resident's symptoms for better resident care, and documentation compliance with State Regulations and with Standards of Nursing Practice. Center for Clinical Standards and Quality/Survey & Certification Group, Centers for Medicare and Medicaid Services, Department of Health & Human Services, Ref: S&C: 14-15-Hospital Requirements for Hospital Medication Administration, Particularly Intravenous (IV) Medications and Post-Operative Care of Patients Receiving IV Opiods, Baltimore, [NAME]land, (MONTH) 14, 2014, pg. 14. Observing the effects medications have on the patient is part of the multi-faceted medication administration process. Patients must be carefully monitored to determine whether the medication results in the therapeutically intended benefit, and to allow for early identification of adverse effects and timely initiation of appropriate corrective action. Depending on the medication and route/delivery mode, monitoring may need to include assessment of: 1. Clinical and laboratory data to evaluate the efficacy of medication therapy, to anticipate or evaluate toxicity and adverse effects. For some medications, including opioids, this may include clinical data such as respiratory status, blood pressure, and oxygenation and carbon [MEDICATION NAME] levels. 2. Physical signs and clinical symptoms relevant to the patient's medication therapy, including but not limited to, somnolence, confusion, agitation, unsteady gait, pruritus, etc . As part of the monitoring process, staff are expected to include the patient's reports of his/her experience of the medication's effects.",2020-09-01
485,ELKHORN HEALTHCARE & REHABILITATION,275056,474 HWY 282,CLANCY,MT,59634,2017-10-26,323,G,0,1,7LYF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to identifying risk factors and root causes for falls, to provide adequate monitoring and anticipate resident needs, and thoroughly evaluate and modify interventions and care plans for the prevention of future falls, for 5 (#s 1, 2, 7, 10, and 12) of 15 sampled residents. Findings include: 1. During an observation on 10/23/17 at 8:00 a.m., resident #7 remained in her recliner sleeping from 8:00 a.m. till 1:00 p.m., with no staff interaction. At 1:40 p.m. the CNA gave the resident a glass of water. The resident was not assisted during the morning to the bathroom, and staff did not show they attempted to anticipate the resident's needs. A review of resident #7's fall log showed the resident had five falls between 8/4/17 and 10/14/17. Further documentation review for falls showed: Review of resident #7's Post Fall Evaluation - Fall Committee form, dated 8/4/17, showed the resident was found on floor near the bathroom. The intervention was that resident #7 was educated about use of the call light to request staff's assistance and to wear no-slip socks or shoes, but did not address why she was near the bathroom. Review of resident #7's Daily Skilled Nurse's Note, dated 8/22/17, showed the resident was complaining of excruciating right hip and rib pain following a fall at 4:00 a.m. The physician was notified and ordered to send the resident to the emergency room . The resident returned that same day with a fracture of the right pelvic and hip area. A review of the care plan showed the fracture had not been addressed. Review of resident #7's Post Fall Evaluation-Fall Committee form, dated 8/23/17, showed the resident was found on floor after ambulating between the bed and bathroom. The intervention was to add a night light to the room, but did not address ambulating to the bathroom. Review of resident #7's Post Fall Evaluation-Fall Committee form, dated 9/25/17, showed the resident was found on the bathroom floor. The intervention was for staff to assist to the bathroom and to remain in the bathroom, until she was assisted back to the chair or bed. A pressure alarm was added. Review of resident #7's Post Fall Evaluation-Fall Committee form, dated 10/1/17, showed the resident was found trying to walk to the bathroom, without her walker, and was assisted to the floor by the CN[NAME] The intervention was full assistance with transfers and mobility and a fall mat was added. A fall mat would potentially create a trip hazard if the resident was walking on her own. Review of resident #7's Post Fall Evaluation-Fall Committee form, dated 10/14/17, showed the resident asked a family member to assist her to the bathroom and she fell ; family notified staff. The intervention was to remind the family member not to assist the resident. This was to happen every time staff interacted with the family member. During an interview on 10/23/17 at 2:15 p.m., the resident stated she had fallen and skinned her elbow, and the nurse changed the elbow dressing. During an observation on 10/23/17 at 4:30 p.m., the resident needed extensive assist of two to transfer from her recliner to a wheelchair and from the wheelchair to the bathroom. 2. During an observation on 10/26/17 at 9:40 a.m., three CNAs assisted resident #12 with pericare, grooming and dressing. The resident was able to sit up at bedside with physical assistance. He was able to stand and transfer to the wheelchair with assistance of staff. Review of resident #12's fall log showed the resident had seven falls between 7/25/17 and 10/11/17. Review of resident #12's Post Fall Evaluation-Fall Committee form, dated 7/25/17, showed the resident stood up from the wheel chair, in front of the dresser, and fell to the left side, sustaining a laceration to the left forearm, and a scrape on the little finger. The intervention to prevent future falls was to switch out the dresser for a shorter dresser. The form did not address the how or why the resident fell to the left after she had stood. Review of resident #12's Post Fall Evaluation-Fall Committee form, dated 8/1/17, showed the resident was found on the floor near the bed. The resident sustained [REDACTED]. The resident was able to get up by himself. No changes were made to the care plan. The resident was educated to use the call light, but the documentation did not show what the resident was doing, or had done, to specifically cause the fall. Review of resident #12's Post Fall Evaluation-Fall Committee form, dated 9/9/17, showed the resident was found on the floor in his room, next to the wheelchair. There was no working alarm on the bed. The intervention was to add a pressure alarm to the wheelchair, but the documentation did not address the lack of the working alarm, or interventions to address the root cause of why the resident fell , or monitoring of the resident to prevent falls. Review of resident #12's Post Fall Evaluation-Fall Committee form, dated 9/16/17, showed the resident was found on the floor in his room on his knees. The wheelchair in the room was tipped over backwards. No changes were made to the care plan. The resident was educated on the use of call light and locking the wheelchair brakes, but the documentation did not address what the resident was doing at the time of the fall to cause the fall specifically. Review of resident #12's Post Fall Evaluation-Fall Committee form, dated 9/19/17, showed the resident was found in another room on the floor. The alarm did not sound as the resident was able to shut it off. The intervention was to keep the alarm box out of resident's reach to prevent the resident from turning it off, but the documentation did not address why the fall occurred, or address monitoring of the resident. Review of resident #12's Post Fall Evaluation-Fall Committee form, dated 9/23/17, showed the resident was found on his bottom in the bathroom, with the wheelchair by his bed. The wheelchair alarm was not found and a new alarm placed. The intervention was to place a blue colored magnet on the door to remind staff to check for functioning and placement of a wheelchair alarm. Staff were educated, but the documentation did not address how or why the resident fell . Review of resident #12's Post Fall Evaluation-Fall Committee form, dated 9/25/17, showed the resident was found on his roommates floor mat. The intervention was for the resident's bed to be kept in a low position while occupied. A pressure alarm and fall mat were in place. The resident was to be assisted to the toilet before and after activities, meals, and hour of sleep. Non-skid strips were placed on floor beside the bed. The resident's walker and wheelchair were to be kept in the oxygen room while in bed. Staff were educated, but the facility did not address why he fell to the floor. Review of resident #12's Post Fall Evaluation-Fall Committee form, dated 10/2/17, showed the resident was found on the floor, sitting next to his bed. No changes were made to the care plan, but 'yes' was circled. Staff were educated on wheeling the resident out of the dining room, so he doesn't wheel himself unnoticed to his room, but the documentation did not address why the resident fell and did not address monitoring of the resident. Review of resident #12's Post Fall Evaluation-Fall Committee form, dated 10/1/17, showed the resident had dressed himself and was lying on his left side on the floor. The resident had removed his alarm. The intervention was to place the resident's clothes in the closet or out of sight, to prevent him from thinking it was time to get up and get wheelchair the without staff. The documentation did not address how the resident fell , or what he was doing specifically that caused the fall, and did not address monitoring of the resident. 3. Review of the facility fall log showed resident #1 had five falls from 4/16/17 through 10/14/17. Review of resident #1's Post Fall Evaluation-Fall Committee form, dated 4/16/17, showed the fall occurred in the dining room, and the resident's foot got caught in the chair and he fell . It was an isolated incident, with no interventions or changes to the plan of care. Review of resident #1's Post Fall Evaluation - Fall Committee form, dated 8/23/17, showed the resident lowered himself to the floor in the hall using the handrail. The intervention was for Staff to watch for cues of fatigue. Review of resident #1's Post Fall Evaluation-Fall Committee form, dated 9/22/17, showed the resident was found on the floor in the bathroom of another resident's room. The intervention was to toilet the resident, before and after meals, and before bed. The form did not include documentation of the root cause of the fall, and did not show why the toileting program would reduce falls. Review of resident #1's Significant Change MDS, with the ARD of 9/8/17, showed the resident was always incontinent of bowel and bladder. During an observation on 10/24/17 at 7:30 a.m., resident #1 was in the dining room for breakfast. He was still in the lobby area at 10:00 a.m., and had not been to his room to be toileted after breakfast. Review of resident #1's Post Fall Evaluation-Fall Committee form, dated 10/2/17, showed the resident was found on the floor by his bedroom door. The intervention was to keep the door open when not providing care. The form did not include documentation of the root cause of the fall and did not identify the effectiveness of the prior interventions. Resident #1 continued to have falls. Review of resident #1's Post Fall Evaluation-Fall Committee form, dated 10/6/17, showed the resident was found sitting on his roommates fall mat, leaning against the bed. The intervention was to add a fall mat and alarm, but did not address why the resident fell from the bed. During an observation and interview on 10/24/17 at 1:50 p.m., resident #1's room did not have a fall mat or alarm. Staff member M stated she had never seen a fall mat or alarm in the room. During an interview on 10/26/17 at 11:10 a.m., staff member D stated the facility met each day and discussed falls. The root cause of a fall had not been part of the discussion, but the facility would add root cause to the form. 4. Review of the facility fall log showed resident #2 had four falls from 3/6/17 through 9/2/17. Review of resident #2's Post Fall Evaluation - Fall Committee form, dated 3/10/17, showed the resident was found sitting on the mat next to her bed. The intervention was to check the resident's position in bed and reposition her closer to the wall. The form did not identify why the resident fell out bed or when and how often staff would reposition the resident. Review of resident #2's Post Fall Evaluation - Fall Committee form, dated 6/4/17, showed the resident was left in her wheelchair in her room without the call light within reach. The resident slid out of her wheelchair. The intervention was to not leave the resident in her room alone, when in her wheelchair and the call light will be within reach. The Care Plan was not followed. Review of resident #2's Fall Care Plan, dated 2/15/17, showed, staff not to leave resident unattended in room while in wheelchair. Review of resident #2's Post Fall Evaluation - Fall Committee form, dated 7/12/17 showed the resident was sitting in her recliner and tried to stand up. The intervention was to leave the door open when not providing care. The root cause was not identified, and the resident had another fall, despite the door being open. The facility did not evaluate the effectiveness of the interventions to reduce falls. Review of resident #2's Post Fall Evaluation - Fall Committee form, dated 9/2/17, showed the resident was found on her floor mat by the bed. Investigation showed the bed alarm was not functioning. The intervention was to make sure the alarm was functioning properly. The form did not identify who, when, or how the alarm was to be monitored, or why the alarm was not addressed by staff to ensure it was always in working order. 5. Review of the facility fall log showed resident #10 had five falls from 8/10/17 through 9/3/17. Review of resident #10's Post Fall Evaluation - Fall Committee form, dated 8/10/17, showed the resident was found on the floor near his bed. The floor was wet from a foot soak. The resident stated he saw stars, and had a large hematoma on the right side of his head. The intervention was that all future foot soaks would be supervised. The resident was sent to the ER. Review of resident #10's Post Fall Evaluation - Fall Committee form, dated 8/24/17, showed the resident was found on the floor. He was approached and began to yell. Air overlay placed on bed, meals in room, bed maintained at standard height and no fall mat due to his height. The form did not identify way the resident's height impaired the use of the fall mat, and did not identify the root cause of the resident's fall. No interventions were implemented to reduce falls with and without injury. Review of resident #10's Post Fall Evaluation - Fall Committee form, dated 8/27/17, showed the resident was found on the floor near the roommates door. No head injury noted. The intervention was to watch for signs and symptoms of UTI. The form did not show the signs and symptoms of a urinary tract infection were related to the fall. Review of resident #10's Post Fall Evaluation - Fall Committee form, dated 8/31/17, showed the resident was crying out and found on the floor of his room, with a laceration to his head. Prior to the fall the resident was refusing all care and treatments. The intervention was to lower the bed, and keep the door open. Review of resident #10's Post Fall Evaluation - Fall Committee form, dated 9/3/17, showed the resident was leaning off the bed and he fell on the floor. The intervention was to change the environment of the room to decrease the chance of an injury. The form did not identify why the resident fell out of bed, and how the environment was changed to reduce injuries. The facility did not evaluate the effectiveness of the interventions for resident #10. During an interview on 10/26/17 at 9:20 a.m., staff member A stated the facility was aware of the number of falls, and the facility would be improving fall prevention through the Quality Assurance/Performance Improvement Committee, to be held next week, to address fall prevention. She stated the prior quality assurance meetings did not implement a process for the areas of concerns relating to falls.",2020-09-01
486,ELKHORN HEALTHCARE & REHABILITATION,275056,474 HWY 282,CLANCY,MT,59634,2017-10-26,329,E,0,1,7LYF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to monitor and provide adequate indications with medical reasons for the continued use of antipsychotic and antianxiety medications, without gradual dose reductions, and failed to provide an explanation for refusals of gradual dose reductions for 3 (#s 1, 5, and 10) of 15 sampled residents; and failed to show the risks and benefits of the medictions use were discussed with the resident or responsible party, for psychopharmacological medications, for 2 residents (#s 6 and 10) of 15 sample residents. Findings include: 1. Review of resident #1's Physician order [REDACTED]. Review of resident #1's Interdisciplinary Progress Note, dated 11/18/16, showed the staff reported to the Geriatric Nurse Practitioner that the resident had an increase in anxiety and restlessness in the evenings. Resident follows other residents, and staff, grabs onto residents, and gets in others space. Received order for extra dose of [MEDICATION NAME]. Review of resident #1's Behavior Monthly Flow Sheet for 11/2016 showed agitation, depression, and [MEDICAL CONDITION] were being monitored. The flow sheet showed no occurrences of these behaviors, or monitoring for the above behaviors. Review of resident #1's Behavior Monthly Flow Sheet for 9/2017 showed monitoring for slapping, spitting and hair pulling, with no documented behaviors. Review of resident #1's proposed Gradual Dose Reduction forms, from 8/14/15 to 4/4/16, showed the GDRs were not attempted related to continued agitation and fearful statements. Review of resident #1's proposed Gradual Dose Reduction form, dated 9/29/17, showed the physician did not recommend a tapering of the antipsychotic medication, but did not include a reason why. During an interview on 10/26/17 at 11:30 a.m., staff member D stated she had not worked at the facility long enough the speak about the GDR process. She did not know why the physician was unwilling to attempt GDRs. 2. Review of resident #10's Physician orders, dated 7/17/17, showed the resident was to receive one milligram of [MEDICATION NAME] each night. A reason for the antianxiety medication was not provided. During an interview on 10/25/17 at 11:30 a.m., staff member D did not know why the resident was receiving the [MEDICATION NAME]. Staff member H stated it was probably for his agitation. Review of resident #10's medical record did not show an increase in agitation at night, and did not show a risk and benefit for the use of the medication. Review of resident #10's Care Plan, dated 8/3/17, did not show the reason for the medication. During an interview on 10/25/17 at 9:40 a.m., staff member A stated the facility had received recent training regarding the use of antipsychotic medications, but had not yet been able to implement the knowledge. 3. A review of resident #5's (MONTH) (YEAR) MAR indicated [REDACTED]. She had been receiving Ability since 3/31/17, and [MEDICATION NAME] and [MEDICATION NAME] since 4/27/15. Review of resident #5's Consultation Report, dated (MONTH) (YEAR), showed the contracted pharmacist recommended a gradual dose reduction for all three medications on 9/14/17. The form had no indication that it had ever been seen by a physician. The areas to be completed on the form were empty. No GDR had been ordered, recommended, or refused. The form was not signed. Further review of resident #5's medical records showed a second form addressed to the resident's physician, also requesting gradual dose reductions for [MEDICATION NAME], and [MEDICATION NAME]. The resident's physician checked she did not recommend a taper for the three medications at the time. She had initialed and signed the form for 9/29/17. She did not write a reason for her refusal to order a GDR. On the form, in typed print, near the physician's initials, the form read inclusion of a reason in a risk vs. benefit statement is imperative, which was blank. 4. Resident #6 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of resident #6's physician medication recapitulation orders for (MONTH) (YEAR) showed the resident was to receive the following medications: [REDACTED] - [MEDICATION NAME] ([MEDICATION NAME]) 0.5 mg tablet oral (by mouth)- every eight hours everyday. As started on 3/10/17. - [MEDICATION NAME] ([MEDICATION NAME]) 0.25 mg tablet oral (by mouth)- PRN: 1 tab every 8 hours PRN anxiety. Started on 3/2/2017. - [MEDICATION NAME] ([MEDICATION NAME] HCl) 40 mg tablet oral (by mouth)- once daily everyday. Give 1 & 1/2 tabs (60 mg) daily. Started on 3/2/17. A review of resident #6's (MONTH) (YEAR) MAR, showed the resident had received [MEDICATION NAME] as ordered on a daily basis from 10/1/17 through 10/22/17. She had also received regularly scheduled [MEDICATION NAME] every eight hours as ordered during the same time period. She had not received any additional PRN [MEDICATION NAME]. A review of resident #6's medical records showed her chart contained three undated informed consents for medications- [MEDICATION NAME] and [MEDICATION NAME] (X2). Each consent form had resident #6's name printed on it, accompanied by her hand written signature. The form explained that her signature on the form showed she accepted the risks as well as any benefits she might incur from taking the medication whose name was printed on the form. There was no other staff or physician's signature on any of the consents showing who might have explained the forms to resident #6. All three of the consent forms were undated and did not show the order day for the medication for which they were written. During an interview on 10/25/17 at 10:30 a.m., staff member C said she was responsible for the GDR program for the residents in conjunction with the facility's pharmacist. She was shown the three informed consents signed by resident #6 and stated that without dates and staff signatures they were worthless.",2020-09-01
487,ELKHORN HEALTHCARE & REHABILITATION,275056,474 HWY 282,CLANCY,MT,59634,2017-10-26,333,E,0,1,7LYF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility staff failed to prevent medication administration errors involving incorrect dosing for 2 (#s 3 and 6); failed to administer ordered medications for 1 (#4); and administered medications without physicians' prescription orders for 6 (#s 4, 5, 7, 8, 12, and 15) out of 15 sampled residents. Findings include: 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He had constant physical pain and suffered a major [MEDICAL CONDITION]. A review of resident #3's MAR indicated [REDACTED]. The MAR indicated [REDACTED]. On 10/15/17, resident #3's MAR indicated [REDACTED]. The corresponding narcotic record showed only one tab of 15 mg [MEDICATION NAME] sulfate had been taken from stock that evening. The staff member who administered the medication was not available for interview. During an interview on 10/25/17 at 10:25 a.m., staff member B stated the medication administration issue for resident #3 had been thoroughly investigated by the facility. 2. Review of resident #6's (MONTH) (YEAR) Physician's Medication Recapitulation orders showed the resident to was ordered to receive [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME] with [MEDICATION NAME]) 10-325 mg, one tab by mouth every 4 hours PRN for pain. In an interview on 10/25/17 at 5:30 p.m., resident #6 said she had some minimal abdominal pain all the time and some left groin moderate pain that was intermittent in nature. She said she did not take pain medication every day, but asked for it only sometimes when her pain would increase. She said she usually received good pain relief from the pain medications she had been receiving. She said if she took more than one or two pain pills a day she would get too tired and just ended up sleeping too much. Review of resident #6's (MONTH) (YEAR) MARs showed that over a period of 14 days, between the dates of 10/9/17 and 10/22/17, resident #6 received [MEDICATION NAME]-[MEDICATION NAME] 18 times. A review of resident #6's corresponding narcotic records for the same time period, between 10/9/17 and 10/22/17, showed [MEDICATION NAME] was checked out in the resident's name 20 different times. The PRN order for [MEDICATION NAME] written on the resident's MAR indicated [REDACTED]. The corresponding narcotic record showed two tabs of [MEDICATION NAME]-[MEDICATION NAME] were removed from narcotic stock for resident #6's use each of the 20 times it was administered to her. 3. A review of resident #4's physician's (MONTH) (YEAR) recapitulation orders showed that he had been ordered to receive: [MEDICATION NAME] 0.5 MG Tablet Oral (By mouth) - once daily Everyday: 0.25 MG PO Q PM. The prescription was two orders, one for .5 mg, and one for .25 mg. A review of resident #4's MAR indicated [REDACTED]. Medication was assigned to be given only at 5:00 p.m. from 10/1/17 through 10/22/17. One signature was signed off in the signature box for each day medication that was administered, although there were two orders. The amount of drug given on those days was not shown. A review of resident #4's corresponding narcotic record, dated 10/9/17, showed the resident had been signed out to receive [MEDICATION NAME] 0.25 mg tabs. It showed that [MEDICATION NAME] was being given 0.25 mg at a time at 5:00 p.m., daily. The MARs did not show the resident received any 0.5 mg doses of [MEDICATION NAME] as was included in resident #4's physician order, to be given daily, everyday. 4. Review of the physician medication recapitulation orders for (MONTH) (YEAR), for #s 4, 5, 7, 8, 12, and 15 showed the following: Review of the MARS for the six residents showed the prior month's medications had been administered from 10/1/17 to 10/22/17 as if the physician orders [REDACTED]. During an interview on 10/25/17 at 4:30 p.m., staff member B was shown the unsigned (MONTH) (YEAR) physician medication recapitulation records for #s 4, 5, and 15. She stated that she had not known that they were unsigned by the physicians. During an interview on 10/25/17 at 9:05 a.m., staff member A said not all of the physician signed recapitulation records for the month of (MONTH) (YEAR) had been returned to the facility yet.",2020-09-01
488,ELKHORN HEALTHCARE & REHABILITATION,275056,474 HWY 282,CLANCY,MT,59634,2017-10-26,371,D,0,1,7LYF11,"Based on observation, record review, and interview, the facility failed to monitor and remove outdated food items stored in the resident refrigerator/freezer on the facility's rehabilitation unit. This failure had the potential to affect all residents who consumed outdated food from the resident food storage refrigerator. Findings include: During an observation of the facility's locked resident nourishment pantry, on 10/23/17 at 3:45 p.m., staff member [NAME] said that the dietary department was responsible for checking expiration dates and food and drink items in the resident nourishment refrigerators/freezers. This was to be done on a daily basis when they placed the day's prepared resident snack items in the refrigerators or freezers. Foods were to be labeled on the day they were placed in the refrigerator and disposed of after three days. During an observation and interview on 10/24/17 at 2:00 p.m., staff member F said the CNA assigned to work on the evening shift on the rehabilitation unit was responsible to check the refrigerator/freezer for outdated and unlabeled food items. The contents of the refrigerator and freezer were inspected. Staff member F disposed of the following items: -Three cartons of sugar free Jello with expiration dates of 10/15/17. -Four cartons of low fat 2% Dairy Milk with expiration dates of 10/22/17. -One half-filled unlabeled can of Pepsi. -One large unlabeled pizza in plastic wrap, encrusted in ice crystals. -One large unlabeled clear plastic bag of dry withered carrot pieces. -One unlabeled clear plastic bag of dry limp broccoli crowns. -Loose tangerines and grapes in various stages of deterioration. A review of the facility's Temperature Log for the Nourishment Fridge and Freezer for October, showed no daily temperature recordings for 10/11/17, 10/18/17, 10/22/17 and 10/23/17. It also showed that the freezer temperature was 22 degrees F. on 10/7/17 and 10/14/17, and 24 degrees F. on 10/15/17. A review of the facility's Temperature Log for the Nourishment Fridge and Freezer showed the acceptable freezer temperature range was from 0-20 degrees F. It also stated Report immediately to supervisor/maintenance if temperature is out of temperature range or (there is) any equipment malfunction. The (MONTH) (YEAR) Temperature Log did not show corrective action had been taken by staff who had recorded the high freezer temperatures on 10/7/17, 10/14/17, and 10/15/17. During an interview on 10/25/17 at 10:00 a.m., staff member A stated the facility had a policy regarding labeling and refrigerator/freezer storage of food brought into the facility by residents. She said this policy was included in the facility's resident admission packet. The resident admission packet had been revised and at the time of the survey the facility did not have a written resident food storage policy. She said the dietary department was responsible to check all the resident food storage refrigerators/freezers for unlabeled and outdated food items and disposing of them as needed.",2020-09-01
489,ELKHORN HEALTHCARE & REHABILITATION,275056,474 HWY 282,CLANCY,MT,59634,2017-10-26,425,E,0,1,7LYF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain medication administration and narcotic reconciliation records to accurately record details for medication use for 3 (#s 3, 4, and 6) of 15 sample residents. The facility failed to review medication and narcotic use documentation to acknowledge and prevent discrepancies. Findings include: 1. Resident #3 was admitted to the facility on [DATE]. He suffered pain secondary to osteoarthritis and benign prostatic hypertrophy. A review of resident #3's MAR showed the resident was to receive both of the following: - Morphine Sulfate ER (Morphine Sulfate) Oral (by mouth) Dose: 30 MG, one by mouth at bedtime (for) pain. - Morphine Sulfate ER (Morphine Sulfate) Oral (by mouth) Dose; 15 mg 1x/day every a.m. (for) pain. A review of resident #3's MAR and corresponding narcotic sign out records, for the time between 10/1/17 and 10/24/17, showed: - Resident #3 had received two 15 mg tabs of morphine sulfate ER in place of one 30 mg tab of morphine sulfateER on [DATE], 10/17/17, 10/18/17, 10/21/17, and 10/22/17. - Resident #3's MARs showed morphine 30 mg had been administered on 10/14/17, but there was no corresponding entry to show any morphine had been removed from stock documented on that date. - Resident #3's MARs showed morphine 30 mg had been administered on 10/15/17, but there was only one tab of morphine 15 mg removed from stock and given at the corresponding time as shown on the narcotic record. - Resident #3's MARs showed morphine 30 mg had been administered on 10/9/17, but there was no corresponding entry documented to show any morphine had been removed from stock on that date. Instead it was noted that there existed two alike entries recorded on the narcotic record as given on 10/10/17. This was inaccurate documentation. 2. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. A review of resident #4's physician recapitulation orders showed that he had been ordered to receive: Lorazepam 0.5 MG Tablet Oral (by mouth) - once daily everyday: 0.25 MG PO Q PM. A review of resident #4's MAR showed both orders were written with one signature box to be signed off. Medication was assigned to be given at 5:00 p.m. From 10/1/17 through 10/22/17, one signature was signed off in the signature box for each day medication was administered. The amount of the drug given on those days was not shown. A review of resident #4's corresponding narcotic record, dated 10/ 9/17, showed the resident received Lorazepam 0.25 mg tabs. Instructions on the narcotic sheet showed the resident was to be given a half tab or 0.125 mg at bedtime. This was incorrectly stated as the order read to administer 0.25 mg every p.m. However, the narcotic record showed the Lorazepam was being given as a full tab, or 0.25 mg, at a time at 5:00 p.m. as it had been ordered. Nowhere on the MAR did it show the resident received any 0.5 mg doses of Lorazepam as prescribed in resident #4's physician order. The 0.5 mg dose of Lorazepam had been not been administered between 10/9/17 and 10/22/17. Review of resident #4's MARs showed the resident had been given Lorazepam on 10/21/17. Review of resident #4's corresponding narcotic record for the same dates did not show Lorazepam had been removed from stock for resident #4 on 10/21/17. 3. Resident #6 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. She experienced abdominal pain. Review of resident #6's (MONTH) (YEAR) Physician Medication Recapitulation orders showed the resident to have been ordered to receive oxycodone-acetaminophen (oxycodone with acetaminophen) 10-325 mg, one tab by mouth every four hours for PRN pain. Review of resident #6's (MONTH) (YEAR) MARs showed that over a period of 14 days, between the dates of 10/9/17 and 10/22/17, resident #6 received oxycodone-acetaminophen 18 times. A review of resident #6's corresponding narcotic records for the same time period, between 10/9/17 and 10/22/17, showed oxycodone was checked out in the resident's name 20 different times. The PRN order for oxycodone written on the resident's MAR showed the resident was to receive one tab of oxycodone-acetaminophen no sooner than every four hours. The corresponding narcotic record showed two tabs of oxycodone-acetaminophen were removed for resident #6's use each of the 20 times it was administered to her. Review of resident #6's MAR and the corresponding narcotic sign out records showed that the documented dates and times oxycodone were administered on the MARs greatly varied from the times and dates oxycodone had been documented as removed from stock and signed out on the narcotic record. Resident #6's narcotic record showed that oxycodone-acetaminophen had been signed out in her name, two tabs at a time, without any corresponding documentation on her MARs. This occurred 17 times during the 13 days between 10/9/17 and 10/22/17. The resident's MARs showed the resident did not receive any oxycodone-acetaminophen on 10/10/17, 10/11/17, and 10/12/17. The corresponding narcotic sign out records showed oxycodone-acetaminophen had been removed from stock twice on 10/10/17 at 9:30 a.m. and 9:00 p.m., twice on 10/11/17 at 9:30 a.m. and 8:00 p.m., and twice on 10/12/17 at 9:00 a.m. and 7:00 p.m. A review of resident #6's MAR and corresponding narcotic record, showed the resident did not receive PRN oxycodone on 10/18/17. On 10/19/17 the resident's MAR showed she had received only one dose at 9:30 p.m. It did not show the amount given. The corresponding narcotic record showed two tabs of oxycodone acetaminophen had been given at 7:50 a.m., at 12:30 p.m., at 5:00 p.m., and at 8:00 p.m. The documentation showed the resident had oxycodone-acetaminophen at both 8:00 p.m. and 9:30 p.m., less than one and a half hour apart. The order was to give one tab oxycodone-acetaminophen no less than four hours apart. In a period of approximately ten hours resident #6 received 9-10 tabs or 90-100 mg of oxycodone per the documentation. The day before, 10/18/17, the resident had not been administered pain medication. During an interview on 10/25/17 at 4:00 p.m., staff member B was shown resident #6's MAR and corresponding narcotic records for (MONTH) (YEAR). The records were compared on a day by day basis and the variances in documentation were discussed. She stated the records looked real bad. She said blank signature blocks on the MAR showed the resident had not received medication on the day the block signified. She said she recognized several of the staff signatures on the narcotic records where there was no corresponding MAR administration entries, as being signatures of travel staff. She stated this was the first time she knew of the documentation variances she was seeing in the records reviewed. She said that administration had conducted narcotic reconciliation in the past without finding discrepancies. She said the facility administration had been having some of the nurse managers administer medications once a week for the purposes of overseeing for potential concerns. No one had reported any concerns to her. She said that after resident #3's physician communicated a concern about potential misappropriation of the resident's morphine, (on 8/29/17), the facility had conducted an investigation of resident #3's medical records. She did not think anyone had compared resident #3's MARs and narcotic records to determine potential discrepancies at the time the investigation was conducted. 4. A review on 10/25/17 of the Shift Accountability records for narcotics and medication with potential for abuse, showed that from (MONTH) (YEAR) through (MONTH) (YEAR) on the South wing narcotic books there were 27 missing signatures when nurses were coming on shift, and medications were counted. It also showed that there were 25 missing signatures of nurses going off shift when medications were counted. A review on 10/25/17 of the Shift Accountability records for narcotics and medication with potential for abuse, showed from (MONTH) (YEAR) through (MONTH) (YEAR) in the North wing narcotic books there were 65 missing nursing signatures for when nurses were coming on shift and counting medications, and 50 missing signatures when counting medications when going off shift. During an interview on 10/25/17 at 1:10 p.m., staff member H stated sometimes we forget to sign off on the narcotic count. During an interview on 10/25/17 at 4:00 p.m., staff member B stated anything left unsigned or blank meant the resident didn't receive their ordered medication. (Refer to Tag F281) During an interview on 10/25/17 at 10:55 a.m., staff member N stated if a narcotic count signature sheet was not signed off, it was not done. During an interview and an observation on 10/26/17 at 7:09 a.m., staff member N showed she had not signed off the South side narcotic books. Staff member N stated she signed off sometime during her shift. Staff member N stated the narcotic count had been completed. (Refer to Tag F281) During a review of the facility's policy titled Omnicare LTC Facility Pharmacy services and Procedure Manual: Policy #5.4/Inventory Control of Controlled Substances showed: Facility should ensure that the incoming and outgoing nurses count all Schedule II controlled substances and other medications with a risk of abuse or diversion at the change of each shift or at least once daily and document the results on the Controlled Substance Count Verification/Shift Count Sheet.",2020-09-01
490,ELKHORN HEALTHCARE & REHABILITATION,275056,474 HWY 282,CLANCY,MT,59634,2017-10-26,431,E,0,1,7LYF11,"Based on observation and interview, the facility failed to check for outdated medications and medical supplies stored in the facility's medication room, and dispose and replace them as needed. The facility also failed to check for outdated medication on one facility medication cart. These failures had the potential to affect all those residents who may have received outdated medication or had been treated using outdated medical supplies stored in the rooms. Findings include: During an interview and observation of the facility's medication room on 2/24/17 at 4:30 p.m., staff member N stated that the nurses were responsible for checking for outdated medication and disposing of it as needed. She said only the facility's DON and the assigned medication cart medication nurses had keys to the medication room. Nurses were not assigned to the task of checking for medication and supply outdates but were expected to check for each individual medication outdate before administering it. She said the facility's contracted pharmacist checked the emergency drug box medications on a monthly basis. The following items were identified and removed as outdated during the interview and observation: - Nine 8 fluid ounce cartons of Diabetishield Mixed Berry Nutritional Drink with an expiration date of Sept'17. - One Allevyn Gentle Border Lite sterile dressing with a label of Exp (YEAR)-07. - Two Hypodermic Needle-Pro Needles with Needle Protection Devices. One labeled (YEAR)-05 exp and the other labeled (YEAR)-06 exp. - Three packages of 1/8 in. by 3 in. Steri-strips each labeled with exp (YEAR)-12. - One box of 100 Kendall Monoject Tuberculin Safety Syringes Lot # 4 labeled with exp (YEAR)-08. - One 7.2 oz, one quarter full, of Nurtrisource Fiber, labeled as opened on 12/15/17. The container's lid was not closed.",2020-09-01
491,ELKHORN HEALTHCARE & REHABILITATION,275056,474 HWY 282,CLANCY,MT,59634,2019-11-06,609,D,1,0,9VF511,"> Based on interview and record review, the facility failed to report a facility incident within the required twenty-four hours to the State Agency for 1 (#5) of 5 sampled residents. Findings include: During an interview on 11/6/19 at 1:29 p.m., staff member A stated he had been advised of suspected misappropriation of funds for resident #5 on (MONTH) 22, 2019. Review of resident #5's Social Service note, dated 7/22/19, showed the ombudsman recommended the facility file a report with APS to report misappropriation of funds for resident #5, and the document showed, APS report has been filed online . Review of a facility email, dated 7/22/19, from staff member C to staff members A and B, showed, Per (name), Ombudsman I filed an APS report regarding (sic) misappropriation of funds for (resident #5). Review of a facility reported incident submitted to the State Survey Agency showed a received date of 7/29/19, seven days after the facility was aware of alleged misappropriation of funds for resident #5, which was not within the required reporting timeline requirements.",2020-09-01
492,ELKHORN HEALTHCARE & REHABILITATION,275056,474 HWY 282,CLANCY,MT,59634,2019-11-06,610,D,1,0,9VF511,"> Based on interview and record review, the facility failed to take appropriate action for the protection of further exploitation for 1 (#1) of 5 sampled residents. Findings include: Review of a State Survey Agency incident report, dated 11/4/19, showed a staff member was given a total of $4000.00 by resident #1. The money was given in the form of two checks. One check was given in (MONTH) 2019, and one check was given in (MONTH) of 2019. During an interview on 11/6/19 at 9:00 a.m., staff member C stated a friend of resident #1's called on 11/4/19, to let staff member C know that NF1 had taken over $4,000.00 dollars from resident #1; $2,000.00 on 10/21/19 and $2,000.00 on 11/3/19. The friend saw NF1 as exploiting resident #1. During an interview on 11/6/19 at 1:09 p.m., resident #1 stated that NF1 came into the facility, after he was terminated from his job. NF1 came to resident #1's room, where resident #1 gave NF1 a check for $2,000.00. No staff had stopped NF1 from entering the facility or from entering resident #1's room. Resident #1 stated NF1 returned to the facility, sometime in (MONTH) 2019, also. NF1 came to resident #1's room and took another $2,000.00 check that resident #1 gave him. No staff stopped NF1 from entering the facility or from entering resident #1's room. During an interview on 11/6/19 at 1:57 p.m., staff member A stated he had told NF1, at the time of his termination, he was not allowed on the facility premises. I had no clue he was coming in and getting checks from (resident #1). Staff member A stated he did not tell staff not to let NF1 in the building, after he was let go from his position, at the facility. Staff member A stated he did train staff right after the incident occurred on Abuse, misappropriation of personal property, and exploitation of residents. Review of the facility investigation of the incident, reported on 11/4/19, showed staff member C had received a call from resident #1's friend. The friend stated NF1 received a check from resident #1's bank account for 2000 dollars, on 10/20/19. The check was cashed on 10/21/19. A second check was written by resident #1 on 11/3/19 for 2000 dollars. The friend tried to put a stop payment on that check, but this was not possible, due to a lack of available time. The second check was cashed. Review of a facility letter, dated 10/18/19, showed NF1 was no longer working at the facility, effective 10/14/19, due to misappropriation of resident property. Review of a facility investigation statement, written and signed by staff member E, showed NF1 entered the facility twice, both times on a Sunday, and resident #1 wrote NF1 a check each time. The statement was dated 11/5/19 at 7:31 a.m. Review of a facility investigation statement, written by staff member A, on 10/14/19, showed NF1 was aware a staff member could not accept gifts from residents. Review of NF1's employee file showed the following: - NF1 had reviewed Employee Receipt of Personnel Handbook on 7/25/18, just after he was hired. The handbook included The residents' rights. - An Abuse, Prohibition, Notification to Staff, was signed by NF1 on 11/9/18, as being read and acknowledged. Review of the Employee Handbook, with an effective date of 5/1/14, showed facility staff were not to, accept a gift, gratuity, or a payment of any kind from a resident . Review of an all staff meeting agenda, dated 10/15/19, showed the staff who attended the meeting were trained in resident rights and being free from exploitation. There was no documentation showing staff were trained on resident rights and exploitation prior to NF1's departure from employment. Review of the facility's Abuse Investigating and Reporting policy and implementation, with a date of 9/1/19, showed the role of the administrator was to ensure any further potential abuse, neglect, exploitation, or mistreatment was prevented. Review of resident #1's care plan, with a target date of 8/19/19, showed the care plan had not been updated to include the need to keep resident #1 safe from the exploitation of others. There were no further actions or training's put in place to prevent NF1 from re-entering the building and further exploiting the resident.",2020-09-01
493,ELKHORN HEALTHCARE & REHABILITATION,275056,474 HWY 282,CLANCY,MT,59634,2019-11-06,677,D,1,0,9VF511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to provide the necessary ADL care for a dependent resident who needed assistance with meals and hygiene, and did not clean a resident's mouth area after a meal, and did not assist with the resident's set up for a meal, before his food became cold, for 1 (#2) of 5 sampled residents. Findings include: 1. During on observation and interview on 11/6/19 at 12:45 p.m., resident #2 was laying on his bed, in his room. Resident #2's mouth was caked with dried food, below the lower lip. Food particles clung to the hairs on his beard and portions of his mustache. Resident #2 stated he needed assistance to wash his face and staff had not assisted him. Review of the resident #2's care plan, with a target date of 2/26/18, showed the resident had an ADL self-care performance deficit related [MEDICAL CONDITION] right sided [MEDICAL CONDITION]. Interventions to improve the resident's current function included cues for performing oral care and personal hygiene. 2. Review of a facility reported incident, showed staff were not assisting resident #2 during a meal on 7/20/19. Review of the investigation following the incident showed the facility had received staff statements, showing there was the staff member, identified in the incident, and other staff in the dining room at the time resident #2 needed assistance. Staff member F stated not being there until resident #2's food was cold. Staff member F asked another staff member to assist in feeding the resident because she was getting off work in ten minutes. Review of a statement from staff member G showed staff member F was in the dining room, at the window while overhead paging was occurring. During an interview on 11/6/19 at 1:57 p.m., staff member A stated staff member G was no longer at the facility, but was not terminated. During an interview on 11/6/19 at 12:45 p.m., resident #2 stated, during the questioning of the specific incident, there were no staff who readily assisted him with his meal, and the meal eventually became cold, due to the resident's need for assistance. The resident stated there was staff in the dining room who could have assisted him, but they did not help him. During an interview on 11/6/19 at 1:57 p.m., staff member A stated there had been at least three other staff in the dining area, during the time resident #2 was unable to get staff to assist him with his meal. Staff member A stated any one of the staff should have assisted resident #2. Review of resident #2's care plan, with a target date of 2/26/18, showed the resident had a focus on his risk for nutritional problems and a [DIAGNOSES REDACTED]. Staff were to set up and assist with resident #2's meals. There was no documentation showing the facility had provided further training for staff member G or the other staff members who worked with resident #2, to ensure the resident received the necessary ADL assistance for meals and hygiene.",2020-09-01
494,ELKHORN HEALTHCARE & REHABILITATION,275056,474 HWY 282,CLANCY,MT,59634,2016-11-30,278,D,0,1,XU0C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to accurately code the use of pain medication on a Significant Change and Quarterly MDS assessment for 1 (#4) of 14 sampled residents. Record review of resident #4's MAR, dated (MONTH) (YEAR), showed resident #4 received PRN pain medication; [MEDICATION NAME]-[MEDICATION NAME]. Review of the Significant Change MDS, with an ARD of 2/14/16, showed resident #4 was not on scheduled pain medications or PRN pain medications. Review of the Quarterly MDS, with an ARD of 11/7/16, showed resident #4 was not on scheduled pain medication or PRN pain medication. The MDS showed the resident was on a non-medication intervention for pain. During an interview on 11/29/16 at 3:00 p.m., staff member K stated she was unsure how to code the pain on the MDS for resident #4, so she did not code anything on the Quarterly MDS.",2020-09-01
495,ELKHORN HEALTHCARE & REHABILITATION,275056,474 HWY 282,CLANCY,MT,59634,2016-11-30,279,D,0,1,XU0C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a pain Care Plan for a resident who utilized pain medications, for 1 (#4) out of 14 sampled residents. Record review of resident #4's MAR, dated (MONTH) (YEAR), showed resident #4 received PRN pain and PRN muscle relaxants. Record review of the physician recapitulation orders, signed 11/23/16, showed the following: -[MEDICATION NAME]-[MEDICATION NAME] 5-325 mg tablet by mouth PRN Q 4 hours, which was ordered on [DATE]. -[MEDICATION NAME] HCl 5 mg tablet by mouth-1 tab TID PRN, which was ordered on [DATE]. Record review of resident #4's Care Plan showed no documentation or interventions for pain and it was not addressed on the plan. During an interview on 11/29/16 at 2:20 p.m., staff member T stated resident #4 was nonverbal, but when she grimaced with her face the staff would provided the resident pain medications. Review of the Quarterly MDS, with an ARD of 11/7/16, showed resident #4 was not on scheduled or PRN pain medication. The MDS showed the resident was on a non-medication intervention for pain. The MDS also showed the resident was able to understand and make herself understood sometimes, which was not consistent with the interview from staff member T's interview. During an interview on 11/29/16 at 3:00 p.m., staff member K stated resident #4's body was stiff that day, and the staff had a difficult time getting her dressed. The staff member asked the nurse for [MEDICATION NAME] and pain medication to help the resident relax. During an interview on 11/29/16 at 2:45 p.m., staff member C stated the resident's medical provider wanted the staff to trial scheduled pain medications and [MEDICATION NAME] twice a day to help with the resident's stiffness, prior to being transferred. The staff member was unsure why the resident became so stiff. She stated some staff felt the [MEDICATION NAME] helped the resident relax, and others did not feel it helped. She felt the resident became stiff prior to transfers related to anxiety. However, there was no documentation to help track what had been successful for the resident. The staff member stated there was no care plan in place that addressed the resident's pain.",2020-09-01
496,ELKHORN HEALTHCARE & REHABILITATION,275056,474 HWY 282,CLANCY,MT,59634,2016-11-30,281,D,0,1,XU0C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, facility nursing staff failed to document efficacies for PRN pain medication and muscle relaxants that were given for 1 (#4) out of 14 sampled residents. During an observation on 11/29/16 at 9:30 a.m., resident #4 was seated in her wheel chair in the main lobby. The resident was moaning and grimacing. A nurse and CNA took the resident into her room. Record review of resident #4's MAR, dated (MONTH) (YEAR), showed resident #4 received PRN pain medication; ([MEDICATION NAME]-[MEDICATION NAME]) 40 times in the last 28 days. The resident's MAR indicated [REDACTED]. The resident also received PRN muscle relaxants; ([MEDICATION NAME] HCL) 37 times in the last 28 days. Record review of the physician recapitulation orders, signed 11/23/16, showed the following: -[MEDICATION NAME]-[MEDICATION NAME] 5-325 mg tablet by mouth PRN Q 4 hours, which was ordered on [DATE]. -[MEDICATION NAME] HCl 5 mg tablet by mouth-1 tab TID PRN, which was ordered on [DATE] Review of the Quarterly MDS, with an ARD of 11/7/16, showed resident #4 was able to understand and make herself understood sometimes. During an interview on 11/29/16 at 2:20 p.m., staff member T stated resident #4 was nonverbal but when she grimaced with her face the staff provided the resident pain medications. She stated she provided the resident with pain medications that morning based on her nonverbal cues. She then went back in one hour and checked on the resident who was asleep. The staff member stated she knew the pain medication worked because the resident was asleep. During an interview on 11/29/16 at 2:30 p.m., staff member K stated the resident's efficacies for the pain medication use was not documented related to the resident being nonverbal. During an interview on 11/29/16 at 2:45 p.m., staff member C stated the nursing staff did not document pain based on a pain scale, but used the residents non-verbal cues to address efficacy. Medications must be accurately administered and documented .Accurate documentation involves recording information on the drug administered, including the client's response to the medication. See generally: Lippincott, Nursing Drug Guide, 1998 (Lippincott) and Perry & Potter, Clinical Nursing Skills & Techniques; 1998, (Perry & Potter).",2020-09-01
497,ELKHORN HEALTHCARE & REHABILITATION,275056,474 HWY 282,CLANCY,MT,59634,2016-11-30,309,D,0,1,XU0C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have an adequate system in place for the interchange of information for a resident who received [MEDICAL TREATMENT] at an alternate facility; and, failed to follow physician orders [REDACTED].#9) out of 14 sampled residents. Findings included: During an interview on 11/30/16 at 2:30 p.m., resident #9 stated she had worked it out with the dietitian at the [MEDICAL TREATMENT] center that she would drink two cups of coffee, and two Diet Mountain Dews, and have ice chips in the evening. She stated she did not drink water at meals. These items would totaled 960 mL per day. She reported that she tried to monitor her own fluids because she had to go to [MEDICAL TREATMENT] for extra days. She did not like going to [MEDICAL TREATMENT] because she felt it was boring. She stated the dietitian at the [MEDICAL TREATMENT] center continued to educate and encourage her to eat more protein. The resident stated she was not offered extra protein, or a protein supplement in the past, from the facility. She stated she had to go out of the building to get extra protein. The resident stated she often had low blood sugars at [MEDICAL TREATMENT]. A review of resident #9's [MEDICAL TREATMENT] Care Plan, dated 4/1/15, showed the following approaches: -Daily weight -Fluid restriction of 1.6 L daily -Transport to (facility name) three times per week -Follow new orders from medical provider -Apply EMALA cream as ordered prior to [MEDICAL TREATMENT] -Observe for signs and symptoms of fluid overload (SOB, decrease urination, weight gain) notify doctor -Resident non-compliant with fluid restriction -Encourage resident to comply with diet and explain negative side effect of non-compliance -Serve diet as ordered by doctor -Fax medical provider of resident non-compliance with diet/fluid restriction -Resident non-compliant with diet at times. Resident non-compliant with fluid restriction A review of the physician recapitulation orders for resident #9, dated 11/21/16, showed the following orders: -Restricted concentrated sweets, regular texture, no added sodium, 1.6 liter fluid restriction, renal diet -1.6 L fluid restriction daily. Monitor every shift, every day. -Weigh daily - am shift. -Weigh daily when returns from [MEDICAL TREATMENT] 3 times per week. A review of the diet card for resident #9 showed the resident was receiving a reduced concentrated sweets, no added sodium, regular diet. There was no documentation of a physician ordered fluid restriction on the diet card. A review of the Informed Refusal of Treatment Form, dated 8/23/16, showed resident #9 signed a risk and benefits agreement for not following her therapeutic diet. However, the physician did not sign the agreement. There was no evidence in the resident's record of a risks and benefits agreement for her fluid restriction. A review of the resident's MAR, dated (MONTH) (YEAR), showed staff documented drug refused for the residents physician ordered fluid restriction. During an interview on 11/30/16 at 8:30 a.m., staff member J stated resident #9 never returned from [MEDICAL TREATMENT] with any written communications. During an interview on 11/30/16 at 9:40 a.m., staff member A stated that there was not a form used to communicate with the [MEDICAL TREATMENT] center, but the [MEDICAL TREATMENT] center had called with new orders or changes. During an interview on 11/30/16 at 9:45 a.m., staff member H stated the fluid restriction was documented on the resident's MAR. The staff member did not know how the food and nutrition department documented or tracked resident #9's fluid restriction. During an interview on 11/30/16 at 10:00 a.m., staff member T stated the facility took resident #9's vital signs and obtained her weight when she returned from [MEDICAL TREATMENT]. She stated the facility did not have a daily communication form with the [MEDICAL TREATMENT] center because the resident had been on [MEDICAL TREATMENT] for so long, and she was stable. The staff member stated that the resident refused her fluid restriction. She stated no education was provided because she felt the resident no longer wanted to live. During an interview on 11/30/16 at 10:05 a.m., staff member I stated the kitchen provided eight ounces of water and eight ounces of milk, per meal, for a resident on a renal diet, but the resident did not like milk. This was 1440 mL per day at meals. She stated that resident #9 had never been on a protein supplement in the time she had worked at the facility. Staff member I stated the food and nutrition department did not provide the resident a special diet since the resident signed a risks and benefits agreement for being non-compliant with her diet. During an interview on 11/30/16 at 11:30 a.m., staff member A stated she did not have a written agreement with the [MEDICAL TREATMENT] center because it was not considered a stand-alone [MEDICAL TREATMENT] center. During an observation on 11/30/16 at 2:30 p.m., resident #9 had just returned from [MEDICAL TREATMENT] and was watching TV in her room. Staff member T entered the resident's room to provide pills with a four ounce cup of water. The staff member asked the resident what her weight was at [MEDICAL TREATMENT]. Staff member T then wrote the number on her hand, and left to document the weight. The resident stated They never weigh me at the facility since they weigh me at [MEDICAL TREATMENT], they just ask me for my weight. During an interview on 11/30/16 at 3:10 p.m., staff member N stated he would not educate a resident who had no intention of following a therapeutic diet. The staff member stated the resident was not lacking in protein, and would not need extra protein during [MEDICAL TREATMENT], or while she had a wound. He reported that he would need to work with [MEDICAL TREATMENT] to make sure the resident's kidneys could handle extra protein. A review of the monthly Patient Report Card for (MONTH) (YEAR), for resident #9, which was provided by the [MEDICAL TREATMENT] center, showed an [MEDICATION NAME] of 3.2, which was below the recommended range of 3.6. According to the monthly report from the [MEDICAL TREATMENT] center, side effects for low [MEDICATION NAME] included muscle breakdown, fluid retention, risk of infection, and poor wound healing. The report recommended the resident to eat more protein (skinless chicken, lean beef, fish, eggs, and other fresh meats) at meals and snacks. A review of the Quarterly Nutrition Note dated 11/29/16, showed NA was documented under pressure ulcers and site/stage. It showed the same under current diet, reason for modified diet, pressure ulcers, and comments. The note failed to address the [MEDICAL TREATMENT] center monthly recommendations, and did not address the resident's wounds. A review of the resident's care plans showed the following: For the Care Plan, dated 2/17/16, the following approaches were documented: -Keep medical provider notified of resident non-compliance -Dietitian at [MEDICAL TREATMENT] center going to work with resident on choosing better snack-making better food choices -8/30/16: Resident signed consent to not follow diet or change eating habits - continued non-compliance with diet For the Care Plan, dated 4/11/15, the following was documented: -Give diet as ordered by doctor -Monitor food/fluid intake -Monitor weight weekly -Give supplement as ordered as needed -Monitor snacks, only offer 1 snack at a time -Explain importance of being compliant with diet-fluid restriction for own health During an interview on 11/30/16 at 4:15 p.m., staff member A stated that they did not track the fluid the resident received at the facility because they did not know how much fluid the resident had while she was at [MEDICAL TREATMENT], showing the lack of communication. She stated the nursing staff was not authorized to care for the resident's fistula. The resident returned to the facility with an intact bandage around her fistula, but the care plan failed to address how emergencies would be handled relating to the fistula and [MEDICAL TREATMENT] treatment. During an interview on 11/30/16 at 4:15 p.m., staff member B stated she felt it would be good to have written documentation between the facility and the [MEDICAL TREATMENT] center after each treatment to facilitate better communication.",2020-09-01
498,ELKHORN HEALTHCARE & REHABILITATION,275056,474 HWY 282,CLANCY,MT,59634,2016-11-30,371,F,0,1,XU0C11,"Based on observation, record review, and interview, the facility failed to ensure food was served and stored in a sanitary manner, and non-food contact surfaces were kept clean in the main kitchen. Cleaning schedules were developed for the kitchen, but they were not comprehensive, and did not include all of the areas that required regular cleaning. This deficiency could affect all residents whom received food from the kitchen. Findings include: During the observation on 11/19/16 at 7:30 a.m., the following concerns were observed in the main kitchen, in the presence of staff member I: - At the base of the door frame's edges, at both of the door entries into the kitchen and the dish room, there was a heavy accumulation of dirt and black matter that could be scraped off with a tip of a pen. - The floor was covered in food debris and crumbs. The edges of the raised level of tile work under the 3-compartment sink had a thick layer of black substance that could be scraped off with the tip of a pen. - The dish room tile flooring had broken tiles (uncleanable surface) under the dish machine, white colored dried substance covered the floor under the dish machine, clumps of dishwashing formula was spread under the dish machine and the wall edges and the edges of the base cove had a heavy accumulation of a black colored substance all throughout the dish room. The grout between the tiles was blackened. The splash board behind the dirty dish counter was dirty and stained with dried matter. The underside of the dirty dish counter had dried food splatter and substance. The splash boards throughout the dish room had dried food splatters and substance. - The floor of the walk-in cooler was torn and rusty. Areas of the floor had food substance and debris present. - The metal storage racks in the walk-in cooler were stained with dried food substance. They had blackish green color fuzzy balls on various parts of the racks. The cleaning schedules did not include how often the racks in the walk-in cooler were cleaned and sanitized. The metal racks were also rusted in various places. Staff member I stated there was no cleaning schedule for the areas that required deeper cleaning. - Water and sprinkler pipes mapping the ceiling of the kitchen were covered with black colored dust. The top of the fire suppression cylinder was covered in dark greasy film. - A trash can, near the canned goods storage area behind the dish room, was covered with black colored dirt; the wall behind the trash can was covered in dried food splatters. - There were at least 4 light fixtures with broken and taped fixture covers. The tape was blackened with dust. Staff member I stated the light fixtures were old, obsolete, and those covers were no longer available. - A half gallon container of cottage cheese, found in the walk-in cooler, had an open date of 11/3, the best use by date stamped on the lid showed 10/19/16. - The reach-in freezer's handle was broken and separated from the surface of the door, creating an uncleanable surface. The bottom surface (interior) of the freezer was covered with spilled food products and crumbs. - The ramp leading to the back exit from the kitchen, surrounding wall surface and edges, had a heavy accumulation of dirt and black colored matter. - The floor tiles in the canned good storage area, behind the dish room, was damaged, or missing. The section of the base board was also missing in the area behind the storage shelves. - The whipped cream topping container had a missing cap, the tip was exposed to air. The can lacked a container open date. During the observations, staff member I stated the kitchen used the best by date before discarding food items. She stated they swept and mopped nightly, however the deep cleaning of the floors had not been performed.",2020-09-01
499,COPPER RIDGE HEALTH AND REHABILITATION CENTER,275060,3251 NETTIE ST,BUTTE,MT,59701,2017-01-11,252,E,0,1,BCW011,"Based on observations, interviews, and record review, the facility failed to identify and take measures for the elimination of institutional odors that affected one of three hallways. Findings include: During an observation on 1/9/17 at 8:50 a.m., an initial tour had taken place at the facility on hallway 300. A strong urine odor had been noted in the hallway. During an observation on 1/9/17 at 1:00 p.m., a strong odor that smelled of urine had been noted on hallway 300 of the facility. During an observation on 1/9/17 at 3:20 p.m., a strong urine odor had been noted in two resident rooms in the 300 hallway. During an observation on 1/10/17 at 7:15 a.m., a strong odor that smelled of urine had been noted in the 300 hallway of the facility, as well as two resident rooms in the 300 hallway. During an observation on 1/10/17 at 9:10 a.m., a strong urine odor had been noted in two resident rooms on the 300 hallway of the facility. During an observation on 1/10/17 at 2:12 p.m., a strong odor of urine and feces was present in the hall. During an observation on 1/10/17 at 3:50 p.m., a strong odor that smelled of urine was present by a resident's room on the 300 hallway. During an interview on 1/10/17 at 9:50 a.m., staff member D stated she noticed a smell of urine. She stated she was unsure of what had caused the smell. Staff member D stated it could have been a mattress of an incontinent resident, a residents' clothing, or that sometimes residents hid soiled briefs in their rooms. The staff member looked in the resident's room, where the odor appeared to be coming from, to see if there was any hidden briefs. No briefs were found in the room. Staff member D stated she was unsure of how often resident mattresses were cleaned. During an interview on 1/10/17 at 10:20 a.m., staff member [NAME] stated the resident rooms on hallway 300 were to be cleaned daily. He stated it was facility policy to deep clean the rooms, which would have included the resident mattresses, once per month. During an interview on 1/10/17 at 10:30 a.m., staff member M stated the mattresses and rooms on hallway 300 should be deep cleaned monthly. She stated the resident rooms on the 300 hallway should be cleaned daily, which should include emptied garages, washed sinks, washed toilets, cleaned mirrors, cleaned night stands, and cleaned windows. During a group interview on 1/10/17 at 11:15 a.m., some residents complained about excessive smells down the 300 hallway of the facility. Review of the facility's bed washing policy showed the purpose of bed washing was to remove soil, control odor, and prevent cross contamination. Review of the facility's Monthly Staff Clean Room Sheet for (MONTH) and (MONTH) of (YEAR), showed the bed frames on the 300 hallway had been checked off as cleaned. The cleaning check lists did not show the mattresses had been cleaned on hallway 300.",2020-09-01
500,COPPER RIDGE HEALTH AND REHABILITATION CENTER,275060,3251 NETTIE ST,BUTTE,MT,59701,2017-01-11,280,D,0,1,BCW011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to follow the care plan for 2 residents (#s1 and 3), and failed to update the care plan for 1 resident (#3) of 15 sampled residents. Findings include: 1. Resident #1 was admitted with [DIAGNOSES REDACTED]. Review of the resident's care plan for constipation and pain showed the following: -Monitor bowel movements daily and inform nurse if the resident goes two days without a bowel movement. Follow the facility protocol for constipation. -Monitor for medication side effects. Keep physician informed as indicated. -Provide [MEDICATION NAME]/laxative per order. Review of the resident's physician orders [REDACTED]. Review of the facility's Bowel Movement Protocol showed the following steps should occur for a resident without a bowel movement: -If the resident does not have a bowel movement in two days, MOM would be given during the morning medication pass. -If this was not effective that same day a laxative is given in the afternoon, and report to the night nurse. The steps taken would be documented on the MAR and bowel monitoring sheet. -If not effective, by the third day the a suppository would be given, and the resident assessed for abdominal discomfort, abdominal distention and firmness, bowel sounds, and a digital exam for fecal impaction performed. If not impaction noted, the physician would be notified for further action. -If the resident was impacted, the nurse was to remove the impaction manually. When the physician was notified, the nurse was to request the use of a stool softener if one was not currently ordered. -A fecal impaction was documented as a reportable event. (Refer to F281 for further bowel protocol information). Review of the resident's Treatments-ADL Flowsheet for 11/2016 and 12/2016 showed the resident did not have documented bowel movements for 11/22/16 through 11/27/16, and 12/25/16 through 12/31/16. Review of the resident's MAR for 12/2016 did not show administration of medications or treatments for 12/25/16 through 12/31/16. The facility did not provide documentation of medications or treatments for 11/2016. During an interview on 1/10/17 at 7:30 a.m., staff member B stated if a resident did not have a bowel movement for three days, she would administer an oral laxative. Staff member B stated if the oral laxative was ineffective, she would administer a suppository. She stated if the suppository was ineffective, she would assess for impaction. Staff member B's interview showed the steps to be taken did not correlate with the steps outlined in the policy. During an interview on 1/10/17 at 9 a.m., staff member C stated she would administer an oral laxative if the resident did not have a bowel movement for three days. Staff member C stated she would administer a suppository if the resident did not have a bowel movement for four days. Staff member C stated if the suppository was ineffective, she would assess for constipation, and perform a digital exam for impaction. If she found the resident had an impaction, she then would administer an enema. If the enema was ineffective, staff member C stated she would perform a digital disimpaction and then notify the resident's physician. Staff member C's interview showed the steps to be taken, did not correlate with the steps outlined in the policy. The facility failed to follow the care plan for resident #1, based on the facility's bowel protocol, when the resident had gone 3 or more days without a bowel movement. 2. Resident #3 was admitted with [DIAGNOSES REDACTED]. Review of #3's Care Plan, dated 5/18/15 to present, showed the resident had been at risk for alteration in nutrition, related to tremors and changes from Parkinson disease. The resident's intervention showed the resident should have been provided an empty cereal bowl to be used to scoop food. The resident's care plan also showed resident #3 had started restorative dining on 1/4/17. Review of resident #3's Diet Card, dated 1/10/17, showed the resident tray had been set up for room delivery. The resident was placed on restorative dining on 1/4/17, which related to fatigue during meals. During an interview on 1/10/17 at 7:45 a.m., staff member I stated resident #3 had usually dined in her room. He stated that she sometimes would eat in the dining room. During an interview on 1/10/17 at 7:50 a.m., staff member J stated resident #3 was tired at meals, and the resident was placed on restorative dining. The resident preferred to eat breakfast in her room. He stated that he did not have the residents diet card with him because the resident would have got her tray in her room that morning. During an interview and observation on 1/10/17 at 8:45 a.m., staff member D stated resident #3 normally slept in, and usually ate breakfast around 9:30 a.m. The staff member had been in the resident's room, and helped the resident into her wheelchair. Then, a restorative aide wheeled the resident to the dining room and parked her at a table. During an observation on 1/10/17 at 8:50 a.m., resident #3 was sitting at a dining room table alone without assistance, or without a breakfast tray. The resident pushed herself away from the table, and attempted to wheel herself back to her room. During an observation on 1/10/17 at 9:00 a.m., staff member F wheeled resident #3 back to her room. The resident did not receive a breakfast tray. During an observation on 1/10/17 at 9:15 a.m., staff member K wheeled resident #3 to the dining room and set her at a table. During an observation on 1/10/17 at 9:20 a.m., resident #3 received a breakfast tray at the dining room table she had been sitting at. The resident had a bowl of hot cereal, a bowl of strawberries, and a bowl of yogurt. The resident tried to eat her strawberries with a fork, but had trouble getting the strawberries to stay on her fork. During an interview on 1/10/17 at 9:30 a.m., staff member L stated resident #3 just recently had been moved to the restorative dining program. She stated the resident had not been using an empty bowl to scoop her food.",2020-09-01
501,COPPER RIDGE HEALTH AND REHABILITATION CENTER,275060,3251 NETTIE ST,BUTTE,MT,59701,2017-01-11,281,D,0,1,BCW011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess for constipation or fecal impaction, provide treatment, and monitor 1 (#1) of 15 sampled residents. The facility failed to follow physician orders for bowel protocol for 1 (#1) of 15 sampled residents. The facility failed to follow physician orders for a medication for 1 (#3) of 15 sampled residents. Findings include: Resident #1 had [DIAGNOSES REDACTED]. Review of resident #1's MAR for 11/2016, showed the resident received a narcotic pain medication 16 times. Review of the resident's MAR for 12/2016, showed the resident received a narcotic pain medication two times daily for pain. Narcotic pain medications increase the risk of constipation. Review of resident #1's Treatments-ADL Flowsheet for 11/2016 and 12/2016, showed the following: -From 11/22/16 through 11/27/16, there were no documented bowel movements. -From 12/25/16 through 12/31/16, there were no documented bowel movements. Review of the resident's MAR for constipation, showed the following: -MOM (an oral laxative) was to be administered if the resident did not have a bowel movement for three days. -Deficol suppository was to be administered if the oral laxative was ineffective. -If the suppository was ineffective after four hours, the nurse was to assess for abdominal discomfort, distention and firmness, assess bowel sounds, and perform a digital exam for fecal impaction. -If the nurse found fecal impaction during an assessment, an enema was to be administered. -If the enema was ineffective, the nurse was to digitally remove the impacted stool and notify the resident's physician. Review of the resident's MAR for 12/2016, did not show medications were administered for constipation. The facility did not provide documentation for 11/2016. Review of the resident's nursing notes for 11/2016 through 12/2016, did not show assessments were performed for abdominal discomfort, distention and firmness, bowel sounds, or a digital exam for fecal impaction, and did not show the physician was notified. During an interview on 1/10/17 at 7:40 a.m., staff member B stated the bowel protocol steps included administering MOM if the resident had no documented bowel movement for three days. She stated if the MOM was ineffective, she would administer a suppository. If the suppository was ineffective, she would check for impaction. Staff member B stated she had removed an impaction, but it had been over a year ago. The steps voiced by staff member B did not correlate to the steps in the bowel policy. During an interview on 1/10/17 at 9:00 a.m., staff member C stated the bowel protocol steps included administering 30 ml of MOM if a resident had no documented bowel movement for three days. She stated if a resident had no documented bowel movement for four days, a suppository would be administered. If the suppository was ineffective, she would perform a digital assessment for impaction. Staff member C stated if she found a resident to be impacted after the assessment, she would administer an enema. Staff member C stated if she had to do a disimpaction, she would notify the physician. Staff member C stated she had not performed a digital exam in at least the last two years. The steps voiced by staff member C did not correlate to the steps in the bowel policy. During an interview on 1/11/17 at 8:43 a.m., staff member NF1 stated he had approved the bowel protocol the facility was currently using. He stated he would expect nursing to notify him if a resident had no bowel movement for more than three days. Staff member NF1 stated he was not aware that resident #1 had gone three or more days without a bowel movement. Review of the facility's Bowel Movement Protocol showed an effective date of 10/2013. The policy showed the following: -Any resident that has not had a bowel movement for two consecutive days would be given MOM during the morning medication pass. -If the resident did not have effective results from the laxative by afternoon shift (2-10 p.m.) of the same day, the nurse would administer a stimulant, laxative suppository, prior to reporting off to the night shift nurse. The administration of the laxative must be completed on the MAR and on the bowel monitoring sheet. -If the resident did not have effective results from the suppository by the morning of the third day, the nurse must; assess the resident for abdominal discomfort, abdominal distention and firmness, assess bowel sounds, and perform a digital exam for fecal impaction. -If there was no fecal impaction, the nurse was to notify the resident's physician for further orders. -If the resident was impacted, the nurse was to remove the impaction manually. When the physician was notified, the nurse was to request the use of a stool softener if one was not currently ordered. -A fecal impaction is a reportable event and should never occur. It must be documented in the nurse's notes, and the DON notified of the incident. During an interview on 1/11/17 at 9:00 a.m., staff member A stated the facility did not track impaction or consider it an reportable event. She stated the information would be found in the nursing notes. Staff member A stated the facility did not routinely review policies and procedures. Documentation is the process of preparing a complete record of a patient's care and is a vital tool for communication among health care team members. Accurate, detailed charting shows the extent and quality of the care that nurses provide, the outcomes of that care, and treatment needs. The most common adverse effects of [MEDICATION NAME] include respiratory (the most serious), sedation, constipation, nausea, and vomiting. Lippincott[NAME] & Wilkins, 2013. Lippincott's Nursing Procedures, sixth edition, Ambler, PA 2. Resident #3 was admitted with the [DIAGNOSES REDACTED]. Review of resident #3's physician progress notes [REDACTED]. The cardiovascular section of the physician progress notes [REDACTED]. Review of resident #3's Physician Order Sheet, dated 12/19/16, showed the physician ordered [MEDICATION NAME], 20 milligrams by mouth, for [MEDICAL CONDITION], as needed. Review of resident #3's Care Plan, dated 5/18/15 to present, showed an intervention for the resident to receive [MEDICATION NAME] whenever there were signs of [MEDICAL CONDITION] in the resident's feet. Review of resident #3's MAR, dated (MONTH) (YEAR), showed [MEDICATION NAME] tablets, 20 milligrams, ordered as needed, for [MEDICAL CONDITION]. It also showed the medication was discontinued on 1/6/17 by staff member B. There was no physician order to discontinue the [MEDICATION NAME] medication on 1/6/17. During an interview on 1/10/17 at 2:10 p.m., staff member G stated she spoke to staff member B about the [MEDICATION NAME] being discontinued for resident #3. Staff member G stated staff member B had not seen [MEDICATION NAME] on the physician recap order, so she had crossed it off the MAR. Staff member G stated she was in the process to get a physician clarification for the medication order, but she didn't see an order to discontinue the [MEDICATION NAME] for resident #3 on 1/6/17.",2020-09-01
502,COPPER RIDGE HEALTH AND REHABILITATION CENTER,275060,3251 NETTIE ST,BUTTE,MT,59701,2017-01-11,309,D,0,1,BCW011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have an adequate system in place for the interchange of information for a resident who received [MEDICAL TREATMENT] at an alternate facility. This failure affected, one (#10) out of 15 sampled residents. Findings include: During an interview on 1/11/17 at 10:50 a.m., staff member P stated there was no correspondence from the [MEDICAL TREATMENT] center to the facility. Staff member P also stated resident #10's medical record showed no indication of [MEDICAL TREATMENT], and if problems occurred when a resident went to [MEDICAL TREATMENT] they would call to report, but usually no information was relayed. During an interview on 1/11/17 at 11:05 a.m., staff member O stated all morning medications were held for resident #10 on [MEDICAL TREATMENT] days, except [MEDICATION NAME], which was held in the morning, and given in the evening. During an interview on 1/11/17 at 11:10 a.m., staff member N stated resident #10's medical chart showed, in diagnoses, that resident #10 was dependent on [MEDICAL TREATMENT]. Staff member N stated the nursing staff should chart in the medical record when the resident left the facility for [MEDICAL TREATMENT]. However, the facility received no correspondence or report from the [MEDICAL TREATMENT] center when the resident returned to the facility. Staff member N stated We hope they would call if there was a problem, but we do not know. During an interview on 1/11/17 at 11:30 p.m., staff member G stated there was no transfer correspondence from [MEDICAL TREATMENT] to the facility. Staff member G stated she called and received reports after residents have gone to [MEDICAL TREATMENT], but resident #10 was the first resident to use (name of [MEDICAL TREATMENT] center). Staff member G did not have the conversations documented for review, however she did say she would create a transfer form to use in the future that would have pertinent information related to the resident, and the [MEDICAL TREATMENT] treatment. A review of the facility's SNF Outpatient [MEDICAL TREATMENT] Services Agreement, effective (MONTH) 2012, showed: 1. Obligations of Nursing Facility and/or Owner. Interchange of information: The Nursing Facility shall provide for the interchange of information useful or necessary for the care of the [MEDICAL CONDITION] Residents, included a Registered Nurse as a contact person at the Nursing Facility whose responsibilities include oversight of provision of Services to the [MEDICAL CONDITION] Residents. 2. Mutual Obligations. Collaboration of Care: Both parties shall ensure that there is documented evidence of collaboration of care and communication between the Nursing Facility and [MEDICAL CONDITION] [MEDICAL TREATMENT] Unit. Documentation shall include, but not be limited to, participation in care conferences, continual quality improvements program, annual review of infection control of policies and procedures, and the signatures of team members from both parties on a Short Term Care Plan and Long Term Care Plan. Team members shall include the physician, nurse, social worker, and dietitian from the [MEDICAL CONDITION] [MEDICAL TREATMENT] Unit, and a representative from the Nursing Facility. The [MEDICAL CONDITION] [MEDICAL TREATMENT] Unit shall keep the original Short Term Care Plan and Long Term Care Plan in the medical record of the [MEDICAL CONDITION] Resident and the Nursing Facility shall maintain a copy. Review of resident #10's Care Plan Report showed the resident went to [MEDICAL TREATMENT] three times per week, due to decreased kidney function. The goal was to maintain vital signs within normal limits and dry weight within 5 lbs. The interventions were to monitor vital signs before going to [MEDICAL TREATMENT], and no blood pressure on the left arm with shunt. Measure dry weight upon return from [MEDICAL TREATMENT], and listen for bruit over the shunt bid and monitor for signs of infection. Use stethoscope over shunt for swishing sound to make sure the shunt is not plugged, and hold the blood pressure medication in the mornings of [MEDICAL TREATMENT]. The care plan lack information for the collaboration of care with the [MEDICAL CONDITION] [MEDICAL TREATMENT] Unit, as defined in the facility's SNF Outpatient [MEDICAL TREATMENT] Services Agreement. Review of resident #10's medical record reflected a lack of consistent documentation that the resident was assessed each time before or after [MEDICAL TREATMENT]. No formal or informal collaboration of care, physical assessments, or interchange of information related to residents #10's [MEDICAL TREATMENT] care was available for review.",2020-09-01
503,COPPER RIDGE HEALTH AND REHABILITATION CENTER,275060,3251 NETTIE ST,BUTTE,MT,59701,2019-02-21,656,D,0,1,3C8F11,"Based on observation, interview, and record review, the facility failed to follow a resident's care plan, resulting in resident pain during a transfer from bed to wheel chair, for 1 (#50) of 22 sampled residents. Findings include: During an observation on 2/20/19 at 4:42 p.m., staff members H and K assisted resident #50 with a pivot transfer from the bed to the wheel chair. The staff members helped resident #50 sit up in bed, and the resident winced in pain as she sat up. The staff members fastened a gait belt around resident #50's waist. Staff member H instructed resident #50 to stand on the count of three. Resident #50 stated, I can't stand. The staff members lifted her by the gait belt and the back of resident #50's pants. The resident stated, Ouch, ouch and winced in pain as the two staff members lifted her, and the staff did not cease the activity. During the transfer resident #50's feet never touched the floor. During an interview on 2/21/19 at 9:20 a.m., staff member H stated they had been using a Hoyer lift for resident #50, but now were doing two person pivot transfers. Staff member H stated resident #50 can not bear weight, but they choose to do a pivot transfer. During an interview on 2/21/19 at 10:55 a.m., staff member G stated the CNAs have access to the resident's care plans; they are located in the black book at the nurses station. Review of resident #50's care plan with an initiation date of 12/4/18 showed, (Resident name) has the potential for a self care deficit r/t (related to) impaired mobility or transfer ability from weakness .Hoyer lift to transfer to commode and chair until able to do a stand pivot transfer. Leave sling in place due to painful for her remove (sic). The staff failed to follow the care plan for the resident.",2020-09-01
504,COPPER RIDGE HEALTH AND REHABILITATION CENTER,275060,3251 NETTIE ST,BUTTE,MT,59701,2019-02-21,689,D,0,1,3C8F11,"Based on observation, interview, and record review, the facility staff failed to transfer a resident safely, which caused the resident pain, for 1 (#50) of 22 sampled residents. Findings include: During an observation on 2/20/19 at 4:42 p.m., staff members H and K assisted resident #50 with a pivot transfer from the bed to the wheel chair. The staff members helped resident #50 sit up in bed, and the resident winced in pain as she sat up. The staff members fastened a gait belt around resident #50's waist. Staff member H instructed resident #50 to stand on the count of three. Resident #50 stated, I can't stand. The staff members lifted her by the gait belt, and the back of resident #50's pants. The resident stated, Ouch, ouch and winced in pain as the two staff members lifted her. The staff did not aknowlege the resident's pain during the transfer, and resident #50's feet did not touch the floor during the transfer. Review of resident #50's care plan, with an initiation date of 12/4/18, showed, Hoyer lift to transfer to commode and chair until able to do a stand pivot transfer. The staff did not follow the resident's care plan for safty with a transfer (Refer to F656). During an interview on 2/21/19 at 9:00 a.m., staff member J stated resident #50 could bear weight some days and not on other days. Staff member J stated the staff could use a Hoyer lift with resident #50, or a or a pivot transfer, It's really up to them. During an interview on 2/21/19 at 9:20 a.m., staff member H stated they had been using a Hoyer lift for resident #50, but now they were doing two person pivot transfers. Staff member H stated resident #50 could not bear weight, but they choose to do a pivot transfer. Review of resident #50's Physical Therapy Discharge Summary, dated 1/16/19 - 2/11/19, showed Chair or Bed to Chair Transfer Substantial/Maximal Assistance. Review of the facility's Patient Transfer Policy, which was undated, showed Hoyer Lift if residents are unable to bear weight on bilateral lower extremities, unable to to assist with bilateral upper extremities, and dependent with control trunk, a Hoyer lift transfer is recommended.Stand Pivot If the resident is deemed safe with this method of transfer by therapy staff and patient is able to bare full weight through unilateral or bilateral lower extremities (hold on), follow 1 step commands, control own trunk in space with no more than minimal assistance, stand pivot transfers may be recommended. A two person stand pivot is recommended for moderate assistance or less.",2020-09-01
505,COPPER RIDGE HEALTH AND REHABILITATION CENTER,275060,3251 NETTIE ST,BUTTE,MT,59701,2019-06-05,658,D,1,0,IEQL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to obtain a lab level ordered by a physician for 1 (#2) of 5 sampled residents. During an interview on 6/5/19 at 1:59 p.m., staff member D stated when lab orders were received from a physician the nurses were to fill out a Lab Requisition sheet and the white copy was sent to the lab and the yellow carbon copy was put on a board. Staff member D stated that it was essential to make sure that the lab sheet was filled out as ordered by the physician. Staff member D stated that the results were checked with the carbon copy of the Lab Requistion sheet, noted, and faxed to the doctor. She then throws the carbon copy of the Lab Requisition sheet away. During an interview on 6/5/19 at 2:44 p.m., staff member F stated when receiving a lab order from a physician the nurse reviews the order and completes the lab order. The lab slip was then posted on a board for night shift, then written on a hard calendar, and was put in the computer under treatments. Staff member I stated when results come in they check to make sure the labs were drawn. If the labs were not drawn she would then make sure they were set up to be drawn, but that doesn't happen. During an interview on 6/5/19 at 2:10 p.m., staff member A stated the process of fulfilling labs ordered by a physician was done by the nurse as they fill out a slip and fax it to the lab. Staff member A reviewed resident #2's physician order, dated 5/29/19, and stated it did not look like the same hand writing. Staff member A stated she had talked to resident #2's physician, and the (Physician) had not ordered a dig level. During an interview on 6/5/19 at 2:15 p.m., staff member J reviewed the physician order [REDACTED].#2's chart. Staff member J stated the hand writing on the order was hers and she had ordered a routine [MEDICATION NAME] level lab on 5/29/19. No [MEDICATION NAME] level was drawn for resident #2 on 5/31/19. Review of resident #2's Medication Administrtation Record for (MONTH) 2019 and (MONTH) 2019 showed resident #2 was recieving [MEDICATION NAME] tablet 0.125 milligrams daily. Review of resident #2's Physician Order, dated 5/29/19, showed .Labs: TSH CMP CBC dig level . Review of resident #2's Nurses Note, dated 5/29/19, showed Labs: TSH, CMP, CBC, dig level in morning. Review of resident #2's Lab Results, dated 5/31/19, showed no level for [MEDICATION NAME]. Review of the facility's policy, Lab and Diagnostic Test Results-Clinical Protocol showed the following: -1. The Physician will identify and order diagnostic and lab testing based on diagnositic and monitoring needs. -2. The staff will process test requisitions and arrange for tests. -3. The labratory, diagnostic radiology provider, or other testing source will report test to facility. -The nurse will review all the results and communicate the results of the test to the physician.",2020-09-01
506,COPPER RIDGE HEALTH AND REHABILITATION CENTER,275060,3251 NETTIE ST,BUTTE,MT,59701,2019-06-05,684,G,1,0,IEQL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to assess and monitor 1 (#1) of 5 sampled residents when there was a change in condition. Resident #1 experienced increased weakness, nausea, vomiting, and diarrhea, however there was not documentation in the medical record showing the resident was assessed and monitored for worsening of condition in the 14 hours prior to the resident being sent to the hospital. Findings include: During an interview on [DATE] at 10:37 a.m., NF1 stated resident #1 had been experiencing increased nausea and diarrhea in the week prior to being sent to the ER. NF1 stated resident #1 would just lay in bed with the blinds closed. NF1 stated she inquired on [DATE] regarding a [MEDICATION NAME] level but did not get a response from the staff. NF1 stated resident #1's nausea had gotten worse and by [DATE] the resident had required transport to the hospital for weakness, nausea, vomiting, and diarrhea. NF1 stated by the time the resident got to the ER her diarrhea was horrible. NF1 stated resident #1 had expired on [DATE], at the hospital from [MEDICATION NAME] toxicity. During an interview on [DATE] at 3:28 p.m., staff member G stated the signs and symptoms for [MEDICATION NAME] toxicity were blood pressure changes, disorientation, and confusion. Staff member G stated she would contact the physician by fax or phone, depending on the acuity. Staff member G stated she would wait 30 minutes for the physician to respond and then attempt to contact again. Staff member G stated if it was in the evening she would wait 20 minutes. Staff member G stated if the physician still did not respond, she would call the DON and the administrator. Staff member G stated she would monitor vital signs, alertness, neurological status, cardiac status, lungs and abdominal condition when a resident had a change in condition. During an interview on [DATE] at 3:35 p.m., staff member H stated the signs and symptoms of [MEDICATION NAME] toxicity were irregular heartbeat, anxiety, sweats, vision changes, pain, nausea, and vomiting. Staff member H stated she would notify the physician right away of any change in condition and get a full set of vitals. Staff member H stated she would monitor the resident closely. Staff member H stated the method in which she would contact the physician depended on the acuity of the resident. Staff member H stated she would document the attempts to contact the physician. During an interview on [DATE] at 4:00 p.m., staff member B stated the expectation for a change in condition was to assess the resident, chart for 72 hours following the change, contact the physician, notify the DON and the administrator, and if need be, contact the medical director. Staff member B stated she would expect a head to toe assessment of the resident. Staff member B stated if it was in the evening, the staff were to contact the management on call. Staff member B stated all the above depended on the acuity of the resident. Staff member B stated she would expect to see more assessments during the shift for a change in condition. During an interview on [DATE] at 4:15 p.m., staff member A stated resident #1 had refused to eat or drink during her admission to the facility, stating she would go on a hunger strike. Staff member A stated resident #1 did not want to be at the facility and had expressed wishes to return home. Staff member A stated the resident had only wanted comfort care until the daughter came in and then the resident agreed to go to the ER. Staff member A stated nursing staff should always call the physician when there is a change in condition. Staff member A stated the only reason the nurse called the physician on [DATE] was because the daughter wanted her to. Staff member A stated the physician was aware of the nausea and that was why the facility got an order for [REDACTED]. Staff member A stated the protocol was to attempt to contact the physician. If unable to contact the resident's physician, staff were to call the on call-provider or the medical director. Staff member A stated neither the on-call physician or the medical director had been contacted in this case as the nurse did not feel the situation was dire. Staff member A stated a set of vital signs were taken on [DATE] at 7:00 p.m. The medical record failed to show further assessments or monitoring of the resident. Review of resident #1's progress notes showed the following: -[DATE] at 1:37 p.m.: complaining of nausea, refused to eat, No emesis. Remained in bed all day. Assist with transfers. -[DATE] at 2:26 p.m.: Complained of nausea after breakfast. Had a few sips of beef broth and peppermint tea for lunch and reported feeling some better. -[DATE] at 11:05 a.m.: has had some nausea and dihhea (sic) last couple of days felt good this am but then loose stool after breakfast. -[DATE] at 2:53 p.m.: Has had no nausea complaints today. Daughters asking to have nausea med if she needs it. Placed call to physician. -[DATE] at 10:48 a.m.: No nausea yesterday or today on this shift. The resident went to a physician appointment and the plan was for family to pick her up at 4 p.m. for discharge to home. -[DATE] at 2:56 p.m.: The resident came back from physician appointment and the physician did not feel the resident was safe to discharge home. Received an order for [REDACTED]. -[DATE] at 10:31 a.m.: No nausea today -[DATE] at 3:42 p.m.: Dietician note; resident not eating d/t nausea. [MEDICATION NAME] order received .At risk for wt loss secondary to no intake/poor intake. -[DATE] at 3:40 a.m.: Episodes of anxiousness three times a day very anxious and upset over leg requesting frequent meds and ice. -[DATE] at 1:09 p.m.: Resident alert. Makes needs known. Denied pain this shift. Medicated for nausea x's 1 with adequate results . -[DATE] at 9:56 a.m.: Late entry-physician messaging service called at 1800 (6:00 p.m.) on [DATE]-no response-pt with increased weakness, nausea, vomiting, and diarrhea, [DATE] at 0900 (9:00 a.m.) pt c/o not feeling well, nausea, weakness. (physician's name) here and notified-he went in and saw pt, order received to send pt to the ER. Family notified and here prior to transferring via ambulance to (hospital name) for eval. Daughter riding on ambulance with pt, ER notified and report given to nurse. Review of resident #1's medical record did not show interventions for diarrhea. Documentation showed the nursing staff failed to recognize the signs and symptoms of [MEDICATION NAME] toxicity and failed to assess and monitor the residents weakness, nausea, and diarrhea for 14 hours prior to admission to the hospital. Review of resident #1's Daily Skilled Notes, from [DATE] through [DATE], showed diarrhea daily, and showed nausea on two days. Progress notes, from [DATE] through [DATE] showed frequent nausea and some diarrhea. The resident's Daily Skilled Notes showed the resident was only assessed one time per day from [DATE]-[DATE]. Review of resident #1's Physical Therapy note, dated [DATE], showed .participates well and is improving with independence with transfers and bed mobility, improved strength . Review of resident #1's Physical Therapy note, dated [DATE], showed .Pt has been sick the last couple days and feeling weaker each day. CNA reports pt is not eating well . Review of resident #1's Weights and Vitals Summary showed the following: -blood pressure was assessed two times per day from [DATE]-[DATE], -oxygen saturation was checked one time on [DATE] -temperature was assessed two times on [DATE] and [DATE], -heart rate was checked four times from [DATE]-[DATE], -respirations were checked two times on [DATE] and [DATE]. Review of resident #1's physician progress notes [REDACTED]. 3 days n/v/d (nausea/vomiting/diarrhea). pt. feels terrible mouth dry lungs (decreased) Heart rate 60 regular abd-flat slightly tender diffuse (no) [MEDICAL CONDITION] skin dry family arrived. pt DNR pt wants to go to ER for comfort care, maybe IV family agrees-daughter is a nurse. Transported by ambulance. Review of resident #1's hospital IP Encounter Report showed, under labs, a [MEDICATION NAME] level of 4.4. Normal reference range was 0XXX,[DATE].0. Under the section Final Impression showed poisoning by [MEDICATION NAME]-glycoside, accidental or unintentional, initial encounter. Review of resident #1's hospital Discharge Summary, dated [DATE], under cause of death, showed [MEDICAL CONDITION] secondary to [MEDICATION NAME] toxicity.",2020-09-01
507,COPPER RIDGE HEALTH AND REHABILITATION CENTER,275060,3251 NETTIE ST,BUTTE,MT,59701,2018-07-31,580,G,1,0,GLJS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to notify the physician of a change in physical condition after a resident's fall with injury, for 1 (#2) of 7 sampled residents, and the resident was found to have a significant injury. Findings include: Family Interview During a family interview on [DATE] at 9:32 a.m., NF3 stated she received a call from the facility that her mother had a fall. She stated her sister came in to see their mom in the morning around 7:45 a.m. and she came a little later. NF3 stated her mother had bruising to the right side of her face, from the top of her head to her cheek and between her eye socket and her ear. NF3 stated she noticed a cut on the top right side of her head above her forehead and to her right shoulder and arm. NF3 stated she told staff member B she wanted her mom to go to the hospital. NF3 stated her mom's eyes were rolling back in her head and she couldn't stand. NF3 stated she and her sister took resident #2 to the hospital. She stated the hospital did a CT scan and found her mom had bleeding in the back of her brain. NF3 stated resident #2 lingered for a week and died at the hospital. NF3 stated the situation could have been different if her mother would have gotten treatment sooner to stop the bleeding by being administered vitamin K right away. NF3 stated, They took away her chance to live by delaying treatment. Resident Fall Detail Review of the facility Occurrence Report for the resident's fall showed resident #2 had a fall in her room on [DATE] at 11:30 p.m. The report showed staff found her laying on her back on the floor with her FWW in her hands. The report showed resident #2 had been confused and had been yelling out and had been given a [MEDICATION NAME] 5 mg at 9:00 a.m. The report showed items that were on the bedside table had been knocked off onto the floor. The follow-up report for the Occurrence Report showed changes to the resident status as facial bruising. Review of resident #2's Neurological Assessment Flow Sheet, showed staff started the assessment at the time of her fall at 11:30 p.m. The form showed both eyes were dilated from 11:30 p.m. through the last check on [DATE] at 4:15 p.m. Observation entries on [DATE] at 8:15 a.m., 12:15 p.m., and 4:15 p.m. showed the resident was drowsy. Review of resident #2's Fax Sheet, showed staff sent a fax to the resident's provider on [DATE] at 11:30 p.m. The fax notified the provider that resident #2 was found on the floor on her back. The fax showed resident #2 had no apparent injury, no complaints of pain, no redness or abrasions, and was assisted to her wheelchair and then to bed. Review of resident #2's nurse's note, dated [DATE] at 11:30 p.m., showed resident #2 had no apparent injuries and the resident was assisted to her wheelchair then to bed. The note showed the family was notified and a fax was sent to resident #2's provider, which did not address a change in condition Review of resident #2's nurse's note titled Late entry for [DATE] at 8:00 a.m. by staff member C, was entered AFTER the nurse's notes dated [DATE] at 3:00 p.m. and [DATE] at 4:30 p.m. The late entry showed resident #2's pupils were equal and reactive and hand grasps were equal. It included the sentence, no request for transfer. There was no documentation that showed resident #2 had bruising to her face. The entry on the Neurological Assessment Flow Sheet on [DATE] at 8:15 showed resident #2's right and left pupils were dilated. No other assessments were documented in resident #2's medical record from 8:00 a.m. through 3:00 p.m. that reflected if any injuries were noted to include bruising to the face until the note dated [DATE] at 3:00 p.m. Review of the nurse's note, dated [DATE] at 3:00 p.m., showed resident #2 was confused and not talking much. The nurse's note showed resident #2's eye was dilated and had strong grips, and was groggy. The nurse's note showed resident #2 had bruising over and on the side of her right eye. The note showed resident #2's family had been with her all day. The note did not contain documentation that showed resident #2's provider has been notified of the dilated eye and the bruising over and on the side of her right eye. Review of resident #2's nurse's note, dated [DATE] at 4:30 p.m., by staff member B, showed resident #2's family requested a transfer to the emergency room . The note showed an order to transfer was received from resident #2's provider, based on the family's request, rather than the facility's. The note showed the family transported resident #2 to the emergency department. Review of resident #2's emergency department notes, dated [DATE] at 10:27 p.m., showed resident #2 presented with a chief complaint of a fall. The physician review of systems showed resident #2 had right sided facial contusions. The emergency department course and medical decision making showed resident #2 was Comfort Care per her POLST, and was diagnosed with [REDACTED]. The note showed a neurosurgeon was consulted and stated there was no surgical indication for the current brain bleed. Resident #2 was admitted to the hospital as an inpatient under Comfort Care. Review of the facility policy and procedure titled, Physician Notification, showed, .All communication verbal or written must be documented in the permanent medical record. 1. Emergent: Post fall with injury or suspected injury, change in mental status, new onset pain, [MEDICAL CONDITION] (no void in 8 hours), no response to bowel protocol, chest pain, shortness of breath with desaturation require a phone call to the physician or on call physician in less than 1 hour from initial occurrence. In summary, resident #2 had a fall in her room on [DATE] at 11:30 p.m. Resident #2's provider was notified of the fall via fax and that there was no injury. Facility staff failed to notify resident #2's provider of changes in her condition, to include facial bruising, the following morning. Resident #2's daughters requested a higher level of care for further assessment of the resident, and transferred her to the emergency department on [DATE] for an evaluation. Resident #2 was diagnosed at the hospital with a midline focal tentorial subdural hematoma. The intra-cranial hemorrhage was non-operable. Resident #2 was admitted as an in-patient at the hospital and transitioned to comfort care on [DATE]. She passed away on [DATE]. Further investigation showed:",2020-09-01
508,COPPER RIDGE HEALTH AND REHABILITATION CENTER,275060,3251 NETTIE ST,BUTTE,MT,59701,2018-07-31,678,D,1,0,GLJS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure staff provided CPR to a resident who was a full code for 1 (#1) of 7 sampled residents. Findings include: Resident #1 was admitted to the facility after a fall at home resulting in a [MEDICAL CONDITION] and a left hip arthroplasty. Review of resident #1's admission records showed he was admitted to the facility to be evaluated and treated with physical and occupational therapy. The admission orders [REDACTED]. The orders were signed by NF1. Review of resident #1's POLST showed the form was not completed. At the bottom of the form was written, Does not want to address at this time and was signed by resident #2's wife and staff member D. The form was not dated. Review of resident #1's nurse's note, dated [DATE] without a time noted, showed, up took meds, meal on wing went to P/T, Ret to Rm. Hoyer into bed went to remove sling Pt became limp color pale. called to room last breath no pulse no B/P expired wife Dr. notified Wife visited him. Review of resident #1's Record of Death showed the date of death as [DATE] at 9:05 a.m. During an interview on [DATE] at 1:45 p.m., staff member D stated resident #1's wife wanted him to be a full code. She stated in the past his wife stated to resident #1 that he didn't want a code but reminded him of how well he came out of the hospital. Staff member D stated the POLST was addressed during the care plan meeting on [DATE] and resident #1 was sleeping throughout the meeting. She stated resident #1's wife kept waking him and would try to talk to him. Staff member D stated resident #1's wife did not want to make the decision for him. She stated resident #1 wanted to go to bed and did not want to address completing the POLST. Staff member D stated if a resident coded, and was a full code, CPR would be administered. Review of resident #1's Care Conference form, dated [DATE], showed resident #1, his wife, and a staff member from nursing, therapy, activities, social services, and dietary attended. The form showed in the notes section, offered/reviewed POLST-declined. During an interview on [DATE] at 3:05 p.m., staff member C stated if a resident is a full code staff is to initiate CPR. Staff member C stated she called resident #1's wife at the time staff had found resident #1 without a pulse and respirations. She stated resident #1's wife said to send him to the hospital, and then said no, and stated she did not know what to do. Staff member C was then told by staff member D that resident #1 had no pulse. Staff member C stated resident #1's wife said she did not know what to do. Staff member C stated she told her she should come and say her goodbyes. Staff member C stated staff members F and H were present also. Staff member C stated she did not know why they did not do CPR. She stated resident #1 was very fragile. Staff member C stated resident #1's wife had stated she knew resident #1 was never going to come home. Staff member C stated if the provider would have been there he wouldn't have had staff provide life saving measures such as CPR for resident #1. During an interview on [DATE] at 4:30 p.m., resident #1's wife stated resident #1 told her he was tired. He was ready to go. She stated she was told his heart failed. She stated when the facility called her at the time he coded he died during the phone call. She stated she thought if he had gone in the ambulance he would have died anyway. During an interview on [DATE] at 5:15 p.m., staff member F stated the CNAs came and got her at the nurse's station and took her down to resident #1's room. She stated she looked at him and checked his pulse and there was nothing. She stated she checked his chest and he had no respirations. She stated he was clinically dead. She stated she did not perform CPR for resident #1 because he was expired. She stated a full code meant she should have started CPR and called a code. She stated resident #1 had stated several times he was tired. She stated she personally could not see performing CPR for him. She stated she should not have made that choice for him. Staff member F stated she was due for her CPR certification and was attending a class on Thursday. A request was made for documentation that showed staff member F's had a current CPR re-certification. No additional information was submitted. During an interview on [DATE] at 2:05 p.m., NF1 stated he had treated resident #1 for several years. NF1 stated the POLST was not completed because resident #1 had dementia and was not able to make cognitive decisions. He stated performing a code and CPR for resident #1 would have been a crime against humanity. He was declining. Review of the facility BLS Log showed staff members B, H, and D were CPR certified.",2020-09-01
509,COPPER RIDGE HEALTH AND REHABILITATION CENTER,275060,3251 NETTIE ST,BUTTE,MT,59701,2018-07-31,689,G,1,0,GLJS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility staff failed to ensure a resident who had a fall with a significant head injury received thorough and ongoing medical assessments and monitoring for the analysis of post fall assessment data to be used for the purpose of identifying resident changes; and staff failed to effectively identify, document, and communicate the fall details, to include notifying the physician of the change of status and head injury for the resident, and allow the physician the opportunity to determine if a higher level of care or treatment was necessary; and failed to address interventions for safety related to accidents and hazards for the fall, which included the resident's transfer to the emergency room in a private vehicle, for 1 (#2) of 7 sampled residents. Findings include: Family Interview During a family interview on [DATE] at 9:32 a.m., NF3 stated she received a call from the facility that her mother had a fall. She stated her sister came in to see their mom in the morning around 7:45 a.m. and she came a little later. NF3 stated her mother had bruising to the right side of her face, from the top of her head to her cheek and between her eye socket and her ear. NF3 stated she noticed a cut on the top right side of her head above her forehead and to her right shoulder and arm. NF3 stated she told staff member B she wanted her mom to go to the hospital. NF3 stated her mom's eyes were rolling back in her head and she couldn't stand. NF3 stated she and her sister took resident #2 to the hospital. She stated the hospital did a CT scan and found her mom had bleeding in the back of her brain. NF3 stated resident #2 lingered for a week and died at the hospital. NF3 stated the situation could have been different if her mother would have gotten treatment sooner to stop the bleeding by being administered vitamin K right away. NF3 stated, They took away her chance to live by delaying treatment. 1. Resident Transfer and Admission to the Hospital During an interview on [DATE] at 2:05 p.m., staff member [NAME] stated just before she and another nurse found resident #2 on the floor she heard a ting of metal sound. She stated they had concerns for resident #2 regarding her medications and her confusion. She stated they found resident #2 laying on the floor, on her back, with her walker in her hands. She stated they assessed resident #2 and then stood her up. She stated resident #2 had normal range of motion to her extremities and there were no signs of blood. She stated if there was an injury bruising would not be noticed for 72 hours unless there had been a tremendously hard impact. Review of resident #2's emergency department notes, dated [DATE] at 10:27 p.m., showed resident #2 presented with a chief complaint of a fall. The physician review of systems showed resident #2 had right sided facial contusions. The emergency department course and medical decision making showed resident #2 was Comfort Care per her POLST, and was diagnosed with [REDACTED]. The note showed a neurosurgeon was consulted and stated there was no surgical indication for the current brain bleed. Resident #2 was admitted to the hospital as an inpatient under Comfort Care. 2. Review of the facility policy and procedure titled, Physician Notification, showed, .All communication verbal or written must be documented in the permanent medical record. 1. Emergent: Post fall with injury or suspected injury, change in mental status, new onset pain, [MEDICAL CONDITION] (no void in 8 hours), no response to bowel protocol, chest pain, shortness of breath with desaturation require a phone call to the physician or on call physician in less than 1 hour from initial occurrence. 3. A review of resident #2's medical record showed the following: a. Initial Assessments Review of resident #2's 5 day admission MDS, with and ARD of [DATE], showed she had severe cognitive impairment, had disorganized thinking, hallucinations and delusions, required extensive assistance from two staff members for transfers toileting, and bed mobility, and extensive assistance of one staff member for walking in her room. Review of resident #2's bladder evaluation dated [DATE] showed the resident was confused and disoriented, required extensive assistance from staff to transfer, had decreased manual dexterity and pain with movement, and had decreased upper and lower extremity muscle strength. The evaluation showed resident #2 had a perception of needing to void, and a pattern of voiding upon arising and after meals. The evaluations showed resident #2 required the assistance of one person and the use of a FWW to facilitate her toileting ability. b. Review of resident #2's fall risk assessment, dated [DATE], showed a score of 20 which represented a high risk for falls. Review of resident #2's care plan, with an initiation date of [DATE], showed a focus area for a self-care deficit due to cognitive impairment. The goal was for resident #2 to be able to safely perform self-care activities. Interventions listed included that staff would assist resident #2 with dressing, ambulation with a walker, closely monitor for loss of balance or fall, monitor for the assistance needed to eat, and provide one person limited assistance to extensive assistance with bed mobility, transfers and toileting. Review of resident #2's Medication Administration Record [REDACTED]. c. Fall Investigation Review of the facility Occurrence Report showed resident #2 had a fall in her room on [DATE] at 11:30 p.m. The report showed staff found her laying on her back on the floor with her FWW in her hands. The report showed resident #2 had been confused and had been yelling out and had been given a [MEDICATION NAME] 5 mg at 9:00 a.m. The report showed items that were on the bedside table had been knocked off onto the floor. The follow-up report for the Occurrence Report showed changes to the resident status as facial bruising. Review of resident #2's Neurological Assessment Flow Sheet, showed staff started the assessment at the time of her fall at 11:30 p.m. The form showed both eyes were dilated from 11:30 p.m. through the last check on [DATE] at 4:15 p.m. Observation entries on [DATE] at 8:15 a.m., 12:15 p.m., and 4:15 p.m. showed the resident was drowsy. Review of a resident #2's Nursing Fax Sheet, sent to the resident's physician, on [DATE] at 11:30 p.m., showed the resident was found on the floor on her back. The fax showed resident #2 had no apparent injury, no complaints of pain, no redness or abrasions, and was assisted to her wheelchair and then to bed. d. Nursing Documentation After the Fall Review of resident #2's nurse's note, dated [DATE] at 11:30 p.m., showed resident #2 was found on the floor, supine with feet under the sink and near the bathroom. The nurse's note showed no apparent injuries and the resident was assisted to her wheelchair then to bed. The note showed the family was notified and a fax was sent to resident #2's provider. Review of resident #2's nurse's note titled Late entry for [DATE] at 8:00 a.m. by staff member C, was entered AFTER the nurse's notes dated [DATE] at 3:00 p.m. and [DATE] at 4:30 p.m. The late entry showed resident #2's pupils were equal and reactive and hand grasps were equal. It included the sentence, no request for transfer. There was no documentation that showed resident #2 had bruising to her face. The entry on the Neurological Assessment Flow Sheet on [DATE] at 8:15 showed resident #2's right and left pupils were dilated. No other assessments were documented in resident #2's medical record from 8:00 a.m. through 3:00 p.m. that reflected if any injuries were noted to include bruising to the face until the note dated [DATE] at 3:00 p.m. Review of resident #2's nurse's note, dated [DATE] at 3:00 p.m., showed resident #2 was confused and not talking much. The nurse's note showed resident #2's eye was dilated and had strong grips, and was groggy. The nurse's note showed resident #2 had bruising over and on the side of her right eye. The note showed resident #2's family had been with her all day. The note did not contain documentation that showed resident #2's provider has been notified of the dilated eye and the bruising over and on the side of her right eye. Review of resident #2's nurse's note, dated [DATE] at 4:30 p.m., by staff member B, showed resident #2's family requested a transfer to the emergency room . The note showed an order to transfer was received from resident #2's provider. The note showed staff was unable to reach the ambulance service and dispatch was notified of the need for a non-emergency transfer. The note showed the family transported resident #2 to the emergency department. Staff member B documented the ER nurse was notified resident #2's family was bringing her to be examined and gave report. The medication list and POLST were faxed to the ER. Review of resident #2's nurse's note, dated [DATE] at 4:30 p.m., by staff member G, showed at 3:00 p.m. family members called her into resident #2's room. The note showed staff member G was asked by the family if they would send resident #2 to the ER. The note showed resident #2's family told staff member G that resident #2 had been found on the floor. Staff member G noted the family had asked that resident #2 be sent to the ER. Staff member G wrote in the note that resident #2's family decided to take their mom to the ER in their care since the ambulance was not able to at that time. Review of resident #2's nurse's note, dated [DATE] at 5:30 p.m., by staff member G, showed the hospital called and reported that resident #2 had a brain bleed, the [MEDICATION NAME] was stopped, and thanked staff member G for sending resident #2 to the ER. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 had a fall in her room on [DATE] at 11:30 p.m. Resident #2's provider was notified of the fall via fax and that there was no injury. Facility staff failed to notify resident #2's provider of changes in her condition and the facial bruising the following morning. Resident #2's daughters took her to the emergency department on [DATE] for an evaluation, rather than the facility identifying the need for further evaluation and treatment at the local hospital. Resident #2 was diagnosed at the hospital with a midline focal tentorial subdural hematoma. The intra-cranial hemorrhage was non-operable. Resident #2 was admitted as an in-patient at the hospital and transitioned to comfort care on [DATE]. She passed away on [DATE].",2020-09-01
510,COPPER RIDGE HEALTH AND REHABILITATION CENTER,275060,3251 NETTIE ST,BUTTE,MT,59701,2017-12-20,657,D,0,1,J1L911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a care plan was updated for a worsening pressure wound for 1 (#16) of 21 sampled residents. Findings include: Resident #16 admitted to the facility on [DATE] with end stage [MEDICAL CONDITION] and metastatic [MEDICAL CONDITION]. Review of resident #16's Braden Scale, for predicting pressure wound risk, was calculated on 12/13/17. The risk was scored as a 12, showing the resident was at a high risk for developing or worsening pressure wounds. During an observation on 12/17/17 at 10:07 a.m., staff member I completed a dressing change for resident #16's coccyx wound. Staff member I stated the wound was assessed as a Stage III pressure wound. The surface of the wound bed was black. Review of resident #16's 11/27/17 Weekly Wound and Skin Assessment sheets reflected the wound was a Stage III. The wound color documented was purple/red. Review of resident #16's 12/18/17 Interdisciplinary Progress Notes reflected an unstageable wound on her coccyx. The treatment for [REDACTED]. This assessment was not included in the Weekly Wound and Skin Assessment sheets. Review of resident #16's care plan, dated 11/22/17 - Present showed the resident had a Stage II pressure wound, therefore, the plan did not accurately reflect the resident's wound status. During an interview on 12/19/17 at 11:08 a.m., staff member H reviewed resident #16's medical record, and stated the resident had a Stage III pressure ulcer. She stated she would update the care plan. She stated the nurses had been instructed to update the care plan. She stated once a care plan had been updated, the information was communicated to her and the nursing staff through the shift change conferences. She stated she was in communication with the nursing staff daily. Review of interdisciplinary progress notes, dated 12/18/17, with staff member H, showed the wound was now documented as unstageable by staff member [NAME] Staff member H stated she would update the care plan, again. She stated this resident was declining very fast. She said she would visit with the nurses about updating the care plans. She stated staff member A had the authority to update the care plans when needed.",2020-09-01
511,COPPER RIDGE HEALTH AND REHABILITATION CENTER,275060,3251 NETTIE ST,BUTTE,MT,59701,2017-12-20,684,D,0,1,J1L911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility nursing staff failed to ensure treatment was provided, utilizing the physician orders, for applying ACE wraps for 1 (#7) of 21 sampled residents. Findings include: Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of resident #7's Quarterly MDS, with an ARD of 12/18/17, showed the resident had a BIMS of 15, cognitively intact. The resident's Functional Status (Section G) showed the resident was an extensive one person assist for dressing and personal hygiene. During an observation on 12/17/17 at 3:43 p.m., resident #7's legs were [MEDICAL CONDITION], with one open area on her lower right leg, which was weeping clear fluid. The open area was on the lower outer aspect of her right shin, and was the size of a quarter. The resident was not wearing compression wraps. During an interview on 12/17/17 at 3:43 p.m., resident #7 stated she used to have her legs wrapped at night, but the staff had recently quit wrapping her legs. She stated she had not had her legs wrapped for over a week. She stated two nurses decided she no longer needed to have her legs wrapped. Resident #7 stated she had a problem with urinary incontinence, and the wraps would become wet. She did not know why staff quit wrapping her legs at night with the ACE bandages. She felt it was important for her legs to be wrapped due to the degree of [MEDICAL CONDITION]. She stated she did not know if her physician had discontinued the compression wraps. During an observation on 12/18/17 at 8:00 a.m., resident #7 was lying in bed, her legs were not wrapped. During an interview on 12/18/17 at 8:00 a.m., resident #7 stated the staff had not wrapped her legs last night and had not offered to wrap her legs. During an interview on 12/18/17 at 8:30 a.m., staff member C stated she thought the ACE wraps had been discontinued. She stated she had not been providing ACE wraps at night. During an interview on 12/18/17 at 8:34 a.m., staff member D stated resident #7 had repeatedly declined the ACE Wraps. She stated she had not approached resident #7 about her refusal of the ACE wraps, and had not provided re-education on the importance of wearing the compression wraps. The staff member stated re-education would be important. She stated she did not know if the ACE wraps had been discontinued by the physician. During an interview on 12/18/17 at 8:36 a.m., staff member [NAME] stated resident #7 enjoyed having her legs wrapped. He stated the resident had not refused her ACE wraps. During an interview on 12/18/17 at 8:42 a.m., resident #7 stated she did not refuse her leg wraps, unless her legs were feeling exceptionally painful, or when she was too hot. Review of resident #7's Physician Orders, dated 7/19/17, showed, Plan: 1. Restarted again a trial of the leg wraps today see if she will tolerate this increased addition to her wound care. No other adjustments are made. Review of resident #7's Physician Orders, dated 7/19/17, showed, Please wrap both legs with ACE wraps while in bed and remove before getting out of bed as patient tolerates. DX: [MEDICAL CONDITION]-[MEDICAL CONDITION]. Review of resident #7's (MONTH) (YEAR) Physician order [REDACTED]. Notes: Remove before getting out of bed, as patient tolerates. order start date 7/19/17. A review of the resident's physician orders [REDACTED]. Review of resident #7's TAR, dated 12/2017, showed, Treatment wraps both legs ACE Wraps while in bed one time daily. Order date 7/19/17. Notes: Remove before getting out of bed as patient tolerates. Review of resident #7's Care Plan, showed an update on 7/19/17, for Orders written to wrap both legs with ACE wraps while in bed and remove before getting out of bed, as patient tolerates, related to [MEDICAL CONDITION] and [MEDICAL CONDITION]. The Goal was to maintain intact skin. The interventions were to monitor for drainage and adjust dressing as needed. On 12/15/17, a hand-written note showed, Resident no longer allows this to be done. The facility failed to address goals or interventions for the continued refusals. During an interview on 12/19/17 at 8:58 a.m., staff member A stated resident #7 had repeatedly refused her ACE wraps, and the staff had provided repeated re-education to the resident on the importance of wearing the compression wraps. She stated the attempts to re-educate had not been documented. She stated the care plan had been updated to reflect refusals, or who had not provided interventions. Staff member A stated it would have been the process to obtain a discontinuation order, if the facility was not going to apply the ACE wraps for the resident, due to continued refusals.",2020-09-01
512,COPPER RIDGE HEALTH AND REHABILITATION CENTER,275060,3251 NETTIE ST,BUTTE,MT,59701,2017-12-20,686,D,0,1,J1L911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure pressure wound treatment and services were consistent with professional standards of clinical practice to promote adequate healing and to prevent a potential for infection for 2 (#s11 and 16) of 21 sampled residents. Findings include: 1. Resident #11 was admitted to the facility on [DATE] after a surgical procedure for an infected Stage IV pressure ulcer, and to receive treatment for [REDACTED]. During an observation of provision of care on 12/18/17 at 8:23 a.m., resident #11's night garments and the bed padding was soaked in pink colored serosanguineous fluid due to a leaky wound dressing; which was located on her sacrum. Staff member J who assisted the resident stated the wound nurse would be changing the dressing this morning. During an interview at 8:32 a.m. staff member K was asked if she was aware that the wound dressing leaked. She asked, if the negative pressure wound therapy device was beeping during the observation of the soaked garments and bedding. She stated, if the if the dressing had an air leak, then the machine would be signaling a warning. Staff member K stated the wound nurse would be changing the dressing today. During an observation on 12/18/17, starting at 9:00 a.m., a dressing change to the wound was completed by staff member [NAME] Poor infection control techniques and inadequate hand hygiene was observed during the dressing change (See F880). Review of resident #11's Hospital Discharge Summary Notes, dated 11/14/17, the Skilled Nursing Facility Orders, dated 11/13/17, and the Physician Encounter Progress notes, dated 11/22/17, all lacked specific orders for the use of the NPWT system for pressure wound treatment and care. Review of resident #11's Weekly Wound and Skin Assessment sheets, showed the wound had been addressed on 11/13/17 during admission. This entry showed, Wound vac in place on coccyx. The wound was not assessed. On 11/15/17, staff member A documented an assessment of the wound. There was an odor to the wound and a scanty amount of drainage. The type of drainage was not documented. On 11/27/17, after 12 days had elapsed since the last assessment, staff member A documented that undermining had increased, measuring 5 cm in depth. On 12/6/17, after 9 days elapsed, staff member A documented Y (yes) under the title drainage type/amount and odor. On 12/12/17, staff member A documented Y under the title drainage type/amount and odor. On 12/18/17, staff member A documented Y under the title drainage type/amount. Review of the resident #11's Baseline Care Plan, dated 11/13/17, showed [DEVICE] treatment was as O (ordered) and wound nurse assessments weekly. Review of resident #11's (MONTH) (YEAR) Treatments showed Monday, Wednesday and Friday, wound care for the vacuum pump dressing by shift, and wound care by half strength Dakins solution every 14 days. The Dakins solution treatments were ended on 12/15/17. However, the actual physician's order was not in the medical record for the order. Review of resident #11's 12/19/17 CAA item #5, reflected the resident had a sore on her coccyx which had required debridement. The resident was admitted to the facility for decubiti care, with the [DEVICE] process. Review of resident #11's 12/8/17 Physician's Progress Notes showed the resident had a Stage III-IV sacral wound, and the treatment was to continue with current management. Review of resident #11's Weekly Wound and Skin Assessment sheet, dated 12/18/17, did not reflect the failed wound therapy (for an unknown period over the weekend the drape was punctured and air was seeping from the system) that had not been communicated to the shift nurses. This failure had not been documented in the nursing progress notes ensuring the shift nurses monitored the dressing effectively and timely to prevent the potential for further failure. Review of resident #11's Weekly Wound and Skin Assessment sheet, showed the last dressing change for the wound was dated 12/12/17. During the dressing change on 12/18/17 at 9:22 a.m., staff member A stated the last dressing change was Friday (12/15/17), however, the medical record lacked documentation to show the dressing had been changed on Friday. During an interview on 12/19/17 at 4:42 p.m., staff member B stated as far as she knew the nursing staff had not been formally trained on the use of the new NWPT system. She stated staff member A was supposed to have spearheaded a staff training for the NWPT system. She stated NPWT devices were a new procedure for the facility. During an interview on 12/20/17 at 7:16 a.m. staff member B provided the instructions- for- use guide for the NWPT. She stated she had not written a policy for this system. During an interview on 12/20/17 at 8:45 a.m., staff member A was asked to describe the policy and procedures for the use of the NPWT device, changing of settings for negative pressure, depending on color and amount of drainage pulled from the wound, orders for the specific settings from the physician, documentation of the amount and the type of drainage, and formal staff competency training's for those staff who cared for the resident. Staff member A stated she was not concerned with the resident's wound drainage, because the wound had not changed and the amount of drainage had not changed. She had been the only one who had been involved in dressing changes and three other floor nurses had been in the room with her, and had watched the dressing changes at different times. She said no formal competency training had been completed for the nurse and the NPWT system was new to the facility. The system had been provided by the respiratory company. She could not change the system settings until she received orders from the doctor. Staff member A then looked for the physician's orders in the resident's medical record and could not find the physician's order. Staff member A looked through the discharge orders, as well as the orders from staff member G's encounter with resident #11 on 11/22/17. There were no orders for the wound vac or the settings. The staff member said the wound clinic started the wound vac when the resident was hospitalized with the infection in the wound. During the observation on 12/20/17 at 8:55 a.m., the NPWT device was set at -125 mmHg. The casing was marked at maximum drainage volume of 300 milliliters. Staff member A stated the resident had absolutely no change in the amount of drainage collected from the wound. She checked the settings, and the device panel was locked. She stated she could not change the settings and that the device was sent to the facility with these settings. Staff member A stated the casing had been changed last Friday, and she would discard the current casing this Friday. 2. Resident #16 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of resident #16's Weekly Wound and Skin Assessment sheets, showed the wound was assessed on 11/15/17 during admission. This entry showed the coccyx wound had not been staged. On 11/27/17, staff member A's documentation showed the wound was a Stage III pressure wound. The appearance of the dressing, and the amount and type of drainage was not documented. On 12/5/17, after 8 days had elapsed since the last assessment, the staging, the amount and type of drainage had not been documented. On 12/13/17, after 8 days elapsed, the dark area measured 4 cm x 2 cm of the total area of 6 cm x 3 cm. The staging, and the amount and type of drainage had not been documented. Review of the facility policy, Skin Treatment Policy and Procedures, last reviewed and approved by staff member F on 11/28/17, showed the following would be included by the nursing staff during the assessment and documentation of the wounds: - appearance of the current dressing covering the wound (i.e.; drainage, type, amount, and order); - appearance of the wound post cleaning of the wound, including the wound base measured in cm and peri-wound measured in cm; - application of the new dressing, type of dressing used and how the resident tolerated the dressing change; and, - complete the skin charting weekly in the wing skin book The Skin Treatment policy and procedure did not show instructions for the use of the NPWT or other similar wound treatment systems. The Skin Treatment policy and procedures also lacked instructions for acceptable infection control procedures and hand hygiene during treatments.",2020-09-01
513,COPPER RIDGE HEALTH AND REHABILITATION CENTER,275060,3251 NETTIE ST,BUTTE,MT,59701,2017-12-20,880,E,0,1,J1L911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to conduct an annual review of its infection prevention and control program to ensure the program did not require changes or updates; and nursing staff failed to practice clean and aseptic techniques during a dressing change for a Stage IV pressure ulcer treated with negative pressure wound therapy system for 1 (#11) of 21 sampled residents. Findings include: 1. During the Infection Control Program interview, on 12/19/17 at 10:15 a.m., staff member B stated she reported all quarterly information regarding tracking and trending of infection control data to the Quality Assurance Committee. Staff member B submitted a one page table, dated 12/31/16, that reflected facility infections for each quarter. Infections listed were the following categories: urinary tract infection, upper and lower respiratory infection, wound infection, cutaneous, blood, gastrointestinal infections, and other. The report did not include a yearly analysis of the facility-wide infection control program that included a comprehensive analysis of all areas of the infection control program. During an interview on 12/20/17 at 8:45 a.m., staff member F stated the facility had not completed an annual infection control analysis, and did not have a written report. Staff member F stated infection control information was brought to the quarterly Quality Assurance Committee meetings. Staff member F submitted a list of infection control training's that staff completed during the year. No other documentation was submitted prior to the end of the survey. 2. Resident #11 was admitted to the facility on [DATE] after a surgical procedure for an infected Stage IV pressure ulcer. During an observation on 12/18/17 at 9:00 a.m., staff member A changed a leaky dressing for resident #11 who received negative pressure wound therapy (NPWT) for a tunneling Stage IV pressure wound. Upon entrance to the room, staff member A placed the dressing change supplies (a box of gloves, foam kit for the wound treatment system, two packages of alcohol wipes, a pair of scissors, a pair of tweezers, and a bulk container of gauze with a lid torn off) on the resident's dresser, on top of the resident's possessions. Staff member A held the tweezers and the scissors with her bare hands when she entered the room. She washed her hands. She pushed the resident's bedside table next to the resident's bed. She placed the mentioned supplies on the resident's bedside table, except for the wound dressing kit, this was placed on the resident's bed, on the blanket. The resident had been observed eating breakfast, using the bedside table at 8:45 a.m., during an interview. The bedside table had beverage stains on it. Staff member A did not clean or sanitize the table, nor place a clean barrier done before placing her dressing change supplies on the bedside table, to ensure no contamination. Staff member A stated the NPWT dressing was last changed on Friday (12/15/17). Staff member A left the room and came back at 9:20 a.m., with a bottle of DermaKlenz cleansing solution. She washed her hands and gloved. Staff member A palpated the resident's drape (tape dressing) located on the sacral wound. She stated the drape was compromised because an air leak was audible when she pressed on the drape. She stated this explained why the resident's garments were soaked with serosanguineous drainage this morning. Staff member A gently removed the drape. She removed the first piece of foam with her gloved right hand, and placed it in her left gloved hand. Next, she used the tweezers to remove the second piece of the foam from the wound. She did not sanitize the tips of the tweezers first. She placed the tweezers back on the bedside table with the tips overhanging the table. She removed her gloves and sanitized her hands with an alcohol based hand sanitizer. She stated she would clean the wound first before she assessed the wound. She picked several pieces of the gauze from the bulk container and sprayed them with the wound cleanser. She did not change her gloves or perform hand hygiene after handling the cleanser bottle. She then inserted the pieces of gauze one at a time inside the wound and wiped inside the wound in one circular motion. Next, staff member A grabbed the cleanser bottle with her right gloved hand and sprayed inside the wound. She placed the wound cleanser on the bedside table, grabbed more gauze with the same gloved hand and wiped inside the wound. The used gauze pieces had pink colored serosanguineous fluid on them when removed from the wound. Staff member A removed her gloves, sanitized her hands, and regloved. Staff member A did not cleanse the surrounding skin (reddish purple in color) around the sacral wound after she cleansed inside the wound. She removed her cellular phone from her left uniform pocket with her right gloved hand. She pressed a few buttons to retrieve a flashlight application on the phone. Both of her gloved hands contacted the unsanitized phone. She looked inside the tunneling wound. She placed the phone on the bed within her reach. She then opened a package of long Q-tips and inserted one inside the wound and measured the wound with the same gloved hands after handling the phone. She stated the wound measured 3 cm x 3 cm x 4 cm. She removed her gloves and regloved only her right hand without performing hand hygiene first. She inserted her gloved right index finger into the wound and with a sweeping motion from side to side assessed the undermining in the wound. Staff member A stated the wound had an undermining from 2 o'clock to 4 o'clock. She removed her gloves, sanitized, and regloved. She split open the foam kit (located on the resident's blanket) with her gloved hands. She used the scissors to cut the drape to size without sanitizing the scissors first. She placed two layers of drape over the wound without first cleansing the resident's skin around the wound. She cut two pieces of foam to size and inserted them inside the wound one at a time with the same gloves. The scissors were placed on the foam packaging between use. She removed her gloves, sanitized her hands, and regloved. She picked up the NWPT device off the floor and placed it on the resident's bed, the bottom of the device contacted the resident's pillow. The device casing was near 3/4 full with drainage. She stated it measured 225 cc. She stated it was time to replace the casing. She snapped the enclosed casing off and discarded the casing. She used the same soiled gloves to snap the new casing in place, and connect the new wound site tubing to the new device tubing. She placed the device back on the floor. She removed her gloves and sanitized her hands. She said she would save the rest of the drape for future use and placed it back into the opened packaging. She wiped the tips of the tweezers and the scissors with alcohol wipes. She did not wipe down the wound cleanser spray bottle. She placed all of the supplies, except for the box of gloves, in the resident's closet. She stated wounds were not clean, wounds had bacteria and bio film on them. She stated this was not a sterile dressing change procedure. She said surgical wounds were considered sterile and required sterile dressing change procedures. During an interview on 12/18/17 at 9:44 a.m., staff member A stated the wound was not clean and that's why the tweezers were not sanitized before being inserted into the wound to remove the foam dressing. She stated Okay when the above concerns were discussed with her. Staff member A did not provide an additional response or information during this interview. Review of the Instructions For Use, for the therapy safety information for the NPWT system, showed the Invia foam dressing kit was a sterile package for single use only. The decision to use clean versus sterile/aseptic technique was dependent on the pathophysiology, doctor preference, and institutional protocol. For foam placement, the instructions showed the Always use dressings from sterile packages that have not been opened and damaged. Do not use if packaging is breached or damaged. For dressing changes, the instructions showed the dressing should be changed every 48 hours and infected wounds required more frequent changes. Review of the facility's Skin Treatment policy and procedures, last reviewed and approved by staff member F on 11/28/17, did not show actual wound care instructions for clean and/or aseptic dressing changes. During an interview on 12/20/17 at 7:16 a.m., staff member B stated she had not written policy and procedure for the use of a negative pressure wound care system for the nurses.",2020-09-01
514,COPPER RIDGE HEALTH AND REHABILITATION CENTER,275060,3251 NETTIE ST,BUTTE,MT,59701,2017-12-20,883,E,0,1,J1L911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the informed consent for vaccinations was completed, and failed document the rationale when the vaccines were not provided, for 1 (#7) resident; and failed to document the administration dates of the pneumonia vaccines, to include the type given, for 1 (#17) of 21 sampled resident's. Findings include: 1. Review of resident #7's Immunization Record, showed an unidentified pneumococcal vaccine, which reflected, 4 years at community, the record did not show if the PVC 13 or PPSV23 was administered. Review of resident #7's Skilled Nursing Facility Orders, dated 3/29/16, showed a pneumococcal vaccine was given, with the date of administration reflected as, current. The facility failed to identify what type of pneumococcal vaccine had been administered and the date of administration. The facility failed to provide the second recommended pneumococcal vaccine to the resident. The facility failed to address the contraindication for not providing the second recommended vaccine, and failed to obtain a consent explaining the benefits versus the risks of the vaccine. Review of resident #7's medical record failed to show the facility had attempted to administer the pneumonia vaccines. 2. Review of resident #17's discharge paper work from the hospital reflected she was current on her influenza and pneumonia vaccines. Review of resident #17's immunization record had a written note in the section labeled pneumonia vaccine that reflected resident #17 received the vaccine within the last five years, but the documentation did not show the date it was given, or if it was the PVC13 or PPSV23. During an interview on 12/19/17 at 7:35 a.m., staff member F stated since she had started her position in (MONTH) (YEAR), the issue of vaccinations had been brought up as a focus area to be addressed in the fall. Staff member F stated the previous facility medical director did not consider vaccinations to be a priority concern. Staff member F stated the new medical director, and the director of nursing, had been working to get all resident's vaccines updated. Staff member F stated this would include what vaccinations had been received, where the resident received the vaccine, and when. Staff member F stated the facility system was currently being updated and changed. Staff member F stated the facility was working on placing the medical information in the database to ensure all information was kept in a central, easily accessible, place. During an interview on 12/19/17 at 8:35 a.m., staff member G stated she began serving as the facility's medical director in (MONTH) (YEAR). Staff member G stated her experience had been that most of the long term care population had not been up to date on the pneumovac vaccination. Staff member G stated the biggest problem had been finding the history needed for each individual, regarding when the vaccine had been given and which vaccine had been given. Staff member G stated there was a timeline issue, and the facility needed to do the research on all residents to determine what the next step would be. Staff member G stated she and the facility administration had started reviewing the protocols in (MONTH) (YEAR), and made decisions for what steps to take in the future. Staff member G stated newly admitted residents would fall under the new protocol. Staff member G stated the facility-wide review was on the docket to begin in (MONTH) (YEAR). Review of the facility policy and procedure titled, Pneumonia Vaccine, Pneumococcal Immunization-PPV, with an approval date of 12/12/17, reflected that an immunization log would be maintained on all residents, and the nursing staff would enter the information from the log into the resident's individual chart. A review of the CDC's Recommended Immunization Schedule for Adults Aged [AGE] years or Older, United States, (YEAR), showed, 7. Pneumococcal vaccination General information for adults who are immuno-competent and aged [AGE] years or older should receive 13-valent pneumococcal conjugate vaccine (PCV13) followed by 23-valent pneumococcal [MEDICATION NAME] vaccine (PPSV23) at least 1 year after PCV13. Adults are recommended to receive 1 dose of PCV13 and 1, 2, or 3 doses of PPSV23 depending on indication. When both PCV13 and PPSV23 are indicated, PCV13 should be administered first; PCV13 and PPSV23 should not be administered during the same visit. If PPSV23 has previously been administered, PCV13 should be administered at least 1 year after PPSV23. When two or more doses of PPSV23 are indicated, the interval between PPSV23 doses should be at least 5 years.",2020-09-01
515,MARIAS CARE CENTER,275061,630 PARK DRIVE,SHELBY,MT,59474,2017-06-01,272,F,0,1,PSBY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete the CAA summary documentation in support of clinical decision making, relevant to each triggered Care Area Assessment, for 6 (#s 4, 5, 6, 7, 8, and 9) of 10 sampled residents. All residents who had MDS assessment completed at the facility were affected, due to the failure of the facility to identify the summary section of the CAA needed to be completed, which was in the software utilized by the facility. Findings include: Resident Record Review Examples: 1. Review of resident #4's Annual MDS, with an ARD of 1/17/17, showed the following CAAs were triggered: -Cognitive Loss -Visual Function -Communication -Urinary Incontinence and Indwelling Catheter -Falls -Nutritional Status - [MEDICAL CONDITION] Medication Use 2. Review of resident #5's Annual MDS, with an ARD of 10/4/16, showed the following CAAs were triggered: -Cognitive Loss -Visual Function -Communication -Urinary Incontinence and Indwelling Catheter -Falls -Nutritional Status - Dental Care - Pressure Ulcers - [MEDICAL CONDITION] Medication Use 3. Review of resident #6's Annual MDS, with an ARD of 5/11/17, showed the following CAAs were triggered: -Cognitive Loss -Visual Function -Urinary Incontinence -Falls -Nutritional Status -Pressure Ulcer(s) 4. Review of resident #7's Annual MDS, with an ARD of 8/21/16, showed the following CAAs were triggered: -Cognitive Loss -Communication -Activities of Daily Living -Urinary Incontinence -Falls -Nutritional Status -Dental Care -Pressure Ulcer(s) -[MEDICAL CONDITION] Medication Use -Pain 5. Review of resident #8's Significant Change MDS, with an ARD of 5/14/17, showed the following CAAs were triggered: -Communication -Activities of Daily Living -Urinary Incontinence and Indwelling Catheter -Falls -Nutritional Status -[MEDICAL CONDITION] Medication Use 6. Review of resident #9's Admission MDS, with an ARD of 1/4/17, showed the following CAAs were triggered: -Cognitive Loss -Communication -Urinary Incontinence -Falls -Nutritional Status -Pressure Ulcer(s) -[MEDICAL CONDITION] Medication Use The indicators section of the CAAs, for the residents, showed indicators that were relevant to the resident but no supporting documentation was provided. The summary section of the CAA included an area for analysis of the CAA findings. Specific items to address in this section included the description of the problem, the causes and contributing factors, and the risk factors related to the care area. Each of the triggered CAAs for residents #s 4, 5, 6, 7, 8, and 9, were blank in this section. The Care Plan consideration section of the CAA had instructions to document reasons a care plan would or would not be developed. Each of the residents triggered CAAs were blank in this area. The Referrals section of each triggered CAA for resident #s 4, 5, 6, 7, 8, and 9 was blank. CAA Process Interviews During an interview on 6/1/17 at 10:05 a.m., staff member [NAME] stated he conferred by phone with staff member B, and that any notes associated with the CAA would be on the CAA and no other format for CAA documentation was used. Staff member [NAME] stated that the RAI manual was the facility policy for completion of the MDS and CAAs. Review of the RAI manual, chapter 4, section 4.5, showed guidance for CAA documentation which included: Relevant documentation for each triggered CAA describes: causes and contributing factors; The nature of the issue or condition (may include presence or lack of objective data and subjective complaints). In other words, what exactly was the issue/problem for this resident and why it was a problem; Complications affecting or caused by the care area for this resident; Risk factors related to the presence of the condition that affects the staff 's decision to proceed to care planning; Factors that must be considered in developing individualized care plan interventions, including the decision to care plan or not to care plan various findings for the individual resident; The need for additional evaluation by the attending physician and other health professionals, as appropriate; The resource(s), or assessment tool(s) used for decision-making, and conclusions that arose from performing the CA[NAME] During an interview on 6/1/17 at 1:55 p.m., with staff members B and E, staff member [NAME] stated they had identified the problem with the CAA process. He said there was a second tab in the CAA program in the software that was not being utilized. Staff member B pointed at her computer screen to a tab labeled, Summary. Within the tab were the sections of the CAA that were blank for resident's # 4, 5, 6, 7, 8, and 9. Staff member [NAME] stated, I just didn't know it was there. I'll do it now. Staff member [NAME] stated the required elements of the CAA, located in the Summary tab, will be monitored to assure completion.",2020-09-01
516,MARIAS CARE CENTER,275061,630 PARK DRIVE,SHELBY,MT,59474,2017-06-01,279,D,0,1,PSBY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to develop a comprehensive care plan to include the use or non-use of oxygen for 1 (#8) of 10 sampled residents. Findings include: Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #8's physician orders [REDACTED]. During an observation on 5/31/17 at 10:40 a.m., resident #8 was observed in his room, sitting in his recliner watching TV. The resident's nasal cannula for his oxygen was sitting on his bedside table. During an observation on 5/31/17 at 11:56 a.m., resident #8 was observed ambulating in the hall using a four-wheeled walker, he was not wearing his oxygen. During an observation 5/31/17 at 2:00 p.m., resident #8 was in his wheelchair in his room. He was not wearing his nasal cannula for his oxygen. During an observation on 6/1/17 at 1:47 p.m., there was a blood oxygen monitor sitting on the bedside table in the resident's room. In an interview on 6/1/17 at 1:47 p.m., resident #8 stated he only wore his oxygen when he needed it. He said he checked it with this (monitor), and said it was usually at 90 percent. During an interview on 6/1/17 at 2:20 p.m., staff member B was unaware of resident #8 taking his own oxygen saturation with his own monitor. Resident #8's care plan, which was effective 2/6/2017 did not address the issue of the resident #8's independence and his unwillingness to continuously wear his oxygen.",2020-09-01
517,MARIAS CARE CENTER,275061,630 PARK DRIVE,SHELBY,MT,59474,2017-06-01,280,D,0,1,PSBY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to revise the care plan when the resident had an acute infection for 2 (#s 6 and 9) of 10 sampled residents; and failed to include resident refusals or preferences on the care plan for 2 (#s 6 and 7) of 10 sampled residents. Findings include: Infection 1. Review of resident #6's nurse's note, dated 5/28/17, showed a urine culture would be done on the urine specimen sent to the lab on 5/28/17 at 8:03 a.m. Review of resident #6's urinalysis lab report, dated 5/28/17, showed resident #6's urine was positive for bacteria and a culture would be completed. Review of resident #6's lab report, dated 5/30/17, showed final culture results of Escherichia Coli >100,000 CFU/ml. Review of resident #6's physician orders [REDACTED]. Review of resident #6's care plan on 6/1/17 at 8:30 a.m., showed no revision to show the presence of infection or treatment with an antibiotic. Prior to exit on 6/1/17, a revised care plan, indicating the presence of infection, was presented by the facility. 2. Review of resident #9's nurse's note, dated 3/28/17, showed resident #9, tested positive for UTI last night shift. The note reflected resident #9 was anxious, agitated, and experienced a fall. Review of resident #9's urinalysis lab report, dated 3/30/17, showed resident #9's urine was positive for bacteria and a culture would be completed. Review of resident #9's lab report, dated 3/30/17, showed final culture results of Escherichia Coli >100,000 CFU/ml. Review of resident #9's Medication Administration Records for (MONTH) and (MONTH) (YEAR), showed the physician had ordered an antibiotic from 3/30/17- 4/4/17 to treat a UTI. Review of resident #9's care plan for the period of 3/27/17- 4/15/17, showed no revision to include the presence of a UTI or treatment with an antibiotic. During an interview on 6/1/17 at 8:49 a.m., staff member [NAME] stated the facility had identified the care plan was not being updated consistently when an infection was identified and had written an action plan to correct the issue. He said the current plan was for facility leadership to meet daily Monday through Friday with condition changes to be reported at that time and the care plan updated that day. Refusals and preferences 3. Review of resident #6's restorative flow sheet showed the resident refused restorative services 7 out of 10 times services were offered in (MONTH) and (MONTH) (YEAR). Review of resident #6's Restorative Therapy, and dated 5/20/15, showed was to receive restorative services 2-4 times per week. Review of resident #6's care plan showed multiple restorative services the resident was to receive and indicated that one of the services was being refused by the resident. The care plan did not indicate the other services were being refused or what was to be done in the event of a refusal. During an interview on 5/31/17 at 1:50 p.m., staff member A stated the restorative program was overseen by the facility administrative nurses as a shared responsibility. She stated the restorative care plan should contain the exercise plan, the frequency, the goal, refusal to participate, and a plan to follow-up after a refusal in an effort to meet the minimum frequency. 4. During observations on 5/30/17 at 12:05 p.m., 3:00 p.m., and 5:55 p.m., resident #7 was in bed resting, watching TV, or reading. During observations on 5/31/17 at 8:30 a.m., 9:20 a.m., 11:50 a.m. and 4:58 p.m., resident #7 was in bed resting, watching TV, or reading. During observations on 6/1/17 at 8:05 a.m. and 11:25 a.m., resident #7 was in bed resting, watching TV, or reading. During interviews on 5/30/17 at 12:05 p.m. and 3:00 p.m., resident #7 stated he spent almost all of his time in his bed. He said he watched TV in bed, read in bed, and rested in bed most of every day and some days he did not get out of bed. Review of resident #7's care plan did not reflect prolonged periods of remaining in bed or associated risk factors such as loss of muscle tone, impaired skin integrity, and depression or confusion due to isolation. During an interview on 6/1/17 at 7:50 a.m., staff members A and F stated resident #7 rarely left his room, per his preference, with most of his time spent in bed. Staff member A stated she did not know if that information was in the resident's care plan, and added, It should be.",2020-09-01
518,MARIAS CARE CENTER,275061,630 PARK DRIVE,SHELBY,MT,59474,2017-06-01,283,D,0,1,PSBY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to properly complete a discharge summary for 1 (#10) of 10 sampled residents. Findings include: Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Review of resident #10's nursing notes reflected the resident left the facility with family to be transferred to another facility and that he was sent with his medications and transfer information. Review of the resident's discharge summary, signed by a physician, showed personal census information, diagnoses, and under the Condition on Discharge, stated only Stable. The discharge summary lacked any information such as customary routines, cognitive ability, communication or vision limitations, mood and behavior patterns, skin conditions, or special treatments for the resident. In an interview on 6/1/17 at 1:05 p.m., staff member J, who was responsible for doing the discharges, stated she was gone the day they did this discharge. She stated they had a form in the computer system that would come up with all the pertinent information to go into a discharge summary. She stated the form was not coming up when the discharge was completed, but it was put in place 6/1/17.",2020-09-01
519,MARIAS CARE CENTER,275061,630 PARK DRIVE,SHELBY,MT,59474,2017-06-01,311,E,1,1,PSBY11,"> Based on interview and record review, the facility failed to perform restorative services for 5 (#s 2, 3, 6, 7, and 13) of 15 sampled and supplemental residents, and had the potential to affect all residents who needed, or were receiving restorative care and service. Findings include: During an interview on 5/30/17 at 11:20 a.m., and again on 5/31/17 at 7:31 a.m., staff member C stated he was a CNA for his shift. When he had to be a CNA, on the floor, he could not get the restorative work completed with the residents. The staff member stated he was able to get some walking and range of motion in, while doing the CNA job, but he was not able to work with all the residents assigned to the restorative program. 1. During an interview on 6/1/17 at 10:10 a.m., resident #13 stated she was to walk with the restorative aide one time a week, but couldn't any more as the restorative aide was working on the floor as a CN[NAME] The resident said when the restorative aide was being a CNA, staff member L used to walk her. Now with two positions, staff member L did not have the time to walk with her. The resident stated she no longer walked. NF3 was visiting during the time of the interview. The visitor stated she was afraid with resident #13 not walking, she would not get the exercise needed for her condition. Review of resident #13's Care Plan Report, with a goal date of 7/28/17, showed the resident required restorative services related to weakness and potential for decreased functional ability. The goal was to preserve her ability to walk, transfer, and participate in ADLs. The intervention was to participate in the restorative program. Review of resident #13's restorative therapy form, with a review date of 2/24/16, showed the resident was to ambulate three times per week, approximately 25 feet with a two-wheel walker, five long arc quads, six seated hip flexion, eight ankle pumps, nine supine hip ad/abduction, 11 heel slides, and 12 adductions with pillow. Review of the Care Center Restorative Master List, with a start date of 4/8/17, and ending 4/27/17, showed resident #13 was seen one time, 4/21/17, for 15 minutes. Review of the Care Center Restorative Master List, with a start date of 4/28/17, and ending 5/4/17, showed resident #13 was seen and participated two times, 4/28/17 and 5/4/17, for 15 minutes each time. Review of the Care Center Restorative Master List, with a start date of 5/6/17, and ending 5/18/17, showed resident #13 was not offered restorative. Review of the Care Center Restorative Master List, with a start date of 5/23/17, and ending 5/28/17, showed resident #13 was not offered restorative. 2. Review of resident #2's Care Plan Report, with an effective date of 3/1/16 to present, showed the resident required restorative services related to weakness and potential for decreased functional mobility. The goal was to preserve ambulation and functional mobility. Interventions were to have the resident ambulate in hallways with a front wheeled walker 2-4 times a week. Review of resident #2's restorative referral form, with a review date of 8/30/16, showed the resident was to complete ambulation in the hallways and encourage wheel chair mobility. The resident was to use a front wheel walker with a gait belt and the wheel chair following. The frequency was 2-4 times a week. Review of the Care Center Restorative Master List, with a start date of 4/8/17, and ending 4/27/17, showed resident #2 was offered and engaged in restorative one time, 5/4/17. Review of the Care Center Restorative Master List, with a start date of 4/28/17, and ending 5/4/17, showed resident #2 was offered restorative one time and refused, 5/4/17. Review of the Care Center Restorative Master List, with a start date of 5/6/17, and ending 5/18/17, showed resident #2 was offered restorative three times, 5/6/17, 5/9/17, and 5/18/17. The resident engaged in the restorative twice and refused one time. 3. Review of resident #3's Care Plan Report, with an effective date of 9/14/16 to present, showed the resident required restorative program which included: 3 sit to stand, 5 long arc quads, 6 seated hip flexion, and 8 ankle pumps. The care plan showed a restorative staff was to ask her 3-4 times a week to participate in her exercise program, showing the resident currently refused. The goal was to maintain her current level of function/activity without injury. Review of resident #3's restorative referral form, with a review date of 8/30/16, showed the resident was to walk with a two wheeled walker at a distance tolerated, 4 days per week with the wheel chair following The resident was also to do 3 sit to stands, five long arc quads, six seated hip flexion, and eight ankle pumps. The frequency was four times a week. Review of the Care Center Restorative Master List, with a start date of 4/8/17, and ending 4/27/17, showed resident #3 was offered, but restorative three times. Review of the Care Center Restorative Master List, with a start date of 4/28/17 and ending 5/4/17, showed resident #3 was offered, but refused restorative two times. Review of the Care Center Restorative Master List, with a start date of 5/23/17 and ending 5/27/17, showed resident #3 was offered, but refused restorative three times. During an interview on 5/30/17 at 4:00 p.m., resident #3 stated she had told the nursing staff she only wanted to walk, not do the other exercises offered in restorative. She said she gave up on them when they continued to offer all the exercises. 4. Review of resident #6's Care Plan Report, with an effective date of 3/20/16-present, showed the resident required restorative services related to weakness, and potential for decreased functional mobility. The goal was to preserve AROM and self feeding. The frequency of services was for 2-4 days per week, 15 minutes per day. The exercises to be provided included elbow flexion, elbow extensions, long arc quads, and terminal knee extensions. The plan also included sit to stand exercises with stand pivot transfers which the care plan showed the resident refused to participate in. Review of resident #6's Restorative Therapy plan, dated 5/20/15, showed the same plan, frequency and exercise list as the care plan but did not indicate the refusal of treatment and had an additional goal to preserve transfer ability. During an interview on 6/1/17 at 12:05 p.m., staff member C stated that this was the treatment plan in place until the end of (MONTH) (YEAR). At that time the sit to stand exercises were removed from the plan, and the care plan was updated. He stated the frequency was unchanged. Review of the Care Center Restorative Master List (daily flowsheet), showed during the month of (MONTH) (YEAR), resident #6 was offered restorative services four times, with services refused once. There was no documentation to indicate the service had been re-offered following the refusal. Review of the same flowsheet for (MONTH) (YEAR) showed restorative services were offered five times and refused on every occasion. There was no evidence that the services were re-offered after the refusals. During an interview on 5/31/17 at 1:50 p.m., staff member A stated the restorative program was overseen by the facility nurses as a shared responsibility. She stated the restorative care plan should contain a plan to follow-up after a refusal of restorative services in an effort to meet the minimum frequency. During an interview on 6/1/17 at 8:49 a.m., staff members A and [NAME] stated that additional attempts to deliver service should be made after a refusal. Per the written restorative plan for resident #6, services should have been provided a minimum of 17-18 times, and a maximum of 34-36 times, during (MONTH) and (MONTH) and were offered nine times. Review of the Annual MDS, with an ARD of 5/11/17, showed a decline in ability to transfer from extensive assistance needed to total assistance needed when compared with the Quarterly MDS, with an ARD of 2/12/17. There was no evidence of an assessment of whether the lack of consistent service was a contributing factor in the resident refusing to participate or in the decline in ability to participate in transfers. 5. Review of resident #7's Care Plan Report, with an effective date of 3/2/16-present, showed resident #7 required restorative services related to weakness and potential for decreased functional mobility. The goal for the service was to preserve lower extremity strength and mobility with a frequency of 15 minutes per day, 2-4 days per week. The planned exercises included long arc quads and ankle dorsiflexion. The plan also included sit to stand exercises and showed the resident refused to participate. Review of resident #7's Restorative Therapy plan showed the same frequency and exercises as the care plan. Review of the Care Center Restorative Master List (daily flowsheet) for (MONTH) and (MONTH) (YEAR) showed resident #7 was provided services four times and participated for 15 minutes each time. Per the written restorative plan for resident #7, services should have been provided a minimum of 17-18 times and a maximum of 34-36 times during (MONTH) and (MONTH) and were offered four times. Process Interview During an interview on 6/1/17 at 8:49 a.m., with staff members A and E, staff member [NAME] stated concerns had been identified with the restorative nursing program, and the facility had developed a written action plan and initiated corrections in (MONTH) (YEAR). Staff member [NAME] stated the problems with the program included monthly program summaries not being completed, team meetings to evaluate resident status were not occurring, and care plan updates were not being done. He did not state that the lack of provision of services was identified as a concern.",2020-09-01
520,MARIAS CARE CENTER,275061,630 PARK DRIVE,SHELBY,MT,59474,2017-06-01,315,D,1,1,PSBY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to attempt to remove a catheter in a timely manner and failed to ensure a catheter bag was kept lower than the level of the bladder for 1 (#8) of 10 sampled residents. Findings include: Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the nurses' notes, dated 5/7/17, showed resident #8 completed the ordered antibiotics for a urinary tract infection. Review of the resident's most current RAI, dated 5/14/17, reflected the resident had a cognition score of 15 of 15, which showed the resident is fully cognitive. The resident was admitted to the facility with an indwelling catheter. Progress notes from the previous facility the resident was residing at reflected a [DIAGNOSES REDACTED]. Review of facility policy regarding evaluation for Indwelling Catheters reflected catheterization may be unavoidable when certain clinical conditions were present: a. Untreatable urethral blockage. b. Terminal illness or severe impairment that makes bed and clothing changes uncomfortable or disruptive. c. Stage III or IV in an area affected by incontinence. Review of the resident's [DIAGNOSES REDACTED]. Requests were made of the facility to provide information regarding assessment for removal of the catheter or to provide documentation that continuing catheterization was necessary. No information was provided. In an interview on 5/31/17 at 2:20 p.m., staff member G stated resident #8 has not seen a nephrologist. She stated if they were attempting to remove the catheter, it would be in the nurses' notes. Review of the resident's nurses' notes did not reflect any attempts at removal or scheduled visits to a nephrologist. During an interview on 6/1/17 at 1:45 p.m., resident #8 stated he wanted to get rid of the catheter. He stated they (facility nursing) hadn't tried to see if he could go on his own, since he was admitted to the facility. During an observation on 5/31/17 at 8:31 a.m., resident #8 was seated on a chair, in the dining room. The resident's four wheeled walker was to the right of the resident. The resident's catheter bag was resting on the seat of the walker. Resident #8 was observed to be sitting lower than the walker. The catheter bag, connected to resident #8 was higher than the resident's bladder. Urine was observed backing through the clear tubing towards the bladder. During an interview on 5/31/17 at 9:05 a.m., staff member H stated resident #8 always had his catheter bag on the seat of his walker. Staff covered the bag with a towel. During an observation on 6/1/17 at 8:15 a.m., resident #8 was in the dining room, seated in a chair. The resident's catheter bag was set on the seat of the walker. The catheter bag was above the resident's bladder. Urine was observed backing through the tubing, toward the bladder. During an interview on 5/31/17 at 2:45 p.m., staff member D stated resident #8 did not have a back-flow feature on his Foley catheter. She stated she did not know of any feature available in a Foley catheter.",2020-09-01
521,MARIAS CARE CENTER,275061,630 PARK DRIVE,SHELBY,MT,59474,2017-06-01,328,D,0,1,PSBY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor and consistently address the oxygen use for one (#4) of 10 sampled residents. Findings include: During observations on 5/31/17, the following occurred: - 7:07 a.m., resident #4 did not have her oxygen on. The oxygen tank, with the nasal cannula and tubing, was on the seat of her walker. - 7:12 a.m., staff member C spoke with resident #4, but did not question why the resident's oxygen was off, or assist to put the nasal cannula on the resident's nose. Staff member C did not check to see if resident #4's oxygen was on. -7:19 a.m., resident #4 continued walking in the hall, near the nursing station, without her oxygen on. -7:40 a.m., resident #4's oxygen was off, the oxygen canister and tubing lay on the resident's walker seat. - 8:20 a.m., the resident was sitting in the dining room, at a table. The resident was not wearing oxygen. Five staff members were in the dining room. None of the staff members assisted resident #4 with her oxygen. - 8:40 a.m., staff member D gave resident #4 her medications. The resident's nasal cannula for her oxygen was not on her nose. The staff member did not assist or ask resident #4 about wearing her oxygen. - 9:14 a.m., resident #4 was outside the dining room, sitting by the nurses station. The resident was not wearing her oxygen. Review of resident #4's (MONTH) (YEAR) treatment sheet showed the physician order, dated 4/26/16, showed the resident should have three liters a minute of oxygen, per nasal cannula, related to the [DIAGNOSES REDACTED]. During an interview on 6/1/17 at 8:55 a.m., staff member D stated resident #4's oximeter reading, at times, read 85-87 percent at room air, after having her oxygen off. Review of resident #4's Care Plan Report, with a goal date of 8/5/17, showed the resident's need for oxygen use, related to [MEDICAL CONDITION] and [MEDICAL CONDITION]. The goal was for the resident to maintain adequate oxygenation with the continuous use of oxygen. Interventions included the need to frequently remind resident #4 to keep her oxygen in place.",2020-09-01
522,MARIAS CARE CENTER,275061,630 PARK DRIVE,SHELBY,MT,59474,2017-06-01,425,D,0,1,PSBY11,"Based on observation, interview, and record review, the facility failed to maintain ongoing communication with the medical provider and the pharmacy to assure an ordered medication was acquired and administered, for 1 (#13) of 15 sampled and supplemental residents. Findings include: During an observation and interview on 5/30/17 at 5:35 p.m., staff member D prepared medication for administration to resident #13. Resident #13 had two medications scheduled for administration at the time of the observation. Staff member D stated one of the medications, Bentyl, was not available because the pharmacy would not provide the medication without approval from the payer, and the payer would not approve payment without an authorization of need from the medical provider. Review of resident #13's Medication Administration Record [REDACTED]. During an interview on 5/31/17 at 1:50 p.m., staff member A stated if a medication was not available, the provider should be contacted to obtain a new order or determine if authorization had been requested and processed. During an interview on 5/31/17 at 4:25 p.m., staff member B stated she had contacted the MD's office and spoke to the nurse, regarding resident #13's ordered Bentyl. Staff member B said the provider had received the authorization request on 5/19/17, and had not yet submitted it for authorization from the payer, according to the MD's nurse. Staff member B stated the MD was not aware resident #13 was not receiving the medication, because the provider believed the pharmacy would send an emergency supply. Review of the facility policy titled, Medication Administration, showed steps for a nurse to follow when a medication was not available. These instructions included contacting the pharmacy to determine when the medication would be available and documenting the conversation. Additional instructions included checking the emergency drug kit and notifying the physician. Review of resident #13's nursing notes from 5/22/17 to 5/30/17, showed no documentation of a physician notification that resident #13 was not receiving the ordered medication. There was no documentation of communication with the pharmacy regarding when the medication would be received.",2020-09-01
523,MARIAS CARE CENTER,275061,630 PARK DRIVE,SHELBY,MT,59474,2017-06-01,431,D,0,1,PSBY11,"Based on observation, interview, and record review, the facility failed to label multi-dose medications, that were time sensitive, for 2 (#s 14 and 15) of 15 sampled and supplemental residents. Findings include: 1. During an observation on 5/31/17 at 7:15 a.m., a Lantus Solostar insulin pen was seen in the medication room refrigerator. Handwritten on the pen was the name of resident #14. The manufacturer's label on the pen showed directions to use the medication within 28 days of first use and then discard. The pen was not labeled with the date of first use. During an interview and observation on 5/31/17 at 7:16 a.m., staff member D inspected the pen and stated she did not know why the pen was not dated. She said it (dating the pen with first use) was usually done. Review of a facility policy titled, Medication Administration, showed the nurse was to check the insulin vials for date of opening and validate it was prior to the 28 day expiration limit. 2. During an observation and interview on 5/31/17 at 11:48 a.m., staff member D prepared a Combivent Respimat Inhaler for administration to resident #15. There was no first use date written on the box or on any part of the inhaler/holder. Staff member D stated the staff did not date the metered dose inhalers. Review of the Combivent Respimat Inhaler manufacturer's package insert showed instructions to date the medication cartridge, in the space provided, with a discard date for three months from when the cartridge is inserted. The directions state to discard the inhaler three months after the cartridge was inserted, even if it had not been used.",2020-09-01
524,MARIAS CARE CENTER,275061,630 PARK DRIVE,SHELBY,MT,59474,2017-06-01,441,E,1,1,PSBY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to: assure adherence linen handling/transport policies, this deficient practice had the potential to affect all residents who utilize the facility laundry; failed to follow standard precautions to prevent the spread of infection by staff not washing or sanitizing their hands during ADL cares for 4 (#s 2, 5, 11, and 12) of 35 sampled and supplemental residents; failed to remove soiled urine collection hats from the adjoining, resident bathroom for 5 (146, 148, 186, 187, 188, and 189) of 35 resident rooms; failed to place ready to eat food in a sanitary place while offering to residents during an activity, with the potential to affect all residents attending; failed to prevent outside vendors from wearing personal protective equipment, worn for sorting dirty laundry, when entering and walking throughout the halls of the facility which could affect all the residents at the facility. Findings include: 1. During an observation on 5/30/17 at 11:19 a.m., staff member C entered resident #2's room. The staff member did not wash his hands upon entering the resident's room. The staff member assisted the resident with putting her shoes on her feet. While assisting the resident with her shoes, the staff member touched the bottom of the resident's shoes. He then placed a gait belt around her waist and assisted her from her bed to her wheelchair, and brought the resident down to the dining room for lunch. The staff member failed to wash his hands when he entered the resident's room and after he left the resident's room, prior to assisting her to the dining room, where he helped the resident put on a clothing protector. The staff member failed to sanitize his hands when he left the dining room. During an observation on 5/30/17 at 11:39 a.m., staff member C entered resident #5's room. The staff member did not wash his hands upon entering the resident's room. The staff member put on a pair of gloves and placed the bedside commode by the resident's recliner. The staff member assisted the resident from her recliner to her bedside commode. He pulled her pants down and removed her wet soiled brief. When the resident had finished on the commode, the staff member assisted her into a standing position with assistance of the FWW and performed peri-care. The staff member pulled out four peri-wipes from the pack. He cleaned the resident front to back, removing a small amount of brown-yellow BM with each wipe. The staff member placed the dirty wipes on the lid of the bedside commode. During this process, the staff member dropped a peri-wipe on the floor, and removed a fresh wipe from the pack using his soiled gloves. He then pulled the resident's pants up and transferred her into her wheelchair, touching her clean clothes with the soiled gloves. The staff member then picked up the dirty peri-wipes off the bedside commode and put them in the trash. He removed his gloves and assisted the resident to the dining room where he put a clean clothing protector on the resident before leaving the dining room. Staff member C did not remove his gloves and disinfect his hands between the clean and dirty ADL's. The staff member failed to wash his hands upon entering and exiting the resident's room and when leaving the dining room. During an observation on 5/30/17 at 11:50 a.m., staff member C entered resident #5's room and moved the bedside commode back into the bathroom, and rinsed out the commode into the toilet. The staff member did not wear gloves or perform hand hygiene when sanitizing the soiled commode. The staff member failed to sanitize the soiled lid of the commode. The staff member left resident #5's room and brought the garbage to the soiled utility room. The staff member failed to wash his hands after washing the bedside commode and when leaving the resident's room. During an observation on 5/30/17 11:56 a.m., staff member C entered resident #11's room and failed to sanitize his hands. The staff member assisted resident #11 with putting on a clean pair of socks, and pants from her dresser. He dressed the resident to her knees, and turned the resident towards the wall to perform peri-care. After putting on a clean pair of gloves, the staff member removed the soiled brief and placed the brief in the garbage. Using four pre-removed peri-wipes to clean the resident from front to back, a light-yellow coloring was present on the soiled wipes. The staff member then put on a clean brief and assisted the resident in pulling up her pants. Staff member C removed his gloves, but failed to sanitize his hands after removing the gloves. The staff member then transferred the resident to her wheelchair, brushed her hair, and gave her a warm damp cloth from the sink to wash her face. The resident was assisted by the staff member to the dining room. The staff member failed to sanitize his hands upon entering the resident's room and between glove changes when transitioning between clean and dirty ADL care. During an interview on 5/30/17 at 1:50 p.m., staff member C stated he felt he could have washed his hands more while performing ADL cares for the residents. He stated it was difficult to perform hand hygiene between each ADL task. The staff member stated he had worked at the facility for four years as a CN[NAME] He stated the last training he attended on hand hygiene was in the last month. Staff member C stated he would be sure to share the importance of hand hygiene with the on-coming CNA, staff member N, prior to her starting her shift. 2. During an observation on 5/30/17 at 12:40 p.m., staff member M assisted resident #12 back to her room after lunch. The staff member washed her hands in the sink and then dampened a wash cloth to clean the resident's face. The staff member then transferred the resident from her wheelchair to her bed using the Hoyer lift. A second CNA, staff member K, entered the resident's room. Both CNA's put on a pair of clean gloves and removed the resident's wet soiled brief. Staff member M cleaned the resident front to back with clean peri-wipes, throwing the wipes in the garbage, while staff member K assisted. Staff member K and staff member M, while still wearing the gloves worn to perform the peri-care, helped the resident pull up her pants, and placed a wedge between the resident's legs, then pulled the bedding up to the resident's chest. Staff member K removed her gloves, did not wash her hands and left the resident's room. Staff member M, while still wearing the soiled gloves worn to perform the peri-care, lifted the resident's head from behind, and fluffed her pillow before resting the resident's head back on the pillow. Staff member M removed her soiled gloves and left the resident's room. Staff member M failed to change gloves and sanitize her hands between dirty and clean ADL care for resident #12, and when leaving the resident's room. During an interview on 5/30/17 at 1:42 p.m., staff member M stated she only sanitized her hands and changed her gloves when performing peri-care on a resident whom had a BM. She stated she was not worried about this when the resident only had a urine soiled brief. Staff member M stated she had been a CNA for a long time and stated she could not recall the last time she had hand hygiene education from the facility. 3. During an observation on 5/30/17 at 2:00 p.m., staff member C spoke with staff member N about the importance of proper hand hygiene during resident cares. During an observation on 5/30/17 at 2:10 p.m., staff member N entered resident #2's room, washed her hands and put on a pair of clean gloves. The staff member then transferred the resident from the wheelchair into a standing position using the sit-to-stand lift. The staff member pulled down the resident's pants and removed a wet soiled brief, then removed her gloves and went to the sink and washed her hands. The staff member then put on a new pair of gloves, and returned to the resident, where she wiped the resident's pannus folds. The staff member then pulled out a clean peri-wipe from the packet and cleaned the resident's labia front to back. The staff member stopped in the middle of the peri-care to remove her soiled gloves and washed her hands in the sink. The resident was still in the sit-to stand lift. Staff member N returned to the resident and put on a clean pair of gloves, where she proceeded to clean the resident's perineum of any BM. The staff member transferred the resident to the toilet, and encouraged the resident to go the bathroom. The staff member removed her soiled gloves and washed her hands. When the resident was finished using the toilet, the staff member put on a clean pair of gloves and performed peri-care again on the resident. The staff member removed her soiled gloves and washed her hands before transferring the resident back to her wheelchair. The staff member left the resident's room to talk to the nurse. When staff member N returned to the resident's room, she failed to wash her hands when entering the resident's room. During an interview on 5/30/17 at 3:15 p.m., staff member N stated she believed she could not wash her hands enough during cares. When asked when the best time to sanitize hands and change gloves would be during a resident's peri-care, the staff member was unable to answer. The staff member stated it was the expectation of the staff to wash their hands when entering and exiting a resident's room. The staff member stated she had been a CNA at the facility for several years, and thought the last training she attended at the facility for hand hygiene was a couple of months ago. During an interview on 5/30/17 at 4:50 p.m., staff member K stated she should have washed her hands upon entering and exiting the resident's room, and between clean and dirty cares. The staff member stated she would double glove at times when providing peri-care, so she could just remove the dirty pair of gloves between the clean and dirty cares. The staff member could not explain why this was not an effective method of hand hygiene. The staff member stated she thought the facility had a hand hygiene training a couple of weeks earlier. During an interview on 5/31/17 at 8:00 p.m., staff member A stated it was the expectation of staff to wash their hands between clean and dirty cares, and upon entering and exiting the resident's rooms after providing cares. She stated the staff had a training on hand hygiene two weeks previous, provided by staff member B. During an interview on 5/31/17 at 8:44 p.m., staff member B stated she had provided all staff with hand hygiene training on (MONTH) 5, (YEAR). She stated she followed up the education with a hand hygiene quiz. The staff member stated she did not follow up the education with a skills evaluation observation of the staff. She stated she was also responsible for tracking the UTI's in the building, and had not noticed a correlation between cares and UTI's. She stated if she did expect such a concern regarding UTI's, she would immediately provide hand hygiene education to the staff providing peri-care. 4. During an observation on 6/1/17 at 11:30 a.m., staff member K prepared to transfer resident #5 from the recliner onto the bedside commode. She took a lap blanket off the resident, folded it and set it on the bed. She removed a positioning wedge from under the resident's lower legs and placed it on the floor. Staff member K put shoes on resident #5's feet. She then pulled a pair of gloves from a box in the resident's closet and laid them on the sink counter. Staff member K brought a bedside commode from the resident's bathroom and placed it next to the recliner. She pulled the resident's wheeled walker close to the foot of the recliner and stated she did not have a gait belt. Staff member K left the room, entered the hallway, and asked staff member C for a gait belt. He handed her the gait belt and she returned to resident #5. Staff member K applied the gait belt around the resident's waist and then donned the gloves that had been laying on the sink counter. She assisted the resident to grab the handles of the walker. After the transfer, staff member K squatted on the floor and removed the resident's pants and stated they were wet. She bunched the pants in her hands and then tossed them onto the floor 3-4 feet away. She removed the resident's soiled brief and stated that is was really-wet. She stood and placed the brief in the trash can. She removed her gloves and discarded them in the trash. Using both hands, she pushed the empty recliner away from the closets and searched through the clothes hanging in the far closet for a pair of pants. After selecting a pair, she took a clean brief, a package of disposable wipes, and a pair of gloves from the near closet. She laid the brief and wipes package on the sink counter and squatted next to the resident with her right knee on the floor. She tucked the gloves between her thigh and her torso and one glove fell on to the floor. Staff member K put the clean pants over resident #5's feet and lower legs, sanitized her hands, grasped the glove tucked against her clothing and picked up the glove off the floor and put them on. She proceeded to assist the resident with peri care and transferring. During an interview on 6/1/17 at 12:45 p.m., staff member K stated that the process did not go as usual. She stated resident #5 was usually able to stand but was weak due to a UTI. Staff member K said that she should wear gloves when there may be contact with urine, BM, or when providing peri care but not for clean tasks like putting clean clothes on the resident. She stated she should wash or sanitize her hands before and after using gloves, and she should not tuck her gloves up against her uniform or use a glove that had been on the floor. Staff member K stated she had been employed at the facility for about a year. She stated she had been tested for competency prior to her employment but not since hire. During an interview on 6/1/17 at 12:58 p.m., staff member A stated staff member K should not have used a glove that had been on the floor or touched the resident's chair and clothing without washing or sanitizing hands after removing gloves. Staff member A said, In a perfect world, soiled clothing should be taken directly out to the linen barrel in the hallway and if that is not possible, should not be thrown on the floor. Review of a policy titled, Handwashing/Hand hygiene, dated (MONTH) (YEAR), showed a list of 19 specific occasions when hands should be washed or sanitized, including: -Before and after direct contact with residents; -After removing gloves; 5. During an observation on 5/31/17 at 4:20 p.m., in the bathroom shared by rooms [ROOM NUMBERS], a urine specimen collection hat was seen on the floor, next to the toilet. The hat was soiled with a dried yellow/brown substance in the bottom and had 10 spots of a dried yellow substance on the rim. During an interview on 5/31/17 at 4:37 p.m., staff member B stated the hats are used to collect urine specimens for lab testing and should be discarded after use. During an interview on 5/31/17 at 4:44 p.m., staff member's F and H stated they had shared responsibility for east and west hallways, which included rooms 146, 148, 186, 187, 188, and 189, among others. Staff member's F and H stated the collection hats are to be thrown away after use and that they did not know why it was left there. During an observation on 5/31/17 at 4:50 p.m., a urine collection hat was seen on the floor, next to the toilet, in the bathroom shared by rooms [ROOM NUMBERS]. The hat had dried brown matter on the left, right, and back sides of the rim and the sides and bottom of the inside. There was an odor of BM on the hat when inspected. During an observation on 5/31/17 at 4:58 p.m., a graduated container, labeled (resident name), 11/11 and an unlabeled urinal, were seen on the tank lid of the toilet, in the bathroom, shared by rooms [ROOM NUMBERS]. The graduated container had a dried yellow/brown substance in the bottom and had an odor of urine. During an interview on 5/31/17 at 5:00 p.m., staff member's F and H stated the graduated container and urinal belonged to a resident who had recently passed away. Staff member F stated the container was used to hold urine when his catheter bag was emptied. Staff member H stated the items should have been thrown away when the resident passed away or when his room was cleaned. Review of a policy titled, Infection Control Policies and Practices, dated (MONTH) (YEAR), showed six objectives for the infection control policies and practices. One of the objectives was to maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general-public. 6. During an observation on 5/30/17 at 1:53 p.m. staff member I was observed offering residents store bought cupcakes, from two plastic containers. While assisting the residents with taking the wrap off the cupcake, staff member I was observed setting down the container on the hall floor, next to the opening to the activity room. Four residents were walking near where the cupcakes sat. The staff member stood up and started to assist the residents in the halls. The cupcake container remained on the floor. At 1:57 p.m., staff member C stood at the nursing station and loudly told staff member I to pick up the cupcakes from the floor. Staff member I continued to give the cupcakes to residents. 7. The facility was operated by a private company inside a county building. The facility laundry was done by hospital staff (per a contract between the facility management company and the hospital). During an observation on 5/31/17 at 9:30 a.m., NF2 was observed collecting the soiled laundry bins in the facility. NF2 brought empty bins to replace the full ones that were taken back to the laundry. The staff member was observed wearing a long white sorting gown throughout the facility. In an interview on 5/31/17 at 9:30 a.m., NF2 stated the gown was worn while sorting. She stated the soiled laundry was collected twice on her shift, and the gown was put in the dirty laundry at the end of her shift. She stated she sorted the laundry in the gown and then wore it throughout the facility, again, on a second collection of soiled laundry. In an interview on 6/1/17 at 9:15 a.m., staff member [NAME] stated the facility was contracted with the hospital for laundry services, and he needed to talk to the infection control person at the hospital about the collection procedures. Staff member A stated it was just like a traveling nurse, You are responsible for them when they are in your facility.",2020-09-01
525,MARIAS CARE CENTER,275061,630 PARK DRIVE,SHELBY,MT,59474,2017-06-01,498,D,1,1,PSBY11,"> Based on observation, interview, and record review, the facility failed to assure staff demonstrated competence with transfers and infection control practices while assisting 1 (#5) of 10 sampled residents. This failure had the potential to affect all residents in the facility who were transferred by staff; or, where staff failed to follow infection control processes during care. Findings include: During an observation on 6/1/17 at 11:30 a.m., staff member K prepared to transfer resident #5 from the recliner onto the bedside commode. She took a lap blanket off the resident, folded it and set it on the bed. She removed a positioning wedge from under the resident's lower legs and placed it on the floor. Staff member K put shoes on resident #5's feet. She then pulled a pair of gloves from a box in the resident's closet and laid them on the sink counter. Staff member K brought a bedside commode from the resident's bathroom and placed it next to the recliner. She pulled the resident's wheeled walker close to the foot of the recliner and stated she did not have a gait belt. Staff member K left the room, entered the hallway, and asked staff member C for a gait belt. He handed her the gait belt and she returned to resident #5. Staff member K applied the gait belt around the resident's waist and then donned the gloves that had been laying on the sink counter. She assisted the resident to grab the handles of the walker. She stood on the resident's left side, and proceeded to place her left arm under the resident's left arm so that her elbow was under the resident's armpit. She then lifted the resident by pulling upwards with her left arm. Her right arm was around the residents back and her hands were interlocked over the resident's right shoulder. The resident called out and her face was distressed. Staff member K assisted the resident to walk a few steps to position her and pulled the commode into place behind the resident and assisted the resident to sit. The resident was unsteady and calling out that she could not stand while the staff member positioned the commode. Staff member K squatted on the floor and removed the resident's pants and stated they were wet. She bunched the pants in her hands and then tossed them onto the floor three-four feet away. She removed the resident's soiled brief and stated that is was really wet. She stood and placed the brief in the trash can. She removed her gloves and discarded them in the trash. Using both hands, she pushed the empty recliner away from the closets and searched through the clothes hanging in the far closet for a pair of pants. After selecting a pair, she took a clean brief, a package of disposable wipes, and a pair of gloves from the near closet. She laid the brief and wipes package on the sink counter and squatted next to the resident with her right knee on the floor. She tucked the gloves between her thigh and her torso and one glove fell on to the floor. Staff member K put the clean pants over resident #5's feet and lower legs, sanitized her hands, grasped the glove tucked against her clothing and picked up the glove off the floor and put them on. She pulled several wipes from the package and dropped one on the floor. She picked it up and discarded it in the trash. Using the same transfer technique as with the initial transfer, except that she had the wipes in her right hand, she attempted to stand the resident in order to provide peri care. The resident called out that she could not stand and sat back down in less than 10 seconds. Staff member K had briefly provided peri care. The staff member attempted to transfer the resident to a standing position again in the same manner, and the resident was unable to reach a standing position and called out that she could not stand. Staff member K stated she was going to get help to assist her to complete the resident's care. During an interview on 6/1/17 at 12:45 p.m., staff member K stated that the process did not go as usual. She stated resident #5 was usually able to stand but was weak, due to a UTI. Staff member K stated the resident calling out was because she was unable to stand and not related to pain. Staff member K said that she should wear gloves when there may be contact with urine, BM, or when providing peri care but not for clean tasks like putting clean clothes on the resident. She stated she should wash or sanitize her hands before and after using gloves and she should not tuck her gloves up against her uniform or use a glove that had been on the floor. Staff member K stated she had been employed at the facility for about a year. She said she had been taught to transfer residents by lifting under the arms when she was trained, prior to employment in the facility. She stated she had been tested for competency prior to her employment but not since hire. During an interview on 6/1/17 at 12:58 p.m., staff member A stated staff member K should not have used a glove that had been on the floor or touched the resident's chair and clothing without washing or sanitizing hands after removing gloves. Staff member A said, In a perfect world, soiled clothing should be taken directly out to the linen barrel in the hallway and if that is not possible, should not be thrown on the floor. She stated resident #5 was to be transferred using a stand-pivot method. Staff member A demonstrated that one staff member would stand to the side of the resident and put both arms around the resident with both hands grasping the gait belt to assist the resident during the transfer. She stated staff were trained not to lift residents under the arms and about the damage such lifting could cause. Staff member A stated she was uncertain if staff member K had any competency testing. Evidence of testing or any evaluation of performance was requested but not provided at the time of the exit. A blank document titled, CNA Competency- Transfer to a Chair or Wheelchair, was provided by the facility as a reference and as a transfer policy. The document was a checklist with a met or not met scoring system. Review of the document showed the staff member was to stand in front of the resident, assure the resident's feet are on the floor, and have the resident lean forward. Grasp the gait belt. It also showed staff should either brace their knees against the resident or use the leg/foot of one foot to brace the weak leg of the resident. See F441 for further information regarding infection control.",2020-09-01
526,MARIAS CARE CENTER,275061,630 PARK DRIVE,SHELBY,MT,59474,2017-06-01,514,D,0,1,PSBY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to maintain accurate medication administration records for 1 (#13) of 15 sampled and supplemental residents. Findings include: During an observation and interview on 5/30/17 at 5:35 p.m., staff member D prepared medication for administration to resident #13. Resident #13 had two medications scheduled for administration at the time of the observation. Staff member D stated one of the medications, [MEDICATION NAME], was not available because the pharmacy would not provide the medication without approval from the payer, and the payer would not approve payment without an authorization of need from the medical provider. Review of resident #13's Medication Administration Record [REDACTED]. On 5/23/17, 5/24/17, 5/25/17, 5/26/17, and 5/30/17, the MAR indicated [REDACTED]. On 5/28/17 and 5/29/17, the MAR indicated [REDACTED]. On 5/27/17, the MAR indicated [REDACTED]. On 5/28/17 and 5/29/17, the MAR indicated [REDACTED]. During an interview on 5/31/17 at 4:02 p.m., staff member A stated she had spoken, by phone, to the staff member who had documented the medication as administered rather than as unavailable. Staff member A stated the documentation was in error and the issue would be reviewed with the staff member. Record review of resident #13's nurse's notes dated 6/1/17 at 10:11 p.m. and 10:17 p.m., sent to the QAD after conclusion of the survey, showed the nurse had not given the medication for either dose on 5/27/17 or for the afternoon dose on 5/28/17. The documentation error had not been noted by the nurse administering the medication or the facility. No evidence was provided that the documentation error was corrected for the 5/29/17 afternoon dose of the [MEDICATION NAME].",2020-09-01
527,MARIAS CARE CENTER,275061,630 PARK DRIVE,SHELBY,MT,59474,2017-06-01,518,F,0,1,PSBY11,"Based on record review and interview, the facility failed to train employees in emergency preparedness, failed to review procedures, and failed to perform drills regarding disasters and emergency preparedness. This deficiency may affect all residents in the facility in the event of an emergency. Findings include: Review of the facility disaster preparedness manual as well as the emergency preparedness manual from the critical access hospital building in which the facility operated, there was no evidence the facility had conducted any disaster drills since 2014. Interviews with staff members were also conducted on 6/1/17 regarding training and participation in any drills. In an interview on 6/1/17 at 10:25 a.m., NF1 stated that a conversation about emergency preparedness was started, years ago with the former administrator, but I never heard back from that person. They have not approached me about participating in any drills with us. In an interview on 6/1/17 at 9:50 a.m., staff member C stated there had not been any training for evacuating the building, or any other disaster type drills, other than fire. Staff member C did not know where residents would be evacuated to, in the event of a large-scale disaster. In an interview on 6/1/17 at 9:52 a.m., staff member D stated there hasn't been any training recently for a disaster, but did think the residents would be evacuated to the civic center nearby. In an interview on 6/1/17 at 10:05 a.m., staff member F stated she hadn't been a part of any disaster or evacuation training at the facility. She stated she didn't know where residents would be taken if they had to evacuate the building.",2020-09-01
528,MARIAS CARE CENTER,275061,630 PARK DRIVE,SHELBY,MT,59474,2018-08-09,610,D,1,1,R3MS11,"> Based on observation, interview, and record review, the facility failed to investigate missing money a resident reported as lost/stolen, for 1 (#15) of 18 sampled residents. Findings include: During an observation on 8/9/18 at 9:49 a.m., resident #15 was sitting in her recliner in her room and asked if there was any information regarding her missing money. Resident #15 said she had $100 dollars in her purse when she was admitted to the facility in (MONTH) (YEAR). She said she had used some of the money after an appointment with her doctor in Great Falls and bought some drinks and a bottle of makeup. She said she thought she had $80-$90 dollars left and had placed the money in the pocket of her slacks which had been taken to the laundry. During an interview on 8/6/18 at 3:09 p.m., resident #15 stated her clothes were placed in a laundry bag to be taken to the laundry the day she returned from a doctor's appointment in Great Falls. Resident #15 thought she had left her money in the pocket of her slacks and thought it could have been close to $100 dollars and has not seen it yet. She stated she had reported it to the staff at the nurses' station and the lady that picked her clothes up was staff member [NAME] Resident #15 thought she had reported it a month ago. During an interview on 8/7/18 at 4:28 p.m., staff member I stated that she had talked with resident #15 frequently. Staff member I stated staff member C took resident #15 shopping after her doctor's appointment and resident #25 spent the missing money she claims she lost in the laundry in Great Falls. Staff member I stated resident #15 was admitted from the hospital, so any money she had on admission would have been placed in her trust account. Staff member I thought someone had given her the money since she was admitted . Staff member I did not say it was being investigated. During an interview on 8/8/18 at 4:05 p.m., staff member C stated she had taken resident #15 to an appointment in Great Falls. The resident's appointment had ended at 9:30 a.m., and staff member C took resident #15 shopping at Target. Staff member C said resident #15 had a $100-dollar bill and she kept telling the resident to place it back in her purse so she would not lose it. Staff member C thought the resident had made a purchase of between $10-$20 dollars when she bought some makeup. Staff member C said she had taken her to another appointment, and the resident had spent some more of her money, but she should have had some left. Staff member C stated she had heard resident #15 had complained about her losing money in the laundry. She said that staff member J asked resident #15 to take off her slacks, and the money was in her pocket and was still missing. Staff member C said she had not documented about the money or what the resident had bought. During an interview on 8/8/18 at 4:15 p.m., staff member A stated she was aware of the missing money. She stated the resident will focus on certain things for a while. Staff member A said she will start to check into this concern if staff member I has not done so. During an interview on 8/9/18 at 7:39 a.m., staff member J stated staff picked up soiled laundry each shift, place the laundry in the barrels and take to the laundry which was on the hospital side. Staff member J said she did not check the residents' pockets prior to taking them to the laundry. Staff member J said she thought the laundry staff checked the residents' pockets prior to washing the clothes. Staff member J said she had not heard about resident #15's missing money. Staff member J said if she knew something was missing she would let the charge nurse know, then staff would check for the items and then would let the laundry know. Staff member J said the laundry returned the resident's clothes and would bring any items they found in the wash and leave it with the staff. During an interview on 8/9/18 at 10:00 a.m., NF1 stated staff go through the residents' pockets when they are sorting. She said that sometimes the residents have left Kleenexes, watches, money, wallets, and dentures in their pockets. NF1 stated they do not keep track of what clothes the money came out of, but, just take it back over to the nursing home and give it to staff. NF1 did not know what the nursing home staff did with it. Review of the facility's Complaint/Incident Investigative Reports showed no evidence of a missing money report being submitted as of 8/13/18.",2020-09-01
529,MARIAS CARE CENTER,275061,630 PARK DRIVE,SHELBY,MT,59474,2018-08-09,656,D,0,1,R3MS11,"Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for 1 (#25) of 18 sampled residents. Findings include: During an observation on 8/6/18 at 12:23 p.m., resident #25 was sitting at the dining room table with a box of Kleenex next to her plate and a plastic garbage can sitting on the floor beside her right leg. Resident #25 was observed throughout lunch to eat independently. She would take a bite of food, suck the juice from it and then spit the rest of the food in the garbage can or spit the food into her napkin. Resident #25 would do this frequently throughout her meal. During an interview on 8/6/18 at 12:30 p.m., staff member [NAME] stated resident #25 would spit her food out frequently. Staff member [NAME] said staff would make sure the resident had Kleenex and a garbage can close to her to spit into. During an interview on 8/6/18 at 2:30 p.m., resident #25 stated she had started spitting and coughing up stuff since she was admitted . Resident #25 said she did not always spit her food out. Resident #25 was aware she had lost weight. Resident #25 said she was not concerned about her weight loss and neither was her family. Resident #25 said she had gone up and down with her weight many times. During an observation on 8/7/18 at 7:50 a.m., resident #25 was asked by a staff member if she was ready to get up for breakfast and resident #25 declined. Resident #25 continued to remain in bed throughout the morning. During an observation on 8/7/18 at 1:09 p.m., resident #25 continued to spit her food out frequently into a garbage can. During an interview on 8/7/18 at 1:47 p.m., staff member K said she visited the nursing home twice a month. She said she continued to monitor resident #25's weight loss and had implemented supplements to help stabilize her weight. Staff member K stated she did not know why resident #25 would spit out her food, but, she was aware of it. During an interview on 8/8/18 at 10:54 a.m., staff member B stated when resident #25 started losing weight she called resident #25's POA about resident #25's spitting out her food, and the resident's POA said this was something the resident had done for as long as she could remember. Staff member B said she did not think about adding the frequent spitting out of food by resident #25 to her care plan. Staff member B thought maybe this should be addressed on resident #25's care plan, as this was her normal. During an interview on 8/9/18 at 10:35 a.m., staff member D stated the resident has had spitting problems since she came here and had heard from family that resident #25 had always done this. Review of resident #25's Care Plan showed weight loss had been addressed, but, it did not show her behavior of frequently spitting out her food, and this was something the resident had always done and may be a contributing factor in the loss of weight.",2020-09-01
530,MARIAS CARE CENTER,275061,630 PARK DRIVE,SHELBY,MT,59474,2018-08-09,657,D,0,1,R3MS11,"Based on observation, interview, and record review, the facility failed to revise a resident's care plan to show the skin impairment to the right lateral heel for 1 (#8) of 18 sampled residents. Findings include: During an observation on 8/7/18 at 1:45 p.m., resident #8 had a hardened callous on his right lateral heel. The callous was approximately 2 cm by 2 cm and had a gray domed callous with a slightly red border around the outer aspect of the callous. The resident had a second wound on the lateral aspect of his left heel. The area was approximately 5 cm by 4 cm. The wound bed had approximately 50% yellow slough and had a small area on the edge which was pink. The surrounding tissue was red and pink with granulation tissue. Review of resident #8's Care Plan, with an initiation date of 5/3/18, showed the resident was at risk for skin breakdown. An intervention was added on 7/7/18, which showed, discolored area with small open area on left heel see EMAR for treatment. The resident's Care Plan failed to identify the skin impairment on the right heel. During an interview on 8/9/18 at 9:34 a.m., staff member C stated the care plan should be updated for a resident who had a change in skin condition. She stated if a resident developed a new skin impairment or had a continued skin impairment, the care plan should be updated to reflect the treatment and interventions. During an interview on 8/9/18 at 10:12 a.m., staff member B stated it was the expectation to update the resident's care plan anytime a new issue was identified. She stated for resident #8, the calloused area on his right lateral heel should have been updated on his care plan with the recommended interventions.",2020-09-01
531,MARIAS CARE CENTER,275061,630 PARK DRIVE,SHELBY,MT,59474,2018-08-09,686,G,0,1,R3MS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow physician orders [REDACTED].#8) of 18 sampled residents. Findings include: During an observation on 8/7/18 at 1:45 p.m., staff member [NAME] removed both of the blue booties from resident #8's heels. She then removed the dressings for a wound on the left heel. The dressing had a small amount of yellow exudate in the middle of the dressing, and did not have an odor. The staff member then assessed both heels for resident #8. The resident had a hardened callous on his right lateral heel. The callous was approximately 2 cm by 2 cm and had a gray domed callous/eschar with a slightly red border around the outer edge of the callous. The resident had a second wound on the lateral aspect of his left heel. The area was approximately 5 cm by 4 cm. The wound bed had approximately 50% yellow slough and had a small area on the edge which showed pink tissue approximately 0.3 cm deep. The surrounding tissue was red and pink with granulation tissue around the border. The wound had no odor. During an interview on 8/9/18 at 9:47 a.m., resident #8 stated he did not recall when he developed the wounds on his heels. He stated he spent all day in bed and had no desire to get out of bed. He stated he was aware of his risk for skin breakdown and thought the staff were providing care for his wounds. He stated he could move a little in his bed, but relied on the staff to move him from side to side, to put the booties on his feet, and pillows under his back and knees. He stated he thought the staff checked his heels twice a day, and believed they changed the dressings to his heels daily. He stated The days do run together in this place. A review of resident #8's Braden Scale for predicting pressure sore risk was completed on 7/15/18, and showed the resident was high risk for developing pressure ulcers with a score of 12. A review of resident #8's Order Summary Report, dated 4/1/18, showed, weekly skin audit in the evening every Sunday: Plus indicates new skin impairment; minus indicates no new impairment (New impairment initiate wound form). A review of resident #8's Order Summary Report dated 5/8/18, showed, Skin Prep to bilateral heels BID, two times a day for [MEDICATION NAME] related to type 2 diabetic with diabetic [MEDICAL CONDITION]. Review of resident #8's Weekly Skin Audits, showed skin audits were completed on the following dates with areas of concern, as follows: 4/25/2018 - Weekly Skin Evaluation 2, completed to the right toe(s), 4/25/2018 - Weekly Skin Evaluation 2, completed to the right buttock, 4/25/2018 - Weekly Skin Evaluation 2, completed to the right ankle (inner), 7/10/2018 - Weekly Skin Evaluation 2, completed to the right heel, 7/18/2018 - Weekly Skin Evaluation 2, completed to the left heel, 8/1/2018 - Weekly Skin Evaluation 2, completed to the left heel, 8/1/2018 - Weekly Skin Evaluation 2, completed to the top of scalp. Review of resident #8's EMAR's for (MONTH) (YEAR), showed weekly skin audits as follows: - 4/1/18: blank - skin assessment not completed, - 4/8/18: x - skin assessment not completed, - 4/15/18: minus - no new skin impairment, - 4/22/18: x - skin assessment not completed, - 4/29/18: x - skin assessment not completed. The facility failed to follow the physician orders [REDACTED]. Review of resident #8's EMAR for (MONTH) (YEAR), showed weekly skin audits as follows: - 6/3/18: minus - no new skin impairment, - 6/10/18: minus - no new skin impairment, - 6/17/18: x - skin assessment not completed, - 6/24/18: minus - no new skin impairment. The facility failed to complete the physician ordered weekly skin assessments for (MONTH) (YEAR). Review of resident #8's Skin/Wound Note, dated 6/20/18, showed, Skin prep applied to bilateral heels. Callous forming on left heel. Reminded resident to keep heels off mattress. According to the resident's (MONTH) (YEAR) EMAR, the resident did not have a skin assessment completed on 6/17/18, and a new skin condition to the left heel was documented on 6/20/18. Further review of resident #8's skin assessments showed no further documentation on skin impairment to the left heel until 7/7/18. Review of resident #8's EMAR for (MONTH) (YEAR), showed weekly skin audits as follows: - 7/1/18: minus - no new skin impairment, - 7/8/18: minus - no new skin impairment, - 7/15/18: x - skin assessment not completed, - 7/22/18: minus - no new skin impairment, - 7/29/18: minus - no new skin impairment. The facility failed to complete the ordered weekly skin assessments for (MONTH) (YEAR) for resident #8. The EMAR showed no new skin impairment or active skin condition was monitored for (MONTH) (YEAR), for the resident's skin change to the left heel, which was identified on 6/20/18. During an interview on 8/9/18 at 9:52 a.m., staff member D stated skin assessments were completed weekly, on Sunday's, for resident #8. She stated the weekly skin checks were documented in the EMAR. She stated if the skin assessment was normal with no new skin concerns a minus sign was documented into the EMAR. She stated if the EMAR showed a plus sign, then the resident had a change in his skin status, and then a weekly skin assessment document would be created. The staff member stated the EMAR would show a minus if the resident had a continued skin impairment, but the wound should be documented on weekly, until healed. The staff member could not explain what an x in the EMAR meant. She stated if a skin change was identified for a resident then she would notify the resident's physician and family. During an interview on 8/9/18 at 10:12 a.m., staff member B stated the weekly skin assessments were documented in the EMAR for each resident. She stated an x in the EMAR meant the wound assessment had not been completed, a minus meant there was no skin concerns or the skin concern was resolved, and a plus meant the resident had an active skin condition which needed treatment. She stated if there was a plus sign in the EMAR, there should be a progress note or a weekly skin assessment note which detailed the wound, type, and treatment. Review of resident #8's Care Directive Note, dated 7/7/18, showed, Skin at Risk, Task- Elevate heels - 7/7/18 new small open area to left heel - use heel trough. Review of resident #8's Skin/Wound Note, dated 7/9/2018, showed, Found a blister on resident's Right lat heel. Approx 2.5 cm in dia. Denies any discomfort. Placed a [MEDICATION NAME] over blister with gauze wrap around that. Informed Dr. Hardy via fax to clinic to advise and order drsg for area (sic). This document did not include an assessment of the wound to the left heel which was identified on 6/20/18 and noted on 7/7/18. Review of resident #8's Skin/Wound Note, dated 7/10/2018, showed, Left heel drsg C/D/I. Right heel gauze removed. [MEDICATION NAME] intact. Blister is intact, has decreased in size. Resident denies any discomfort. Rewrapped with gauze wrap (sic). Review of resident #8's Weekly Skin Evaluation 2, dated 7/10/18, showed, right heel has a dry scab, oval shaped, blister with 100% eschar. The Weekly Skin Evaluation did not address the wound to the resident's left heel. Review of resident #8's Weekly Skin Evaluation 2, dated 7/18/18, showed, left heel area appears as old blister that is partially open. It measures 6 cm by 3.5 cm and 0.2 cm deep. The shape of wound is irregular round with 50% covered with eschar and 0.2 cm around edge of the left side open. Wound typed as blister, with yellow wound bed. Wound bed has 50% eschar and 50% scab, and has a 0.2 area around edge where wound bed is visible. Review of resident #8's Nursing Progress Note, dated 7/24/18, showed, wound nurse made rounds today, right heel no changes on treatment continue skin prep BID. left heel apply skin prep to non macerated areas, hydrogel and collogen applied to open area cover with island dressing, continuously float both heels on wedge. upon entering room left heel not floated properly on wedge. no dressing in place, no noted drainage or odor. open wound measured approximately 2 cm x 2.5 cm, 0.1 cm red boarder. approximately 4.5 cm x 5 cm macerated area. resident had no complaints of pain and resting comfortably in bed. No new dressing applied awaiting orders. Heels re floated properly on wedge. CAN's advised and re oriented on how to properly float heels, with special attention to making sure the left is properly floated(sic). During an interview on 8/9/18 at 9:52 a.m., staff member D stated it was important to follow the physician's orders [REDACTED]. The staff member said a wound care nurse came to the facility on ce a month, or on an as needed basis, when a new skin impairment was identified. She stated she was aware of the wounds to resident #8's heels, but was not sure when these were first identified. The staff member stated they recently changed their computer system to Point Click Care, and had a training on how to complete and document the weekly skin assessments at that time. During an interview on 8/9/18 at 10:12 a.m., staff member B said a wound care nurse came to the facility and conducted wound evaluations about once a month, or on an as needed basis. She stated the nurses had a recent in-service on completing skin assessments and how to document the completion of the skin assessments when the facility switched to Point Click Care in (MONTH) (YEAR). The staff member stated she was aware of the pressure ulcer to resident #8's left heel, but could not say when it was first identified. She stated it was the expectation for the staff to follow the physician orders [REDACTED].#8. During an interview on 8/9/18 at 10:45 a.m., staff member A stated the facility had made skin assessments a quality improvement project for (YEAR) until they determined the quality improvement project was resolved in (MONTH) (YEAR). She stated they had developed sheets called, skin grab and goes, which the nurses were to use to perform their weekly skin assessments for the residents. She stated the form walked the nurses through everything they would need to do for skin assessments. She stated the sheets were returned to the QA team and they would review them. Anything which was not completed, or any missing information, the nurse was notified and made to complete the assessment. She stated they had removed the audit process on the weekly skin assessments in (MONTH) (YEAR), right before they switched to Point Click Care, because the nurses were not missing any skin checks, and they felt the nurses had become compliant with their wound assessments, and the concern was resolved. Staff member A noted the physician ordered skin assessments were not being completed as ordered for resident #8, which correlated with when they removed the audits for the, skin grab and go assessments. She stated it was the expectation that all nurses were completing the skin assessments as ordered by the physician and were to complete the wound assessment sheets when a new skin impairment was identified. She stated it was the expectation for nurses to follow the physician orders [REDACTED]. Review of resident #8's Weekly Skin Assessments and EMAR from (MONTH) (YEAR) to (MONTH) (YEAR), showed the facility failed to follow the physician orders [REDACTED]. A new skin change to the residents left heel was first identified on 6/20/18. The EMAR and Weekly Skin Evaluations did not reflect the new skin impairment. There was no further documentation of the left heel wound until the 7/7/18, in the Care Directive Note, which identified an open area on the resident's left heel. A Skin Evaluation was not completed for the open area on the resident's left heel until 7/10/18. The wound to the resident's left lateral heel progressed from intact on 7/10/18 to an open area on 7/24/18. By not following the physicians orders to complete weekly skin checks for this resident that was high risk for skin breakdown, the facility failed to prevent the development of a unstageable pressure ulcer on resident #8's left lateral heel.",2020-09-01
532,MARIAS CARE CENTER,275061,630 PARK DRIVE,SHELBY,MT,59474,2018-08-09,883,E,0,1,R3MS11,"Based on interview and record review, the facility failed to determine the immunization status related to the two pneumococcal vaccines (PPSV23 and PCV13), and failed to ensure both types of pneumococcal vaccines had been offered to 5 (#s 3, 8, 10, 20, and 23) of 18 sampled residents. Findings include: During an interview on 8/6/18 at 3:19 p.m., resident #20's wife stated she did not recall if the facility had offered her husband the pneumococcal vaccines, and was not sure if he needed the vaccine. She stated she did not recall if the facility had ever talked to her about the pneumococcal vaccines for her husband. Review of the immunization records for resident #s 3, 8, 10, 20, and 23, failed to show documentation that the residents had received both types of the pneumococcal vaccines (PPSV23 and PCV13), the consent for the vaccine, or the education provided regarding the benefits and potential side effects of the vaccines. During an interview on 8/8/18 at 4:26 p.m., staff member B stated the facility did not have evidence of updated PPSV23 and PCV13 for resident #s 3, 8, 10, 20, and 23. She stated it was the expectation to determine the resident's vaccine history upon admission, and update any outdated vaccines based upon the CDC vaccination guidelines for the two pneumococcal vaccines. During an interview on 8/9/18 at 10:45 a.m., staff member A stated it was the expectation that all residents would be up-to-date on their vaccines. She stated the facility had identified this as a concern in (MONTH) (YEAR), and had been waiting for the clinic to come over and update the residents on their pneumococcal vaccines, but they had not been over yet. She stated it was the facility's responsibility to facilitate this for the residents. During an interview on 8/9/18 at 11:08 a.m., staff member B stated when a resident was admitted to the facility, their immunization history was reviewed. She stated if the resident came to the facility from the community, they would track down their immunizations through their local physician. She stated if they did not have the required immunization, education and consents were to be provided to the patients or their power of attorney which outlined the risks and benefits of the vaccines. She stated if the patient or family member decline the vaccine, then a note was made that education was provided, and the patient declined. She stated they were over-due to update resident #s 3, 8, 10, 20, and 23. She stated the facility had attempted to update the identified residents for their pneumococcal vaccines in (MONTH) (YEAR). She stated consents were signed, and requests for immunizations were sent to the local health clinic to vaccinate the identified residents. She said the facility relied on the health clinic to do the vaccinations for the residents at the facility, because they did not have their own pharmacy to obtain the required vaccines. She stated it was the facility's responsibility to follow up with the health clinic, and determine when they would be in to complete the requested vaccinations. A review of the facility's policy and procedure titled, Influenza and Pneumococcal Vaccine Administration, showed, 2. Pneumococcal vaccination occurs with Center residents only, upon admission and with repeated vaccination occurring per CDC guidelines. a. Licensed nursing staff reviews/evaluates potential contraindication with residents via the Resident Pneumococcal Vaccine Informed Consent and a current version of either the CDC Pneumococcal PCV 13 Vaccine information Statement or CDC Pneumococcal PPSV 23 Vaccine information Statement . c. A log is maintained documenting the number of residents who received each version of the vaccine, as well as the number who refused and did not get vaccinated (via the Pneumococcal Vaccine PCV 13 Record, the Pneumococcal Vaccine PPSV 23 Record, and the Pneumococcal Vaccine Refusal Record). 3. Documentation of resident or employee receiving vaccine(s) is kept on the residents' or employee's Immunization Record.",2020-09-01
533,MARIAS CARE CENTER,275061,630 PARK DRIVE,SHELBY,MT,59474,2019-09-19,688,E,1,1,5V4811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to provide and accurately document restorative care for 2 (#s 1 and 9) of 17 sampled residents. This deficiency has the potential to affect all residents on restorative care. Findings include: 1. During an observation and interview on 9/16/19 at 11:30 a.m., and 9/17/19 at 2:55 p.m., resident #1 and NF2, both mentioned several concerns with the facility. Exercise activities were not being completed, and there were no restorative aides. Resident #1's legs were swollen. NF2 was concerned about the resident's loss of progress, and the effect of the [MEDICAL CONDITION] on her health. During an observation and interview on 9/19/19 at 8:20 a.m., resident #1 showed her swollen legs and commented that a stool was provided to elevate her legs, but she had difficulty using the stool. Resident #1 expressed the desire to walk in the hallway. During an interview on 9/19/19 at 9:00 a.m., staff member J stated he was not able to complete restorative tasks with the residents and there were no other restorative aides. During an interview on 9/19/19 at 9:00 a.m., staff member J stated some CNAs offered resident #1 opportunities to walk in the hallway. Staff member J stated resident #1 would sometimes refuse walking sessions offered by the staff. Review of resident #1's Care Plan, showed the resident had Impaired mobility R/T: decreased ROM. decreased bed mobility. decreased transfer skills. decreased ambulation skills. Date Initiated was 4/03/2018. The goal was for resident was to maintain her current level of function. Interventions included: NURSING REHAB/RESTORATIVE: Walking Program AMB GAIT 4WW 20-50 FEET. Target date was 11/06/2019. Review of resident #1's form, titled Look Back Report, dated 8/18/19 to 9/18/19, showed restorative data NA, NA for all walk in corridor sessions. The resident was not coded RR (Resident Refused) for any of the sessions during this time. Review of resident #1's paper records for restorative programs showed two sessions completed in August, 2019. 2. During an observation on 9/16/19 at 12:04 p.m., resident #9 was sitting in a wheel chair at the dining room table for lunch. The resident was assisted by staff to enter and exit the dining room by being pushed in her wheel chair. The resident was not observed walking. During an observation on 9/17/19 at 7:52 a.m., resident #9 was in the dining room seated in a wheel chair. The resident was not observed to have walked from the dining room when finished with breakfast. During an observation on 9/17/19 at 11:28 a.m., resident #9 was sitting in a wheel chair in the activity room. The resident was assisted by staff to push her into the dining room for lunch. The resident was not observed to have walked. During an interview on 9/19/19 at 9:29 a.m., staff member I said resident #9 does not walk in her room or the hallway. The staff member said, Years ago she used to walk with a stand by assist of one staff person and walker. Staff member I said the resident is weak, refuses, and feels afraid of falling. Review of resident #9's Care Plan, showed the resident had Impaired mobility R/T . decreased ambulation skills. Date initiated was 4/03/18. The goal was to have the resident maintain her present ambulation. The target date was 12/4/19. Under Interventions, it showed: NURSING REHAB/RESTORATIVE: Walking Program. AMBULATE GAIT FWW W/C TO FOLLOW. Review of resident #9's form, titled, Look Back Report for (MONTH) 8/18/19 through 9/17/19, showed the resident was coded twenty eight times under Walk in Room and Walk in Corridor both as N[NAME] The resident was also coded six times, WALK IN ROOM: SELF PERFORMANCE - How resident walks between locations in his/her room, as a 4 TOTAL DEPENDENCE - Full staff performance, and WALK IN ROOM: SUPPORT PROVIDED - How resident walks between locations in his/her room, as a, 2 One person physical assist. The resident was not coded RR (Resident Refused).",2020-09-01
534,MARIAS CARE CENTER,275061,630 PARK DRIVE,SHELBY,MT,59474,2019-09-19,801,E,0,1,5V4811,"Based on observation, interview, and record review, the facility failed to ensure the dietary manager completed a certification program approved by a national certifying body or had higher education in a related field. This had the potential to affect residents who consumed food prepared and served by the facility. Findings include: During the initial tour of the kitchen on 9/16/19 at 11:50 a.m., no documentation of advanced training for the dietary manager was posted. During an interview on 9/16/19 at 11:50 a.m., staff member [NAME] stated she was enrolled in an online program titled Certified Dietary Manager/Certified Food Protection Professional, and expected to complete the training by (MONTH) 2020. This training program was being supervised by the facility's part-time dietitian, staff member K. During an interview on 9/16/19 at 11:50 a.m., staff member [NAME] stated the dietician came to the facility two times each month. During an interview on 9/19/19 at 9:00 a.m., staff member L stated the dietary manager was hired into the management position in (MONTH) of (YEAR). A review of records on 9/19/19, showed staff member [NAME] was participating in the online Certified Dietary Manager/Certified Food Protection Professional program, but had not completed that training.",2020-09-01
535,MARIAS CARE CENTER,275061,630 PARK DRIVE,SHELBY,MT,59474,2017-09-26,310,D,1,0,3LR111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, observation, and record review, the facility failed to provide services which would maintain or improve a resident's ability of bowel and bladder elimination by maintaining use of a portable urinal and using the toilet instead of a bedside commode for 1 (#1) of 6 sampled residents. This deficient practice had the potential to affect all residents who needed assistance to improve or maintain their bowel and bladder elimination. Findings include: Resident #1 was admitted to the facility on [DATE], and was re-admitted on [DATE], with [DIAGNOSES REDACTED]. Review of resident #1's Initial MDS, with an ARD of 4/21/17, showed the resident had a BIMS of 14, cognitively intact. The Functional Assessment (Section G) showed the resident needed extensive assistance with two or more staff for use of the toilet, and had a functional limitation on one side of his body. The Bladder and Bowel Assessment (Section H) showed the resident was frequently incontinent of urine and had no current or previous attempt at an elimination training program. The resident was noted as always being continent of bowel. Review of resident #1's Discharge MDS, with an ARD date 6/29/17, showed the resident had a BIMS of 14, and was cognitively intact. The Bladder and Bowel Assessment (Section H) showed the resident was frequently incontinent of bladder and frequently incontinent of bowel. Review of resident #1's Initial MDS, with an ARD of 7/6/17, showed the resident had a BIMS of 14, and was cognitively intact. The Functional Assessment (Section G) showed the resident was totally dependent on staff for one person assistance with toileting, and had a functional limitation on one side of his body. The Bladder and Bowel Assessment (Section H) showed the resident was occasionally incontinent with bladder elimination and a trial of a urinary toileting training program was attempted with no improvement. Review of resident #1's Clinical Assessment, dated 7/26/17, showed the resident needed assist x 1 for toileting before and after meals due to incontinence of bowel and bladder. Additional Information showed, If you can't assist him right away when his call light is on, stop and let him know you will be with him as quick as you can. Encourage him to be independent with mobility to and from dining room assist as needed. Resident requested to be toileted every 3 hours even at night. Please do not leave him on the commode for more than 20 minutes. Review of resident #1's Care Plan, dated 6/30/17 to present, showed a problem with bowel incontinence related to inability to toilet self. The goal was to maintain or improve current level of bowel function unless deterioration was clinically unavoidable. The interventions showed to place the resident on the commode daily in the morning for bowel movement, after breakfast, check and change every 2 hours and as needed for incontinence. Answer call light as quickly as possible, if unable to assist him at that time let him know that you will be there as soon as possible. Review of resident #1's Care Plan, dated 6/30/17 to present, showed a problem with bladder incontinence related to urgency and inability. The resident had a goal to manage incontinence by staff preventing skin breakdown in the next 90 days. The interventions showed, The resident wanted to be toileted every 3 hours consistently even at night. Recommended to check for incontinence, clean and dry skin if wet or soiled. Use pads/briefs to manage incontinence. Review of resident #1's Care Plan, dated 6/30/17 to present, showed a problem with impaired physical mobility, with a goal to maintain current level of mobility with no increase in the incidence of falls. The provided intervention was to keep items the resident frequently used in arms reach. A problem was also identified for alteration in psychosocial wellbeing and mood, due to history of [MEDICAL CONDITION], and showed signs and symptoms of depression. The goal was to ensure resident had meaningful relationships and will have feelings of comfort and hope. The interventions to meet those goals included to have staff encourage resident to complete tasks and resolve problems and make decisions regarding his day to day life. During an interview on 9/21/17 at 1:49 p.m., resident #1's family member stated when she visited the resident in (MONTH) (YEAR), she had to ask which room the resident was in, and the staff pointed to a room with a light on over the door, and said, that was his room. She stated before she even walked into the resident's room, the resident's call light was on because he needed to use the bathroom. She stated the resident had a urinal in his room, but it was above his bed on the window sill, and he could not even reach the urinal to use it. She stated the resident had his call bell on for over an hour before anyone came to the room to check on him. He had waited so long for someone to help him get to the bathroom, he had been incontinent of his bladder, and soiled his brief. She stated she could tell resident #1 was embarrassed. She stated the resident was continent of his bowel and bladder when he entered the facility and was no longer continent of his bladder and sometimes he was incontinent of his bowels as well. She stated the resident had come to the facility to get rehab and work towards going home. The family member stated she was concerned at this rate he would never be able to go home, and he was too young to spend the rest of his life in a long term care center. During an observation on 9/25/17 at 10:30 a.m., resident #1 was laying on his back in bed. The front of the resident's sweatpants were wet. The resident pushed the call bell for assistance to be changed. There was an empty urinal on the windowsill above the resident's bed, which was out of arms reach for the resident, and dated 9/1/17. During an interview on 9/25/17 at 10:30 a.m., resident #1 stated he was helped to the commode after breakfast, but was not able to eliminate. He stated after he was laid back onto his bed, he had an accident and urinated in his brief around 9:30 a.m. He stated he put on his call bell to let the CNA know, and when she answered the bell, she asked him if he could wait to be changed until she came back to get him up for lunch. The resident stated he had agreed because he did not want to be a problem. The resident stated he used to use the urinal, but was not very consistent with it since he could not always reach it when needed. He stated he also did not like to use the urinal since he had to keep it in a plastic bag when he had it on his bedside table. The resident stated he did not care if the urinal was in a plastic bag when it was on the bedside stand and would have used it more if it he did not have to keep it in the plastic. The resident stated even if he was able to reach the urinal, he could not use it anymore because he couldn't undo his brief. The resident stated the facility had never asked him why he no longer used his urinal or made any attempt to put his urinal where he could reach it or attempted to reassess him for his ability to use the urinal. The resident stated he had many episodes of incontinence both of urine and bowel, he stated it was his preference to be toileted instead of eliminating in his brief. The resident stated the staff have told him he was not the only resident in the facility that needed help, and they could not drop everything just to help him get into his Sit to Stand to take him to the bathroom. Resident #1 stated he would prefer to use the toilet instead of the bedside commode, but the facility had a hard time getting the Sit to Stand lift into the bathroom, so it was easier for them to use the commode instead of the toilet. The resident stated he had waited from 20 minutes to one hour sometimes for someone to answer his call light. He stated when he was made to wait for extended periods, he would have an accident in his pants. He stated when that happened he felt bad. The resident stated he did not wish to be a problem, and always tried to say please and thank you. During an observation on 9/25/17 at 10:58 a.m., staff member H entered resident #1's room and assisted the resident from his bed onto the bedside commode. Resident #1 told staff member H he had an accident and was wet. Resident #1's T-shirt was wet up to his back and his sweat pants were wet to his thighs. The resident's bed was wet from the comforter down to the plastic mattress. When the staff member removed the resident's pants and wet soiled brief, the brief was full and swollen with a light odorous amber colored urine. The staff member assisted the resident onto a commode in the middle of the room. The resident apologized to the staff member about having to change his clothes. The staff member helped the resident dress in a clean shirt, pants and brief. The resident left his room, and the staff member changed his bed linens. During an interview on 9/25/17 at 11:15 a.m., staff member H stated she had assisted resident #1 onto his commode after breakfast around 9:00 a.m., and the resident had not been able to eliminate. She then assisted him back into his bed. She stated she had checked on him right before she went on break around 10:00 a.m., and he was dry and had not needed to be changed. She stated the resident was a frequent caller on his call light because he did not like to help himself, even if it was to get his Chapstick which was on his bedside table next to him. The staff member stated they used the commode for the resident because it was difficult to get the Sit to Stand lift in the bathroom for the resident to use the toilet, so the commode was used instead. She stated she had not asked the resident what his preference was since that was how they had always toileted the resident. Staff member H stated she was not sure why he no longer used his urinal. During an interview on 9/25/17 at 4:12 p.m., staff member C stated resident #1 was fully continent of his bowel and bladder when he arrived at the facility. She stated resident #1 used his call light frequently for staff to assist him with tasks, he should be able to perform himself, such as reaching his Chapstick on his night stand. She stated resident #1 was fully cognizant of when he needed to go to the bathroom, but would not always go when he was toileted by staff. Staff member C stated the resident would manipulate or lie about the staff not helping him. The staff member stated she was not aware the resident was no longer using his urinal or why. Staff member C stated she was also not aware of his preference to use the toilet instead of the commode, but knew the lifts didn't fit well into the conjoined bathrooms. During an interview on 9/26/17 at 9:20 a.m., staff member N stated the resident would initially refuse to get out of bed to use the toilet, but with continued encouragement he will go, and can be continent. Staff member N stated the resident no longer used his urinal, and was not sure why, but felt he could use it if encouraged. Staff member N stated he would take the resident into the toilet because it was his preference. During an interview on 9/26/17 at 12:02 p.m., staff member D stated the staff attempted to answer resident #1's call light as soon as possible. She stated the resident did use a urinal when he was first admitted to the facility, but had stopped using the urinal, she stated she was not sure why. She stated the resident was not re-assessed or re-educated on the urinal to see if there were any other modalities which would help him to continue using his urinal. Staff member D stated the resident used his call bell excessively for things he could reach by himself on his nightstand. Staff member D stated she was not aware the resident wanted to use his toilet instead of the bedside commode. She stated the resident was not specifically tried on a bowel or bladder retraining program to encourage bowel and bladder continence. During an interview on 9/26/17 at 12:17 p.m., staff member B stated it was the expectation of all skilled staff to check and change the residents before and after meals as well as every 2 hours when briefs were soiled. She stated she was not aware resident #1 was no longer using his urinal and was not aware the resident would prefer to be toileted on the toilet instead of on the bedside commode. Staff member B stated the staff probably used the bedside commode because it was difficult to get the Sit to Stand lift into the resident's bathroom.",2020-09-01
536,MARIAS CARE CENTER,275061,630 PARK DRIVE,SHELBY,MT,59474,2017-09-26,312,E,1,0,3LR111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain adequate personal hygiene from regularly scheduled bath/showers for 3 (#s 1, 2, and 6) of 6 sampled residents. This deficient practice had the potential to affect all residents who were dependent upon staff for assistance with bathing. Findings include: 1. Resident #1 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of resident #1's Initial MDS, with an ARD of 7/6/17, showed the resident had a BIMS of 14, and was cognitively intact. The Functional Assessment (Section G) showed the resident was totally dependent on staff with one person assistance for bathing, and had a functional limitation on one side of his body. During an observation on 9/25/17 at 10:58 a.m., resident #1 was lying in his bed in a wet brief. The resident had a damp urine spot on his sweat pants from his thigh up his back. His T-shirt was also saturated with urine up to the middle of his back. The resident's bed was soaked with urine from the comforter through to the mattress. Staff member H changed the resident's clothes and wiped his peri-area and his buttocks, but did not clean his legs or his back which were exposed to the urine. During an interview on 9/25/17 at 11:15 a.m., staff member H stated the resident usually was wet from urine several times a day. She stated she usually would change his bedding 2-3 times a day because it would get soaked with urine. During an observation on 9/25/17 at 11:19 a.m., resident #1's hair was unwashed and had multiple cow-licks and his face was not shaved. During an interview on 9/25/17 at 11:30 a.m., resident #1 stated he was scheduled to have a bath yesterday (Sunday 9/24/17). He explained the CNA approached him and asked if he wanted his bath today or wanted to wait until tomorrow. The resident stated he did not want to be a problem so he said he could wait until tomorrow (Monday 9/25/17). The resident stated no one approached him that day to offer him a shower to make up for the shower they did not provide him yesterday. The resident stated he would like to have a bath or shower on a regular basis. During an interview on 9/25/17 at 12:00 p.m., staff member C stated she checked the bath schedule and it showed resident #1 was on the schedule to get a baths on Sunday and Wednesday. She stated she could not tell if the resident was offered a bath on Sunday, and was not sure if he even received a bath on Sunday as scheduled. She stated she did not know how the CNA's communicated with each other about the need to reschedule baths with residents. The staff member stated she expected the CNA's to provide the baths and showers as scheduled. She did not follow up with the CNA or resident #1 about the need of a shower on 9/25/17 since he was not provided a shower on 9/24/17. During an interview on 9/26/17 at 11:00 a.m., resident #1 stated he did not get a shower yesterday and was not offered a shower today. He stated he would have liked to have a shower and hoped the facility would offer him a shower on Wednesday, since he was not offered a shower on Sunday, Monday, or Tuesday. Review of the facility's bath schedule, showed resident #1 was scheduled to receive a bath in the mornings, twice a week on Sundays and Wednesdays. Review of resident #1's shower logs from 7/1/17 through 9/25/17 showed the resident was not provided a shower on: - 7/7/17 to 8/2/17, showed 26 days without a shower; - 8/3/17 to 8/9/17, showed 7 days without a shower; - 8/23/17 to 9/6/17, showed the resident was out of the facility, but was still not provided a shower by the facility until 9/13/17, which was 22 days without a shower; - 9/21/17 to 9/26/17, resident was asked to reschedule his shower on 9/24/17 to 9/25/17 and was not provided a shower on 9/25/17 or 9/26/17. 2. Resident #2 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of resident #2's Significant Change MDS, with an ARD of 9/6/17, showed the resident had a BIMS of 0, severely cognitively impaired. The Functional Assessment showed the resident was totally dependent with a one person assist for bathing. During an interview on 9/25/17 at 5:00 p.m., resident #2's family member stated the resident did smell of urine at times and looked like he was not always shaved. During an interview on 9/25/17 at 6:40 p.m., resident #2's family member stated she had received a phone call from resident #2's doctor's office. They had explained they were seeing the resident for a follow up and wanted her to come to the clinic to see the condition of her father. She stated the physician was concerned about the care the resident was receiving from the facility. The resident's family member stated when she arrived at the physician's clinic, resident #2 smelled of urine and had food in his hair, on his face, his shirt was covered in food, and he had dried food in his lap. Resident #2's family member stated there was another time when she had stopped by the facility to surprise resident #2, and he had smelled of urine, and he had dried food on his face and clothes. She stated she had to have the staff change all his clothes before they could leave the facility. She stated she was not sure he was bathed on a regular basis. Review of the facility's bath schedule, showed resident #2 was scheduled to receive a bath in the mornings, twice a week, on Wednesdays and Saturdays. Review of resident #2's shower logs from 7/1/17 through 9/25/17 showed the resident was not provided a shower on: - 7/15/17 to 7/25/17, showed 10 days without a shower; - 8/17/17 to 8/23/17, showed 6 days without a shower; - 8/24/17 to 9/12/17, showed 20 days without a shower; - 9/6/17 to 9/13/17, showed 7 days without a shower. 3. Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of resident #6's Initial MDS, with an ARD of 8/1/17, showed the resident had a BIMS of 03, highly cognitively impaired. The Functional Assessment showed the resident was an extensive assist with one person for bathing. During an observation on 9/26/17 at 11:00 a.m., resident #6 was sitting in his room, his hair was not clean, and his face was not shaven. Review of the facility's bath schedule, showed resident #6 was scheduled to receive a bath in the mornings, twice a week on, Wednesdays and Saturdays. Review of resident #6's shower logs from 8/2/17 through 9/25/17 showed the resident was not provided a shower on: - 8/6/17 to 9/2/17, showed 28 days without a shower; - 9/3/17 to 9/26/17, showed 24 days without a shower. A review of the facility's Bath Worksheets, used by the CNA's at the facility, failed to show any further days for which residents #s 1, 2, and 6 were provided baths which may not have been documented into the electronic health record used by the facility. During an interview on 9/25/17 at 12:54 p.m., staff member F stated there were times when there were not enough staff to provide care to meet resident needs, including bathing. She stated there was improvement in providing these services since a bath aide was added to the schedule, but if there were not three staff to work on the halls, the bath aide was pulled off of baths to work the hall, leaving the staff on the floor responsible to provide the showers. Staff member F stated when there was no bath aide, the aides assigned to the halls were expected to give baths to residents in their assignments, but she could not always get the baths done. She said that on 9/24/17, she was asked to give baths, but was sent home before all the baths were given. During an interview on 9/26/17 at 8:15 a.m., staff member L stated as far as she knew, residents were provided baths on their regularly scheduled days. She stated it was important to make a note in the chart if they refused. During an interview on 9/26/17 at 12:15 p.m., staff member B stated showers and baths were provided to residents on their scheduled shower day by the assigned bath aide or if the bath aide was not available, by the responsible CNA on shift. She stated it was the expectation of staff to complete the scheduled showers for all residents, and if the resident refused, to go back later and ask the resident again. Staff member B stated it was the responsibility of the charge nurse on shift to ensure the residents received their scheduled baths/showers. Staff member B stated there was not currently a reliable communication method to notify the CNA's on each shift if a resident missed or received their regularly scheduled bath. She stated she felt the staff may not be very good at documenting the showers which were provided. During an interview on 9/26/17 at 1:00 p.m., staff member A stated it was the expectation of staff to provide the showers as scheduled. If a resident refused, repeat attempts should be made to encourage or schedule a follow up shower that same week. Staff member A stated it had been difficult to get the staff to document the showers provided. She stated an audit was done once a month to make sure showers/baths were provided. Staff member A stated she was not aware some residents had not been provided their regularly scheduled bath or shower. During an interview on 9/26/17 at 2:15 p.m., staff member K stated when a bath was given, the CNA was responsible to enter the level of resident performance and staff support provided into the electronic documentation system. She said the process was to be done for all baths, regardless of who gave the bath and what type of bath was given.",2020-09-01
537,MARIAS CARE CENTER,275061,630 PARK DRIVE,SHELBY,MT,59474,2017-09-26,314,D,1,0,3LR111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to identify and evaluate risk factors causing a pressure ulcer and to implement and evaluate interventions to treat a pressure ulcer for 1 (#4) of 6 sampled residents. Findings include: Review of resident #4's Braden Scale risk assessment, dated 6/2/17, showed the score for the resident's risk of skin breakdown was 15. The assessment form showed a score of 15 or less indicated high risk for skin breakdown. During an interview and record review of resident #4's assessments, on 9/26/17 at 11:35 a.m., no other Braden Scale risk assessment was found by staff member C. Staff member C stated she did not know how often a Braden Scale risk assessment was to be completed. Review of a facility policy titled, Skin Integrity, showed a nurse was to complete a Braden Scale assessment quarterly, when a new skin impairment was noted, and with a significant change in condition. Resident #4 had not had an assessment within the past three months or when he was noted to have a new pressure ulcer. Review of resident #4's Quarterly MDS, with an ARD of 6/8/17, showed the resident was at risk for development of a pressure ulcer based on a formal risk assessment tool and by clinical assessment. The MDS showed the resident did not have a pressure ulcer at the time. Review of resident #4's clinical note, dated 7/17/17, showed the presence of a new Stage II pressure ulcer. The note showed the nurse was alerted to the wound after CNAs observed the wound while toileting the resident. During an interview on 9/25/17 at 5:10 p.m., staff member C stated wounds were to be assessed and documented on weekly. Review of resident #4's Wound/Skin Evaluation Forms, dated 7/19/17 through 9/20/17 showed resident #4 had eight wound evaluations in the ten weeks since the wound was present. The review showed that the wound was assessed on 8/6/17 and the next assessment was 8/16/17, a span of ten days. The review showed that the wound was assessed on 8/21/17 and the next assessment was 9/8/17, a span of eighteen days. The review showed that the next assessment after 9/8/17, was 9/20/17, a span of twelve days. During observations on 9/25/17 from 1:44 p.m. - 2:12 p.m. and 9/26/17 from 7:40 a.m. - 8:06 a.m., resident #4 was seen sitting on the toilet on a riser seat. The u-shaped toilet seat was in the upright position so that as he sat, his upper buttocks and coccyx region were in contact with the underside of the raised seat. At each observation, resident #4 was listening to a book via a books-on-tape player. The player was in the bathroom, tucked in the handrail next to the toilet, and the volume was high. During these two continuous observations, he was noted to be sitting more than 25 minutes without any staff member entering the room to check on him. During an interview on 9/25/17 at 4:10 p.m., staff member J stated resident #4 likes to make his own choices. He likes to listen to his books-on-tape and he wants to listen while he is sitting on the toilet, and that he will sit there for long periods. During an observation and interview on 9/26/17 at 8:06 a.m., staff members K and L transferred resident #4 from the toilet to his wheelchair using a mechanical sit-to-stand lift. During the transfer, staff member K provided perineal care to resident #4 while he was standing in the lift, and his buttocks and coccyx were visible. There was a visible ring of redness around the buttocks, which included an area on the medial left buttock, that was covered by a rectangular white dressing. Staff members K and L stated resident #4 liked to sit on the toilet and listen to his books-on-tape. When asked if resident #4 could listen to his books-on -tape while in his wheelchair or in bed, staff member L stated resident #4 wanted the room quiet and dark when he laid down to sleep, and staff member K stated resident #4 only listened to his books-on-tape while sitting on the toilet. Staff member K stated the CNAs had to follow resident choice. During an interview on 9/26/17 at 9:42 a.m., resident #4 stated no one had really talked to him about the risks of sitting too long on the toilet. He said he would be willing to listen to his books-on-tape seated in the wheelchair or lying in bed as long as he could continue to listen when he was on the toilet as well. During an interview on 9/26/17 at 1:11 p.m., staff member H stated resident #4 could not reposition himself in bed but could help with his positioning by using the trapeze. She said he needed staff assistance to reposition. During an interview on 9/26/17 at 1:13 p.m., staff member K stated resident #4 could not reposition himself in bed. She said the resident told the staff how he wanted to lay (sic) and they put him that way. Staff member K stated resident #4 used the trapeze to help with repositioning and sitting up in his bed. She said he had to be transferred with a mechanical lift. Review of a facility policy titled, Skin Integrity, showed the following were to be completed when there was a known skin impairment: -a nurse was to evaluate the environment, mobility equipment, functional and cognitive ability, medications, and labs, to identify interventions to promote healing/resolution of skin impairment; -nurse was to notify the Food and Nutrition Services Manager, or Registered Dietician, of a new pressure sore or worsening wound condition, for a nutritional evaluation; -weekly wound rounds were to be conducted by a team detailed in the policy; -the evaluation of the wound was done during the rounds and was to be documented on the Wound Evaluation Form; -the DNS (DON)or designee was to complete a comprehensive review of the resident's record to determine if the ulcer was avoidable or unavoidable (definitions included in the policy), and the findings were to be documented in the nurse's (clinical) notes. -ulcers were to be reviewed at the Nutrition Hydration Skin Committee Meeting. During an observation on 9/26/17 at 7:50 a.m., resident #4's bed was noted to have standard pressure redistribution mattress and standard pressure redistribution wheelchair cushion. During an interview on 9/26/17 at 7:52 a.m., staff member C stated she had never evaluated resident #4's environment or mobility to identify interventions needed to promote healing. She stated the IDT (Nutrition Hydration Skin Committee) would determine if an evaluation was needed and would refer the resident to OT/PT if needed. During an interview and review of resident #4's clinical notes on 9/26/17 at 10:00 a.m., staff member B stated she had located one note from the weekly IDT (Nutrition Hydration Skin Committee Meeting). The note showed the resident had a stage II ulcer on his buttock, that his weight was stable, and he did not receive a supplement, and that the wound was progressing. No note was found or provided that showed a review of resident #4's record was completed or if the wound was avoidable or unavoidable. No documentation was found or provided to show the resident had been educated regarding the risks when sitting on the toilet for prolonged periods or that alternative opportunities for listening to his books-on tape were discussed. Review of resident #4's Nutrition Evaluation Form, dated 9/7/17, showed three times, in a section titled, Supplement/Intake CC's, the resident was not receiving a nutritional supplement. In the same section, under additional info, the form showed liquid protein supplement for wound healing. In other areas on the form, the dietician referred to the liquid protein supplement for wound healing, but it was unclear if the resident was receiving a supplement at the time, or if the addition of a liquid protein supplement was being recommended. Review of resident #4's physician's orders [REDACTED].#4. During an interview and record review on 9/26/17 at 11:55 a.m., staff member M stated resident #4 was not receiving a liquid protein supplement or any other nutritional supplement from the dietary staff. He stated the process was for the dietician to evaluate the resident's nutritional needs and provide a notice to the dietary staff if there was a new order and the change was added to the diet and supplement list. Review of the current diet and supplement list showed no liquid protein supplement for resident #4. He stated nursing could be providing a supplement. During an interview on 9/26/17 at 12:00 noon, staff member C stated resident #4 was not receiving a liquid protein supplement from the nursing department during the day shift (6:00 a.m.-6:00 p.m.). During an interview on 9/26/17 at 2:10 p.m., staff member B stated resident #4 was not receiving a liquid protein supplement. She stated it may have been decided not to provide the supplement due to his recent high blood glucose findings. She stated she was aware of protein supplements designed for diabetic residents. During an interview and record review on 9/26/17 at 3:00 p.m., staff member D stated she had found the dietician's written recommendation in a stack of papers on her desk. Review of a document titled, Nutritional Recommendations By Registered Dietician, dated 9/7/17, showed the name of resident #4 and the recommendation, liquid protein supplement for wound? Review of resident #4's care plan showed a problem of Potential for alteration in skin integrity and past history of breakdown. The goals for this problem included: - Resident will have intact skin unless clinically unavoidable; -skin injury upper left buttock will heal without complications; - Current skin breakdown on his buttocks will heal without complications. Identified 7/17/17. Interventions for the problem included informing the resident of the consequences if he does not allow position changes, reminding him that sitting on the toilet for prolonged periods was not good for his skin, limiting his time on the toilet to 45 minutes at a time and then lying him down and playing his book-on-tape.",2020-09-01
538,MARIAS CARE CENTER,275061,630 PARK DRIVE,SHELBY,MT,59474,2017-09-26,353,E,1,0,3LR111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to provide timely and adequate services for the provision of answering call lights, for 5 (#s 1, 2, 3, 5, and 6) of 6 sampled residents. This deficient practice had the potential to affect all residents who were dependent on staff to provide assistance with transfers, and toileting. Findings include: 1. Resident #1 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of resident #1's Initial MDS, with an ARD of 7/6/17, showed the resident had a BIMS of 14, and was cognitively intact. The Functional Assessment (Section G) showed the resident was totally dependent on staff for one person assistance with bathing, toileting and bed mobility, and was a limited one person assist for bed mobility. The resident had functional limitation on one side of his body. During an interview on 9/21/17 at 1:49 p.m., resident #1's family member stated when she visited the resident in (MONTH) of (YEAR), she had asked which room the resident was in, and the staff pointed to a room with a light on over the door, and was told that was resident #1's room. She stated during her visit to see resident #1, his call light was on before she entered his room and was not answered for over an hour. She stated the resident and explained to her, he needed to use the bathroom, and could not reach his urinal. She stated the resident had his call bell on for over an hour before anyone came to the room to check on him. He had waited so long for someone to help him get to the bathroom he was incontinent of his bladder. She stated she could tell resident #1 was embarrassed. During an interview on 9/25/17 at 10:30 a.m., resident #1 stated he had an accident and urinated in his brief around 9:30 a.m. He stated he put on his call bell to let the CNA know, and she asked him if he could wait to be changed until she came back to get him up for lunch. The resident stated he had agreed because he did not want to be a problem. The resident stated the staff have told him he was not the only resident in the facility that needed help, and they have over 30 residents and can't drop everything just to help him. The resident stated he has waited from 20 minutes to over an hour at times for someone to answer his call light. He stated when had to wait for extended periods, he would usually have an accident in his pants. He stated when that happened he felt bad. The resident stated he did not wish to be a problem, and always tried to say please and thank you. During an observation on 9/25/17 at 10:58 a.m., staff member H entered resident #1's room, and turned his call light off which was on since 10:30 a.m., and assisted the resident from his bed onto the bedside commode. Resident #1 told staff member H he had an accident and was wet. Resident #1's T-shirt was wet up to his back and his sweat pants were wet to his thighs. The resident's bed was wet from the comforter to the plastic mattress. When the staff member removed the resident's pants and wet soiled brief, the brief was swollen and full of light amber colored urine. The resident apologized to the staff member about having to change his clothes. The staff member helped the resident dress in a clean shirt, pants and brief. The resident left his room, and the staff member stripped his bed linens. During an interview on 9/25/17 at 11:15 a.m., staff member H stated she had assisted resident #1 onto his commode after breakfast around 9:00 a.m., and the resident had not been able to eliminate. She stated she then assisted him back into his bed. She stated she had checked on him right before she went on break around 10:00 a.m., and he was dry and had not needed to be changed. She stated the resident was a frequent caller on his call light because he did not like to help himself, even it was just to get his Chapstick, which was on the bedside table next to him. 2. During an observation on 9/26/17 at 7:51 a.m., resident #1 had finished his breakfast and asked staff member C if he could be helped to the bathroom. Staff member C stated she would ask the CNA to help him. The resident asked if he should just wait in his room, and staff member C stated he should, and she would ask the CNA to help him when she was available. The resident went and waited in the doorway of his room, waiting for the CNA to assist him with toileting. During an observation on 9/26/17 at 8:00 a.m., resident #1 approached staff member C and asked if he should just wait here (by the nurse's station) instead for the CN[NAME] Staff member C stated the CNA was coming to help him, but she was helping the shower aide with another resident in the shower. Staff member C stated to resident #1, I know you are impatient but she (CNA) is moving as fast as she can. During an observation on 9/26/17 at 8:06 a.m., Staff member H walked by staff member C, and was told by staff member C, resident #1 needed to use the bathroom. Staff member H walked down to the resident's room and did not see him in his room, so she walked up to staff member C and asked where the resident was. Staff member C stated she did not know. Staff member H went into another room to assist a different resident. During an observation on 9/26/17 at 8:20 a.m., resident #1 wheeled by staff member C and asked if the CNA had come out of the shower room yet. Staff member H stated the CNA could not find him and now she didn't know where the CNA was. Staff member C did not offer to take the resident to his room or help him to the toilet. During an observation on 9/26/17 at 8:25 a.m., Staff member H assisted resident #1 to his room. The resident had to wait 25 minutes to be assisted by staff to the bathroom. During an interview on 9/26/17 at 8:27 a.m., resident #1 stated, My guts were all tore up this morning. He stated he felt like he had to go to the bathroom but was not able to go and asked to be laid down instead. The resident stated he felt he was being a problem for the staff and didn't want to keep bothering them to take him to the bathroom, even though his stomach was upset. During an interview on 9/25/17 at 4:12 p.m., staff member C stated resident #1 used his call light frequently for staff to assist him with tasks he should be able to perform himself, such as reaching his Chapstick on his night stand. She stated resident #1 was fully cognizant of when he needed to go to the bathroom, but would not always go when he was toileted by staff. Staff member C stated the resident liked to manipulate the staff to do things for him and would lie if they did not help him. 3. Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of resident #6's Initial MDS, with an ARD of 8/1/17, showed the resident had a BIMS of 03, highly cognitively impaired. The Functional Assessment showed the resident was an extensive assist with one person for bathing, transfers, and toileting. During an observation on 9/25/17 at 1:00 p.m., in the West Wing of the facility, call lights were on above the following rooms: resident #5's room, resident #6's room, room [ROOM NUMBER], and resident #3's room. Staff member G was picking up the empty meal trays after lunch on the West Wing. Staff member G entered resident #5's room and asked the resident what he needed. Resident #5 stated he wanted to lay down in bed. Staff member G told the resident she would get someone to help him to bed. She turned off his call light and left the room. The staff member did not get assistance for resident #5, instead she entered resident #6's room. During an observation on 9/25/17 at 1:04 p.m., staff member G entered resident #6's room and asked the resident what he needed. The resident stated he would like to lay down in his bed. Staff member G turned off his call light and stated she would need to get help, since this was not her hall she would need to let staff member J know to help him get into bed. Staff member G did not seek assistance for resident #6, instead she exited his room and entered resident #3's room. During an observation on 9/25/17 at 1:05 p.m., staff member G entered resident #3's room and asked the resident what she needed. The resident's husband said she wanted to lay down. Staff member G stated she would get someone to help them, and turned off the residents call light. Staff member G did not get help for the resident and entered a resident's room whose call bell was not on. She came out with an empty meal tray and put the meal tray on the cart. During an observation on 9/25/17 at 1:07 p.m., staff member G answered a resident's call light, asking the resident what she needed. The resident explained she needed her oxygen changed before she went to Bingo. The staff member stated she would get someone to help the resident. She went to the doorway and stared down the hall. When staff member G did not see another staff member to help her, she turned off the resident's call light and exited the resident's room. The staff member entered another resident's room which did not have a call light on and removed the meal tray and placed it on the cart. Staff member G did not seek further assistance for any of the residents for which she had turned off the call lights. During an observation on 9/25/17 at 1:24 p.m., staff member C went into resident #6's room and told him she could not help him get into bed because she was not to lift. She stated she would get someone to help him. She moved the resident in his wheelchair by the sink away from his bed and reminded him not to get up without assistance. The resident stated he understood. The staff member stated she would let his CNA know he wanted to get into bed, and left to get him a cup of coffee. During an observation on 9/25/17 at 1:25 p.m., staff member I had picked up the resident who needed a new oxygen tank and was bringing her down for Bingo. Staff member I, passed staff member G, and asked if she could get an oxygen tank for the resident. Staff member G said she would in a minute. During an observation on 9/25/17 at 1:26 p.m., While staff member G was off the West Hall getting an oxygen tank for the resident, resident #3 turned her call light back on. A second CNA, staff member J, walked by resident #'s 5 and 6's rooms to answer resident #3's call light, whose husband had turned the light on for a second time. Staff member G had not asked staff member J to assist resident #s 5 or 6. During an observation at 9/25/17 at 1:37 p.m., staff member F entered resident #6's room to assist him to his bed. The staff member transferred the resident from his wheelchair to his bed with the use of a gait belt and stand and pivot. Resident #6's wheelchair cushion was wet. His pants were wet to his thighs and his shirt was wet half way up his back with urine. The front of the resident's pants were bulging and wet. The staff member changed the resident's clothes and put on a clean brief, then cleaned his wheelchair, and transferred the resident back into his wheelchair. The staff member stripped the now soiled bedding from the resident's bed and left the room. The staff member did not return to make the bed. The resident, who wanted to be laid down, was still sitting in his wheelchair. During an interview on 9/25/17 at 1:43 p.m., resident #6 stated he still wanted to lay down but he felt better now that he was changed from his wet clothes. He stated he was used to being wet, but would prefer not to sit for long periods in his soiled pants, but he stated it was the norm around here. He stated he luckily had not had any skin issues, and was used to having to wait to be toileted. The resident stated he would prefer to use the toilet but didn't think that would be possible. He explained he felt he had waited so long for someone to help him he almost felt like he could go pee again. During an interview on 9/25/17 at 1:50 p.m., staff member G stated she would usually turned the call lights off because it was how she remembered to get the residents help. She stated she could not help resident #6 because he was a two person assist and she would need help to transfer him. She stated she did not get help for resident #6 because she was busy helping other residents. Staff member G stated she was both activities and a CNA and could help the staff on the floor with transfers, toileting, and meals. She stated she was currently just doing activities. Staff member G stated she still had her CNA license and would help on the floor when needed. When asked if she got help for the other residents whose call lights she had turned off, she said she had gotten busy, but would follow up on it. During an observation on 9/25/17 at 1:56 p.m., resident #6 was assisted into his bed by staff member F. Resident #6 was assisted to bed after waiting 56 minutes for assistance. He was incontinent of his urine during the time he rang his call bell to the time he was assisted to bed. 4. During an observation on 9/26/17 at 8:27 a.m., resident #6 was wheeling himself down the West Hall towards his bedroom. The resident stopped staff member K in the hall and asked if she could help him to his bed. The staff member told the resident he would need to wait because she was still trying to get the other residents up for breakfast. The staff member did not find additional assistance for the resident. The resident went to his bedroom. In the resident's room, his bed was stripped to the mattress. During an observation on 9/26/17 at 8:53 a.m., resident #6 was sitting in his room in his wheelchair, his bed did not have any sheets and there was a slight smell of urine in the room. On the resident's bedside table was a un-dated urinal which was one-quarter full of light yellow/amber urine. During an observation on 9/26/17 at 9:27 a.m., resident #6 was sitting in his wheelchair in his room watching television. He stated no one had come to put him to bed yet, and he really wanted to lay down. The resident's bed was still stripped to the mattress. During an interview on 9/26/17 at 9:46 a.m., staff member K stated she had to stay in the dining room with the residents if there were no other staff in the dining room. She stated she had not been able to get back to resident #6 to make his bed and help him lay down. She stated he had a dry brief on this morning when she helped him get out of bed, but his sheets were soaked through and she had to strip his bed down. She stated she had not been able to get back to make his bed. She stated she was not sure when his urinal was last changed. Staff member K stated she felt the facility had enough staff to manage the number of residents and their acuity status. 5. Resident #2 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of resident #2's Significant Change MDS, with an ARD of 9/6/17, showed the resident had a BIMS of 0, severely cognitively impaired. The Functional Assessment showed the resident was totally dependent with a one person assist for bathing, transfers, toileting and bed mobility. During an interview on 9/25/17 at 6:38 p.m., resident #2's family member stated she was concerned the facility did not have enough staff to take care of all the residents. She stated she had visited resident #2 one evening after work and walked in to his room to find him laying naked in bed, in a BM soiled brief and was uncovered, with the door open. The family member stated she reported this immediately to the facility who investigated the incident. She stated the facility explained the resident had been having problems with loose stool all day, and the CNA which was helping to change his brief, was called away by another CNA, and failed to return to finish changing resident #2's brief. The family member stated she was told the CNA was counseled, and was told it was a onetime, unfortunate event. The family member stated she was still not sure she felt the facility had enough staff to help all the residents based on their acuity level. She stated she had spoken to the facility's administrator about her concerns and she was told they were adequately staffed based on the census and acuity. During an interview on 9/26/17 at 12:02 p.m., staff member D stated it was the expectation of the all staff to answer call lights, and if they can not help the resident, they are expected to leave the call light on and get help for the resident. The call light should not be turned off until the need of the resident was met. She stated all clinical staff, including nurses, can assist the residents with toileting, transfers and meals. Staff member D stated she felt there were enough CNA's on duty to provide the needed services for residents based on their acuity. She stated the facility had been short a nurse for a couple months, since July, and she had been covering shifts and helping on the floor. During an interview on 9/26/17 at 12:15 p.m., staff member B stated it was the expectation of all staff to answer call lights and assist the resident if they can. If they are unable to help the resident it was the expectation they would find help. She stated it was the expectation the call light be left on by the staff member until the need of the resident was met. She stated any staff which were both activities and CNA's could help the resident at any time. She stated they had repeated staff training's which addressed the culture of this is not my hall or my resident. Staff member B explained all staff can answer the call light. The staff member stated she felt the facility was adequately staffed based on census and resident acuity. She stated they had been trying to hire another nurse since July. Staff member B stated the staff turnover rate was high during the summer, but had since stabilized. She stated any resident who was unable to verbally express their need, should be checked by the CNA's every 2 hours; and for the resident's which can ask for assistance, but are unable to assist themselves, should be toileted or their needs met when they ask for assistance. During an interview on 9/26/17 at 1:00 p.m., staff member A stated it was the expectation of staff to answer call lights and make sure the needs of the resident had been met before turning off the call light. She stated she felt the facility was adequately staffed based on the census and resident acuity. She stated the facility was currently trying to hire another nurse. The staff member stated the facility showed it was over staffed for CNA's.",2020-09-01
539,MARIAS CARE CENTER,275061,630 PARK DRIVE,SHELBY,MT,59474,2017-09-26,406,D,1,0,3LR111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to provide PT/OT services for 1 (#1) of 6 sampled residents. This deficient practice had the potential to affect all residents who recieved PT/OT services. Findings include: 1. Resident #1 was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Review of resident #1's Initial MDS, with an ARD of 4/21/17, showed the resident had a BIMS of 14, cognitively intact. Review of resident #1's Physician Orders, dated 8/15/17, showed, PT and OT evaluation and treatment as indicated for non-traumatic [MEDICATION NAME] hemorrhage, sequelae of cerebral infarction, pain in left shoulder, and pain in joint. Review of resident #1's Clinical Notes, dated 8/15/17, showed Provider in to see resident for routine visit. New orders for PT and OT to eval and treat. Resident aware he must participate in both PT an OT to receive the benefits as well as not being discharged from the therapies. Mother, (resident mother), notified of resident being ordered PT and OT. Review of resident #1's clinical record failed to show any progress notes from PT and OT after the physician ordered services on 8/15/17. During an interview on 9/25/17 at 10:30 a.m., resident #1 stated he would like to have more PT and OT so he could eventually go home. He stated he did not always get restorative services, but a couple days a week. He felt he was starting to be able to move his left leg more, but the range of motion in his left hand is non-existent. He stated he was not sure he would be able to have PT/OT because it was ordered and he never got the services. Resident #1 stated no one had explained to him why he would not be receiving additional therapy services. During an interview on 9/26/17 at 8:50 a.m., NF2 and NF3 stated they had received an order from the provider on 8/15/17 for resident #1 to receive PT/OT evaluations and treatment services. NF2 and NF3 stated they did not feel the resident needed these services since they had already provided PT/OT services for him in (MONTH) (YEAR) and discharged him with orders for restorative services by the facility. They stated after speaking with the facility's restorative aide on 8/15/17, they established the resident did not need PT/OT services since he did not have a change in his functional status. They stated they did not meet with the resident to complete an evaluation to determine a need for the services on 8/15/17. They did not make a progress note on the visit with the restorative aide. They stated they had attempted to contact the provider to let him know they would not provide PT/OT services for resident #1, but the physician was on vacation. She stated she did not follow up with the physician when he got back to town. NF2 and NF3 stated they did not notify the resident, the resident's POA, or the facility of their determination to cancel the PT/OT orders for resident #1. During an interview on 9/26/17 at 9:00 a.m., staff member N stated PT/OT had approached him regarding the need for therapy services for resident #1 on 8/15/17. He stated the resident was progressing with restorative, but he takes one step forward and two steps back. During an interview on 9/26/17 at 12:17 p.m., staff member B stated it was the expectation that physician orders [REDACTED]. She stated the PT/OT services were contracted services by the facility. She stated the orders are walked down to the PT/OT department by the nurse, and then PT/OT arranged services. She stated the therapy department would send progress notes or discharge summaries with updated resident services. She stated they would usually know when physical therapy discharged a resident because they are discharged with restorative services. Staff member B stated they did not have a process in place to follow up on ordered therapy services to ensure they were provided as ordered. She explained the PT/OT department was not part of their IDT team, or QA process. During an interview on 9/26/17 at 1:00 p.m., staff member A stated the staff currntly walk new orders over to the PT/OT department, but they did not have a method in place to follow up to ensure these services are provided as ordered by the physician.",2020-09-01
540,CENTRAL MONTANA NURSING & REHABILITATION CENTER,275064,410 WENDELL AVE,LEWISTOWN,MT,59457,2016-06-08,368,E,0,1,N0YW11,"Based on observation and interview, the facility failed to verbally offer a nourishing snack at bedtime to all residents residing in the facility. Findings include: During an interview on 6/7/16 at 3:00 p.m., the resident council members stated the facility does not verbally offer a bedtime snack to all residents. The council members stated specific residents liked a particular snack in the evenings, and they received the preferred snack on most nights. The council members stated not all residents were offered a snack, but residents could request a snack, and staff would get it for them. Some of the residents at the resident council group meeting stated they did not know snacks were available at bedtime. During observations on 6/7/16 between 7:50 p.m. - 8:45 p.m., staff did not have the snack cart out and did not offer a bedtime snack to all the residents. During an interview on 6/7/16 at 7:55 p.m., resident #11 stated she was not aware they could eat before bedtime, and that she had not been offered a snack that evening. During an interview on 6/7/16 at 8:00 p.m., staff member C stated the staff did not offer each resident a bedtime snack. He stated if the resident was diabetic, the CNA's must ask a nurse to ok the snack. He stated he was not aware of any specific snacks available for the diabetic residents. During an interview on 6/7/16 at 8:05 p.m., staff member D stated the staff were supposed to ask every resident if they would like a snack before going to bed. She stated the snack cart was in the clean linen closet, but she had not pulled the snack cart out that evening. During an interview on 6/7/16 at 8:15 p.m., staff member [NAME] stated the CNAs usually do the snack pass. She stated she was aware of some of the snacks specific residents liked, so she tried to place those snacks on her med cart to pass with the bedtime medications. During an interview on 6/6/16 at 3:00 p.m., resident #12 stated she had lost weight since entering the facility because she did not like the food being served. She stated she had been eating bread and sweet milk (Ensure), because I have to take care of my diabetes. The resident stated there were no evening snacks offered. She stated, The lady (that provides them) goes home at 6:00 p.m. and there is nothing.",2020-09-01
541,CENTRAL MONTANA NURSING & REHABILITATION CENTER,275064,410 WENDELL AVE,LEWISTOWN,MT,59457,2016-06-08,387,D,0,1,N0YW11,"Based on record review and interview, the facility failed to ensure a physician face-to-face contact with a resident occurred once every 60 days for 1 (#4) of 10 sampled residents. Findings include: Review of resident #4's medical record reflected no physician visits occurred from 7/16/15 through 2/15/16. During an interview on 6/7/16 at 2:30 p.m., staff member B stated resident #4's physician moved his practice. Staff member B stated resident #4 has a new physician currently. Staff member B stated there were no physician visits from 7/16/15 through 2/15/16 for the resident.",2020-09-01
542,CENTRAL MONTANA NURSING & REHABILITATION CENTER,275064,410 WENDELL AVE,LEWISTOWN,MT,59457,2019-09-05,602,E,1,0,45BK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure residents were free from misappropriation of property, and exploitation for 5 (#s 4, 6, 7, 8, and 9) of 9 sampled residents. Findings include: During an interview on [DATE] at 11:05 a.m., staff member C stated APS notified the Executive Director (ED), on [DATE], of a possible exploitation situation between NF4 and resident #8. Staff member C stated resident #8 was in charge of his own affairs until his death on [DATE]. NF4 was an employee and a family friend of resident #8. APS had been notified by resident #8's bank that NF4 had been writing checks on resident #8's account, after his death. Staff member C stated the facility placed NF4 on suspension, and initiated an investigation to determine if any other residents had been affected. Staff member C stated she was responsible for managing the balances and keeping copies of the receipts. Staff member C stated she started working at the facility in (MONTH) of (YEAR), and was not sure how the process was handled prior to her arrival. During an interview on [DATE] at 12:50 p.m., staff member A stated she was notified by APS on [DATE] of possible misappropriation of resident #8's funds by NF4. Staff member A stated the Medicaid Fraud Unit was also involved in the investigation. During an interview on [DATE] at 9:07 a.m., staff member C stated four residents used a trust account for personal spending. She said the Social Services Designee (SSD) usually did the shopping for the residents. Staff member C stated the SSD was given cash, and brought back the receipts and the purchases. Any staff member available was asked to co-sign the receipt to confirm the purchases had been made. Staff member C stated she kept the receipts and maintained the bookkeeping records. Staff member C said the shopping began in (MONTH) of (YEAR), around Christmastime. Staff member C stated she wondered about the items because of the number of shoes and junior clothes purchased. However, because NF4 had been at the facility longer, staff member C stated she felt uncomfortable questioning NF4. Staff member C stated the internal investigation revealed four residents (#s 4, 6, 7, and 9) were potentially affected by NF4's actions. All receipts from (MONTH) (YEAR) to the present were compared to the possessions of the corresponding resident. If the items on the receipt were not found, the resident was reimbursed the amount of the purchase. Staff member C stated that all oriented residents were interviewed. If the resident was not oriented, the resident's representative was interviewed. No other incidents of misappropriation were identified during these interviews. Staff member C felt the misappropriation occurred because NF4 was personable and well-liked by her co-workers. The facility had been aware of the relationship between NF4 and resident #8. However, resident #8 was competent, and never expressed any problems with how NF4 was handling his property. During an interview on [DATE] at 9:52 a.m., staff member A stated NF4 had been the SSD since [DATE], and had been a CNA prior to that. Staff member A stated the facility was aware of the potential conflict of interest, and had counseled NF4 regarding the need to treat resident #8 just like any other resident. Staff member A stated the facility became aware that NF4 was on resident #8's bank account. Staff member A stated NF4 was notified that is was a conflict of interest and her name needed to be removed from resident #8's bank account immediately. Staff member A stated she did not follow-up with NF4 to confirm if this had been done. In (MONTH) of 2019, staff member A questioned NF4 about several packages which resident #8 had received during the Christmas season. NF4 told staff member A these were gifts, and admitted she had accepted a gift from resident #8. Staff member A stated NF4 was suspended on [DATE], pending an investigation, and was subsequently terminated on [DATE]. Review of the facility policy, Abuse, Corporal Punishment, Involuntary Seclusion, Mistreatment, Neglect, Misappropriation of Resident Property, and Exploitation, dated (MONTH) (YEAR), showed, Examples of misappropriation of resident property are theft of money from a bank account, unauthorized or coerced purchases from resident's funds, and a resident who provides a gift to staff in order to receive ongoing care, based on staff's persuasion. The policy also defines exploitation as, Taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion.",2020-09-01
543,CENTRAL MONTANA NURSING & REHABILITATION CENTER,275064,410 WENDELL AVE,LEWISTOWN,MT,59457,2019-09-05,609,D,1,0,45BK11,"> Based on observation, interview, and record review, the facility failed to report an allegation of abuse between two residents (#s 3 and 9), which involved involuntary seclusion, for 1 (#9) of 9 sampled residents. Findings include: During an observation on 9/3/19 at 4:40 p.m., resident #9 was talking loudly in the dining room. She was directing her voice towards resident #3. Resident #3 responded by making faces and smiling at resident #9. Resident #3 and resident #9 were seated at separate tables. None of the staff in the dining room spoke to resident #9 about the volume of her voice. Resident #9 continued to speak loudly until she received something to drink. She did not direct her speech to resident #3 after receiving something to drink. During an interview on 9/4/19 at 11:16 a.m., staff member [NAME] denied ever hearing any staff member order a resident to their room. Staff member [NAME] stated she did not remember anything memorable about an interaction on 6/20/19, between resident #3, resident #9, and staff member B. During a telephone interview on 9/4/19 at 12:30 p.m., staff member G stated she was working on the day staff member B intervened between resident #3 and resident #9. Staff member G stated she observed staff member B getting up from the desk quickly, and moving towards the lobby area where several residents were watching television. Staff member G stated she got up to follow, in case she was needed. Staff member G stated staff member B used a stern voice when speaking with resident #3 and resident #9. Staff member G observed staff member B escort resident #9 to her room. She remembers staff member B talking to resident #9 about not being allowed to touch other residents, and saying, It is almost time for lunch. Staff member G stated the door to resident #9's room was left open. Staff member G stated she saw staff member F during the incident, and thinking staff member F looked, surprised. Staff member G stated she spoke with resident #3 shortly after the incident and the resident was confused about what had happened, but not tearful or upset. Staff member G stated she did not document anything because no contact between resident #3 and resident #9 was made, and no injuries had occurred. She also stated she did not consider the incident to be any type of abuse, and therefore did not consider reporting the incident. During a telephone interview on 9/4/19 at 3:49 p.m., staff member F stated she observed staff member B, yelling at (resident name) and (resident name) about their behavior. Staff member F stated she heard staff member B say, You can just stay in your room until supper. Staff member F stated she thought this happened about 4:00 p.m., but did not remember the date, or who else might have been present. Staff member F stated she reported the incident to staff member A on a weekend, after the incident because staff member A was gone on the day of the incident. Staff member F stated she felt staff member B was treating the residents, like children. Staff member F stated she also talked to staff member C about the incident, but was unable to say exactly when. During an interview on 9/4/19 at 4:30 p.m., staff member A stated staff member F reported the incident to her on 7/13/19 or 7/14/19. Staff member A stated staff member F reported a number of issues she was having with staff member B, and the incident with resident #3 and resident #9 was more of a, Oh, by the way, this happened while you were gone . Staff member A stated staff member F said she felt staff member B was a bit too direct. Staff member A stated staff member F never said the residents had been yelled at. Staff member A stated she did not immediately report the alleged abuse because she, was not sure the report was totally accurate, and staff member F frequently had complaints about staff member B. Staff member A stated she did counsel staff member B regarding the issues brought to her by staff member F, including the incident with resident #3 and resident #9. Staff member A did not document the conversation with staff member F. Staff member A also stated she did not document her conversation with staff member B. Staff member A stated she was aware all alleged abuse must be reported, and she felt the facility complied with this requirement. Staff member A reviewed staff schedules to determine when the incident may have occurred. She stated, based on her review, the incident most likely occurred on 6/20/19. Staff member A reviewed the notes from the daily stand up meetings with managers, and did not find any notation about the incident between resident #3 and resident #9. During an interview on 9/5/19 at 9:07 a.m., staff member C stated she remembers hearing about the incident, through the grapevine. She denies staff member F talked to her directly about the incident. Staff member C denies hearing any yelling, or commotion on 6/20/19, the date the incident was supposed to have occurred. Review of resident #9's Nursing Progress Notes, dated from 6/1/19 to the present, failed to show any documentation of the incident which occurred on 6/20/19. Review of resident #9's Social Service Notes, dated from 6/1/19 to the present, failed to show any documentation of the incident which occurred on 6/20/19. Review of resident #3's Nursing Progress Notes, dated from 6/1/19 to the present, failed to show any documentation of the incident which occurred on 6/20/19. Review of resident #3's Social Service Notes, dated from 6/1/19 to the present, failed to show any documentation of the incident which occurred on 6/20/19. Review of the facility policy, Abuse, Corporal Punishment, Involuntary Seclusion, Mistreatment, Neglect, Misappropriation of Resident Property, and Exploitation, dated (MONTH) (YEAR), showed, The (facility name) immediately reports all suspected and/or allegations of abuse, neglect .in accordance with state and federal law. Review of the facility policy, Abuse Prohibition Notification,' dated (MONTH) (YEAR), showed, 4. Alleged violations involving mistreatment, neglect, or abuse .are reported immediately to the Executive Director (ED) and to other officials in accordance with Federal and State law. At the time of an alleged violation, an investigation is initiated . A request was made for all documentation associated with the report of the alleged abuse. No documentation was provided prior to the end of the survey.",2020-09-01
544,CENTRAL MONTANA NURSING & REHABILITATION CENTER,275064,410 WENDELL AVE,LEWISTOWN,MT,59457,2019-09-05,610,D,1,0,45BK11,"> Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse between two residents (#s 3 and 9), which included involuntary seclusion for 1 (#9) of 9 sampled residents. Findings include: During an interview on 9/4/19 at 12:12 p.m., staff member A stated she received a verbal report of an allegation of abuse, in the form of involuntary seclusion, from staff member F. Staff member A believed this report was received on 7/13/19 or 7/14/19. Staff member A stated she did not immediately report the alleged abuse because she was unsure if the report was accurate. She stated because her staff was aware of the definition of involuntary seclusion, she found it hard to believe this would have occurred. Staff member A also said staff member F had complained about staff member B on several occasions. Staff member A counseled staff member B regarding the alleged abuse, but did not document this conversation. Staff member A stated she also did not document her conversation with staff member F. Staff member A did not document anything related to an investigation into the alleged abuse. Staff member A stated she was aware of the reporting and investigation requirements associated with abuse, and she felt the facility always investigated and reported allegations of abuse, except in this case. Review of facility policy, Abuse, Corporal Punishment, Involuntary Seclusion, Mistreatment, Neglect, Misappropriation of Resident Property, and Exploitation, dated (MONTH) (YEAR), showed, The (facility name) conducts a thorough investigation of potential, suspected and/or allegations of abuse, neglect .in accordance with state and federal regulations. Review of facility policy, Abuse Prohibition Notification, dated (MONTH) (YEAR), showed, 4.At the time of an alleged violation, an investigation is initiated. The alleged victim is protected to prevent harm during the investigation. The results of the investigation are reported to the ED or his/her designated representative .not to exceed five working days of the incident. A request was made for any documentation of the investigation associated with the alleged abuse. No documentation was provided prior to the end of the survey.",2020-09-01
545,CENTRAL MONTANA NURSING & REHABILITATION CENTER,275064,410 WENDELL AVE,LEWISTOWN,MT,59457,2019-09-05,812,E,1,0,45BK11,"> Based on observation, interview, and record review, the facility failed to ensure proper food storage and labeling, in accordance with professional standards for food service safety. The deficient practice had the potential to affect all residents receiving services. Findings include: During an observation on 9/3/19 at 3:25 p.m., the following items were found in the kitchen walk-in coolers: -small metal bin containing cut cucumbers, not dated -tray of donuts, partially covered with unsecured, white freezer paper, fan blowing so one third of donuts was not covered -single serve cups containing canned fruit, not covered, not dated -metal bin of shredded cheese, covered with plastic wrap, not dated -single serve bowls of lettuce salad, plastic bowl lids placed loosely on top, not secured, not dated -tray with single serve cups of salad dressing, half of the cups had lids, half did not, the entire tray was covered with plastic wrap, date on plastic wrap was 8/21 During an observation on 9/5/19 at 8:06 a.m., a metal bin containing unknown frozen food was loosely covered with plastic wrap, then aluminum foil, and a plastic lid placed on top of the plastic wrap and aluminum foil. There was no date or identification of the food found in the container. There were brown crumbs on top of the plastic lid. During an observation on 9/5/19 at 8:11 a.m., the following items were found in the kitchen walk-in coolers: - a metal bin which contained five individual cups of salsa with individual lids, not dated - a container marked potato salad with a date of 8/30 - an open bag of cooked chicken pieces, closed with a twist tie, not dated - a container of pasta salad with peas, not dated - a large bowl of lettuce salad, not dated - a metal bin of hard-boiled eggs, not dated - a large box of leaf lettuce, uncovered on the bottom shelf - a tray of individual cups of salad dressing, not dated - a tray of sliced banana bread, not dated - a metal tray with individually bagged slices of bread, not dated - a partial banana in a covered bowl, not dated - a tray of cheese slices, covered with plastic wrap and marked, for 8-27 - a bin of chopped onions, covered with plastic wrap and marked, for 8-28 - a metal bin of sliced pickles, not dated - a tray of pieces of cake, not dated During an interview on 9/3/19 at 3:55 p.m., staff member J stated the food should be removed from the coolers after five days. Staff member J was not able to explain why the salad dressing had not been removed from the cooler after five days. Staff member J stated the rolling cart, in the cooler, which contained the undated shredded cheese and uncovered, undated, fruit and undated lettuce salad, was for use in the nursing home at dinner. She stated the entire cart should be covered with the plastic sheet and the diet aide must have just forgotten to pull the plastic cover down. Staff member J pulled the plastic cover over the cart containing the undated, uncovered items. The Dietary Manager was not available for interview. Review of facility policy titled, General Food Preparation and Handling, dated 12/07, showed, 15. Leftovers must be dated, labeled, covered, cooled and stored .in the refrigerator .Use leftovers within 3 days or discard.",2020-09-01
546,CENTRAL MONTANA NURSING & REHABILITATION CENTER,275064,410 WENDELL AVE,LEWISTOWN,MT,59457,2017-09-07,166,D,0,1,GK0911,"Based on record review and interview, the facility failed to adequately document a grievance decision and notify the resident of the facility's decision, in writing, for 2 (#s 17 and 18) of 18 sampled and supplemental residents. Findings include: 1. Review of a grievance filed by a family member for resident #17, dated 6/19/17, showed the grievance form had not been completed in the following sections: - a summary of the investigation findings; - whether the grievance was confirmed; - whether the grievance was resolved, and how it was resolved; - whether the person who filed the grievance was notified of the outcome of the investigation; - the date, time, and method of notification to the person who filed the grievance; - the signature of the staff member who notified the person who filed the grievance. Review of the grievance, dated 6/19/17, showed audits were to be conducted to assess the concern. A request was made for the audit results, but none were provided. 2. Review of a grievance filed by resident #18, dated 5/1/17, showed the grievance form had not been completed in the following sections: - if the grievance was confirmed; - how the grievance was resolved; - if the person who filed the grievance was notified of the outcome of the investigation; - the date, time, and method of notification to the person who filed the grievance. During an interview on 9/6/17 at 4:50 p.m., staff member A stated the facility attempted to resolve a grievance within 48 hours, and part of the resolution included a follow up with the complainant. During an interview on 9/7/17 at 10:15 a.m., staff member A stated the department manager responsible for the area of concern on the grievance conducted the investigation and determined the appropriate action, and then passed the form back to the Executive Director (Administrator). She stated that the Executive Director or the department manager could complete the remainder of the form and make the notifications to the complainant. Staff member A stated the grievance process included reviewing the grievance at the daily stand-up meeting. During an interview on 9/7/17 at 12:55 p.m., staff member A stated the facility had taken steps, such as education and auditing, to address the grievances, but there was no evidence to show notification was made to the person who filed the grievance.",2020-09-01
547,CENTRAL MONTANA NURSING & REHABILITATION CENTER,275064,410 WENDELL AVE,LEWISTOWN,MT,59457,2017-09-07,225,D,0,1,GK0911,"Based on interview and record review, the facility failed to ensure they did not employ an individual found guilty of misappropriation of property, by not thoroughly investing a conviction of theft for 1 of 5 employee files reviewed. Findings include: Review of staff member L's personnel file showed an application for employment was completed and signed on 6/15/17. The same file showed an acknowledgement for a background check was signed by staff member L on 6/15/17. Review of the background check showed staff member L was found guilty of a misdemeanor theft on 11/17/14. The memo, told (name of Executive Director) 6/27/17, was handwritten on the document. During an interview on 9/7/17 at 11:30 a.m., staff member H stated she completed the applicant's background check and saw the theft conviction. She stated she made the administrator aware, and had made the handwritten note on the background check document. Staff member H stated she had interviewed the applicant (staff member L) regarding the theft, but had not documented the interview. She stated she had not done any follow up to confirm what staff member L had told her regarding the circumstances of the theft. During an interview and record review on 9/7/17 at 11:35 a.m., staff member C stated staff member I had interviewed the applicant and determined the offense did not exclude her from being hired. Staff member C stated there was no documentation of the interview. Staff member D stated there was no evidence of follow up with the alleged victim of the theft. He stated the facility had accepted the applicant's statement of the charges as truthful because the applicant had been honest about disclosing the conviction on her application. After reviewing the application, which showed the applicant had denied ever having been convicted of a crime, staff member D shook his head and said, oh. Staff member D stated there was no evidence the facility had requested or received police or court records to validate the theft would not exclude the applicant from employment.",2020-09-01
548,CENTRAL MONTANA NURSING & REHABILITATION CENTER,275064,410 WENDELL AVE,LEWISTOWN,MT,59457,2017-09-07,253,D,0,1,GK0911,"Based on observation and interview, the facility failed to repair walls after water/steam damage in 1 of 4 bath houses sampled; and to ensure cleanliness and maintenance of wheelchairs and therapeutic chair cushions for 1 (#3) of 12 sampled residents. Findings include: 1. During the tour of the facility on 9/5/17 at 2:44 p.m., the wall/ceiling paint was peeled back and torn away from the ceiling surface in the bath house marked as Bath 130. The surface area of the missing paint measured approximately 20 inches by 6 inches and was exposing the underlying wall construction. The area of concern was in the shower stall. The paint was still hanging from the ceiling. During an interview on 9/6/17 at 9:38 a.m., staff member F stated he was not aware of the wall damage in the shower room of the bath house and that it would be repaired. 2. During the provision of care on 9/5/17 at 4:30 p.m., resident #3's wheelchair cushion (lateral support cushion) was stuck to the seat of her wheelchair. Dirt and debris was observed when the cushion was separated from the seat of the wheelchair. The cushion was stained in several locations with whitish colored drip stains. The vinyl covering of the therapeutic cushion was completely worn off on the back of the cushion, where the back of the resident contacted this surface area of the cushion. During an observation on 9/6/17 at 8:15 a.m., the wheelchair and the cushion of resident #3 was in the same dirty condition. During an interview on 9/6/17 at 9:12 a.m., staff member I stated the wheelchairs were washed nightly, all wheelchairs every night, by the nocturnal shift staff. She stated the cushions were wiped down when needed. During an observation on 9/7/17 at 11:00 a.m. and at 2:25 p.m., the wheelchair and the cushion of resident #3 was in the same dirty condition. During an interview on 9/6/17 at 2:00 p.m., staff member A stated the wheelchairs were washed on the bath day of the residents. She stated they were washed by the nocturnal staff. Staff member A stated damaged cushions would be replaced. During an interview on 9/7/17 at 11:15 a.m., staff member G stated the wheelchairs were washed by the night staff and the cushions were wiped down as needed. She stated damaged cushions would be reported to the nurse. During an interview on 9/7/17 at 1:20 p.m., staff member K stated damaged cushions would be reported to the maintenance, or to the social services, or would be reordered. She said she was not aware that resident #3's chair was dirty and the cushion was damaged.",2020-09-01
549,CENTRAL MONTANA NURSING & REHABILITATION CENTER,275064,410 WENDELL AVE,LEWISTOWN,MT,59457,2017-09-07,274,D,0,1,GK0911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct a comprehensive assessment with a completion date within 14 days of initiation of Hospice services for 1 (#6); and to complete a Significant Change in Status Assessment within 14 days of the ARD for 1 (#7) of 12 sampled residents. Findings include: 1. Review of resident #6's physician's orders [REDACTED]. Review of resident #6's MDS assessments showed no MDS was completed after Hospice services were initiated and no MDS showed Hospice services were being received. During an interview on 9/6/17 at 9:20 a.m., staff member B stated the Significant Change in Status MDS had not been completed for resident #6. She said there were problems with scheduling and completing MDS assessments due to the MDS nurses being needed to work as floor (direct care) nurses. Staff member B stated she had been working the floor instead of being assigned to complete the MDS's. Staff member B stated she knew the MDS rule regarding completion of a Significant Change in Status Assessment after initiation of Hospice, but she just could not get the assessment done. 2. Review of resident #7's Significant Change in Status Assessment MDS, with an ARD of 12/2/16, showed a completion date of 2/24/17. The assessment was signed by staff member N. Staff member N was not available for interview during the survey. During an interview on 9/6/17 at 8:40 a.m., staff member C stated the facility was aware of discrepancies in the MDS process, such as missed assessments and assessments that had been initiated but not completed timely. Staff member C said she had no explanation for the discrepancies.",2020-09-01
550,CENTRAL MONTANA NURSING & REHABILITATION CENTER,275064,410 WENDELL AVE,LEWISTOWN,MT,59457,2017-09-07,275,D,0,1,GK0911,"Based on record review and interview, the facility failed to complete annual MDS assessments timely for 2 (#s 3 and 11) of 12 sampled residents. Findings include: 1. Review of resident #3's annual MDS had an ARD of 4/24/17, and V0200 B and V0200 C dates of 5/12/17; the completion of the assessment was late by 5 days. The assessment was not completed timely. 2. Review of resident #11's annual MDS had an ARD of 5/8/17, and V0200 B and V0200 C dates of 5/25/17; the completion of the assessment was late by 4 days. The assessment was not completed timely. During an interview on 9/6/17 at 8:40 a.m., staff member C stated the facility was aware of discrepancies in the MDS process, such as missed assessments and assessments that had been initiated but not completed timely. Staff member C said she had no explanation for the discrepancies.",2020-09-01
551,CENTRAL MONTANA NURSING & REHABILITATION CENTER,275064,410 WENDELL AVE,LEWISTOWN,MT,59457,2017-09-07,276,D,0,1,GK0911,"Based on interview and record review, the facility failed to complete a Quarterly MDS within 92 days of the previous MDS for 2 (#s 6 and 7) of 12 sampled residents. Findings include: 1. Review of resident #6's MDS's showed an Admission MDS, with an ARD of 8/17/16. The next assessment was a Quarterly MDS, with an ARD of 2/2/17. An assessment which was due, with an ARD by 11/17/16, was not done. 2. Review of resident #7's MDS's showed an Admission MDS, with an ARD of 7/8/16. The next assessment was a SCSA, with an ARD of 12/2/16. An assessment which was due, with an ARD by 10/8/16, was not done. During an interview on 9/6/17 at 8:40 a.m., staff member C stated the facility was aware of discrepancies in the MDS process, such as missed assessments and assessments that had been initiated but not completed timely. Staff member C said she had no explanation for the discrepancies. During an interview on 9/6/17 at 9:20 a.m., staff member B stated she had been completing the MDS assessments but had taken a leave of absence, and staff member N was completing assessments. She said there was no one to complete the assessments for a brief period, and when staff member N was learning the MDS process, assessments were not done or were late. Staff member N was not available for interview during the survey.",2020-09-01
552,CENTRAL MONTANA NURSING & REHABILITATION CENTER,275064,410 WENDELL AVE,LEWISTOWN,MT,59457,2017-09-07,278,D,0,1,GK0911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately code an MDS assessment for 2 (#s 7 and 11) of 12 sampled residents. Findings include: 1. Resident #11 was admitted to the facility on [DATE] with right shoulder [MEDICAL CONDITION], chronic pain and history of stroke. Review of the annual MDS, with an ARD of 5/8/17, showed the resident had no ROM impairment in her upper extremities, G0400 A was coded a zero. Review of the quarterly MDS, with an ARD of 7/10/17, showed the resident had a ROM impairment in her upper extremities, G0400 A was coded a two. During an interview on 9/7/17 at 9:55 a.m., staff member C provided documentation showing the resident's ROM did not decline, but the annual MDS was coded inaccurately. One of the documents was the H&P, dated 6/4/14, and it showed the resident had severe [MEDICAL CONDITION] and her shoulders were extremely debilitated and arthritic. Review of the physician's progress note, dated 5/17/17, showed PT was attempted again for gentle stretches and chronic pain. The resident refused. 2. Review of resident #7's Annual MDS, with an ARD of 6/22/17, showed the resident coded as taking an antidepressant on zero days of the look-back period (6/16/17- 6/22/17). Review of resident #7's MAR for (MONTH) (YEAR) showed he received [MEDICATION NAME], an antidepressant, for seven days from 6/16/17 -6/22/17. During an interview on 9/7/17 at 1:40 p.m., staff member B stated there was an error in the coding for resident #7's Annual MDS. She stated she reviewed the MAR and physician orders [REDACTED].",2020-09-01
553,CENTRAL MONTANA NURSING & REHABILITATION CENTER,275064,410 WENDELL AVE,LEWISTOWN,MT,59457,2017-09-07,283,D,0,1,GK0911,"Based on record review and interview, the facility failed to complete the required elements of a discharge summary and recapitulation of stay, for 1 (#12) of 2 discharged residents reviewed. Findings include: 1. Review of resident #12's medical record showed the resident was discharged from the facility on 7/21/17. The physician's phone order on 7/20/17 showed resident #12 was discharged to another local health facility. Review of resident #12's closed medical record showed no evidence of a discharge summary or the Discharge Transition Plan completed by the nursing staff and the social services staff addressing the resident's vital signs assessment, special care instructions including nutrition needs, scheduled physician follow up appointments, durable medical equipment, as well as rehabilitation and psychosocial/behavioral needs, medications, and specific discharge goals. During an interview on 9/7/17 at 1:30 p.m., staff member C stated she could not find the discharge summary in the medical record, and stated it was not completed.",2020-09-01
554,CENTRAL MONTANA NURSING & REHABILITATION CENTER,275064,410 WENDELL AVE,LEWISTOWN,MT,59457,2017-09-07,318,D,0,1,GK0911,"Based on observation, interview, and record review, the facility failed to provide range of motion (ROM) exercises for a resident with impaired mobility for 1 (#7) of 12 sampled residents. Findings include: Review of resident #7's Admission MDS, with an ARD of 7/8/16, showed a limitation in functional ROM on one side for both upper and lower extremities. Review of resident #7's SCSA MDS, with an ARD of 12/2/16, showed a limitation in functional ROM on one side for the upper extremities, and on both sides for the lower extremities. Review of resident #7's Quarterly MDS, with an ARD of 8/10/17, showed a dash as the answer for functional impairment of upper and lower extremities, meaning the functional ROM was not assessed. During an interview and observation with resident #7 on 9/6/17 at 9:32 a.m., the resident stated she could not move her left-side extremities and demonstrated her lack of mobility. Resident #7 stated she does not receive ROM exercises. She stated her physician told her ROM exercises were unlikely to restore her lost function but she did not know why she did not receive passive ROM to prevent further decline or complications of impaired mobility. During an interview on 9/6/17 at 10:25 a.m., staff member A stated she was uncertain if resident #7 had a restorative nursing program for ROM exercises. She stated she would find out if there was a program in place, and if there was not a program, what was the basis for that decision. During an interview on 9/6/17 at 11:37 a.m., staff member A stated resident #7 was not on a restorative nursing program and was not receiving ROM exercises. She stated restorative programs are sometimes initiated by a therapist and sometimes initiated through nursing staff. She stated the Director of Nursing Services was the Restorative RN for the facility. The facility had an interim Director of Nursing Services, who was a staff RN working as a direct care nurse, who was not functioning in the capacity of a Restorative RN. The previous Director of Nursing Services/Restorative RN was not available for interview during the survey. No further information was provided regarding assessment of resident #7's limitation in functional ROM or why she was not receiving ROM exercises. Review of a facility policy titled, Restorative Program, updated (MONTH) 2014, showed a list of residents who may be appropriate for a restorative program. The list included, Any resident who has declined in level of function from baseline. The policy showed a procedure that residents are evaluated for restorative needs with a change of condition via the Resident Assessment Instrument (MDS) process.",2020-09-01
555,CENTRAL MONTANA NURSING & REHABILITATION CENTER,275064,410 WENDELL AVE,LEWISTOWN,MT,59457,2017-09-07,371,E,0,1,GK0911,"Based on observation, record review, and interview, the facility failed to ensure proper storage of food/beverages and cleanliness in the main kitchen. Findings include: 1. During the initial tour of the kitchen, on 9/5/17 at 2:01 p.m. the following concerns were noted: (Staff member [NAME] was present during the observations) - Two wet kitchen rags were on the cook's counter, not immersed in sanitizing solution. Staff member [NAME] stated perhaps staff forgot to fill buckets during the shift change, she removed, and placed the rags in the dirty laundry bin. - Dried food substance/drips and mold were adhered to the storage racks in two walk-in coolers (the review of the cleaning schedule showed these racks were not on the cleaning schedule for (MONTH) (YEAR)) - The silicone seal between the compartment housing the dish machine motor and top of the dish machine, was torn and the section of the seal was missing. This created an uncleanable and unsanitary surface. The top of the dish machine and the surfaces behind the motor were covered with stains and debris. The review of the cleaning schedule showed the machine was on a biweekly cleaning schedule. Staff member [NAME] stated perhaps it could be cleaned more frequently. - The air gaps located under the two-compartment and the three-compartment sinks were covered in black matter and needed scrubbing. - The floors under and behind the snack prep counter, the two compartment sink and the pellet warmer had heavy accumulation of food crumbs, debris, cans of pop and a serving container for coffee cream. - The surfaces underside of the two Hobart mixers, (where the mixing attachments connected) were covered in dried dough and dried food splatter stains, while they were observed in clean storage. - A portion of the base board and the wall was missing by the staff beverage counter. This hole in the wall measured approximately 2.5 inches by 3 inches and housed dirt and debris. During an interview on 9/6/17 at 10:30 a.m., staff member [NAME] requested the list of the concerns found on 9/5/17, and stated she was conducting an inservice training to the staff later that day. 2. During an observation on 9/6/17 at 7:50 a.m., the nozzles of the juice machine, in the dining room, were covered with a layer of brownish color dried and caked on beverage stains. The machine dispensed 4 different types of juice; heavily stained and sticky nozzles showed they were not dismantled and soaked in sanitizing solution regularly. During an interview on 9/7/17 at 10:50 a.m., staff member J stated it had been a long struggle trying to encourage the staff to dismantle and to clean the juice machine. She stated she was aware of the potential health risks created by potential bacterial over population on the surfaces of the nozzles that dispensed the beverages, if the machine was not cleaned properly. She stated she was going to suggest removal of the juice machine. The juice machine was in the same condition, with discolored stains and stickiness to the touch during the observation on 9/7/17 at 11:00 a.m.",2020-09-01
556,CENTRAL MONTANA NURSING & REHABILITATION CENTER,275064,410 WENDELL AVE,LEWISTOWN,MT,59457,2017-09-07,441,D,0,1,GK0911,"Based on observation, interview, and record review, the facility failed to practice changing gloves and sanitizing hands, between dirty and clean tasks for 1 (# 1) of 12 sampled residents. The facility failed to provide evidence of TB testing or screening for 5 (L, O, P, Q, and R) of 5 new employee files reviewed. Findings include: 1. During an observation on 9/6/17 at 9:24 a.m., staff member G provided peri-care for resident #1. From the beginning of the task, until resident #1 had transferred back to her w/c, staff member G did not change her gloves, or sanitize her hands. After providing peri-care, using wipes and gloved hands, staff member G did not take off her gloves, or wash/sanitize her hands, before moving on to placing a clean incontinence product, pulling up resident #1's pants, and adjusting resident #1's clothing. Staff member G then assisted resident #1 to a sitting position in her w/c. Staff member G then removed her gloves and sanitized her hands. During an interview on 9/6/17 at 9:24 a.m., staff member G said, After I do peri-care, I pull up the attends and the pants, then I change my gloves. Staff member G said she thought that was the way the facility expected the care to be given. A review of the facility policy, Handwashing/Hand Hygiene, reflected, 7 h. Before moving from a contaminated body site to a clean body site during resident care A review of the facility policy, CNA Competency Peri-Care, Female, reflected, after cleaning the peri area staff should, 17 , remove and discard gloves. 18. Complete hand hygiene and put on clean gloves, and 19. Assist resident to dress. 2. Review of the personnel files for staff members L, O, P, Q, and R showed no evidence of testing or screening for TB. During an interview on 9/7/17 at 1:08 p.m., staff member C stated the facility conducted TB testing for new employees, and documented the data on a form, in a black binder, until the testing process was completed. She stated the form was then to be given to the business office to be filed in the employee's personnel file. Staff member C stated the black binder was missing and there was no other evidence the TB testing had been done.",2020-09-01
557,CENTRAL MONTANA NURSING & REHABILITATION CENTER,275064,410 WENDELL AVE,LEWISTOWN,MT,59457,2018-11-29,558,D,0,1,2DDR11,"Based on observation and interview, the facility failed to ensure that 1 (#8) of 13 residents had their telephone within reach in order to make and receive phone calls. This had the potential to affect any resident with a phone that was not able to reach their phone. Findings include: During an observation on 11/27/18 at 7:30 a.m., resident #8 was in bed sleeping. Her phone was on her recliner. The resident was unable to reach her telephone. During an observation on 11/27/18 at 9:15 a.m., resident #8 was lying in bed with her oxygen on. Resident #8's telephone was sitting on her recliner. The resident was unable to reach the telephone. During an observation on 11/27/18 at 2:37 p.m., resident #8 was laying in bed. Resident #8's telephone was sitting on the recliner. Resident #8 was unable to reach the telephone to make a phone call. During an observation on 11/28/18 at 7:37 a.m., resident #8 was laying in bed. Resident #8's telephone was sitting on her recliner out of her reach. During an observation and interview on 11/28/18 at 9:00 a.m., resident #8 was sitting in her wheel chair in her room. Resident #8's phone was sitting on her recliner across the room. Resident #8 stated she could not reach the phone to make a phone call or answer it if someone called her. During an observation on 11/28/18 at 1:50 p.m., resident #8 was laying in bed. Resident #8's telephone was sitting on her recliner. She was not able to reach the telephone if it rang or to make a phone call.",2020-09-01
558,CENTRAL MONTANA NURSING & REHABILITATION CENTER,275064,410 WENDELL AVE,LEWISTOWN,MT,59457,2018-11-29,657,D,0,1,2DDR11,"Based on observation, interview, and record review, the facility failed to revise a care plan after the colored oxygen tubing, initiated as a fall reduction intervention, was no longer needed for 1 (#8) of 13 sampled residents. This had the potential to affect any resident in the building with interventions that were no longer necessary. Findings include: During an observation on 11/27/18 at 7:30 a.m., resident #8 was in bed sleeping. Her oxygen was on and the tubing was clear in color. During an observation on 11/27/18 at 9:15 a.m., resident #8 was lying in bed with her oxygen on. The tubing was clear in color. During an observation on 11/27/18 at 12:28 p.m., resident #8 was sitting in her wheel chair in the dining room. Resident #8 had her oxygen on, the tubing was clear in color. During an observation on 11/27/18 at 2:37 p.m., resident #8 was laying in bed. Her oxygen was on. The tubing was clear in color. During an observation on 11/28/18 at 7:37 a.m., resident #8 was laying in bed. Her oxygen tubing was clear in color. During an observation on 11/28/18 at 9:00 a.m., resident #8 was sitting in her wheel chair in her room. Resident #8's oxygen was on, and the tubing was clear. During an observation on 11/28/18 at 1:50 p.m., resident #8 was laying in bed. Her oxygen was on and the tubing was clear in color. During an observation on 11/29/18 at 9:00 a.m., resident #8 was observed sitting in her wheel chair in the lobby with her oxygen in place. The oxygen tubing was clear in color, not green as documented on the care plan. The oxygen tubing in her room was observed and was clear in color. Review of resident #8's care plan dated 10/7/18, showed resident #8 was to have green colored oxygen tubing for visual reminder as a fall prevention intervention. During an interview on 11/28/18 at 2:10 p.m, staff member A stated the oxygen tubing should be changed on the care plan as the resident does not walk anymore, and the green color was to help reduce falls.",2020-09-01
559,CENTRAL MONTANA NURSING & REHABILITATION CENTER,275064,410 WENDELL AVE,LEWISTOWN,MT,59457,2018-11-29,689,D,0,1,2DDR11,"Based on observation, record review, and interview, the facility staff failed to transfer and use the facility's mechanical lift properly in order to prevent accidents for 1 (#3) of 13 sampled residents. This had the potential to affect any resident in the building requiring a mechanical lift in order to transfer from one surface to another. Findings include: During an observation on 11/27/18 at 11:30 a.m., staff members F and G transferred resident #3 from the bed to the wheel chair using a Vanderlift II. Staff members F and G placed the sling under resident #3 while she was in bed. Staff members F and G secured the resident in the sling, opened the legs of the lift for a wide base, and placed the brakes in the locked position. Staff members F and G then started raising the resident off the bed with the lift. Staff members F and G then moved the resident over to the wheel chair. The brakes on the wheel chair were in the locked position. Staff members F and G placed the lift to the side of the wheel chair to lower the resident. The lift legs were in the closed position. Staff members F and G lowered resident #3 to the wheel chair. While lowering resident #3 to her wheel chair, the lift leg in the front of the wheel chair raised up off of the ground approximately one inch to two inches. Staff member F stated the brakes should always be locked when lowering a person from the lift. She stated the base of the legs only needed to be open when you lower a person down into a chair from the front side of the chair. She stated since they went from the side of the wheel chair to lower resident #3, the legs of the base did not need to be open. Review of the Vanderlift II manufacturer book in section Transfer from a Bed or Stretcher, showed .open the base to its widest position . The facility provided a copy of the training and education given to nursing staff on 11/27/18 for Vanderlift training. During and interview on 11/29/18 at 9:20 a.m., staff member A stated the staff should follow the manufacturers guide for the lift use, as each lift is different.",2020-09-01
560,CENTRAL MONTANA NURSING & REHABILITATION CENTER,275064,410 WENDELL AVE,LEWISTOWN,MT,59457,2018-11-29,802,E,0,1,2DDR11,"Based on observation, interview, and record review, the facility failed to ensure dietary personnel were adequately trained to have the competencies and skill sets to identify safe food handling practices, temperature zones, and the necessary actions to take when foods fall out of the safety temperature zones. These failures had the potential to affect all residents who consumed food prepared in the kitchen. Findings include: During an observation, and interview on 11/26/18 at 12:30 p.m., staff member [NAME] stated she was still fairly new in the job role, and was not yet on her own. Staff member [NAME] was able to verbalize the process for checking food temperatures and that the facility kept a log of the temperature values. Staff member [NAME] was asked what she would do if the temperature for hot food was too low. Staff member [NAME] said, It's never happened to me. During the dining observation on 11/26/18 at 12:30 p.m., staff member D was observed touching her face with her gloved hand, and was observed leaving the work area, then returning with gloves on her hands. Staff member D proceeded to open butter pats, remove the tops from ice cream cups, and place cottage cheese plates, and fruit plates onto trays, potentially contaminating food items after staff member D touched her face with her gloved hand. During an interview on 11/26/18 at 12:30 p.m., staff member D was asked about the facility practice for hand washing and glove use. Staff member D stated she would change her gloves about every three times (of washing/sanitizing), or if her hands were dirty. Staff member D was asked if she should have changed her gloves and she said, I didn't touch any food. During an observation on 11/27/18 at 12:30 p.m., staff member D was asked to spot check a glass of milk, which was found to be 60 degrees. Staff member D was asked what the temperature zone was for cold food items and said, I'm guessing it should be between 40 to 50 degrees. During an interview on 11/29/18 at 8:30 a.m., staff member C stated that all dietary staff were trained on safe food handling practices, annually. During an interview on 11/29/18 at 9:50 a.m., staff member A stated there were three new kitchen employees, which included staff member E, who had not gone through any food service training as of 11/29/18. Staff member A also stated that any new employee should be with a senior staff member who has had training. A review of a facility in-service training, titled, Safe Food Handling, for all nutritional staff, dated Monday, (MONTH) 19th (no year), showed training content which included the safe food handling temperature danger zone of above 41 degrees for cold beverages and below 135 degrees for hot food. Staff member D had signed the attendance roster. During a review of the facility Food Temperature Logs, dated 11/1/18 through 11/27/18, showed there were thirty five instances where either the hot food temperature was below 135 degrees, the cold food temperature was above 41 degrees, or not tested at all, during shifts where staff member [NAME] was in training with a senior staff member, including staff member D. A review of the facility policy, titled Glove Use, published 7/08, showed, .change gloves whenever leaving the work station or changing the type of food being prepared . A review of a facility policy, titled HACCP (Hazard Analysis and Critical Control Points) And Food Safety Basics, with revision dates of 12/07 and 12/18, showed, Facility staff will be well trained on food safety policies and procedures. Supervisors will monitor staff and correct any problems or concerns at the time they occur .",2020-09-01
561,CENTRAL MONTANA NURSING & REHABILITATION CENTER,275064,410 WENDELL AVE,LEWISTOWN,MT,59457,2018-11-29,812,F,0,1,2DDR11,"Based on observation, interview, and record review, the facility failed to ensure proper food safety requirements were met by maintaining cold food temperatures less than 41 degrees, and hot food temperatures greater than 135 degrees, and failed to consistently record beverage temperatures prior to distribution to the resident(s). These failures had the potential to affect all residents who consumed food from the kitchen. Findings include: During an observation on 11/26/18 at 1:00 p.m., milk cartons were observed in a bowl on the cart and not cooled with ice. During an observation on 11/26/18 at 5:30 p.m., staff member D was asked to spot check the temperature of a glass of pre-poured milk. The check showed a temperature of 43 degrees, not the required 41 degrees or less. During an interview on 11/26/18 at 1:00 p.m., staff member [NAME] was asked what the process was if a hot food item was not at 135 degrees. Staff member [NAME] stated It's never happened to me. During an interview with the resident group council, on 11/27/18 at 10:00 a.m., multiple residents who attended stated the hot food was cold at times, and the milk was warm. During an observation on 11/27/18 at 12:50 p.m., staff member D was asked to spot check a glass of pre-poured milk. The check showed a temperature of 60 degrees. The milk was sent out to the resident. During an interview on 11/27/18 at 12:50 p.m., staff member D was asked what the temperature range was for cold food items. Staff member D stated I'm guessing it should be between 40 to 50 degrees. During an interview on 11/29/18 at 8:30 a.m., staff member C described the process for checking the temperature of the food. She stated the food is to be placed into the steam table, and the food was to sit for five minutes before checking the temperature. If the food item is less than 135 degrees, the staff are to take corrective action and get a new pan of food and ensure the holding temperature was above 135 degrees. Staff member C stated they had heard there were complaints of the milk being warm, but thought the issue was resolved. Staff member C also stated they were aware there needed to be a different system to keep beverages cold, and that they also had ideas on how to decrease the amount of time it took to get the food to the residents. Staff member C stated all staff are in-serviced on safe food handling annually, and the facility used the ServSafe standards for food temperature safety zones. A review of a facility in-service training, titled Safe Food Handling, for all nutritional staff, dated Monday, (MONTH) 19th (no year), showed training content which included the safe food handling temperature danger zone of above 41 degrees for cold beverages, and below 135 degrees for hot foods. A review of the facility policy, titled Food Temperatures, revised 2/18 showed, .All hot food items must be held at a temperature of at least 135 degrees Fahrenheit, but no greater then 165 degrees Fahrenheit. All cold food items must be held at a temperature of 35 - 40 degrees Fahrenheit or below . A review of facility policy, titled Handling Cold Foods For Tray line, revised 2/18, showed, .Cold temperatures will be taken prior to meal service and recorded on appropriate form .milk will be placed in a pan of ice for use at meal service . During a review of the facility Food Temperature Logs, dated 11/1/18 through 11/27/18, there were thirty instances where the food holding temperature for hot foods were below 135 degrees. There were 39 instances where beverage temperatures, for cold drinks were taken, in which 23 were above 41 degrees, not including the spot check of pre-poured milk on 11/27/18, which was at 60 degrees.",2020-09-01
562,CENTRAL MONTANA NURSING & REHABILITATION CENTER,275064,410 WENDELL AVE,LEWISTOWN,MT,59457,2018-11-29,880,E,0,1,2DDR11,"Based on observations, record review, and interview, the facility staff failed to maintain safe infection control practices when staff changed from a dirty task to a clean task, during the provision of resident care, for 3 (#s 5, 17, and 18) of 20 sampled and supplemental residents; and, failed to ensure the potential transmission of communicable diseases or infections during meal service, when staff reused food trays, when serving meals to different residents, without sanitizing or washing the trays prior to reuse. Findings include: 1. During an observation on 11/27/18 at 9:00 a.m., staff member G and H assisted resident #17 into the bathroom and placed her on the toilet. Both staff members had already donned gloves prior to care. Staff member G removed resident #17's night clothes and soiled brief, and discarded the brief in the garbage. Staff member G assisted resident #17 to get dressed with clean pants and a clean brief, while the resident was on the toilet. Staff member G assisted resident #17 into a standing position. Staff member G washed resident #17's peri area with wipes, threw the wipes into the garbage and pulled resident #17's pants up. Staff member G assisted resident #17 into the wheelchair. Staff member G disposed of the gloves in the garbage can and washed her hands. Staff member G failed to wash her hands and change her gloves when going from the soiled task to the clean task. While staff member G assisted resident #17 to get dressed, staff member H stripped soiled bedding and placed it in a laundry bag, prepared items for grooming, and straightened the room. Staff member H removed her gloves and washed her hands. Staff member H failed to wash her hands and change her gloves when changing from a dirty task to a clean task. During an interview on 11/27/18 at 9:30 a.m., staff member G stated the correct procedure for peri care was to wipe the resident from front to back, but failed to report that washing hands or changing gloves during peri care was necessary. Staff member G stated she did not wash her hands or apply new gloves during care for resident #17. During an interview on 11/27/18 at 9:30 a.m., staff member H stated she should of removed her gloves and washed her hands when going from soiled items to clean items while providing care for resident #17. 2. During an observation on 11/27/18 at 11:43 a.m., staff members I and J assisted the resident with peri care and a linen change for resident #5. Both staff members had already donned gloves prior to resident's care. Staff member I unfastened and opened the resident's soiled brief and tucked it under resident #5's legs. Staff member I cleansed resident #5's genitals with disposable wipes. Staff members I and J rolled the resident over to his side. Staff member I cleansed resident #5's buttocks, while staff member J held the resident in position. Staff member I proceeded to roll the soiled brief, and a pad, under the resident. Staff member I placed a clean brief over the rolled items, began fastening the brief, and realized the sheet was soiled. Staff member I then rolled the soiled sheet under resident #5. Staff member I removed her gloves and placed them in the garbage. Staff member I washed her hands and left the room to obtain fresh linen. Staff member I returned to the room, washed her hands, donned new gloves, and proceeded to care for the resident. Staff member J assisted staff member I with positioning the resident, removing the soiled brief and linen, and assisted with making the bed with clean linen. Staff members I and J removed their gloves and washed their hands. Staff member J did not wash her hands or change her gloves while assisting with peri care and linen change. Staff member I did not wash her hands or change her gloves while assisting with peri care. During an interview on 11/27/18 at 12:05 p.m., Staff members I and J stated they should have changed their gloves while providing care for resident #5 when changing from the soiled brief and linen to a the clean task with the clean brief and linen. During an interview on 11/27/18 at 2:00 p.m., Staff member B stated staff had been educated on proper peri care, and had also recently been in-serviced on procedures for proper peri care. A facility copy of the peri care education was requested. A review of the facility's policy, CNA Competency peri care, on 11/28/18, include, .complete hand hygiene and put on clean gloves. Provide clean, dry linens and incontinence products as needed . 3. During an observation on 11/28/18 at 7:45 a.m., staff members J and L provided assistance with dressing, toileting, peri care, and assistance with transfers for resident #18. Staff member J washed her hands, put on a pair of gloves, picked up the trash can from the bathroom, and moved it closer to the bed. She obtained the wipes and placed them next to the bed. Staff member L knocked, entered the room, washed her hands, and put on a pair of gloves. Staff member J obtained the clean clothes for resident #18 to wear for the day, from the closet. Staff member J uncovered resident #18, unfastened the residents' brief, and wiped the residents' front peri area from front to back. Staff members J and L rolled resident #18 to her right side, and staff member J provided peri care. Staff member J wiped the resident from front to back, removed the brief, removed her gloves, and washed her hands. Staff member J put on a clean pair of gloves, obtained a towel, and patted resident #18's peri area dry. Staff members J and L placed a clean brief on resident #18, a clean pair of pants, shoes, socks, and assisted her to sit on the edge of the bed. Staff member J removed resident #18's gown, obtained the deodorant from the drawer, applied it, and placed a sweater on resident #18. Staff member L removed her gloves and applied a gait belt around resident #18's waist. Staff member J obtained the walker, removed her gloves, stood resident #18, and pulled up resident #18's pants. Staff member L moved the fall pads to the other side of the room, removed her gloves, and washed her hands. Staff member J locked the brakes on the wheel chair and assisted resident #18 to sit in the wheel chair. Staff member J removed the gait belt, placed the deodorant in the drawer, took out the toothpaste and toothbrush, turned the water on, and placed resident #18 at the sink. Staff member J placed toothpaste on the residents' and toothbrush, handed it to resident #18 to brush her own teeth. Staff member J put on a new pair of gloves, removed the dirty linen from the bed and the dirty gown, placed them in a pillow case to take to the laundry room, removed the garbage, placed a new bag in the garbage, removed her gloves, and sanitized her hands. Resident #18 stated she needed to use the bathroom. Staff member J assisted the resident to the bathroom. Staff member J put on a clean pair of gloves, and assisted resident #18 to stand up from the toilet. Staff member J wiped the resident from front to back, removed her gloves, and put on a new pair of gloves. Staff member J pulled up the resident's incontinent product and pants. Staff member J assisted resident #18 to ambulate to the wheel chair and sit down. Staff member J removed the gait belt, moved the walker out of the way, removed her gloves, flushed the toilet, put the wipes away, washed her hands. Staff member J failed to wash or sanitize hands prior to moving to the clean task from the dirty task. 4. During a dining observation on 11/27/18 at 7:35 a.m., staff members F, M and A were assisting with meal delivery. The staff member was observed removing a tray with a resident's meal and beverage from the top of the steam table and took it to the table where the resident was sitting. The staff member placed the food tray down on the table, unloaded the tray and assisted the resident with their meal set up. The staff member picked up the tray and returned it to the steam table, and placed it back on top of the steam table, without sanitizing the tray before reuse for the next resident being served. Staff members F, M and A were observed to repeat the same process for all resident's served during the meal, in which the trays were not washed or sanitized prior to reuse. During an observation on 11/27/18 at 7:35 a.m., staff member D was observed touching the bottom of a tray that had been placed on a resident's table. Staff member D picked up a clean bowl and placed her gloved thumb inside the bowl, prior to filling the bowl with food. Staff member D opened butter pats and placed them on pancakes. Staff member D was observed flipping through the menu rolodex, removed the breakfast menu slip from the menu rolodex, which is pre-filled prior to each meal, and placed it on the tray. Staff member D was observed repeating these steps, without changing gloves or sanitizing hands, in-between touching soiled items, to touching clean items. During an interview on 11/27/18 at 7:55 a.m., staff member C was asked about the meal delivery process in the dining area, and the re-use of trays without sanitizing between residents. Staff member C stated, It's not the way I would do it. During an interview on 11/28/18 at 10:15 a.m., staff member A stated they (the facility) had not looked at the process of reusing trays during the meal sessions as being an infection control risk prior to the survey.",2020-09-01
563,COMMUNITY NURSING HOME OF ANACONDA,275065,615 MAIN ST,ANACONDA,MT,59711,2017-02-23,248,D,0,1,2STE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide ongoing individualized activities for resident's with cognitive deficits for 2 (#s 7 and 8), out of 10 sampled residents. Findings include: 1. Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #7's Minimum Data Set, dated dated [DATE], reflected the resident required staff to anticipate his needs, and was a 1-2 person assist with all of his activities of daily living. The Activities Assessment reflected the resident's activity preferences were reading books, music, animals, and being in the outdoors. Review of resident #7's activity assessment, dated 1/2/17, reflected documentation under additional comments that showed, (Resident) has advance (sic) dementia and is not able to do things for himself. He is not able to hold his attention and understand tasks that are being asked of him. Staff do one on one activities with him. Review of resident #7's care plan, with a revision date of 11/30/16, reflected he was dependent on staff for his activities. Goals for resident #7's activity needs reflected staff would offer activities that he would be able to participate in, related to his cognitive status. Interventions listed included 1:1 visits, activities for socialization, and activities that did not involve overly demanding cognitive tasks. Some activities listed in the interventions included looking at small tractors and cars, sorting items, and wheeling about the facility halls. During an observation on 2/21/17 at 3:40 p.m., resident #7 was sitting in the hallway next to room [ROOM NUMBER] in his wheelchair. No activities were offered. He was moving his wheelchair back and forth in a rhythmic motion, banging his wheelchair on the wall behind him. He was wearing socks, and no shoes. He had a Velcro seatbelt around his waist that was fastened to his wheelchair. When resident #7 was interviewed he was not able to answer any questions due to his cognitive deficit and smiled occasionally. During an observation on 2/22/17 at 11:30 a.m., resident #7 was sitting near the front door at the intersection next to room [ROOM NUMBER]. Resident #7 was not engaged in any activity with staff or in a group. He had backed his wheelchair into a small recessed area that had a children's tactile toy attached to the wall, with his back to the toy. During an observation on 2/22/17 from 2:00 p.m.- 2:40 p.m., resident #7 was in the hallway by room [ROOM NUMBER], and the small recessed area that had a children's tactile toy attached to the wall. He was not engaged in activities. He had removed his socks. He did not have shoes on, and his feet were bare as he was moving back and forth against the wall. Other residents passed him in their wheelchairs and walkers. His Velcro safety belt was undone. During an observation on 2/22/17 at 5:00 p.m., resident #7 was in his wheelchair in the hallway next to the dining room. He was not engaged in any activity. During an observation on 2/23/17, from 9:45 a.m. to 10:15 a.m., resident #7 was in the front area by room [ROOM NUMBER] rocking in his wheelchair. He was not engaged in any activity. He had a blanket on his lap that he was manipulating into a ball with his hands. During an interview on 2/23/17 at 11:10 a.m., staff member N stated staff used to have tactile items out in the front area for resident #7. Staff member N stated activity staff were supposed to read to him. During an interview on 2/23/17 at 2:10 p.m., staff member O stated the resident had interactions with staff at meal times while he was being assisted to eat. Staff member O stated because of the resident's cognitive deficit he was unable to participate in groups because he would grab items, was very strong, and could not understand directions. During an interview on 2/23/17 at 2:45 p.m., staff member D stated staff provided 1:1 activities for resident #7. Staff member D stated resident #7 had interactions with staff that walked by him, and when they said hello. Review of resident #7's daily activity log for the month of (MONTH) (YEAR), reflected no 1:1 activities were provided for 23 out of 30 days. Review of resident #7's daily activity log for the month of (MONTH) (YEAR), reflected no 1:1 activities were provided for 20 out of 31 days. Review of resident #7's daily activity log for the month of (MONTH) (YEAR), reflected no 1:1 activities were provided for 21 out of 30 days. Review of resident #7's daily activity log for the month of (MONTH) (YEAR), reflected no 1:1 activities were provided for 27 out of 31 days. Review of resident #7's daily activity log for the month of (MONTH) (YEAR), reflected no 1:1 activities were provided for 26 out of 31 days. Review of resident #7's daily activity log for the month of (MONTH) (YEAR) reflected no 1:1 activities were provided for 14 out of 22 days. During an interview on 2/23/17 at 12:00 p.m., resident #7's wife stated her husband liked music. She stated her husband was a handy man in the past, and could fix anything. She stated he enjoyed working with his hands. She stated it was hard for him to stay concentrated on any of the group activities due to his short attention span. 2. Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #8's Activities Assessment, dated 1/3/17, showed the resident's activity preferences were church service, music, news, pets, reading, and social activities. The comments from the same assessment, which were not documented by staff member D until 2/23/17, showed the following comments: She does enjoy one on one visits with the staff reading to her in her room. She also prefers to have her radio in her room. Many times Resident #8 will attend the news group that is offered in the mornings, and she does participate in conversation during this group. She will attend some large group activities when she is not tired. Review of resident #8's care plan with a revision date of 12/15/16 showed the following: -Invite resident #8 to scheduled activities. She does need assistance to attend. -Resident #8 needs 1 to 1 visits and activities such as reading the paper. Encourage her to sit by front table for conversations and listen to activities. -Resident #8 needs assistance/escort to and from activity functions of interest. -Resident #8 prefers activities which do not involve overly demanding cognitive tasks. Encourage in activities such as musical programs and social events. -Music to be provided in room when not involved in activities for stimulation. Has radio and room and enjoys music. During an interview on 2/23/17 at 8:45 a.m., staff member N stated that resident #8 did not like to do activities, she mostly ate and slept during the day. She stated that resident #8 would sometimes go to the TV room. During an interview on 2/23/17 at 9:24 a.m., staff member C stated resident #8 was cognitively aware, and visited with her family a lot when they came to visit. She stated when the resident was around people, she talked a lot. During an interview on 2/23/17 at 10:05 a.m., resident #8 was seated in the TV room, head down, with no residents or staff around. The resident stated she liked music, and the staff played it for her sometimes but not often. She stated the staff visited with her sometimes but not often. During an observation on 2/23/17 at 10:50 a.m., resident #8 was still seated in the TV room, head down, and out of view of the staff. The resident was crying at the table. Staff did not intervene. Review of resident #8's activity log for (MONTH) (YEAR), showed only one 1:1 activity was provided on (MONTH) 6th. There was also 11 days out of 22, where the resident did not have any activities documented Review of resident #8's daily activity log for (MONTH) (YEAR), showed 1:1 activity's were provided on the following days; (MONTH) 1st, 4th, 16th, 23rd, and 28th. There were 8 days in the month of January, where the resident did not have any activities documented.",2020-09-01
564,COMMUNITY NURSING HOME OF ANACONDA,275065,615 MAIN ST,ANACONDA,MT,59711,2017-02-23,280,E,0,1,2STE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to update care plans for 3 (#s 1, 7, and 9 ) out of 10 sampled residents. Findings include: 1. Review of resident #1's Care Plan, with a revision date of 1/19/17, showed the resident had been receiving restorative exercises for his right elbow, and hand range of motion. The care plan also showed the resident had been doing a restorative walking program. The goal was to walk in the hallway, with his walker 100 feet, three times weekly. The care plan also showed the resident was taking [MEDICATION NAME] two times daily for diabetes, but the resident's MAR and physician orders did not show the resident was on [MEDICATION NAME]. Review of the facility's Restorative Program Schedule, dated 2/6/17, showed resident #1 was not scheduled to receive restorative services. During an interview on 2/21/17 at 2:45 p.m., staff member K stated resident #1 was not on the restorative nursing program at that time. She had stated the resident had been discharged from the restorative program because he had refused to participate. Review of the resident's Progress Notes for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR), showed the resident had been encouraged one time, on 12/17/16, to move his arms to help with stiffness. During an interview on 2/21/17 at 2:50 p.m., staff member C stated resident #1 was currently on a restorative nursing program. She stated that the facility had weekly restorative meetings to review the residents in the restorative program. Staff member C had looked in the electronic medical record and stated it showed the resident had not been on restorative nursing. During an interview on 2/21/17 at 3:00 p.m., staff member [NAME] stated she had participated in the weekly restorative nursing meetings. She stated resident #1 had been on restorative nursing for a right wrist fracture. She stated resident #1 might be off of the restorative nursing program, and that she would have had to check. During an interview on 2/21/17 at 3:15 p.m., staff member [NAME] stated resident #1 had been taken off the restorative nursing program in (MONTH) (YEAR), but it was taken off of the resident's chart. She stated that she had taken it off of the resident's care plan at that time. During an interview on 2/21/17 at 4:30 p.m., staff member C stated care plan meetings were held annually, quarterly, and with any significant change. She stated resident #1 had a care plan meeting in (MONTH) (YEAR), and was not sure why the restorative nursing was still on his care plan. During an observation on 2/22/17 at 10:05 a.m., resident #1 had ambulated with his walker from his bed to the shower room. Resident #1 stated he had not been getting help from staff when he ambulated. 2. Review of resident #9's Physician Orders, dated 3/2/15, showed the resident had a consistent carbohydrate diet order with no added salt, and the resident could choose his own meals. Review of resident #9's Care Plan, with a revision date of 12/21/16, showed the resident had been on a consistent carbohydrate diet. The plan did not show the no added salt which had been ordered by the physician. Review of resident #9's Diet Card showed the resident was on a regular diet. The card did not show what had been ordered by the physician. During an interview and observation on 2/23/17 at 12:00 p.m., resident #9 had been served a peanut butter and jelly sandwich for lunch, and some orange juice. He stated that the lunch that had been on the menu had not had enough flavor or salt. He stated that he had to salt his food on his own because the food was bland. The resident had access to salt at the table if he had wanted to salt his food. The physician diet order was to have no added salt. During an interview on 2/23/17 at 12:20 p.m., staff member C stated resident #9's diet card showed he had been on a regular diet. She stated that the physician order showed a consistent carbohydrate diet with no added salt. She stated she got a new order from the physician that day to change the resident's diet order to regular. 3. Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation on 2/21/17 at 3:40 p.m., resident #7 was sitting in the hallway next to room [ROOM NUMBER] in his wheelchair. He was moving his wheelchair back and forth in a rhythmic motion banging his wheelchair on the wall behind him. He was wearing socks, but was not wearing shoes. During an observation on 2/22/17 at 11:30 a.m., resident #7 was sitting in his wheelchair next to room one, in the hallway. He was wearing socks but not shoes. During an observation on 2/22/17, from 2:00 p.m.- 2:40 p.m., resident #7 was in the hallway, by room one. He had removed his socks. He did not have shoes on, and his feet were bare. He was moving back and forth against the wall. Other residents passed by him in their wheelchairs, and walking with walkers. Review of resident #7's care plan, with a revision date of 12/5/16, reflected a focus area of at risk for falls. One of the interventions listed reflected the resident was to wear his shoes when he was up. During an interview on 2/23/17 at 11:10 a.m., staff member N stated staff no longer put on the resident's shoes because he would take them off. During an interview on 2/23/17 at 12:25 p.m., staff member C stated resident #7 always took his shoes off so staff quite putting them on. She stated the facility would complete an audit and see if they needed to revise the resident's care plan to remove the intervention of putting on his shoes on while he was up in his wheelchair.",2020-09-01
565,COMMUNITY NURSING HOME OF ANACONDA,275065,615 MAIN ST,ANACONDA,MT,59711,2017-02-23,281,D,0,1,2STE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to meet professional standards for quality care, for administering physician ordered medications for 2 (#'s 1 and 2) of 12 sampled residents. Findings include: 1. Review of resident #1's Physician order [REDACTED]. Review of resident #1's Progress Notes for (MONTH) (YEAR), showed a medication (artificial tear eye drops), had been unavailable to be administered to the resident from 2/19/17 through 2/21/17. During an interview on 2/21/17 at 4:00 p.m., staff member L stated resident #1 had not received his artificial tear eye drops, because the medication had not been in the medication cart. She stated that the night shift nursing staff checked the medications in the cart, and ordered medications that were running out of stock. She stated It's my fault for not writing down on the order sheet that the resident had been out of his artificial tears. During an interview and observation on 2/21/17 at 4:15 p.m., staff member L verbalized to resident #1 he had not been receiving his eye drops, but that the eye drops had been ordered, and would be delivered from the pharmacy that evening. 2. Review of resident #2's Physician order [REDACTED]. This occurred for the following medications: [REDACTED] - Aspirin 325 milligrams - [MEDICATION NAME] 20 milligrams - [MEDICATION NAME] 10 units - [MEDICATION NAME] 2.5 milligrams - Multivitamins - Quetiapine [MEDICATION NAME] 100 milligrams - [MEDICATION NAME] 20 milligrams - Tamsulosin 0.4 milligrams - Vitamin D3 5000 units - [MEDICATION NAME] 75 milligrams During an interview on 2/22/17 at 9:00 a.m., staff member C stated a new nurse worked the evening shift on 2/8/17, and that nurse had not changed the shift option on the electronic record system, which should have been reflected as night shift. Because she did not change the time option on her computer, the nurse was not alerted to give any of the 8:00 p.m. medications to the resident. The nurse stated that this was a medication error. Staff member C stated the nurse was educated the following week. REFERENCE Nurses are obligated to follow the orders of a licensed physician or other designated health care provider unless the orders would result in client harm. DeLaune, S. & Ladner, P. (1998). Fundamentals of Nursing, Standards and Practice (p.237). Albany, N.Y.",2020-09-01
566,COMMUNITY NURSING HOME OF ANACONDA,275065,615 MAIN ST,ANACONDA,MT,59711,2017-02-23,323,D,0,1,2STE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews the facility failed to maintain the handrails throughout the facility, which had the potential to cause injuries due disrepair of the handrails. This failure had the potential to affect any resident who touched or used the rails. Findings include: During observations throughout the facility on 2/21/17 at 9:30 a.m., the handrails were noted to be separated at the end of the rails, causing a gap. The gaps had sharp edges where the hand rails had separated, and this created a hazard for anyone who touched the sharp edges. During an interview on 2/22/17 at 10:45 a.m., staff member C had stated that maintenance had a plan to caulk the cracks on the hand rails. During an interview on 2/22/17 at 10:50 a.m., staff member P had stated that caulking the cracks on the hand rails would not be an adequate method of repairing the rails. The staff member stated he planned to cut the hand rails, and reassemble them to remove the gaps and sharp edges. During an interview on 2/22/17 at 12:30 p.m., staff member I stated the handrails had cracks like that for the past [AGE] years. Staff member P stated he would look to see if any incident reports for resident injuries had been completed due to the hazardous sharp edges. No incident reports had been provided by the facility.",2020-09-01
567,COMMUNITY NURSING HOME OF ANACONDA,275065,615 MAIN ST,ANACONDA,MT,59711,2017-02-23,328,G,0,1,2STE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide needed oxygen to a resident on a continuous basis to maintain an adequate saturation level, for 1 (#6) out of 10 sampled residents. Findings include: Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation and interview on 2/21/17 at 12:05 p.m., resident #6 was sitting in the dining room eating her lunch meal. Her oxygen tank gauge was observed to be empty, and was set at 5 liters per minute. The resident stated she was not aware her oxygen tank was empty, and asked that the nurse be told immediately. Staff member M was notified, and the staff member then obtained a new oxygen tank for resident #6. During an observation and interview on 2/22/17 at 5:06 p.m., resident #6 was sitting in the dining room eating her supper meal. Her oxygen tank was observed to be close to empty, and was set at 5 liters per minute. Resident #6 continued to stay in the dining room with an empty oxygen tank from 5:06 p.m. until 5:35 p.m. at which time the surveyor asked resident #6 if she was aware her oxygen tank was empty. Resident #6 asked that the nurse be notified immediately to get her a new oxygen tank. Staff member F was notified by the surveyor. Staff member F obtained a new oxygen tank for resident #6. Staff member F assessed the resident's oxygen saturation with a result of 83%. Resident #6's oxygen saturation returned to 92% after she received her oxygen therapy. Staff member F stated she would notify the CNA that the resident's tank was empty. Staff member F stated resident #6 should not have been without oxygen. Review of resident #6's physician orders, dated 4/13/15, reflected oxygen per nasal cannula to keep saturation greater then 92%. Review of resident #6's laboratory results, and physician progress notes [REDACTED].#6's CO2 levels were being monitored, along with a physical assessment of her lung function. Review of resident #6's Treatment Administration record for the month of (MONTH) (YEAR), reflected an order started on 6/9/15, for oxygen per nasal cannula to keep saturations greater than 92%, two times a day. Entries of saturation levels were documented for 8:00 a.m. and 8:00 p.m. Staff also documented how many liters per minute were used, ranging from 5-7 liters per minute. Review of resident #6's Care Plan regarding oxygen use, revised on 12/29/16, reflected a goal that the resident would display an optimal breathing pattern daily, and be compliant with oxygen use. Some of the interventions listed reflected that staff would monitor for difficulty in breathing on exertion, and provide oxygen therapy, as ordered, by the physician.",2020-09-01
568,COMMUNITY NURSING HOME OF ANACONDA,275065,615 MAIN ST,ANACONDA,MT,59711,2017-02-23,333,E,0,1,2STE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to identify and follow up on medications, for the treatment of [REDACTED].#'s 1, 2, 3, 4, and 8) residents out of 10 sampled residents. Findings include: 1. Review of resident #3's MAR indicated [REDACTED] -Artificial tears solution, instill 2 drop in right eye, 5 times per day, for dry eye at 8:00 p.m. 2. Review of resident #4's MAR indicated [REDACTED] -[MEDICATION NAME] HCL tablet 50 mg, give 1 tablet by mouth, three times a day for pain, at 8:00 p.m. 3. Review of resident #8's MAR indicated [REDACTED] -20 mL of [MEDICATION NAME] liquid by mouth for pain at 8:00 p.m. -[MEDICATION NAME] solution 1 drop in both yes for dry eyes at 8:00 p.m. During an interview on 2/22/17 at 9:00 a.m., staff member C stated a new nurse worked the evening shift on 2/8/17, and did not change the shift on her computer to night shift. Because she did not change the time on her computer, she was not alerted to give any of the 8:00 p.m. medications to the residents. The staff member stated that this was a medication error. Staff member C stated the nurse was educated the following week. Record review of the Medication Variance Reports did not show any reports for medication errors on 2/8/17. The facility did not follow-up with the medication errors with documentation or written education in a timely manner. 4. Review of resident #1's Progress Notes for (MONTH) (YEAR), showed a medication (artificial tears eye drops), had been unavailable to be administered to a resident from 2/19/17 through 2/21/17. Review of resident #1's Physician order [REDACTED]. Review of resident #1's MAR for (MONTH) (YEAR), showed the resident had received artificial tears from 2/19/17 to 2/21/17. The MAR indicated [REDACTED] Review of the facility's Medication Variance Reports for (MONTH) (YEAR), had not shown that resident #1 was identified as not having received his artificial tears, or fish oil capsule. During an interview on 2/21/17 at 4:00 p.m., staff member L stated resident #1 had not received his artificial tears eye drops because the medication had not been in the medication cart. She stated that the night shift nurses checked the medications in the cart, and ordered medications that were running out of stock. She stated It's my fault for not writing down on the order sheet that the resident had been out of his artificial tears. During an interview on 2/21/17 at 4:10 p.m., staff member C stated if a medication was out of stock, staff could call the pharmacy to have the medication delivered. She stated medications that residents did not receive due to the medication not being ordered by the facility, would be considered a medication error. During an interview and observation on 2/21/17 at 4:15 p.m., staff member L verbalized to resident #1 he had not been receiving his eye drops, but that the eye drops had been ordered, and would be delivered from the pharmacy that evening. 5. Review of resident #2's MAR for (MONTH) (YEAR), showed the resident had not received 10 of his scheduled physician ordered medications on 2/8/17 at 8:00 p.m. The following medications had been noted not given on the MAR: -Aspirin 325 milligrams -[MEDICATION NAME] 20 milligrams -[MEDICATION NAME] 10 units -[MEDICATION NAME] 2.5 milligrams -Multivitamins -Quetiapine [MEDICATION NAME] 100 milligrams -[MEDICATION NAME] 20 milligrams -Tamsulosin 0.4 milligrams -Vitamin D3 5000 units -[MEDICATION NAME] 75 milligrams The medications had been noted on resident #2's Physician order [REDACTED]. Review of the facility's Medication Variance Reports for (MONTH) (YEAR), showed on 2/9/17 for resident #2, that a new nurse had forgotten to change her assignment in the computer to administer the medications, and the medications had not shown up on the resident's MAR indicated [REDACTED]. During an interview on 2/22/17 at 8:40 a.m., staff member C stated that if resident #2's MAR indicated [REDACTED]. She stated she would look for the paper charting to see if that was the reason the medications had not been documented as administered. Review of the facility's policy for the Pharmacy Process dated, 3/1/16, showed that medication errors that had been discovered by an employee must complete a Medication Variance Report. It showed that the medication error was classified on the National Medication Error Index, and the variance reports should be reviewed at the Medication Committee monthly.",2020-09-01
569,COMMUNITY NURSING HOME OF ANACONDA,275065,615 MAIN ST,ANACONDA,MT,59711,2017-02-23,367,D,0,1,2STE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to follow a therapeutic diet ordered by a physician for 2 (#s 1 and 9) of 10 sampled residents. Findings include: 1. Review of resident #1's Physician order [REDACTED]. Review of resident #1's Diet Card showed that the resident was on a regular diet. Review of resident #1's Care Plan, with a revision date of 1/19/17, showed that the resident had been taking in a regular diet, and that the resident had preferred to not comply with the low sodium diet. During an observation and interview on 2/21/17, at 12:05 p.m., resident #1 had been served two regular sodas, pudding, steamed mixed vegetables, and turkey noodle casserole. The resident had stated the casserole was too spicy to eat and it was too salty. The resident had salt available for use on his food tray. During an interview on 2/21/17 at 12:15 p.m., staff member C stated resident #1 had been non-compliant with his no added salt diet. She stated she was unsure why the diet card said regular, and the physician order [REDACTED]. During an interview on 2/23/17 at 11:00 a.m., staff member H stated that resident #1 had a diet order of no added salt, and the order had been changed to the resident's preference but the nurse or dietitian should have obtained a physician order [REDACTED]. 2. Review of resident #9's Physician order [REDACTED]. Review of resident #9's diagnoses, showed the resident has [MEDICAL CONDITION] (high cholesterol) and Type II diabetes. Review of resident #9's Diet Card showed the resident was on a regular diet. Review of resident #9's Care Plan, with a revision date of 12/21/16, showed that the resident was on a consistent carbohydrate diet, with fortified meals served at all meals for added protein. The care plan had not addressed the no added salt diet. During an interview on 2/23/17 at 11:00 a.m., staff member H stated that resident #9 had a diet order of no added salt, and the order had been changed to the resident's preference. During an interview and observation on 2/23/17 at 12:00 p.m., resident #9 had a regular diet for lunch, that consisted of a peanut butter and jelly sandwich and orange juice. The resident had refused what had been on the menu for lunch that day. The resident had access to salt if he wanted to add it to his meals. The resident stated he had been allowed to have salt on his meals.",2020-09-01
570,COMMUNITY NURSING HOME OF ANACONDA,275065,615 MAIN ST,ANACONDA,MT,59711,2017-02-23,431,E,0,1,2STE11,"Based on observation, interview, and record review, the facility failed to verify placement, and reconcile the disposal of a controlled substance, for 3 (#s 1, 2, and 5) of 10 sampled residents. Findings include: During a medication administration observation on 2/22/17 at 1:55 p.m., staff member M had removed a Fentanyl dermal patch from resident #1. The staff member disposed of the Fentanyl patch in the RX Destroyer (drug disposal system). No other facility staff had witnessed staff member M dispose of, or reconcile, the Fentanyl patch. During an interview on 2/22/17 at 2:20 p.m., staff member M stated the facility had not had a policy on disposing or reconciling Fentanyl patches. She stated that the Fentanyl patches were signed out when they were administered to residents, but they were not signed off when they were disposed of. During an interview on 2/22/17 at 2:25 p.m., staff member F stated the facility did not need two nursing signatures to waste Fentanyl patches that had been taken off of a resident. During an interview on 2/22/17 at 2:40 p.m., staff member C stated two nurses should be present when disposing a Fentanyl patch. She stated the facility had not had a policy that two nurses needed to sign off on the disposal of a Fentanyl patch. She stated that if a nurse disposed of a Fentanyl patch, and it had not been witnessed by another nurse, that the disposal of the narcotic patch would not be able to be tracked or verified that it had been disposed of. During an interview on 2/22/17 at 4:20 p.m., staff member NF1 stated it was a standard practice to have two nurses witness, and sign off that a Fentanyl patch had been wasted. He stated that if two nurses did not witness and sing off on the disposal of a Fentanyl patch, then there would be no way to track or know about the disposal of the Fentanyl patch. Review of resident #1's MAR for (MONTH) (YEAR), showed that the resident had not had his Fentanyl patch verified for placement on 2/1/17 or 2/7/17 at the start of the nursing shift. Review of resident #2's MAR for (MONTH) (YEAR), showed that the resident's Fentanyl patch had not been verified for placement on 2/2/17 for night shift, 2/7/17 for day shift, and 2/16/17 for night shift. During a medication administration observation on 2/22/17 at 2:00 p.m., staff member M had removed a Fentanyl dermal patch from resident #5. The staff member disposed of the Fentanyl patch in the RX Destroyer (drug disposal system). No other facility staff had witnessed staff member M dispose of, or reconcile, the Fentanyl patch. Review of the facility's policy on Transdermal Medication Disposal, dated 8/2015, had not addressed the verification of a disposed Fentanyl patch. This facility policy did not match what had been stated in an interview with staff member NF1 on 2/22/17.",2020-09-01
571,COMMUNITY NURSING HOME OF ANACONDA,275065,615 MAIN ST,ANACONDA,MT,59711,2017-02-23,441,D,0,1,2STE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to use personal protective equipment while administering insulin for 2 (#s 11 and 12) of 12 sampled and supplemental residents. Findings include: 1. During an observation on 2/22/17 at 9:15 a.m., staff member M had administered Humalog, 3 units subcutaneous to resident #11. The staff member had not used gloves during this injection of medication to a resident, that had potential to come into contact with blood. During an interview on 2/22/17 at 9:20 a.m., staff member M had stated that she was not sure what the facility policy was for giving injections with the use of gloves. She stated that she had worn gloves when she would check blood sugars. During an interview and record review on 2/23/17 at 11:30 a.m., staff member C stated she would use gloves if she would have given a resident an insulin injection. The CDC guidelines had been reviewed and discussed with staff member C, and showed that gloves were to be used if there was a potential risk of the nurse coming into contact with blood. 2. During an observation on 2/22/17 at 9:18 a.m., staff member M had administered [MEDICATION NAME], 13 units subcutaneous to resident #12. The staff member did not use gloves during the injection of medication to a resident. The nurse had the potential to come into contact with blood. Review of the facility's Standard Precautions Policy and Procedures dated (MONTH) (YEAR), showed that standard precautions would apply to all patients, regardless of [DIAGNOSES REDACTED]. Standard precautions would apply to blood. It also showed that gloves should be worn when touching blood.",2020-09-01
572,COMMUNITY NURSING HOME OF ANACONDA,275065,615 MAIN ST,ANACONDA,MT,59711,2019-04-11,658,D,1,0,RT4011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to follow a physician order [REDACTED]. Review of the Physician order [REDACTED]. Check and rewrap every 2 to 3 hours. Review of resident #1's Progress Note, dated 2/21/19, showed the physician came into the facility to examine the resident's feet. The compression wraps were not on the resident's legs and feet. Dr. (name) wants these on, as ordered. During an interview of 4/11/19 at 2:25 p.m., staff member B stated he did not know why the compression wraps were not placed on resident #1, as the physician had ordered. Record review for resident #1 showed the resident discharged to the hospital on [DATE] for a surgical wound infection.",2020-09-01
573,COMMUNITY NURSING HOME OF ANACONDA,275065,615 MAIN ST,ANACONDA,MT,59711,2019-04-11,689,G,1,0,RT4011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to assess the resident's safety with transfers, for a resident that experienced [MEDICAL CONDITION] episodes during the transfers, resulting in repeated falls, to include one fall with a [MEDICAL CONDITION], for 1 (#1) and failed to identify the root causes and implement fall prevention interventions for 8 falls for 1 (#2); and failed to adequately assess and treat pain for 17 days after a fall for 1 (#3) of 3 sampled residents. Findings include: 1. Review of resident #1's Progress Note, dated 1/16/19, showed the CNA reported the resident's eyes rolled in the back of his head, and the resident had passed out while being toileted. His vitals were taken, but the physician was not notified. Review of resident #1's Physician Visit Note, dated 1/17/19, showed the facility staff reported he was no longer able to stand on his lower extremities. No transfer assessment was completed for the safety of the sit to stand lift. Review of resident #1's Progress Note, dated 1/23/19, showed the resident had passed out while getting ready to be toileted. Vitals were taken, but the physician was not notified. Review of resident #1's Progress Note, dated 2/5/19, showed it was reported by the CNA that the resident had slumped backwards onto the toilet and was staring off into space, during the transfer. Vitals were taken. No further follow-up assessments were completed for the incident. Review of resident #1's Progress Note, dated 2/18/19, showed the resident was taken into the bathroom on the sit to stand lift, and as he was lowered onto the toilet, and he passed out. The fall intervention implemented was to continue to monitor. Review of resident #1's Progress Note, dated 2/22/19, showed it was reported by the CNA that the resident was being assisted to the bathroom, and became unresponsive for a short time. No assessment was completed for the reason for the unresponsive episode, and the physician was not notified. During an interview on 4/11/19 at 11:00 a.m., staff member D stated the physician should have been notified of the [MEDICAL CONDITION] episodes. She stated she thought the episodes were a vagal response to being up in the sit to stand lift. She was not aware of the reason for the lack of notification to the physician. Review of resident #1's Progress Note, dated 2/24/19, showed Noted brief periods of [MEDICAL CONDITION] during toileting at beginning of shift, less than two minutes. The nurse asked the resident to wear oxygen during the toileting process, and he declined. Review of resident #1's Progress Note, dated 3/8/19, showed While resident was being taken to the restroom per sit to stand lift, the CNA reported that resident lost consciousness and needed to be lowered to the floor but body went limp approximately 12 inches above floor. His vitals were taken and he was assisted to bed with the hoyer lift. Pain was evident when (the resident) rolled on his side by grimacing. The resident refused to go to the hospital for an evaluation. During an interview on 4/11/19 at 2:10 p.m., staff member C stated she was called to the resident's room after the fall. He was on the floor, but kind of sitting up. She said she suspected the resident had broken something when he was put into the bed, and was grimacing. The facility did not have documentation the resident's range of motion was assessed after the fall. Review of resident #1's Fall Huddle note, dated 3/8/19, showed the resident had a fall while [MEDICAL CONDITION] during a sit to stand transfer. The resident was then admitted to the hospital, with a [MEDICAL CONDITION] femur. The interventions for the fall were to Close monitor while in lift. Use 2 people and lift for resident. Review of resident #1's Care Plan showed he was to use the Hoyer Lift for transfers, which was not how the resident was being transferred by staff. During an interview on 4/11/18 at 12:40 p.m., staff member A stated the resident refused to use the Hoyer Lift. The refusals were not documented on the resident's Care Plan. She stated the facility did not have a transfer assessment for resident #1 for the safe use of the sit to stand lift. Review of the Report to the State Survey Agency, dated 3/19/19, showed a refresher inservice on the use of equipment for all staff would be completed. The fracture for resident #1 was not noted on the report. During an interview at 1:15 p.m., staff member A stated the inservice had not been implemented yet. She stated physical therapy would come to the facility in (MONTH) for the training. During an interview on 4/11/19 at 2:25 p.m., staff member B stated he had been aware of resident #1's [MEDICAL CONDITION] episodes, but did not know why the physician had not been notified. Staff member B stated he had no further information regarding the fall with a fracture on 3/8/19. 2. Review of resident #2's Post Fall Huddle reports showed the resident had fallen nine times in the past three months. Review of resident #2's Post-Fall Huddle, dated 1/2/19, showed the resident was found on the floor of her bathroom, with her pants around her legs. The interventions implemented for the fall were to provide frequent checks while the resident was out of bed, and to take the resident to the bathroom more frequently. These interventions were not on resident #2's Care Plan when the plan was reviewed. Review of resident #2's Post-Fall Huddle, dated 1/28/19, showed the resident tried to sit in a chair that had wheels. The chair rolled, and the resident landed on the floor. The intervention for the fall was to watch resident to make sure she only sits in stationary chair. Review of resident #2's Post-Fall Huddle, dated 1/29/19, showed the resident was in the activity room and tried to sit in a chair. She missed the chair and landed on the floor. The intervention for the fall for the prevention of future falls, was to keep close eye on resident and help her sit. This intervention was not on the Care Plan when the plan was reviewed. Review of resident #2's Post-Fall Huddle, dated 2/10/19, showed the resident was found on the floor in the TV room. The intervention implemented for future fall prevention was to provide more frequent check, always watching her when she is out of room. Review of resident #2's Post-Fall Huddle, dated 3/1/19, showed the resident slid out of her wheelchair while in the TV room. No interventions were implemented for the resident's safety with falls. Review of resident #2's Post-Fall Huddle, dated 3/5/19, showed the resident was found on the floor in the TV room. The intervention was for Closer monitoring. Review of resident #2's Post-Fall Huddle, dated 3/6/19, showed the resident slipped out of her wheelchair and landed on the floor. The intervention was Close monitoring. This intervention has been utilized prior, and had shown to be unsuccessful as a safety intervention. Review of resident #2's Post-Fall Huddle, dated 3/13/19, showed the resident was found on the floor of her bathroom. Her feet were bare. The intervention was to keep gripper socks on at all times, and shoes on when up. Review of resident #2's Post-Fall Huddle, dated 3/22/19, showed the resident attempted to transfer from her wheelchair to a chair in the TV room, and fell . The intervention was to keep closer eye on her when she is out of bed. The facility repeatedly failed to identify root causes for the resident's frequent falls, and no evidence was provided to show the facility evaluated the effectiveness of the interventions which were implemented for the repeated falls. 3. Review of resident #3's Post-Fall Huddle, dated 1/31/19, showed the resident was walking the dining room with her four-wheeled walker. Staff heard moaning and found the resident sitting on the floor. She complained of left hip pain, and was sent to the ER for an X-ray, which did not show broken bones. Review of resident #3's Progress Note, dated 2/1/19, showed the resident complained of all over pain and leg pain. She was using her wheelchair for mobility. The note showed, Resident still complains of leg pain with transfers. Review of resident #3's Progress Note, dated 2/2/19, showed the resident required a two person assist with transfers when bearing weight. Has not been able to bear weight without increased pain since start of shift. Resident did not want to go to dining room. Complained of pain in left hip with transfers. Review of resident #3's Progress Note, dated 2/3/19, showed the resident continued to bear minimal weight on the left leg during transfers. Slight swelling and light purple bruising noted in left hip area. Review of resident #3's Progress Note, dated 2/5/19, showed the resident had a visit from the nurse practitioner. Resident has been having extreme pain in her left hip after her fall, did have a CT scan, which showed nothing broken. NP will look at the CT again, in the mean time she will be put on Tylenol #3 every 6 hours. Review of resident #3's Progress Note, dated 2/7/19, showed the resident continued to complain of left hip pain with transfer. Tylenol #3 given per order and resident does seem to obtain some relief. Review of resident #3's Progress Note, dated 2/8/19, showed the resident complained of pain in the left hip when adjusted in bed and during transfers. Tylenol #3 given per order related to left hip pain after fall on 1/31/19. Seems to help with pain, except during transfers and repositioning. Will continue to monitor. Review of resident #3's Progress Note, dated 2/15/19, showed the physician wants the resident to have another hip x-ray on Monday if resident is still not bearing weight on her left hip. Review of resident #3's Progress Note, dated 2/17/19, showed she returned from the ER, with a pathological [MEDICAL CONDITION] illium. A new order for [MEDICATION NAME] was implemented for pain management., which was 18 days after the initial fall.",2020-09-01
574,COMMUNITY NURSING HOME OF ANACONDA,275065,615 MAIN ST,ANACONDA,MT,59711,2018-05-31,568,D,0,1,YBEO11,"Based on interview and record review, the facility failed to provide quarterly statements to the resident, or resident representative, for personal funds being held by the facility for 2 (#s 11 and 25) of 12 sampled residents. Findings include: 1. During an interview on 5/29/18 at 4:40 p.m., resident #11 stated he did not know if he had personal funds being held in an account by the facility. During an interview on 5/30/18 at 3:03 p.m., staff member [NAME] stated resident #11 had funds being held in a trust account, by the facility, for disbursement as directed by the resident or resident representative. During an interview on 5/30/18 at 3:25 p.m., staff member [NAME] stated resident #11's funds were maintained in a bank account, but she did not issue a quarterly statement to the resident or the resident representative. She stated staff member G may issue quarterly statements. Staff member G stated she did not issue quarterly statements, but statements may have been issued by a higher organizational accountant. Review of resident #11's Trust - Transaction History, showed, in two sections, that no statement had been issued. During an interview on 5/31/18 at 10:28 a.m., staff member G stated the facility was not in compliance with the requirement to issue quarterly statements to resident #11, or resident #11's representative. 2. During an interview on 5/29/18 at 3:07 p.m., NF3 stated there were funds for resident #25 held by the facility for disbursement as directed by NF3. She stated she had not received quarterly statements of the funds. During an interview on 5/30/18 at 3:03 p.m., staff member [NAME] stated resident #25 had funds held by the facility, in a petty cash account. She stated the funds were deposited by NF3, and were used to pay for resident #25's haircuts. Staff member [NAME] stated NF3 would occasionally ask about the status of the account, so she knew when she needed to add funds. She stated she tracked the funds in a software program, but she had never provided a statement of the funds, held by the facility, for resident #25. Review of resident #25's Trust - Transaction History, showed the last statement date was 4/30/15. During an interview on 5/31/18 at 10:28 a.m., staff member G stated the facility was not in compliance with the requirement to issue quarterly statements to resident #25's representative.",2020-09-01
575,COMMUNITY NURSING HOME OF ANACONDA,275065,615 MAIN ST,ANACONDA,MT,59711,2018-05-31,577,C,0,1,YBEO11,"Based on observation, interview, and record review, the facility failed to post the results of the most current survey to include posting the plan of correction. The failure could affect all residents wanting to review the postings, to include family, visitors, and public. Findings include: During an observation and record review on 5/31/18 at 9:00 a.m., the survey postings were located on the opposite wall from the entrance area. The survey results posted were from the recertification survey in (MONTH) of (YEAR). Review of the state survey dates, prior to entering the facility, showed the last survey completed at the facility was in (MONTH) (YEAR). This survey was not included in the postings. During an interview on 5/31/18 at 9:30 a.m., staff member A and B stated they were unaware the correct survey was not available. Staff member B stated, Sometimes, (name) pulls the binders out to read, and must have placed it somewhere else.",2020-09-01
576,COMMUNITY NURSING HOME OF ANACONDA,275065,615 MAIN ST,ANACONDA,MT,59711,2018-05-31,623,D,0,1,YBEO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written notice of the reason for transfer to the hospital, to the resident or the resident's representative for 1 (#26) of 12 sampled residents. Findings include: During an interview on 5/29/18 at 2:32 p.m., resident #26 stated she was transferred to the hospital a month or two ago. She stated she did not know why she went to the hospital, but believed it had something to do with her heart. Resident #26 denied that she had a respiratory infection within the past few months. Resident #26 stated neither she nor her (representative) had received written notification of the reason for transfer, from the facility. Review of resident #26's progress notes, dated 3/22/18 - 3/24/18, showed the physician was notified of signs and symptoms of respiratory illness, orders were initiated to treat the illness, and later, to send resident #26 to the emergency room . Review of resident #26's hospital Discharge Summary, dated 4/5/18, showed she was admitted to the hospital on [DATE], with [DIAGNOSES REDACTED]. During an interview on 5/30/18 at 6:05 p.m., staff members A and B stated when a resident was transferred to the hospital, the resident and/or family were notified by phone or in person, and transfer documents were provided to the hospital. Staff members A and B stated the facility did not have a process to provide written notification for the reason for transfer to the hospital to the resident or their representative, and were unaware of the requirement. Staff member B stated no written notice for the reason for resident #26's transfer to the hospital was provided to resident #26 or her representative.",2020-09-01
577,COMMUNITY NURSING HOME OF ANACONDA,275065,615 MAIN ST,ANACONDA,MT,59711,2018-05-31,655,D,0,1,YBEO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a baseline care plan, within 48 hours, for a newly admitted resident, for 1 (#3) of 12 sampled residents. The deficient practice may negatively affect the residents pain management, positioning, and fall prevention. Findings include: During an interview on 5/29/18 at 10:24 a.m., resident #3 stated he could not answer questions, and wanted NF2, whom he stated was his guardian, to be interviewed on his behalf. Review of resident #3's profile in his EHR, showed the name of NF2, and that she was his guardian. During an interview on 5/29/18 at 2:51 p.m., NF2 stated she had not been involved in the development of a care plan, and had not been invited to participate in a care conference. She stated resident #3 was admitted to the facility on [DATE], after a fall that had resulted in a [MEDICAL CONDITION]. Review of resident #3's EHR showed a comprehensive care plan was developed with an initiation date of 5/14/18. No other care plan was located. During an interview on 5/30/18 at 10:10 a.m., staff member D stated she tried to complete the baseline care plan, for a newly admitted resident, within the first few days. She clarified stating she tried to complete the baseline care plan in one to two days. She stated resident #3's baseline care plan was initiated on 5/14/18. Staff member D stated resident #3 was admitted late on Thursday, 5/10/18, and she worked on the CP when she returned to work after her days off. Staff member D could not state the process for how the facility ensured a baseline care plan was completed within 48 hours, if the admission occurred late on Thursday or on a Friday. She stated resident #3's baseline care plan was not initiated within 48 hours. She stated resident #3 was admitted after a [MEDICAL CONDITION], and the nurses and CNAs needed the care plan information to provide appropriate fall prevention, pain management, and mobility/positioning assistance.",2020-09-01
578,COMMUNITY NURSING HOME OF ANACONDA,275065,615 MAIN ST,ANACONDA,MT,59711,2018-05-31,656,D,0,1,YBEO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to address sexual behaviors for 1 (#30); constipation issues for 1 (#30); and failed to address chronic pain for 1 (#27) of 12 sampled residents. This failure resulted in significant discomfort for one resident (#30), had the potential to result in pain for another resident (#27), and had the potential to place female residents at risk for sexual abuse. Findings include: 1. During an interview on 5/30/18 at 7:30 a.m., resident #30 said he had problems with constipation and felt miserable during those periods. Review of resident #30's nursing progress notes, dated 11/30/17, showed the resident did not have a bowel movement from 11/17/17 until 11/30/17, 13 days without a bowel movement. Review of resident #30's MARs, for March, April, and (MONTH) (YEAR), showed the resident had an order for [REDACTED].>- Milk of Magnesia Suspension 400 mg/5 ml, give 30 ml by mouth every 72 hours as needed for constipation. The start date was 11/27/17. Review of the bowel movement Look Back Reports and the P[NAME] response history for resident #30 showed either staff were not charting or the resident was not having consistent bowel movements. Review of resident #30's Social Service note and MDS Coordinator note, both dated 5/4/18, showed the resident was often constipated and received milk of magnesia. Both notes showed the resident used the bathroom, independently. During an interview on 5/31/18 at 8:16 a.m., staff member B stated resident #30, usually, used the toilet on his own. The staff were not always aware if the resident had a bowel movement. Review of resident #30's care plan, with a start date of 5/3/18, did not identifying interventions or the need for monitoring resident #30's bowel regimen, for constipation problems. 2. Review of resident #30's nurse progress note, dated 11/10/17, showed resident #30 had a history of [REDACTED]. Review of resident #30's social services progress notes, dated 11/6/17, showed the resident touched a female resident twice, sexually inappropriately. Review of resident #30's nurse progress note, dated 5/29/18 at 5:13 p.m., showed resident #30 had put his hand on a female resident's peri area, on 5/24/18. On 5/26/18, resident #30 put his hand between a female resident's legs. The same day, resident #30 was observed invading a female resident's space. Staff member [NAME] said she didn't know why the interdisciplinary team had not identified the resident's inappropriate sexual abuse related to the incident 11/6/17, and the resident's history prior to admit. The staff members stated they were told the resident had not displayed any sexual behaviors while in the hospital's behavioral unit. Review of resident #30's care plan, with a start date of 5/3/18, did not identify the history of sexual behaviors, or the interventions, or the need for monitoring resident #30's present sexual behaviors. 3. During an interview on 5/29/18 at 11:47 a.m., resident #27 stated he had pain to his lower back area most of the time. He stated the nurses gave him Tylenol for his pain, if he asked for it. During an interview on 5/30/18 at 11:01 a.m., staff member C stated resident #27 had back pain, and had the ability to request Tylenol when needed. She stated the Tylenol was effective to relieve his pain. Review of resident #27's Pain Assessments, dated 12/1/17 and 3/6/18, showed frequent pain at a moderate level, which made it hard for resident #27 to sleep at night. Review of resident #27's Medication Administration Records for 11/2017, 12/2017, 3/2018, and 4/2018 showed the administration of [MEDICATION NAME] (generic Tylenol) from 1-6 times per month, for back pain. Review of resident #27's care plan did not show a focus area for pain or use of the [MEDICATION NAME]/Tylenol to treat his pain. During an interview on 5/31/18 at 3:00 p.m., staff member D stated resident #27's care plan should have included his use of Tylenol to treat his back pain.",2020-09-01
579,COMMUNITY NURSING HOME OF ANACONDA,275065,615 MAIN ST,ANACONDA,MT,59711,2018-05-31,658,D,0,1,YBEO11,"Based on observation, interview, and record review, the facility failed to remain with the resident during the administration of medication taken via a nebulizer for 1 (#27) of 12 sampled residents. This failure had the potential to result in adverse consequences of the resident not receiving his ordered medication. Findings include: During an observation on 5/29/18 at 10:50 a.m., resident #27 was using a nebulizer to receive medication. He was unattended in his room. During an observation and interview on 5/29/18 at 11:04 a.m., resident #27 continued using the nebulizer to receive medication. There was no nurse in the room. Resident #27 stated the nurses put the medication into the nebulizer, but they did not stay in the room while the nebulizer was running. During an observation and interview on 5/30/18 at 11:09 a.m., staff member C prepared a vial of medication for administration to resident #27 via a nebulizer. She poured the medication into the reservoir, turned on the nebulizer and handed the inhalation device to resident #27. Staff member C left the room immediately after handing resident #27 the inhalation device. After leaving the room, staff member C stated resident #27 did not have an assessment to self-administer the medication, or an order to self-administer the medication. She stated she did not think resident #27's care plan included the self-administration of medication. She stated she did not consider leaving him using the nebulizer unattended as self-administration of medication. She stated she did not return after the medication was completed because resident #27 could turn off the nebulizer when he was finished with the medication. During an interview on 5/30/18 at 11:50 a.m., staff member B stated she did not know resident #27 using his nebulizer unattended would be considered as self-administration of medication. She stated nurses were expected to remain with residents to ensure completion of medication administration. Review of a policy titled, Medication Administration and Recording, showed, in section R, point 9, The nurse administering the medication shall stay with the patient until the medication is taken.",2020-09-01
580,COMMUNITY NURSING HOME OF ANACONDA,275065,615 MAIN ST,ANACONDA,MT,59711,2018-05-31,684,D,0,1,YBEO11,"Based on interview and record review, the facility nursing staff failed to provide bowel regimen care for 1 (# 30) out of 12 sampled residents which resulted in significant discomfort, and the deficient practice was by over a period of time involving multiple staff. Findings include: During an interview on 5/30/18 at 7:30 a.m., resident #30 said he had problems with constipation and he was miserable during those periods. Review of resident #30's Quarterly MDS with an ARD of 4/29/18 showed he had long and short term memory loss. The assessment showed the resident made poor decisions, and needed to be cued and supervised for decision making. Review of resident #30's MARs, for March, April, and (MONTH) (YEAR), showed the resident had orders for: - Milk of Magnesia Suspension 400 mg/5 ml, give 30 ml by mouth every 72 hours as needed for constipation, with a start date of 11/27/17, and; - Senna 8.6 mg, one tablet, twice a day for constipation, with a start date of 3/6/18. - During the month of March, nursing gave resident #30 daily Senna and MOM, prn, twice; once effective, once unknown. - During the month of April, the resident received Senna daily and MOM four times; twice effective, and twice ineffective. - During the month of May, the resident received Senna daily and MOM twice; ineffective once and unknown once. Review of resident #30's nursing progress note, dated 11/30/17, showed the resident did not have a bowel movement from 11/17/17 until 11/30/17, 13 days without a bowel movement. Review of the bowel movement Look Back Reports and the P[NAME] response history for resident #30 showed; - from 2/28/18 through 3/31/18, staff charted the resident had one bowel movement on 3/29/18; - from 4/1/18 through 4/30/18, staff charted the resident had a bowel movement on 4/3/18, 4/13/18, and 4/21/18; - from 5/1/18 through 5/30/18, staff charted the resident had a bowel movement on 5/7, 5/13, 5/15, 5/25, and 5/26/18. Review of resident #30's Social Service and MDS Coordinator notes, both dated 5/4/18, showed the resident was often constipated and received milk of magnesia. Both notes showed the resident independently used the bathroom. During an interview on 5/31/18 at 8:16 a.m., staff member B stated resident #30, usually, used the toilet on his own. The staff were not always aware if the resident had a bowel movement. The facility did not have a bowel protocol and the staff member went with a person-centered approach. Review of resident #30's care plan, initiated on 4/30/18, showed the resident had impaired cognitive function, would receive cares, and the resident needed assistance with all decision making. Related to the risk of skin injury, the staff needed to monitor during toileting and incontinence care. The start date for that intervention was 5/3/18. The resident's care plan did not recognize his need for monitoring his bowel regimen for constipation problems.",2020-09-01
581,COMMUNITY NURSING HOME OF ANACONDA,275065,615 MAIN ST,ANACONDA,MT,59711,2018-05-31,685,D,0,1,YBEO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to reschedule a visual examination for a resident who missed an examination while hospitalized for [REDACTED].#26) of 12 sampled residents. Findings include: During an interview and observation on 5/29/18 at 2:30 p.m., resident #26 stated she needed cataract surgery to her right eye. The right eye was observed to have a white, opaque covering over the pupil and the iris. Resident #26 stated she needed to be examined by an eye doctor because her left eye was torn and separating. The left eye was noted to appear to have a gap along the outer canthus, and was severely reddened adjacent to the apparent gap. Resident #26 was unable to consistently state if her visual status had declined. Review of resident #26's progress notes, dated 3/22/18 - 4/5/18, showed monitoring of the left eye due to bulging and drainage. The notes showed resident #26 had an eye examination scheduled for 3/29/18. The notes showed resident #26 was transferred to the hospital for an unrelated issue on 3/24/18, and returned to the facility on [DATE]. During an interview on 5/31/18 at 11:33 a.m., staff member B stated she was not aware resident #26 had missed an eye examination, and there should have been follow-up completed to reschedule the appointment after the resident returned from the hospital.",2020-09-01
582,COMMUNITY NURSING HOME OF ANACONDA,275065,615 MAIN ST,ANACONDA,MT,59711,2018-05-31,695,D,0,1,YBEO11,"Based on observation, interview, and record review, the facility failed to clean oxygen concentrators being used to provide supplemental oxygen for 2 (#s 26 and 27) of 12 sampled residents, which may compromise the resident's respiratory function, and contribute to complications, such as infection. Findings include: 1. a. During an interview and observation on 5/29/18 at 2:37 p.m., resident #26 was observed to be receiving oxygen via a nasal cannula. She stated the staff changed the oxygen tubing regularly, but could not state if anyone cleaned the concentrator. A sticker on the tubing was dated 5/1, and a card on the back of the concentrator showed the last documented service date was 4/28/17. There was visible dust hanging from the vent-type openings on the back of the concentrator, and a fine white powdery substance on the filter door, covering the small air-inlet holes. The powdery substance fell away when brushed with a gloved finger. During an observation and interview on 5/31/18 at 8:55 a.m., staff member B observed the concentrator and stated it was dusty with loose dust falling from the openings on the back of the concentrator, and a fine, white substance on the air-inlet holes on the filter door. She stated the condition of the concentrator was not acceptable practice, and they needed to determine who should be providing routine cleaning to the concentrator. b. During an observation on 5/29/18 at 11:45 a.m., resident #27 was observed receiving oxygen, via a nasal cannula, with an oxygen concentrator. During an observation on 5/30/18 at 12:17 p.m., resident #27's oxygen tubing was not dated. There was dust visible on the vent-type openings on the back of the concentrator. There was a thick layer of a fine, white powdery substance on the filter door covering the air-inlet holes. During an interview and observation on 5/30/18 at 4:55 p.m., staff member A observed resident #27's concentrator. She stated it had dust on the openings on the back of the concentrator, and a fine, white substance on the air-inlet holes of the filter door. She stated the concentrator was not clean and did not meet her expectations. During an interview on 5/30/18 at 5:00 p.m., staff member A stated she thought (the oxygen supply vendor) was maintaining the oxygen equipment but was not sure of the process or what cleaning and maintenance was done by the facility vs what was done by the supplier. Staff members A and B stated there was no evidence of the concentrators being cleaned. Review of the manufacturer's instructions, provided by the facility, for cleaning the concentrator showed: - Periodically, use a damp cloth to wipe down the exterior case of the (concentrator brand.) - The filter door has small holes where outside air enters the unit. At least once each week, use a damp cloth to wipe down this area and make sure the holes are unobstructed.",2020-09-01
583,COMMUNITY NURSING HOME OF ANACONDA,275065,615 MAIN ST,ANACONDA,MT,59711,2018-05-31,761,E,0,1,YBEO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to dispose of expired stock supplies, stored a beverage with the medications, failed to maintain an accurate label on a topical medication for 1 (#24); and failed to label time-sensitive inhaled medications with an opened date for 4 (#s 4, 5, 28, and 30) of 17 sampled and supplemental residents. Findings include: 1. During an observation of medication administration on [DATE] at 11:02 a.m., staff member F applied Votaren gel 1% to resident #24's knees. Resident #24 declined application of the gel to his hips. Review of resident #24's [MEDICATION NAME] Gel label showed an order to apply the gel topically to the resident's hip and knees four times a day as needed for pain. Staff member F stated the order had changed, and was no longer ordered on an as needed' basis, but was scheduled. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. The order date was [DATE]. The order documented on the gel's label did not match the order documented on the physician's orders [REDACTED].>During an interview on [DATE] at 11:20 a.m., staff member F stated the pharmacy should have sent a new label when the order changed, and the directions on the current label could lead to an administration error. 2. During an observation and interview on [DATE] at 11:16 a.m., staff member C administered [MEDICATION NAME] Respimat inhaler to resident #4. The medication canister showed a space to write the discard date. The space for the date was blank. The label showed a dispensed date of [DATE]. Staff member C stated she did not know the time frame for when to discard the medication. She stated she would, .keep it until it was used up. Review of the manufacturer's package insert showed the medication was to be discarded after 90 days, even if there was still medication remaining. 3. During an observation of the medication storage room refrigerator on [DATE] at 9:50 a.m., the following were observed: - A frozen 15.2-ounce bottle of Mighty Mango Naked juice, in the freezer compartment; - An opened box of [MEDICATION NAME] high dose individual flu vaccines, expiration date ,[DATE], with one dose remaining; - A box of 12 hemorrhoid suppositories with an expiration date of ,[DATE]. During an interview on [DATE] at 9:53 a.m., staff member F stated the night shift nurses were to check for outdated items on Wednesday and Sunday nights when re-ordering was done. During an observation of the medication cart on [DATE] at 10:00 a.m., the following were observed: - An [MEDICATION NAME] Diskus inhaler ,[DATE] mcg which was opened and not dated. The label showed the name of resident #5, dosing instructions for one puff twice a day, and a dispensed date of [DATE]. The counter on the diskus showed 51 doses remaining. - An [MEDICATION NAME] Diskus inhaler ,[DATE] mcg which was opened and not dated. The label showed the name of resident #4, dosing instructions, and a dispensed date of [DATE]. The counter showed 42 doses remaining. - An [MEDICATION NAME] Diskus inhaler ,[DATE] mcg which was opened and not dated. The label showed the name of resident #30, dosing instructions, and a dispensed date of [DATE]. The counter showed 42 doses remaining. - A Breo Elipta inhaler ,[DATE] mcg which was opened and not dated. The label showed the name of resident #28, dosing instructions, and the dispensed date of [DATE]. The counter showed 23 doses remaining. During an interview on [DATE] at 10:10 a.m., staff member F stated the [MEDICATION NAME] Diskus packaging showed the medication expires 30 days after opening the foil wrapper. She stated a nurse would not know when the medication was expired if the diskus inhaler was not labeled with the opening date. Staff member F stated the Breo Elipta had an area to document the open and discard dates on the medication canister, but the spaces were blank. She stated the packaging instructions showed the medication expires six weeks after opening, and the canister should be labeled with the dates so the medication was not used after it had expired.",2020-09-01
584,COMMUNITY NURSING HOME OF ANACONDA,275065,615 MAIN ST,ANACONDA,MT,59711,2018-05-31,867,F,0,1,YBEO11,"Based on interview and record review, the facility failed to implement appropriate plans of action to correct identified quality deficiencies which could affect all residents in the facility. Findings include: 1. a. Review of the QAPI committee meeting minutes, dated 9/7/17, showed the committee had met and: - reviewed medication variance; - the infection control report; - citations from the regulations cited during the recertification survey; - discussed the Food and Nutrition Bowel Regime project. The project would be reported on during the next meeting. - reviewed the Nursing QAs Quality measures; - continued to work on information gathering to understand the numerator/denominator and exclusion/inclusion criterion. - old business consisted of the need for education, focusing on geriatrics and dementia. No documentation was available showing the implementation of appropriate action plans to correct identified deficiencies. There was no documentation showing the QAPI committee had systems in place to ensure the facility took the necessary steps to identify the cause and correct the issues. The committee did not have a system for monitoring departmental performance data routinely in order to identify deviations in performance and adverse events. b. No documentation was available for the 12/17 QAPI quarterly committee meeting having been held. During an interview on 5/31/18 at 10:29 a.m., staff members A and B stated the quality assurance committee should have met in (MONTH) (YEAR), but neither staff member had their positions at that time and were not sure if the meeting had occurred. c. Review of QAPI committee minutes, dated 3/15/18 showed the committee; - reviewed the medication variance and infection control report but did not identify the concerns or the implementation of plans to correct any identified deficiencies. - mentioned audits being continued for improving feeding practices; - identified the need for medication time changes, wanting less times to have to pass medications and; - brought up resident/family satisfaction surveys as a project along with the need to increase the facility census. There was no documentation showing the committee had put systems in place to monitor the performance data routinely and identify and correct quality deficiencies. During an interview on 5/31/18 at 10:29 a.m., staff member B stated there were too many medication pass times. No project had started. The staff member stated she had not decided on details of the plan. Staff member A and B stated the committee had not identified any of the concerns brought up during the current recertification survey.",2020-09-01
585,COMMUNITY NURSING HOME OF ANACONDA,275065,615 MAIN ST,ANACONDA,MT,59711,2018-05-31,868,F,0,1,YBEO11,"Based on interview and record review, the facility failed to meet at least quarterly as a committee to identify issues and concerns of the facility for the ongoing quality of care of all residents. Findings include: Review of the Quality Assurance and Performance Improvement Committee Minutes dated 9/7/17 and 5/15/18, showed no documentation the committee had met in-between the two dates. The two meetings were eight months apart. During an interview on 5/31/18 at 10:29 a.m., staff members A and B stated they were not aware if the committee had met in (MONTH) or as neither one were in their positions during that time.",2020-09-01
586,COMMUNITY NURSING HOME OF ANACONDA,275065,615 MAIN ST,ANACONDA,MT,59711,2018-05-31,880,E,0,1,YBEO11,"Based on observation, interview, and record review, the facility failed to use standard hand hygiene practices to prevent the potential spread of infection for 3 (#s 1, 4, and 14) of 17 sampled and supplemental residents. Findings include: 1. a. During an observation on 5/30/18 at 7:31 a.m., staff member C pushed the medication cart down the hallway, to resident #1's room. She utilized a computer keyboard to access resident #1's physician's orders, and prepared his insulin for injection, by accessing drawers in the medication cart. She knocked on the door frame and entered resident #1's room. Staff member C donned gloves, without hand hygiene, and administered the resident's insulin injection. During an observation on 5/30/18 at 11:12 a.m., staff member C pushed the medication cart down the hallway, to resident #14's room. She utilized a computer keyboard to access resident #14's physician's orders, and prepared his eye drops for administration by accessing drawers in the medication cart. She knocked on the door and entered resident #14's room. Staff member C donned gloves, without hand hygiene, and administered the resident's eye drops. During an interview on 5/30/18 at 2:32 p.m., staff member C stated she did not think she had to wash or sanitize her hands before she left a room and when she entered a different room. She stated she had washed her hands prior to leaving the previous room, and thought that was all that was needed. She stated she did handle her keys, return and remove items from the medication cart, document in the computer, and push the cart prior to entering the room, and her hands could be contaminated. She stated she did not know what the facility policy showed regarding if she needed to wash her hands before donning gloves. b. During an observation and interview on 5/31/18 at 11:11 a.m., staff member F pushed the cart to resident #4's doorway. She accessed resident #4's physician's orders utilizing a computer keyboard, and prepared eye drops and an inhaler for administration. She knocked on the resident's door and entered. Staff member F donned gloves, without hand hygiene, and administered the medications. Staff member F stated she should have washed her hands before donning the gloves. During an interview on 5/30/18 at 4:35 p.m., staff members A and B stated hand hygiene training was done upon hire, annually, and as needed. Staff member A stated it was her expectation for nurses to wash or sanitize their hands when entering a room to provide medication, treatment, or other procedures. Review of the facility policy, with the subject, Hand Hygiene, showed, Use alcohol-based hand rub or wash hands with soap and water before and after having direct contact with patients or contact with objects in patient's rooms. The expectation is the health care provider will perform hand hygiene upon entry and exit of the patient's room. Note: Hand hygiene performed once after one patient and before the next patient is sufficient to decontaminate your hands if you are not re-contaminating your hands in between patients (touching the telephone, charts, or keyboard, etc.).",2020-09-01
587,COMMUNITY NURSING HOME OF ANACONDA,275065,615 MAIN ST,ANACONDA,MT,59711,2019-09-05,645,D,0,1,YQK111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete and document a PASRR Level II screening for 1 (#14) of 22 sampled residents, which resulted in the resident not being screened appropriately and provided the necessary services for the resident's mental health needs. Findings include: Resident #14 was admitted to the facility with the following Diagnosis: [REDACTED]. During an observation and interview on 9/3/19 at 2:30 p.m., resident #14 stated in a very loud and enraged tone of voice, about how angry he was with his nephew and how he ended up at the facility after several moves from other facilities. Resident #14 repeated himself with increased volume and use of profanities as he told of his frustrations with his nephew and family, and the treatment of [REDACTED]. During an interview on 9/4/19 at 1:33 p.m., staff member A stated the facility's Social Worker left employment at the facility in (MONTH) of (YEAR), and the facility management had chosen to not fill the Social Worker position. She said since the facility did not have a Social Worker, the PASRR Level II was not completed for resident #14. Review of resident #14's medical record showed a PASRR Level I Screen dated 9/28/18, had been completed by the facility's Social Worker, and determination approved for referral for a Level II screen. The Level I Screen showed [MEDICAL CONDITION] as the serious mental illness diagnosis, and [MEDICATION NAME] as the antipsychotic medication taken by the resident.",2020-09-01
588,COMMUNITY NURSING HOME OF ANACONDA,275065,615 MAIN ST,ANACONDA,MT,59711,2019-09-05,686,D,0,1,YQK111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish physician orders [REDACTED].#76) of 22 sampled residents. Findings include: During an observation on 9/3/19 at 3:00 p.m., resident #76 had one Stage II pressure ulcer on her right sacrum which measured 4x4 cm round, with a macerated skin flap which pulled away with the dressing. She had a second Stage II pressure ulcer on her left sacrum, which measured 4x4 cm round. The resident also had a third Stage I pressure ulcer on her right ischium. Staff member B pressed on the Stage I pressure ulcer and noted it did not blanch. Staff member B applied a clean dressing to the three pressure ulcers. Review of resident #76's Admission Skin Assessment, dated 8/27/19, showed the right buttock had one Stage II pressure ulcer which measured 2 cm in length and 2 cm in width. The Admission Skin Assessment did not mention the Stage I pressure ulcer on the resident's ischium or the Stage II pressure ulcer on the resident's left buttock. During an interview on 9/3/19 at 3:30 p.m., resident #76's family member stated the resident was recently admitted to the facility on hospice. He stated the resident was admitted with a pressure ulcer on her buttock, but was not aware if it had improved or worsened since the resident was admitted to the facility. Review of resident #76's Skin Assessment, dated 9/4/19, showed the resident had one Stage II pressure ulcer on her right buttock, which measured 4 cm in length, 4 cm in width, and 0.5 cm in depth. A second Stage II pressure ulcer on her left buttock which measured 4 cm in length, 4 cm in width, and 0.5 cm in depth. The third Stage I pressure ulcer on the resident's ischium was not mentioned in this skin assessment. A review of resident #76's nursing progress notes from 9/3/19 to 9/5/19, did not show documentation regarding the third Stage I pressure ulcer on the resident's ischium. Review of resident #76's Treatment Administration Record, failed to show orders for wound treatment and monitoring for the pressure ulcers. The record failed to show any wound care orders were obtained from the time the patient was admitted until 9/5/19. Review of resident #76's Physician Orders, failed to show an order for [REDACTED]. Review of resident #76's Hospice Treatment Orders, failed to show an order in the resident's chart for treatment and monitoring of the resident's three pressure ulcers. During an interview on 9/5/19 at 8:37 a.m., staff member B stated they would follow the facility's standing orders for treatment of [REDACTED]. She stated since resident #76 was on hospice, they relied on hospice to manage and treat the resident's pressure ulcers. She stated she was not sure what the current orders were for treating or monitoring resident #76's pressure ulcers. She stated she failed to document her 9/3/19 findings of the Stage I pressure ulcer on the resident's ischium. During an interview on 9/5/19 at 9:02 a.m., staff member A stated it was the expectation the staff obtain physician orders [REDACTED]. She stated if a resident was admitted to the facility with a pressure ulcer, they would follow the facility's standing orders for pressure ulcers until they obtained a physician order [REDACTED]. She stated it was the expectation for staff to follow the standing orders for pressure ulcers until a physician order [REDACTED]. The facility failed to obtain wound treatment orders for resident #76, from the time of her admission on 8/27/19 to 9/5/19. A review of the facility's Standing Nursing Orders for pressure sores, showed, Nursing will: - Assess the area (at a minimum of weekly) - If Stage I, gently apply moisturizing cream and keep pressure off area as much as possible - If Stage II, cleanse area with normal saline solution or would cleanser, dabbing area (DO NOT RUB), then applying protective dressing. Nursing will assess the pressure sore and contact Physician for further care as needed (sic) A review of the facility's Skin Protocol, showed: 1. Skin issues to be reported include pressure areas, vascular ulcers, skin tears, hematomas, boils, blisters, open wounds, etc. MT (Medication/ Treatment) nurse logs new skin issue into the Active Wounds List on the S: Drive. The MT nurse is responsible for skin issue assessments and prescribing treatment per standing orders. Pressure areas are not to be Staged until assessment by the RN charge nurse, MDS RN or Skin/Wound RN. If an area appears to be the result of pressure notify the RN charge nurse through verbal or written communication (STOP AND WATCH). 2. The MT nurse enters skin incident under 'Risk Management', completes initial 'Wound Assessment' in Point Click Care, and places the resident on alert charting. The MT nurse writes a Physician order [REDACTED]. At the end of the order, state that the order can be dc'd when the area is healed (this way, another order doesn't need to be written to stop the treatment). When addressing skin issues that appear pressure related, describe the skin as found, including measurements but do not Stage, prescribe a dressing such as Allevyn to cushion the area until further assessment by the RN(s). Regardless of the time of day that the incident occurs, the MT /Charge nurse will notify the family/responsible party. Be sure that the communication is documented (also include the form in which they were notified i.e. spoke to, message left, in person, etc.) . 3. The physician's orders [REDACTED]. If the order contains an antibiotic ointment or similar, then the order will need to be faxed to Pharmacy and they will enter the antibiotic order in the MAR. It is still the MT /charge nurse's responsibility to place the order in the TAR. Any changes in skin treatment orders require that a new physician's orders [REDACTED]. Discontinues the previous treatment order and 2. Identifies the new prescribed treatment. The new order is then faxed to the primary physician on an SBAR with the update as an FYI. 4. During the course of the skin issue treatment, the MT nurse will follow the daily treatment as directed on the Treatment Administration Record (TAR); the MT nurse will summarize the skin issue condition and treatment, as well as monthly on the nursing Monthly Summary until it is resolved. 5. The RN charge nurse will provide a weekly review of all skin issues. The RN will update/complete the Wound Assessment weekly A review of the facility's policy and procedure titled, Prevention of Skin Injury/Pressure Ulcers, showed, .C. For Stage I pressure sores, follow preventive measures. D. For Stage 1 pressure sores will be as follows: 1. Cleanse the open areas with normal saline or cleansing solution with a cotton ball or sterile gauze. Dab the area, do not rub. Pat the area dry with a sterile gauze. Apply the appropriate treatment. a. Check area for evidence of would infection b. Wound base free of non-viable tissue. c. Wound with evidence of healing. d. Wound pain management. 2. Check the pressure ulcer area every shift and/or dressing. 3. If removing adhesive dressings, gently peel from outer edges inward or as directed. 4. Follow preventive measures. 5. Physical therapy and/or wound care nurse may be asked to assess the area .",2020-09-01
589,COMMUNITY NURSING HOME OF ANACONDA,275065,615 MAIN ST,ANACONDA,MT,59711,2019-09-05,727,F,0,1,YQK111,"Based on interview and record review, the facility failed to ensure the roles of administrator and director of nursing were clearly defined and documented in facility policies, and failed to ensure the director of nursing was working full-time for 35 or more hours per week. This had the potential to affect all residents in the facility, with the lack of designation of administrator and director of nursing duties to ensure completion of all necessary resident cares and treatments in the facility. Findings include: During an interview on 9/3/19 at 1:28 p.m., staff member A stated she was the DON, and the Administrator at the facility, and staff member C assisted her with the necessary duties of her two roles. Staff member A stated she worked ten hour shifts on Monday thru Thursday and was on call after hours, and staff member C worked ten hour shifts on Tuesday thru Friday. Staff member A stated there were no specific roles defined for each role of the DON, and the Administrator, and there were no timesheet notations for the separate positions. Staff member A stated she was hired as the DON, and the Administrator Training, in (MONTH) of (YEAR). When staff member A received her permanent nursing home administrator license in (MONTH) of 2019, the former facility Administrator left the position at the facility. During an interview on 9/5/19 at 7:44 a.m., staff member A stated her combined position as the DON and the Administrator was a salaried position, and staff member C's position was an hourly position. Staff member A stated she did not split her time between her two roles as the DON, and the Administrator on the facility's timesheets. Staff member A stated she felt like she wore both hats of DON and Administrator every second of the day, and took care of what needed to be done at the facility. Staff member A stated she worked very closely with staff member C, and they had a verbal agreement on what needed to be done on a daily basis at the facility, but they had no formal, written documentation detailing their shared job duties and responsibilities. Review of the facility's CASPER Report 1702D, for the period of 6/1/19 thru 6/30/19, showed no system employee ID or Job Title listing for the Facility Administrator or staffing hours for that position. Registered Nurse Director of Nursing (Exempt), and Registered Nurse Director of Nursing (Non-Exempt) were listed on the report for staff member A and staff member C, and hours were reported for both positions. The report showed staff member A's hours as 160 and staff member C's hours as 147.50 for the period of 6/1/19 thru 6/30/19.",2020-09-01
590,GALLATIN REST HOME,275066,1221 W DURSTON RD,BOZEMAN,MT,59715,2017-06-08,278,D,0,1,P2FD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately code the use of an external catheter on an MDS for 1 (#8) of 14 sampled residents. Findings include: 1. Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation and interview on 6/5/17 at 9:41 a.m., the resident was seated in a wheelchair, in his room, with the door open. The resident had a covered catheter bag attached to a bar under the wheelchair. Staff member T stated the resident had used a condom catheter for many years due to incontinence of urine. A review of resident 8's Annual MDS, with an ARD of 12/19/16, in section H0100 Bowel and Bladder, reflected the resident used an external catheter. A review of resident 8's Quarterly MDS, with an ARD of 3/20/17, in section H0100 Bowel and Bladder, reflected the resident did not use an appliance for incontinence. During an interview on 6/7/17 at 11:30 a.m., staff member G stated, the Quarterly MDS, with an ARD of 3/20/17, in section H0100, should have been coded as having an external catheter. The staff member stated, I cannot imagine he did not have a catheter during the look back period of this MDS.",2020-09-01
591,GALLATIN REST HOME,275066,1221 W DURSTON RD,BOZEMAN,MT,59715,2017-06-08,279,D,0,1,P2FD11,"**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 comprehensive person-centered care plan for 2 (#s 1 and 2) out of 14 sampled residents. Resident #1 wore a partial and had difficulty chewing, and resident #2 physically resisted care by hitting and kicking staff, and exhibited inappropriate sexual behaviors. Findings include: 1. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #1's diet order, dated 1/6/17, reflected a regular mechanical soft diet, with small chopped and ground food. Review of resident #1's admission Nursing Evaluation/Data Collection form, dated 12/21/16, reflected under the oral assessment the resident had an upper partial. Review of resident #1's admission Nutrition Assessment form, dated 12/28/16, 2/28/17, and 5/22/17, reflected the resident had chewing and swallowing problems. Review of resident 1's care plan, with a review date of 5/26/17, did not reflect the resident had an upper partial. In the oral care section of the care plan, the area labeled Own Teeth had the box checked for both upper and lower. During an interview and observation on 6/6/17 at 1 p.m., the resident reported concerns for her diet and the food she was served. The resident explained she had a partial denture on the top of her mouth and missing molars. The resident explained she needed soft foods, and had to be careful with her diet. The resident explained she had difficulty chewing and, the kitchen knew she needed her food chopped and soft. The resident still had her lunch tray on her bedside table. The resident stated the potatoes and carrots in her soup were still raw and hard so she didn't eat them. The resident stated her food was not frequently softened, especially the vegetables. The resident asked the surveyor to try to cut through the potatoes and carrots she left in her bowl of soup. The potatoes were observed to be soft on the very outside, but crunchy raw in the middle portion. The carrots were observed to be hard to cut and rubbery. The resident stated she did not eat her sandwich, as it was slices of ham, and she could not chew it. The sandwich was observed to be made with slices of ham that were not chopped into small pieces. The resident stated she needs to have a sandwich such as tuna or chicken salad. During an interview on 6/7/17 at 2:10 p.m., staff member H stated the care plan was not correct and the current care plan was changed to reflect the resident had dentures. Staff member H added to the care plan the resident had trouble chewing, and to offer foods that did not require extensive chewing. During an interview on 6/8/17 at 9:20 a.m., staff member D stated the ham sandwich was an error on the kitchen's part. She stated the kitchen normally had tuna or ham salad made prior to lunch but had run out. She stated the kitchen staff made a sliced ham sandwich instead. 2. Resident #2 was admitted with [DIAGNOSES REDACTED]. Review of resident #2's nurse's notes from admission to current reflected several entries of rejection of care and sexually inappropriate behaviors, which included. Resisting Care 1 incident in (MONTH) (YEAR) 3 incidents in (MONTH) (YEAR) 4 incidents in (MONTH) (YEAR) 1 incident in (MONTH) (YEAR) 3 incidents in (MONTH) (YEAR) 1 incident in (MONTH) (YEAR) 4 incidents in (MONTH) (YEAR) 1 incident in (MONTH) (YEAR) 2 incidents in (MONTH) (YEAR) Sexually Inappropriate Behavior 8 incidents in (MONTH) (YEAR) 10 incidents in (MONTH) (YEAR) 3 incidents in (MONTH) (YEAR) 6 incidents in (MONTH) (YEAR) 2 incidents in (MONTH) (YEAR) 4 incidents in (MONTH) (YEAR) 2 incidents in (MONTH) (YEAR) Review of resident 2's Significant Change MDS, with the ARD of 12/19/16, reflected the resident was resistant to care during the seven day look back period on 12/17/16. Review of resident 2's Significant change MDS, with the ARD of 3/20/17, reflected the resident was dependent upon staff for all ADL care, received his nutrition through a Peg tube, and required a lift for transfers. Review of resident 2's care plan, under the Problems heading, reflected the resident could be sexually inappropriate with an intervention for staff to tell him the sexual comments are not appropriate. The care plan did not reflect measurable goals to determine if the behavior would be decreased. The interventions did not address other options for staff when the behavior continued or occurred repeatedly. A second entry, under the Problems heading, reflected the resident did not like being alone, has hit and kicked staff, and smeared feces. The care plan did not reflect measurable goals for to determine if the behavior to decrease, or what steps staff would take to address the behavior to protect themselves from repeated physical abuse, and address the resident's reactions to care needing to be provided by staff. During an interview on 6/8/17 at 2:25 p.m., staff member G stated she would look at the MDS triggers related to a nurse's note, dated 12/17/16, that reflected the resident resisted care and tried to hit the CNA assisting him. Staff member G submitted information and stated the behavior was not considered rejection of care in the nurse's note for 12/17/16, because even though the resident tried to hit the CNA, it did not reflect that the care was not completed. During an interview on 6/8/17 at 4:00 p.m., NF3 stated the resident does not liked to be moved and will resist care. During an interview on 6/6/17 at 12:00 p.m., staff member C stated she did not complete the care plans for any resident that had history of depression. During an on 6/6/17 at 2:00 p.m., staff member G stated she also completed the care plans for any resident on an anti-depressant medication, but only documented interventions related to the medications effectiveness, side effects, and information related to risks and benefits.",2020-09-01
592,GALLATIN REST HOME,275066,1221 W DURSTON RD,BOZEMAN,MT,59715,2017-06-08,281,E,0,1,P2FD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to document efficacy of prn medications for 4 (#s 1, 7, 15, and 17), failed to contact the physician with blood glucose levels that were out of range for 1 (#18), and failed to have licensed nursing staff administer and document the use of topical medications for 1 (#8) of 18 sampled and supplemental residents. This had the potential to affect all residents receiving prn medications, blood glucose checks, and administration of topical prescription drugs in the facility. Findings include: 1. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #1's Medication Administration Record for the month of (MONTH) (YEAR) reflected the resident was administered [MEDICATION NAME] for pain 17 times without the efficacy of the medication documented. The (MONTH) (YEAR) MAR reflected the resident was administered [MEDICATION NAME] for anxiety 16 times without the efficacy of the medication documented. During an interview on 6/7/17 at 1:50 p.m., staff member H stated when prn medication was administered the nurse is to document 1-2 hours later, to show if the medication was effective. 2. Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. A review resident 7's MAR, and nursing notes, for (MONTH) (YEAR), reflected staff administered PRN medications on the follow days without documentation of the efficacy for [MEDICATION NAME] 0.25-0.5 mgs every 3 hours PRN, and [MEDICATION NAME] 2.5-5 mgs every 4 hours PRN: - 5/19/17 - 5/20/17 - 5/22/17 - 5/23/17 - 5/24/17 - 5/26/17 - 5/28/17 - 5/29/17 - 5/31/17 A review of the resident's MAR, for (MONTH) (YEAR), reflected staff administered PRN medications on the follow days without documentation of the efficacy for [MEDICATION NAME] 0.25- 0.5 mgs every 3 hours PRN, and [MEDICATION NAME] 2.5-5 mgs every 4 hours PRN: - 6/4/17 During an interview on 6/5/17 at 4:35 p.m., staff member H stated the efficacy for all PRN medications should be documented on the PRN medication sheet within one hour of administration. 3. Resident #15 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the resident's MAR, and nursing notes, for (MONTH) (YEAR), reflected staff administered PRN medications on the follow days without documentation of the efficacy for [MEDICATION NAME] 5-10 mgs every 4 hours PRN, and Tylenol 650 mgs every 4 hours PRN: - 5/24/17 - 5/25/17 - 5/26/17 - 5/27/17 - 5/30/17 - 5/31/17 During an interview on 6/5/17 at 4:38 p.m., staff member T the efficacy for all PRN medications should have been documented on the PRN medication sheet within 20 minutes after administration. 4. Resident #17 was admitted to the facility with [DIAGNOSES REDACTED]. A review of resident 17's MAR, and nursing notes, for (MONTH) (YEAR), reflected staff administered PRN medications on the follow days without document the efficacy for [MEDICATION NAME] 2.5- 5 mgs every 4 hours PRN: - 6/1/17 During an interview on 6/5/17 at 4:42 p.m., staff member I stated the efficacy for all PRN medication should be documented on the PRN medication sheet within one-two hours of administration. 5. Resident #18 was admitted to the facility with [DIAGNOSES REDACTED]. A review of resident #18's Physician Orders, dated (MONTH) (YEAR), read, 4/13/15- Contact MD if FSBS is less than 100. A review of resident 18's MAR, for (MONTH) (YEAR), reflected fasting blood glucose levels below 100 on: - 4/3/17- her sugar was 94. The physician was not notified per nurses notes. - 4/7/17- her sugar was 97. The physician was not notified per nurses notes. - 4/11/17- her sugar was 98. The physician was not notified per nurses notes. - 4/19/17- her sugar was 93. The physician was not notified per nurses notes. - 4/23/17- her sugar was 97. The physician was not notified per nurses notes. A review of resident 18's MAR, for (MONTH) (YEAR), reflected fasting blood glucose levels below 100 on: - 5/17/17- her sugar was 94. The physician was not notified per nurses notes. - 5/25/17- her sugar was 89. The physician was not notified per nurses notes. During an interview on 6/8/17 at 1:45 p.m., staff member G stated the physician should have been notified of fasting blood glucose levels below 100. The staff member stated nurses did not document physician notification of fasting blood glucose levels below 100. A review of the facility's policy, Charting and Documentation, page 1, read, 1. All observations, medications administered, services performed, etc., must be documented in the resident's clinical record. 6. Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. A review of resident 8's MAR and TAR, for (MONTH) and (MONTH) (YEAR), did not show evidence that staff had been documenting the use of the Trivase 2% cream PRN. A review of Skin Integrity Nurses Notes, dated 12/5/16, read, Type of skin issue: excoriation of scrotum (2 x 2 cm) and penis (1 x 1 cm). Exudate: none. Wound bed description: red. Pain: yes. Resident's response: wears condom cath (sic), suggesting only day use off at HS. Treatment provided: cleanse, Trivase. During an observation on 6/6/17 at 9:53 a.m., a two ounce tube of Trivase 2% cream was in the resident's room. The cream had just been used by staff member M during the perineal morning care. The resident wore a condom catheter. His scrotum was bright red, and there was a small, superficial, open area, approximately 0.5 cm x 0.5 cm to the base of his penis, just left of the scrotum raphe. The resident's skin on his buttocks were red. During an interview on 6/6/17 at 11:00 a.m., staff member U stated only licensed nurses were allowed to apply Trivase cream to the resident's skin. The staff member stated Trivase 2% cream is a prescription, and it is kept locked in the medication cart. The staff member had not been informed that a tube of Trivase 2% cream was being kept in the resident's room. During an interview on 6/6/17 at 1:45 p.m., staff member M stated she had applied the Trivase 2% cream to the resident's scrotum. The staff member stated she had not received instructions on the application of the cream, and did not know if a skin assessment was required when applying the cream to inflamed skin. The staff member did not know what Trivase 2% cream was, but stated it had been prescribed for use on the resident. During an interview on 6/7/17 at 9:25 a.m., staff member O stated she had applied the Trivase 2% cream to the resident's scrotum in the past. The staff member stated she had not received instructions on the application of the cream, and did not know if a skin assessment was required when applying the cream to inflamed skin. The staff member did not know what Trivase cream was, but stated it had been prescribed for use on the resident. At 9:30 a.m., staff member O stated only licensed nurses should have been applying Trivase cream to the resident. During an interview on 6/7/17 at 9:37 a.m., staff member N stated she had applied the Trivase 2% cream to the resident's scrotum in the past. The staff member stated she had not received instructions on the application of the cream, and did not know if a skin assessment was required when applying the cream to inflamed skin. During an observation on 6/7/17 at 9:40 a.m., staff member G entered the resident's room with a tube of Trivase 2% cream. The staff member donned clean gloves, and applied a small about to the resident's scrotum and buttocks. The staff member exited the resident's room, leaving the Trivase 2% cream on the resident's night stand. At 9:45 a.m., staff member G returned to the resident's room, and removed the Trivase cream. The cream was put back into the medication cart, and the cart was locked. During an interview on 6/7/17 at 9:57 a.m., staff member N stated the facility CNAs applied the Trivase 2% cream to the resident's scrotum and buttocks. The staff member did not know what Trivase was, but stated it had been prescribed for use on the resident. During an interview on 6/7/17 at 10:40 a.m., staff member H stated only licensed nurses should be applying Trivase cream to the resident's skin. The staff member stated Trivase 2% cream is a prescription, and therefore not used by CNA staff. A review of resident 8' TAR on 6/7/17 at 4:31 p.m., showed Trivase crm (sic) to perianal (sic) area BID PRN for skin irritation S.P (sic) (Standing Precautions). A return phone call from NF2 was received on 6/13/17 at 12:52 p.m. NF2 stated Trivase cream should be applied by a licensed nurse, not a CN[NAME] A review of the facility's policy, in the Nursing Services Policy and Procedure Manual for Long-Term Care, for Administering Topical Medications, page 54, read, Preparation 1. Verify that there is a physician's medication order for this procedure .Equipment and Supplies 1. Medication Administration Record. Steps in the procedure 4. Unlock the medication cart. 6. Check the label on the medication and confirm the medication name and dose with the MAR. Documentation- Follow documentation guidelines in the procedure entitled Documentation of Medication Administration. References Standards for nursing practice for administration of medication provide, in pertinent part that: Medications must be accurately administered and documented. Accurate administration includes transcribing the drug order correctly, delivering the correct drug, to the correct resident, by the correct route, in the correct dose. Accurate documentation involves recording information on the drug administered, including the client's response to the medication. Lippincott, Nursing Drug Guide, 1998 (Lippincott) and Perry & Potter, Clinical Nursing Skills & Techniques; 1998, (Perry & Potter). Nurses are obligated to follow the orders of a licensed physician or other designated health care provider unless the orders would result in client harm. DeLaune, S. & Ladner, P. (1998). Fundamentals of Nursing, Standards and Practice (p.237). Albany, N.Y.",2020-09-01
593,GALLATIN REST HOME,275066,1221 W DURSTON RD,BOZEMAN,MT,59715,2017-06-08,329,D,0,1,P2FD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility failed to ensure a resident was free from unnecessary medications by failing to assess and monitor adverse behaviors indicated for the use of an antianxiety medication, to show the medication was necessary for treatment of [REDACTED]. This had the potential to affect all residents receiving antianxiety medications without the assessment and monitoring for adverse behaviors indicated. Findings include: 1. Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. The resident did not have a [DIAGNOSES REDACTED]. A review of resident 7's MAR, for (MONTH) (YEAR), reflected staff administered PRN [MEDICATION NAME] 0.25-0.5 mgs every 3 hours PRN, 14 times. Staff failed to document assessments or monitoring for adverse behaviors and efficacy nine times. Review of resident #7's Admission MDS, with an ARD of 5/19/17, section E, showed the resident had no behaviors during the seven day look back period. Review of resident #7's complete medical record lacked evidence the facility had put behavior monitoring and behavioral interventions in place to assist with the reduction of [MEDICAL CONDITION] medications. During an interview on 6/6/17 at 3:40 p.m., staff member I stated resident #7 was admitted to the facility without a [DIAGNOSES REDACTED]. The staff member stated the [MEDICATION NAME] helped the resident with anxiety symptoms related to cognitive loss. She stated the resident had not exhibited behaviors while at the facility. A return phone call from NF2 was received on 6/13/17 at 12:52 p.m. NF2 stated residents receiving an antianxiety medication should have a supporting diagnosis.",2020-09-01
594,GALLATIN REST HOME,275066,1221 W DURSTON RD,BOZEMAN,MT,59715,2017-06-08,333,E,0,1,P2FD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor and date two open vials of insulin, continued to use a vial of insulin with an expiration date of 11/2016, and failed to administer insulin when sliding scale glucose readings indicated extra insulin coverage was needed for 1 (#15) of 18 sampled and supplemental residents. Findings include: 1. Resident #15 was admitted to the facility with [DIAGNOSES REDACTED]. A review of resident 15's MARs, dated (MONTH) (YEAR) and (MONTH) (YEAR), reflected missed doses of insulin for sliding scale glucose readings on: - 5/27/17; blood glucose readings were 249. The resident should have received 2 units of [MEDICATION NAME]. He received 0 units. - 5/30/17; blood glucose readings were 278. The resident should have received 4 units of [MEDICATION NAME]. He received 0 units. - 6/4/17; blood glucose readings were 214. The resident should have received 2 units of [MEDICATION NAME]. He received 0 units. During an interview on 6/8/17 at 11:20 a.m., staff member B stated the resident should have been administered doses of insulin to cover the blood glucose levels. The staff member stated all staff members administering medications were responsible for ensuring medications were not expired, and ensuring medications have a when opened date clearly written on the bottle, especially vials of insulin. 2. A review of the resident 15's MARs, dated (MONTH) (YEAR) and (MONTH) (YEAR), reflected staff administered: - [MEDICATION NAME] 4 units at breakfast, 10 units at lunch, and 14 units at dinner daily. - [MEDICATION NAME] 25 units at bedtime daily. During an observation on 6/6/17 at 2:58 p.m., of the medications carts for Hall A and B reflected the following was found: - An opened, half full, vial of [MEDICATION NAME], and an opened, half full, vial of [MEDICATION NAME]. They were found in the top right drawer of the cart. The vials were not dated when opened. - The [MEDICATION NAME] bottle had a printed manufacturer's recommended expiration date of 11/2016. During an interview on 6/6/17 at 3:05 p.m., staff member I stated all opened insulin vials must be dated when opened. The staff member stated opened vials of insulin should be used within 28 days of being opened. During an observation and interview on 6/7/17 at 8:35 a.m., the same opened vial of [MEDICATION NAME], with an expiration date 11/2016, was in the medication cart for Halls A and B. Staff member H stated she had not been aware of the [MEDICATION NAME] insulin's expiration date of, 11/2016. She stated the expired [MEDICATION NAME] was administered to resident #15 earlier that morning. The staff member stated the expired insulin vial should have been replaced prior to being used. Staff member H stated she should have checked the expiration date prior to administering earlier that morning, and stated, that's not good. During an interview on 6/7/17 at 8:38 a.m., staff member A was informed of expired insulin being administered to resident #15. The staff member stated she had not been aware of the expired insulin being administered to the resident, and would take care of it. During an interview on 6/7/17 at 2:40 p.m., staff member I stated the expired of vial of [MEDICATION NAME]had been put back into the medication cart for Hall A and B on 6/6/17. The staff member stated, staff member H had replaced the insulin from the facility's Emergency Medication Kit after administering a dose of insulin. Staff member I stated she was not thinking to replace the expired insulin when it was found the day before when the expired insulin was brought to her attention. A review of the facility's policy, Adverse Consequences and Medication Errors, page 8, read, .4. The staff and practitioner shall strive to minimize adverse consequences by: a. Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication. A review of the facility's policy, Administering Medications, page 5, read, .9. The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container. A review of the facility's policy, Disposal of Medications, page 1, read, 1. Discontinued medications, expired medications and / or medications left in the nursing facility after a resident's discharge or expiration, which do not qualify for return to the pharmacy and are not sent home with the resident, are identified and removed from the current medication supply and destroyed in a timely manner. A review of the facility's policy, Storage of Medications, page 33, read, .4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals (sic). All such drugs shall be returned to the dispensing pharmacy or destroyed.",2020-09-01
595,GALLATIN REST HOME,275066,1221 W DURSTON RD,BOZEMAN,MT,59715,2017-06-08,367,D,0,1,P2FD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prepare food in a form designed to meet individual needs for 1 (#1) resident out of 14 sampled residents. This had the potential to affect all residents who received food from the kitchen at the facility. Findings include: 1. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #1's diet order, dated 1/6/17, reflected a regular mechanical soft diet, with small chopped and ground food. During an observation and interview on 6/6/17 at 1 p.m., the resident reported concerns for her diet. The resident explained she needed things soft and had to be careful with her diet. The resident explained she had difficulty chewing and the kitchen knew she needed her food chopped and soft. The resident asked the surveyor to try to cut through the potatoes and carrots she left in her bowl of soup. The potatoes were observed to be soft on the very outside, but crunchy raw in the middle portion. The carrots were observed to be hard to cut and rubbery. The resident stated she did not eat her sandwich as it was slices of ham and she could not chew it. The sandwich was observed to be made with slices of ham that were not chopped into small pieces. The resident stated she needs to have a salad sandwich such as tuna or chicken. During an interview on 6/8/17 at 9:20 a.m., staff member D stated the ham sandwich was an error on the kitchen's part. She stated the kitchen normally had tuna or ham salad made prior to lunch but had run out. She stated the kitchen staff made a sliced ham sandwich instead.",2020-09-01
596,GALLATIN REST HOME,275066,1221 W DURSTON RD,BOZEMAN,MT,59715,2017-06-08,431,D,0,1,P2FD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor and date two open vials of insulin for 1 (#15) of 18 sampled and supplemental residents, and continued to use a vial of insulin with an expiration date of (MONTH) (YEAR). Findings include: 1. Resident #15 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the resident's MARs, dated (MONTH) (YEAR) and (MONTH) (YEAR), reflected staff administered: - Novolog three times daily; 4 units at breakfast; 10 units at lunch; and 14 units at dinner. - Lantus 25 units at bedtime daily. During an observation on [DATE] at 2:58 p.m., of the medications carts for Hall A and B reflected the following: - An opened, half full, 10 ml vial of Novolog, and an opened, half full 10 ml vial of Lantus were found in the top right drawer of the cart. The vials were not dated when opened. - The Novolog bottle had a printed manufacture recommended expiration date of ,[DATE]. During an interview on [DATE] at 3:05 p.m., staff member I stated all opened insulin vials must be dated when opened. The staff member stated opened vials of insulin should be used within 28 days of being opened. During an observation, and interview on [DATE] at 8:35 a.m., the same opened vial of Novolog, expiration date ,[DATE], was in the medication cart for Halls A and B. During an interview on [DATE] at 8:38 a.m., staff member A was informed of expired insulin being administered to resident #15. The staff member stated she had not been aware of the expired insulin being administered to the resident, and would take care of it. During an interview on [DATE] at 2:40 p.m., staff member I stated the expired of vial of Novolog insulin had been put back into the medication cart for Hall A and B. The staff member stated, staff member H had replaced the insulin from the facility's Emergency Medication Kit after administering a dose of insulin. Staff member I stated she was not thinking to replace the expired insulin when it was found the day before. A return phone call from NF2 was received on [DATE] at 12:52 p.m. NF2 stated visits to the facility are done every calendar month, and most his time is spent reviewing medications and lab work. He stated he does go through one medication cart a month, and has discussed his concerns identified with the facility. NF2 stated the facility staff should be documenting the dates of when insulin is opened, and staff should be discarding any medication exceeding the manufactures expired date. A review of the facility's policy, Storage of Medications, page 33, read, .4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals (sic). All such drugs shall be returned to the dispensing pharmacy or destroyed.",2020-09-01
597,GALLATIN REST HOME,275066,1221 W DURSTON RD,BOZEMAN,MT,59715,2017-06-08,441,E,0,1,P2FD11,"Based on observation, interview, and record review, the facility failed to clean lifts after removing them from residents rooms, and failed to clean a Maxi-lift kept in a shared bathroom for 1 (#8) and his roommate. This had the potential to affect all residents who required the use of a lift for transfers in the facility. Findings include: During an observation on 6/6/17 at 8:50 a.m., staff member N assisted a resident with a transfer from the toilet to her wheelchair. After the resident was assisted to her wheelchair from the lift, staff member N placed the lift outside of the resident's room in the hallway and did not sanitize the lift. Staff member N stated housekeeping staff cleaned the lifts. During an interview on 6/6/17 at 11:00 a.m., staff member W stated housekeeping used a green power cleaner to clean the lifts one time a shift. Staff member W stated she cleaned the lifts after the floors and hallways were cleaned. During an observation on 6/6/17 at 11:05 a.m., staff member V assisted a resident with toileting and used a Sara lift to transfer the resident onto the toilet and back into her wheelchair. Staff member V returned the lift to the hallway and did not clean the lift. During an observation and interview on 6/6/17 at 10:01 a.m., the Maxi-lift was used on resident #8 by staff members L and M. At 1:40 p.m., staff member M stated the lift did not get cleaned after use on resident #8. The staff member stated the lifts were to be cleaned after use on each resident, and housekeeping cleaned the lifts every shift. During an interview on 6/6/17 at 1:55 p.m., staff member K stated housekeepers cleaned the lifts every week. The staff member stated CNAs were required to clean the lifts after every use on each resident. During an observation and interview on 6/7/17 at 8:40 a.m., the Maxi-lift was used on resident #8 by staff members N and O. At 9:57 a.m., staff member N stated the lift did not get cleaned after use on resident #8. The staff member stated the lifts were to be cleaned once a shift with cleaning wipes. She stated housekeeping cleaned the lifts daily. During an observation and interview on 6/7/17 at 10:20 a.m., staff member P wheeled a chair scale from a resident's room into a storage room, across from the nurses station for Halls A, B, and C. The staff member stated the chair scale had just been used to weigh a resident, and he was putting the scale into the storage room. The staff member stated the lifts were cleaned daily, during no specific set time, and the cleaning was done by housekeeping staff. Review of the facility Operational Infection Control policy and procedure reflected on page 10, Policy Statement, .resident-care equipment .will be cleaned according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. Listed in item 1. d. of the policy was, .reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment).",2020-09-01
598,GALLATIN REST HOME,275066,1221 W DURSTON RD,BOZEMAN,MT,59715,2018-10-04,555,D,0,1,OFFF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's right to consent to the use and be informed of the risks and benefits of the use of psychoactive medications for 1 (#5) of 17 sampled residents. Findings include: Record review of resident #5's medical chart showed that he was admitted to the facility on [DATE]. He had orders for [MEDICATION NAME] 15 mg PO Q HS initiated on 6/18/18. Record review of resident #5's Physician Orders, dated 6/18/18, showed an order to discontinue [MEDICATION NAME] and start [MEDICATION NAME] 7.5 mg po qhs x 7 days then 15 mg po qhs. Record review of resident #5's Nurse's Notes dated 6/18/18, showed that staff member F left a voicemail message for resident #5's power of attorney, providing notification of new physician orders [REDACTED]. During an interview on 10/3/18 at 2:32 p.m., staff member A provided a copy of resident #5's Nurse's Notes, dated 6/18/18. Staff member A said that staff member F left a message for the resident's Power of Attorney, but a Risk-Benefit Acknowledgement for the use of [MEDICATION NAME] was not on file. Review of resident #5's medical record lacked evidence of supporting documentation for the resident or his power of attorney's consent and education regarding risk vs. benefits for the use of [MEDICATION NAME].",2020-09-01
599,GALLATIN REST HOME,275066,1221 W DURSTON RD,BOZEMAN,MT,59715,2018-10-04,557,D,0,1,OFFF11,"Based on observation and interview, the facility failed to ensure the dignity of 2 (#'s 16 and 57) of 17 sampled residents. Findings include: 1. During an observation on 10/1/18 at 3:35 p.m., Prevail disposable undergarments were observed sitting on the counter in resident #16's bedroom. Resident #16's bedroom door was open and she was observed sitting on the edge of her bed. During an interview on 10/3/18 at 10:34 a.m., staff member [NAME] stated that she had observed incontinence pads sitting on counters and bedside tables in resident rooms. She said staff should put the items away and they should not be placed on the counters or bed side tables. During an observation on 10/3/18 at 1:10 p.m., Prevail disposable undergarments were observed sitting on the counter in resident #16's room. The door was open and the disposable undergarments were visible from the hallway. During an interview on 10/3/18 at 1:12 p.m., resident #16 stated that staff placed the incontinence supplies on the counter in her room. Resident #16 stated, it bothers me that the pads are left on the counter and she wanted them moved so they were not in plain sight. Resident #16 was observed placing her Prevail pads on the bottom shelf of a shelving unit in her bedroom. 2. During an observation on 10/2/18 at 8:52 a.m., staff member G was observed assisting resident #57 with breakfast. Staff member G was observed lifting a spoon, filled with cheerios and milk, to resident #57's mouth. Two cheerios fell from the resident's spoon and onto her clothing protector. Staff member G used the spoon to scoop up the food that had fallen onto the clothing protector and placed the spoon back into resident #57's bowl. Resident #57 was observed using the same spoon to eat the remainder of her cereal. During an observation on 10/2/18 at 8:54 a.m., cheerios were not observed on the resident's clothing protector, the floor, nor were they observed on the resident's tray. Staff member G was not observed getting up from the table to discard any food into the garbage. During an interview on 10/2/18 at 9:16 a.m., staff member G stated that resident #57 can feed herself but sometimes she needs prompting. Staff member G stated that she assisted resident #57 with her cheerios that morning. She does not recall any cheerios falling onto resident #57's clothing protector, but if a resident were to spill on themselves, she should pick up the fallen food and throw it away.",2020-09-01
600,GALLATIN REST HOME,275066,1221 W DURSTON RD,BOZEMAN,MT,59715,2018-10-04,583,E,0,1,OFFF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to protect resident's protected health information (PHI) for 3 (#s 32, 48 and 206); and failed to ensure the privacy of 1 (#52) of 21 sampled and supplemental residents. Findings include: 1. During an observation on 10/1/18, from 2:44 p.m. to 3:30 p.m., the (MONTH) (YEAR) Medication Administration Record on the medication cart for the A/B Hall had been left open exposing PHI for resident #206. Multiple staff, residents, and visitors walked past the opened MAR with visible PHI. The Controlled Substances Narcotic binder had also been left open exposing PHI for resident #206. During an interview on 10/1/18 at 3:26 p.m., staff member I stated all PHI should have been kept confidential; including MAR information, since PHI was clearly visible. Staff member I stated she was not assigned to work on the A/B Hall, and was not sure by whom the MAR and Narcotic binder had been left open. Resident #206 was admitted to the facility with [DIAGNOSES REDACTED]. A review of resident #206's (MONTH) (YEAR) MAR showed orders for [MEDICATION NAME] 25/100 milligrams (mgs), 2 tablets three times a day, [MEDICATION NAME] 50 mgs twice a day, [MEDICATION NAME] 80 mg daily, Aspirin 325 mgs twice daily, [MEDICATION NAME] 5-10 mgs every four hours PRN (as needed) for pain, Tylenol 1000 mgs three times daily, [MEDICATION NAME] 500 mg every six hours PRN, Calcium [MEDICATION NAME] 500 mg daily, [MEDICATION NAME] 17 grams (gms) daily, Senna twice daily, and [MEDICATION NAME] 900 mg at bedtime. 2. During an observation on 10/2/18 at 8:20 a.m., the (MONTH) (YEAR) Medication Administration Record on the medication cart for the C Hall had been left open exposing PHI for resident #48; including future physician and laboratory appointments. Multiple staff, residents, and visitors walked past the opened MAR with visible PHI exposed. During an interview on 10/2/18 at 8:58 a.m., staff member M stated the MAR containing PHI should not have been left opened. Staff member M stated she was planning to administer a narcotic; [MEDICATION NAME], to resident #48. Staff member M stated the MAR and Narcotic binder should have been kept covered, or closed. Resident #48 was admitted to the facility with [DIAGNOSES REDACTED]. A review of resident #48's (MONTH) (YEAR) MAR showed orders for Refresh eye drops in both eyes twice daily PRN, [MEDICATION NAME] eye drops twice daily, [MEDICATION NAME] 100 micrograms (mcg) daily, [MEDICATION NAME] 2 mg twice daily, [MEDICATION NAME] 40 mg daily, [MEDICATION NAME] 10 mg daily, calcitonin nasal spray alternate nostrils daily, [MEDICATION NAME] 12.5 mgs daily, [MEDICATION NAME] 30 mg twice daily, [MEDICATION NAME] 10 mgs every six hours PRN, [MEDICATION NAME]es PRN to back, [MEDICATION NAME] 100 mg daily, [MEDICATION NAME] 4 mg every four hour PRN, and [MEDICATION NAME] 2 mg PRN. 3. During an observation on 10/3/18 at 9:01 a.m., the (MONTH) (YEAR) Medication Administration Record on the medication cart for the A/B Hall had been left open. Visible PHI for resident #32 was available for multiple staff, residents, and family members to observe. During an interview on 10/3/18 at 9:11 a.m., staff member I stated the MAR should have been kept closed. Staff member I stated PHI should always be kept confidential. 4. During an observation on 10/3/18 at 4:00 p.m., the (MONTH) (YEAR) Medication Administration Record on the medication cart for the C Hall had been left open exposing PHI for resident #48. Visible PHI for resident #48 was available for multiple staff, residents, and family members to observe. During an interview on 10/3/18 at 4:15 p.m., staff member J stated she opened the MAR at 3:30 p.m., but was called away, and left the MAR open, exposing resident #48's PHI. Staff member J stated she should have ensured the MAR book was not left open. Review of the facility's policy, Privacy Notice- Protected Health Information (PHI), read, .h .(1) That the facility is required by law to maintain the privacy of PHI and to provide resident with notice of its legal duties and privacy policies; (2) That the facility is required by law to notify affected individuals following a breach of unsecured protected health information; (3) That the facility is required to abide by the terms of its current effective privacy notice . 5. During an observation on 10/1/18 at 3:35 p.m., resident #52 was observed receiving assistance with using the bathroom by staff member H. The bathroom was an adjoining room, which is used by residents from two separate bedrooms. The bathroom door that was observed to be open was on the opposing side of resident #52's room. No curtain was pulled in the adjoining room to allow for the resident's privacy. During an interview on 10/1/18 at 3:35 p.m., resident #16 stated staff will sometimes leave the door open when they are assisting residents with toileting. She stated she did not know why they do that, but it bothers her that they do. She stated that if staff were assisting her with toileting she would ask them to shut the door if it was left open. During an interview on 10/3/18 at 10:34 a.m., staff member [NAME] stated that she had not recently observed staff leaving the door open while assisting residents in the restroom, but she had observed it in the past. Staff member [NAME] stated that some of the residents use wheelchairs and it is hard to maneuver in the bathrooms. Staff member [NAME] stated staff should use the curtains in the rooms to provide for a resident's privacy. Record review of resident #52's medical chart showed she had a BIMS score of 99; she was unable to participate in an interview. An interview was attempted on 10/3/18 at 1:31 p.m., but resident #52 was unable to answer questions.",2020-09-01
601,GALLATIN REST HOME,275066,1221 W DURSTON RD,BOZEMAN,MT,59715,2018-10-04,623,D,0,1,OFFF11,"Based on interview and record review, the facility failed to provide, in writing, notice of transfer/discharge from the facility for 2 (#s 55 and 60) of 17 sampled residents. Finding include: 1. During an interview on 10/4/18 at 11:19 a.m., staff member A stated the facility staff did not notify the ombudsman of the discharge for resident #60. Review of resident #60's medical record showed the resident was discharged to home with family on 7/4/18. There was no information in the record that the Ombudsman had been notified of the discharge. 2. During an interview on 10/4/18 at 11:22 a.m., staff member A stated the facility staff did not notify the Ombudsman of the discharge for resident #55. Review of resident #55's MDS, with an ARD of 6/1/18, showed resident #55 was discharged from the facility on 6/1/18.",2020-09-01
602,GALLATIN REST HOME,275066,1221 W DURSTON RD,BOZEMAN,MT,59715,2018-10-04,657,D,0,1,OFFF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to review and revise the care plan for 2 (#s 13 and 23) of 17 sampled residents. Findings include: 1. During an observation on 10/1/18 at 3:09 p.m., resident #23 was observed in her room sitting in her chair. Resident #23's right hand was resting in a hand splint. A notice was observed hanging on the wall which read, Please put R resting hand splint on (resident #23) everyday from 8am - to noon. The paper was signed by staff member S and was dated 3/23 (sic). During a record review on 10/1/18, resident #23's Care Plan showed no documentation of the resident's need to wear a hand splint to prevent contracture. Review of resident #23's OT- Therapist Progress and Discharge Summary, dated 4/5/18, and electronically signed by staff member S showed, Pt and staff educated in donning/doffing resting hand splint, monitoring skin condition, and RNA program to maintain PROM and prevent contractures. Attached to the discharge summary was a document signed by staff member S which showed, Due to the neurologic condition, pt is presenting with increasing tone in R U/LE. Pt has had varied amounts of pain with PROM to R UE which is affecting hygiene. In order to prevent contracture, decrease pain with hygiene, and improve joint alignment pt requires WHFO. Pt has been progressed to increase tolerance for up to 4 hrs/day. Staff has been educated in donning/doffing including the discharge wear schedule of 8 am-noon daily, as tolerated. Nursing notified on skin check and instructed to re-refer to skilled OT if necessary. Pt is able to verbalize pain, however requires assist to donn/doff. Review of the facility policy Resident Mobility and Range of Motion, showed, as part of the comprehensive assessment, the facility will identify conditions that place a resident at risk for complications related to ROM and mobility, including contractures, the care plan will be developed based on the comprehensive assessment, and the care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. On 10/3/18 the facility provided an updated copy of resident #23's Care Plan which showed, 10/3/18 Resting hand splint per OT directions. No specific interventions were identified within the plan. 2. During an interview on 10/4/18 at 9:30 a.m., staff member A stated resident #13 had not attempted to leave the facility since the wander guard was placed. Record review of the Interdisciplinary Notes, showed resident #13 had a wander guard placed on her ankle, on 7/27/16, after getting out the front door of the facility while in her wheel chair. Physician orders dated 10/1/18 through 10/31/18, showed an order for [REDACTED]. Review of resident #13's care plan, with an effective date of 7/6/18 through 10/6/18, lacked information regarding the wander guard documented on the care plan.",2020-09-01
603,GALLATIN REST HOME,275066,1221 W DURSTON RD,BOZEMAN,MT,59715,2018-10-04,658,D,0,1,OFFF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the faciltiy staff failed to administer the correct dose of medication via a PEG tube and failed to dispose of narcotic, [MEDICATION NAME], patches appropriately, for 1 (#16) of 17 sampled residents. Findings include: Peg Tube medication administration: 1a. During an observation and interview on 10/2/18 at 11:30 a.m., staff member [NAME] added 10 mL (milliliters) of tap water to a crushed [MEDICATION NAME] tablet in the medication cup for resident #16. The medication cup tips onto its side, spilling part of the contents onto the bedside table. Visible white medication particles could be seen in the fluid on the table. Staff member [NAME] added another 10 mLs of tap water to the medication cup and administered the remaining [MEDICATION NAME] to resident #16 through a Percutaneous endoscopic gastrostomy (PEG). Resident #16 was admitted to the facility with [DIAGNOSES REDACTED]. A review of resident #16's (MONTH) (YEAR) Medication Administration Record [REDACTED]. During an interview on 10/3/18 at 1:44 p.m., staff member [NAME] stated she did not notice the [MEDICATION NAME] medication had spilled onto the bedside table when she added water. Staff member [NAME] stated she should have retrieved another [MEDICATION NAME] tablet, crushed it, and administered it to the resident when the medication cup tipped over. Review of the facility policy, Administering Medications through an Enteral Tube, read, .26. If administering more than one medication, flush with 15 mL (or prescribed amount) warm sterile or purified water between medications. 27. When the last of the medication begins to drain from the tubing, flush the tubing with 15 mL of warm sterile or purified water (or prescribed amount). [MEDICATION NAME] Patch Disposal: b. During an interview on 10/3/18 at 4:06 p.m., staff member T stated all [MEDICATION NAME]es should be disposed of with a the standard two nurse signature. Staff member T stated all replaced patches are put into the sharps container. Review of the Narcotic Book for the D Hall showed staff did not always have two nurses sign off for the destruction of [MEDICATION NAME]es when they were replaced. During an interview on 10/4/18 at 10:55 a.m., staff member [NAME] stated she did not know two nurse signatures were required when disposing of [MEDICATION NAME]es. Staff member [NAME] stated she discarded used patches into the sharps container that was attached to the medication cart. Review of the facility policy, Disposal of Medications, read, .2. Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances (or those classified as such by state regulation) are subject to special handling, storage, disposal, and record keeping in the nursing facility in accordance with federal and state laws and regulations .a. For (facility name), the appropriate method of medication destruction is as follows: Log medication for destruction with two (2) licensed nurses.",2020-09-01
604,GALLATIN REST HOME,275066,1221 W DURSTON RD,BOZEMAN,MT,59715,2018-10-04,684,D,0,1,OFFF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide needed care and services in accordance with a resident's comprehensive person-centered care plan for 2 (#'s 28 and 23) of 17 sampled residents. Findings include: 1. During an observation on 10/3/18 at 7:37 a.m., resident #28 was observed sitting in the dining room in his wheelchair waiting for breakfast at his assigned table. At 9:12 a.m., the resident was pushed to his room and placed in front of the television in his bedroom. Resident #28 remained up in his wheelchair after breakfast until 10:41 a.m., when his call light was pulled by a visiting family member. During an interview on 10/3/18 at 10:34 a.m., staff member [NAME] stated that staff need to reposition resident #28 every two hours. Staff member [NAME] stated it would not be acceptable for the resident to remain in his wheelchair any amount of time over two hours. Staff member [NAME] stated after meals, staff are to reposition resident #28 to his bed. During an interview on 10/3/18 at 2:12 p.m., staff member P stated resident #28 must be repositioned every two hours, even if he is in his bed. She stated the aides have a tracking sheet that they are supposed to be filling out. Staff member P stated the flow sheets are broken up over shifts. Staff member P stated one shift is equivalent to eight hours, and resident #28 should be re-positioned at minimum, four times during the eight hour shift. Review of resident #28's Braden Scale showed he had a score of 12; at high risk of developing pressure ulcers. Review of resident #28's Care Plan dated 8/14/18, effective date of 8/15/18, section: Problems/Strengths, showed, Pressure injury/moisture associated skin damage to coccyx, buttocks (gluteal cleft) related to decline in mobility, weight loss, and incontinence. Section: Goals of the Care Plan showed, Skin will heal without complication. Section: Interventions showed, Assist resident to lie down between meals or activities, and assist to turn and reposition frequently throughout all shifts. Review of facility Care Plan/Nursing Flow Sheet binder showed resident #28's Care Plan had an attached document, dated 8/15/18, that read, resident #28 MUST lie down between meals/activities and be repositioned/turned frequently throughout all 3 shifts. Review of resident #28's Nursing Flow sheet for the month of (MONTH) (YEAR) showed resident #28 was not repositioned on the following dates during Night shift hours: -9/7/18 -9/8/18 -9/9/18 -9/15/18 -9/16/18 -9/21/18 -9/22/18 -9/23/18 -9/24/18 -9/26/18 -9/27/18 -9/29/18 Review of resident #28's Nursing Flow sheet for the month of (MONTH) (YEAR) showed resident #28 was not repositioned on the following shifts and dates: -AM; 8/20/18 -AM; 8/21/18 -AM; 8/22/18 -AM; 8/23/18 -AM; 8/24/18 -AM; 8/25/18 -AM; 8/26/18 -AM; 8/28/18 -AM; 8/29/18 -AM; 8/30/18 -AM; 8/31/18 -PM; 8/23/18 -PM; 8/29/18 -PM; 8/30/18 -Night; 8/16/18 2. During an observation on 10/3/18 at 7:38 a.m., resident #23 was observed lying in her bed on her back. Her feet were not elevated and her left foot was not placed in a heel bootie. During an observation on 10/3/18 at 8:15 a.m., resident #23 was observed lying in her bed on her back. Her left foot was not placed in a heel bootie. Resident #23's food tray was observed on her bed side table and a staff member entered the room at 8:34 a.m., to assist the resident with eating. During an observation on 10/3/18 at 9:45 a.m., resident #23 was observed still lying in bed on her back. Her feet were not elevated and her left foot was not placed in a heel bootie. During an observation on 10/3/18 at 10:29 a.m., resident #23 was observed lying in her bed, on her back, and watching television. Her left foot was not placed in a heel bootie. During an interview on 10/3/18 at 10:34 a.m., staff member [NAME] stated facility staff need to reposition resident #23 every two hours. Staff member [NAME] stated it would not be acceptable for a resident to remain in the same position in their bed and would need to be repositioned side-to-side to meet the repositioning requirement, or transferred into a chair to releive pressure. During an interview on 10/3/18 at 2:12 p.m., staff member P stated resident #23 must be repositioned every two hours. She stated aides have a tracking sheet that they are supposed to be filling out. Staff member P stated the flow sheets are broken up over shifts. Staff member P stated one shift is equivalent to eight hours, and resident #23 should be re-positioned at a minimum of four times during an eight hour shift. Review of resident #23's Braden Scale showed she a score of 9; at high risk of developing pressure ulcers. Review of resident #23's Care Plan, dated 8/31/18- 11/3/18, section Problems, showed, Skin Integrity Impaired. Section: Intervention showed, turn and reposition Q 2 hours and PRN when in bed or wheel chair, and use heel booties when in bed to help cushion heels if monitoring for skin breakdown or sore on heels. Review of resident #23's physician progress notes [REDACTED]. Review of resident #23's Nursing Flow sheet for the month of (MONTH) (YEAR) showed that resident #23 was not repositioned on the following dates during Night shift hours: -9/7/18 -9/8/18 -9/9/18 -9/14/18 -9/15/18 -9/16/18 -9/20/18 -9/21/18 -9/22/18 -9/23/18 -9/26/18 -9/27/18 -9/29/18",2020-09-01
605,GALLATIN REST HOME,275066,1221 W DURSTON RD,BOZEMAN,MT,59715,2018-10-04,688,D,0,1,OFFF11,"Based on observation, interview, and record review, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion for 1 (#23) of 17 sampled residents. Findings include: During an observation on 10/1/18 at 3:09 p.m., a notice was observed hanging on the wall in resident #23's room which read: Please put R resting hand splint on (Resident #23) everyday from 8am - to noon. During an observation on 10/3/18 at 8:15 a.m., resident #23 was observed lying in her bed. She had her right hand on top of the blanket that was covering her body. She did not have her splint on her hand. During an observation on 10/3/18 at 10:45 a.m., resident #23 was observed still lying in bed. Her hand splint was not on and it was observed sitting on the counter in her bedroom. During an observation on 10/4/18 at 9:42 a.m., resident #23 was observed in her room, lying in bed, on her back. Her splint was not on her right hand. During an interview on 10/4/18 at 9:42 a.m., staff member [NAME] stated resident #23 was supposed to wear her hand splint every day. She stated the hand splint was supposed to be on from 8 a.m. to noon. Staff member [NAME] said she did not provide documentation for the application of the hand splint on the MAR indicated [REDACTED]. Review of resident #23's OT- Therapist Progress and Discharge Summary dated 4/5/18 showed, patient and staff educated in donning/doffing resting hand splint to maintain PROM and prevent contractures with a document attached and signed by staff member S that read, In order to prevent contracture, decrease pain with hygiene, and improve joint alignment pt requires WHFO. Pt has been progressed to increase tolerance for up to 4 hrs/day. Staff has been educated in donning/doffing including the discharge wear schedule of 8 am-noon daily, as tolerated. During an interview on 10/4/18 at 11:30 a.m., staff member S stated resident #23 had an active order to wear a hand splint on her right hand, daily as tolerated. She stated she trained staff on the use of the hand splint, it is noted in the resident's discharge summary notes, and she placed a notice in the resident's bedroom. Staff member S stated she was not aware if resident #23 had ever declined to wear her splint. She stated no staff had communicated to her that resident #23 had refused to wear it.",2020-09-01
606,GALLATIN REST HOME,275066,1221 W DURSTON RD,BOZEMAN,MT,59715,2018-10-04,759,E,0,1,OFFF11,"**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 (#16) of 17 sampled residents. The facility medication error rate was 7%. Findings include: During an observation and interview on 10/2/18 at 10:15 a.m., staff member [NAME] prepared medications that were to be administered to resident #16 using a jejunostomy tube (J-tube). The staff member crushed several tablets, one at a time, and put them into individual clear medication cups. Resident #16 declined the medications when they were prepared, and she stated she would inform staff member [NAME] when she returned from a meeting, and was willing to receive her medications. At 11:22 a.m., staff member [NAME] administered the crushed medications to resident #16 using the resident's J-tube. Staff member [NAME] did not flush with sterile or purified water between medications. At 11:30 a.m., staff member [NAME] added 10 mL (milliliters) of tap water to the crushed [MEDICATION NAME] tablet in the medication cup. The medication cup tipped onto its side, spilling part of the contents onto the bedside table. Visible white medication particles could be seen in the fluid on the table. Staff member [NAME] added another 10 mL's of tap water to the medication cup and administered the remaining [MEDICATION NAME] to resident #16. Staff member [NAME] stated she was not sure how much fluid needed to be added to the [MEDICATION NAME], and she added 60 mL's of tap water. Staff member [NAME] did not flush between each medication after administering through the Percutaneous endoscopic gastrostomy (PEG). Resident #16 was admitted to the facility with [DIAGNOSES REDACTED]. A review of resident #16's (MONTH) (YEAR) Medication Administration Record [REDACTED]. During an interview on 10/3/18 at 1:44 p.m., staff member [NAME] stated she did not flush with fluids between medication administrations to resident #16. Staff member [NAME] stated she was not aware that medications should have been flushed with fluids in-between the administration of medications. Staff member [NAME] stated she did not notice the [MEDICATION NAME] medication had spilled onto the bedside table when she added water. Staff member [NAME] stated she should have retrieved another [MEDICATION NAME] tablet, crushed it, and administered it to the resident. Review of the facility's policy, Administering Medications through an Enteral Tube, read, .26. If administering more than one medication, flush with 15 mL (or prescribed amount) warm sterile or purified water between medications. 27. When the last of the medication begins to drain from the tubing, flush the tubing with 15 mL of warm sterile or purified water (or prescribed amount).",2020-09-01
607,GALLATIN REST HOME,275066,1221 W DURSTON RD,BOZEMAN,MT,59715,2018-10-04,812,F,0,1,OFFF11,"Based on observation and interview, the facility failed to ensure staff served food and fluids in a manner to prevent potential food contamination. This had the potential to affect all residents in the facility who were served food and fluids from the kitchen. Findings include: During an observation on 10/1/18 at 12:15 p.m., staff member C held a cup with ice in it and put her index finger in the cup, which touched the ice. During an observation on 10/1/18 at 12:15 p.m., staff member N served a tray, picked the drinking cups up by the rim and sat them on the table. During an observation on 10/1/18 at 12:17 p.m., staff member O served a tray, picked the dessert up by the rim of the round dish, and sat it on the table. Staff member O served another tray. She picked the drinking cups up from the tray by the rims, and then placed them on the table. During an observation on 10/1/18 at 12:18 p.m., staff member C pinched two cups together to place on the tray. Her index finger was inside of one cup and her thumb was inside the other. During an observation on 10/1/18 at 12:19 p.m., staff member D dropped a butter pack on the floor and picked it up with gloved hands. She then placed the butter on a cart to be thrown out, then picked up a plate of lemon meringue pie, with the same gloved hands, and served it to a resident. During an observation on 10/1/18 at 12:22 p.m., staff member C touched her glasses with gloved hands, then with the same gloved hands, served a plate of food to a resident. Then staff member C opened a can of soda and placed a straw into the can. During an observation on 10/2/18 at 8:12 a.m., staff member Q served a male resident his tray and picked up the juice cup by the rim and placed it on the table. During an observation on 10/2/18 at 8:15 a.m., staff member R served a resident tray and picked the bowls of pureed food up from the rim of the bowls and placed them on the table for the resident. Staff member R then served another resident her tray, placing her hand on the rim of the drinking cups and placing the cups on the table. During an interview on 10/3/18 at 7:35 a.m., staff member R stated never grab the cup by the rim when putting it on the table. During an interview on 10/3/18 at 7:39 a.m., staff member B stated the nurses come in and do a short seminar with the dietary staff, and every year or two the dietary staff are trained on hand hygiene practices. She stated the process for proper hand hygiene technique while serving is to make sure to wash hands, put gloves on when food is going to be handled, and when switching tasks re-wash and re-glove. Staff member B stated they never pick any dishes up by the rim, always from the bottom when serving residents. During an interview on 10/3/18 at 7:40 a.m., staff member D stated, never use the rim of the glass to serve the drink.",2020-09-01
608,GALLATIN REST HOME,275066,1221 W DURSTON RD,BOZEMAN,MT,59715,2019-11-27,600,D,0,1,18S411,"Based on interview and record review, the facility failed to prevent neglect from occurring when a certified nursing assistant refused to provide incontinence care upon request from a resident, for 1 (#13) of 20 sampled residents. Findings include: During an interview on 11/25/19 at 10:50 a.m., resident #13 stated he did not recall the event and had not had trouble with staff or concerns. During an interview on 11/27/19 at 9:23 a.m., staff member A stated that resident #13's family member had brought forth a concern of an incident with resident #13, and a certified nursing assistant, involving the resident's request for incontinence care during nightshift being refused. Staff member A stated staff member H was a newer certified nursing assistant. Staff member A stated during the investigation she had interviewed the staff member and found staff member H was trained to perform rounds at certain times during the night. Staff member A stated because of the set rounding times, staff member H thought she was not supposed to be waking up residents and thought resident #13 would have to wait until the specified time to change his brief, even though the resident was awake and called for assistance for incontinence care. Staff member A stated she interviewed resident #13, and he did not remember what time he had put on his call light. Staff member A stated she discussed with staff member H that if a resident calls for assistance she should not wait for the scheduled round time to provide assistance and that it is a dignity issue to leave residents in wet briefs. Staff member A stated that all staff abuse training was up to date at the time of the incident. Staff member A stated the incident was quickly resolved and found it was just getting the staff member to know common sense that when a resident pushes a call light she is to provide the needed assistance. Staff member A stated staff member H was given one to one training. Review of resident #13's careplan, dated 11/4/19-2/4/20, showed the following under the category of toileting: - Toilet prn resident request, - Functional ability is marked as extensive assist of one, - Check and change N[NAME]. Review of the facility's Record of Complaint, dated 9/4/19, showed, (staff member) admitted she did not change him because she was trying to keep a schedule. Review of the facility's Abuse Training, dated 8/15/19, showed the training covered abuse, neglect, and exploitation. Staff member H did not sign the inservice sign-in sheet on 8/15/19, but completed the training paperwork handouts on 8/30/19. Review of the facility's Abuse policy, dated (MONTH) (YEAR), showed, actual signs of physical neglect, as inadequate provision of care and caregiver indifference to resident's personal care and needs.",2020-09-01
609,GALLATIN REST HOME,275066,1221 W DURSTON RD,BOZEMAN,MT,59715,2019-11-27,623,D,0,1,18S411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written notification to the resident or responsible party, prior to a transfer to the hospital, for 2 (#s 32 and 37) of 20 sampled residents. Findings include: During an interview on 11/25/19 at 11:12 a.m., resident #37 said he was at the facility for rehabilitation. He was admitted from the hospital on [DATE]. During an interview on 11/25/19 at 11:24 a.m., staff member C said resident #37 was transferred to the hospital several times since he was first admitted to the facility. Review of resident #37's Discharge Summaries from the hospital, showed the resident had been transferred to the hospital on [DATE], 8/29/19, and 10/24/19. The written notifications for transfers was not found. During an interview on 11/27/19 at 1:14 p.m., staff member A stated that staff member G would complete the written Transfer form going forward. 2. During an interview on 11/27/19 at 8:09 a.m., staff member B stated social services does the transfer notifications and would have one for resident #32's most recent hospitalization . During an interview on 11/27/19 at 8:56 a.m., staff member D stated that resident #32 was not notified in writing for the reason of transfer from the facility to the hospital. Staff member D stated that the facility utilizes a form for discharge notification, but never for transfers to the hospital, because the resident is assumed to be coming back to the facility. Staff member D stated the facility notifies the family by phone when a resident is transferred out of the facility. During an interview on 11/27/19 at 9:36 a.m., staff member A stated she did not realize the facility was not giving transfer notifications in writing for residents, but would be going forward for transfers to the hospital. Staff member A stated the facility was notifying the resident in writing for discharges. Review of the facility's blank form for discharge showed a title of, Notice of Transfer or Discharge, and contained the information needed for the notification of transfer in writing. Review of resident #32's hospital report, dated 10/7/19, showed the resident had been transferred from the facility and was admitted to the hospital. A request for resident #32's transfer notification for 10/7/19 on 11/26/19 at 1:57 p.m., was not provided by the facility.",2020-09-01
610,GLENDIVE MEDICAL CENTER N H,275067,202 PROSPECT DR,GLENDIVE,MT,59330,2017-08-03,279,D,0,1,4SIE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete and update comprehensive care plans for 1 (# 8) out of 10 sampled residents. Findings include: During an observation on 8/2/17 at 2:45 p.m., resident #8 was sitting down, in the 500 hallway, with her feet up on a black padded leg device, which was was placed on the foot rest of her wheelchair. During an observation on 8/3/17 at 8:15 a.m., resident #8 was sitting in the dining room in her wheelchair, waiting for her breakfast. She had a black padded leg device placed on the foot rest of her wheelchair. Review of the resident's fall care plan, last edited 12/14/16, showed resident #8 was to have foot and leg supports on, while in the wheelchair. The care plan failed to show an intervention for a padded leg device. Review of resident #8's skin care plan, last edited 6/8/17, showed the resident was to have pressure reducing foot and leg supports, while up in the wheel chair. During an interview on 8/2/17 at 3:40 p.m., staff member A stated resident #8 used the black pressure relieving device for positioning and not for support for the resident's feet. During an interview on 8/2/17 at 4:00 p.m., staff member C stated the care plan should have never been documented as it was. She stated the device was used for two different reasons. The care plan did not show the black device was used for positioning. Review of resident #3's medical record failed to include a physician's orders [REDACTED].",2020-09-01
611,GLENDIVE MEDICAL CENTER N H,275067,202 PROSPECT DR,GLENDIVE,MT,59330,2017-08-03,310,E,0,1,4SIE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to prevent resident declines in ADL status related to eating during meals. This affected 2 (#s 1 and 3) out of 10 sampled residents. Findings include: 1. Resident #3 was admitted to the facility with [MEDICAL CONDITION] disease, [MEDICAL CONDITIONS] arthritis, and nutritional deficiencies. During an observation on 8/1/17 at 8:15 a.m., resident #3 was sitting in her wheelchair in the dining room. Her breakfast tray was served to her by 8:27 a.m. Resident #3 stirred her hot cereal and played with her silverware until 9:07 a.m. At 9:07 a.m., staff member T asked the resident if she would like to start eating, and gave the resident three bites of the cereal. After the third bite, resident #3 began licking her spoon for three minutes. At 9:15 a.m., staff member T asked the resident if she would like help eating so her food did not get cold, although more than 30 minutes had already passed. During an observation and interview on 8/2/17 at 1:35 p.m., staff member T was assisting resident #3 with her meal, and feeding the resident with a spoon. When asked, staff member T stated she was helping the resident because she was unsure how long the resident should sit at the dinner table without eating. Staff member T stated that she was unsure if there were any interventions on the resident's care plan for needed assistance while eating. Staff member T acknowledged that she fed the resident on 8/1/17, during the morning breakfast meal, because the resident did need prompting to feed herself. Staff member T stated she prompted the resident a few times on both 8/1/17 and 8/2/17, and the resident could redirect herself from what she was doing, and then take a bite of her food. Staff member T stated she was unsure why she did not give resident #3 more prompting to take bites of the food. Review of resident #3's pocket care plan, with an updated date of 7/27/17, showed the resident was to have left and right angled utensils during meals. The resident was on an assistive device program for feeding herself. Review of resident #3's care plan showed the following information was documented for the ADL and Restorative care plan sections: - Restorative Nursing, last edited 7/12/17, resident #3 will participate in Assist to Self-Feed program at least one meal daily, feeding self - 25% of meal and allowing staff to feed the balance of meal as offered by Restorative Aide. The staff were prompted on the plan to supervise and record the resident's ability to assist herself while eating. The facility failed to provide documentation of the resident's abilities to eat independently. - ADL's, last edited 6/23/17, showed resident #3 was limited assistance of one staff member at mealtime and may need cueing while eating. Resident #3 was able to use both left and right angled utensils at mealtime. The resident tended to pocket food in her mouth at mealtime and needed good oral care after meals. During an interview on 8/2/17 at 2:00 p.m., staff member B stated staff member T and C were in charge of the pocket care plans for the direct care floor staff. She stated the care plan interventions did not match with the floor staff's pocket care plans. Staff member B stated there appeared to be a disconnect in the system for updating interventions on the pocket care plans. During an interview on 8/2/17 at 3:05 p.m., staff member C stated the goal for resident #3 was to get the resident back to feeding herself. Staff member C stated it would be a good idea for resident #3 to be on a restorative program to keep her eating abilities strong. She stated there was restorative goals and interventions on the Restorative Nursing Care Plan, and some interventions on resident #3's ADL section of the care plan. Staff member C stated there was an employee that evaluated resident #3 for the restorative program, and this was in her scope of practice, because she was being supervised by a registered nurse. Staff member C stated there was no evaluations completed by therapy for this. Review of resident #3's MDS's showed the following: - Significant Change, ARD dated 6/20/17, Section G0110H, resident #3's eating ADL's were coded as a 2 (limited assist) and a 2 (1 person assist). - Significant Change, ARD dated 4/11/17, Section G0110H, resident #3's eating ADL's were coded as a 3 (extensive assist) and a 2 (1 person assist). - Quarterly, ARD dated 3/7/17, Section G0110H, resident #3's eating ADL's were coded as a 3 (extensive assist) and a 2 (1 person assist). Review of resident #3's TAR, dated (MONTH) (YEAR), failed to show a restorative eating program listed for the resident. Review of resident #3's medical record failed to show physician orders [REDACTED]. 2. Review of the resident #1's Physician order [REDACTED]. During an observation on 8/1/17, from 7:55 a.m. to 8:55 a.m., resident #1 was not offered cuing by staff to chew or swallow her food. During an observation on 8/2/17, from 8:40 a.m. to 9:50 a.m., resident #1 was not offered cuing to chew or swallow her food by any staff member. During an interview on 8/2/17 at 8:40 a.m., staff member L stated resident #1 did not need any help at meals, and she ate independently. Staff member L then stood up and asked the resident if she was hungry. Resident #1 opened her mouth and showed the staff member all the food she had been pocketing in the mouth. Staff member L did not cue the resident to chew or swallow her food. During an observation on 8/2/17 at 8:45 a.m., staff member B asked resident #1 if she felt like eating. Resident #1 did not respond but had a mouth full of food, which she had pocketed. Staff member B did not cue the resident to chew or swallow the food. During an interview on 8/2/17 at 9:50 a.m., staff member I stated resident #1 did not need help at meals and ate independently. Review of resident #1's Care Plan, last updated 6/14/17, did not reflect the physician's orders [REDACTED].#1 to chew or swallow. The care plan showed the following, Provide (resident #1) with a Regular/Mechanical Soft/Regular 1/2 portions diet. Review of resident #1's pocket care plan, updated 7/27/17, did not reflect the physician's orders [REDACTED].#1 to chew or swallow. The pocket care plan showed, Mechanical Soft, 1/2 portions. There was a documented symbol, which stood for Resident NOT to be assisted by Feeding Assistant.",2020-09-01
612,GLENDIVE MEDICAL CENTER N H,275067,202 PROSPECT DR,GLENDIVE,MT,59330,2018-10-18,552,D,0,1,Y1J011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's right to consent to the use of psychoactive medications for 1 (#39) of 14 sampled residents. Findings include: During an interview on 10/17/18 at 12:48 p.m., staff member A stated, Consents were mailed to (resident #39's) guardian, and the [MEDICAL CONDITION] Medication notifications were not signed. Staff member A stated, We sent them again. Staff member A stated the facility did not have any documentation which showed that the resident or his guardian consented to the use of the medications, although the documents had not been received. Record review of resident #39's medical chart showed unsigned [MEDICAL CONDITION] Medication Notifications for [MEDICATION NAME] 2.5 mg daily, [MEDICATION NAME] 225 mg daily, and [MEDICATION NAME] 0.5 mg every six hours as needed. A note was observed on the unsigned consents which reflected, Mailed 8/2/18.",2020-09-01
613,GLENDIVE MEDICAL CENTER N H,275067,202 PROSPECT DR,GLENDIVE,MT,59330,2018-10-18,656,D,0,1,Y1J011,"**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 comprehensive care plan for 1 (#2), failed to utilize interventions identified on a care plan for a resident who refused care, for 1 (#12); failed to identify and address a resident's preference for being dressed prior to meals, on the comprehensive care plan, for 1 (#32), and failed to complete an assessment and ongoing monitoring of a position change alarm for 1 (#38) of 14 sampled residents. Findings include: 1. During an interview on 10/16/18 at 10:50 a.m., resident #2 stated he had a lock box in his room and the nurses keep the key to his lockbox in the medication cart. Resident #2 stated he moved rooms recently and was missing some pictures and a belt. He stated he, told the nurse and no one has been able to find the missing items. Resident #2 stated he was sure the items were not in his room and he knew they were not in his lock box because the nurse just opened it for him the night before. Resident #2 stated the nurses kept the key to his lockbox in the medication cart, and this was not something he had agreed to. During an interview on 10/16/18 at 3:21 p.m., staff member B stated resident #2 moved rooms a couple of months ago. She stated resident #2 keeps his wallet locked in a lock box in his room, and the key is kept in the medication cart. During an interview on 10/16/18 at 3:29 p.m., staff member C stated, If (resident #2) wants to access his wallet, we give him a key. She stated the key is in the medication cart. Staff member C stated, I believe there is a memo in the MAR indicated [REDACTED] During an observation and record review on 10/16/18 at 3:30 p.m., a key, which was placed inside of a small baggie, was observed in the medication cart. No documentation or notes were observed on the MAR indicated [REDACTED]. Review of resident #2's medical chart showed a note on front of the chart which stated, Contact SSs if he asks for money and another note which stated, Remember: Any money withdrawn must be approved by the guardian wife prior to withdrawal, signed 2/3/16. During an interview on 10/16/18 at 3:36 p.m., staff member D stated resident #2's guardian had requested that access to trust fund money be approved prior to any withdrawals and that was what the note on resident #2's chart referred to. She stated resident #2 wins coins from playing BINGO and he locks his wallet and his money in the lock box in his room. Staff member D stated, this has been the protocol for a long time and, It is not currently in his care plan, but it should be, and I will update it right away. She stated the key for the lock box is kept in the medication cart and nursing staff are trained on the procedure during onboarding. During an interview on 10/16/18 at 3:43 p.m., staff member B stated the lock box protocol and storage of keys in the medication carts is not a part of the on-boarding process for new nursing staff. Staff member B stated she did not believe that resident #2 provided consent for his key to be locked up and stated, I can see where this is a restricted access issue. Review of Resident #2's Care Plan on 10/16/18 showed, there was no documentation of the restricted access to the resident's lock box in his room. On 10/17/18, staff member D submitted an updated Care Plan for resident #2 which identified the use and protocols for resident's #2's lock box and withdrawals from his trust fund account. During an interview on 10/17/18 at 7:25 a.m., staff member [NAME] stated there was no training for nursing staff regarding lock boxes in resident rooms, and lock box keys being stored in medication carts. 2. During an observation on 10/17/18 at 3:10 p.m., resident #12 was sitting in a recliner in the common area, sleeping. Staff member M placed a gait belt around resident #12's waist. Staff member I came over to help staff member M. Staff member I stated, We are going to take you to the bathroom, is that ok with you? Resident #12 stated, No. Staff member I proceeded to lift resident #12 with staff member M. Staff member I stated, you have to help me out, stand up. Resident #12 stated, ouch, ouch. Staff member I and M placed her in her wheel chair. Staff member M asked if she was ok. Resident #12 did not reply. During an interview on 10/17/18 at 3:25 p.m., staff member I stated she did not hear that resident #12 replied no when asked to be transferred to her wheel chair to use the bathroom. Staff member I stated that resident #12 smelled of BM and urine, and staff member I felt that she needed to go to the bathroom. Review of resident #12's Care Plan showed, If (resident name) is hitting out, yelling at staff when they're trying to assist her - assure her that she is safe and allow her to calm down and then return in a few minutes. The staff did not utilize the interventions identified on the care plan for resident #12 during the transfer. 3. During an observation on 10/16/18 at 11:00 a.m., resident #32 was observed in the dining room, dressed in a hospital gown, seated in her wheelchair for brunch. During an interview on 10/16/18 at 11:06 a.m., resident #32 stated it really bugs her that the staff do not dress her before brunch. She stated that she had a really pretty dresses that she would love to wear to brunch, but it never seems to happen. During an interview on 10/17/18 at 9:10 a.m., staff member A stated resident #32 had a personality disorder and she changed her mind often. Staff member A stated, she is asked if she wants to get dressed before brunch but she will refuse, and then later be upset that she is not changed into clothes. Staff member A stated that resident #32's refusals are not documented anywhere. Review of resident #32's medical record did not show that the resident is resistant to being dressed, then changes her mind due to her personality disorder. 4. During an observation on 10/16/18 at 8:42 a.m., resident #38 was observed cleaning up a spill around her sink while seated on her wheel chair. A position change alarm was observed on her wheel chair. During an interview on 10/17/18 at 9:23 a.m., staff member M stated she was not sure why resident #38 had a position change alarm, but that she would check her record. During an interview on 10/17/18 at 9:27 a.m., staff member A stated resident #38 had a couple of falls in the past, after she was taken off Hospice services. Staff member A stated resident #38 thought she was able to walk again, and the position change alarm was put on by staff as a precaution. During an interview on 9:29 a.m., staff member M stated, I just looked at her care plan and she is at risk for falls, so it alarms us when she gets up so we can go help her. The resident's comprehensive care plan did not reflect the current status of the alarm use. Review of resident #38's medical record did not show an order for [REDACTED].",2020-09-01
614,GLENDIVE MEDICAL CENTER N H,275067,202 PROSPECT DR,GLENDIVE,MT,59330,2018-10-18,661,D,0,1,Y1J011,"Based on interview and record review the facility failed to provide discharge instructions for 1 (#4) of 17 sampled and supplemental residents. Findings include: During an interview on 10/18/2018 at 2:00 p.m., staff member A stated discharge instructions for resident #4 could not be found. Review of resident #4's closed record, showed there were no discharge instructions documented or provided to the resident or her representative.",2020-09-01
615,GLENDIVE MEDICAL CENTER N H,275067,202 PROSPECT DR,GLENDIVE,MT,59330,2018-10-18,676,D,0,1,Y1J011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate supervision and cueing for a resident who needed ADL assistance during meals, and the resident was identified to need assistance. The staff failed to document the resident's intake sufficiently for food or liquids, per the dietitian's recommendations, for 1 (#12) of 14 sampled residents. Findings include: During an observation on 10/15/18 at 4:33 p.m., resident #12 was observed sitting at the table in the dining room, waiting for her food to be served. She was given a glass of ice water, which she finished while waiting on her food. After finishing her own drink, resident #12 took another residents drink who had previously eaten and had already left the dining area. Resident #12 poured the orange liquid into her own cup and she drank the orange liquid. When she finished, resident #12 was observed taking another drink from the same resident, which was a container of Hormel thickened chocolate milk. Resident #12 poured the milk into her own cup, then drank the contents from her cup. No staff were observed at the table during this time. During an observation on 10/15/18 at 4:40 p.m., resident #12's food was served. No staff was observed sitting at the table, either to assist or observe the resident. During an observation on 10/15/18 at 4:49 p.m., resident #12 was observed taking two small bites of a dinner roll. Staff member G sat down at the table and began assisting another resident with her meal. Staff member H also sat down at the table and began assisting another resident at the table with her meal. Staff member G and staff member H were not seated next to resident #12. During an observation on 10/15/18 at 4:52 p.m., resident #12 was observed propelling herself out of the dining room in her wheelchair. She did not consume any additional food. Resident #12 did not have any interactions with staff during her meal. She was not provided verbal cues, and she was not offered any alternatives. During an interview on 10/16/18 at 9:48 a.m., staff member G stated resident #12 had been eating less in the last two weeks. Staff member G stated he recalled resident #12 not eating much of her food during dinner the day before; she ate a couple of bites of her dinner roll and played with her cake. Staff member G stated he had not witnessed resident #12 taking drinks from others. He stated, I believe she has a regular diet. Staff member G stated staff are supposed to be monitoring resident #12 during meals and providing her with cueing if she doesn't eat. Staff member G stated that staff are not assigned to specific residents while they are in the dining room. Record review of resident #12's Care Plan showed resident #12 had a goal in place to be free of significant weight changes, PO intake will meet estimated needs and preferences will be met. Approaches section showed, Encourage fluid intake at snacks and meals. Review of the facility policy Dining Experience, revised on 7/17, showed, Special tables are set aside for individuals requiring extra attention .tables will be set with 2 residents requiring feeding assistance and with 2 that require cuing. This allows for 1 CNA or paidfeeding assistant to sit with residents requiring feeding assistance and cuing, (sic). During an interview on 10/17/18 at 12:49 p.m., staff member B stated she was not aware that resident #12, is not eating like she used to. Staff member B stated the CNA coordinator is responsible for ensuring cueing and supervision of residents during meals. She stated, Ultimately it is the responsibility of the ADON or DON. Staff member B stated the primary CNA coordinator is out on medical leave and the facility recently hired a new CNA coordinator. She stated resident #12 should have been supervised and cued to eat more during dinner on 10/15/18. Staff member B stated, someone should have been assigned to her; there should have been two CNA's at the table. Staff member B reviewed resident #12's food and liquid intake logs. No food intake was recorded for (MONTH) 16, (YEAR) or (MONTH) 17, (YEAR). Staff member B stated staff should be recording all intake of food and liquids for resident #12 after it is consumed. Review of the facility policy Dining Experience, revised on 7/17, showed, Nursing staff will assist residents as needed from the dining room and record percentages consumed, as well as amounts of fluids consumed. During an interview on 10/17/18 at 2:16 p.m., staff member A stated, Percentage of food consumed is something that we train the nursing staff on. She stated staff should be recording meal intake and liquid intake percentages at the end of meals. Record review of resident #12's Quarterly Dietary Assessment, dated 8/8/18, showed a [DIAGNOSES REDACTED]. Review of Resident #12's Nutrition Intake documentation showed, between (MONTH) 1, (YEAR)-October 16, (YEAR), nursing staff failed to document food intake percentages for resident #12 on 46 of 96 assigned timeframes. In addition, fluid intake documentation was not completed for 5 assigned shifts during this timeframe.",2020-09-01
616,GLENDIVE MEDICAL CENTER N H,275067,202 PROSPECT DR,GLENDIVE,MT,59330,2018-10-18,688,D,0,1,Y1J011,"Based on interview and record review, the facility failed to ensure a resident referrel from physical therapy was not communicated, implemented, and carried out, for a continuum of care, for 1 (#15), of 14 sampled residents. Findings include: During an interview on 10/17/18 at 3:33p.m., staff member L stated resident #15 was not on a restorative program. During an interview on 10/17/2018 at 3:41 p.m., staff member B stated all residents receive a PT assessment at the time of admission. She stated, We have our PT do an assessment and then follow their recommendations. Staff member B stated resident #15's orders should have been followed and stated, The person in charge of this no longer works here, and I don't know how it was missed. Record review of resident #15's Physician Orders, dated 8/23/18 and signed 9/16/18, showed, PT evaluation completed. No skilled PT services @ this time, recommend restorative LE strengthening and ambulation .4-5x/day in hallways. Record review of resident #15's Care Plan showed no documentation that resident #15 was to complete restorative LE strengthening and ambulation.",2020-09-01
617,GLENDIVE MEDICAL CENTER N H,275067,202 PROSPECT DR,GLENDIVE,MT,59330,2018-10-18,758,E,0,1,Y1J011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a gradual dose reduction for a resident who was ordered a [MEDICAL CONDITION] medication, and the IDT team failed to identify the need for the GDR, for 1 (#9) of 14 sampled residents. Findings include: During an interview on 10/17/18 at 3:45 p.m., staff member [NAME] stated a gradual dose reduction for resident #9 was not completed. Record review of resident #9's medical chart showed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of resident #9's Mood and Behavior Meeting Notes, dated 8/30/18, showed, resident #9 received [MEDICATION NAME] 10mg every morning and Last gradual dose reduction: None.",2020-09-01
618,GLENDIVE MEDICAL CENTER N H,275067,202 PROSPECT DR,GLENDIVE,MT,59330,2018-10-18,812,F,0,1,Y1J011,"Based on observation, interview, and record review, the facility failed to properly store dishes in the kitchen, label and date food in the refrigerator, and use proper hand hygiene while serving food. This had the potential to affect all residents who consumed food prepared and served by the facility. Findings include: During an observation on 10/16/18 at 8:16 a.m., the following was identified: - 17 small plates were observed, all stored upright and uncovered, open to potential dust and debris, in the main kitchen. - There was a four-level shelving unit by the cooking area. On the second shelf there were seven stacks of small plates and small bowls, all facing up, and open to potential dust and debris. During an interview on 10/16/18 at 8:26 a.m., staff member O stated, teh four level shelving unit was a drying rack for dishes. After they dry, they are put away. He stated the dishes were usually stored upright. During an observation on 10/16/18 at 8:26 a.m., a wire cart with wheels, next to a preparation area, contained small black plastic soup bowls. The cart was located near a high traffic area. There was a white flakey substance observed inside the clean bowls. During an observation and interview on 10/16/18 at 8:19 a.m., eight covered glasses of orange juice were observed in the refridgerator. The cups did not have labels or a date. Staff member N stated the juice cups were for the residents and would be used that morning, and she was not sure why they were not labeled or dated. During an observation on 10/16/18 at 8:21 a.m., two servings of what appears to be Jello, were unlabeled and undated. They were observed in a refridgerator in the main kitchen. Review of the Storage of Food policy and procedure with a recent change date of 11/17 showed, All prepared foods will be labeled and dated. During an observation of dining service on 10/15/18 at 4:17 p.m., staff member R reached in a bin full of packaged crackers with gloved hands, touched a soup dish, a serving utensil, then a roll, with same gloved hands. The staff member did not sanitize going from soiled to clean tasks or items. During an observation of dining service on 10/15/18 at 4:23 p.m., staff member R rested her gloved hands on the steam table, then tore apart rolls for the residents with the same gloved hands, without sanitizing her hands. During an observation of dining service on 10/17/18 at 10:28 a.m., staff member S grabbed a piece of raisin bread for a resident with gloved hands, served resident meals, grabbed an additional piece of toast, touched a cap on a Sharpie pen and wrote on a diet card, then proceeded to grab a piece of toast for a residents plate without changing his gloves. During an interview on 10/17/18 at 10:36 a.m., staff member S stated there were monthly meetings where hand hygiene was reviewed and they also have annual online training that covered proper hand hygeine. Staff member S stated he usually used tongs to pick up toast, but he dropped them on the floor and did not have a back-up. During an interview on 10/17/18 at 1:04 p.m., staff member T stated he held a daily huddle with staff which often included the topic of proper hand hygiene techniques. He stated the dietary staff also completed in-service trainings two times per month. Review of the facility's Hand Hygiene policy and Procedure with a recent change date of 11/17 showed no language regarding proper hand hygiene when serving resident meals.",2020-09-01
619,GLENDIVE MEDICAL CENTER N H,275067,202 PROSPECT DR,GLENDIVE,MT,59330,2018-10-18,880,D,0,1,Y1J011,"Based on observation and interview, the facility failed to use proper hand hygiene techniques while assisting residents in the dining room for 2 (#s 30 and 31) of 14 sampled residents. Findings include: During an observation on 10/16/18 at 10:30 a.m., staff member U was provided eating assistance to residents #30 and 31. Staff member U touched her face and assisted resident #30, then assisted #31. Resident #30 coughed leaving sputum on staff member U's arm. Staff member U wiped off the sputum with resident #30's clothing protector and picked up resident #31's spoon and fed her. Staff member U rested her chin on her hand with her left elbow on the table, pushed in a chair, grabbed resident #31's cup and gave resident #31 a drink, then assisted resident #31 with her yogurt. Staff member U touched her right hand to her mouth and then continued to assist resident #31 with her yogurt. During this observation staff member U did not wash or sanitize her hands. During an interview on 10/16/18 at 11:37 a.m., staff member U stated, in morning meetings and at staff meetings they often talk about proper hand hygiene techniques. Staff member U stated she used hand sanitizer often but if They are really groady I wash my hands. Staff member U stated when she is assists residents in the dining room she uses the hand sanitizer on the wall because she does not have any hand sanitizer available to her at the table with the residents. Staff member U stated, I wash my hands before I sit down, and if I get anything on them I'll go wash them.",2020-09-01
620,GLENDIVE MEDICAL CENTER N H,275067,202 PROSPECT DR,GLENDIVE,MT,59330,2018-10-18,881,F,0,1,Y1J011,"Based on interview and record review, the facility failed to develop and implement a facility-wide antibiotic stewardship program that included written antibiotic use protocols. This failure had the potential to affect all residents receiving antibiotics. Findings include: During an interview on 10/17/18 at 11:10 a.m., staff member F stated, We do not have written antibiotic use protocols. She stated she was working with the hospital antibiotic stewardship committee and she expects it will be completed in, the next two to three months. During an interview on 10/17/18 at 12:06 p.m., staff member A stated, We have a policy for antibiotic stewardship, but we do not have protocols in place. She stated, We thought this requirement was supposed to be implemented in 2019. Review of the facility policy, Antimicrobial Stewardship Program, dated 3/18, showed the policy did not include antibiotic use protocols. The facility did not produce written antibiotic use protocols during the time of the survey.",2020-09-01
621,HOT SPRINGS HEALTH & REHABILITATION CENTER,275069,600 1ST AVE N,HOT SPRINGS,MT,59845,2017-08-09,202,B,0,1,43PH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to obtain a physician order [REDACTED]. at the facility. The failure to document the residents transfer and recapitulation of stay, had the potential to affect residents who may discharge the facility to an alternate living arrangement, or who needed continuing services in the community. This practice affected 1 (#10) of 1 deceased resident's clinical record. Findings include: Review of resident #10's clinical record failed to show evidence a physician's orders [REDACTED].#10's body to the mortuary, after resident #10 had passed away on [DATE]. The clinical record lacked a recapitulation of resident #10's stay at the facility. The Record of Death, filled out by the facility, lacked a signature from the receiving mortician, representing the funeral home. During an interview on [DATE] at 12:00 p.m., staff member B said the facility did not have a policy or procedure that guided staff after the death of a resident. She said the nurses just learned the protocol during their work, but there was not a set protocol. Staff member B said she was unable to locate a recapitulation of resident #10's stay, and was not sure if one had been completed, We just don't have one. She said a recapitulation of a resident's stay was something the facility performed with each discharge, but she had no explanation for why there was not a recapitulation for resident #10. Staff member B felt that perhaps a traveling nurse, who cared for the resident, did not know the protocol. Staff member B felt the lack of a signature from the receiving mortician, on the Record of Death, was an oversite by the nurse.",2020-09-01
622,HOT SPRINGS HEALTH & REHABILITATION CENTER,275069,600 1ST AVE N,HOT SPRINGS,MT,59845,2017-08-09,253,E,0,1,43PH11,"Based on observation and interview, the facility failed to maintain exterior doors for keeping pests out of the facility by not properly sealing the bottoms of the doors where the door met the threshold of the frame for 3 of 7 exterior doors. Findings include: 1. During an observation on 8/8/17 at 8:40 a.m., the convenience exit out of the east wing activity room was inspected. The door was not sealed, there was a gap on the lower half of the door as well as the bottom of the door over the threshold, with light showing through. 2. During an observation on 8/8/17 at 8:45 a.m., the west corridor exit door was inspected. There was a large unsealed gap under the door. 3. During an observation on 8/8/17 at 4:57 p.m., resident room 21 was inspected. There was a large gap, approximately one-quarter inch, under the exterior screen door. The sliding glass door was observed to be open the entire duration of the survey. 4. During the tour of the building on 8/8/17 at 9:03 a.m., staff members A and F accompanied the surveyor when the activity room exit door and the east hall exits were inspected. Staff member F killed a spider near the staff break room on the east hall. Staff member A stated he agreed that with the large temperature differential between the day time and the night time, pests could easily enter the building through the unsealed openings at night. Staff member A stated he did not care for insects. 5. During an observation on 8/8/17 at 8:15 a.m., a large spider was in the public bathroom sink right across from the large dining room. 6. During an observation on 8/9/17 at 2:10 p.m., a large spider was killed by staff member H in the east hall in front of resident room 24. During an interview on 8/8/17 at 10:40 a.m., staff member F stated the contractor was called and he would be back by the end of the week to spray the facility again. Staff member F stated as soon as he fixed the drier, he would work on sealing all the exit door openings.",2020-09-01
623,HOT SPRINGS HEALTH & REHABILITATION CENTER,275069,600 1ST AVE N,HOT SPRINGS,MT,59845,2017-08-09,278,E,0,1,43PH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility failed to complete section V for care planning for 4 (#s 3, 4, 5, and 6) and failed to ensure the MDS assessment was coded accurately for [DIAGNOSES REDACTED].#s 6) resident; and the facility failed to document the correct heights and weights on the MDS assessments for 2 (#s 3 and 4) of 10 sampled residents. Findings include: 1. Resident #5 was admitted to the facility on [DATE] with multiple diagnoses. Review of the Admission MDS, with an ARD of 8/31/16, showed that Section V did not indicate which triggered care areas would be care planned for the resident. 2. Resident #6 was admitted to the facility 11/3/16 with multiple diagnoses. Review of resident #6's Admission MDS, with an ARD date of 11/10/16, and the Quarterly MDS, with an ARD dated of 5/4/17, showed that Section V of these MDS's did not indicate which triggered care areas would be care planned for the resident. A comparison of the two MDS's, showed discrepancies between diagnoses. There were [DIAGNOSES REDACTED]. -CAD; -[MEDICAL CONDITION]; -GERD; -[MEDICAL CONDITION] Disorder; -Restlessness and agitation; -Conduct disorder vs dissociative and [DIAGNOSES REDACTED]; and, -DM vs DM2 During an interview on 8/8/17 at 10:45 a.m., staff member B said, We should have verified the current active diagnoses. She said she did not know why the errors occurred, and said that the triggered areas in section V were auto filled. Staff member B said, Apparently, we did not check these (the diagnoses). She said, We should have changed the zero's in the section V columns to show the triggered areas for care planning. She said she felt the zeros had been added because the facility was developing the care plans by hand. Staff member B said, she and a second MDS nurse were responsible for completing the MDS's for the residents, and that they both had to work the floor, and this took time away from the MDS duties. 3. Resident #3 was admitted to the facility on [DATE] with multiple diagnosis. Review of the comprehensive MDS assessment, with an ARD of 9/8/16, showed K0200B was not coded to reflect the resident's current weight. Review of the Section V0200B of the same MDS assessment showed the Care Planning Decision was coded with zeros and failed to reflect the care planning areas. Review of the Nursing Admission Evaluation, dated 9/1/16, showed the resident's weight was 101 pounds. During an interview on 8/8/17 at 9:55 a.m., staff member B stated transmission would not be possible with a blank weight assessment. However, she did not provide any additional information. 4. Resident #4 was admitted to the facility on [DATE] with multiple diagnoses. Review of the comprehensive MDS assessment, with an ARD of 4/14/17, showed K0200A was not coded to reflect the resident's current height. Review of the Section V0200B of the same MDS assessment showed the Care Planning Decision was coded with zeros and failed to reflect the care planning areas. Review of the Quarterly MDS assessment, with an ARD of 6/21/17, showed K0200B was not coded to reflect the resident's current weight. Review of the Section V0200B of the same MDS assessment showed the Care Planning Decision was coded with zeros and failed to reflect the care planning areas. Review of the Nursing Admission Evaluation, dated 4/11/17, showed the resident's height was five feet.",2020-09-01
624,HOT SPRINGS HEALTH & REHABILITATION CENTER,275069,600 1ST AVE N,HOT SPRINGS,MT,59845,2017-08-09,287,D,0,1,43PH11,"Based on interview and record review, the facility failed to ensure MDS information was signed as completed in a timely manner and available for automated data processing, as required, for 1 (#3) of 10 sampled residents' MDS assessments. Findings include: Review of resident #3's Quarterly MDS, with an ARD of 9/8/17, showed section Z0500B was not signed until 10/18/17, 40 days after the ARD, as to the attestation of its completion by the RN. During an interview on 8/8/17 at 10:50 a.m., staff member B stated that due to the staffing constraints, this assessment was completed late.",2020-09-01
625,HOT SPRINGS HEALTH & REHABILITATION CENTER,275069,600 1ST AVE N,HOT SPRINGS,MT,59845,2017-08-09,312,D,0,1,43PH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assist with hydration and grooming for 1 (#3) of 4 sampled care observations. Findings include: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #3's comprehensive MDS, with an ARD of 9/8/16, showed the resident's decision making was severely impaired, she rarely made decisions. The MDS showed the resident required extensive assistance with eating and personal hygiene from one to two care givers. The resident could not be understood. Review of Care Conference Summary, dated 6/13/17, showed the team and family decision that the hygiene was really important to the resident; her teeth needed to be brushed, hair was to be combed, and her clothes had to be clean. Review of the CMS-802 provided by the facility on 8/7/17, showed the resident's communication was triggered under item 24, ROM/Contracture's under item 26, and hydration under item 28. Review of the 5/18/17 plan of care showed the resident was refusing care, however, the plan of care was not specific to the actual care areas for refusals. The plan of care showed the resident was at risk for dehydration. The intervention was only to ensure that the resident consumed 75% of the fluids at meal times. The intervention failed to show what to do if the resident failed to consume 75% of the fluids at meal times. During an observation on 8/8/17 at 8:37 a.m., resident #3 received assistance from staff members J and K during morning care after she woke up. A cooler with two glasses of nectar thickened (water and red beverage) in water was located on a night stand near the room's bathroom, not within the resident's reach. The cooler was zipped closed. Staff member J stated the coolers were provided at night, but it looked like she was not offered her fluids last night. Staff member J stated the resident could hold the glass, but needed assistance with the cooler. Staff member J stated if she fell asleep last night then they probably did not wake her up. Staff member J offered the thickened water to the resident while staff member K provided oral care to the resident. The resident drank the water. In the meantime, staff member K removed the resident's dentures from her mouth. The dentures were covered in food debris. Staff member K wiped and removed additional food debris from the resident's mouth. The resident did not resist oral care. Staff member K brushed the dentures. Staff member K stated this was usually how the resident presented in the morning with dentures in her mouth. She stated perhaps the resident refused oral care at night, although, she was not sure. Staff members J and K both stated dentures should be removed and soaked over night, brushed in the morning before placing in the residents' mouths, after the residents' received oral care. Staff member K also stated there was a definite decline in the resident's condition, as she slept more and was weaker than usual. During an observation on 8/9/17 at 7:35 a.m., a zipped cooler was on the night stand next to the resident's bathroom. Two glasses of thickened fluids were still wrapped with Saran wrap and were untouched in the cooler. The ice in the cooler was melted and now in water form. The resident was not in the room. The night stand was not within the reach of the resident if she was in bed. During an interview on 8/9/17 at 8:35 a.m., staff member J stated that resident #3 presented the same this morning as well, with dentures in her mouth when she woke up. Staff member J was sitting in the dining room and was attempting to feed the resident. The resident was very sleepy and could not be aroused. Staff member J stated they had to remove and brush the dentures, and provided oral care to the resident this morning. Staff member J stated there was only one CNA on the floor last night by himself. She stated she came to work at 4 a.m. that morning to help. Staff member J stated the resident was declining lately, eating/drinking less and sleeping more, pointing at the resident who could not be aroused. Staff member J stated the resident was left to sleep through the breakfast, but offered a banana (her favorite) when she woke up. Review of the meal monitoring for June, (MONTH) and (MONTH) of (YEAR) showed only the fluid consumed at meal times were documented, but not the fluids consumed between meals and during the daily activities. Review of the dietary notes lacked documentation as to resident's risk factors for dehydration, addressing recent decline, but showed that the resident did not have signs of dehydration on 8/9/17, on the day the potential dehydration concern was brought to the attention of the facility staff. During an interview on 8/8/17 10:05 a.m. staff member B stated residents were provided or assisted with oral care twice daily, once in the morning and once before going to bed. During an interview on 8/8/17 at 10:45 a.m., staff member L stated the coolers of thickened fluids were placed in the nurses' station between 7:00 and 8:00 p.m. in the evening. The coolers were refreshed/replaced at 10:00 a.m. in the morning. Staff member L stated resident #3 received thickened fluids only at her bedside. She stated resident #3 required help to drink her fluids. Staff member L stated the resident had to be offered and assisted by the staff to drink her fluids. The facility failed to ensure staff regularly documented that they offered fluids and that they were aware of the resident's dehydration risk due to a decline in overall activities of daily living requiring extensive staff assistance due to neurological deficit, multiple medications, chewing and swallowing problems, occasional refusals, unclear speech, and in recent, an overall decline in condition. When the food and fluid intake started to decline, as a result of her disease process, the facility did not evaluate the actual consumption of fluid, document new interventions, monitor implementation of the new interventions, and train the staff with the new interventions in assisting the resident with fluid consumption. The facility also failed to show that the resident was offered oral care not only before bedtime, but other times during the day due to possible refusals at night. The facility did not evaluate if the oral care was routinely refused at night, or it was not provided because of other issues at night. The plan of care failed to address the oral care was a specific care area of refusal by the resident with steps to prevent it.",2020-09-01
626,HOT SPRINGS HEALTH & REHABILITATION CENTER,275069,600 1ST AVE N,HOT SPRINGS,MT,59845,2017-08-09,318,E,0,1,43PH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to provide a nursing restorative program to ensure adequate and preventive care in range of motion (active - performed by the resident or passive performed by the staff) for 15 (#s 1, 2, 3, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, 17, 18, and 19) of 20 sampled and supplemental residents. Findings include: 1. Review of the Office Census Verification Worksheet provided by the facility, showed the 15 residents listed in the Based on Statement, above, either needed, or could have benefited, from restorative services. Review of the Policy: Restorative Program, provided by the facility showed, The following residents may be appropriate for a restorative program: - Any resident identified and evaluated to be appropriate on admission for a restorative program to reach their highest potential; -Any resident who has declined in level of function from baseline; and, -Any resident discontinued from active therapy that requires ongoing restorative to maintain their therapy gains. During an interview on 8/9/17 at 12:15 p.m., staff member B said, We used to have a RA program, but now we don't because of a lack of staffing. We have a new CNA class going on now, and when they (the new CNAs) become certified, one of them will be trained by the PT/OT to provide RA services. Staff member B said some of the services, like the walk-to-dine strengthening, had been being provided to the residents by the general CNA staff. She said there was no documentation or assessments detailing each resident's planned restorative services, resident progress/lack of progress, or documenting the delivery of restorative services. Staff member B said restorative services had been documented when the facility was running the RA program, but the services had not been documented since (MONTH) (YEAR) when the facility last had staff for the RA program. Review of the RA documentation provided by the facility confirmed the program documentation stopped being conducted in (MONTH) of (YEAR). 2. Resident #3 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the Physical Therapy Discharge Summary, for the service dates of 6/2/17 - 7/12/17, showed PT was to assess the resident's functional abilities, facilitate motor control, increase LE ROM and strength, increase independence with gait, promote safety awareness, improve tone in LE, improve dynamic balance and develop and instruct in restorative nursing program in order to enhance the resident's quality of life by improving the increased level of assistance from caregivers, preserve skin integrity and to increase in the participation with functional daily activities. The discharge recommendations included the following: - Two person maximum assist to continue ambulation with FWW for short distances in room, for example from the bed to the toilet, from the bed to the wheelchair and visa versa. - Restorative Program Established and staff trained. The PT discharge summary also showed strategy 2 for was not met as the resident was walking 10 feet at an extremely slow pace with discontinuous pattern and flexed knee posture. However, the PT failed to direct the nursing staff to provide passive ROM exercises to the LE to lower the flexed knee posture. Review of the resident's medical record showed there was absolutely no follow up by nursing and/or an establishment of a RA program to facilitate the PT recommendations after resident #3's participation in a 5-week PT program. During the observations of provision of care on 8/8/17 at 8:37 a.m., and transfers (from wheelchair to the scale chair) on 8/9/17 at 8:45 a.m., resident #3 was not weight bearing and her knees were flexed. During the interview on 8/9/17 at 7:15 a.m., staff members J and K stated there was no formal restorative program in place where they performed with the residents, where the nurses monitored and evaluated program participants periodically for improvement and/or decline in their condition. Staff member K stated that the only ROM was demonstrated by the residents was when they were dressed and transferred on a daily basis. This did not amount to the 15 minute program with multiple repetitions and different types of exercises. They both stated they had such a program before, but with staffing problems and a lack of an RA, the program ceased to exist. Staff member J stated she used to be a RA, but no longer. Staff member J stated the notebook is gone for the restorative program. She said the notebook was with the ADL sheets, but it was gone for 1.5 years now. During an observation on 8/9/17 at 8:45 a.m., staff member K and staff member J transferred the resident from one wheelchair to the next to weigh the resident. The resident was limp, could not bear her body weight and her knees were flexed. At this time, staff member K stated before she went on vacation on 7/19/17, the resident was able to stand. Staff member K stated she suspected a stroke for the resident to decline like this. During an interview on 8/8/17 at 5:00 p.m., staff member B stated they had not coded nursing restorative programs in the MDS assessments in a while. She stated there was no formal program where residents' were provided a structured restorative program with documentation until the facility was staffed better. During an interview on 8/8/17 at 5:15 p.m., staff member N stated there was no formal restorative program in the facility like before. She stated too many staff changes caused the system to fail. She stated resident #6 was to be on a walk-to-dine program but he was not receiving it. Staff member N stated resident #13 needed the walk-to-dine or walking program in general. She stated resident #13 loved to walk, but she had dementia and was impulsive and fell frequently. Staff member N stated resident #13 would benefit from staff supervision with a consistent walking program. Staff member N stated resident #3 was declining lately, but she was a good candidate for sit-to-stand with a SteadyMate device. Staff member N stated resident #9 was just on Med A and staff needed to use the Evolve Stand Frame with the resident twice daily. Staff member N stated she was not sure if the restorative notebook was even there anymore. She said after the resident goals were made it was up to nursing to implement the restorative program. The facility failed to perform a comprehensive review or focused review to identify routine preventative care to its residents. The facility failed to ensure with staff changes residents' unique risk factors were still evaluated and preventative care measures were put in place consistently and routinely. And finally, the facility failed to ensure that the program participants' progress or decline, if unavoidable, was monitored and documented.",2020-09-01
627,HOT SPRINGS HEALTH & REHABILITATION CENTER,275069,600 1ST AVE N,HOT SPRINGS,MT,59845,2017-08-09,353,E,0,1,43PH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to maintain enough active staff to provide consistent Restorative Aide services to 15 (#s 1, 2, 3, 6, 7, 8, 11, 12, 13, 14, 15, 16, 17, 18, and 19) of 20 sampled and supplemental residents. Findings include: 1. Review of the Office Census Verification Worksheet provided by the facility, showed the 15 individuals listed above needed, or could benefit from, restorative services. During an interview on 8/9/17 at 12:15 p.m., staff member B said, We use to have a RA program, but now we don't because of a lack of staffing. We have a new CNA class going on now, and when they (the new CNAs) become certified, one of them will be trained by the PT/OT to provide RA services. See F318 for further details of needed RA services in the facility. 2. Resident #3 was admitted to the facility on [DATE] with multiple diagnosis. Review of the 9/8/16 (ARD) comprehensive MDS and 5/17/17 (ARD) Quarterly MDS showed resident #3 required assistance from one care giver for eating and hygiene. During the entrance interview on 8/7/17 at 2:05 p.m., staff member A stated the facility census was 34. During the provision of care observations on 8/8/17 at 8:37 a.m., the resident required bed mobility, personal hygiene and transfer assistance from two staff members. The resident's oral care was not completed from the night before. The resident's cooler housing two glasses of thickened fluids were observed untouched on the mornings of 8/8/17 and 8/9/17, with beverages sitting in water, in the cooler, that was zipped closed, located on a night stand placed away from the resident's bed. During the interview on 8/9/17 at 8:35 a.m., staff member J stated there was only one CNA working last night. She stated it appeared resident #3 did not receive oral care last night, because her dentures were still in her mouth and she required oral care. Staff member J stated staff member M was the only CNA working last night. Staff member M was not available for interview. During an interview on 8/8/17 at 9:55 a.m., staff member B stated resident #3's Admission MDS assessment was late because the MDS coordinator's services were needed on the floor due to short staffing. During the interview on 8/9/17 at 2:10 p.m., staff member B stated she stayed later than usual last night to help put the residents in bed. She stated her MDS coordinator and herself took floor shifts frequently due to a staffing shortage. She stated the geographical area also put a strain on finding staff members.",2020-09-01
628,HOT SPRINGS HEALTH & REHABILITATION CENTER,275069,600 1ST AVE N,HOT SPRINGS,MT,59845,2019-11-14,600,D,0,1,D4BR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect two (#s 42 and 175) of 15 sampled and supplemental residents from abuse, which had the potential to result in physical and/or mental harm. Findings include: [NAME] Review of the facility Investigation Report, undated, showed NF3 had been verbally abusive and threatening to resident #175. The nurse lost her composure and used an expletive that was directed at the resident. NF3 reported the incident to the facility Manager on Duty, who did not immediately report the incident to the administrator or the DON. During an interview on 11/14/19 at 11:25 a.m., staff member [NAME] stated she did not report the incident because she thought the situation was resolved and handled appropriately. Resident #175, his wife and NF3 discussed the situation, and resident #175 apologized, saying he can be cantankerous. During an interview on 11/14/19 at 11:31 a.m., staff member C stated NF3 was allowed to finish her shift that day. This left residents in the facility at risk for verbal abuse. She stated NF3 was suspended on 5/12/19, and was no longer working for the facility as of 5/16/19. During an interview on 11/14/19 at 11:45 a.m., resident #175 stated he did not remember the details of the incident, as it was a long time ago. He stated he had no further concerns, and had been treated with dignity and respect by staff members. B. Review of the facility's incident report, dated 7/10/19, which concerned resident #42, showed: Received an allegation of abuse and spoke with the C.N.[NAME] at approx. 1500 on 7/10/19. The aide had a conversation with a nurse, supposedly passed on during shift to shift report. The allegation was that a male aide was found in bed with (resident #42). That is all the aide could tell the Executive Director at the time. Tried contacting the two licenses nurses mentioned. Left voice mails with both nurses. The nurse who supposedly found the aide in bed with (resident #42) called back at 1615 hours and gave a verbal statement in regard to what she saw. The incident apparently occurred on 7/4 or the early morning of 7/5/19 at approx 0100. The nurse was looking for the aide and went into (resident #42's) room to turn off their TV. When she looked at (resident #42) she observed the male aide fully clothed lying in bed next to the (resident #42). He supposedly had his arm around (resident #42's) face and was stroking it, and talking to (resident #42). The nurse stated what are you doing because she had been looking for him for an hour. The male aide stated that he was talking to the resident. (Resident #42) has dementia and is non-interviewable . Male aide suspended, physician, family, .police notified. (sic) The investigation results, dated 7/10/19, showed: Verified that the alleged abuse did occur, and that the inappropriate physical contact was of a non-sexual type. The investigation results showed both NF1 and NF2 were no longer working at the facility as of 7/10/19 and 7/13/19, respectively. The results also showed the resident was continually monitored for psycho-social needs and found to remain at baseline for the duration of the investigation. During an interview on 11/13/19 at 4:45 p.m., staff member A stated resident #42 no longer resided in the facility. Staff member A stated as soon as the incident was reported to him, the nurse on shift conducted a head to toe exam with resident #42 and did not observe any signs or symptoms that would indicate abuse. Staff member A stated NF1 was identified and suspended immediately. Staff member A stated all residents were interviewed to ensure their safety, and no residents stated they felt unsafe around the NF1 or any other staff. Staff member A stated the results of the investigation indicated that no sexual contact had occurred, and the primary care provider decided, It was not feasible to put the resident through an examination based upon not finding any visual signs of trauma. During an interview on 11/13/19 at 4:52 p.m., staff member A stated to address this systemically, the facility ensured all staff were trained on abuse during monthly staff meetings, starting in (MONTH) 2019. Staff member A stated the incident was discussed in QAPI, and the team had started monthly in-services on abuse. Staff member A stated the facility plans on continuing monthly education through the foreseeable future. During an interview on 11/13/19 at 4:41 p.m., staff member C stated she started working at the facility in mid-July of 2019, and she remembered the facility had a mandatory in-service training on abuse in August. During an interview on 11/14/19 at 9:44 a.m., Staff member D stated if she were to see a staff member lying in bed with a resident, she would report it to the nurse immediately as it could be abuse. Review of resident #42's [DIAGNOSES REDACTED]. Review of resident #42's care plan, dated 10/17/19, showed: Resident #42, has bed against one wall, and utilizes bed mobility bars for repositioning and use during incontinent care; In room activities: 1:1 sensory stimulation, grooming, .(Resident #42) has a behavior problem r/t delusional disorder, psychotic mood, [MEDICAL CONDITION], and hx of sexualized behaviors .caregivers to provide opportunity for positive interaction, attention. Review of resident #42's MDS, ARD 7/15/19, showed a BIMS had not been conducted because, Resident is rarely/never understood, and resident #42 had a Memory problem for short term and long term memory. Resident #42's MDS showed she was severely impaired for cognitive skills in daily decision making, and was reliant on staff for all ADLs. Review of NF2's file showed a background check was completed and cleared upon hire. NF2's file showed she had signed the facility's Abuse Prohibition and Notification Policy on 5/28/18. NF2's file showed she was no longer employed by the facility on 7/7/19. Review of the Charge Nurse's job description, updated (MONTH) 2012, showed: Supervises and evaluates the implementation of Resident Bill of Rights .identifies performance concerns with supervised staff .Assumes accountability for knowing and complying with policies and procedures contained in the employee handbook. Review of NF1's file showed he had signed the Abuse Prohibition and Notification Policy on 3/25/19. NF1 had also signed the facility's code of conduct and employee handbook on 3/25/19. NF1 was no longer working at the facility as of 7/10/19 due to failure to meet standards. Review of the facility's in-service education summary showed staff attended a lecture on abuse on 7/10/19; 8/9/19; 9/10/19; and 11/18/19. The in-service education on 11/18/19 was conducted by the region's ombudsman. Review of the facility's QAPI meeting, dated 8/13/19, showed abuse as a discussion point. Review of the facility's Resident Rights document, published 9/2010, showed: A resident has the right to be free from verbal, mental, and physical abuse, neglect, or financial exploitation.",2020-09-01
629,HOT SPRINGS HEALTH & REHABILITATION CENTER,275069,600 1ST AVE N,HOT SPRINGS,MT,59845,2019-11-14,609,D,0,1,D4BR11,"Based on interview and record review, the facility failed to report abuse allegations for two (#'s 42 and 175) of 15 sampled and supplemental residents in a timely manner. Findings include: Review of the facility's incident report showed an unidentified staff member had reported to staff member A on 7/10/19 that NF2 had reported to her during shift change that she had seen NF1 lying in bed with resident #42 on 7/4/19. Review of a facility Disciplinary Action Form, dated 5/21/19, showed, On 5/11/19 staff member [NAME] was working as the weekend Manager on Duty. A nurse reported to her that an incident of staff to resident verbal abuse had occurred with resident #175. Staff member [NAME] did not follow the (company's) Abuse Reporting Policy by not informing the ED or DON immediately that abuse did occur. This forced the facilitiy to report the abuse incident a day late. During an interview on 11/13/19 at 4:41 p.m., staff member C stated, We report abuse immediately, like as soon as possible to staff members A and B. During an interview on 11/13/19 at 4:45 p.m., staff member A stated, during the facility's (MONTH) in-service meeting, (management) made sure that everyone understood that when you have allegations you need to report it immediately, because it had been one week since the incident occurred. Staff member A stated to address this systemically, the facility ensured all staff were trained on when and how to report abuse during monthly staff meetings, starting in (MONTH) 2019. Staff member A stated the incident was discussed in QAPI, and the team had decided to address it with monthly in-services. Staff member A stated the facility plans on continuing monthly educations through the foreseeable future. During an interview on 11/14/19 at 9:44 a.m., staff member D stated she would report suspected abuse straight away to the nurse on shift. Review of NF2's file showed she had signed the facility's Abuse Prohibition and Notification Policy on 5/28/18. Review of a document titled, Improvement Plan, in the employee's file showed, Make sure to contact (Director of Nursing Services/Executive Director) when there is an event in the facility. Additionally, her file showed she was no longer employed by the facility on 7/7/19 for failure to report abuse. Review of the facility's QAPI meeting, dated 8/13/19, showed the team reviewed timely abuse reporting. Review of the facility's May-October Abuse Timeliness Report Audit Form showed the facility had reported 16/17 incidents to the state reporting site the same day the incident occurred. The facility's monthly in-service education, updated 9/2017, showed staff reviewed the policy for reporting suspected abuse immediately, and no later than two hours after suspecting an incident had occurred, every month from January-November 2019, with the exception of October. The facility's Abuse Prohibition and Notification Policy, updated 11/2016, showed: Alleged violations involving mistreatment, neglect, or abuse .are reported to the Executive Director.",2020-09-01
630,HOT SPRINGS HEALTH & REHABILITATION CENTER,275069,600 1ST AVE N,HOT SPRINGS,MT,59845,2019-11-14,623,D,0,1,D4BR11,"Based on interview and record review, the facility failed to provide written notification of the reason for transfer to the hospital; and failed to send a copy of the notice to the Omdsman for two (#16 and #23) of 13 sampled residents. Findings include: 1. During an interview on 11/13/19 at 9:41 a.m., resident #16 stated he had been transported to the hospital for emergency gallbladder surgery a few months prior. Review of Nurse's Notes, dated 8/1/19, showed resident #16 had left for an appointment, and on 8/3/19, the resident had been transported back to the facility after an emergency gallbladder surgery. During an interview on 11/14/19 at 11:06 a.m., staff member B stated the facility had not provided a written notice of transfer to resident #16 and had not sent a copy to the ombudsman. Review of the facility's Admission Packet, updated 9/2013, showed, The facility will offer a bed hold to and discuss the bed hold rate with the Resident at the time of transfer to an acute hospital. The Admission Packet did not include a statement that showed the facility would notify, in writing, the resident/resident's representative and ombudsman of the reason for transfer. 2. Review of resident #23's Census Entry, dated 10/7/19, showed the resident went to a doctor appointment, and was checked into the hospital. During an interview on 11/14/19 at 9:11 a.m., staff member C stated a verbal message by phone was provided to the family representative for the discharge to the hospital. She stated the residents know this is their home, and the facility does not provide a written notice to the resident or the ombudsman for the discharge to the hospital. Review of the facility bed hold policy for resident #23 showed signatures upon admission to the facility acknowledging the policy.",2020-09-01
631,SHERIDAN MEMORIAL NURSING HOME,275070,440 W LAUREL AVE,PLENTYWOOD,MT,59254,2019-04-04,658,D,0,1,Inf,"**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 practice by leaving medication by the bedside for 1 (#23) of 25 sampled and supplemental residents, and facility staff administered as needed medications, outside the scope of practice, for 1 (#5) of 12 sampled residents, which had the potential to affect all residents with orders for as needed medications. Findings include: 1. During an observation and interview on 4/1/19 at 5:19 p.m., a cup filled with pills and another cup filled with applesauce were noted on resident #23's bedside table. The resident stated the applesauce makes the pills easier to swallow, and It depends on whether I'm tired or not whether the nurse leaves her pills with her. During an interview on 4/1/19 at 5:30 p.m., staff member A stated (staff member G) did that and she shouldn't have. During an interview on 4/1/19 at 6:01 p.m., staff member G stated That was me. I shouldn't have done that. (Resident #23) took her [MEDICATION NAME]/levadopa and wanted to wait till supper to take the rest. Staff member G stated It was a mistake. Review of the facility Medication Administration Policy, last updated 11/18 showed, under Section II - Preparing Medications and Administering Medications: K. Do not leave drugs unattended . N. Stay until the resident has completely swallowed each medication . If left unattended, resident may not take dose or may save drugs, causing risk to health. Review of the Medication Administration Skills Checklist for Unlicensed Assistive Personnel, completed 2/11/19, showed that staff member G had been trained on the medication administration policy. 2. During a medication observation and interview on 4/3/19 at 1:10 p.m., staff member J removed [MEDICATION NAME] 5 mg from the narcotic cabinet and entered the number remaining on the narcotic log. Staff member J verbally notified staff member K that resident #5 had requested a pain pill. Staff member J entered resident #5's room and administered the [MEDICATION NAME] 5 mg. Staff member J stated the nurse (staff member K) would document the administration on the MAR and sign the narcotic log. During an interview on 4/3/19 at 2:27 p.m., staff member A stated the staff member who performed the training for the medication aides was out of the facility. Review of facility policy Nursing Home Medication Administration did not contain any reference to a medication aide II. Review of the Medication Administration Skills Checklist for Unlicensed Assistive Personnel did not identify the restriction that as needed medications can not be administered by a medication aide II staff member, as per the certification. It was identified the facility was following the standards of practice for a medication aide I rather than a medication aide II.",2020-09-01
632,SHERIDAN MEMORIAL NURSING HOME,275070,440 W LAUREL AVE,PLENTYWOOD,MT,59254,2019-04-04,659,D,0,1,Inf,"Based on observation, interview, and record review, the facility failed to ensure staff were properly trained to operate the MaxiLift (a mechanical lift), which led to a resident being left suspended several feet above her bed for an extended period of time for 1 (#9) of 25 sampled and supplemental residents. Findings include: During an observation and interview on 4/2/19 at 12:06 p.m., resident #9 was receiving a bath from staff member E. Staff member [NAME] stated they only needed one person when using the the MaxiLift to assist with a resident transfer. Staff member [NAME] placed resident #9 in her geri-chair, covered her in towels and a bath blanket, and returned her to her room. Staff member [NAME] placed resident #9 back in the MaxiLift and began to lift her out of her geri-chair to place her in bed. The battery on the lift began to beep. Staff member [NAME] used the call light to get the attention of another CNA to bring her a new battery. Resident #9 was suspended approximately 2-3 feet above her bed. The battery that had been brought into resident #9's room was dead. Staff member [NAME] stated There is no emergency release on this lift. She used the call light to gain the attention of the CNA in order to get another battery, so resident #9 could be lowered to the bed. Staff member [NAME] stated again that she did not know of any emergency release for the MaxiLift. A CNA answered the call light, and was asked to bring in another battery. The CNA brought back a battery that had power, and resident #9 was lowered to her bed. Resident #9 was not able to converse, so an interview to determine how she felt during the transfer was not possible. She was observed grabbing at the towels and blanket that were placed on her during the transfer. During an interview on 4/3/19 at 8:16 a.m., staff member A stated, We usually only use one person assist (for the lift) and that is based on their (resident) competency. She stated both batteries had been checked in the morning, and there was a greater than 50% charge. During an interview on 4/3/19 at 9:40 a.m., staff member A stated there was an emergency release on the MaxiLift. She stated staff had not been trained on the release, and none of the staff were aware of this release. During an observation and interview on 4/3/19 at 9:41 a.m., staff member B showed how to tell whether a lift battery was charged. He then removed an old battery from the MaxiLift and replaced it with a fully charged battery, then operated the lift. He stated the lift had an emergency release and then demonstrated how it worked. During an interview on 4/3/19 at 10:12 a.m., staff member D stated We go over the mechanism itself before we use it (the lift) during the CNA class. She stated They are told not to use the lift alone at first. She stated the resident should be lifted just high enough to clear the top of the bed. Staff member D stated If the resident has tubes, or were really acute, such as in a hospital setting, then she would use two staff during a lift transfer. Staff member D stated the CNA's do skills testing every year. She further stated staff member [NAME] was not in her CNA class. Review of the MaxiLift manufacturer's instructions for use, page six, showed It is the responsibility of each facility or medical professional to determine if a one or two person transfer is more appropriate, based on the task, resident load, environment, capability, and skill level of the staff members. Review of staff member E's Nursing Home Skills Evaluation dated (YEAR) showed an evaluation of good under the section of Mechanical Lift and Wheelchair safety.",2020-09-01
633,SHERIDAN MEMORIAL NURSING HOME,275070,440 W LAUREL AVE,PLENTYWOOD,MT,59254,2019-04-04,684,D,0,1,Inf,"Based on observation, interview, and record review, the facility failed to thoroughly assess, identify, evaluate, monitor effectively, and provide interventions for a resident who had an inability to position himself during meals for 1 (#8) of 12 sampled residents. Findings include: During an observation and interview on 4/1/19 at 6:02 p.m., staff member G was assisting resident #8 with the meal, in the dining room. The staff member had resident #8 reclined in a geri-chair, with the resident's head and back raised at a 25 degree incline. Staff member G stated resident #8 ate better, or liked to lay reclined in the geri-chair. The staff member stated being unsure of what position the resident should be positioned at for meals. The staff member went to raise the head of resident #8's chair but stopped and left the resident sitting with the same degree of incline. Resident #8 was observed given fluids from sip cups by staff member [NAME] During an observation and interview on 4/1/19 at 6:13 p.m., staff member H start to assist resident #8 with the meal. The staff member did not change the resident's positioning in the geri-chair. The chair remained at 25 degree incline for resident #8's upper body. Staff member H stated it would not hurt if resident's head was up higher. The staff member did not raise the resident's head. The staff member stated resident #8 ate cheerios cereal, with thickners, in the cereal at breakfast. The staff member stated the resident usually had no problems eating this for breakfast. The staff member stated the resident had never choked while he, the staff member, was assisting with the meal. During an observation and interview on 4/2/19 at 8:07 a.m., staff member I was assisting resident #8 with the breakfast meal. The resident was sitting at a 45 degree angle. The staff member stated resident #8 did not choke, ever, while she assisted him, but he was to be seated at a 45 degree angle, in his chair. During an interview on 4/2/19 at 4:35 p.m., staff member J stated resident #8 should be at a 45 degree angle when eating. Staff member K stated resident #8 never had swallowing problems that she was aware of. Staff member K stated resident #8 was hard to position. The staff member stated she tried to sit resident #8 upright but 35 degrees was about the most she could get him to sit at. The staff member stated the resident had a pureed diet with ground meat, because of his ability to chew, but had corn flakes for breakfast. Staff member K stated using straws for resident #8's fluids, to give him more control with swallowing. During an interview on 04/03/19 at 9:08 a.m., staff member A stated nursing preferred resident #8 to be positioned at 35-45 degrees angle for the back of the geri-chair when eating. The staff member stated she would tell all staff to position his chair that way. The staff member stated she could not find where they had requested a speech evaluation but did remember the provider saying he would approve the evaluation when resident #8 got where he was having trouble. Staff member A stated I don't know of anytime he has choked. During an observation and interview on 4/3/19 at 7:47 a.m., resident #8 was positione, in a geri-chair at a 35 degree incline. Staff member L stated the registered dietician had said resident #8 needed to be positioned in the geri-chair with his head up to eat. The resident should be positioned at or around 45 degree incline of the upper body. The staff member stated the resident did have problems with teeth. She said the teeth were in bad shape. The resident had more of a chewing problem than swallowing. The staff member thought they had asked the provider about an speech evaluation but thought he said no. I know there are issues with the chair right now. We prefer he sit up more when eating. The staff member stated it being difficult to eat when he was reclined too much. During an interview on 4/3/19 at 1:27 p.m., NF1 stated she attended care plan meetings. Nothing was mentioned of concerns with resident #8's swallowing but she felt it was a better practice to raise the chair back so he would not choke on the food. In the past NF1 had been to the facility while resident #8 was eating. She stated staff had raised the back of resident #8's chair while eating. Review of registered dietician assessment showed resident #8 was to receive a dysphasia 2 diet, regular fluid consistency, sippy cups, and mighty shakes 3 times a day. For the portion of dental showed swallowing was adequate, that he had his own teeth and chewing was impaired, and he required full assist with meals. Review of all the registered dietary notes available and the resident's personalized care plan showed no documentation that identified positioning for meals or while drinking fluids. There were no notes showing therapies had worked with resident #8 for positioning to lower the risk of aspirating. The care plan showed no interventions for staff to follow which would assist with aspiration related to food and fluids.",2020-09-01
634,SHERIDAN MEMORIAL NURSING HOME,275070,440 W LAUREL AVE,PLENTYWOOD,MT,59254,2019-04-04,758,D,0,1,Inf,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have a physician review the prn (as needed), [MEDICAL CONDITION] medication, every 14 days, for 2 (#s 22 and 29 ) of 25 sampled and supplemental residents which had the potential for continued paradoxical effects for resident #22, and the potential for unwarranted use for resident #29. During an interview on 4/3/19 at 8:06 a.m., staff member F stated every now and then resident #22 will resist care, but most of the time he is in a pretty good mood. She stated I back off and let him cool down, re-approach later, or another staff face will usually help. She stated when he tries to leave, I try to redirect him, or offer him his kitty or dog. Then I let the nurse know. During an interview on 4/3/19 at 8:10 a.m., staff member J stated I give prn medication with the okay from the nurse. She said A lot of times I start with Tylenol first because resident #22 has headaches. She stated Then I give him [MEDICATION NAME] with the okay of the nurse. When he is looking to elope I walk and talk to him and try to change his mind. He did elope awhile ago, with no injury. Review of the physician progress notes [REDACTED].#22 has had some paradoxical effects when taking [MEDICATION NAME]. The note showed the scheduled [MEDICATION NAME] was discontinued, however the prn dose was left in place. During an interview on 4/3/19 at 3:37 p.m., staff member A stated they currently do not do the 14 day medication reviews from a physician for any of the prn, [MEDICAL CONDITION] medications.",2020-09-01
635,SHERIDAN MEMORIAL NURSING HOME,275070,440 W LAUREL AVE,PLENTYWOOD,MT,59254,2019-04-04,759,D,0,1,Inf,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to document the correct administration time for medications for--- 1 (#33) of 12 sampled residents. The calculated facility error rate was 7.41%. Findings include: During an observation on 4/3/19 at 7:42 a.m., resident #33 received the following medications: [REDACTED] Calcium with Vitamin D, [MEDICATION NAME] 37.5 mg, Vitamin B1 100mg, Celecoxib 100 mg, and [MEDICATION NAME] 150 mg. Review of resident #33's MAR indicated [REDACTED]. [MEDICATION NAME] 500mg and 1b. [MEDICATION NAME] topical 0.05% cream were documented as being administered on 4/3/19 at 7:52 a.m. along with the medications listed above. These administration of the above medications was not observed by the surveyor. During an interview on 4/3/19 at 2:27 p.m., staff member A stated she questioned staff member J about the medications (1a and 1b), and was told they were actually given later. Staff member A instructed staff member J on how to correct the administration time in the electronic medical record.",2020-09-01
636,SHERIDAN MEMORIAL NURSING HOME,275070,440 W LAUREL AVE,PLENTYWOOD,MT,59254,2019-04-04,761,E,0,1,Inf,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to properly store medication, to properly dispose of expired medication, and to ensure Schedule III-V controlled substances were separately locked; and not locked under the same access system used to obtain non-scheduled medications. These failures affected 3 (#s 7, 20, and 24) of 25 sampled and supplemental residents, and had the potential to affect all residents who have medication stored in the facility's medication room, as well as all residents with orders for Schedule III-V controlled substances. Findings include: 1. During an observation of the facility's medication storage room on [DATE] at 8:19 a.m., a box of [MEDICATION NAME] Single Ject for resident #20, had an expiration date of ,[DATE], and the injectables packaged within the box had an expiration date of ,[DATE]. A [MEDICATION NAME] Flex Touch pen for resident #24, with an open date of [DATE], and expiration date of [DATE], was noted in the refrigerator. Manufacturer's instruction for use showed the insulin should not be stored in the refridgerator while being used. A bottle of Saline nasal relief NaCl.65%, with an expiration date of ,[DATE] and no resident name on the bottle, was found in the storage area. A syringe of 0.9% sodium chloride injection was noted loose, without it's sterile packaging in a box with triple antibiotic cream and white [MEDICATION NAME] jelly. Review of the facility Nursing Home Medication Administration Policy, last updated ,[DATE], showed all medications are to be given in a safe manner and be consistent with State and Federal guidelines/regulations. 2. During observation and interview on [DATE] at 7:28 a.m., resident #7 was given [MEDICATION NAME] 1mg orally. The medication was removed from the drawer in the medication cart that contains resident medications that are not Schedule II controlled substances. Staff member J stated that [MEDICATION NAME] is stored with the regular medications and is not locked up separately. During an interview on [DATE] at 2:27 p.m., staff member A stated only Schedule II controlled substances are locked separately. The Schedule III-V controlled substances are stored with other non-controlled medications, and are not signed out on a narcotic log.",2020-09-01
637,SHERIDAN MEMORIAL NURSING HOME,275070,440 W LAUREL AVE,PLENTYWOOD,MT,59254,2016-09-14,371,D,0,1,Z0NZ11,"Based on observation and interview, the facility failed to remove expired food from the resident refrigerator, and document the date the food items were opened. This deficiency had the potential to affect all residents who stored their food in the refrigerator. Findings include: During an observation on 9/13/16 at 7:15 a.m., the refrigerator located on the hallway near room 64 contained expired food, which was: A bottle of Essential Every Day Blend Ranch, with the expiration date of 7/12/15; a bottle of Essential Everyday Brand Strawberry Syrup, with the expiration date of 4/23/15; a jar of bread and butter pickles, with the expiration date of 3/2016; and an opened wine cooler, with no open date documented on the bottle. In the freezer was one frozen dinner entree with an expiration date of 12/6/15, and ice cream which had been opened, but the open date was not documented on the container. During an interview on 9/13/16 at 4:20 p.m., staff member B stated all the staff were responsible for clearing the refrigerator out. She stated she was not aware there was expired food in the refrigerator. .",2020-09-01
638,SHERIDAN MEMORIAL NURSING HOME,275070,440 W LAUREL AVE,PLENTYWOOD,MT,59254,2016-09-14,441,D,0,1,Z0NZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure infection control was maintained by not labeling and separating personal belongings of the residents in resident rooms, for 3 double occupied rooms, out of 32 total rooms. Findings include: During an observation on 9/13/16, in room [ROOM NUMBER], personal resident items were not labeled with the resident name, and were on the countertop located by the sink. There was a cup containing a set of unlabeled dentures. Two tooth brushes were sitting in the same clear container on the back of the sink. During an interview on 9/13/16 at 11:40 a.m., staff member A stated the personal items in the rooms were not labeled, but she thought they probably should be. She said typically the resident in bed one had the top two drawers, and the bottom two drawers were occupied by the resident in bed two. During an observation on 9/13/16 at 11:45 a.m., in room [ROOM NUMBER], the following was found: an unlabeled bottle of lotion setting on the countertop of the sink area, and unlabeled combs in a metal container, unlabeled perfume lotions, and various unlabeled cosmetic products. During an observation on 9/13/16 at 11:55 a.m., in room [ROOM NUMBER], there was an unlabeled personal shaver, two unlabeled toothbrushes, unlabeled lotions, unlabeled shave cream, unlabeled mouth wash, and unlabeled baby powder on the counter top by the sink.",2020-09-01
639,ROSEBUD HEALTH CARE CENTER,275072,383 N 17TH AVE,FORSYTH,MT,59327,2017-02-23,244,E,0,1,KT7011,"Based on interview and record review, the facility failed to respond to Resident Council concerns. This practice had the potential to affect all residents at the facility. Findings include: During an interview on 2/22/17 at 2:00 p.m., the group stated the food was debatable and that their concerns with the food had been brought up during the resident council meetings previously. The group stated that the dietary manager had not returned to follow-up with concerns. Also, the group stated that the department heads typically did not address council concerns with the residents after they were discussed during the monthly meetings. During an interview on 2/22/17 at 2:25 p.m., staff member D stated the Resident Council concerns were not getting followed up on prior to (MONTH) (YEAR). Staff member D stated she was unaware it was a federal regulation to follow up on concerns brought up at the Resident Council Meetings. She stated she just had discovered it was a requirement when she was doing some research that day. Staff member D provided the forms that the facility planned to implement. The forms provided were not completed with the meeting minutes, and follow up was not completed by the responsible staff. Review of the Resident Council minutes showed concerns were identified in (MONTH) (YEAR) relating to cooler temperatures in the resident rooms. The documentation showed a member of the group asked if a staff member could check the thermostat in her room daily to see if the temperatures were varying from morning to evening. The facility failed to provide documentation of follow-up of the concerns, or cold resident rooms for (MONTH) (YEAR). Review of the Resident Council minutes for (MONTH) (YEAR) showed Resident Council concerns would be documented and followed up on by department heads. The facility failed to provide the documentation of follow-up for (MONTH) (YEAR). Also, concerns from the (MONTH) (YEAR) were not addressed or followed up on according to the (MONTH) (YEAR) Resident Council minutes. Review of the Resident Council minutes for (MONTH) (YEAR) showed the new forms were going to be utilized to ensure the issues identified at the Resident Council meetings were going to be addressed by the staff members responsible for them. The concerns identified at the meeting included: portions of meals; temperatures of meals; temperatures in the dining room; temperatures in the bath houses; missing clothing; and the time of church on Sundays. The facility failed to provide documentation of the follow up on the concerns for the (MONTH) (YEAR) meeting.",2020-09-01
640,ROSEBUD HEALTH CARE CENTER,275072,383 N 17TH AVE,FORSYTH,MT,59327,2017-02-23,364,F,0,1,KT7011,"Based on interview and record review, the facility failed to consistently monitor and document food holding temperatures to ensure both hot and cold foods were served at proper temperatures. This deficiency had the potential to affect all residents in the facility, including 1 (#7), who received food from the Dietary Department. During an interview on 2/21/17 at 4:00 p.m., staff member F stated the Dietary Department had been working on Quality Assurance projects, including maintaining acceptable food temperatures, and creating menus with pictures. Staff member F stated residents in the past had voiced concerns related to food temperatures, and were unsure what some menu items were, so pictures could help. During an interview on 2/22/17 at 4:15 p.m., staff member G was preparing dinner in the kitchen and was asked about food holding temperatures. Staff member G was able to identify the Danger Zone for food holding temperatures between 40 and 140 degrees Fahrenheit. Staff member G stated food temperatures should be documented for both hot and cold foods for every meal, but sometimes this was missed because the kitchen staff were busy with other tasks, such as preparing snacks and supplements. Staff member G also stated it was difficult to maintain holding food temperatures because residents were not always present and available in the dining room when it was time to serve food. During an interview on 2/23/17 at 10:00 a.m., resident #7 stated food temperatures could be inconsistent for both hot and cold menu items, based on what was being served and who was cooking. Resident #7 stated he ate in the dining room the majority of the time, and he and other residents had voiced concerns related to food temperatures. A review of the facility's Meal Temps tracking sheets showed the facility Dietary Department should record: original temperature, serving temperature, and final temperature for breakfast, lunch, and supper. The tracking sheets were dated back to (MONTH) (YEAR), and reflected a lack of evidence for consistent meal temperature tracking: - (MONTH) (YEAR): showed 17 days of tracking logs or 51 meals. Of those only 31 meals had temperature tracking. (MONTH) (YEAR) should have had 93 opportunities for meal temperatures to be recorded. - (MONTH) (YEAR): showed 17 days on nine daily tracking logs, for a total of 20 meals with temperature tracking. (MONTH) (YEAR) should have had 93 opportunities for meal temperatures to be recorded. - (MONTH) (YEAR): showed 14 tracking sheets out of 22 days, for a total of 28 meals with temperature tracking. (MONTH) (YEAR), at the time of survey, should have had 66 opportunities for meal temperatures to be recorded. No actual temperatures were recorded for any cold food in any of the tracking records. Cold foods were only documented as Cold on the temperature tracking sheets.",2020-09-01
641,ROSEBUD HEALTH CARE CENTER,275072,383 N 17TH AVE,FORSYTH,MT,59327,2017-02-23,371,F,0,1,KT7011,"Based on observation, interview, and record review, the facility failed to remove expired food from the resident refrigerator, located in the dining area of the facility; failed to prepare food in a sanitary environment, specifically by having open doors to the outside, dirty fans in the kitchen oscillating over food areas and clean tableware, and having a walkway through the kitchen where staff were not using hairnets. This deficiency had the potential to affect all residents in the facility who received service from the kitchen. Findings include: 1. During an observation on 2/21/17 at 4:00 p.m., the refrigerator located in the resident dining room had two bottles of yellow mustard with an expiration date of (MONTH) 31, (YEAR); Irish Cream coffee creamer with an expiration date of (MONTH) 27, (YEAR); and a jug of milk that had a sell by date of (MONTH) 17, (YEAR). During an interview, staff member [NAME] stated it was the nursing assistants that helped set up beverages in the morning, and she thought they were responsible for cleaning out the resident refridgerator. She stated the nursing assistants had been out all week, and perhaps that is why the expired food was in the refrigerator. When staff member [NAME] was told about the (MONTH) and (MONTH) (YEAR) dates, she stated she wasn't sure who was responsible for making sure the food in the refrigerator was not expired. 2. During an observation on 2/22/17 at 8:10 a.m., staff member H walked down the dietary hallway. Staff member H opened the first door which had a sign posted reading Keep Closed / Restricted Hallway and walked through a second door which had a sign posted reading Dietary Staff Only Past This Point. Staff member H was not wearing a hair net, and he did not wash his hands before reaching in the individually wrapped bulk condiments, getting items for his coffee. The doors remained open when staff member H left the kitchen. During an interview on 2/23/17 at 9:30 a.m., staff member H stated he was not a member of the dietary staff, and it had been a long time since anyone had brought up not going down the hallway, stating We just ignore those signs and have not thought about them. 3. During an observation of the kitchen on 2/22/17, beginning at 3:50 p.m., dust was visible on the ceiling tiles above the gas range oven. A self-closing door was propped open to a back storage room and maintenance area, directly off the back of the kitchen. Maintenance staff was using the hallway as a throughway and were not wearing hair nets while walking past a cart of food trays. A fan next to the dietary door was turned on, and it was visibly dirty with accumulated dust on the screen. The fan was oscillating over clean stored dishes with the food contact surfaces up. There also was a covered cart, which had been left uncovered, with the cover draped over the top of the cart. Inside the cart was clean bowls and water mugs that the fan's air was blowing on. During an interview on 2/22/17 at 4:15 p.m., staff member G explained the process for the cleaning schedule each day he worked in the kitchen. Staff member G stated from the fans appearance, they needed to be cleaned. During an interview on 2/22/17 at 4:30 p.m., staff member I stated the fans in the kitchen should have been cleaned to prevent the dust build up, and if anyone was in the kitchen area around food items or in the cooking area, they should be wearing a hair net. During an interview on 2/22/17 at 4:45 p.m., staff member A stated staff used to use the hallway through the Dietary Department, and he had posted the signs to dissuade staff from using the hallway as an exit. He stated if you do not have business in the kitchen, you should not be in there, and anyone in the kitchen needed to be wearing a hair net. A review of U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration Food Code, showed: Dietary Staff must wear hair restraints to prevent their hair from contacting exposed food. REFERENCE: U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2005, Food Code, Pg 43.",2020-09-01
642,ROSEBUD HEALTH CARE CENTER,275072,383 N 17TH AVE,FORSYTH,MT,59327,2018-06-28,554,D,0,1,4QSX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff supervised residents during medication administration for those residents who did not have self-administration of medication orders; and failed to update the self-administration of medication assessments for 3 (#s 8, 13, and 18) of 16 sampled and supplemental residents. Findings include: 1. During an observation on 6/26/18 at 7:42 a.m., staff member G left resident #8's inhalers on the breakfast table, told the resident she was going to just leave the inhalers on the table and that there was no rush for the resident to take them. She then walked out of the dining room. During an observation on 6/26/18 at 8:10 a.m., resident #8's inhalers remained on the table. A review of resident #8's physician orders for (MONTH) (YEAR) showed there was no physician orders for resident #8 to administer her own medications. There was no updated self-administration of medication form in the medical record. A review of resident #8's care plan showed there was no documentation that resident #8 was able to safely administer the medications. During an interview on 6/26/18 at 8:05 a.m., staff member G stated there was no physician order for [REDACTED]. 2. During an observation on 6/26/18 at 7:42 a.m., staff member G left six pills in a medication cup, and an [MEDICATION NAME] inhaler on the table in front of resident #13, while she was attempting to eat her breakfast. Staff member G left the dining room. During an observation on 6/26/18 at 8:10 a.m., resident #13's pills were no longer in the pill cup on the table. The inhaler remained on the table. A review of resident #13's (MONTH) (YEAR) physician orders showed there was no order for self-administration of medications for resident #13. There was no updated self-administration of medication form in the medical record. A review of resident #13's care plan showed there was no documentation for resident #13 to safely administer medications. During an interview on 6/26/18 at 8:05 a.m., staff member G stated there was no physician order for [REDACTED]. 3. During an observation on 6/26/18 at 9:50 a.m., of resident #18's room, a large full bottle of Tums was found in the resident's room on the resident's bedside table. No staff members were in the room. During an interview on 6/26/18 at 9:50 a.m., resident #18 said the bottle of Tums had been brought to her by a family member to take for heartburn. Resident #18 said she did not know if the nursing staff knew she had the Tums in her room. She stated surely they knew by now and that she had them for several days. She said she did not know if she had been given approval by her physician to self-administer the Tums. She said she had been taking one or two Tums, as she needed, for heartburn after meals. During an interview on 6/26/18 at 9:50 a.m., staff member G said that resident #18 did not have self-medication privileges. She said resident #18's family had previously provided the resident with Tums. The resident and her family had been told that the medication could not be kept in the resident's room. The resident had been told by staff to let the nursing staff know if medications were brought to her by her family, and arrangements would be made for the nurses to store and administer the medication if the resident's physician had ordered it. Staff member G said she had not been aware that resident #18 had Tums in her room. She said she would retrieve the medication and speak with resident #18 about her medications, and the need for them to be administered by the nursing staff. A review of resident #18's MARS for (MONTH) (YEAR), showed the resident's physician had provided a standing order for the resident to receive Calcium [MEDICATION NAME] (Tums) 500 mg tabs: 2-4 tabs PO PRN GI upset (Maximum of 15 tabs/24 hours). A review of resident #18's Standing Orders Administration Record, dated (MONTH) (YEAR), was blank. Resident #18 had not been administered any standing ordered medications for the month of June. Tums had not been administered by the nursing staff since the beginning of (MONTH) (YEAR).",2020-09-01
643,ROSEBUD HEALTH CARE CENTER,275072,383 N 17TH AVE,FORSYTH,MT,59327,2018-06-28,623,E,0,1,4QSX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written transfer notice to residents, their POA's, and the ombudsman for 6 (#s 1, 3, 11, 16, 18, and 19) of 16 sampled and supplemental residents, who were transferred from the facility to the hospital between the dates of 1/1/18 and 6/26/18. Findings include: During an interview on 6/26/18 at 10:40 a.m., staff member B was asked where in the residents' medical records were copies of written resident transfer notifications kept. Staff member B did not answer the question but asked for further information, saying she was not sure what she was being asked for. After some discussion of the regulation for written notification to be given to residents or their POA's, before they transfer out of the facility, staff member B asked for the CMS tag numbers concerning resident transfer notification requirements. A review of a computerized generated list of residents who were hospitalized between 1/1/18 and 6/26/18 showed the following: Resident #1 had been transferred to the hospital from the facility on 3/10/18 for pneumonia. Resident #3 had been transferred to the hospital from the facility on 5/23/18 with acute GI bleeding. Resident #11 had been transferred to the hospital from the facility on 3/12/18 and 5/10/18 for urinary tract infections. Resident #16 had been transferred to the hospital from the facility on 3/25/18 for pneumonia, and on 4/12/18 for a scheduled hip surgery. Resident #18 had been transferred to the hospital from the facility on 3/28/18 for pneumonia. Resident #19 had been transferred to the hospital from the facility on 2/8/18 for pneumonia and [MEDICAL CONDITION], and on 3/9/18. During an interview on 6/26/18 at 4:00 p.m., staff member B was asked again for the copies of resident transfer notifications. Staff member B said the facility had not yet begun to provide residents or their POA's and the facility ombudsman with written transfer notification prior to resident transfers to the hospital or to anywhere else. No resident had received written transfer information since 1/1/18. On 6/28/18 at 9:30 a.m., staff member B provided a copy of a new policy she had just written, titled Resident Notice of Transfer or Discharge. The policy showed an effective date of 6/26/18 and had not been signed for administrative, medical staff, or outside professional approval. Staff member B said she would be providing residents, their POA's, and the facility ombudsman with written notification, as described in the new policy, from that day going forward. She was planning QAPI approval for the policy at the next scheduled QAPI meeting.",2020-09-01
644,ROSEBUD HEALTH CARE CENTER,275072,383 N 17TH AVE,FORSYTH,MT,59327,2018-06-28,625,D,0,1,4QSX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a bed-hold notice when the resident was transferred to the hospital for 3 (#s 1, 11, and 19) of 16 sampled and supplemental residents. Findings include: 1. During an interview on 6/27/18 at 1:50 p.m., staff member B stated there was no bed hold paperwork provided to the residents or their representative when transferred to the hospital. a. Review of resident #1's medical record showed resident #1 was hospitalized from [DATE] to 3/23/18. There was no documentation that a bed-hold notice had been provided to the resident or the representative. b. Review of resident #11's medical record showed resident #11 was hospitalized from [DATE] to 5/17/18. There was no documentation that a bed-hold notice had been provided to the resident or the representative. c. Review of resident #19's medical record showed resident #19 was hospitalized from [DATE] to 3/28/18. There was no documentation that a bed-hold notice had been provided to the resident or the representative.",2020-09-01
645,ROSEBUD HEALTH CARE CENTER,275072,383 N 17TH AVE,FORSYTH,MT,59327,2018-06-28,695,D,0,1,4QSX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 1(#6) of 16 sampled residents received were administered oxygen at the rate the physician had prescribed. Findings include: During an observation on 6/25/18 at 7:50 a.m., resident #6 was observed using an oxygen cannula connected to an oxygen concentrator. It was turned on at a rate of three liters per minute. During an interview on 6/25/18 at 7:54 a.m., staff member L was informed resident #6 was receiving oxygen at the rate of three liters per minute. Staff member L checked resident #6's MARS and stated the resident was ordered to receive oxygen by cannula at the rate of two liters per minute. Staff member L immediately lowered resident #6's oxygen rate to two liters per minute. The resident did not voice concern and did not have signs of respiratory distress. A review of resident #6's (MONTH) (YEAR) Physician order [REDACTED]. A review of the facility's policy , titled Oxygen Use, showed the following: It is the policy of (facility name) to provide oxygen administration in a systematic approach in the NH to ensure professional standards of quality for oxygen dependent elders . A provider order for the oxygen will be written in the chart and on the Detailed (sic) written order form from (the contracted respiratory equipment company) . Set the flow meter to the rate ordered by the provider.",2020-09-01
646,ROSEBUD HEALTH CARE CENTER,275072,383 N 17TH AVE,FORSYTH,MT,59327,2018-06-28,755,D,0,1,4QSX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility nursing staff dispensed scheduled narcotic medications without professional licensing to dispense the medications, when moving the narcotic tablets from the original container to an alternate container, which was for the convenience of counting a large quantity of medications, for 1 (#NF2) of 16 sampled and supplemental residents; and nursing staff failed to document on the facility narcotic administration records the administration of medication for 2 (#s 16 and 19) of 7 sampled residents. Findings include: 1. During an observation of a narcotic medication count at shift change on 6/25/18 at 5:50 p.m., staff member K counted the controlled medications stored in the facility's medication cart, while staff member J read the narcotic record books and verified the amounts of medications, as voiced by staff member K. Staff member K pulled a large stock bottle containing 13 tabs of [MEDICATION NAME] 50 mg and labeled for patient #NF2 from the locked cupboard. During an interview on 6/25/18 at 5:50 p.m., staff member K said that originally the stock bottle held 250 tabs. She said rather than attempting to count the full bottle of 250 tabs the nurses had been taking ten tabs out of the bottle every ten days and putting them into a smaller labeled pill bottle. She said the nurses didn't count the tabs in the large bottle for daily narcotic counts, but counted the tabs in the smaller container. She said the nurses administered the ten tabs as ordered, half a tab at night and in the morning till gone, and repeated the process, taking out only 10 tabs to cover the next 10 day period. Staff member K said this procedure had been going on for a long time, and the same procedure was used for other residents' medications that came in large stock bottles that had been provided by resident families. She didn't know if the facility pharmacist was aware of or condoned the procedure of transferring medication to another bottle. During an interview on 6/27/18 at 3:15 p.m., staff member F said that the act of transferring 10 tabs from one bottle into another constituted dispensing and is not to be done by nurses but only by a registered pharmacist. She stated she was unaware that the nurses had been performing shift change narcotic counts by using this process. She said because the stock bottle of medication had been provided by an out of facility pharmacy, she, as a licensed registered pharmacist, was unwilling to transfer the medication in smaller volumes, and into more than one container, for counting purposes. During an interview on 6/27/18 at 3:30 p.m., staff member B said the facility's pharmacy had said they would not have anything to do with medications coming into the facility from another pharmacy. She said patient #NF2's family had been purchasing stock bottles of [MEDICATION NAME] and bringing them into the facility to be administered by the facility nurses to the resident in order to save money. During an interview on 6/27/18 at 4:25 p.m., staff member B said she had called patient #NF2's family. She said she had explained the need for the resident's [MEDICATION NAME] medication to be dispensed in either smaller amounts from the outside pharmacy, or be obtained from the facility's pharmacy. After explaining the costs of each to the family, the decision had been made for patient #NF2's [MEDICATION NAME] to be dispensed in the future from the facility's pharmacy. The pharmacy had agreed to dispense the ordered [MEDICATION NAME] on narcotic cards that could be easily counted for amounts during nursing narcotic counts. Alternate concerns were identified related to the practice of medication administration services completed during the LTC survey, when nursing staff from the LTC certified facility completed medication count of the CAH patients (in which deficient practice was identified with the system used) and LTC patients during the same session, co-mingling the LTC and CAH staffing duties (refer to F835-Administration). 2. During an observation of a narcotic medication count during shift change on 6/25/18 at 5:50 p.m., the count of [MEDICATION NAME] 50 mg tabs for resident #16 was found to be short by one tab. A review of resident #16's MARS for (MONTH) (YEAR), showed the resident record was signed out as having been administered [MEDICATION NAME] 50 mg at 8:00 a.m. on 6/25/18 by staff member [MI] A review of resident #16's Individual Patient's Narcotics Record did not show staff member L had signed out an 8:00 a.m. [MEDICATION NAME] dose for the resident. On 6/25/18 at 6:10 p.m., staff member L had left the facility prior to the completion of the shift change narcotic count. She was called and informed of the narcotic record's missing documentation. She later returned to the facility and signed resident #16's narcotic record to show she had administered the resident's ordered 8:00 a.m. [MEDICATION NAME] dose earlier that morning. A review of the facility's policy titled Narcotic Control with an effective date of 9/03 and a last revision date of 12/16 included .If the count is not accurate, the nurse going off duty is to remain until the count is reconciled or the nursing supervisor approves leaving the facility. Discrepancies found at any time, change of shift or otherwise, need to be immediately reported to the In-Charge, On-Call supervisor. The Director of Nursing will initiate investigation to determine the cause of the inaccuracy and contact the pharmacist per facility policy . 3. During an interview on 6/27/18 at 9:39 a.m., staff member G said the facility required nursing staff to complete medication error reports when errors of medication administration and omission were found. She said the error reports were to be completed by the staff member who determined that an error occurred. The reports were to be given to staff member B for investigation. A review of resident #19's MARS for (MONTH) of (YEAR) showed resident #19 was ordered to receive [MEDICATION NAME] 50 mg PO three times a day and [MEDICATION NAME] 20 mg PO twice a day. Both medications were scheduled to be given at 8:00 p.m., daily. A review of the Individual Patients Narcotics Record for resident #19 showed information entered on 6/21/18 at 7:30 p.m., had been crossed off and the amount remaining column had been adjusted on 6/22/18 for both medications, [MEDICATION NAME] and [MEDICATION NAME]. The record did not have a note as to why the information had been crossed out. During an interview on 6/27/18 at 10:30 a.m., staff member B said she did not know the circumstances as to why resident #19's Narcotic Records for [MEDICATION NAME] and [MEDICATION NAME] had been crossed off on 6/21/18. During an interview on 6/27/18 at 10:30 a.m., staff member C said staff member J, who had signed the narcotic record on 6/21/18, had not submitted any medication error reports. During an interview on 6/27/18 at 10:40 a.m., staff member B said she had called staff member [NAME] She said staff member J stated she was aware of the crossed out narcotic records for resident #19. Staff member J had signed out the medications to be given and had failed to administer them. Her failure to administer both [MEDICATION NAME] and [MEDICATION NAME], as scheduled for 8:00 p.m., was discovered during the shift to shift narcotic count conducted on 6/22/18, in the morning. Staff member B said staff member J said she had not completed any medication error reports for the medications not administered. A review of the facility's policy titled Medication Variance effective on (MONTH) 2008 and revised on (MONTH) (YEAR), showed the following: All medication variances shall be reported by the individual that discovers or is intimately involved in the incident by completing an incident report. All incident reports are to be submitted to the Director of Nursing. The facility medication error reports for (MONTH) (YEAR) were reviewed to verify that resident #19 did not get her [MEDICATION NAME] and [MEDICATION NAME] as ordered on [DATE] at 8:00 p.m. There were no medication error reports for resident #19 for (MONTH) (YEAR). During an interview on 6/27/18 at 1:30 p.m., staff member B said that normally no investigations of the medication error events are conducted by the facility DON or Administrator, and neither one normally signs the medication error reports. No evidence was provided to show the medication error events had been analyzed for root cause analysis and actions to prevent reoccurrence. On 6/27/18 at 5:00 p.m., staff member B provided a copy of a new form titled Follow-up for a Medication Event. Staff member B said this form was being considered for use for the future investigation of any medication error reports and would be presented for all staff to use when it was finalized by the facility QAPI committee.",2020-09-01
647,ROSEBUD HEALTH CARE CENTER,275072,383 N 17TH AVE,FORSYTH,MT,59327,2018-06-28,756,E,0,1,4QSX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to assure a registered pharmacist conducted monthly resident medication regimen reviews for 9 (#s 1, 5, 7, 8, 11, 13, 16, 18, and 22) of 16 sampled and supplemental residents. The facility also failed to develop and maintain policies and procedures for the pharmacist's medication regimen reviews. These failures had the potential to affect all sampled and supplemental residents. Findings include: During a interview on 6/27/18 at 2:00 p.m., staff member F said she was aware that she had completed some resident medication regimen reviews late, and said she may have missed a few. She said she had taken leave in (MONTH) (YEAR). She stated that she knew before she took leave that she would be missing some days of work but had not made formal arrangements, as she had done in the past, for another pharmacist to perform the medication regimen reviews while she was absent. She said she had thought that she would be able to work it out and do the reviews herself. She also said when residents were hospitalized she did not have access to their medical records, and she was unable to do their reviews until after they returned to the facility. She said most of the time the reviews did not get done during the months residents were hospitalized . For the medication regimen reviews, staff member F said she looked at resident's lab work, researched the resident's diagnoses, diets and weights, and read the nursing progress notes. She stated she usually did not document her findings in the resident charts. She said that her charting did not show all the work she usually performed. She said the nurses were requesting the gradual dose reductions of the [MEDICAL CONDITION] medications ordered for residents, and she did not have a full understanding of what was happening because the requests were made at a different time of the month and not on the dates she performed the medication regimen reviews. A record review of resident medication regimen reviews showed: Resident #1's medications were not reviewed in the month of (MONTH) of (YEAR). Resident #5's medications were not reviewed in the month of (MONTH) (YEAR). Resident #7's medications were not reviewed in the month of (MONTH) (YEAR). Resident #8's medications were not reviewed in the months of (MONTH) (YEAR) and (MONTH) (YEAR). Resident #11's medications were not reviewed in the month of (MONTH) (YEAR). Resident #13's medications were not reviewed in the month of (MONTH) (YEAR). Resident #16's medications were not reviewed in the months of (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR). Resident #18's medications were not reviewed in (MONTH) (YEAR). Resident #22's medications were not reviewed in the months of (MONTH) (YEAR) and (MONTH) (YEAR). During an interview on 6/27/18 at 5:00 p.m., staff member A said that no formal arrangements had been made for another pharmacist to perform the monthly resident medication regimen reviews while the regular pharmacist was on leave. A written copy of the facility's policy/procedure for Pharmacist Drug Regimen Review was requested on 6/26/18, and a copy of a note concerning Drug Regimen Review was provided on the same day. A review of the note showed it was sent on 6/26/18 to staff member B from staff member M. It showed the following: (Staff member F) from (the facility's contracted pharmacy) manages (the facility) nursing home drug regimen reviews and provides written reviews to each provider on a monthly basis. (The facility's medical director), after reviewing the guidance document, either chooses to make changes on an individual basis or not. Either way, he signs the pharmacist's review and a copy is maintained in the patient chart.",2020-09-01
648,ROSEBUD HEALTH CARE CENTER,275072,383 N 17TH AVE,FORSYTH,MT,59327,2018-06-28,812,E,0,1,4QSX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure staff handled resident eating utensils in a manner to prevent potential food contamination for 1 (#8) of 16 sampled and supplemental residents; and failed to ensure staff members carried food filled plates in a manner that prevented potential food contamination for the residents; and failed to discard outdated food items timely when food was stored in one of the facility's kitchen refrigerators. All of the failures has the potential to negatively affect all residents who ate the outdated food from the facility kitchen, or who were assisted by the staff in the dining room. Findings include: The following concerns were identified in the dining room and kitchen: a. During an observation of the resident dining room on [DATE] at 5:25 p.m., staff member I carried a plate with waffles and eggs to resident #8's place at her dining table. Staff member I picked up the resident's table knife, upside down, and held it in her ungloved hand with her fingers wrapped around the knife's serrated edge, while she adjusted resident #8's lap apron, and situated the plate of food, water, and juice glasses in front of the resident. She proceeded to use the knife to butter the resident's waffle, and put syrup on it, then cut the waffle into bite sized pieces using the same knife. During an interview on [DATE] at 5:30 p.m., staff member I said she had been focused on caring for the resident and had not been aware of how she had been holding the resident's knife. b. During an observation of the resident dining room on [DATE] at 5:25 p.m., staff member D was observed receiving food filled dinner plates and serving them to the residents. She held the residents' plates with one hand, placing her thumb on the top edge of the plate near the plated food, while keeping her remaining hand and fingers under the plate to support it. During an observation of the resident dining room on [DATE] at 12:15 p.m., staff member D was again seen serving food filled dinner plates with her thumb on the top edge of the plates near food. During an interview on [DATE] at 12:20 p.m., staff member D stated she usually held dinner plates in the manner described above. c. During an observation of one of the facility's kitchen refrigerators on [DATE] at 4:55 p.m., and interview with staff member D on [DATE] at 4:55 p.m., a large plastic bag of cut onions was found labeled with a date of ,[DATE]. Staff member D said the onion pieces were considered good for four days after their labeled date. She said they had expired on [DATE] and should have been discarded the night before. A bag of cut carrot pieces was dated ,[DATE]. During an interview on [DATE] at 4:55 p.m., staff member D said the carrot pieces were also good for four days after their labeled date. She removed them for disposal as they had expired 7 days before. In the back of the refrigerator a large plastic container held cherries in cherry juice. The container was dated ,[DATE]. Staff member D removed the cherries from the refrigerator, saying she would dispose of them, because they had expired more than two months ago.",2020-09-01
649,ROSEBUD HEALTH CARE CENTER,275072,383 N 17TH AVE,FORSYTH,MT,59327,2018-06-28,835,D,0,1,4QSX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, facility administration failed to provide adequate oversight for staffing services to ensure licensed nurses did not co-mingle the provision of services between two separately certified facilities, which included the Skilled Nursing Facility (SNF) and the Critical Access Hospital (CAH). Nursing staff were scheduled and working at the SNF, but then were observed completing duties for the CAH while on shift. Findings include: During an observation of a narcotic medication count at shift change on 6/25/18 at 5:50 p.m., staff member K counted the controlled medications stored in the facility's medication cart, while staff member J read the narcotic record books and verified the amounts of medications, as voiced by staff member K. Staff member K pulled a large stock bottle containing 13 tabs of [MEDICATION NAME] 50 mg and labeled for patient #NF2 from the locked cupboard. It was identified during the co-mingled medication count (for SNF and CAH) that the nursing staff dispensed the narcotic medications without professional licensing to do so (refer to F755 for medication dispensing concern related to the CAH patient). During an interview on 6/27/18 at 3:30 p.m., staff member B said patient #NF2's family had been purchasing stock bottles of [MEDICATION NAME] and bringing them into the facility to be administered by the facility nurses.",2020-09-01
650,ROSEBUD HEALTH CARE CENTER,275072,383 N 17TH AVE,FORSYTH,MT,59327,2018-06-28,880,E,0,1,4QSX11,"Based on observation and interview, the facility failed to assure proper ventilation in the facility's laundry room to avoid air flow from the laundry room's contaminated dirty area to the laundry room's clean area. This had the potential to affect all residents who received clean laundry from the facility's laundry room. Findings include: During an observation of the facility's laundry room on 6/27/18 at 1:46 p.m., staff member [NAME] pointed out the locations of the air ventilation vents for in-coming and out-going air flow in the facility's one room laundry. The room did not have walls separating the washing machines and the sorting of dirty laundry on the dirty side of the room from the dryers and folding of clean clothes on the clean side of the room. Air came into the room over the washing machines, and dirty laundry sorting tables and was carried out of the room in a vent in the ceiling on the clean side of the room in front of the dryers where the clean laundry was folded. Air flowed from the dirty laundry side into the clean area before exiting the room with the potential for air contamination of the clean laundry. During an interview on 6/27/18 at 5:00 p.m., staff member A said he had assumed that when the new laundry room had been under construction the project managers had made sure the air ventilation was up to regulation standards. He said he would have to see that changes were made.",2020-09-01
651,ROSEBUD HEALTH CARE CENTER,275072,383 N 17TH AVE,FORSYTH,MT,59327,2019-08-08,637,D,0,1,4TC011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete a Significant Change MDS for 2 (#s 12 and 15) of 15 sampled residents, after falls with fractures. Findings include: 1. During an observation and interview on 8/6/19 at 10:06 a.m., resident #15 was seen with a cast on her right arm. Resident #15 stated she was right handed, so it had been difficult to feed herself with the left hand. She stated the wrist had been painful, and she took pain medication. Review of resident #15's Admission MDS, with the ARD of 6/9/19, showed the resident had no pain and required limited assistance with ADLs. Review of resident #15's Fall Incident Report, dated 7/1/19, showed the resident fell and fractured her right wrist. Review of resident #15's progress note, dated 7/1/19, showed resident #15 was given Tylenol for pain management, was able to pull her pants up and down when toileting, but was not able to manage buttons. Review of resident #15's progress note, dated 8/6/19, showed she had, two small blood blisters intact lower buttocks. Resident #15 reported she had difficulty wiping herself and may have caused them. During an interview on 8/6/19 at 11:45 a.m., staff member D stated the facility would complete a significant change assessment any time there was a decline in status. Staff member D stated, A decline in ADLs and an increase in pain would be a significant change. During an interview on 8/7/19 at 10:45 a.m., staff member H stated resident #15 now had difficulty wiping herself after toileting, and needed more assistance. 2. During an observation and interview on 8/5/19 at 5:25 p.m., resident #12 was seated in her wheelchair in the dining room. She was unable to answer questions coherently and said, I don't really know, or hummed. Review of resident #12's Incident Report, dated 9/26/18, showed resident #12 sustained a [MEDICAL CONDITION] from a fall. Review of resident #12's Quarterly MDS, with an ARD of 8/12/18, showed most ADLs required limited assistance, and walked with limited assistance. She had no pain. Review of resident #12's Annual MDS, with an ARD of 11/11/18, showed most ADLs required extensive assistance, total dependence for transfers, and was not able to ambulate. She had some pain, received PRN medications. A significant change MDS was not completed after the fall on 9/26/18, with a major injury, a decline in ADLs, and an increase in pain.",2020-09-01
652,ROSEBUD HEALTH CARE CENTER,275072,383 N 17TH AVE,FORSYTH,MT,59327,2019-08-08,641,D,0,1,4TC011,"Based on observation, interview and record review, the facility failed to accurately assess the resident's status for 1 (#17) of 15 sampled residents. This deficiency has the potential to affect all residents. Findings include: During an observation and interview on 8/5/19 at 2:50 p.m., resident #17 was seen sitting in her room, in her recliner, watching television. A wanderguard bracelet was noted on her left wrist. Resident #17 was aware she was in the nursing home, but was unable to say what had brought her here. During an interview on 8/5/19 at 3:12 p.m., staff member A stated resident #17 did have a wanderguard on, but could not remember the last time she triggered an alarm by attempting to leave the facility unaccompanied. Staff member A stated resident #17's family took her out almost every day. This triggered an alarm, but it was expected. During a telephone interview on 8/8/19 at 7:40 a.m., staff member D stated she had only been made aware of resident #17's wanderguard on the previous day. Staff member D stated she believed it had not been added to the resident's assessment because she had not seen the order for it. During an interview on 8/8/19 at 9:20 a.m., staff member B stated the admission order for the wanderguard was intended to be used only if the resident exhibited exiting behaviors. Staff member B stated resident #17 did not exhibit exiting behavior until early (MONTH) of (YEAR). Staff member B stated once the wanderquard was applied, a treatment was entered on the TAR so nursing staff could check the battery nightly. Staff member B stated the wanderguards needed to be changed yearly due to battery life. Reveiw of resident #17's admission orders [REDACTED]. Review of resident #17's nursing note, dated 7/2/18, showed the resident was found walking outside on the sidewalk at 1:30 a.m. Resident #17 told the staff she was on her way to get her hair done. The note indicated resident #17 was dressed appropriately for the weather, and was easily redirected back into the facility. A wanderguard was place on resident #17 after this incident. Review of resident #17's care plan, dated (MONTH) of (YEAR), showed a handwritten note, 7/2/18 wanderguard worn 24 hours/day to monitor safety. This note had been placed under the Cognition section of the care plan. Review of resident #17's care plan, dated (MONTH) of 2019, showed, Wanderguard worn for safety, under ADL section of the care plan. Review of resident #17's TAR's, dated (MONTH) 2019 through (MONTH) 2019, showed no indication of wanderguard battery checks. Review of resident #17's Quarterly MDS, with an ARD of 8/26/18, showed no wandering behaviors, and no wanderguard in use. Review of resident #17's Annual MDS, with an ARD of 5/26/19, showed no wandering behaviors, and no wanderguard in use.",2020-09-01
653,ROSEBUD HEALTH CARE CENTER,275072,383 N 17TH AVE,FORSYTH,MT,59327,2019-08-08,657,E,0,1,4TC011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to revise the care plans to accurately reflect the problems and interventions for 4 (#s 10, 12, 15, and 16) of 15 sampled residents. Findings inlcude: 1. Review of resident #16's Incident Reports showed seven falls. Two of the falls which resulted in injury were related to toileting needs not being met, and a lack of adequate supervision. Review of resident #16's current Fall Care Plan did not include the seven falls, but showed, I am at risk for falls due to a long history of falls. A hand written note, on the bottom of the care plan, dated 3/2019, showed, fx pubis, d/t fall. No new interventions were documented after the fall with the fracture. Interventions found on the current Fall Care Plan included: - I am encouraged to use my call light for assistance. - Anticipate my needs as I don't use my call light very much. - Answer my call light promptly. - Alarm on at all times when in bed and answer quickly as I may not hear it, am impulsive, and will try and get up without help. The interventions did not include toileting needs, an increase in supervision, or new interventions after each fall. During an interview on 8/8/19 at 1:45 p.m., staff member B stated the nursing staff was responsible for updating the care plans. She stated, in the end, it is staff member D's responsiblity to ensure accuracy. 2. During an observation on 8/6/19 at 12:10 p.m., resident #10 received grapes for dessert instead of jello. Resident #10 did not eat the grapes. She was on a soft diet and appeared to have difficulty chewing. During an interview on 8/6/19 at 12:11 p.m., staff member I stated resident #10's family member wanted her to have only fruit for dessert. Review of resident #10 Care Plan showed, I cannot tell you what I want/need. During an observation on 8/7/19 at 7:55 a.m., resident #10 received biscuits and gravy, but not hot cereal, which was on the menu. During an interview on 8/7/19 at 8:25 a.m., staff member J stated resident #10 could have one or the other, because the family member wanted her to have small portions. Review of her diet order showed, fruit and oatmeal for breakfast. Review of resident #10's Diet Care Plan, dated 1/2019, showed she was at risk for weight loss due to severe dementia. The interventions did not include fruit only for dessert, or a restriction on breakfast items. 3. During an observation and interview on 8/6/19 at 10:06 a.m., resident #15 was seen with a cast on her right arm. Resident #15 stated she was right handed, so it had been difficult to feed herself with the left hand. She stated the wrist had been painful, and she took pain medication. Review of resident #15's Admission MDS, with the ARD of 6/9/19, showed the resident had no pain and required limited assistance with ADLs. Review of resident #15's Fall Incident Report, dated 7/1/19, showed the resident fell and fractured her right wrist. Review of resident #15's progress note, dated 7/1/19, showed resident #15 was given Tylenol for pain management, was able to pull her pants up and down when toileting, but was not able to manage buttons. Review of resident #15's progress note, dated 8/6/19, showed she had, two small blood blisters intact lower buttocks. Resident #15 reported she had difficulty wiping herself and may have caused them. During an interview on 8/7/19 at 10:45 a.m., staff member H stated resident #15 now had difficulty wiping herself after toileting, and needed more assistance. 4. During an observation and interview on 8/5/19 at 5:25 p.m., resident #12 was seated in her wheelchair in the dining room. She was unable to answer questions coherently and said, I don't really know, or hummed. Review of resident #12's Incident Reports showed six falls from 7/4/18 to 5/31/19, three with injuries, one of which was a major injury. During an interview on 8/6/19 at 10:35 a.m., staff member F said resident #12 needs monitoring due to risk for falls. Staff member F stated resident #12 fell and broke her hip a few months ago. Staff member F stated no other concerns regarding resident #12's care. During an interview on 8/8/19 at 10:32 a.m., staff member K said resident #12 used a wheelchair and needed monitoring due to falls. Staff member K stated throughout the day they monitored her by offering water, offering and giving her assistance for toilet needs, and adjusting her oxygen tubing. Staff member K said resident #12 did not remember to use call light, still thinks she is a nurse, and tried to help residents and staff with tasks. Review of resident #12's care plans, dated (MONTH) (YEAR) through (MONTH) 2019, did not include any of the six falls, the [MEDICAL CONDITION], and no new fall prevention interventions. The care plan showed I am at risk for falls due to a hx of falls, some wandering, mildly hearing impaired, hx of cataract. The interventions to prevent falls included: - Keep my environment free of clutter and well lit. - I am encouraged to use my call light for assistance. Answer my call light promptly. - Anticipate my needs and be sure my environment is safe. - Encourage me to use FWW if I am walking and assist x 1-2 or SBA as needed depending on how I am doing. - Encourage restorative to help keep me strong and active and prevent further decline. Interventions did not include new fall prevention intervention after falls, or an increase in supervision.",2020-09-01
654,ROSEBUD HEALTH CARE CENTER,275072,383 N 17TH AVE,FORSYTH,MT,59327,2019-08-08,658,D,0,1,4TC011,"**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 quality by administering a medication without a valid physician's orders [REDACTED].#6); not seeking clarification for a physician's orders [REDACTED].#6); and, not documenting the appearance of a pressure ulcer at the time of admission, or with subsequent dressing changes for 1 (#121) of 16 sampled and supplemental residents. These deficient practices have the potential to affect all residents. Findings include: 1. During a medication administration observation on 8/7/19 at 8:03 a.m., staff member [NAME] administered [MEDICATION NAME] 7.5 mg to resident #6. Review of resident #6's MAR, dated (MONTH) 2019, showed a handwritten entry dated 8/1/19. The entry was for [MEDICATION NAME] 7.5 mg twice a day. Review of resident #6's physician's orders [REDACTED]. During an observation and interview on 8/7/19 at 1:57 p.m., staff member F stated there should be an order in the chart. Staff member F was unable to locate an order in the chart. Staff member F reviewed the carbon copies of all pending orders, and did not find an order for [REDACTED].>During an observation and interview on 8/7/19 at 2:05 p.m., staff member B found the discharge medications sheet in resident #6's medical record. She stated this is what is used to reconcile medications from the hospital with medications on the MAR used by nursing home staff. She stated there should be a physician's signature on the sheet, and the order was not valid without it. Staff member B stated the nurse who readmitted resident #6 to the nursing home should have gotten a clarification. Review of resident #6's discharge medication list from the hospital, dated 8/1/19, showed [MEDICATION NAME] had been lined through, and [MEDICATION NAME] 7.5 mg twice a day had been handwritten on the sheet. The discharge medication sheet listed all medications resident #6 had been on when discharged from the hospital on [DATE]. No physician's signature was found on the sheet. Review of the facility's policy, Medication Administration and Safe Handling, showed, All medications require an order which is written on the physician/prescriber order form and must be dated, timed, and signed by the licensed prescriber. 2. During a medication administration observation on 8/7/19 at 8:36 a.m., staff member [NAME] prepared the Humalog 75/25 insulin pen for administration of insulin to resident #6. Resident #6 asked what his blood sugar was. Staff member [NAME] stated it was 179. Resident #6 refused the insulin initially. When staff member F, a nurse familiar to the resident, attempted to give the insulin, resident #6 accepted the administration of the insulin. Review of resident #6's MAR, dated (MONTH) 2019, showed if fingerstick blood glucose results were, abnormally hi (sic) or low, call the provider. During an interview on 8/7/19 at 8:40 a.m., staff member [NAME] stated the high and low parameters for resident #6's order were greater than 400 and less than 70. Staff member [NAME] stated resident #6 usually became difficult, demanding, or belligerent when his blood sugar was either high or low. During an interview on 8/7/19 at 8:45 a.m., staff member F stated the high and low parameters for resident #6's order were greater than 400 and less than 60. Staff member F stated resident #6 does not usually show symptoms when his blood sugar was either high or low. Staff member F stated she had seen resident #6's blood glucose in the high 20's, without symptoms. During an interview on 8/7/19 at 1:57 p.m., staff member B stated there was not a policy or definition of parameters for high and low fingerstick blood glucose results. When asked how a nurse is supposed to know when resident #6's fingerstick blood glucose was abnormally high or low, she stated the nurses watch for behavior changes. Staff member B was not able to explain why the interpretation of the blood glucose parameters were not the same from nurse to nurse. She stated it would be better if the order was clarified to contain specific number values for the blood glucose results. 3. During an observation and interview on 8/6/19 at 3:27 p.m., resident #121 had a dressing on her right shoulder blade. Resident #121 stated she fell at home, broke her hip, and laid on the floor for three days. She stated she developed a sore on her shoulder blade from laying on the floor for so long. Resident #121 stated the nurses had been taking care of it since her fall in June. She stated she thought it was getting better, but she could not see it, and did not know what it looked like. During an interview on 8/6/19 at 10:15 a.m., staff member F stated the dressing change for resident #121 was done on bath days, and once a week the wound was measured, and the appearance of the wound was documented. Review of resident #121's physician's orders [REDACTED]. Review of resident #121's admission nursing note, dated 7/26/19, showed, Unstageable wound to right scapula. The note did not indicate the type of dressing or measurements of the wound. Review of resident #121's nursing note, dated 7/27/19, showed, Drsg (dressing) in place to L (left) scapula. Review of resident #121's nursing note, dated 7/28/19, showed, Resident had bath today. Drsg removed from R (right) scapula, area cleansed & new drsg applied. Review of resident #121's TAR, dated (MONTH) 2019, showed dressing changes were signed off as being done on 7/26/19 and 7/28/19. No nursing note was found for the 7/26/19 dressing change. The nursing note for the 7/28/19 dressing change did not contain any reference to the appearance or size of the wound. Review of resident #121's TAR, dated (MONTH) 2019, showed dressing changes were signed off as being done on 8/1/19 and 8/4/19. The nursing notes for these days did not contain a reference to the appearance or size of the wound. Review of the facility's policy, Skin Care, dated 2/2018, showed the following: 1. The nurse will examine the wound . contact provider for further treatment orders. 2. orders will then be written on the treatment sheet. Orders will be discontinued once skin issue is healed. 3. Place a nurse's note in the resident's chart: what was found, what was done. 5. Initiate a wound or pressure sore identification and progress record . Review of facility's policy, Pressure Ulcer, Care and Prevention of, showed the following: 10. With each dressing change (daily), please address the following in the nursing notes surrounding care: a. Location and staging of the wound; the size, depth and presence of any undermining or tunneling; b. Exudate if present, color, smell . d. Wound bed: color, type of tissue, presence of necrosis, wound edge condition and surrounding tissue.",2020-09-01
655,ROSEBUD HEALTH CARE CENTER,275072,383 N 17TH AVE,FORSYTH,MT,59327,2019-08-08,689,G,0,1,4TC011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent falls with injuries, failed to implement interventions to prevent falls with and without injuires, failed to determine the root cause of falls, and failed to provide adequate supervision for 3 (#s 12, 16, and 17) of 15 sampled residents. This defieciency has the potential to affect all residents. Findings include: 1. During an observation and interview on 8/5/19 at 5:30 p.m., resident #12 was sitting in her wheelchair in the dining room. She was incoherent in her answers and said, I don't really know, or hummed softly. Review of resident #12's Incident Reports showed six falls from 7/4/18 to 5/31/19, three with injuries, including a [MEDICAL CONDITION]. During an interview on 8/6/19 at 10:35 a.m., staff member F said resident #12 needed monitoring due to risk for falls. Review of resident #12's care plans, dated (MONTH) (YEAR) through (MONTH) 2019, did not include any of the six falls, the [MEDICAL CONDITION], or any new fall prevention interventions. The care plan showed, I am at risk for falls due to a hx of fall, some wandering, mildly hearing impaired, hx of cataract. The interventions to prevent falls included: - Keep my environment free of clutter and well lit. - I am encouraged to use my call light for assistance. Answer my call light promptly. - Anticipate my needs and be sure my environment is safe. - Encourage me to use FWW if I am walking and assist x 1-2 or SBA as needed depending on how I am doing. - Encourage restorative to help keep me strong and active and prevent further decline. Interventions did not include increased supervision. Review of resident #12's Incident Reports, dated 7/4/19, 9/13/18, 9/26/18, 1/4/19, 1/20/19, and 5/31/19, showed falls and no change in care plan. Review of resident #12's Incident Reports, dated 7/4/19, 9/13/18, 9/26/18, 1/4/19, and 1/20/19, showed falls and the need for increased monitoring. Review of resident #12's Incident Report, dated 9/26/18, showed she was walking in the hallway, on her way to a bathroom. A staff member witnessed her walking, and attempted to assist resident #12. The staff member was not able to reach resident #12 before she fell . Resident #12 leaned on the wall, slipped, and fell to the floor, hitting her right hip and the back of her head. Analysis and recommendations showed, Due to (diagnosis) of dementia, (patient) unable to follow directions to ask for assistance and unable to make sound judgment . and continue the current care plan. The Accident Prevention Team Recommendations showed, staff needs to monitor more frequently and whereabouts. Review of resident #12's Fall Risk Evaluations, dated 8/16/18, showed resident #12 was at risk for falls. Review of Falls Meeting notes, dated 10/25/18, showed resident #12 had the following concerns: Make sure to monitor resident's whereabouts. Monitor resident more frequently due to her mental status and increased confusion. 2. During an observation on 8/5/19 at 2:35 p.m., resident #16 was lying in bed with a side rail up, and a bed alarm on. Review of resident #16's Incident Reports showed she had falls on 9/21/18, 1/2/19, 1/3/19, 3/2/19, 4/1/19, 5/24/19, and 8/2/19. The fall on 1/3/19 showed compression fractures to lower back; the fall on 3/2/19 showed a pelvis fracture; and the fall on 4/1/19 showed a laceration to the head which required five sutures. Review of resident #16's Incident Report dated 9/21/18, for Accident Prevention Team Recommendations, showed Encourage call light use to ask for help and staff to increase toileting frequently. Review of resident #16's Incident Report dated 1/2/19, for Accident Prevention Team Recommendations, showed Staff to check on her more frequentlly; toilet before and after meals and bedtime. Review of resident #16's Incident Report dated 1/3/19, for Accident Prevention Team Recommendations, showed Staff to anticipate needs. Review of resident #16's Incident Report dated 3/2/19, for Accident Prevention Team Recommendations, showed Toilet every 2 hours, monitor for urine on floor. Review of resident #16's Incident Report dated 4/1/19, for Accident Prevention Team Recommendations, showed Remind resident to ask for help. Know where she is every hour. Review of resident #16's Incident Report dated 5/24/19, for Accident Prevention Team Recommendations, showed Resident had not been toileted since before breakfast. Found to be incontinent of BM. CNAs involved spoken to. All CNAs on floor talked to avoidable fall if resident had been toileted as scheduled. During an interview on 8/7/19 at 9:50 a.m., staff member G stated the high fall risk residents would be identifed on the restorative programs for each resident. During an interview on 8/7/19 at 10:00 a.m., staff member F stated resident #16 remains at high risk for falls. She has had multiple falls and we check on her every 2 hours. Most of her falls are in the morning when she is ready to get up. During an interview on 8/8/19 at 8:50 a.m., staff member I stated residents who use walkers and wheelchairs are at high risk for falls. Resident #16's interventions were alarms. An increase in toileting was not mentioned as an intervention. Review of resident #16's Fall Care Plan did not identify the seven falls. The interventions did not inlcude an increase in toileting needs or more supervision in the morning. Review of resident #16's Falls Meeting note, dated 3/14/19, showed Monitor resident's whereabouts at all times. Toilet resident after meals, before bedtime, and when resident gets up in the morning. Review of resident #16's Falls Meeting note, dated 4/18/19, showed Toilet resident more frequently. Toilet when rounds every 2 hours. Review of resident #16's Falls Meeting note, dated 6/12/19, showed Toilet resident more frequently. Toilet when doing rounds. During an interview on 8/8/19 at 1:45 p.m. staff member B stated the nurses write the incident report after a fall, and any witnesses would write a statement. The facility was working on implementing a fall huddle. The fall team meets once a month to review falls. She stated all residents were at high risk for falls. The nursing staff is responsible for updating the care plans after falls. When asked about the root cause of individual falls, she asked You mean why they fell ? 3. During an observation on 8/6/19 at 10:29 a.m., resident #17 was in her room, sitting in her recliner, watching television. Resident #17 had a wanderguard bracelet on her left wrist and was seated on a sensor pad chair alarm. During an interview on 8/8/19 at 7:59 a.m., NF1 stated she would have liked staff to be more encouraging when resident #17 refused to participate in restorative services. Review of resident #17's Quarterly MDS, with an ARD of 11/25/18, showed one non-injury fall since the last assessment in (MONTH) of (YEAR). Review of resident #17's Significant Change MDS, with an ARD of 2/24/19, showed two or more non-injury falls since the last assessment in (MONTH) of (YEAR). Review of resident #17's Quarterly MDS, with an ARD of 5/26/19, showed two or more non-injury falls since the last assessment in (MONTH) of 2019. Review of resident #17's nursing notes showed falls occurring on 10/3/18, 12/14/18, 12/16/18, 1/13/19, 2/5/19, 2/6/19, 2/19/19 (twice), 3/6/19, 3/8/19, 4/26/19, 4/29/19, and 5/26/19. All of the falls were categorized as non-injury falls. Review of resident #17's admission care plan, dated 5/2018, showed the following interventions: -Help me with all transfers and ambulating. -Answer my call light promptly. -Remind me NOT to get up and walk without your help. -I am VERY independent and don't like to bother you. Review of resident #17's care plans, dated 11/2018 and 2/2019, showed no revisions until 3/8/19. Review of resident #17's care plan, with hand written revisions, showed the following changes: -3/8/19 - Please get me up b/4 (sic) breakfast per family req. (request) -3/14/19 - note regarding multiple falls related to bathroom use, family requested that she not be left alone -5/26/19 - crossed out - Make sure I have my call light nearby at all times and answer it promptly. -5/26/19 - note regarding family request for use of pressure pad alarm -no date - Remind me to ask for help and offer help often -no date - Offer to help me with all transfers and ambulating. SBA (stand by assist) to limited (assist) Review of resident #17's Incident Reports related to falls since 1/1/19, showed the following: -1/13/19 fall to floor in room, no care plan changes, Accident Prevention Team Recommendations - staff to monitor whereabouts, anticipate needs, and offer toileting every 2 hours -2/5/19 fall to floor in room, no care plan changes, Accident Prevention Team Recommendations - remind her to ask for help, staff to anticipate needs -2/6/19 found on floor in room, no care plan changes, Accident Prevention Team Recommendations - monitor whereabouts, offer her help and assistance consistently -3/6/19 fall to floor in room, no care plan changes, Accident Prevention Team Recommendations - staff ambulating with resident to and from meals -3/8/19 found on floor in room, care plan changes dated 3/14/19 to not leave alone in bathroom, Accident Prevention Team Recommendations - toilet every 2 hours -4/26/19 found on floor in doorway of room, no care plan changes, Accident Prevention Team Recommendations - alarm placed in chair per family request -4/29/19 found on floor in room, no care plan changes, Accident Prevention Team Recommendations - alarm placed per family due to impulsiveness -5/26/19 found on floor in room, no care plan changes, Accident Prevention Team Recommendations - remind staff to check on her frequently Review of resident #17's physician's orders [REDACTED]. Review of resident #17's medical record showed no documentation of any falls since 5/28/19, the date when the pressure pad alarm was placed.",2020-09-01
656,ROSEBUD HEALTH CARE CENTER,275072,383 N 17TH AVE,FORSYTH,MT,59327,2019-08-08,835,D,0,1,4TC011,"Based on observation and interview, facility administration failed to provide adequate oversight of staffing to ensure staff did not co-mingle the provision of services between two separately certified facilities, which included Long-Term Care residents and Critical Access Hospital (CAH) swing bed patients. This deficient practice has the potential to affect all long term care residents and seven swing bed residents. Findings include: During a medication observation on 8/7/19 at 8:03 a.m., staff member [NAME] administered medications to resident #6, a Long-Term Care resident. During a medication observation on 8/7/19 at 8:12 a.m., staff member [NAME] administered medications to NFP2, a CAH swing bed patient. During a medication observation on 8/7/19 at 8:22 a.m., staff member [NAME] administered medications to NFP3, a CAH swing bed patient. During a medication observation and interview on 8/7/19 at 8:29 a.m., staff member [NAME] provided medications to NFP1, a CAH swing bed patient, who was allowed to self-administer medications. A copy of the Self-administration Assessment for NFP1 was requested. Staff member B stated NF1 was a CAH swing bed and therefore, was not a nursing home resident. During an interview on 8/8/19 at 8:15 a.m., staff member C stated the Plan of Correction completed after the last Recertification Survey in (MONTH) of (YEAR), was being followed, and she did not understand why there might be an issue with staffing. Staff member C stated the schedules for the hospital and ED were separate from the nursing home schedule. Staff member C stated the Riverside Lane hallway contained seven CAH private pay swing bed patients and two LTC residents. Staff member C stated her Plan of Correction included a map which identified the beds which were certified as CAH beds and the beds that were certified as LTC beds. Staff member C stated that since the CAH certified swing beds were physically located within the LTC area, and not located in the hospital area, it was acceptable to have the staff take care of both types of patients as long as the staff expense was allocated correctly on the staff member's timesheet.",2020-09-01
657,FAITH LUTHERAN HOME,275073,1000 6TH AVE N,WOLF POINT,MT,59201,2019-01-09,609,D,0,1,DEEK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to timely report and thoroughly investigate an injury of unknown origin for 1 (# 8) of 13 sampled residents, resulting in a fractured tibia. Findings include: Review of resident #8's Nursing Progress Note, dated 8/17/18, showed the resident had a swollen right ankle which was tender to the touch and had faint bruising. The resident did not know how her ankle got hurt. Review of resident #8's Nursing Progress Note, dated 8/18/18, showed the resident's right ankle was swollen, painful and had a slight bruise. Tylenol was given for pain. Review of resident #8's Nursing Progress Note, dated 8/20/18, showed the resident's right ankle was deep purple and [MEDICAL CONDITION]. The resident was not able to bear weight. Pass on at report time tonight to continue to monitor the right ankle and lower leg. Review of resident #8's Nursing Progress Note, dated 8/21/18, showed the right ankle was more tender and continued with the purple bruising. She was sent to the hospital and diagnosed with [REDACTED]. Review of a facility Event Report, dated 8/21/18, showed the injury of unknown origin was reported four days after the discovery of the injury. It showed staff were interviewed and had no recollection of an incident, or what may have caused this injury. The staff interviews and investigation were requested, and staff member D stated nothing was documented regarding the injury of unknown origin investigation. During an interview on 1/9/19 at 2:22 p.m., staff member [NAME] stated he had noted the injury on 8/17/18, but he did not know what he was dealing with, and it was the end of the shift. Staff member B stated the doctor should have been notified, and it should have been reported.",2020-09-01
658,FAITH LUTHERAN HOME,275073,1000 6TH AVE N,WOLF POINT,MT,59201,2019-01-09,759,D,0,1,DEEK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to ensure the medication error rate was less than 5 percent, which affected 1 (#17) of 13 sampled residents. The facility medication error rate was 8 percent. Findings include: During an observation and interview on 1/8/19 at 4:32 p.m., staff member A administered two doses of insulin, from two different insulin pens, to resident #17; [MEDICATION NAME] 30 units and [MEDICATION NAME] 8 units. Staff member A administered both doses of insulin into resident #17's left arm. Staff member A stated she only primed an insulin pen when the pen was new. She stated she did not prime opened pens with insulin prior to use. A review of resident #17's medical record showed the resident was admitted to the facility with [DIAGNOSES REDACTED]. During an interview on 1/9/19 at 7:48 a.m., staff members C and D stated insulin pens did not need to be primed prior to administering doses to the residents. Staff member D stated the manufactures recommendations did not mention priming insulin pens prior to use. Staff member C stated the facility had conducted a test the previous night, and found that pens did not need to be primed with 2 units of insulin, and one unit was sufficient to get an insulin bleb at the end of the needle. Staff member D stated she had called the consulting pharmacist, but had not heard back. Staff member D stated the facility did not have a policy and procedure for priming insulin pens prior to use. Review of a note, from staff member D, dated 1/9/19 at 10:30 a.m., read, I recognize when 'google' insulin pens it states to prime before each injection but insert did not instruct that step and insulin pen priming was not instructed with this pen type. Review of a facility document, Insulin Administration Using an Insulin Pen, read, .10. Look at the dose window and turn the dosage knob to '2' units. 11. Holding the pen with the needle pointing upwards, press the button until at least a drop of insulin appears. This will prime the needle and remove any air from the needle. Repeat this step if needed until a drop appears. During an interview on 1/9/19 at 4:20 p.m., staff member B stated insulin pens must be primed prior to administering to remove air bubbles and ensure an accurate dose of insulin is provided. Review of a facsimile from the facility, dated 1/10/19 at 12:28 p.m., policy for Insulin Pen Injections, initiated 1/2019, read, .#7. Prime the needle: dial 2 units, hold pen with needle pointing up and tap reservoir gently to move air to the top of the needle, press the push button on your syringe as far as it will go or until a drop of insulin appears. Note: you may need to repeat this several times to remove all the air . Review of a facsimile document from the facility, How to Use an Insulin Pen, read, .Step 2- Do an air shot (Prime the needle) 1. Dial 2 units. 2. Hold the syringe with needle pointing up and tap reservoir gently to move air bubbles to top of needle.",2020-09-01
659,FAITH LUTHERAN HOME,275073,1000 6TH AVE N,WOLF POINT,MT,59201,2019-01-09,760,D,0,1,DEEK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to ensure 1 (#17) of 13 sampled residents was free from potential critical outcomes by failing to prime two insulin pens prior to administering the insulin. Findings include: During an observation and interview on 1/8/19 at 4:32 p.m., staff member A administered two doses of insulin, from two different insulin pens, to resident #17; [MEDICATION NAME] 30 units and [MEDICATION NAME] 8 units. Staff member A administered both doses of insulin into resident #17's left arm. Staff member A stated she only primed an insulin pen when the pen was new. She stated she did not prime opened pens with insulin prior to use. A review of resident #17's medical record showed the resident was admitted to the facility with [DIAGNOSES REDACTED]. A review of resident #17's (MONTH) 2019 Medication Administration Record [REDACTED]. During an interview on 1/9/19 at 7:48 a.m., staff members C and D stated insulin pens did not need to be primed prior to administering doses to the residents. Staff member D stated the manufactures recommendations did not mention priming insulin pens prior to use. Staff member C stated the facility had conducted a test the previous night, and found that pens did not need to be primed with 2 units of insulin, and one unit was sufficient to get an insulin bleb at the end of the needle. Staff member D stated she had called the consulting pharmacist, but had not heard back. Staff member D stated the facility did not have a policy and procedure for priming insulin pens prior to use. During an interview on 1/9/19 at 4:20 p.m., staff member B stated insulin pens must be primed prior to administering to remove air bubbles and ensure an accurate dose of insulin is provided. Review of a facsimile from the facility, dated 1/10/19 at 12:28 p.m., policy for Insulin Pen Injections, initiated 1/2019, read, .#7. Prime the needle: dial 2 units, hold pen with needle pointing up and tap reservoir gently to move air to the top of the needle, press the push button on your syringe as far as it will go or until a drop of insulin appears. Note: you may need to repeat this several times to remove all the air . Review of a facsimile document from the facility, How to Use an Insulin Pen, read, .Step 2- Do an air shot (Prime the needle) 1. Dial 2 units. 2. Hold the syringe with needle pointing up and tap reservoir gently to move air bubbles to top of needle.",2020-09-01
660,FAITH LUTHERAN HOME,275073,1000 6TH AVE N,WOLF POINT,MT,59201,2017-10-25,246,E,0,1,GXFG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, staff failed to ensure 1 (#5) of 14 sampled residents was positioned correctly, for an extended period of time, to ensure comfort when receiving assistance at the dining room table during meals to cough, choke, spit, gasp for air, his eyes bulged, and he communicated non-verbally that this caused him to be afraid. Findings include: 1. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. A review of resident #5's Care Plan, initiated 2/21/17, read, Staff or family members need to hold beverage containers, (resident's name) will not pick them up by himself. Eats in reclining position. A review of resident #5's Therapist Mobility Assessment, dated 3/9/17, read, He currently uses a 'Geri Rolling Chair' with pillows, wedges, and blankets to help make him comfortable and provide some support and positioning due to his extreme tone and position needs. He is at a high risk of skin breakdown. He requires a tilt-n-recline wheelchair with custom molded seating, and recline feature, along with other accessories to be able to provide him the proper positioning and pressure relief he needs. He currently is at the mercy of the staff to reposition him continuously. He is at great risk given his [DIAGNOSES REDACTED]. During an observation and interview on 10/23/17 at 7:58 a.m., resident #5 was brought into the dining room, while he was reclined in a Geri-wheelchair. The foot of the chair was elevated, and the resident was lying flat in the chair. The head of the chair was elevated less than 30 degrees. The resident had a pillow under each of his legs, under each arm, and under his head. At times, the resident had liquids running out of the corners of his mouth. At 8:17 a.m., staff member Q stated liquids were easier to pour into the resident's mouth when he was reclined less than 30 degrees. During an observation and interview on 10/23/17 at 11:22 a.m., staff member G assisted resident #5 with lunch by spoon feeding the resident. The resident was in a semi-reclined position, with the head of his chair elevated less than 30 degrees. The resident had a pillow under each of his legs, under each arm, and under his head. The resident coughed, and spit food and liquids out of his mouth. Staff member G stated the resident needed to be positioned with pillows because of his frame and stature. A review of resident #5's Care Plan, initiated 10/23/17, read, Have head of bed and head of chair elevated 45 degrees whenever giving fluid or foods. A review of the resident's medical records showed a lack of evidence that a speech and physical therapy assessment had been conducted by the facility to determine posture and positioning. During an interview on 10/24/17 at 12:35 p.m., staff member A stated various pillows were needed to be used in attempts to position resident #5 for posture and comfort. The staff member stated the facility had tried to order a new custom, padded, personal wheelchair in (MONTH) and (MONTH) of (YEAR), but was denied funding by Medicaid and Indian Health Services. She stated she planned to contact The Tribe for funding to purchase a wheelchair, but had not done so. During an interview on 10/24/17 at 4:10 p.m., staff member J stated the facility had not requested an evaluation by the Physical Therapy department to assess positioning during meals. On 10/24/17 at 12:47 p.m., staff member A provided a copy of the facility's Guidelines for Safe and Efficient Feeding of Patients (sic) with Oropharyngeal Dysphagia, copyright 1989, which is used by the facility staff. The Guidelines, read, page 2, Causes of Swallowing Difficulties- Many medical conditions can cause a patient to have a slow, inefficient, and/or unsafe swallow .[MEDICAL CONDITION], etc. Each type of swallowing problem requires a different combination of diet, posture, and methods of feeding .Page 4. The Patient's Head and Body Position Before and During Eating- The patient's head and body position can be quite important in successful oral intake .The occupational and physical therapists may be helpful in providing supports and wheelchair modifications for a patient who has difficulty assuming the desired swallowing posture.",2020-09-01
661,FAITH LUTHERAN HOME,275073,1000 6TH AVE N,WOLF POINT,MT,59201,2017-10-25,280,E,0,1,GXFG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to update care plans to reflect residents' current status and care for 3 (#s 5, 6 and 13) of 14 sampled residents. Findings include: 1. A review of the resident's physician orders [REDACTED].#6 showed he had a suprapubic catheter placed on 9/22/17. Resident #6 returned to the facility on [DATE] with physician's orders [REDACTED]. Aftercare instructions of the suprapubic catheter also included, Drink 8 glasses of water every day. Check the skin around your catheter a few times every day. Watch for redness and swelling. Look for any fluids coming out of the opening. Do not use powder or cream around the catheter opening. Do not take tub baths or use pools or hot tubs. Review of resident #6's (MONTH) (YEAR) treatment records showed the resident was to change the catheter bag twice a month. Review of resident #6's current care plan showed the plan had last been updated on 9/20/17. Resident #6's current care plan did not show the resident's catheter bag was to be changed. Resident #6's current care plan did not include the new interventions from the aftercare instructions. During an interview on 10/24/17 at 8:20 a.m., staff member A said the catheter bag changes should be on the care plan. During an interview on 10/24/17 at 9:00 a.m., staff member K said the information on the aftercare, and changing the catheter bag twice a month should have been on the care plan. Staff member K said it was an oversight on her part. Staff member K said hopefully it would have been caught on the next assessment. 2. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation on 10/23/17 at 7:58 a.m., resident #5 was brought into the dining room. He was reclined in a Geri-wheelchair, and he had a pillow under each of his legs, under his hips, under each arm, and under his head. He had several blankets covering his body, and the top blanket was tucked into the side of the Geri-wheelchair, which assisted with positioning. Staff member Q stated the resident required several pillows and blankets to assist with his posture while he was sitting in the Geri-wheelchair. During an observation and interview on 10/23/17 at 11:22 a.m., staff member G assisted resident #5 with lunch by spoon feeding the resident pureed turkey, potatoes, and vegetables. The resident had a pillow under each of his legs, under his hips, under each arm, and under his head. He had a blanket covering his body, and it was tucked into the side of the Geri-wheelchair, which assisted with positioning. Staff member G stated the resident required the pillows and blankets to assist with his posture while he was sitting in the Geri-wheelchair. A review of resident #5's current Care Plan, initiated 2/21/17, did not show the need for seven pillows to assist him with positioning while he was seated in the Geri-wheelchair. During an interview on 10/23/17 at 5:15 p.m., staff member K stated the resident's care plan would be revised to reflect his status while seated in the Geri-wheelchair. 3. Review of resident #13's Annual MDS, dated [DATE], and Quarterly MDS, dated [DATE], showed resident #13 had limitations in ROM on both sides of the body, in both the upper and lower extremities. Review of resident #13's physician note, dated 10/27/16, reflected ROM restrictions in the left upper extremity, as well as both lower extremities and the hamstrings, heel cords, left shoulder girdle, elbow, and hand. The note contained an order to conduct ROM exercises to the upper and lower extremities, 1-2 times a day. A review of the care plan for resident #13 lacked evidence that ROM or general rehabilitation had been included in the care plan as a problem area. During an interview on 10/24/17 at 3:00 p.m., staff member Z said that she conducted ROM with resident #13 for upper and lower body strength every day. She said they had just started working with resident #13 to have her stand up at her walker. Staff member Z said resident #13 had decided one day that she wasn't going to walk any more. Recently resident #13 had decided she was going to start walking again. Staff member Z said she had worked, in the past, with the therapist and resident #13, and did not refer resident #13 back to the therapist when she decided she wanted to walk again. Staff member Z tried to locate a written rehabilitation care plan for resident #13. Staff member Z said there was not a specific rehabilitation plan set up for resident #13, and there was no specific plans or goals written on the care plan for resident #13's restorative care.",2020-09-01
662,FAITH LUTHERAN HOME,275073,1000 6TH AVE N,WOLF POINT,MT,59201,2017-10-25,309,G,0,1,GXFG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain the highest practicable well-being for 1 (#5) of 14 sampled residents, by free-pouring unmeasured amounts of un-thickened Pepsi and orange juice into the resident's mouth which caused the resident to cough, choke, spit, gasp for air, his eyes bulged, and he communicated non-verbally this caused him to be afraid. Findings include: 1. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. A review of resident #5's Admission MDS, with an ARD of 2/15/17, showed the resident was non-verbal, and was not easily understood by others. Resident #5 required extensive and total assistance to perform his activities of daily living. The resident's primary mode of transportation was a Geri-wheelchair propelled by the staff. A review of resident #5's Quarterly MDS, with an ARD of 8/1/17, showed the resident was non-verbal, and was not easily understood by others. He required extensive and total assistance to perform his activities of daily living. The resident's primary mode of transportation was a Geri-wheelchair propelled by the staff. A review of resident #5's (MONTH) (YEAR) Physician Order, initiated on 5/30/17, read, House Diet- Puree/soft texture; pudding consistency. Thicken liquids except Pepsi. A review of resident #5's Care Plan, initiated 2/21/17, read, Staff or family members need to hold beverage containers, (resident's name) will not pick them up by himself. Eats in reclining position. A review of resident #5's nurse's notes, dated 2/9/17, read, Resident's family stated he needs to be fed, is a big risk for choking and aspiration, and will some times (sic) spit food onto the floor and may eat until he reaches the point of emesis. During the initial tour of the facility on 10/22/17 at 3:46 p.m., staff member C stated the resident was non-verbal, but could communicate with his eyes. The staff member stated the facility staff had learned how to communicate with the resident. Staff member C stated the resident could be asked a question, and looking up, meant yes, looking horizontal, meant no. During an observation and interview on 10/23/17 at 7:58 a.m., resident #5 was brought into the dining room while he was reclined in a Geri-wheelchair. The foot of the chair was elevated, and the resident was lying flat in the chair. The head of the chair was elevated less than 30 degrees. The resident had a pillow under each of his legs, under each arm, and under his head. At 8:13 a.m., staff member Q sat next to resident #5. She began to assist the resident with breakfast; spoon-feeding him oatmeal and poached eggs. The resident was in a semi-reclined position, with the head of his chair elevated less than 30 degrees. The resident would open his mouth, and the staff member would free-pour an unmeasured amount of Pepsi, alternating with orange juice, into his mouth, after each mouthful of oatmeal. The resident coughed, choked, and gasped for air after each mouthful of food, followed by Pepsi and orange juice. At times, the resident even had liquids running out of both corners of his mouth. Staff member Q cleaned the drool with a clothing protector and towel after each coughing episode. At 8:17 a.m., staff member Q stated the resident was to receive thickened liquids, except for Pepsi and orange juice. The staff member stated non-thickened liquids were easier to pour into the resident's mouth, even though it caused him to cough, and gasp for air. Stridor (harsh vibrating noise) could be heard from the resident with each breath he took during the meal. Licensed staff were not observed assessing the resident's lung sounds. During an observation and interview on 10/23/17 at 9:12 a.m., staff members G and H transferred resident #5 into his bed. At 9:16 a.m., staff member H free-poured an unmeasured amount of Pepsi into the resident's mouth from a 16.9-ounce Pepsi bottle. The resident was reclined, almost lying flat in bed, when he began to cough, spit, and drooled Pepsi from the corners of his mouth. At 9:20 a.m., staff member H free-poured an unmeasured amount of Pepsi into the resident's mouth while lying reclined in the bed. The resident coughed, choked, and gasped for air, as Pepsi drooled from the corners of his mouth. Staff member H cleaned the drool with a Kleenex after each cough. At 9:23 p.m., staff members G and H stated the resident drank up to four-12 ounce cans of Pepsi each day. At 9:24 a.m., staff member H free-poured an unmeasured amount of Pepsi into the resident's mouth while he continued to lie reclined in the bed. The resident coughed, choked, and gasped for air, as Pepsi drooled from the corners of his mouth. At 9:25 a.m., staff members G and H stated the resident did not cough, choke, gasp, or drool as much when thickened liquids were offered. During an interview on 10/23/17 at 10:45 a.m., staff member A stated the facility staff were required to thicken all liquids given to the resident except for Pepsi. Staff member A stated she understood the concerns observed by the surveyors when staff administered the free-pouring of unmeasured amounts of Pepsi, and the resident coughed, choked, and gasped for air. During an observation and interview on 10/23/17 at 11:22 a.m., staff member G assisted resident #5 with lunch; spoon-feeding him pureed turkey, potatoes, and vegetables. The resident was in a semi-reclined position, with the head of his chair elevated less than 30 degrees. The resident opened his mouth, and the staff member would free-pour an unmeasured amount of Pepsi from a 6 ounce paper cup into his mouth, after each mouthful of pureed food. The resident coughed and spit food and liquids out of his mouth. Staff member G used Kleenex to clean the resident's mouth, then would free-pour unmeasured amounts of Pepsi into his mouth. The resident's eyes bulged a few times during the coughing episodes. Stridor could be heard from the resident with each breath he took during the meal. Licensed staff were not observed assessing the resident's lung sounds. During an interview on 10/24/17 at 10:25 a.m., staff member I stated resident #5 had been admitted to the facility from home. She stated the resident was given Pepsi as a reward. She stated the resident was to receive thickened liquids, except for Pepsi. She was not aware of how much liquids resident #5 should have received at any one given time. Staff member I stated she had not assessed the resident's lung sounds after receiving Pepsi, and thought it was a good idea to add to his assessments. During an observation and interview on 10/23/17 at 1:20 p.m., staff members G and H entered resident #5's room. The resident was supine in bed, the head of his bed was elevated less than 30 degrees, and he was making gurgling sounds. Staff member G stated the head of the bed was supposed to be raised when he makes those noises. After the resident was weighed, and clean pants were put on him, staff member G lowered the resident's head of the bed to less than 30 degrees. Staff member G free-poured unmeasured Pepsi into the resident's mouth while he laid supine in bed. The resident began coughing, gasping for breath, and stridor could be heard from the resident with each breath he took. Staff members G and H gathered their supplies, the scale, and exited the resident's room. During an interview on 10/23/17 at 4:20 p.m., staff member O stated the resident was at a very, very terrible risk for an aspiration pneumonia. Staff member O stated he was not aware that facility staff were free-pouring unmeasured amounts of Pepsi into the resident's mouth. The staff member stated he was not aware that resident #5 was receiving up to four-12 ounce cans of Pepsi a day while reclined less than 30 degrees, and that the resident was coughing, choking, and was gasping for air. Staff member O stated free-pouring unmeasured amounts of Pepsi into the resident's mouth, to the point of it drooling form the corners of the resident's mouth, should have been closely monitored. Staff member O stated he needed to provide some education to the staff to reduce the risk of potential aspiration pneumonia to resident #5. During an interview on 10/24/17 at 9:05 a.m., staff member K stated the resident's care plan had been updated to include elevating the head of the resident's chair and bed. A review of resident #5's Care Plan, initiated 10/23/17, read, Have head of bed and head of chair elevated 45 degrees whenever giving fluid or foods. All fluids must be thickened. (MONTH) have 1 can of Pepsi per day, thickened, Nursing will provide Pepsi. 1 teaspoon of food or fluid to be given at a time when being fed. During an interview on 10/24/17 at 10:40 a.m., NF1 stated the resident was always propped up during meals at home, and if the resident's position changed, the resident would be repositioned. NF1 stated the resident had limited episodes of coughing, or choking during meal time while at home. During an interview on 10/25/17 at 7:31 a.m., resident #5 was asked if he was frightened or scared when staff poured Pepsi into his mouth, and he coughed or choked. The resident moved his eyes up and down to communicate yes. Review of the facility's Guidelines for Safe and Efficient Feeding of Patients (sic) with Oropharyngeal Dysphagia, copyright 1989, provided by staff member A, read, page 2, Causes of Swallowing Difficulties- Many medical conditions can cause a patient to have a slow, inefficient, and/or unsafe swallow .[MEDICAL CONDITION], etc .Each type of swallowing problem requires a different combination of diet, posture, and methods of feeding .Page 4. The Patient's Head and Body Position Before and During Eating- The patient's head and body position can be quite important in successful oral intake .The occupational and physical therapists may be helpful in providing supports and wheelchair modifications for a patient who has difficulty assuming the desired swallowing posture.",2020-09-01
663,FAITH LUTHERAN HOME,275073,1000 6TH AVE N,WOLF POINT,MT,59201,2017-10-25,431,E,0,1,GXFG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to label and date opened multi-dose vials of insulin for 4 (#s 6, 15, 16, and 17) of 17 sampled and supplemental residents. Findings include: 1. Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. A review of resident #6's (MONTH) (YEAR) Medication Administration Record [REDACTED] During an observation and interview on [DATE] at 7:55 a.m., a manufactures box of insulin with a multi-dose vial of Humalog was found in the top drawer of the medication cart. The box had a label reading, opened, and was dated [DATE]. The multi-dose vial of insulin was not dated. Staff member C stated the multi-dose vials of insulin were not expired, and the vials did not need to be labeled. 2. Resident #15 was admitted to the facility with [DIAGNOSES REDACTED]. A review of resident #15's (MONTH) (YEAR) Medication Administration Record [REDACTED] During an observation and interview on [DATE] at 7:57 a.m., two manufacture boxes of insulin with multi-dose vials of Humalog and Lantus was found in the top drawer of the west medication cart. The Humalog box had a label reading, opened, and was dated [DATE]. The multi-dose vial of insulin was not dated. The Lantus box had a label reading, opened, and was dated [DATE]. The multi-dose vial of insulin was not dated. At 8:09 a.m. staff member C stated multi-dose vials of insulin were not labeled with open dates. 3. Resident #16 was admitted to the facility with [DIAGNOSES REDACTED]. A review of resident #16's (MONTH) (YEAR) Medication Administration Record [REDACTED] During an observation and interview on [DATE] at 8:00 a.m., a manufactures box of insulin with a multi-dose vial of Levemir was found in the top drawer of the south medication cart. The box had a label that read, opened, and was dated [DATE]. The multi-dose vial of insulin was not dated. Staff member D stated multi-dose vials of insulin were not dated, only the manufacture's box was. 4. Resident #17 was admitted to the facility with [DIAGNOSES REDACTED]. A review of resident #17's (MONTH) (YEAR) Medication Administration Record [REDACTED] During an observation and interview on [DATE] at 8:05 a.m., a manufactures box of insulin with a multi-dose vial of Humalog was found in the top drawer of the south medication cart. The box had a label reading, opened, and was dated [DATE]. The multi-dose vial of insulin was not dated. Staff member D stated open label stickers were available to facility staff, and staff should have been dating the multi-dose vials of insulin. During an interview on [DATE] at 5:10 p.m., staff member C stated the facility did not need to label multi-dose vials of insulin. He stated labeling the box was acceptable. A review of the facility's policy, Vials and Ampules of Injectable Medications, copyright 2006, read, B. The date opened and the initials of the first person to use the vial are recorded on multidose (sic) vials (on the vial label or an accessory label affixed for that purpose).",2020-09-01
664,FAITH LUTHERAN HOME,275073,1000 6TH AVE N,WOLF POINT,MT,59201,2017-10-25,441,D,0,1,GXFG11,"Based on observation, interview, and record review, the facility staff failed to follow standard precautions to prevent the potential spread of infection by not sanitizing a mechanical lift after use between resident care for 2 (#s 3 and 5) of 14 sampled residents. Findings include: 1. During an observation on 10/23/17 at 8:47 a.m., staff members [NAME] and F transferred resident #3 from his wheelchair to his bed using the mechanical lift. After the transfer was complete, staff member F put the sling on top of the lift, then hung the sling behind the resident's bedroom door. The lift was wheeled down the hall, and put into the closet nook next to the nurse's station. The staff members did not clean, or sanitize the lift after being used. A review of resident #3's Quarterly MDS, with an ARD of 8/8/17, showed the resident required extensive and total assistance for transfers, and performing activities of daily living. During an interview on 10/23/17 at 8:57 a.m., staff member F stated the night shift nursing staff were responsible for sanitizing the mechanical lifts. 2. During an observation on 10/23/17 at 9:15 a.m., staff members G and H transferred resident #5 from his wheelchair to his bed using the mechanical lift. After the transfer was complete, staff member H put the sling on top of the lift, then hung the sling on a hook in the resident's room. Staff member H asked staff member D to put the lift in the closet nook next to the nursing station. A review of resident #5's Quarterly MDS, with an ARD of 8/1/17, showed the resident required extensive, and total assistance with transferring, and performing his activities of daily living. During an interview on 10/23/17 at 11:07 a.m., staff member D stated all lifts were cleaned at night by the night shift staff members, and as needed when visibly soiled. During an interview on 10/23/17 at 11:11 a.m., staff member [NAME] stated the lifts were to be cleaned after each use during resident care. The staff member stated she thought staff member F had cleaned the lift prior to parking it in the closet nook next to the nurse's station. During an interview on 10/23/17 at 11:16 a.m., staff member G stated the lifts were cleaned each night, by the night shift staff members. During an interview on 10/23/17 at 11:26 a.m., staff member A stated the facility did not have a policy and procedure for cleaning, and/or sanitizing the mechanical lifts. The staff member stated all staff were responsible for using the Cavi-wipes after each resident use.",2020-09-01
665,FAITH LUTHERAN HOME,275073,1000 6TH AVE N,WOLF POINT,MT,59201,2017-10-25,514,D,0,1,GXFG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain an accurate medical record of 1 (#6) of 14 sampled residents. Findings include: Resident #6 returned to the facility on [DATE] after a suprapubic catheter had been placed. Review of resident #6's physician's orders [REDACTED]. This order had been placed on resident #6's 10/2017 treatment record. The 10/2017 treatment record failed to show the catheter bag had been changed at any time between 10/1/17 and 10/23/17. During an interview on 10/24/17 at 8:20 a.m., staff member A said the catheter bag changes should be documented on the treatment sheet. Staff member A reviewed the 10/2017 treatment sheet where the line showed Change cath (sic) bag 2xmthly (sic). Staff member A said the treatment record should have had two days blocked off to show which days the catheter bag needed to be changed. Staff member A said the ward clerk should have blocked those days off. Staff member A said she knew it had been changed, staff member A did not know why the nurse had not signed it off. Staff member A retrieved the charge slip for resident #6. The charge slip contained the catheter bag stickers with the dates the bags had been changed. During an interview on 10/24/17 at 11:00 a.m., staff member AA said the days for resident #6's catheter bag change should have been blocked off. Staff member AA said she added to the treatment record for the catheter bag to be changed on the first and the fifteenth days of the month.",2020-09-01
666,WIBAUX COUNTY NURSING HOME,275079,712 WIBAUX ST S,WIBAUX,MT,59353,2016-07-22,157,G,0,1,CB4611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform the physician of the formation of a pressure ulcer for 1 (#2) of 10 sampled residents. The facility failed to notify the physician of severe weight loss for 2 (#'s 2 and 4) of 10 sampled residents. Findings include: Pressure Ulcer 1. Review of resident #2's progress notes showed on 7/16/16 at 11:44 a.m., the resident was noted to have a Slight opening to resident's coccyx above crack. Area is reddened and measures 1 cm x 0.2 cm. Area cleansed and Allyvn (sic) dressing placed on. During an interview on 7/21/16 at 7:15 a.m., staff member K stated she did not call the physician and notify him of resident #2's coccyx wound. Staff member K stated; It was a hectic day and I guess I forgot. Staff member K also said she did not get an order from the physician to treat the wound. Weight Loss 1. Resident #2 had a severe weight loss of 18.5% in 30 days. Review of the facility's weight records for May, June, and (MONTH) showed resident #2 weighed 123 pounds in May, 121 pounds in June, and 102 pounds in July. This was a weight loss of 19 pounds or 15.7% in 30 days. Any weight loss greater than 5% in 30 days is considered a severe weight loss. A reweigh for resident #2 was requested on 7/20/16 at 11:00 a.m. This information was provided on 7/20/16 at 3:25 p.m. Resident #2's new weight was 98.6 pounds which indicated a severe weight loss of 18.5% in 30 days. Review of nursing notes from (MONTH) 1, (YEAR) to (MONTH) 20, (YEAR) showed the physician was not notified of resident #2's severe weight loss. During an interview on 7/19/16 at 8:00 a.m., staff member C said she does not inform the registered dietician or physician when a resident has a significant or severe weight loss or weight gain. Staff member C said the nurses should notify the physician of any significant or severe weight loss or weight gain. During an interview on 7/21/16 at 4:00 p.m., resident #2's physician stated he was aware the resident's dietary intake was down but he had not been aware of her weight change from 121 pounds in (MONTH) to 98.6 pounds in (MONTH) until the facility notified him on the evening of 7/20/16. 2. Resident # 4 had a weight loss of 11.6% in 90 days. Review of the facility's weight records for May, June, and (MONTH) showed resident #4 weighed 163 pounds in May, 180 pounds in (MONTH) and 144 pounds in July. This was a weight loss of 19 pounds or 11.6% in 90 days. Review of nursing notes from (MONTH) 1, (YEAR) to (MONTH) 21, (YEAR) showed the physician was not notified for resident #4's 11.6% weight loss. During an interview on 7/21/16 at 7:15 a.m., staff members A, and B said resident #4 had a lot of [MEDICAL CONDITION] in (MONTH) and June, and the provider added [MEDICATION NAME] on 6/2/16 in an attempt to decrease resident #4's [MEDICAL CONDITION]. Staff member A said the provider had not been notified of the 36 pound weight loss, in 30 days, for resident #4. During an interview on 7/21/16 at 5:45 p.m., staff member A said resident #4's provider had been notified of her weight loss. Staff member A said the provider decreased resident #4's [MEDICATION NAME] from 40 mg twice a day to [MEDICATION NAME] 40 mg once a day. During an interview on 7/21/16 at 7:10 a.m., staff member A said the physician had not been notified of the severe weight losses for residents #2, and #4. Review of the facility's policy titled Weight Assessment and Intervention states under Weight Assessment; 3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will notify the Dietician in writing. During an interview on 7/20/16 at 11:25 a.m., contracted staff member AA said the facility had not notified her regarding the weight losses experienced by resident #2 and resident #4.",2020-09-01
667,WIBAUX COUNTY NURSING HOME,275079,712 WIBAUX ST S,WIBAUX,MT,59353,2016-07-22,164,D,0,1,CB4611,"Based on observation and interview, the facility failed to obtain personal and confidential information in a private setting for 1 (#12) of 14 sampled and supplemental residents. Finding include: During an observation on 7/21/16 at 3:30 p.m., staff member G approached a table in the dining room where a surveyor, resident #4 and resident #12 were sitting. Staff member G stood near resident #12 and proceeded to gather information and query resident #12 regarding his diet and food consumption, as well as his health conditions. Staff member G asked resident #12 if he had difficulty swallowing or chewing, if he wore dentures, and did he have any nausea, diarrhea or vomiting. Staff member G asked how many snacks a day the resident was consuming, and if he was continuing to eat cookies and drink chocolate milkshakes. Staff member G stated resident #12 was at a healthy weight at 175 pounds. During an interview on 7/21/16 at 3:45 p.m., staff member G stated she probably should have asked the resident to speak with her in a quiet corner. Staff member G stated she did see a problem with sharing private information in a public setting. During an interview on 7/21/16 at 3:50 p.m., staff member A stated it would be inappropriate to interview a resident regarding his health and personal preferences in the company of others. Staff member A stated she would call the agency staff member G contracted with and talk to her employer.",2020-09-01
668,WIBAUX COUNTY NURSING HOME,275079,712 WIBAUX ST S,WIBAUX,MT,59353,2016-07-22,226,J,0,1,CB4611,"On 7/21/16 at 2:45 p.m., the facility administrator was notified that an immediate jeopardy situation existed for 1 of 14 sampled and supplemental residents related to investigation and protection in a situation of abuse under F226 with a scope and severity of a [NAME] PLAN TO REMOVE THE IMMEDIATE JEOPARDY The facility submitted an acceptable plan to remove the immediacy on 7/22/16 at 7:50 a.m. The deficient practice remained at the scope and severity of G once the immediacy was removed. A summary of the facility's plan to remove the immediate jeopardy was as follows: 1. The nurse named in the allegation will no longer be employed at the facility. 2. The resident and her family were notified of the termination. 3. A new policy for investigating abuse was initiated. Based on observation, interview and record review, the facility failed to thoroughly investigate an incident of reported abuse, and failed to protect a resident from further abuse for 1 (#5) of 14 sampled and supplemental residents. Findings include: A review of the Reporting Form dated 6/27/16, submitted by staff member A, showed the facility received a report alleging abuse from resident #5 on 6/25/16, against staff member M. The incident report showed Resident said a traveling nurse had entered her room when she was in bed, touched her breasts unfastened her attends (sic) looked at her peri area, and did not attach her attends correctly, that she wet the bed. The resident was unsure who the staff member was or when this occurred. A review of the Five Day Investigation Results Report dated, 7/1/16, showed, During my investigation I learned that a nurse had gone into the resident's room to perform a skin check on (resident #5). I explained to (resident #5) that the nurse was performing a skin assessment when she was lying in bed. This resident has had skin inspections done before but usually during her shower, so I explained that some nurses prefer to do skin inspections while the person is in the bed. (Resident #5) understood this. I spoke with {the} nurse to ensure that she explains what she is doing to the resident and that they understood. A review of a hand written, undated chronological account of events, provided by staff member A, showed Resident (#5) brought concern to staff member M on 6/25/16. On 6/27/16 resident (#5) came to me and told me that a staff (traveling) had touched her breasts and removed her attends (sic) and looked at her peri area and they did not attach her attend correctly and she wet the bed. Resident (#5) was unable to tell me who the staff member was or when the incident happened and she has not been working since. Staff member A reviewed the work schedule and identified a number of traveling staff to interview, including staff member M. Staff member A spoke with resident #5 on 6/27/16 and 6/28/16 in an attempt to determine the identity of the nurse. On 6/29/16 staff member A again asked resident #5 who the staff member was, and the resident pointed to staff member M. Staff member A interviewed staff member M, who stated she had completed a skin check on resident #5 while she was in bed. Staff member M stated she had told resident #5 to put her call light on when she was in bed. Staff member A then spoke with resident #5, and explained that staff member M was doing a skin check just like other nurses have done. Staff member A stated that I have done skin checks like (staff member M). Resident #5 was upset and stated No you have not. Staff member A reassured resident #5 and the investigation was concluded. A requests for copies of statements gathered during the investigation reflected a lack of documentation of statements. During an interview on 7/20/16 at 11:30 a.m., resident #5 stated, she was at the nurses' station wearing her pajamas, when staff member M said, I have to feel you all over. The resident and staff member discussed using the call light to notify the nurse when the resident was in bed. Resident #5 stated, The nurse came in and took my diaper off and felt my boobs. I felt weird, like I was being sexually abused. She (staff member M) felt down here (gesturing toward her genitals), I really felt sexually abused. She (staff member M) didn't get my diaper back up. I don't know who else she did that to. Another night she came in again and wanted to do the same thing, and I told her to get out. Resident #5 stated she reported the abuse to an aide the next morning because, I felt like I had been molested. When asked if she had been told the results of an investigation of the incident, resident #5 stated she never heard anything more about the incident. She also stated it would be a waste of effort to bring it up again as, they don't believe me anyway. Resident #5 stated the incident had left her feeling nervous and hurt her ability to trust anyone. During an observation on 7/20/16 at 12:10 p.m., resident #5 was visibly upset and tearful, and stated I feel like it was ignored. She was shaking, her face was red and she was trembling. During an interview on 7/21/16 at 8:30 a.m., resident #5 cried as she relayed an inability to sleep the night before due to fear and uncertainty regarding the discussion of the incident yesterday. She was concerned about retaliation. Her demeanor was sad and uncertain. During an interview on 7/21/16 at 10:15 a.m., staff member M stated there was nothing unusual about the skin assessment she performed on resident #5. Staff member M stated the resident never made any comments to her after her report of abuse. Staff member M stated she was told an investigation of abuse was being conducted. Staff member M does not recall being interviewed regarding the incident. Staff member M was later told by staff member B the incident had been investigated and nothing was found. During an interview on 7/21/16 at 9:40 a.m., staff member A stated she had no further documentation of the investigation. Staff member A also stated she was aware staff member M had continued to work with resident #5. Staff member A stated she had instructed staff member M to have a CNA accompany her when performing skin assessments on resident #5. During an interview on 7/21/16 at 9:50 a.m., staff member D stated she is at times involved in investigating incidents, but not always. Social Services was not involved in this investigation. Staff member D was unsure of what criteria might be used to determine her involvement. Staff member D was under the assumption the issue had been resolved. Staff member D had never talked with resident #5 regarding the incident until the previous day, 7/20/16, when she had noted the resident's distress. During an interview on 7/21/16 at 10:00 a.m., a family member of resident #5 stated she had been told about the incident by the resident, who was visibly upset. The family member was told by staff member A that they had looked into the allegations and knew what had happened and assured her the facility would take care of the situation. The family member stated both she and the resident had been upset by the incident. The subject had come up a number of times and she knew the incident scared resident #5 a lot, and it had harmed her ability to feel safe. The family member wondered why the assessment would be carried out at night in resident #5's bed. A review of a Weekly Skin Integrity Review log showed resident #5 had skin assessments completed by staff member M on 6/1/16, 6/14/16, 6/17/16, and the day of the alleged incident 6/22/16. Staff member M continued skin assessments on 6/29/16, 7/6/16 and 7/14/16. The 7/14/16 assessment includes a note by staff member M stating Done by CNA, resident refused this staff member to assess. A review of the Handout for Abuse Policy provided by the facility stated: - The administrator will be responsible for investigating all reports of abuse or suspected abuse. -The staff will report any suspicion of abuse to their supervisor, and continue to report until the administrator or designee is informed, regardless of the day or time. -Employees who are being investigating will be suspended from work pending an objective investigation. A review of the Wibaux County Nursing Home Reporting Resident Abuse document dated (MONTH) (YEAR), showed: -The DON must complete a Resident Abuse Form and obtain a written, signed, and dated statement from the person reporting the incident. -A complete copy of the Resident Abuse Form and written statements from witnesses, if any, must be provided to the administrator within 24 hours of the occurrence of such incident.",2020-09-01
669,WIBAUX COUNTY NURSING HOME,275079,712 WIBAUX ST S,WIBAUX,MT,59353,2016-07-22,241,D,0,1,CB4611,"Based on observation and interview, the facility failed to treat residents with dignity and respect for 2 (#s 2, 7) of 14 sampled and supplemental residents. Findings include: 1. During an observation on 7/20/16 at 8:00 a.m., staff member H was sitting next to resident #7 assisting with breakfast. At 8:02 a.m., staff member H left the table and resident #7 picked up his spoon and took a bite of oatmeal. Resident #7 had a second bite of oatmeal before staff member H returned to the table. Staff member H took the spoon from resident #7's hand and scooped up a bite of oatmeal, which she placed in his mouth. Resident #7 picked up a piece of toast from his plate and took a bite. While he was still chewing, staff member H put a spoonful of oatmeal into his mouth. Resident #7 continued to chew his food as staff member H brought another spoonful of food to his mouth. The resident opened his mouth, which was full, and the staff member spilt the oatmeal off the spoon onto the resident's clothing protector. Resident #7 picked up his toast and took a bite. As he was still chewing and attempting to swallow, staff member H brought another spoonful of oatmeal to his lips. The resident was using his fork to eat his eggs as staff member H held a spoonful of oatmeal about 6 from his mouth, ready to slide into his mouth. Staff member H moved the spoon, and the oatmeal fell on to the resident's clothing protector. Staff member H left the table at 8:14 a.m. Resident #7 continued to eat his breakfast. During an observation on 7/20/16 at 12:10 p.m., staff member C entered the dining room and asked who she could help. Staff member C sat in a chair next to resident #7 and said, you should eat your desert. Staff member C picked up the resident's buttered roll and moved it farther from the resident and moved his desert plate closer. Staff member C picked up a spoonful of desert and it dripped down the front of resident #7's clothing protector. Staff member C again picked up the resident's roll and moved it. The staff member then used her ungloved fingers to remove a sliced strawberry from his desert plate. During an interview on 7/21/16 at 4:35 p.m., staff member I stated that when assisting a resident to eat she will notice if they had begun to eat. If they had not, she will put food on a spoon and offer the spoon. In this way she can encourage the resident to eat. Sometimes the resident will get tired and she will take over to ensure they obtain adequate intake. She tries to watch the resident to get clues to when they are ready for another bite. During an interview on 7/21/16 at 3:55 p.m., staff member F stated she tries to watch to be sure a resident has swallowed after each bite she feeds them. She will offer a drink of liquids between every 2-3 bites of food. With some residents, she will offer more frequent liquids. She stated many residents will let you know when they are ready for another bite by opening their mouth. If they do not open their mouth she will ask what they would like next. She has received training and assisting residents to eat at national nursing conventions and in-service training in the facility. 2. During an observation on 7/20/16 at 8:31 a.m., staff member H was bending over resident #2, who was lying at about a 45 degree angle in her bed. Resident #2 had her eyes closed and her head was hanging slightly toward her right side. Staff member H poured juice into the residents' mouth. Resident #2 was chewing and food was seen inside her mouth. Staff member H was encouraging resident #2 to swallow before she went back to sleep. The resident continued to move the food around in her mouth, but did not respond verbally. Staff member H attempted to pour water into the resident's mouth, which was closed, and the water fell on to her shirt and clothing protector. Staff member H again told the resident she needed to swallow what was in her mouth before she went back to sleep. Staff member H poured more juice into the resident's mouth. The resident continued to move food around in her mouth. Resident #2 began to cough and sputter, and said, no. The resident continued for 10 seconds to cough and move the food around in her mouth. Staff member H picked up the food tray and left the room. Staff member H returned and offered the resident more juice. While the resident continued to chew and had not opened her eyes, she asked, is that all there will be? Staff member H replied, yes. Staff member H cleaned off the resident's table and left the room. The resident remained unmoving in her bed, her mouth agape, and began to snore. During an interview on 7/20/16 at 8:40 a.m., staff member H stated that resident #2 is a feeder. When staff member H was asked about the food remaining in the residents' mouth, she stated oh, I can go get it out. This surveyor requested the administrator be called to check on the resident. During an observation on 7/20/16 at 8:44 a.m., staff member A donned gloves and used a swab to remove food from resident #2's mouth. A piece of food was removed and wrapped in the glove as it was being thrown in the trash.",2020-09-01
670,WIBAUX COUNTY NURSING HOME,275079,712 WIBAUX ST S,WIBAUX,MT,59353,2016-07-22,279,D,0,1,CB4611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to review and revise a resident's comprehensive care plan following a significant change in assessment with the development of a pressure heel ulcer and subsequent [DIAGNOSES REDACTED].#1) of 10 sampled residents. Findings include: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A record review of Weekly Skin Integrity Review forms for Resident #1, dated 3/15/15 through 7/11/16, showed the following recordings as signed by nursing staff: 5/21/16 Left heel 1/2 x 1/2 cms black area with redness. 5/24/16 Left heel 1/2 x 1/2 cm black area with redness, tender to touch 5/30/16 Left heel 1/2 cm x 1/2 cm area with redness 6/6/16 Diabetic ulcer left heel 6/13/16 Charted in computer 6/20/16 Diabetic ulcer left heel 6/2716 Diabetic ulcer to left heel 7/4/16 Diabetic ulcer left heel. No drainage 7/6/16 Open areas right leg above ankle. 2 smaller open areas on side of foot. 7/11/16 Diabetic ulcer left heel, right leg above ankle, 2 on side of foot From 3/15/15 through 8/27/15, the records were checked to show skin intact. There were references made to a small open area to right lateral heel made on 8/13/15, 8/27/15, and 9/17/15. On 9/15/15 it was again reported that Resident #1's skin was intact and remained so until the entry of 5/21/16 as listed above. No further entries were found to be made after 7/11/16. A record review of a Wound Care Flow Sheet for Resident #1 showed the following measurements and descriptions of the resident's diabetic ulcer of the left heel as recorded by 3 different nursing staff members. 5/24/16 diabetic ulcer left heel 6/3/16 1 cm x 2.8 cm diabetic ulcer outer left heel 6/27/16 1 cm x 3 cm diabetic ulcer lateral left heel 6/30/16 1.5 cm x 3 diabetic ulcer left heel lateral A record review of written orders for medical treatment of [REDACTED]. 5/20/16 Air mattress and protective heel boots while in bed. 5/27/16 Dressing change q 2 day if intact. 5/28/16 Obtain culture of wound to left heel then start Keflex 500 am tid x 10 days. 5/27/16 Change drsg to L heel q 2 days with alleryon (sic). 5/31/16 [MEDICATION NAME] to wound left lateral foot. Cut [MEDICATION NAME] to fit wound bed, cover /c Hypofix (sic) tape. 7/9/16 Medicated honey to wound bed then wrap /c cotton gauze, change every morning. A record review of lab results, dated 7/16/16, included a culture and gram stain of resident #1's left heel wound as sent to the facility by a local clinic. It showed that the culture had grown 3 plus [MEDICAL CONDITION]. The document showed that it had been sent to the facility from the local clinic on 7/19/16 at 10:23 p.m. Review of a progress note, dated 7/18/16, documented debridement of resident #1's wound on the left lateral heel. It showed 2/3 of the thickness of the eschar was able to be removed of 80% of the total wound area. Depth continues to be unknown due to no granulation tissue present at this time. The wound is described as a 5.3 (cms) in length and 3.4 (cms) in width with a small amount of serous exudate absent of odor. A record review of the MDSs, as completed for resident #1 in (YEAR), showed that an MDS had been completed for a Significant Change in her assessment on 6/1/16. During an observation on 7/19/16 at 1:35 p.m., wound evaluation of Resident #1's right and left foot ulcers was done. The right foot showed a healed skin tear on the lower ankle with a 1 cm x 1 cm dried brown scab with no drainage. The left foot showed a 4-5 cms x 3-4 cms oval ulcer of 1 cm depth on the top of the foot near the ankle without drainage or odor. The left heel had a 5 cms x 5 cms area on the heel pad of black torn skin with blackness under the pad callous which was approximately 1/3 of the sole of the foot. A review of the Care Plan for Resident #1 showed a problem start date of 4/8/16 for the category of Pressure Ulcer. Under Goal it stated Resident's skin will remain intact. Under Approach were listed the following, each dated 4/8/16: Assist to turn and reposition q2H and as needed. Encourage adequate food and fluid intake. Encourage to spend time out of bed every shift. Report any skin abnormalities to nurse. Skin checks q week as per facility protocol. Assist with peri care after incontinence as needed. The Pressure Ulcer category showed that it had been last reviewed/revised on 04/08/2016 at 12:46 PM. A review of the Care Plan for Resident #1 showed a problem start date of 5/27/16 for the category of Pain: I have pain because I have a diabetic ulcer on my left outer heel. Under Approach were listed the following by approach start date: 6/7/16 I need to have medication for the pain my scheduled Tylenol and also Tylenol #3 PRN. 5/27/16 I will have my dressing changed per the doctor's orders (Aqua cell (sic) to wound bed changed Tuesday and Friday) The Pain category showed that it had been last reviewed/revised on 6/7/16. Under the category of Pressure Ulcer the Care Plan for resident #1 did not show that she had an ulcer on her left heel. Nowhere in the Care Plan did it show the changes that were ordered for wound care and dressing changes over time nor did it document the debridement procedure done on 7/18/16. It did not show that culture of the left heel wound had shown positive [MEDICAL CONDITION] or whether isolation precautions or infection control measures had been determined necessary or implemented. The Care Plan was not updated to reflect the need to use an air mattress or protective heel boots while the resident was in bed.",2020-09-01
671,WIBAUX COUNTY NURSING HOME,275079,712 WIBAUX ST S,WIBAUX,MT,59353,2016-07-22,280,E,0,1,CB4611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to update care plans with interventions for severe weight loss and weight gain concerns for 5 (#s 2, 4, 8, 12, and 13) of 14 sampled and supplemental residents. The facility also failed to update a care plan for 1 (#4) of 14 sampled and supplemental residents for identified transfer concerns and interventions. The facility failed to update a care plan for 1 (#2) of 14 sampled and supplemental residents with an identified pressure ulcer and interventions for the treatment of [REDACTED]. 1. a. Resident #2 had a severe weight loss of 15.7% in 30 days. During a record review of resident weights, resident #2 was shown to have a severe weight loss of 15.7% between her weight in (MONTH) and being weighed in July. The facility did not update the severe weight loss as a concern on resident #2's care plan. The facility did not update the approaches, as identified by the occupational therapist, on resident #2's care plan. The facility did not update the care plan nutritional approaches to reflect nursing staff had been assisting or feeding resident #2 for at least one month per an interview with staff member H on 7/21/16 at 10:30 a.m. See F325. b. Resident #2 was identified as having a pressure ulcer on her coccyx. During a record review, nursing notes on 7/16/16 showed staff member K documented resident #2 had an opening of 1 cm by 0.2 cm on the coccyx above her crack. Staff member K started a treatment of [REDACTED]. Resident #2's pressure ulcer care plan was not updated to reflect the resident had an actual problem with a pressure ulcer. The care plan was not updated with any new approaches for treatment, healing, or prevention of new pressure ulcers. 2. Resident #4 had a severe weight loss of 20% in 30 days. During a record review of resident weights, resident #4 was shown to have a severe weight loss of 20% between her weight in (MONTH) and being weighed in July. The facility did not update the severe weight loss as a concern on resident #4's care plan. The facility did not update resident #4's care plan to include monitoring of weight loss or weight gain in relation to the resident's identified [MEDICAL CONDITION] concerns. 3. Resident #8 had a weight gain of 12% in 3 months. During a record review of resident weights, resident #8 was shown to have a weight gain of 12%. The facility did not update the nutritional care plan to show this was a concern for the resident. The facility did not update the nutritional care plan to show approaches put into place to assist the resident with maintaining a steady weight. See F325. 4. Resident #12 had a weight gain of 9.4% in 3 months. During a record review of resident weights, resident #12 was shown to have a weight gain of 9.4%. The facility did not update the nutritional care plan to show this was a concern. Resident #12 had a preference for beer and cookies. These preferences were not addressed on resident #12's nutritional care plan. See F325. 5. Resident #13 had a weight gain of 9.4% in 3 months. During a record review of resident weights, resident #13 was shown to have a weight gain of 9.4%. The facility did not update the nutritional care plan to show this was a concern. The facility did not update the nutritional care plan with new approaches to address the weight gain. See F325. 6. Resident #4 was identified as needing increased help in her ADLs (activities of daily living) by CNA staff and staff member N. During a record review, nursing notes on 6/4/16 showed staff member N was informed by a CNA (certified nurse aide) that resident #4 was not transferring well. The staff was concerned the resident would have a fall and asked if resident #4 could be transferred using a lift. Staff member N talked to resident #4 and she agreed to use a sit to stand lift. During a review of resident #4's care plan, it showed the resident was an assist of 1 to stand up from her bed, chair, or the toilet. The care plan for resident #4 did not show the resident had a change in the approaches for her transfers, using a sit to stand lift on her ADLs or her Falls care plan. During an interview on 7/21/16 at 12:00 p.m., staff member D said her name tends to be on a lot of the care plans as an editor. Staff member D said the disciplines responsible are the ones who will update their sections and monitor the approaches for effectiveness. Staff member D said, As an example, the dietary manager would put problems and approaches on the nutritional care plan and nursing would put problems and approaches on the care plans related to nursing concerns. Staff member D said nursing would monitor the approaches for effectiveness and update the approaches as needed if the current approaches were identified as ineffective.",2020-09-01
672,WIBAUX COUNTY NURSING HOME,275079,712 WIBAUX ST S,WIBAUX,MT,59353,2016-07-22,309,G,0,1,CB4611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to accurately assess a resident and implement a care plan to promote the healing and prevent further deterioration of a resident's heel ulcer. It failed to evaluate and revise care interventions to prevent the spread of infection of this wound. This occurred for 1 resident (#1) of 10 sampled. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During the initial survey tour of the facility on 7/19/16 at 7:20 a.m., staff member K stated that lab results for a culture and sensitivity of resident #1's left heel ulcer had been received during the prior shift and that it was positive [MEDICAL CONDITION]. Resident #1 was asleep in bed with her lower legs elevated. Both legs showed clean dry dressings to both the right and left heels. No foul odor was noted. During a family interview on 7/19/16 at 1:30 p.m., resident #1's family member said she had previously been notified of the development of an ulcer on the resident's right heel by the facility. She had also been told by the facility staff that the right heel had almost completely healed. During a visit to the facility on [DATE], resident #1 had complained to her family member that her heel pain had increased in severity. The family member looked at the resident's right heel and found it almost completely healed. She then looked at the resident's left heel. It was swollen, red, and warm on the resident's left heel and part of the sole of the foot. She said she was very alarmed when she saw it. She said she had not been aware there was any wound on the resident's left leg or foot until her observation of the resident's left heel on 7/9/16. A review of the MARs for resident #1 showed that Tylenol #3 had been administered to the resident for left heel pain relief at least once a day or more between 7/1/16 and 7/19/16. A record review of Weekly Skin Integrity Review forms for Resident #1, dated 3/15/15 through 7/11/16, showed the following recordings as signed by nursing staff: 5/21/16 Left heel 1/2 x 1/2 cms black area with redness. 5/24/16 Left heel 1/2 x 1/2 cm black area with redness, tender to touch 5/30/16 Left heel 1/2 cm x 1/2 cm area with redness 6/6/16 Diabetic ulcer left heel 6/13/16 Charted in computer 6/20/16 Diabetic ulcer left heel 6/2716 Diabetic ulcer to left heel 7/4/16 Diabetic ulcer left heel. No drainage 7/6/16 Open areas right leg above ankle. 2 smaller open areas on side of foot. 7/11/16 Diabetic ulcer left heel, right leg above ankle, 2 on side of foot From 3/15/15 through 8/27/15, the records were checked to show skin intact. There were references made to a small open area to right lateral heel made on 8/13/15, 8/27/15, and 9/17/15. On 9/15/15 it was again reported that Resident #1's skin was intact and remained so until the entry of 5/21/16 as listed above. No further entries were found to be made after 7/11/16. A record review of a Wound Care Flow Sheet for Resident #1 showed the following measurements and descriptions of the resident's diabetic ulcer of the left heel as recorded by 3 different nursing staff members: 5/24/16 diabetic ulcer left heel 6/3/16 1 cm x 2.8 cm diabetic ulcer outer left heel 6/27/16 1 cm x 3 cm diabetic ulcer lateral left heel 6/30/16 1.5 cm x 3 cm diabetic ulcer left heel lateral A record review of lab results, dated 7/16/16, of a culture and gram stain of resident #1's left heel wound as sent to the facility by a community clinic showed that the culture had grown 3 [MEDICAL CONDITION]. The document showed that it had been sent to the facility from the clinic on 7/19/16 at 10:23 p.m. A review of physician orders [REDACTED].#1 was ordered to receive [MEDICATION NAME] 100 mg BID x 3 weeks on 7/18/16. Prior to this, Resident #1 had been ordered on [DATE] to receive Keflex 500 mg BID x 7 days for infection. A record review of a progress note, dated 7/18/16 which documented Provider BB's debridement of resident #1's wound on the left lateral heel showed 2/3 of the thickness of the eschar was able to be removed of 80% of the total wound area. Depth continues to be unknown due to no granulation tissue present at this time. The wound was described as a pressure type wound of 5.3 (cms) in length and 3.4 (cms) in width with small, serous exudate with odor absent. The procedure was performed by a wound care specialist contracted outside the facility. A record review of medical Provider #CC's progress notes, as performed on 7/18/16 with an encounter date of 7/12/16, showed a [DIAGNOSES REDACTED]. A record review of the MDSs, as completed for resident #1 in (YEAR), showed that an MDS had been completed for a Significant Change in her assessment on 6/1/16. During an observation on 7/19/16 at 1:35 p.m., wound evaluation of Resident #1 right and left foot ulcers was done. The right foot showed a healed skin tear on the lower ankle with a 1 cm x 1 cm dried brown scab with no drainage. The left foot showed a 4-5 cms x 3-4 cms oval ulcer of 1 cm depth on the top of the foot near the ankle without drainage or odor. The left heel had a 5 cms x 5 cms area on the heel pad of black torn skin with blackness under the pad callous which was approximately 1/3 of the sole of the foot. During a wound evaluation of resident #1's left heel ulcer on 7/18/16 at 1:40 p.m., the resident's primary medical provider also evaluated the resident's wounds. She said she thought the ulcer on top of the resident's left foot was due to the resident wearing protective heel covers whose Velcro straps had been too tightly wrapped. She was heard to verbally instruct staff member K to make sure to keep the resident's legs elevated as much as possible. During intermittent observations on 7/19/16 through 7/22/16, resident #1 was not seen ambulatory. She always had her lower legs elevated, except when she was sitting in a wheelchair for meals where she had her feet supported off the floor by the wheelchair. A record review of the resident's care plan showed on 4/8/16 the resident had the potential for skin breakdown/incontinence R/T limited mobility and diabetes mellitus and incontinence exhibited by long periods of time in bed sleeping. It also showed that the resident's skin was intact. The care plan did not show that any additions or revisions had been made under the category of pressure sores since 4/8/16. The care plan did not document the resident'[MEDICAL CONDITION] infection or contain interventions to prevent the spread of the infection.",2020-09-01
673,WIBAUX COUNTY NURSING HOME,275079,712 WIBAUX ST S,WIBAUX,MT,59353,2016-07-22,325,J,0,1,CB4611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 7/21/16 2:45 p.m., the facility administrator was notified that an immediate jeopardy situation existed for 1 of 10 sampled residents related to weight loss under F325 with a scope and severity of a [NAME] PLAN TO REMOVE THE IMMEDIATE JEOPARDY The facility submitted an acceptable plan to remove the immediacy on 7/22/16 at 7:50 a.m. The deficient practice remained at the scope and severity of G once the immediacy was removed. A summary of the facility's plan to remove the immediate jeopardy was as follows: 1. Residents were assessed by an interdisciplinary staff and diets were updated and supplements were added where needed. 2. Physicians and families were notified. 3. Weekly meetings will be conducted to monitor and adjust as needed. Based on record reviews, interviews, and observations, the facility failed to assess, intervene, or prevent severe weight loss for 1 (#2) of 10 sampled residents. The facility also failed to assess, intervene, or prevent a weight gain for 3 (#s 8, 12, and 13) of 14 sampled and supplemental residents. Findings include: 1. Resident #2 had a severe weight loss of 18.5% in 30 days. Review of the facility's weight records for May, June, and (MONTH) showed resident #2 weighed 123 pounds in May, 121 pounds in June, and 102 pounds in July. This was a weight loss of 19 pounds or 15.7% in 30 days. Any weight loss greater than 5% in 30 days is considered a severe weight loss. A reweigh for resident #2 was requested on 7/20/16 at 11:00 a.m. This information was provided on 7/20/16 at 3:25 p.m. Resident #2's new weight was 98.6 pounds which indicated a severe weight loss of 18.5% in 30 days. Review of resident #2's initial nutrition assessment, completed on 3/21/16, showed the resident's ideal body weight to be 121 pounds. Resident #2's weight was documented as 125 pounds at the time of that assessment. A quarterly nutrition assessment was done on 6/8/16 and resident #2's weight was documented as 121 pounds, and the dietician noted the resident's weight to be stable. During an observation on 7/20/16 at 8:15 a.m., resident #2 was in bed. The head of her bed was raised at a 45 degree angle. Her upper body and head were leaning off to the right side of the bed. A tray of food was on a bedside table next to the resident. The food on the tray appeared to be untouched. Resident #2 appeared to be asleep. At 8:19 a.m., staff member H entered the resident's room and approached resident #2. Staff member H spoke to the resident and the resident did not respond verbally or physically. Staff member H was observed to place a piece of quiche in resident #2's mouth. Resident #2 was not observed to chew or swallow the food in her mouth. Resident #2 appeared to be asleep, her eyes were closed and she did not verbally or physically acknowledge staff member H. During a continued observation on 7/20/16 at 8:31 a.m., staff member H was bent over resident #2, who was lying at about a 45 degree angle in her bed. Resident #2 had her eyes closed and her head was hanging slightly toward her right side. Staff member H poured juice into the residents' mouth. Resident #2 was chewing and food was seen inside her mouth. Staff member H was encouraging resident #2 to swallow before she went back to sleep. The resident continued to move the food around in her mouth, but did not respond verbally. Staff member H attempted to pour water into the resident's mouth, which was closed, and the water fell on to her shirt and clothing protector. Staff member H again told the resident she needed to swallow what was in her mouth before she went back to sleep. Staff member H poured more juice into the resident's mouth. The resident continued to move food around in her mouth. Resident #2 began to cough and sputter, and said, no. The resident continued, for 10 seconds, to cough and move the food around in her mouth. Staff member H picked up the food tray and left the room. Staff member H returned and offered the resident more juice. While the resident continued to chew and had not opened her eyes, she asked, is that all there will be? Staff member H replied, yes. Staff member H cleaned off the resident's table and left the room. Resident #2 remained unmoving in her bed, her mouth agape, and began to snore. During an interview on 7/20/16 at 8:40 a.m., staff member H was asked about the food remaining in the residents' mouth, she stated Oh, I can go get it out. It was requested the administrator be called to check on the resident. During an observation on 7/20/16 at 8:44 a.m., staff member A donned gloves and used a swab to remove food from resident #2's mouth. A piece of food was also removed and wrapped in the glove as it was being thrown in the trash. During a review of the dietary intake record for resident #2, it showed the resident had consumed 26-50% of her breakfast. Based on the observation of resident #2's breakfast tray when it was removed from the room by staff member H, and the food staff member A removed from resident #2's mouth; the resident appeared to have consumed 5% of her breakfast. Review of resident #2's admission MDS, with an ARD of 3/22/16, section G, showed the resident required supervision, with a 1 person assist for eating. A review of resident #2's significant change MDS, with an ARD of 6/20/16, section G, showed resident #2 required limited assistance of 1 staff. During an interview on 7/20/16 at 8:20 a.m., staff member H said resident #2 spent most of her time in bed and most of her meals were fed to her while she was in bed. Staff member H thought resident #2 would be put on comfort measures the next time the doctor saw her. Staff member H said the resident's overall condition had really declined in the last month. During an interview on 7/21/16 at 10:30 a.m., staff member H said resident #2 needed more assistance with eating for at least the last month. Staff member H said this had been reported to the charge nurse and documented in the resident's record. During a review of resident #2's nursing progress notes, it was documented on 7/2/16 by a nurse that a CNA mentioned that this resident needs to sit at a feeder table for assistance or doesn't eat much at meals. During a review of resident #2's current care plan, dated 6/23/16, showed the resident had a potential for weight loss related to poor meal intake. The goal was stated as, Resident will maintain a healthy weight. And the approach was, Resident will receive a heath (sic) supplement with meals. The current care plan did not address the resident's need for assistance to eat. During an interview on 7/21/16 at 7:15 a.m., staff member A said the facility does not have a team that oversees and monitors weight loss and/or weight gain concerns of the residents. Staff member A stated resident #2's physician was notified of her severe weight loss on 7/20/16 at 6:10 p.m. Staff member A stated resident #2's physician had ordered an evaluation by the OT (occupational therapist) at the time of that notification. The physician notification and the occupational therapy assessment occurred after a request was made for resident #2's current weight on 7/20/16 at 11:00 a.m. During a record review, an occupational therapy evaluation was documented in resident #2's record that on 7/20/16 at 7:35 p.m., resident #2 was evaluated by the occupational therapist for diet textures, thickened liquids, and positioning while eating. The recommendations of the occupational therapist were for a pureed diet, nectar thick liquids, and for the patient to be placed in a Broda/Geri-chair during all meals. Prior to this evaluation, the resident was receiving a regular diet as documented on resident #2's initial dietary assessment dated [DATE]. The positioning of resident #2, while eating, was not addressed until 7/20/16 when the occupational therapist completed his evaluation. During an interview on 7/21/16 at 7:15 a.m., staff members A and B said resident #2 was now having a puree diet, thickened liquids, and was to sit in a Broda chair for all meals per the OT's recommendations. During an observation on 7/21/16 at 12:03 p.m., resident #2 was sitting up in a Broda chair in the dining area of the memory care unit. On the table in front of resident #2 was a plate of pureed foods. Resident #2 noticed the flowers on the dining table and she commented on how pretty they were. Staff member H started to feed resident #2 and assist her with her fluids that were on the table. Staff member H got a smaller glass from the cupboard and poured some thickened fluid in the smaller glass. Staff member H gave the smaller glass to resident #2 and resident #2 drank from the glass without assistance. Staff member H continued to feed resident #2 and assist her with fluid intake. Resident #2 consumed about 75% of the pureed foods on her plate. Staff member H then offered resident #2 a 4 ounce container of ice cream. Resident #2 ate all the ice cream with staff member H feeding it to her. Staff member H asked resident #2 if she wanted another ice cream, and resident #2 indicated she did. Resident #2 did not have a Mighty Shake on her tray, which the registered dietician had said to continue with all of resident #2's meals. During an interview on 7/21/16 at 12:25 p.m., staff member H said she poured the juice into a smaller glass so resident #2 could manage it herself. Staff member H said she told the kitchen to hold the Mighty Shake until after resident #2 had completed her meal intake. Staff member H said she wanted to make sure resident #2 ate most of her meal before she got her Mighty Shake. Staff member H said resident #2 would get the Mighty Shake with her snack that afternoon. During an interview on 7/20/16 at 11:25 a.m., staff member C said she did not calculate the percentage of weight loss or weight gain for any resident, unless she was doing section K of an MDS for a resident. Staff member C said she did not calculate weight loss or weight gain for 30, 60, or 90 days. Staff member C said the registered dietician visited the facility monthly and they would discuss resident weight loss or weight gain at that time. Staff member C said if she had a weight or dietary concern regarding a resident, she would make a note of the concern and place the note in a binder that she and the dietician would review on the monthly dietician visit. During an interview on 7/21/16 at 10:50 a.m., contracted staff member AA said the facility had not notified her of resident #2's weight loss concerns until 7/20/16. Contracted staff member AA said she would do visits on an as needed basis, especially in the case of a severe weight loss. Contracted staff member AA said she would have addressed resident #2's weight loss and put interventions into place if the facility would have notified her. She was at the facility to assess the weight concerns for residents #2, #4, #8, #12, and #13. During a review of the new dietary assessment, done by the registered dietician on 7/21/16, showed the resident had a 22% weight loss in 30 days, according to the dietician's calculations. This new dietary assessment also showed the resident was to continue receiving a Mighty Shake TID with meals and was also to receive Juven BID. During an interview on 7/21/16 at 3:00 p.m., staff member A said the facility did not consistently record or monitor the amount of the supplements consumed by the residents. 2. Resident #8 had a weight gain of 12% in 3 months. Review of the admission dietary assessment for resident #8 showed her initial weight was 150 pounds. The facility's weight records showed resident #8 weighed 150 for (MONTH) (YEAR), 162 pounds for (MONTH) (YEAR), and 168 pounds for (MONTH) (YEAR). Resident #8 had a weight gain of 18 pounds or 12% in 90 days. During a record review, the initial dietary assessment, dated 4/22/16, showed the dietician noted resident #8 was to receive a regular diet with no supplements, and her ideal body weight was 125 pounds. During a review of resident #8's care plan, dated 4/19/16, a nutritional care plan was not included in the care plan document. Resident #8's care plan did not address her 12% weight gain. During an interview on 7/21/16 at 7:15 a.m., staff member A said the facility had not notified resident #8's physician of her 18 pound weight gain. During an interview on 7/21/16 at 11:25 a.m., contracted staff member AA said the facility had not notified her of a 18 pound weight gain for resident #8. Contracted staff member AA said she would be doing a new dietary assessment for resident #8 to address her 18 pound weight gain. During an interview on 7/21/16 at 4:00 p.m., resident #8's physician said the facility had not notified him of resident #8's weight gain. During a review of nursing notes from 6/1/2016 to 7/20/16 showed the facility failed to contact the physician of resident #8's 12% weight gain. 3. Resident #12 had a weight gain of 9.4% in 3 months. Review of the facility's weight records for May, June, and (MONTH) showed resident #12 weighed 159 pounds for May, 165 pounds for June, and 174 pounds for July. This was a weight gain of 15 pounds or 9.4% in 90 days. During an interview on 7/21/16 at 7:15 a.m., staff members A, B, and C said resident #12 had terrible dietary habits. Staff member C said resident #12 drinks beer and eats cookies all day long and then cannot eat his meals. Staff member C said she had spoken repeatedly to resident #12 about this and resident #12 continued to do as he wanted. During an interview on 7/21/16 at 11:25 a.m., contracted staff member AA said the facility had not notified her of a 15 pound weight gain for resident #12. Contracted staff member AA said she was not aware of resident #12's consumption of beer and cookies to the extent of resident #12 weight increasing 15 pounds in 3 months. Contracted staff member said she would be doing a new dietary assessment for resident #12 to address his food preferences and his 15 pound weight gain. During dining observations on 7/19/16, 7/20/16, and 7/21/16, resident #12 was observed to be in the dining room for all meals. Resident #12 had an electric wheelchair and was not dependent on staff pushing him into the dining room. Resident #12 was observed to be sitting at a table for all meals served during those observation periods. Resident #12 was observed with food in front of him, and he appeared to be eating during those observation periods. During a record review, nursing notes from 6/1/16 to 7/20/16 showed the facility failed to contact resident #12's physician about the resident's 15 pound weight gain. Resident #12's record did not show any educational attempts were made by staff member C regarding his beer and cookie intake and it could affect his weight and health. Review of resident #12's nutritional care plan, dated 6/9/16, did not show resident #12 preferred to drink beer and eat cookies more than he preferred to eat food provided by the facility at meal times. The nutritional care did not address resident #12's weight gain of 15 pounds. 5. Resident #13 had a weight gain of 9.4% in 3 months. Review of the facility's weight records for May, June, and (MONTH) showed resident #12 weighed 127 pounds for May, 133 pounds for June, and 139 pounds for July. This was a weight gain of 12 pounds or 9.4% in 90 days. During an interview on 7/21/16 at 7:15 a.m., staff members A and B said resident #13 was not a big eater at the time of her admission. Staff member A said resident #13 needed assistance to eat and once nursing staff started to feed her, the resident started eating more. Staff member B said resident #13's dietary intake had increased to such an extent that she would get mad if staff weren't feeding her fast enough. During a record review, nursing notes from 6/1/16 to 7/21/16 did not show the physician had been notified of resident #13's weight gain. During a review of resident #13's nutritional care plan, dated 4/27/16, showed the resident had impaired swallowing related to her dementia. The approach, dated 7/20/16 at 7:34 p.m., showed the resident was to sit at the assist table and my staff assists me to eat. I open my mouth and want more food as soon as I have swallowed my first bite. If I don't like something I will spit it out at my staff. The nutritional care plan did not address resident #13's weight gain of 12 pounds. During an interview on 7/20/16 at 11:25 a.m., staff C stated the only time she calculated weight loss or weight gain for was for reporting in Section K of the MDS (minimum data set). Staff member C stated she did not calculate weight loss or weight gain on a 30, 60, or 90 day basis. During an interview on 7/21/16 at 7:15 a.m., staff members A, B, and C stated the physicians, PA (physician assistant), and NP (nurse practitioner) were not provided with comparison weights for residents they were rounding on. Staff members A, B, and C acknowledged the medical providers would not know if a resident had a weight loss or weight gain unless a nursing staff member brought it to the provider's attention. Staff member A stated no physicians had been notified of weight loss or weight gain for any residents at the facility. During an interview on 7/21/16 at 10:50 a.m., contracted staff member AA stated she visits the facility once a month and meets with staff member C. Contracted staff member AA stated she and staff member C do dietary assessments, update diet plans, and address weight concerns together. Contracted staff member AA said she comes to the facility on a PRN basis when she is requested by the physicians or the facility. She said if the facility would have notified her of the weight losses and/or weight gains for residents #2, #4, #8, #12, and #13 she would have come to the facility and done new dietary assessments and addressed those weight concerns. Review of the facility's policy titled Weight Assessment and Intervention showed, 1. The nursing staff will measure resident weights on admission. Unless ordered by PCP (sic) to be more frequently, weights will be measured monthly thereafter. and 3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will notify the Dietician in writing. Verbal notification must be confirmed in writing. The analysis section of this policy showed 1. Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the: .",2020-09-01
674,WIBAUX COUNTY NURSING HOME,275079,712 WIBAUX ST S,WIBAUX,MT,59353,2016-07-22,441,F,0,1,CB4611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations and interviews, the facility failed to have an 1) Infection Control Program that investigated, controlled, and prevented infections in the facility. The facility was unable to show documentation of a record of incidents and corrective actions as related to infections in the facility. This deficiency has the potential to affect all residents in the facility. 2) The facility failed to assess, intervene, and protect the facility's residents from communicable diseases for 1 (#1) or 14 sampled and supplemental residents. 3)The facility failed to maintain a sanitary environment free from airborne contamination from the soiled laundry area. Specifically, the facility failed to maintain negative air pressure in the soiled laundry area. This had the potential to affect all facility residents with a census of 32 residents at the time of survey. Findings include: 1. During an interview on 7/20/16 at 11:45 a.m., staff member A said she had held the infection control position during the last year and was presently training another person for the position. When asked what items were being monitored by infection control, staff member A explained the nurses were expected to provide information in the stand-up morning conferences about resident infections and antibiotic orders. She said she was able to monitor antibiotic use through the computer via medication records and nursing progress notes. Documentation of the infection control investigations were requested. The requested information had not been provided before the survey was completed. A copy of the facility's annual infection report was requested, staff member A stated there was none. She stated she used to do infection mapping but had not done it for awhile. When asked for copies of forms used for infection control, the facility provided 2 empty forms labeled Infection Report, with a date of 11/2010, and A Line Listing of Infections by Elder Care Consulting, Inc. The DON stated the latter form was meant to convey infection information to the facility's QAPI committee. When asked for documentation of any QAPI committee response to infection control information, the DON stated that there was no paperwork done for this. No completed documentation forms were seen by the survey team. A record review of the facility's Infection Control Isolation Precautions, revised (MONTH) 2012, showed, Standard Precautions shall be used when caring for residents at all times regardless of their suspected or confirmed infection status. Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. Under Contact Precautions in this same record it showed, In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. The decision on whether precautions are necessary will be evaluated on a case by case basis. Infections with multi-drug resistant organisms are included in the list of examples of infections requiring Contact Precautions. 2. Resident #1 was admitted to the facility on [DATE]. During a record review, nursing notes showed resident #1 had open diabetic wounds to her right and left feet. A record review of lab results, dated 7/16/16, of a culture and gram stain of resident #1's left heel wound as sent to the facility by the community clinic, showed that the culture had grown 3 plus Methicillin Resistant Staphylococcus aureus. The document showed that it had been sent to the facility from the clinic on 7/19/16 at 10:23 p.m. A review of physician orders [REDACTED].#1 was ordered to receive [MEDICATION NAME] 100 mg BID x 3 weeks on 7/18/16. Prior to this, resident #1 had been ordered on [DATE] to receive Keflex 500 mg BID x 7 days for infection. In an interview on 7/20/16 at 8:05 a.m., Staff member K was asked if resident #1 was on isolation precautions. She said that she did not think she was on any precautions other than universal precautions. She stated she was aware that resident #1's heel ulcer had cultured positive for MRS[NAME] She stated the nurses did not usually make the decision to place a resident on transmission-based precautions, but they were usually told by the DON/administrator whether or not to institute contact isolation precautions. During an interview on 7/21/16 at 6:10 p.m., Staff member B was asked to show infection control documentation regarding isolation policy decisions made for residents. She was unable to provide any at that time. When asked specifically for documentation of whether or not Resident #1 had been placed on contact isolation she did not answer. She said that she had spoken in conversation with the facility's DON/administrator about the potential need for isolation, but that there had not been any formal decision made. She said that normally they did not hold meetings for infection control or record decisions made. Nurses were told verbally of isolation needs by the DON of the facility. During this interview, staff member B was requested to provide any evidence of infection investigation or surveillance activity to prevent infection spread. Staff member B said she would look for it and provide it if found. None was received. In an interview on 7/21/16 at 12:40 p.m., staff member L was asked if resident #1 was on isolation precautions. Staff member L said she had heard by word of mouth that resident #1 had a positive MRSA wound culture. She did not know if the resident had been placed on contact isolation precautions and said there was a question as to whether precautions were needed since the resident's wounds were covered with dressings. She stated she had obtained a disposable gown and gloves and used them for the resident's wound dressing change and had double bagged the dirty dressing and taken it to the garbage room for maintenance to dispose of. Staff member L asked the surveyor whether the resident's room should have a sign on the door regarding MRS[NAME] On 7/22/16 at 8:15 a.m., a survey record request form that had requested any paperwork to document the infection control program was returned to the surveyors by the facility DON/administrator with the words Don't Have written next to the request. 2. During an interview on 7/20/16 at 7:30 a.m., staff member J stated she always wears a gown when she sorts laundry. She pointed to the gown hanging in the soiled laundry area. During an observation on 7/21/16 at 8:30 a.m., staff member J was observed sorting laundry in the soiled laundry area. The door into the clean laundry area was propped open and a breeze was blowing from the clean area, through the soiled area and out into the hallway. The washing machine was immediately inside the clean area. Staff member J was not wearing a gown, but was wearing gloves. Some items of personal clothing had been thrown on the floor beneath the sink. Staff member J picked them up off the floor and threw them into a sorting bin. Staff member J stated she was going out into the facility to collect more laundry. She removed her gloves and tossed them into the trash, and then removed a clean pair and placed them onto her hands. Upon returning to the soiled laundry area, staff member J opened the laundry bin and pulled out soiled laundry, while a breeze blew from the clean area, through the soiled area and into the hallway. During an interview on 7/21/16 at 8:45 a.m., staff member J stated she always wears a gown, but had not today because it was so hot. Staff member J said she did not like to wash her hands between glove changes because it was difficult to put gloves on wet hands. A review of the policy for Laundry and Bedding, Soiled, revised (MONTH) 2009, showed anyone who handles soiled laundry must wear protective gloves and other appropriate equipment (e.g., gowns if soiling of clothes is likely).",2020-09-01
675,WIBAUX COUNTY NURSING HOME,275079,712 WIBAUX ST S,WIBAUX,MT,59353,2016-07-22,498,E,0,1,CB4611,"Based on observation, interview, and record review, the facility failed to ensure all certified nursing assistants were trained to assist residents with eating for 1 (#2) of 10 sampled residents, and maintaining an appropriate supply of oxygen for 1 (#11) of 14 sampled and supplemental residents. Findings include: 1. During an observation on 7/19/16 at 7:30 a.m., resident #11 was observed in the dining room. She was sitting in a wheelchair with an oxygen bottle behind her, and she had a nasal cannula below her nostrils. Resident #11's oxygen bottle gauge was observed. The gauge needle was resting on the peg in the red section of the gauge indicating the oxygen tank was empty. Resident #11 was eating breakfast. During an observation on 7/19/16 at 8:10 a.m., resident #11 had completed her breakfast. The resident still had a nasal cannula below her nostrils. Resident #11 still had the oxygen bottle behind her and the gauge needle was resting on the peg in the red section of the gauge. During an interview on 7/19/16 at 8:12 a.m., staff member Q said resident #11's oxygen bottle was empty of oxygen and should be replaced. Staff member Q pushed resident #11 out of the dining room, and to a door where the facility stored the portable oxygen bottles. Resident #11's oxygen bottle was replaced. Staff member Q said CNA staff replace oxygen bottles as needed. Staff member Q said there was no schedule to check and replace oxygen bottles. Staff member Q said, I check oxygen bottle gauges for levels when I think about it or every couple of hours. A record review showed the facility had failed to do an annual evaluation for staff member Q to evaluate her effectiveness at performing her assigned job duties. The record review also showed the facility failed to ensure staff member Q was proficient in performing all CNA skills due to lack of a CNA skills assessment being done for staff member Q. During an observation on 7/20/16 at 10:20 a.m., resident #11's was in the dining room. Her oxygen bottle was observed to be empty. The gauge showed the needle was resting on the peg in the red section of the gauge showing it was empty. During an observation on 7/20/16 at 10:50 a.m., resident #11 was still seated in the dining room. Her oxygen bottle was observed to be empty. During an observation on 7/20/16 at 11:00 a.m., resident #11 left the dining room and was going down the hallway to her room. Staff member P stopped resident #11 and viewed the gauge on resident #11's oxygen bottle. Staff member P told the resident her bottle was empty and needed to be changed. Staff member P pushed resident #11 into her room and closed the door into the hallway. Staff member P did not enter the resident's room. As staff member P was closing the door she said to resident #11, I'll be back in 10 minutes to get you. Staff member P left resident #11 unattended. During an interview on 7/20/16 at 11:05 a.m., resident #11 said she had needed to go to the bathroom. Resident #11 continued talking but said she was short of breath. Resident #11 continued to talk until staff member P opened the hallway door to resident #11's room. During an observation on 7/20/16 at 11:20 a.m., staff member P changed resident #11's oxygen bottle. During an interview on 7/20/16 at 11:23 a.m., staff member P said she sets resident #11's oxygen gauge to 3 liters per minute. Staff member P said that was the second oxygen bottle resident #11 had received that day. Staff member P said she tried to check resident #11's oxygen bottle every couple of hours and if her gauge was in the red, it needed to be changed. A record review showed the facility had failed to do an annual evaluation for staff member P to evaluate her effectiveness at performing her assigned job duties. The record review also showed the facility failed to ensure staff member P was proficient in performing all CNA skills due to lack of a CNA skills assessment being done for staff member P. 2. During an observation on 7/20/16 at 8:15 a.m., resident #2 was observed in bed. The head of her bed was raised to a 45 degree angle. A bedside table had been placed 3 feet from the side of the resident's bed. On the bedside table was a kitchen tray with several glasses containing liquids, and a covered plate. Underneath the cover on the plate was a slice of quiche, a slice of toast, and a bowl of cereal. All items on the kitchen tray had remained untouched and the resident was asleep. No staff were in the room. At 8:19 a.m., staff member H entered resident #2's room. Staff member H walked up to resident #2's bedside and called the resident by name. Staff member H bent over resident #2, telling her it was time to wake up and eat some breakfast. Resident #2 did not respond physically or verbally to staff member H. Staff member H picked up an oral swab and proceeded to clean resident #2's mouth out. Resident #2 appeared to be sleeping. Staff member H asked the resident if she wanted a drink of juice. Resident #2 did not respond and still appeared to be sleeping. Staff member H picked a glass containing a liquid and held the glass to resident #2's lips. Staff member H removed the glass from the resident's mouth and wiped the resident's chin with a towel. Resident #2 made a Unh sound and staff member H placed the glass to the resident's mouth again. Staff member H again wiped the resident's chin with a towel. Staff member H asked the resident if she wanted a bite of quiche. Resident #2 did not respond physically or verbally. Resident #2's eyes were closed. Staff member H cut the quiche into 8 chunks and speared a chunk on the fork and placed the food in resident #2's mouth. Staff member H told resident #2 she needed to wake up and chew her food. Resident #2 did not respond to staff member H verbally or physically and her eyes remained closed. Staff member H then speared another piece of quiche with the fork and stood over the resident. During an interview on 7/20/16 at 8:25 a.m., staff member H said resident #2 spends all her time in bed, sleeping most of the time. Staff member H said the resident's food and fluid intake was very poor. A record review showed the facility had failed to do an annual evaluation for staff member H to evaluate her effectiveness at performing her assigned job duties. The record review also showed the facility failed to ensure staff member H was proficient in performing all CNA skills due to lack of a CNA skills assessment being done for staff member H.",2020-09-01
676,WIBAUX COUNTY NURSING HOME,275079,712 WIBAUX ST S,WIBAUX,MT,59353,2016-07-22,520,F,0,1,CB4611,"Based on interview and record review, the facility failed to maintain a viable quality assessment committee that met quarterly, and 75% of the time had no physician in attendance. This deficiency has the potential to affect all facility residents with a current census of 32 at the time of survey. Findings include: A review of attendance at Quality Assessment and Assurance Committee notes showed the following: *Meeting 8/3/15 - no physician present *Meeting 9/30/15 - no physician present *Meeting 1/21/16 - physician present *Meeting 4/21/16 - no physician present During an interview on 7/19/16 at 7:15 a.m., staff member A stated the Quality Assessment and Assurance Committee meets quarterly, and that the medical director is part of the committee but has been unable to attend recently. During an interview on 7/20/16 at 11:45 a.m., staff member A was asked what items were being monitored by infection control. Staff Member A explained she was able to monitor antibiotic use through the computer via medication records and nursing progress notes. When asked for documentation of infection control investigations she did not provide them. When asked for a copy of the facility's annual infection report, she stated there was none. She stated she used to do infection mapping but had not done it for awhile. When asked for copies of forms used for infection control, the facility provided 2 empty forms labeled Infection Report, with a date of 11/2010, and A Line Listing of Infections by Elder Care Consulting, Inc. The DON stated the latter form was meant to convey infection information to the facility's QAPI committee. When asked for documentation of any QAPI committee response to infection control information the DON stated that there was no paperwork done for this. No completed documentation forms were seen by the survey team. During an interview on 7/21/16 at 7:15 a.m., staff member A said the facility did not have a committee formed that would review, monitor, and trend, weight loss or gain concerns for the residents.",2020-09-01
677,WIBAUX COUNTY NURSING HOME,275079,712 WIBAUX ST S,WIBAUX,MT,59353,2017-09-13,154,D,0,1,13A511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to inform a resident or family member of the risks and benefits of [MEDICAL CONDITION] medications used for 1 (#8) of 10 sampled residents. Findings include: Review of resident #8's Consent For Use Of [MEDICAL CONDITION] Medication, dated 3/20/17, showed the Power of Attorney had been informed of the risks and benefits of resident #8 receiving [MEDICATION NAME], 20 mg, every morning, and [MEDICATION NAME], 0.5 mg, every evening. Review of resident #8's Medication Administration Record, [REDACTED]. The (MONTH) (YEAR) medication administration did not show the resident was still receiving [MEDICATION NAME] or [MEDICATION NAME]. During an interview on 9/13/17 at 4:15 p.m., staff member A said the Consent For Use Of [MEDICAL CONDITION] Medication form did not match the [MEDICAL CONDITION] medications resident #8 was currently receiving. Staff member A said the form needed to be updated when [MEDICAL CONDITION] medications were changed for a resident.",2020-09-01
678,WIBAUX COUNTY NURSING HOME,275079,712 WIBAUX ST S,WIBAUX,MT,59353,2017-09-13,323,D,0,1,13A511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to lock wheelchair brakes during the transfer of 2 (#s 6 and 9) of 10 sampled residents. Findings include: 1. Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #6's Annual MDS, with an ARD of 9/26/16, showed the resident was non-verbal. She was rarely or never understood by others, and was rarely or never able to understand others. She required extensive, total assistance, with activities of daily living, and required the use of a Hoyer lift during transfers. The resident's primary mode of transportation was a wheelchair. During an observation on 9/12/17 at 10:30 a.m., staff members G and H transferred resident #6 to her wheelchair, using the Hoyer lift. The brakes on the resident's wheelchair were not locked when this occurred. During an interview on 9/12/17 at 10:50 a.m., staff member G stated the wheelchair brakes did not necessarily need to be locked if two staff members were in attendance. During an interview on 9/12/17 at 1:10 p.m., staff member H stated the wheelchair brakes should have been locked during the transfer of resident #6. 2. Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #9's Admission MDS, with an ARD of 8/24/17, showed the resident required extensive, two-person assistance, with transfers. Her primary mode of transportation was a wheelchair, which she could self-propel, with her feet. During an observation and interview on 9/13/17 at 9:45 a.m., staff members H and I assisted the resident from her wheelchair to a standing-scale in the resident's room. The wheelchair brakes were not locked, and the wheelchair rolled away from the resident when she stood up. At 9:50 a.m., staff members H and I assisted the resident back to her wheelchair. The brakes were not locked. As the resident sat on the wheelchair, it rolled several inches backwards from the momentum. Staff member I stated the wheelchair brakes should have been locked before, and after, the resident was assisted from the wheelchair. During an interview on 9/13/17 at 10:00 a.m., staff member H stated the wheelchair brakes should have been locked when the resident was assisted to and from the wheelchair. During an interview and record review on 9/13/17 at 10:15 a.m., staff member A stated the facility did not have a policy for locking wheelchair brakes during the transfer of a resident. The staff member provided a Procedure Checklists, which is reviewed with each CNA staff member. A review of the facility's Procedure Checklist, read, Transferring a resident from bed to wheelchair .5 Locks wheelchair wheels (sic).",2020-09-01
679,WIBAUX COUNTY NURSING HOME,275079,712 WIBAUX ST S,WIBAUX,MT,59353,2017-09-13,353,E,0,1,13A511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed the ensure sufficient staff were present on the secure care unit for resident care and monitoring during mealtime, for 10 (#s 1, 2, 8, 11, 12, 13, 14, 15, 16, and 17) of 17 sampled and supplemental residents. Findings include: During an observation on 9/13/17 at 7:35 a.m., staff member J was in a resident room fixing a resident's hair. Resident #8 was calling out. Staff member J put the curling iron she was using away, walked to the dining area, and assisted resident #8 to her bathroom, which was in room [ROOM NUMBER]. No other staff were observed on the secure unit or in the dining area. During an observation on 9/13/17 at 12:10 p.m., residents 1, 2, 11, 12, 13, 14, 15, 16, and 17, all who resided on the secure care unit, were seated at tables in the dining area and eating lunch. No staff were observed in the dining area. Raised voices were heard coming from room # 206. Staff member J was observed in room [ROOM NUMBER] with resident #8. Resident #8 was in a shirt and a pull-up. Staff member J was trying to assist resident #8 in putting her pants on. Resident #8 continued to move around the room and call out. The observations continued, which included: - At 12:15 p.m., the residents were still eating the lunch meal, and unattended. Staff member J was with resident #8 attempting to get resident #8's pants on. - At 12:20 p.m., residents were continuing to eat the lunch meal. Resident #14 started yelling, and resident #16 told him to shut up. Staff member J was with resident #8, who was wandering up and down the hallway, calling out, and staff member J was still attempting to get resident #8 dressed in her pants. No staff were in the dining room offering assistance to resident #14 and #16, or monitoring others. - At 12:25 p.m., residents continued to eat the lunch meal, unmonitored. Staff member A was made aware of the situation, and the concern with the lack of staff monitoring during the meal. Staff member A was then observed in the dining area of the secure care unit. Staff member J was still attempting to get resident #8's pants on the resident at this time. During an interview on 9/13/17 at 7:40 a.m., staff member J said she was the only staff member working on the secure care unit. Staff member J said there was only one CNA scheduled to the secure care unit. During an interview on 9/13/17 at 3:30 p.m., staff member A said she thought having one staff on the secure care unit was enough. Staff member A said other staff from the main facility would check in on the secure care unit as often as they could, when the staff were not busy.",2020-09-01
680,WIBAUX COUNTY NURSING HOME,275079,712 WIBAUX ST S,WIBAUX,MT,59353,2017-09-13,431,E,0,1,13A511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to label and date opened multi-dose vials of insulin for 2 (#s 5 and 11) of 17 sampled and supplemental residents. This practice had the potential to affect all residents receiving insulin from the facility staff. Findings include: 1. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation and interview on 9/12/17 at 11:15 a.m., staff member C administered insulin to resident #5, and it was observed that the multi-dose vial of Novolog was not dated when opened. The vial was kept in the medication cart, and was inside the manufacturer's packaging box. An opened date, written on the box, read, 9/6/17. Staff member C stated the vial of insulin should have been labeled and dated when opened, not the box. The staff member labeled the vial with the opened date of 9/6/17. During an observation and interview on 9/12/17 at 3:45 p.m., a multi-dose vial of Lantus was observed to not be dated when opened. The vial was kept in the medication cart, and was inside the manufacturers packaging box. An opened date, written on the box, read, 8/22/17. Staff member B stated the opened vial of insulin should have been dated when opened. She stated the facility provided labels for when items were opened, so they could be dated, and one should have been put on the vials when they were opened. 2. Resident #11 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation and interview on 9/12/17 at 3:55 p.m., a multi-dose vial of Levemir was not dated when opened. The vial was kept in the medication cart, and was inside the manufacturer's packaging box. An opened date, written on the box, read, 9/6/17. Staff member D stated the opened vial of insulin should have been dated when opened. The staff member stated the manufactures packaged box sometimes got crushed, and were thrown away. She stated the vial itself, should have been labeled. During an interview on 9/12/17 at 4:57 p.m., staff members A and F stated the facility did not have a policy on dating insulin vials when opened. On 9/13/17 at 7:40 a.m., staff member A provided a copy of the facility's policy, Insulin Storage, Labeling, and Administration, dated 9/12/17. The policy read, 9. Insulin vials are to be labeled with a sticker indicating an open date and expiration date. Insulin boxes are to be labeled with an open dated and expiration date as well.",2020-09-01
681,APPLE REHAB COONEY,275080,2555 E BROADWAY,HELENA,MT,59601,2017-02-08,279,D,0,1,GYUD11,"Based on interview and record review, the facility failed to update the resident's care plan, after a Significant Change MDS was completed, and the resident had a change in ADL status, for 1 (#5) of 15 sampled residents Findings include: Resident #5 was admitted to the facility with dementia and depressive episodes. Review of the resident's Significant Change MDS, with an ARD of 12/7/16, section G, showed the resident needed the following ADL support: G0110A - Bed Mobility - 3 extensive assist G0110B - Transfers - 3 extensive assist G0110C - Walk in Room - 8 didn't occur G0110D - Walk in Corridor - 8 didn't occur G0110E - Locomotion on Unit - 4 total assist G0110F - Locomotion off Unit - 4 total assist G0110G - Dressing - 4 total assist G0110H - Eating - 1 supervision G0110I - Toilet Use - 4 total assist G0110J - Personal Hygiene - 1 supervision G0120 - Bathing - 3 extensive assist Review of the resident's care plan, with a target date of 12/6/16, showed resident #5 had the following interventions in place: 1. Staff to remain in bathroom with resident until she is finished, and maintain a line of site 2. Ensure there is an unobstructed path to the bathroom 3. Ensure disposable briefs are available at all times 4. Resident has a front wheeled walked for mobility, is independent in the use of her walker 5. Bed Mobility: Independent in bed mobility 6. Bathing: Requires Minimum assist x 1 with bathing 7. Oral Care: Independent with oral care 8. Personal Hygiene: Independent with personal hygiene 9. Dressing: Independent with dressing 10. Transfer: Independent with transfers 11. Toileting: Independent with toileting During an interview on 2/6/17 at 1:52 p.m., staff member F stated that resident #5's care plan showed the resident was independent in her cares, but the MDS showed many areas of total and extensive assist. Staff member F stated they were aware that the care plan should have been updated to reflect the actual care resident #5 needed. The facility failed to update resident #5's care plan as her ADL care needs increased.",2020-09-01
682,APPLE REHAB COONEY,275080,2555 E BROADWAY,HELENA,MT,59601,2017-02-08,280,D,0,1,GYUD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to update the resident's care plan after the Quarterly MDS assessment was completed, when the resident had a change in ADL status, for 1 (#6) of 15 sampled residents. Findings include: Resident #6 was admitted to the facility with dementia without behaviors, [MEDICAL CONDITION], and a fractured femur. Review of the resident's Quarterly MDS, with an ARD of 1/22/17, section G, showed the resident needed the following ADL support: G0110A - Bed Mobility - 3 extensive assist G0110B - Transfers - 4 total assist G0110C - Walk in Room - 8 didn't occur G0110D - Walk in Corridor - 8 didn't occur G0110E - Locomotion on Unit - 4 total assist G0110F - Locomotion off Unit - 4 total assist G0110G - Dressing - 4 total assist G0110H - Eating - 0 independent G0110I - Toilet Use - 4 total assist G0110J - Personal Hygiene - 4 total assist G0120 - Bathing - 4 total assist Review of the resident's care plan, with a target date of 11/21/14, showed resident #6 had the following interventions in place for her ADL's: 1. Bed mobility: Provide supervision 2. Encourage and assist resident to put on/take off bed clothes daily. Assist resident with applying and removing TED hose daily 3. Encourage the resident to participate in ADL cares to the fullest extent possible. Praise for tasks she completes independently 4. Personal Hygiene: Supervision 5. Resident prefers bathing during the day. Provide assistance of one for bathing 6. Toilet use: (MONTH) require assistance for toileting During an interview on 2/7/17 at 2:00 p.m., staff member C stated that there were two people in charge of updating the care plans. Staff member C stated they realized the care plans need to be updated more often, and acknowledged that resident #6's MDS assessment did not match the ADL section of the care plan. He stated, Our care plans are getting better, but I know they need still need some work. The facility failed to update resident #6's care plan as her ADL care needs increased.",2020-09-01
683,APPLE REHAB COONEY,275080,2555 E BROADWAY,HELENA,MT,59601,2019-05-22,658,G,1,0,T2P611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility nursing staff failed to ensure professional standards of practice were followed by not appropriately identifying a resident prior to medication administration for 2 (#s 1 and 5), which resulted in resident #1 being given the wrong medications, and nursing staff failed to accurately read the MAR for 1 (#2) of 5 sampled and supplemental residents, which resulted in resident #2 receiving an overdose of medication. Findings include: Identification of residents: 1. During an interview on 5/22/19 at 12:45 p.m., staff member B stated resident #1 received another resident's medication on 5/6/19. Staff member B stated staff member [NAME] was preparing medications for another resident, when resident #1 called and requested to have her medications. Staff member [NAME] had drawn up resident #1's medications earlier and had put them aside as resident #1 had not wanted them at that time. Staff member B stated staff member [NAME] grabbed the wrong medication cup and gave resident #1 the medications belonging to another resident. Resident #1 received [MEDICATION NAME] 40 mg and [MEDICATION NAME] 75 mg instead of her prescribed medications. Staff member B stated the resident was transferred to the hospital via ambulance for evaluation. Staff member [NAME] failed to ensure the right medications were administered to resident #1, which precipitated the transfer. During an interview on 5/22/19 at 3:30 p.m., staff member B stated the expectation for medication administration was for it to be done appropriately and safely. During an interview on 5/22/19 at 5:00 p.m., staff member B stated the protocol for medication pass was to observe the rights of medication administration. Review of resident #1's nurse's note dated 5/6/19 showed resident #1 was given another residents medication and was transported to the hospital via ambulance. The note showed the hospital informed the facility the resident had a previously documented reaction to oxy ([MEDICATION NAME]). Review of resident #1's Admission Record showed an allergy to [MEDICATION NAME]. 2. During an observation of medication pass, staff member D administered medications to resident #5. Staff member D had pre-poured the resident's medications. She grabbed the cup the medications were in and walked over and handed the medications to resident #5. Staff member D did not ask the resident her name or attempt to identify her in any other manner. During an interview on 5/22/19 at 8:45 a.m., staff member D stated the MARs have pictures to assist in identifying the residents. Staff member D stated if there was no picture she would ask the CNAs who the residents were. Staff member D stated she had only been working at the facility for one week. During an interview on 5/22/19 at 8:50 a.m., staff member C stated if a resident was coherent then she would ask them their name. Staff member C stated the MARs have pictures to help identify the residents. Reading the MAR: 3. During an interview on 5/22/19 at 12:40 p.m., staff member B stated resident #2 had received an extra 15 mg dose of [MEDICATION NAME], a sedative, on 12/28/18. Staff member B stated the resident was supposed to have 45 mg of [MEDICATION NAME] at bedtime, however the facility was out of 15 mg tablets. Staff member B stated resident #2 received two, 30 mg doses of [MEDICATION NAME]. Staff member B stated the night nurse did not accurately read the MAR indicated [REDACTED]. Review of resident #2's nurse's note, dated 12/29/18 at 4:30 a.m., showed resident #2 had a fall at 3:40 a.m., after the administration of the extra [MEDICATION NAME]. The note also showed the resident was very somnolent. Review of resident #2's nurse's note, dated 12/29/18 showed the nurse that worked the 6-10 shift the night prior had administered 30 mg of [MEDICATION NAME] to resident #2 at 9:00 p.m., and the night shift nurse had administered another 30 mg of [MEDICATION NAME] at 11:00 p.m. Review of the facility policy titled General Dose Preparation and Medication Administration showed the following: - .#3 Dose preparation 3.2 Facility staff should only prepare medications for one resident at a time . - .#4 Facility staff should: 4.1.1 Verify each time a medication is administered that it is the correct medication, at the correct dosage, at the correct route, at the correct date, at the correct time, for the correct resident. 4.1.2 Confirm that the MAR indicated [REDACTED]. - .#5 During medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: 5.1 Identify the resident per facility policy .",2020-09-01
684,APPLE REHAB COONEY,275080,2555 E BROADWAY,HELENA,MT,59601,2019-05-22,760,G,1,0,T2P611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for 2 (#s 1 and 2) of 4 sampled residents. Resident #1 was given the wrong medication and required transport to the hospital. Resident #2 was given an overdose of medication and sustained a fall following the incident. Findings include: 1. During an interview on 5/22/19 at 12:45 p.m., staff member B stated resident #1 received the wrong medications. Staff member B stated staff member [NAME] had drawn up medications for resident #1, however the resident had refused the medications at that time. Staff member [NAME] then began to draw up medications, [MEDICATION NAME] 40 mg and [MEDICATION NAME] 75 mg, for another resident when resident #1 called and stated she was ready for her medications. Staff member B stated staff member [NAME] grabbed the wrong medication cup and gave resident #1 medications belonging to another resident. Staff member B stated resident #1 was transferred from the facility to the hospital for evaluation following the incident. Staff member B stated she observed staff member [NAME] administering medications to other residents and there were no further incidents that night. Staff member B stated there was a staff meeting on 4/25/19 in which she discussed with nursing staff how to file a medication error report. Staff member B stated there was a staff meeting last Wednesday (5/15/19) in which she went over the rights of medication administration. There was no evidence of follow up on staff member E's competency with medication administration. Review of resident #1's nurse's note, dated 5/6/19 at 8:00 p.m., showed resident #1 received another resident's HS meds around 7:15 p.m. The resident had just left the facility via ambulance for monitoring at the ER. At 9:20 p.m., the facility received word from the hospital that resident #1 would be admitted for observation. The resident did not return to the facility. The nurse's note showed the ER nurse informed the facility the resident had a previously documented reaction to oxy ([MEDICATION NAME]), that being hallucinations. Review of resident #1's Admission Record showed an allergy to [MEDICATION NAME]. During an interview on 5/22/19 at 3:23 p.m., NF1 stated resident #1 had been transferred to the hospital because she received the wrong medications. NF1 stated the physician stated the resident received a very high dose of medication. During an interview on 5/22/19 at 3:30 p.m., staff member B stated it was the expectation that medication administration be done appropriately and safely. During an interview on 5/22/19 at 4:40 p.m., staff member C stated she received two days of orientation on the day shift and one day of orientation on the night shift. During an interview on 5/22/19 at 4:45 p.m., staff member D stated she received three days of orientation. During an interview on 5/22/19 at 5:00 p.m., staff member B stated the facility had just added medication errors to QAPI recently and had not started the monitoring yet. Staff member B stated the facility was implementing a checklist for safe medication administration but hadn't officially started them yet. Staff member B stated the protocol for medication pass was to observe the rights of medication administration. Staff member B stated nurses get three days of orientation on the floor. Staff member B stated the protocol for refused medications was to reapproach the resident, contact the physician, and waste the medications. The facility failed to have a system in place for monitoring nursing staff's competency with medication administration. 2. During an interview on 5/22/19 at 12:40 p.m., staff member B stated resident #2 had received an extra 15 mg of [MEDICATION NAME], a sedative, on 12/28/18. Staff member B stated the resident was to receive 45 mg, however had received 60 mg. Staff member B stated the nurse that worked the 6-10 shift had administered 30 mg of [MEDICATION NAME]. The resident was to receive 45 mg, however the facility did not have the 15 mg tablets available. Staff member B stated the nurse that worked the night shift came on at ten and administered another 30 mg of [MEDICATION NAME]. Staff member B stated the night nurse did not check to see whether the medication had already been given. Review of resident #2's nurse's note, dated 12/29/18 at 4:30 a.m., showed resident #2 fell while being assisted from wheel chair to recliner at 3:40 a.m. The note showed the resident had not received injuries and was very somnolent. The resident refused transport to the ED. Review of resident #2's nurse's note, dated 12/29/18 at 6:30 a.m., showed the night nurse stated resident #2 was given her [MEDICATION NAME], 30 mg, at 11:00 p.m. on 12/28/18. The 6-10 nurse happened to be at the nurse's station and stated resident #2 had received [MEDICATION NAME] 30 mg at 9:00 p.m. on 12/28/18. Nursing then instructed a CNA to get a full set of vital signs on resident #2. The residents blood glucose was 64 and required intervention. The resident's vital signs were as follows: -At 6:40 a.m., 88/62, 72, 18, 90%, 98.1 -At 8:00 a.m., 95/70, 78, 19, 94%, 97.8 -At 11:35 a.m., 116/82, 78, 19, 94%, 97.9 -At 3:00 p.m., 128/85, 86, 19, 95%, 98.0 During an interview on 5/22/19 at 8:45 a.m., staff member D stated the MARs had pictures of the residents and if there was no picture, she would ask the CNAs who the residents were. Staff member D stated she had only worked at the facility for one week. During an interview on 5/22/19 at 8:50 a.m., staff member C stated if the resident was coherent she would ask the resident to state their name and if not, there were pictures on the MARs to help identify the resident. Review of the facility policy titled, General Dose Preparation and Medication Administration, showed the following: - .#3 Dose preparation 3.2 Facility staff should only prepare medications for one resident at a time . - .#4 Facility staff should: 4.1.1 Verify each time a medication is administered that it is the correct medication, at the correct dosage, at the correct route, at the correct date, at the correct time, for the correct resident. 4.1.2 Confirm that the MAR indicated [REDACTED]. - .#5 During medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: 5.1 Identify the resident per facility policy .",2020-09-01
685,APPLE REHAB COONEY,275080,2555 E BROADWAY,HELENA,MT,59601,2018-05-31,580,D,1,1,1FL911,"> Based on interview and record review, the facility failed to notify the resident's physician and representative of a medication error which caused the resident to have red and blurry eyes, for 1 (#2); and failed to notify the physician and representative of two pressure ulcer areas which caused the resident discomfort, for 1 (#35) of 31 sampled residents. Finding include: 1. During an interview on 5/30/18 at 11:30 a.m., resident #2 stated she was given the wrong eye drops on Sunday 5/27/18. Resident #2 stated the nurse came in and put eye drops in her eyes that she thought were hers, until she looked at the color of the lid for the container. Resident #2 stated the lid to her eye drop container was colored purple and the lid on the eye drops the nurse used was green. Resident #2 stated she told the nurse it was the wrong drops. She stated the nurse looked at the eye drops and told her he would be right back but never returned. Resident #2 stated she rinsed her eyes with water after she received the wrong eye drops. She stated the next morning the whites of her eyes were red and her vision was blurry. Resident #2 stated she reported it to staff member A that morning. A review of the facility form titled Event Investigation Statement Form, showed resident #2 had reported to staff member A she received the wrong eye drops. The form showed staff member A called the pharmacist to report the side effects resident #2 reported. The pharmacist told staff member A redness of the eyes and blurred vision were not side effects of the medication. The form did not show that resident #2's physician or representative had been notified. During an interview on 5/31/18 at 3:47 p.m., staff member A stated he investigated the incident as far as he could, and then reported it to the DON. Staff member A stated he did not notify resident #2's physician or representative about the medication error. During an interview on 5/31/18 at 4:12 p.m., staff member B stated staff member A had documented the medication error on the wrong form. Staff member B stated staff member A should have documented the error on an IR (incident report) as it had instructions to call the resident's physician and representative. 2. During an interview on 5/29/18 at 1:14 p.m., resident #35's wife stated she was not notified by the facility of two pressure ulcers on the resident's coccyx. She stated she only found out about the skin change because the resident was complaining of discomfort on his bottom, so she looked, and was surprised to find two reddened areas on his bottom. Review of resident #35's Interdisciplinary Progress Notes, dated 5/13/18 showed, patient reports pain to buttocks, this nurse assessed area. Found 2 stage II non-blanchable areas size of nickel. Resident encouraged to reposition onto his side when in bed. (sic) During an interview on 5/30/18 at 8:03 a.m., staff member C stated a travel nurse had completed the skin assessment for resident #35 on 5/13/18. She stated the expectation was for all staff to notify the family and the provider of any skin changes, and that was not done for resident #35. During an interview on 5/30/18 at 8:30 a.m., staff member G stated it was the expectation of the nurses to notify the physician and the family of any changes in the resident's condition.",2020-09-01
686,APPLE REHAB COONEY,275080,2555 E BROADWAY,HELENA,MT,59601,2018-05-31,600,E,0,1,1FL911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect residents from a staff member who kissed resident's on the face, mouth, and forehead, but the residents lacked the cognitive ability to consent for the kissing by a staff member, for 3 (#s 30, 35, and 49) of 31 sampled residents. Findings include: During an interview on 5/30/18 at 3:31 p.m., staff member F stated she had witnessed staff member C kiss resident #s 30, 35, and 49, on the forehead, the cheek and at times on the lips. She stated staff member C would kiss residents almost everyday. The staff member stated she knew two of the residents were married and she believed their wives would not be comfortable with another individual kissing their husbands. She said she did not feel the actions of staff member C were appropriate or professional, especially for residents who could not cognitively give consent. During an interview on 5/30/18 at 3:40 p.m., staff member [NAME] stated she had witnessed staff member C kiss resident #s 30, 35, and 49 on the mouth, the cheek, and the forehead, on several different occasions, almost every day. She stated she did not feel this was appropriate for the staff member to kiss the residents since they had a cognitive deficit and could not communicate their consent. During an interview on 5/30/18 at 3:41 p.m., staff member B stated he did not have any concerns with staff members kissing the residents. He stated kissing or hugging a resident without their consent would be considered abuse, and should be reported and investigated. He said he had not been notified of such an incident by any of the staff. He said he had witnessed staff member C kiss resident #30 on the lips several weeks ago when the resident's family was there, and they seemed comfortable with the interaction. He stated he had not reported the incident or educated staff member C after that witnessed interaction. During an interview on 5/30/18 at 3:51 p.m., staff member C reviewed the different types of abuse and stated kissing a resident who lacked the cognitive ability to provide consent would be considered abuse. She stated, I may be the worst at it, and said she would kiss certain residents on their cheeks or lips, because, They like it, and they get upset if I don't give them a kiss. She stated she had kissed resident #s 30, 35, and 49, but felt they wanted the interaction. She said they would not be able to give her consent to kiss them because of their cognitive deficit. She stated she would not tolerate other staff to kiss the residents if the resident was not comfortable or was not cognitively intact to give consent of the interaction. She stated she knew resident #30's family was comfortable with her kissing the resident, but was not sure how the resident himself might feel about the interaction, because he was not able to express his own feelings. She stated she was not sure how the other residents or their families might feel about her kissing them either. 1. Review of resident #30's MDS, with an ARD of 4/13/18, showed the resident was severely cognitively impaired with a BIMS of 0. During an interview on 5/30/18 at 4:15 p.m., resident #30's family member stated they did not mind if staff member C kissed the resident. They stated they were not sure how the resident might feel about it, but felt he enjoyed the attention. 2. Review of resident #35's MDS, with an ARD of 4/17/18, showed the resident was severely cognitively impaired with a BIMS of 04. During an interview on 5/29/18 at 3:57 p.m., resident #35's wife stated she would not like it if the staff kissed her husband. She stated she was not aware if staff kissed her husband, but said she would not tolerate it. She stated she would put her foot down immediately if she witnessed it. 3. Review of resident #49's MDS, with an ARD of 4/28/18, showed the resident was severely cognitively impaired with a BIMS of 07. During an interview on 5/30/18 at 4:04 p.m., resident #49 stated she did not recall if a staff member had kissed her, but stated they would not dare, because I would pop them one. A review of the facility's policy and procedure titled, Abuse/Resident, showed, To ensure each resident is treated with kindness, [MEDICATION NAME] and in a dignified manner. To ensure any alleged abuse is thoroughly investigated and acted upon in accordance with all regulations and applicable laws .'Sexual abuse' includes but is not limited to, sexual harassment, sexual coercion, or sexual assault .III. Prevention: c. Identify, correct and intervene in situations in which abuse, neglect and /or misappropriation of resident property is more likely to occur .The supervision of staff to identify inappropriate behaviors and act accordingly. IV. Identification: a. Identify events, such as suspicious bruising of residents, occurrences, patterns and trends that may constitute abuse and respond accordingly. V/VI. Investigation/Protection: a. Anyone witnessing, and/or having knowledge of the abuse or mistreatment of [REDACTED]. f. the DNS or designee will immediately conduct an investigation upon submission of a report.",2020-09-01
687,APPLE REHAB COONEY,275080,2555 E BROADWAY,HELENA,MT,59601,2018-05-31,609,E,0,1,1FL911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure an environment in which staff feel safe to report alleged violations of abuse without fear of reprisal for 3 (#s 30, 35, and 49) of 31 sampled residents. Findings include: During an interview on 5/30/18 at 3:31 p.m., staff member F stated she had witnessed staff member C kiss resident #s 30, 35, and 49, on the forehead, the cheek and at times on the lips. She stated she had wanted to report the incidents immediately but was afraid of retaliation from staff members B, C and H. She stated she had been trained to report any concerns with abuse to her nurse manager or to staff member B. She stated she did eventually share her concern with staff member [NAME] and believed that the staff member had reported the incident. She stated after she reported the incidents to staff member E, she noticed staff member C was still kissing the residents. She stated after she realized nothing had changed, she thought she should tell staff member B, but was afraid of retaliation. She said she had called and reported the kissing to the ombudsman, but was told that was not my area and after that, she stated she did not feel anyone would listen to her concerns. During an interview on 5/30/18 at 3:40 p.m., staff member [NAME] stated she had witnessed staff member C kiss resident #s 30, 35, and 49 on the mouth, the cheek and the forehead. She also stated she had received a report of the same concern from another staff member. She stated she reported the incident to staff member B immediately after she witnessed it. She stated she was fearful of reporting, because she was afraid of retaliation from staff members B, C and H. She stated she had reported these incidents to staff member B several weeks back, and nothing was done. During an interview on 5/30/18 at 3:41 p.m., staff member B stated the staff were trained routinely, on how to report, when to report, and what to report. He stated he thought the staff were comfortable to report any incidents of alleged abuse, even if allegation was of staff to resident abuse. He stated he was not aware any staff were fearful of retribution if they reported allegation of abuse regarding another staff member. A review of the facility's policy and procedure titled, Abuse/Resident, showed, To ensure each resident is treated with kindness, [MEDICATION NAME] and in a dignified manner. To ensure any alleged abuse is thoroughly investigated and acted upon in accordance with all regulations and applicable laws .III. Prevention: a. Provide residents, families and staff on how and to whom they may report concerns, incidents and grievances without the fear of retribution. b. Provide feedback regarding the concerns that have been expressed. c. Identify, correct and intervene in situations in which abuse, neglect and /or misappropriation of resident property is more likely to occur .The supervision of staff to identify inappropriate behaviors and act accordingly .V/VI. Investigation/Protection: a. Anyone witnessing, and/or having knowledge of the abuse or mistreatment of [REDACTED]. f. the DNS or designee will immediately conduct an investigation upon submission of a report.",2020-09-01
688,APPLE REHAB COONEY,275080,2555 E BROADWAY,HELENA,MT,59601,2018-05-31,657,D,0,1,1FL911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to revise the care plan for pressure ulcers and use of a catheter for 1 (#12) of 31 sampled residents. Findings include: A review of Resident #12's medical record showed the resident re-entered the facility after a brief hospital stay on 3/12/18 with a Foley catheter. Review of the Discharge Instructions for Resident #12 showed the resident should be assisted to lay down in the afternoon to, .alleviate pressure on her coccyx from being up in the wheel chair during the day. a. During an interview on 5/29/18 at 12:55 p.m., resident #12 said she had a sore on her bottom which she thought was healing. Resident #12 was observed to have a pressure cushion in her wheel chair and a pressure mattress on her bed. Review of resident #12's IDT Progress Notes, dated 2/26/18, showed a nurse had found an open area on the left coccyx. A progress noted, dated 3/7/18, at 1:00 p.m., showed the left buttocks had a Stage II ulcer. During an observation on 5/30/18 at 4:25 p.m., resident #12 was in bed on her back waiting for the nurse to change her dressings on her buttocks, and then would get up in her wheel chair and go to the dining room for dinner. Resident #12 was also observed to have a Foley catheter. During an observation on 5/30/18 at 4:25 p.m., staff member G changed the dressing on resident #12's buttocks. Staff member G stated she was not able to stage the largest of the two pressure ulcers observed. Review of resident #12's physician progress notes [REDACTED]. Review of resident #12's TARs for March, April, and (MONTH) (YEAR), showed various treatments for the pressure ulcers, but did not show any discharge instructions on helping the resident to lay down in the afternoon to relieve pressure on her buttocks. Review of the facility's CNA - ADL Tracking Form for March, April, and (MONTH) (YEAR), did not show information for assisting the resident to lay down in the afternoon to help relieve pressure on her buttocks. Review of resident #12's Care Plan, with a date of 1/16/18, showed the care plan was reviewed and updated on 4/10/18, but it did not include a focus area of pressure ulcers or to assist the resident to lay down in the afternoon to help relieve the pressure on her buttocks. b. Review of resident #12's Hospitalist Discharge Summary, with a discharge date of [DATE], showed under the Physical Exam section, Foley catheter is in place draining clear yellow urine. Review of resident #12's Physician Orders, dated and signed 5/3/18, showed cath care Q shift with output - every shift everyday. It did not show an order for [REDACTED]. Review of resident #12's Care Plan dated 1/16/18, showed the care plan was reviewed and updated on 4/10/18, but did not show the resident had a catheter, and required catheter care and catheter changes.",2020-09-01
689,APPLE REHAB COONEY,275080,2555 E BROADWAY,HELENA,MT,59601,2018-05-31,660,D,1,1,1FL911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to ensure discharge plans were identified and updated regularly throughout a resident's stay, to ensure the resident was assisted with the identified needs and services upon discharge, and the information was reviewed with the resident and representative, for 1 (#33) of 31 sampled residents. Findings include: Resident #33 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation and interview on 4/29/18 at 8:42 a.m., resident #33 was in her room with her daughter. Resident #33 was hard of hearing and had difficulty communicating. Resident #33 was pleasant and calm sitting in her recliner. Resident #33's daughter stated she had no concerns with the care her mother received at the facility. She stated the only problem she had was not having any directions or help with getting things set up for her mother's discharge. She stated the facility had known from the beginning her mother was going home with her to Washington State. She stated her mother's insurance and Medicare people asked her if someone at the facility was helping her with her mother's discharge. She stated she told them she was doing everything she could to plan for a discharge which was planned for 5/22/18. She stated she was panicked that she would not have her home prepared because she was not told or assisted with knowing what to prepare for when the resident discharged . She stated she was working on setting up doctors, medical equipment, and transportation for her mother as she would be discharging soon. Resident #33's daughter stated she and her husband came to help her sister when her mother was hospitalized . Resident #33's daughter stated she had been at the facility daily since her mother was admitted . Resident #33's daughter stated she was supposed to be discharged on (MONTH) 22, but her therapy was continued to the end of the month. She stated her mother had reached her baseline and was ready to discharge. She stated they did not have anyone tell her what to expect for her mother's discharge. She stated she had been calling her mother's insurance company, Medicare, and different places, to get things set up such as trying to get a hospital bed. She stated they had one family meeting since her mother had been admitted . Resident #33's daughter stated the facility said her mother would be discharged this Thursday (5/31/18). She stated she was not aware that someone should have been helping her with all of the discharge planning. She stated today the physical therapist came in and talked with her and told her her mother had reached her goals and would be discharged . She stated she wasn't told how her mother would get her medications, but she had already arranged for doctors in Washington State to see her mother. She stated no one had helped her do any of the arrangements for physicians, therapists, home health, or equipment she would need for her mother when she got her home. During an interview on 5/31/18 at 9:55 a.m., staff member A stated he was not sure if resident #33 would discharge today. Staff member A stated he received a call from resident #33's daughter and she told him she had spoken with Medicare and was told her mother would qualify for another week of therapy. Staff member A stated he transferred the call to the social service director so resident #33's daughter could discuss therapy and discharge plans. During an interview on 5/31/18 at 10:31 a.m., resident #33's daughter stated she had not been given any discharge information for her mother yet. She stated she was getting her mom to Washington State on her own initiation. She stated when she called (staff member D) and told her that her mom got another week she said she knew about it. Resident #33's daughter stated staff member D had not told her that until she had the conversation with her. She stated she thought the staff was great, but did not feel like the management was helpful. She stated, If I wasn't self propelled I would have nothing set up waiting for the staff here to help me. Resident #33's daughter stated she would have loved to have had a discharge plan and help with getting everything organized. During an interview on 5/31/18 at 3:22 p.m., staff member D stated she started her current position approximately six months ago. She stated discharge planning usually started in the resident's first care conference. She stated in the care conference staff members listen to recommendations made from the therapy staff. She stated the staff discussed if the resident needed home health care and/or outpatient services. She stated she received the therapy recommendations and then a physician's order. She stated she then sends therapy notes and discharge orders to the home health agency the resident chooses. She stated if the resident needed medical equipment the therapy would set that up because they had to do a face to face assessment with the resident. She stated she had notified resident #33's daughter last week, around (MONTH) 23 or 24th, that her mother would be discharging. She stated she did not have documentation to show the discharge was an ongoing process from admission to discharge. She stated she did not have documentation to show how resident #33 was assisted with obtaining services and equipment for her discharge to another state. Staff member D stated she did not receive training and was not aware the discharge process required ongoing documentation in the medical record of treatment preferences, referrals to agencies or other entities, and an evaluation of discharge needs or the discharge plan. Staff member D stated an evaluation was not done and therefore was not discussed with resident #33 or her daughter. Review of the facility policy and procedure titled Discharge/Community showed the purpose was to provide the resident with a comprehensive discharge plan to ensure a smooth transition into the community. Listed under procedure was, 1. Initiate discharge planning on admission to the facility. 2. During the final week of the resident's stay, each interdisciplinary team member will provide a written summary of the resident's current status and needs. 3. Residents will be referred to the appropriate community agencies .",2020-09-01
690,APPLE REHAB COONEY,275080,2555 E BROADWAY,HELENA,MT,59601,2018-05-31,661,D,1,1,1FL911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to have a discharge summary in the medical record that included a post-discharge plan of care that was developed with the participation of the resident and their representative that included arrangements for the resident's follow-up care and post-discharge medical services, for 1 (#33) of 31 sampled residents. Findings include: Resident #33 was admitted to the facility with [DIAGNOSES REDACTED]. During an interview on 5/31/18 at 10:31 a.m., resident #33's daughter stated she had not been given any discharge information for her mother. She stated she was getting her mom to[NAME]on her own initiation. She stated when she called staff member D and told her that her mom got another week, staff member D told her she was aware of that also. Resident #33's daughter stated staff member D did not tell her of the extension of her mother's therapy. She stated she thought the staff was great but didn't feel like the management was helpful. She stated, If I wasn't self propelled I would have nothing set up if I would have waited for the staff here to help me. Resident #33's daughter stated she would have loved to have had a discharge plan and help with getting everything organized. During an interview on 5/31/18 at 3:22 p.m., staff member D stated she did not have a Discharge Summary that included a recapitulation of the resident's stay, a final summary of the resident's status, and a post-discharge plan of care that showed where the resident planned to reside and any arrangements that were made for the resident's follow-up care and post-discharge medical care and services. Staff member D stated she had notified resident #33's daughter last week, around (MONTH) 23rd or 24th, that her mother would be discharging. She stated she did not have documentation to support the discharge process. Staff member D stated an evaluation of the discharge plan was not done and therefore was not discussed with resident #33 or her daughter, prior to discharge. Review of the facility policy and procedure titled Discharge/Community showed the purpose was to provide the resident with a comprehensive discharge plan to ensure a smooth transition into the community. Listed under procedure was, . 2. During the final week of the resident's stay, each interdisciplinary team member will provide a written summary of the resident's current status and needs. 3. Residents will be referred to the appropriate community agencies .",2020-09-01
691,APPLE REHAB COONEY,275080,2555 E BROADWAY,HELENA,MT,59601,2018-05-31,690,D,0,1,1FL911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to thoroughly address the use of a catheter on admission and throughout the resident's stay, to include failing to obtain an adequate physician's orders [REDACTED].#12) of 31 sampled residents. Findings include: During an observation on 5/30/18 at 4:25 p.m., resident #12 was observed to have a Foley catheter. Review of resident #12's Hospitalist Discharge Summary, with a discharge date of [DATE], showed under the Physical Exam section, Foley catheter is in place draining clear yellow urine. Review of resident #12's Physician Orders, dated and signed 5/3/18, showed cath care Q shift with output - every shift everyday. The order did not show when the catheter was to be changed, or the reason why resident #12 had the catheter. Review of resident #12's TARs for March, April, and (MONTH) (YEAR), showed Foley cath care Q shift w/output. On the TAR for (MONTH) (YEAR) showed, cath changed 5/25/18, with no signature of who changed the catheter or the size of the catheter used. A review of resident #12's Resident Status/Update Report, dated 5/26/18, showed the catheter was changed on, .5/25/18 due to not knowing when it was changed last, and the resident was complaining. Review of resident #12's Care Plan, dated 1/16/18, showed the care plan was reviewed and updated on 4/10/18, but the plan did not show the resident had a catheter, required catheter care, or catheter changes. During an interview on 5/31/18 at 2:25 p.m., staff member K stated she was a [MEDICATION NAME]. She stated no one told her of the two residents who had catheters, but had seen them herself. Staff member K said she saw in the CNAs ADL sheets that she was to complete catheter care and write down how much output resident #12 had during her shift. During an interview on 5/31/18 at 2:30 p.m., staff member J said if she was there to work for a week, she would check the treatment sheets and/or medication sheets to see when the catheter was last changed and/or check the physician's orders [REDACTED].",2020-09-01
692,APPLE REHAB COONEY,275080,2555 E BROADWAY,HELENA,MT,59601,2018-05-31,868,C,0,1,1FL911,"Based on interview and record review, the facility failed to ensure the facility's Medical Director attended the QAPI meetings at least quarterly; and if unable to attend, to provide details and content of the meeting for the Medical Director to review and acknowledge, for the continued oversight of care and services and identification of deficient practices. This deficient practice had the potential to affect all residents receiving service from the facility or who were involved in QAPI activities. Findings include: Review of the facility's QAPI Meeting Attendance roster showed the Medical Director failed to attend a QAPI meeting on the following dates: 5/19/17, 6/15/17, 8/10/17, 10/5/17, 11/17/17, 12/21/17, 2/15/18, 4/26/18, and 5/24/18. A request was submitted to the facility for evidence relating to the Medical Director's acknowledgement of the QAPI meeting minutes when not in attendance, and if there were any concerns relating to the minutes reviewed. No further information was provided during the survey. During an interview on 5/31/18 at 3:51 p.m., staff member B stated the Medical Director was informed in advance of the QAPI meetings and was invited to every meeting. Staff member B stated the facility used to follow up with their Medical Director when she missed a meeting and would send her the meeting minutes for every QAPI meeting. He stated she used to send back acknowledgement of the information, but had not been sending a response back on recent meeting minutes. He stated when he followed up with the Medical Director, he was told she was not able to attend due to her busy schedule with delivering babies, and/or her clinic hours interfered with the meeting dates/times. He stated the facility had not explored other methods to encourage the Medical Director to attend a QAPI meeting quarterly.",2020-09-01
693,APPLE REHAB COONEY,275080,2555 E BROADWAY,HELENA,MT,59601,2018-05-31,880,D,0,1,1FL911,"Based on observation and interview, the facility staff failed to ensure gloves were changed between a dirty and clean ADL procedure for 1 (#9) out of 31 sampled residents. Findings include: During an observation and interview on 5/29/18 at 7:30 a.m., staff member K provided hygiene and incontinent care for resident #9. Staff member K washed her hands and applied gloves. Staff member K assisted resident #9 with incontinent care while she was in her bed. Staff member K had gloves on and was cleansing resident #9's perineal area. When staff member K was done, she continued to wear her contaminated gloves to log roll the resident and apply a clean brief while touching the resident's legs, socks, and clean pants. Staff member K then removed her gloves and washed her hands. Staff member K stated she should have removed her gloves after providing incontinent care and washed her hands before she continued to apply the clean brief, and the resident's clothing. Review of the facility policy and procedure titled Handwashing-Employees, showed staff are instructed to wash their hands after removal of their gloves.",2020-09-01
694,APPLE REHAB COONEY,275080,2555 E BROADWAY,HELENA,MT,59601,2018-05-31,883,E,0,1,1FL911,"Based on record review and interview, the facility failed to have a documented system for tracking residents that had or had not received the pneumococcal vaccine for 5 (#s 2, 9, 32, 33, and 110) out of 31 sampled residents. Findings include: During the infection control interview on 5/31/18 at 1:45 p.m., staff member I stated nursing staff checked the admission records from the transferring facility and/or physician records to establish if the resident was administered the pneumococcal vaccination prior to admission. Staff member I stated if the admission information did not show the resident received the vaccine staff would call the resident's primary physician and request the information. Review of the immunization records for resident #s 2, 9, 32, 33, and 110, failed to show documentation that the residents had received the pneumococcal vaccine, what type had been given, the consent for the vaccine, or education provided regarding the benefits and potential side effects of the vaccine. During an interview on 5/31/18 at 4:20 p.m., staff member I stated the facility would contact the resident's primary physician or clinic for the vaccine records. Staff member I stated the facility would submit the documentation the following day to the survey team. No further information was submitted prior to the end of the survey. Further information was received from the facility after the survey was finalized, which was from another clinic that showed resident #2, 9, 32, and 33 had received their pneumococcal 13 and 23 vaccine. No further information was submitted for resident #110. The individual medical records failed to show a method for tracking the influenza or pneumococcal vaccine. Review of the facility infection control Resident Health Guidelines showed, The major components of the immunization program include: .7. All vaccinations administered are documented on the Master Immunization Record.",2020-09-01
695,APPLE REHAB COONEY,275080,2555 E BROADWAY,HELENA,MT,59601,2017-07-14,309,E,1,0,JO6P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to show that the residents' medical records contained sufficient evidence of communication between the facility and the [MEDICAL TREATMENT] clinic in order to establish comprehensive plans of care that met the residents' acute and long term health goals, preferences and highest well being for 3 (#s 1, 2, and 3) of 3 residents who received [MEDICAL TREATMENT] treatments. The facility failed to ensure the medical records were complete with [MEDICAL TREATMENT] records including the pre/post [MEDICAL TREATMENT] assessments and treatment records, progress notes, plans of care, medications, and labs, for 3 (#s 1, 2, and 3) of 3 sampled residents who required hemo or peritoneal [MEDICAL TREATMENT] treatments. Findings include: 1. Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Review of the Daily Skilled Nurse's Notes showed the resident received CCPD every night. The cycler was set up by a family member at the facility. Review of the resident #1's closed medical record showed a lack of the following: - current peritoneal [MEDICAL TREATMENT] treatment records, - the pre and post [MEDICAL TREATMENT] assessments, - pertinent [MEDICAL TREATMENT] plan of care goals and interventions that were established by the [MEDICAL TREATMENT] clinic, - monthly physician notes, and - laboratory values pertinent to evaluate the resident's current condition and potential complications that may be caused by insufficient [MEDICAL TREATMENT]. During an interview on 7/14/17 at 6:40 a.m., staff member A stated he could obtain the [MEDICAL TREATMENT] documents from the [MEDICAL TREATMENT] center for the residents receiving [MEDICAL TREATMENT]. At 2:00 p.m., staff member A provided a stack of faxed papers that were sent to the facility from the [MEDICAL TREATMENT] center. The stack included resident #1's [MEDICAL TREATMENT] plan of care established by the [MEDICAL TREATMENT] clinic, a progress note, dated 3/11/17, from the [MEDICAL TREATMENT] physician, the 4/4/17 and 5/15/17 monthly [MEDICAL TREATMENT] progress notes from the [MEDICAL TREATMENT] physician, the 5/15/17 [MEDICAL TREATMENT] plan of care (the resident was in the facility between 3/24/17 and 4/20/17), [MEDICAL TREATMENT] monthly reviews for (MONTH) and (MONTH) (YEAR), [MEDICAL TREATMENT] cycler readings for (MONTH) and (MONTH) (YEAR), and the list of the [MEDICAL TREATMENT] medications for (MONTH) and (MONTH) (YEAR). The faxed documents lacked the resident's monthly [MEDICAL TREATMENT] lab results. Review of the faxed [MEDICAL TREATMENT] records showed the resident had [MEDICAL CONDITION] (may result in weakness and fatigue), blood in her stools, vaginal bleeding, gangrene of the left first toe, infections on the toes of her left foot, arthritic pain, [DIAGNOSES REDACTED] (may cause weakness), very low [MEDICATION NAME] (2.2 mg/dl on 3/23/17), blood [MEDICAL CONDITION], obstructive sleep apnea, UTIs, wounds with poor arterial circulation, and poor psychosocial health. Review of the 3/24/17 Interim Plan of Care reflected that the issues mentioned above were not considered in the LTC plan of care as challenges in the outcome of the resident's progress in her rehabilitation at the LTC facility. 2. Resident #2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the plan of care, dated 3/9/17, showed the resident was on [MEDICAL TREATMENT] due to [MEDICAL CONDITION] on Mondays, Wednesdays and Fridays. One care plan goal was being free from signs and symptoms of [MEDICAL TREATMENT] complications. Interventions included observations and reporting of the [MEDICAL CONDITION], heart and lung changes (assessed through the vitals) and [MEDICAL CONDITION]. Interventions also included obtaining labs. Review of the medical record reflected a lack of resident's pre and post [MEDICAL TREATMENT] and vitals assessments. The medical record contained one [MEDICAL TREATMENT] Communication with Long Term Care Center tool, dated 3/15/17. The form was filled out after [MEDICAL TREATMENT], which was at the bottom of the form. The top of the form was left blank. The tool lacked assessments of the resident before leaving for [MEDICAL TREATMENT]. The only weight records found in the medical records were on 1/15/17, 1/22/17, 1/29/17, 2/5/17, 2/12/17, 2/19/17 and 3/14/17. The tool, called Vital Signs, included only three dates for (YEAR) where the resident's vitals were assessed, which occurred on 6/15/17, 6/18/17 and 7/1/17. The resident's temperature, pulse and respirations were only assessed on 6/15/17 on this Vital Signs sheet. In (YEAR), the resident's vitals were assessed twice in (MONTH) and four times in November. The medical record lacked [MEDICAL TREATMENT] treatment sheets, monthly [MEDICAL TREATMENT] labs and the monthly [MEDICAL TREATMENT] physician's progress notes. By reviewing the medical record, one could not obtain knowledge of [MEDICAL TREATMENT] sufficiency, complications during treatments, or nutrient and fluid needs, for this resident. During an interview on 7/13/17 at 4:35 p.m., staff member N and the surveyor reviewed resident #2's MARs. The MARs included a stack of blank copies of the [MEDICAL TREATMENT] Communication with Long Term Care Center tool. When asked about this tool, staff member N stated the top portion of the form was to be filled out by the LTC nurse prior to [MEDICAL TREATMENT]. The resident then was given the form to take to the [MEDICAL TREATMENT] clinic. Staff member N said the [MEDICAL TREATMENT] clinic was supposed to fill out the bottom portion of the tool and send it back with the resident. Staff member N stated the [MEDICAL TREATMENT] clinic never sent them back. She said she would visualize the resident after treatments, but did not document the post [MEDICAL TREATMENT] observation. She stated the resident had breakthrough bleeding every now and then, but resident knew what to do. She stated when he had breakthrough bleeding it would bleed lots. Staff member N stated the resident also had access problems. Review of the LTC plan of care, dated 3/9/17, had a lack of interventions for potential post [MEDICAL TREATMENT] complications and what needed to be done by all the nursing staff in a case of an emergency. Review of the [MEDICAL TREATMENT] plan of care, dated (MONTH) (YEAR), reflected the resident's access site bled around the needle site, he had prolonged breakthrough bleeding post [MEDICAL TREATMENT], he had shortness of breath the night before [MEDICAL TREATMENT], the resident received oxygen during [MEDICAL TREATMENT], and he had [MEDICAL CONDITION]. He also did not have a pneumonia vaccination. These care concerns were not addressed in the LTC plan of care. During an interview on 7/13/17 at 4:25 p.m. staff member C stated she confirmed that the medical record lacked the documentation of resident #2's assessments before and after [MEDICAL TREATMENT], and the nursing entries for potential [MEDICAL TREATMENT] complications in the medical record. She stated she confirmed that the medical record lacked vitals assessments. 3. Resident #3 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident was discharged from the facility on 4/7/17. Review of the daily nursing entries reflected the resident received CCPD provided by a cycler every night. Review of the closed medical record showed a lack of the [MEDICAL TREATMENT] care plan, nightly peritoneal treatment sheets, including the pre and post [MEDICAL TREATMENT] vitals assessments and other pertinent [MEDICAL TREATMENT] plan of care goals and interventions, physician notes, and laboratory values pertinent to the sufficiency of peritoneal [MEDICAL TREATMENT]. During an interview on 7/14/17 on 10:33 a.m., staff member A stated he could obtain the [MEDICAL TREATMENT] documents from the [MEDICAL TREATMENT] center for the residents receiving [MEDICAL TREATMENT]. At 2:00 p.m., staff member A provided a stack of faxed papers containing resident #2's medical records at the [MEDICAL TREATMENT] clinic. The stack included resident's #3's 3/9/17 [MEDICAL TREATMENT] plan of care, monthly physician's progress note for (MONTH) (YEAR), H&P for the hospital admission on 3/20/17, and the list of his [MEDICAL TREATMENT] medications for (MONTH) (YEAR). The faxed documents lacked resident's monthly [MEDICAL TREATMENT] lab results and the monthly CCPD treatment readings. These documents were not part of the resident's medical record until 7/14/17; the resident was discharged from the LTC on 4/7/17. Review of the 3/9/17 [MEDICAL TREATMENT] plan of care reflected the resident was not able to manage his CCPD well, he had a hard time understanding his medication regimen, he was unable to manage his diabetes and weight, he was constipated, he had problems with uncontrolled hypertension and [MEDICAL CONDITION], and he had a detached retina causing vision issues. Review of the 3/28/17 LTC Interim Plan of Care lacked the issues identified by the [MEDICAL TREATMENT] plan of care.",2020-09-01
696,APPLE REHAB COONEY,275080,2555 E BROADWAY,HELENA,MT,59601,2017-07-14,314,E,1,0,JO6P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to assess, monitor, and document skin breakdowns for 3 (#s 1, 6, and 7) of 7 sampled residents. The facility failed to ensure that a new protocol was established with new management arrangements ensuring the current clinical standards of practice in skin management and treatment in order to accurately monitor the healing process and prevent further skin issues; all staff, including the contracted temporary staff, were educated with the newly established skin management and treatment protocol; and finally the facility failed to ensure all skin issues were identified, assessed and documented in the medical records of the residents in a timely manner by the appropriate staff.Findings include: 1. Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Review of the 3/24/17 initial Nursing Assessment, under the title Bowel Function/Habits, showed the resident was wearing briefs, had redness and excoriation to her sacrum/coccyx, and she had open areas on her left buttock. The answers to the Skin Questions on the assessment showed the resident was status [REDACTED]. Review of the Interdisciplinary Progress notes, dated 3/24/17, also showed the resident had red and excoriated sacrum and coccyx. The note also showed the left buttock had open areas and was tender. The resident also had black areas to the left foot's 1st, 2nd, 3rd and 5th toes. Neither nursing assessment document was complete as to the stage, size, and appearance of the open areas on the left buttock including undermining, depth, drainage, and status of wounds' tissue. Review of the telephone orders showed the physician ordered skin prep to the buttocks and coccyx for excoriation, and Alevyn dressing to the left buttock on 4/5/17 reflecting the resident still had open areas. The medical record lacked a nursing assessment of the skin condition on 4/5/17. Review of the complete closed medical record did not reflect the site, stage, size, appearance of the open areas on the left buttock including undermining, depth, drainage, and status of wounds' tissue on a weekly basis by an RN. The medical record did not reflect the use of a PUSH tool or other standardized validated tool to assess pressure wound healing, and type of skin wound. The resident's MD did not assess the resident's wounds or identify the type of the wounds. The medical record did not reflect that the staff educated the resident of the risks associated with being a high risk for pressure wounds, and being compliant with repositioning. The medical record did not reflect when the resident was noncompliant with repositioning, and if the staff notified the physician when the resident was noncompliant with repositioning. The medical record did not reflect a consistent assessment and the plan for reporting to the physician related to the development and worsening of pressure wounds for this resident. 2. Resident #6 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the 5/4/17 Interdisciplinary Progress Notes showed the resident developed an open area, measuring approximately a quarter size on her right buttock. The LPN who wrote the entry did not assess the wound as to type, stage, and appearance, including undermining, depth, drainage and notification of the nurse manager for further assessments. The LPN notified the physician. The resident's Braden scale score was 20 in (MONTH) (YEAR), reflecting the resident was at high risk for developing pressure wounds. During an interview on 7/14/17 at 9:30 a.m., staff member A and C were asked to provide the weekly skin assessments completed by the CNAs during baths once a week. A set of Skin Care Alert slips were provided. The Skin Care Alerts showed the CNAs' documentation of the skin concerns on 5/10, 5/18, 5/23, 5/31, 6/6, 6/14 and 6/20/17 where the entries showed the resident had a small red area. The Skin Care Alerts for 5/10, 5/18, 5/23 and 5/31/17 showed the red area was one inch by one inch with no drainage. The medical record of the resident lacked the corresponding nursing assessments to these weekly Skin Care Alerts. On 5/5/17, the resident was placed on hospice. The resident's medical record did not contain any further skin assessments. Review of resident #6's 3/9/17 plan of care showed the skin issues to be referred to the skin nurse for review. 3. Resident #7 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the initial nursing assessment and progress notes, completed on 6/14/17, showed the resident had three Stage II wounds, one on the coccyx, one on the left inner leg, and one on the right hip. The only other progress note to mention the open areas was dated 7/12/17 and reflected the open areas had dressings on them. The entry also reflected the coccyx was slowly healing. The medical record lacked the weekly assessment of the wounds as to site, type, size, and appearance including, undermining, depth, drainage of the tissues involved and notification of the nurse manager for further assessments. The resident's wounds were not assessed and documented by the RN on a weekly basis. During an interview on 7/14/17 at 11:15 a.m., staff member J stated weekly wound assessments were not done by him. He stated currently, they did not have a nurse manager who assessed the wounds. He said the CNAs and nurses worked well with good communication to heal the residents, but the documentation could be improved. When interviewed again at 11:58 a.m., staff member J stated the Skin Care Alert slips were implemented two weeks ago by the interim nurse manager. During an interview on 7/14/17 at 11:36 a.m., staff member K stated she was instructed by staff member B that staff member C would be taking on the skin assessments. Staff member K stated she would assess the wounds reported to her by the CNAs on the bath days, but staff member K would notify staff member B to look at the skin concerns. When interviewed again at 11:56 a.m., staff member K stated the Skin Care Alert slips were implemented two weeks ago by staff member B. During an interview on 7/14/17 at 9:29 a.m. staff member C stated the CNAs were marking the pink slips during the weekly bath days with potential skin issues. She stated these would be presented to the charge nurses for a complete skin assessment and documentation. During an interview on 7/14/17 at 9:32 a.m., staff member A stated nurses assessed the residents' wounds upon admission and then document the weekly assessments in the nursing progress notes in the medical record. Staff member A stated they lost both of their nurse managers. He stated now that staff member B was here, the systems were expected to be back in order. He stated staff member C was in training to become a nurse manager. During an interview on 7/14/17 at 12:19 p.m., staff member R stated she was a [MEDICATION NAME] CNA, and today was her first day. She stated she gave baths to three residents that morning. She stated she had never seen the Skin Care Alert slips before. She stated one resident had an open area and she notified the nurse verbally. During an interview on 7/14/17 at 12:40 p.m., staff member Q stated she had been employed at the facility for about six months. Staff member Q was able to show the location of the Skin Care Alert slips in one of the bath houses. She stated they have been using them since she had been working at the facility. She stated all bath rooms had the slips. During an interview on 7/14/17 at 12:50 p.m., staff member P stated she was a [MEDICATION NAME] CNA, and today was her last day. She stated she did not receive any training on skin assessment protocol on the residents' bath days. She stated she did not give any baths during her employment at the facility. Staff member P stated she provided personal care to a resident that morning, and reported the resident's skin issue to the charge nurse. She stated she never saw the Skin Care Alert slips before.",2020-09-01
697,APPLE REHAB COONEY,275080,2555 E BROADWAY,HELENA,MT,59601,2017-07-14,514,B,1,0,JO6P11,"> Based on record review and interview, the facility failed to ensure medical records were complete with dates for 4 (#s 2, 3, 5 and 6) of 7 sampled residents medical records. Findings include: A review of medical record documentation for resident #2, #3, #5, and #6, showed: 1. Resident #2's nursing entries in the Interdisciplinary Progress Notes were not dated with the year on the following dates: 4/6, 4/7, 4/8, and 4/9. 2. Resident #3's Interdisciplinary Discharge Summary reflected the resident's discharge date was not entered into the document. The resident was discharged from the facility on 4/7/17. 3. Resident #5's nursing entries in the Interdisciplinary Progress Notes were not dated with the year on the following dates: 5/22, 4/6, 4/3, and 3/24. The resident's Skin Care Alerts, dated 3/7, 3/14, 3/21, and 3/28, were not marked with the current year. 4. Resident #6's Interdisciplinary Progress Notes were not dated with the year on the following date: 5/4. The resident's Skin Care Alerts, dated 5/10, 5/18, 5/23, 5/31, 6/6, 6/14 and 6/20, were not marked with the current year. During an interview on 7/14/17 at 2:56 p.m., staff member C was shown the missing years from the Skin Care Alerts. Staff member C could not provide any additional information.",2020-09-01
698,APPLE REHAB COONEY,275080,2555 E BROADWAY,HELENA,MT,59601,2019-07-26,584,E,1,1,2FG311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, the facility failed to maintain comfortable temperatures in the long-term care section of the facility for 6 (#s 9, 11, 22, 26, 28, and 111) of 23 sampled and supplemental residents. Findings include: During an observation on 7/22/19 at 1:02 p.m., showed multiple oscillating fans were running in the four hallways of the long-term care section of the facility. There were two, 40-inch, industrial floor fans sitting to the side of the hallways on the 300 and 400 units. They were pointed down the hallways from the outside doors toward the center of the facility. During an interview on 7/22/19 at 1:10 p.m., resident #9 said the big fans were noisy. She said the staff would open the outside doors in the evening and turn on the big fans to pull cool air into the building. During an interview on 7/22/19 at 4:10 p.m., resident #111 said her room was hot and she would like a fan for her room. The resident said she had problems sleeping at night because the room was hot and stuffy. During an interview on 7/22/19 at 4:17 p.m., resident #26 said her room was too hot. During an observation on 7/22/19 at 4:25 p.m., staff member A walked through the double doors between the long-term care unit and the rehabilitation unit. After passing through the doors, staff member A commented how much cooler it was on the rehabilitation unit. During an interview on 7/22/19 at 4:30 p.m., NF1 said a few of the residents had complained to her about the facility being too hot. NF1 said she had noticed a lot of residents sitting in the center area by the fans. During an interview on 7/23/19 at 7:57 a.m., resident #29 said her room was too hot. The resident said she had problems sleeping at night because the room was hot and stuffy. Resident #29 said she had asked her son to bring her a small fan to use in her room. During an interview on 7/23/19 at 10:35 a.m., staff member [NAME] said no resident rooms on the long-term care unit had air conditioning. The staff member said some residents like their rooms warm but many others did not. During an interview on 7/24/19 at 8:44 a.m., staff member D said some of the residents had complained about the building being hot. She said she did not go into resident rooms very often so she was not aware of how hot the resident rooms had gotten. Staff member D said, The facility had a bunch of big floor fans sitting in the circle the other day. Staff member D identified the circle as an area in front of the nursing station. During the group meeting on 7/24/19 at 10:00 a.m., resident #s 9, 22, and 38 said the facility had been very, very warm the last couple of weeks. Resident #22 said he spent quite a bit of time in his room watching television, and the last two weeks had been very hot in his room. During an observation on 7/25/19, the following temperatures were noted: - 7:36 a.m., 200 Hallway- 75.1, room [ROOM NUMBER]- 75.5, 200 Utility Room- 76.1, - 7:39 a.m., 100 Hallway- 78.2, room [ROOM NUMBER]- 78.2, room [ROOM NUMBER]- 77.1, room [ROOM NUMBER]- 77.4, room [ROOM NUMBER]- 77.1, Nutrition Room- 81.6, and Pharmacy- 80.8, - 7:44 a.m., 400 Hallway- 77.9, room [ROOM NUMBER]- 77.6, room [ROOM NUMBER]- 77.4, - 7:46 a.m., 300 Hallway- 75.8, room [ROOM NUMBER]- 75.4, room [ROOM NUMBER]- 78.8. - 1:42 p.m., 200 Hallway- 75.6, room [ROOM NUMBER]- 75.1, - 1:43 p.m., 100 Hallway- 77.9, room [ROOM NUMBER]- 78.3, room [ROOM NUMBER]- 79.8, room [ROOM NUMBER]- 77.2, room [ROOM NUMBER]- 76.8, Nutrition Room- 84.6, and Pharmacy- 79.3. The pharmacy had a tub of ice setting on the floor with a fan blowing on it. - 1:48 p.m., 400 Hallway- 77.8, room [ROOM NUMBER]- 76.9, room [ROOM NUMBER]- 76.1, - 1:49 p.m., 300 Hallway- 76.4, room [ROOM NUMBER]- 75.1, room [ROOM NUMBER]- 77.2. - 4:40 p.m., room [ROOM NUMBER]- 84.2 and resident #11 was in bed and was covered with a sheet. He had a damp towel on his forehead and 2 fans running. room [ROOM NUMBER]- 81.5, room [ROOM NUMBER]- 81.5, room [ROOM NUMBER]- 81.6, Nutrition Room- 85.4, - 4:47 p.m., 200 Hallway- 74.5, - 4:49 p.m., 400 Hallway- 78.9, room [ROOM NUMBER]- 78.9, room [ROOM NUMBER]- 79.3, - 4:52 p.m., Hallway 300- 80.3, room [ROOM NUMBER]- 77.9, room [ROOM NUMBER]- 80.9. During an interview on 7/25/19 at 4:55 p.m., staff member I said room [ROOM NUMBER] was probably the hottest room in the facility. He said the 100 wing tends to be the hottest wing in the building. Staff member I said, Maybe we need to do something about that. During an observation on 7/26/19 at 8:21 a.m., the 100 hallway temperature was 78.9, room [ROOM NUMBER]- 80.1, room [ROOM NUMBER]- 79.8, and room [ROOM NUMBER]- 80.4. During an observation and interview on 7/26/19 at 8:23 a.m., resident #11 said his room was boiling last night. The resident was set up with a sheet covering him. Attached to the foot of his bed was a fan. The bottom of the bedsheet was clipped to the fan, creating a tent over the resident. The fan was on, blowing under the sheet, and up toward the resident's face. The resident's room at the time of interview was 80.4 degrees. Resident #11 said his room was always hot. There were 3 fans running in the resident's room at the time of interview. During an interview on 7/26/19 at 10:11 a.m., staff member A said he was really not aware of any concerns about the temperatures inside the facility. Staff member A said the maintenance man was installing an air conditioning unit on the 100 wing at the time of the interview. Staff member A said there was a possibility the facility would be installing a window unit in room [ROOM NUMBER]. Staff member A said he would talk to resident #11 about it.",2020-09-01
699,APPLE REHAB COONEY,275080,2555 E BROADWAY,HELENA,MT,59601,2019-07-26,636,D,0,1,2FG311,"During observation, interview, and record review, it showed a comprehensive MDS assessment for 1 (#2) of 16 sampled residents was not completed in the required 14 day time frame. Findings include: During an observation and interview on 7/23/19 at 10:06 a.m., resident #2 was in his room with a nurse. Resident #2 was observed receiving a dressing change to his lower extremities. Resident #2 had multiple areas of broken skin, bruising, and dry skin on his upper and lower extremities. Resident #2 said he was taking an anticoagulant at that time. Review of resident #2's Admission MDS, with an ARD of 6/30/19, showed Section Z, Assessment Administration, was not completed and signed off, by the MDS Coordinator, until 7/6/19. During an interview on 7/25/19 at 10:45 a.m., staff member C said she did not complete Section Z of resident #2's MDS until the physical therapist had completed Section O and signed Section Z. Staff member C said resident #2's Admission MDS was not completed in the required 14 day time frame.",2020-09-01
700,APPLE REHAB COONEY,275080,2555 E BROADWAY,HELENA,MT,59601,2019-07-26,637,D,0,1,2FG311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to submit a significant change MDS for 1 (#28) of 16 sampled residents. Findings include: During an observation and interview on 7/23/19 at 8:10 a.m., resident #28 was in bed eating breakfast. Resident #28 said she had fallen over her walker in another facility and broken both her legs. The resident said she had also hurt her back. Resident #28 said she was on hospice. Review of resident #28's physician orders [REDACTED]. The resident's clinical record showed the resident had signed a hospice contract on 6/13/19. Review of resident #28's Admission MDS, with an ARD of 6/7/19, did not show the resident was receiving hospice benefits at that time. The facility had not completed a Significant Change MDS when resident #28 signed the hospice contract to receive hospice services. During an interview on 7/25/19 at 9:45 a.m., staff member C said she was not aware resident #28 was receiving hospice services. Staff member C said she would have to review her records before confirming a Significant Change MDS should have been done for the resident. She said she would do a late entry Significant Change MDS if it was indicated. During an interview on 7/25/19 at 10:38 a.m., staff member C said she had reviewed resident #28's clinical record, and her RAI manual with regards to the requirement for submission of a Significant Change MDS. Staff member C said her training information showed a significant change MDS should have been completed by 6/29/19 and submitted by 7/10/19. She said she would complete a significant change MDS and get it submitted right away. Staff member C said she did not know how she missed resident #28 and the start of her hospice services. Staff member C said the resident's condition had not changed since her admission, she had not gotten better or worse. Staff member C did not know what had prompted the physician to order a hospice consultation for this resident.",2020-09-01
701,APPLE REHAB COONEY,275080,2555 E BROADWAY,HELENA,MT,59601,2019-07-26,640,E,0,1,2FG311,"Based on interview and record review, the facility failed to ensure MDS assessments were submitted in the required 14 day time frame for 5 (#s 2, 3, 4, 7, and 8) of 23 sampled and supplemental residents. Findings include: 1. Review of Resident #2's Admission MDS, with an ARD of 6/30/19, showed it was not transmitted until 7/23/19. 2. Review of resident #3's Significant Change MDS, with an ARD of 6/14/19, showed it was not transmitted until 7/22/19. 3. Review of resident #4's Quarterly MDS, with an ARD of 6/19/19, showed it was not transmitted until 7/22/19. 4. Review of resident #7's Annual MDS, with an ARD of 6/17/19, showed it was not transmitted until 7/23/19. 5. Review of resident #8's Annual MDS, with an ARD of 6/16/19, showed it was not transmitted until 7/23/19. During an interview on 7/25/19 at 10:45 a.m., staff member B said staff member C had been in the hospital with a bowel obstruction. Staff member B said the facility did not have another registered nurse trained to sign off and transmit MDS assessments. Staff member C said she completed and transmitted the MDS assessments as soon as she returned to work.",2020-09-01
702,APPLE REHAB COONEY,275080,2555 E BROADWAY,HELENA,MT,59601,2019-07-26,761,F,0,1,2FG311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all expired stock medications were disposed of, and not available for resident use; failed to maintain record of safe storage for refrigerated medications by failing to maintain a record log of medication refrigerator temperatures; and failed to ensure stock medications and supplies were stored at the appropriate temperature to prevent damage or harm to the medications. This had the potential to affect all residents using stock medications and supplies. Findings include: During an observation and interview with staff member G and staff member H, in the facility's medication storage room, on 7/24/19 at 10:39 a.m., the following expired medications were found: - Readi Cat 2 [MEDICATION NAME] Oral Suspension 450 ml x 2, expiration date 11/18 - Acidophilus [MEDICATION NAME] capsules, expiration date 6/19 - Magnesium [MEDICATION NAME] 10 fl oz x 2, expiration date 6/19 - Gas-X Chewables 18 tablets, expiration date 7/18 - [MEDICATION NAME] Gel 3 fl oz., expiration date 10/15 - BioFreeze Professional 3 ml packets (1 box of 66 packets), expiration date 5/19 - 2 loose [MEDICATION NAME] Suppositories 25 mg in the bottom of the refrigerator - Assure Dose Control Solution bottles in box - Level 1 - Level 2, date opened 8/18/18 was written on box, expiration date 5/19. Medications found in the medication storage room that belonged to discharged residents included: - pill pack of 14 [MEDICATION NAME] 20 mg tablets - Liquid [MEDICATION NAME] 1000 mg bottle - Bag of 3 [MEDICATION NAME] Suppositories 650 mg - Bag of 5 [MEDICATION NAME] Suppositories 10 mg. - 4 boxes of [MEDICATION NAME] 100 units/ml, 3 ml in each prefilled pen, 5 in each box. During an observation and interview on 7/24/19 at 10:39 a.m., the temperature log on the outside door of the medication refrigerator in the medication storage room showed the last entry was completed on 7/22/19 (2 days prior). Staff member G stated the night shift was responsible for monitoring the medication refrigerator log. During an observation on 7/24/19 at 1:44 p.m., the temperature was noted to be 84.6 degrees in the medication storage room. Staff member H was also in the medication storage room at the time while medication expiration dates were being checked, and staff member H intermittently fanned the door open and closed to help reduce excessive heat in the room. During an interview on 7/24/19 at 2:00 p.m., staff member H stated when residents were discharged , the facility would receive orders to send the medications with the resident. Otherwise, the medications were destroyed in kitty litter, or in the bottle of Rx Destroyer located under the sink in the medication storage room. The medications checked on 7/24/19 at 10:39 a.m., showed this system was not followed. During an observation and interview on 7/24/19 at 2:05 p.m., stored on the middle shelf of a metal cart in the medication storage room, was a large clear plastic bag, of approximately 50+ filled and empty bottles of medications, for a resident in the facility. Staff member H stated the bag of medications belonged to a resident, and the facility was waiting for the family to pick up the medications. During an observation on 7/24/19 at 2:10 p.m., the temperature of the cabinet above the sink in the medication storage room was 83.6 degrees. During an observation on 7/24/19 at 2:35 p.m., in the medication storage room, the temperature of the medication cabinet above the refrigerator was 86.6 degrees, and the temperature of the medication cabinets above the sink were 86.3 degrees. During an observation and interview with staff member H in the medication storage room on 7/24/19 at 4:08 p.m., the following boxes of medications were found stored in the upper medication cabinets, to the left of the medication refrigerator: - Athletes Foot Creme - instructions on the box showed to store at controlled room temperature of 68 - 77 degrees fahrenheit. - [MEDICATION NAME] - instructions on the box showed to store at 68 - 77 degrees fahrenheit and protect from moisture. During an interview on 7/24/19 at 4:25 p.m., when asked about going into the medication storage room, and the temperature of the room, staff member K stated she goes into the medication storage room often during each of her shifts, and she stated it was always warm in there. During a phone interview with NF2 on 7/24/19 at 4:37 p.m., she stated the medication storage temperature had a recommended range of 60 to 77 degrees. Boxes of medications she checked at her pharmacy showed to store the medications at 68 to 77 degrees. When asked about the implications of storing medications at an elevated temperature, she stated it depended on the active ingredient; a creme may turn to a liquid or a salt may clump together. NF2 stated, for over the counter medications, it was more of an expiration date issue. During an interview on 7/25/19 at 7:32 a.m., staff member A stated there were no temperature logs maintained for air temperatures in the medication storage room, just temperatures for the medication refrigerator. During an observation of the medication cart in the rehabilitation dining room on 7/25/19 at 8:03 a.m., the following expired medications were found: - Vitamin C 250 mg 100 tablet bottle, expiration date 5/19 - Phos-Nak Powder Concentrate packets 0.05 OZ x 1, expiration date 1/19 - Phos-Nak Powder Concentrate packets 0.05 OZ x 93, expiration date 5/19. During an interview on 7/25/19 at 8:05 a.m., staff member H and staff member J stated medications that residents had brought into the facility at admission, were kept in the bottom drawer of the medication carts. The staff were trained to look for the residents' stock medications at the time of discharge to return to the family. During an observation of the medication cart on the 100 and 200 wings on 7/25/19 at 9:21 a.m., the following expired medications were found: - [MEDICATION NAME] Inhalation Solution 0.63 mg vials (opened box of 21 vials with expiration date of 3/19) - [MEDICATION NAME] 1 mg per vial with 1 vial sterile water, expiration date 11/18 - BioFreeze 3 ml packs x 12, expiration date 5/19 During a phone interview on 7/26/19 at 12:33 p.m., staff member L stated the pharmacy does not receive medications to destroy since Montana is a non-return state, meaning unused medications cannot be returned to the pharmacy. When asked if he had been involved with policies and procedures for the facility, staff member L stated he couldn't really answer that, he wasn't sure if the facility followed their procedures or pharmacy procedures. When asked about safe storage temperatures for medications, staff member L stated that it depended on the medication, but below 80 degrees should be okay, unless it needed to be refrigerated. When asked about damage to medications exposed to higher temperatures, staff member L stated it depended on the medication. When asked about medication regimen review, staff member L stated he reviewed all charts for appropriate medications on a monthly basis, but did not check temperatures of the medication storage areas in the facility, and was last onsite at the facility on (MONTH) 15th. Review of the facility policy, Discharge Planning, showed . 5. Obtain a physician order for [REDACTED].>Review of the facility policy, Expired or Discontinued Non-Controlled Medications, showed: .2. Licensed nursing staff should place all discontinued or out dated medications in a designated, secured location for destruction. 3. Licensed nursing staff should dispose of discontinued mediation, out-dated medications, or medications left in facility after a resident has been discharged in a timely fashion, or no more than 90 days of the date the medication was discontinued by Provider. 4. Licensed nursing staff should destroy non-controlled medications in the presence of another licensed staff member. Review of the facility policy, Storage and Expiration of Medications, Biologicals, Syringes and Needles, showed: .11. Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges. Facility staff should monitor the temperature of vaccines twice a day. 11.1 Room Temperature: 59 degrees to 77 degrees F or 15 to 25 degrees C 11.2 Refrigeration: 36 degrees to 46 degrees F or 2 to 8 degrees C 11.3 Freezing: -4 degrees to 14 degrees F or -20 to -10 degrees C",2020-09-01
703,APPLE REHAB COONEY,275080,2555 E BROADWAY,HELENA,MT,59601,2019-07-26,880,D,0,1,2FG311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the safe storage and maintenance of oxygen and nebulizer therapy supplies for 2 (#s 61 and 65) of 16 sampled residents, to prevent the spread of infections. Findings include: 1. During an observation on 7/23/19 at 10:11 a.m., no labeling was found on resident #61's O2 tubings connected to the oxygen concentrator, or the nebulizer equipment in the resident's room. Review of resident #61's clinical record [DIAGNOSES REDACTED]. During a record review on 7/26/19 at 8:00 a.m., no orders to change the O2 tubing or nebulizer equipment were found on the TAR or MAR of resident #61's medical record chart. 2. During an interview on 7/23/19 at 7:59 a.m., resident #65 stated that she was a former smoker and was recently hospitalized for [REDACTED]. Staff member G, who was in the resident's room at the time, was asked about nebulizer cleaning procedures. Staff member G stated she rinsed the nebulizer canister in water after use, and and then set the nebulizer canister out to dry anywhere. When asked about the nebulizer treatment facility policy, staff member G stated she kind of generally knew, but not sure if she's ever read it. During an observation on 7/23/19 at 8:07 a.m., resident #65's nebulizer face mask was observed wet and laying face down on the resident's bedside table, and the nebulizer canister was wet and positioned upright, also resting directly on the bedside table, without a protective layer underneath. During an observation on 7/23/19 at 4:43 p.m., no labeling was found on resident #65's O2 tubing connected to the nebulizer equipment located in the resident's room. During an interview on 7/25/19 at 2:16 p.m., staff member B and staff member H stated residents' O2 tubing and nebulizer tubing equipment was changed on a weekly basis, on Thursdays. During an interview and record review on 7/25/19 at 2:17 p.m., staff member J reviewed the MAR and TAR for resident #65 and stated no record for O2 tubing changes were on the resident's orders in the chart. When asked, staff member J stated that he rinsed the nebulizer canister in water and then turned it upside down to dry on a paper towel, after a resident had received a nebulizer treatment. Staff member J stated he may forget to clean the nebulizer equipment sometimes if he got busy. Staff member J stated he wasn't familiar with the facility policy regarding nebulizer treatment cleanings, that's just the way he does it. During an interview on 7/26/19 at 10:55 a.m., staff member D stated residents' O2 tubing was changed on Thursdays and the tubing should be labeled with the date on a piece of tape, but she was not sure where the label was placed on the O2 tubing. When asked about nebulizer equipment, she said it should be rinsed and dried after use. Review of the facility policy, dated 2/26/19, Oxygen Use, showed: .10. Change Cannulas every week. 11. Change Hand Held Nebulizer and nebulizer mask every week. 12. Change Cannula Tubing (that connects to cannula) every week. Review of facility policy, dated 2/26/19, Nebulizer Use, showed: - 11. Change Cannulas every week. - 12. Change Hand Held Nebulizer and nebulizer mask every week. - 13. Change Cannula Tubing (that connects to cannula) every week.",2020-09-01
704,APPLE REHAB COONEY,275080,2555 E BROADWAY,HELENA,MT,59601,2019-10-03,558,D,1,0,4A9F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, the facility failed to ensure the resident had his call light within reach for 1 (#2) of 7 sampled residents resulting in the resident not being able to activate his call light when he needed help. Findings include: During an observation and interview on 10/1/19 at 10:47 a.m., staff member B provided wound care to resident #2's [MEDICAL CONDITION] over his body and applied a dressing to his left elbow skin tear. Resident #2 was in bed laying on his back with the HOB elevated. Resident #2's call light was tied to the side rail and hanging with the button end out of his reach. Resident #2 had very limited range of motion to his upper extremities and stated he had chronic shoulder pain to both of his shoulders especially the right shoulder. During an interview on 10/2/19 at 8:30 a.m., NF4 stated she has found resident #2's call bell on the floor or tied to the rail where he can not reach it multiple times. She stated a lady that lived across the hall had helped him with his call light once. NF4 stated Last week on Tuesday his call button was tied to the rail and the actual button was hanging down too far for him to be able to reach. NF4 stated It is no use telling someone because there is no way to tell why it is on the floor. The call button is his lifeline. During an observation on 10/2/19 at 11:15 a.m., staff member K placed resident #2's call light in his hand, and he demonstrated he could push the button effectively. During an observation on 10/3/19 at 7:45 a.m., resident #2 was in bed laying on his back. The call light was clipped on the right side of the bed on the sheet. The call light hanging down off the side of the bed, with the button at the end, close to the bed frame. Resident #2 was not able to reach the call light to summon for help. Review of resident #2's care plan, with a last reviewed date of 7/2/19, showed resident #2 had limited physical mobility related to [MEDICAL CONDITION]. Interventions included he was totally dependent on staff for locomotion, transfers, positioning, eating, personal hygiene, and dressing. Under the focus area, Oxygen therapy related to [MEDICAL CONDITION], were listed interventions to provide reassurance and allay anxiety: Have an agreed-on method for the resident to call for assistance (e.g., call light, bell). Stay with the resident during episodes of respiratory distress. There were no other areas in resident #2's care plan that addressed how the call light needed to be made accessible to the resident. Review of the facility policy and procedure titled, Call System-Resident's Room, showed PURPOSE: To respond to resident's requests and needs. CLINICAL POLICIES: l . Each resident will have a call light within his/her reach in the room .",2020-09-01
705,APPLE REHAB COONEY,275080,2555 E BROADWAY,HELENA,MT,59601,2019-10-03,609,D,1,0,4A9F11,"> Based on interview and record review, the facility failed to report an abuse allegation that caused a resident to feel panicked to the State Survey Agency and appropriate authorities for 1 (#1) of 7 sampled residents. Findings include: During an interview on 10/1/19 at 7:55 a.m., resident #1 stated a woman had wrapped her legs in a bed sheet where she could not move resulting in feelings of panic. Resident #1 stated that after wrapping her legs with the sheets she overheard the nurse say, That will fix her. During an interview on 10/1/19 at 10:03 a.m., NF1 stated she was aware of an incident on the night of (MONTH) 24, 2019 after 10 p.m., where resident #1's legs were wrapped in bed sheets as an illegal restraint. NF1 stated she had met with staff member Q in regards to the incident where her mothers legs were wrapped making her unable to move. During an interview on 10/1/19 at 11:59 a.m., staff member A stated she was aware of an event where staff had tucked resident #1's legs under with a bed sheets, but the investigation revealed the resident was not immobilized. During an interview on 10/1/19 at 12:08 p.m., staff member Q stated he had spoke with resident #1's daughter about the incident and was not sure why it was not reported, but he did speak with the staff involved that denied that the wrapping resident #1's legs with sheets causing immobilization, and stating the comment of that will fix her had occurred. Review of resident #1's Complaint/Grievance report, dated 9/26/19, showed under findings, Legs were wrapped in sheets to prevent itching, not immobilization. No incident of the abuse allegation was reported to the State Survey Agency.",2020-09-01
706,APPLE REHAB COONEY,275080,2555 E BROADWAY,HELENA,MT,59601,2019-10-03,658,D,1,0,4A9F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to ensure a resident's wound care was performed as ordered to his left elbow for 1 (#2) of 7 sampled residents, placing the resident at risk for infection. Findings include: During an observation and interview, on 10/1/19 at 10:47 a.m., staff member B provided wound care to resident #2's [MEDICAL CONDITION] over his body and cleansed and applied a dressing to his left elbow skin tear. NF4 knocked and came into his room for a visit. NF4 reported a concern that resident #2's elbow had been an issue a few weeks before the current injury in the same place. NF4 stated the first time he had an injury to his left elbow the same bandage was left on his left elbow for nine days. NF4 stated she talked to staff member A about the dressing not being changed. NF4 stated staff member A told her she could not believe the dressing had been on that long and took care of it shortly after that conversation. NF4 stated the concern had occurred three to four weeks ago. Review of an Incident report for resident #2, dated 8/30/19, showed the resident had received an injury to his left elbow while rolling through doorway to room. Review of a fax, located in resident #2's medical record, dated 8/30/19, showed notification to the provider of the injury, and a request for wound care orders to clean area, apply triple antibiotic ointment, and cover with adhesive [MEDICATION NAME] every 3 days until healed. Located under the physician's comments showed yes, as noted above thanks. Review of resident #2's Treatment Administration Record, dated (MONTH) 2019, showed Wound care to left elbow-clean area, apply triple antibiotic ointment, & cover with adhesive [MEDICATION NAME] drsg. change every 3 days until healed. The dates of (MONTH) 30th and 31st contained a signature that showed it had been completed. Review of resident #2's Treatment Administration Record, dated (MONTH) 2019, showed no entry to continue the treatment to resident #2's left elbow wound which would have continued on (MONTH) 2nd or 3rd. During an interview on 10/3/19 at 2:45 p.m., staff member A stated the left elbow wound treatment must not have been carried over to the (MONTH) 2019 Treatment Administration Record. Staff member A stated the process to treat and monitor wounds was for the nurse to complete an incident report, and notify the provider. Staff member A stated if the provider ordered a treatment for [REDACTED]. Staff member A stated she and the nurse managers met weekly to discuss skin and wounds and their status and any issues. Staff member A stated the facility was currently in a process to add a new form to record and monitor skin issues to assist with tracking. Review of resident #2's medical record did not have other documentation to show that the left elbow wound had been treated as ordered after 8/31/19.",2020-09-01
707,FRIENDSHIP VILLA,275081,2300 WILSON,MILES CITY,MT,59301,2018-02-22,554,E,0,1,J30811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to ensure 3 (#s 5, 18, and 40) of 17 sampled and supplemental residents who had medications in their room was stored safely and securely, and failed to assess and obtain physician orders [REDACTED].#s 5 and 40) of 17 sampled and supplemental residents for self administration of medications. Findings include: 1. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation on 2/20/18 at 3:55 p.m., a bowl of halls cough drops was observed on the side table. Review of the resident #5's Self Medication Assessment form had Section 1 (Does the resident have the cognitive and functional abilities to self-administer medications? 1 - yes, 1a - no) 1a was marked which indicated the resident did not have the cognitive capability to self-administer medications. The form was signed by an RN and dated 4/21/17. 2. Resident #40 was admitted with [DIAGNOSES REDACTED]. During an observation on 2/20/18 at 4:26 p.m., a tube of Biofreeze was observed on the over bed table. Review of resident #40's Self Medication Assessment form was not completed. 3. Resident #18 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation on 2/20/18 at 3:45 p.m., a bottle of SAF Cleans Advanced Formula Saline spray was observed on resident #18's bedside table. Review of resident #18's Self Medication Assessment form section 2b (Resident has requested to self-administer medications) was marked no, which indicated resident #18 did not desire to self-administer his medications. During an interview on 2/21/18 at 10:30 a.m., staff member J stated the nursing staff is to fill out the self medication assessment, obtain a physician order [REDACTED]. Staff member J stated it did not appear that resident #40's assessment was completed. She stated she believed the policy was for the staff to reassess the resident every 3 months. Staff member J stated she was unable to find a physician order [REDACTED]. A review of the facility's Self Administration of Medications policy showed: .2. If the resident has expressed a desire to self administer, the interdisciplinary team will complete and (sic) assessment of the resident's cognitive, physical, and visual ability to carry out this responsibility . 4. If the resident is deemed capable to self-administer medications, then the drugs will be stored in a locked box in the resident's room, unless determined otherwise by the interdisciplinary team . 5. Nursing is to get an order from the physician for self-administration of medications . 7. Documentation of the ability to self-administer medications will appear on the resident's plan of care.",2020-09-01
708,FRIENDSHIP VILLA,275081,2300 WILSON,MILES CITY,MT,59301,2018-02-22,609,D,0,1,J30811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to report and investigate bruises of unknown origin for 1 (#24) of 14 sampled residents. Findings include: Resident #24 was admitted with [DIAGNOSES REDACTED]. Review of resident #24's nursing notes showed the following: -11/5/17 bruising noted to both of the resident's wrists, above her right eye, and to her right antecubital area. -1/9/18 bruise noted to top of the resident's right hand. -2/9/18 bruise noted to the resident's right upper thigh. During an interview on 2/21/18 at 1:25 p.m., staff member B stated the bruises were not reported or investigated as bruises of unknown origin. During an interview on 2/22/18 at 7:32 a.m., staff member C stated staff is expected to report bruises of unknown origin to the administrator immediately, or the DON if the administrator is unavailable.",2020-09-01
709,FRIENDSHIP VILLA,275081,2300 WILSON,MILES CITY,MT,59301,2018-02-22,655,D,0,1,J30811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a baseline care plan was in place for 1 (#151) of 17 sampled and supplemental residents. Findings include: Resident #151 was admitted to the facility on [DATE]. Review of resident #151's admission orders [REDACTED]. Review of resident #151's medical record failed to show the facility had implemented a baseline care plan for the resident that addressed the focus, goals, and interventions for resident #151's anxiety, [MEDICAL CONDITION] disorder, depression, [MEDICAL CONDITION], and pain. During an interview on 2/22/18 at 8:31 a.m., staff member J said she was not at the facility to write the baseline care plan for resident #151 within 48 hours of admission. Staff member J said baseline care plans for new admissions had been identified as a problem. A review of the facility's policy, Care Planning, showed, A Baseline Care plan is started by nursing staff on the first day of admission to provide guidance to direct care givers as soon as possible after admission and completed no later than 48 hour (sic) after admission.",2020-09-01
710,FRIENDSHIP VILLA,275081,2300 WILSON,MILES CITY,MT,59301,2018-02-22,656,E,0,1,J30811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans for 4 (#s 5, 18, 40, and 151) of 17 sampled and supplemental residents. Findings include: 1. Resident #151 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #151's care plan, with a date initiated of 2/14/18, showed: -Focus area: I am taking antidepressant/antianxiety/antipsychotic medications for my [DIAGNOSES REDACTED]. -Goal: I want to be free of side effects and stable in my illness. -Interventions: Staff will observe for lack of therapeutic benefits of my medication and for side effects for these drugs which include headache, dizziness/lightheadness, upset stomach, constipation, nausea, anxiety, vomiting and report them to my doctor. Review of resident #151's care plan did not show a focus, goals, or interventions for the resident's [DIAGNOSES REDACTED]. During an interview on 2/22/18 at 8:31 a.m., staff member J said she probably should have given each [MEDICAL CONDITION] medication its' own focus, goals, and interventions. Staff member J said she was not aware resident #151 had a [DIAGNOSES REDACTED]. A review of the facility's policy, Care Planning, showed, Nursing, Dietary, Therapeutic, Recreation, and Social Services staff complete formal assessments, interviews, and observations and begin formulating the full care plan as soon after admission as possible. 2. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation on 2/20/18 at 3:55 p.m., a bowl of Halls cough drops was observed on the side table. A review of resident #5's care plan showed no information regarding the resident's ability to self administer medications. 3. Resident #40 was admitted with [DIAGNOSES REDACTED]. During an observation on 2/20/18 at 4:26 p.m., a tube of Biofreeze was observed on the over bed table. A review of resident #40's care plan showed no information regarding the resident's ability to self administer medications. 4. Resident #18 was observed on 2/20/18 at 3:45 p.m., a bottle of SAF Cleans Advanced Formula Saline spray was observed on resident #18's bedside table. A review of resident #18's care plan showed no information regarding the resident's ability to self administer any medications. Review of the facility Self Administration of Medications policy showed . 4. If the resident is deemed capable to self-administer medications, then the drugs will be stored in a locked box in the resident's room, unless determined otherwise by the interdisciplinary team 5. Nursing is to get an order from the physician for self-administration of medications . 7. Documentation of the ability to self-administer medications will appear on the resident's plan of care.",2020-09-01
711,FRIENDSHIP VILLA,275081,2300 WILSON,MILES CITY,MT,59301,2018-02-22,657,E,0,1,J30811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to update resident care plans for 4 (#s 24, 34, 50, and 151) of 17 sampled and supplemental residents. Findings include: 1. During an observation and interview on 2/20/18 at 6:41 p.m., resident #34 was sitting in a wheelchair in her room. Resident #34 said she had fallen three times in January. Resident #34 said she had a walker but she did not use it any more because she was afraid of falling again. Resident #34 said, I feel more safe getting from place to place in my wheelchair. Review of resident #34's care plan showed, under interventions, resident #34 would use her walker at all times when ambulating in her room. The care plan had a revised date of 10/13/17. The care plan for resident #34 did not contain any reference to her preference in using her wheelchair for safety. 2. Review of resident #50's dietary progress note, dated 2/13/18, showed the resident had a 5% desired weight loss for the quarter. Resident #50's current weight was 296 pounds. Review of a fax cover sheet, dated 1/11/18, showed the dietician had asked resident #50's physician that resident #50 be placed on a carbohydrate controlled diet. Resident #50's physician agreed with that recommendation. Review of resident #50's care plan did not show the resident was receiving a carbohydrate controlled diet. Resident #50's care plan did not identify or address the resident's 5% weight loss in three months, as documented by staff member O on 2/13/18. Review of the Diet/Eating focus section for resident #50 showed the resident was overweight. This was last revised on 2/27/17. Review of the Diet/Eating goal section for resident #50 showed the resident wanted to maintain weight and not gain any weight. This was last revised on 2/15/18. Review of the Diet/Eating intervention section for resident #50 showed the resident would accept smaller portions, 1% milk, and fruit for dessert to help prevent further weight gain. The resident needed to be weighed monthly, and the resident needed the meal intake monitored and recorded. This was last revised on 2/27/17. 3. Resident #151 was admitted to the facility with [DIAGNOSES REDACTED]. Review of a Diet Order & Communication, dated 2/1/18, showed resident #151 was to receive protein shakes twice a day. Review of fax cover sheet, dated 2/6/18, showed the dietician had requested resident #151 receive a 4 ounce house supplement as needed. The physician agreed with the dietician's request, and clarified it with, 4 oz house supplement PRN up to 4/day. Review of resident #151's care plan failed to show the protein shakes twice a day, or the 4 ounce house supplements, as needed up to four times a day, had been added to the resident's current care plan. During an interview on 2/21/18 at 4:50 p.m., staff member O said she did not update the dietary section of the resident care plans. Staff member O said the MDS coordinator did that. During an interview on 2/22/18 at 8:31 a.m., Staff member J said the resident has the main input for developing care plans. Staff member J said the care plans should be updated to reflect each resident and their current care and needs. A review of facility policy, Care Planning, showed, Care Plans should be updated between care conferences to reflect current care needs of the individual resident as changes occur. 4. Resident #24 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation on 2/21/18 at 9:30 a.m., Resident #24 was transferred from the bed to the wheel chair with assistance by staff members H and [MI] Review of resident #24's annual MDS, with an ARD of 12-20-17, showed the resident required extensive assistance of two staff for transfers. Review of the care plan, dated 1/10/18, showed the resident was an assist of one for transfers. The care plan did not reflect the resident's current transfer status. During an interview on 2/22/18 at 7:30 a.m., staff member C stated the facility should have updated the resident's care plan to reflect a two person assist. During an interview on 2/22/18 at 8:39 a.m., staff member J stated the care plan, for resident #24, should have been updated to reflect her current transfer status.",2020-09-01
712,FRIENDSHIP VILLA,275081,2300 WILSON,MILES CITY,MT,59301,2018-02-22,689,D,0,1,J30811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to prevent falls for 1 (#351); failed to use a gait belt for transfers for 1 (#24); and, failed to ensure residents did not use electric heaters in their rooms for 1 (#351) of 14 sampled residents. Findings include: 1. Resident #351 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation on 2/21/18 at 7:05 a.m., resident #351 was observed lying on his left side, on the floor, in front of his recliner wearing his oxygen. Resident #351 stated he stumbled. Resident #351's call light was on his bed, not near his recliner which he had been sitting in. Staff members A, C, and P came in the room to assist resident #351. Resident #351 stated he did not hurt too bad and had no broken bones when asked by staff if his arms or head hurt. Staff members C and P placed a gait belt around his waist. Two other staff members entered the room to help assist resident #351 from the floor and to his recliner. There was no range of motion prior to assisting him from the floor to the recliner. Staff member P left the room and returned with the equipment to take resident #351's vital signs. At 7:44 a.m., staff member C checked resident #351's pupils and asked him again if he hurt or wanted to see the physician. Resident #351 stated you guys are the boss so if you want me to go I will. Staff member R checked resident #351's range of motion after he was assisted to the recliner, not prior to moving him. During an observation on 02/21/18 at 4:00 p.m., an electric space heater was in resident #351's room. It was plugged in and the heater was in the middle of the room. Resident #351's oxygen tubing was strung across the floor from the oxygen concentrator. Resident #351 was sitting in his recliner and had no call light within reach to use for staff assistance. Review of resident #351's care plan, with an initiation date of 2/15/18, showed he was at risk for fall due to previous falls, severe vision loss, tremors, use of a walker, oxygen tubing, and diuretic medication. The intervention documented was to remind him to be aware of oxygen tubing when transferring and ambulating. During an interview on 2/21/18 at 7:48 a.m., staff member P stated if a person falls the CNAs get a nurse, get the resident up and take vitals, the nurse comes back and assess' the resident. She stated one person stays with the resident and one person goes to get nurse. She stated gait belts are used for transfers for the residents who need it. She stated some residents do not need assist. During an interview on 2/21/18 at 7:50 a.m., staff member R stated since the staff members did not witness the fall, the policy is to start neuro checks. She stated they also have to notify family and physician, report incident to the DON, Administrator, and MDS. Staff member R stated they are to make sure the resident has shoes, socks, and call light in place. Staff member R stated resident #351 had been declining and his oxygen saturation had not been good. She stated resident #351 had vagal response on toilet the night before. During an interview on 2/22/18 at 8:30 a.m., staff member Q stated the residents should always have their call light in place. Review of the facility policy, Answering the Call Light, showed under General Guidelines . 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Review of the facility policy, Neurological Assessment, included . 8. Determine motor ability: a. Have resident move all extremities, b. Ask resident to squeeze your fingers. Note strength bilaterally, c. Have resident plantar and dorsiflex. Note strength bilaterally. Ask resident if he/she has any numbness or tingling in legs/feet/toes and document accordingly . 9. Determine sensation in extremities. Rub resident's arm at the same time to see if resident has decreased sensation in either arm. Check sensation in lower extremities also and document accordingly . 10. Check gag reflex with a tongue depressor, if safe for resident. Review of the facility policy, Electric Fireplace or Portable Space Heaters, showed in the procedure section 2. No space heaters are allowed to be used in the facilities unless in a non-sleeping staff and employee area where the heating elements do not exceed 212 degrees Fahrenheit. 2. Resident #24 was admitted with [DIAGNOSES REDACTED]. During an observation on 2/21/18 at 9:30 a.m., staff members H and L performed personal care for resident #24. Staff members H and L washed their hands, donned clean gloves, raised the bed, pulled the bed out, removed the resident's bottoms, removed the resident's undergarment, cleansed the resident from front to back, put on a clean undergarment, put on clean pants, removed their gloves, washed their hands, donned clean gloves, lowered the bed, and locked the brakes. Staff members H and L transferred resident #24 to her wheel chair by grabbing the waistband of the resident's pants. Staff members H and L did not use a gait belt during the transfer. Review of resident #24's Annual MDS, with an ARD of 12-20-17, showed extensive assistance of two staff needed for transfers. During an interview on 2/21/18 at 9:43 a.m., staff member L stated a gait belt was not used because the resident did not have a gait belt in her room. Staff member L stated the facility was short on gait belts. During an interview on 2/22/18 at 7:28 a.m., staff member C stated the expectation for gait belt use was for staff to use a gait belt when performing pivot or stand by assist transfers. Review of the facility Transfer Belt Policy, reflected the utilization of a transfer (gait) belt with residents during transfers, ambulation and gait training. Transfer belts will be available at each resident's bedside .staff should check for presence of belt on first rounds.",2020-09-01
713,FRIENDSHIP VILLA,275081,2300 WILSON,MILES CITY,MT,59301,2018-02-22,758,D,0,1,J30811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure [MEDICAL CONDITION] medications were time limited to fourteen days for 1 (#151) of 17 sampled and supplemental residents. Findings include: Review of resident #151's admission orders [REDACTED]. During an interview on 2/22/18 at 7:43 a.m., staff member C said we try to stick to the 14 day general rule. Staff member C said the pharmacist identified residents' receiving PRN [MEDICAL CONDITION] medications outside the 14 day timeline. Staff member C said resident #151 was admitted on [DATE], and the pharmacist had not been to the facility for the drug regimen review yet. Staff member C said she was not aware of the new regulations regarding PRN [MEDICAL CONDITION] medications.",2020-09-01
714,FRIENDSHIP VILLA,275081,2300 WILSON,MILES CITY,MT,59301,2018-02-22,801,E,0,1,J30811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and observation, the facility failed to ensure the dietary manager completed a certification program approved by a national certifying body; or had an associate's or higher degree in food service management or in hospitality from an accredited institution of higher learning. The failure of the dietary manager to posess the necessary education, may affect any resident receiving meals or services from dietary department. Findings include: During the initial tour and observation of the kitchen, on 2/20/18 starting at 3:56 p.m., concerns with kitchen equipment, staff practices, recipes not being followed, and improper food storage were identified (See F812 and 908 for more information). During the initial tour of the kitchen, staff member D was not available for interview. During an interview on 2/20/18 at 5:00 p.m., staff member O stated she visited the facility on a weekly basis. She was not employed full time overseeing the managerial duties. She stated she was not sure if the dietary manager was a certified dietary manager. She stated she would check with him and get back to the surveyors. During an interview on 2/21/18 at 10:36 a.m., staff member O stated the dietary manager was employed there for the past 2-3 years. She stated he had taken the dietary managers' certification course previously when he worked for the State, but he did not complete the course. She stated he was one class shy of finishing the course. She did not know when the course was taken. During an interview on 2/21/18 at 1:05 p.m., staff member D stated he became a dietary manager in (MONTH) (YEAR). He stated he had been cooking for [AGE] years or more. He stated since he became a manager, he had been short staffed and he had been cooking instead. He stated he had been posting ads for three cooks. He stated staff member O was helping him with managerial issues, because he generally finished his cooking shift at around 1:30 p.m. and this left no time to work on managerial issues and duties. Staff member NF1, who joined the interview, stated his company took over the kitchen management in (MONTH) of (YEAR) and he would make sure staff member D was signed into a certification program that day.",2020-09-01
715,FRIENDSHIP VILLA,275081,2300 WILSON,MILES CITY,MT,59301,2018-02-22,803,E,0,1,J30811,"Based on observation, interview, and record review, the facility failed to ensure standardized menus with standardized recipes were utilized by all staff in the kitchen, and any changes made to the recipes were first approved by the registered dietitian. The deficiency may affect any resident receiving meals from the facility. Findings include: During the meal observation and testing of a evening meal tray on 2/20/18 at 5:45 p.m., the following concerns were documented: - Steamed peas tasted sweet, however tasted good. - Pork madellions tasted good and were tender. - Chicken tenders tasted good, they were warm but not hot. - The noodles tasted blend, they were warm. - Staff member G stated he added sugar to boiled peas to enhance the taste. He stated the recipe did not call for the addition of sugar, but it was something he learned over the years as a cook. He stated he was trained with a chef. He stated the registered dietitian was not notified. - Staff member G stated he added, garlic and onion powders, Worcestershire sauce and pepper to the pork medallions to enhance the taste. He stated the recipe was not updated with the new ingredients and the registered dietitian was not notified. Staff member G also stated he never added salt to any of the recipes as they had residents with no added salt diet orders. During an interview on 02/21/18 10:36 a.m., staff member O stated she was not aware that the cook was making changes to the recipes. She did not know the sugar was added to the peas by the cook last night. She sated she would revisit the issue with the cooks. She stated she would review the diet orders with the physicians as well. She provided the copies of the 2/20/18 evening meal's recipes. All of the recipes listed iodized salt as an ingredient. None of the recipes were updated with staff member G's ingredient additions and lacked the authorizations of the registered dietitian. She also stated she would revisit the food labeling and storage with the staff. Review of the residents' diet orders showed 18 residents had physicians' orders for no added salt diets, and 16 residents had orders for combination of reduced calorie/carbohydrate diets. The facility census was 48. The cook did not follow the standardized recipes for the evening meal served on 2/20/18. The meal tasted good and was acceptable, however, the registered dietititan must review and approve all alterations to the receipes to ensure all of the menu items are still appropriate for the therapuetic diets ordered by the physicians.",2020-09-01
716,FRIENDSHIP VILLA,275081,2300 WILSON,MILES CITY,MT,59301,2018-02-22,810,D,0,1,J30811,"Based on observation, interview, and record review, the facility staff failed to provide 1 (#33) of 14 sampled residents with the proper special eating equipment during mealtimes as his care plan directed. Findings include: Resident #33 was observed on 2/20/18 at 6:05 p.m. Resident #33 did not receive double handled cups for any of his liquids during the meal. Review of resident #33's care plan dated 10/31/16, showed he was to receive double handled cups for all liquids to make it easier to drink without spilling. During an interview on 2/21/18 at 9:00 a.m., staff member R stated resident #33 should be provided double handled cups at mealtimes due to his tremors. She stated information like that is communicated to the kitchen by telling them the resident needs something special like double handled cups for his liquid. During an interview on 2/21/18 at 3:44 p.m., staff member D stated that he has not had time to go over the care plan for residents due to working the floor. He stated the diet order communication is more common then the care plan. Staff member D stated he was supposed to attend care plan meeting but does not have time . He stated he has only attended 2 care plans. During an interview on 2/21/18 at 4:00 p.m., staff member S stated resident #33 does not get any type of special silverware or cups for his meals. Staff member S said the kitchen staff would supply any type of special thing like that to a resident. Staff member S stated resident #33 gets all regular things at meals and does not usually require assist from staff for meals.",2020-09-01
717,FRIENDSHIP VILLA,275081,2300 WILSON,MILES CITY,MT,59301,2018-02-22,812,E,0,1,J30811,"Based on observation and interview, the facility failed to ensure proper food preparation and storage in the kitchen. The deficiency affects all of the residents who received services from the kitchen. Findings include: During the initial tour of the kitchen on 2/20/18 at 4:00 p.m., the following concerns were observed in the kitchen: (staff member G accompanied the surveyors) - The commercial meat slicer was left uncovered while it was in storage status. Staff member G stated it was stored that way. - The commercial stand up Hobart mixer was left uncovered while it was in storage status. Staff member G stated it was stored that way. Additionally, the stand and the underside of the mixer had dried food splatters; and one of its attachments was not covered as well while in storage status. - The Kitchen Aide, small mixer, located on the baker's counter, was not covered while it was in storage status. - The soup and sauce ladles were hanging face up, creating potential for dust collection on the food contact surfaces. - The handles of the utensils were not facing the same direction, found in the baker's drawer, creating potential for the food worker to touch the food contact surfaces of the utensils. - Two souffle cups of orange colored cheese were not labeled and dated in the walk-in cooler. - One souffle cup of unidentified item was not labeled and dated in the walk-in cooler. - A Ziploc bag of orange colored liquid was not labeled and dated in the walk-in cooler. The freshness of the left over food product could not be determined. - Tortillas covered in Saran wrap were not labeled and dated in the walk-in cooler. The freshness of the tortillas could not be determined. - An opened and wrapped package of ground beef was browned (indicating air exposure) at the tip and was not dated. The freshness of the product could not be determined. - An opened package of turkey slices in a Ziploc bag was not dated when the package was first opened. The freshness of the product could not be determined. - An opened package of ham slices was not wrapped air tight and was not dated when the package was opened. The freshness of the product could not be determined. During an interview on 2/20/18 at 4:15 p.m., staff member G stated they froze the left overs and kept them for 6 months. He stated left overs from the traylines would be tossed.",2020-09-01
718,FRIENDSHIP VILLA,275081,2300 WILSON,MILES CITY,MT,59301,2018-02-22,880,D,0,1,J30811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure staff washed/sanitized their hands, and changed gloves between dirty and clean procedures during the provision of ADL care for 1 (#24) of 14 sampled residents. Findings include: Resident #24 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation on 2/21/18 at 9:30 a.m., staff members H and L performed personal care for resident #24. Staff members H and L washed their hands, donned clean gloves, raised the bed, pulled the bed out, removed the resident's bottoms, removed the resident's undergarment, cleansed the resident from front to back, did not change gloves or wash/sanitize their hands, put on a clean undergarment, put on clean pants, removed their gloves, washed their hands, donned clean gloves, lowered the resident's bed, locked the brakes. transferred the resident to her wheel chair, put the resident's top on, washed the resident's face, combed her hair, emptied the garbage, and washed their hands. During an interview on 2/21/18 at 9:43 a.m., staff member L stated she should have changed gloves before putting clean clothes on the resident. During an observation on 2/21/18 at 4:43 p.m., staff members M and N performed personal care for resident #24. Staff members M and N washed their hands, donned clean gloves, pulled the resident's pants down, removed the soiled undergarment, cleansed the resident from front to back, did not change gloves or sanitize hands, put on a clean undergarment, pulled the resident's pants up, removed their gloves, washed their hands, and disposed of the garbage. During an interview on 2/21/18 at 4:54 p.m., staff member M stated she should have changed gloves before putting the clean brief on. During an interview on 2/22/18 at 7:30 a.m., staff member C stated the expectation for glove use was to change gloves from dirty to clean, such as after performing peri care and before putting a clean brief on.",2020-09-01
719,FRIENDSHIP VILLA,275081,2300 WILSON,MILES CITY,MT,59301,2018-02-22,908,E,0,1,J30811,"Based on observation, record review, and interview, the facility failed to ensure safe and proper operation of the kitchen equipment (the commercial meat slicer and the walk-in cooler). This deficiency may affect any resident receiving food from the kitchen when the equipment is used for the preparation or storage of food. Findings include: 1. During an observation and interview on 2/20/18 at 4:20 p.m., excessive amounts of ice and frost accumulation (1/3 of the ceiling, approximately 4 inches thick) was observed in the walk-in freezer's ceiling on both sides of the compressor; and on the floor where it created a slip and fall hazard for the kitchen staff. The freezer shelves were full of food. The freezer temperature, shown on the door panel, was -5 degrees Fahrenheit. Staff member G, who accompanied the surveyors, stated the freezer was in this condition for 7-8 months. He stated they were looking into repairing the door seal. He stated the dietary manager would have more information, but he was not working that day. 2. During an observation on 2/20/18 at 4:15 p.m., a hole measuring approximately 9 inches in length and 5 inches in depth was noted on the kitchen floor, in front of the walk-in cooler. The portion of the tile and flooring was missing. The surface was uncleanable and created a trip hazard for the kitchen staff. During an interview on 02/21/18 at 1:21 p.m., staff member D (staff member NF1 was also present) stated the walk-in freezer was on its last leg. Staff member D stated to please ask the maintenance manager for the specifics of this ongoing concern of the walk-in freezer. Staff member D stated the concern was beyond just the seal on the door, although that was a problem also. Staff member D stated the walk-in cooler and the freezer were very old. The freezer door was not sealing properly as well adding to the existing problem. Staff member D stated he placed a repair order for the broken floor with maintenance. Staff member D also stated the commercial meat slicer was not covered, because he did not allow his staff to use it. He stated the slicer was rusty and missing guards making it dangerous to use. He stated they needed a new meat slicer. During an interview on 02/21/18 at 4:35 p.m., staff member O stated repair issues in the kitchen were usually verbally communicated to the maintenance. She stated she would double check on that. During an interview on 02/21/18 at 4:45 p.m., staff member I stated that the panels that made up the freezer were shifting down and shifting side ways creating openings and allowing the moist air from outside to enter the freezer causing excessive ice buildup. He stated he repaired a crack one time this last summer. He stated the facility needed to replace the freezer at some point. Staff member I showed the small notebook hanging in the kitchen stating it was used to document repair issues. Staff member I stated he checked the notebook daily when he passed by the kitchen. Review of the notebook showed a lack of documentation of the repair requests for the damaged floor and the ice build up in the freezer. The facility lacked a working system in place for requesting work orders showing time lines and resolutions. During the exit meeting on 2/22/18 at 10:40 a.m., staff member A stated they requested a bid to replace the freezer, but she did not elaborate further as to when this was done and who was providing the bid.",2020-09-01
720,FRIENDSHIP VILLA,275081,2300 WILSON,MILES CITY,MT,59301,2018-02-22,919,D,0,1,J30811,"Based on observations, interview, and record review, the facility staff failed to ensure each resident had a call light in place and within reach to call the staff for assistance for 4 (#s 5, 15, 33, and 351) of 17 sampled and supplemental residents. Findings include: During the survey observations showed the following concerns: a. During an observation on 2/20/18 at 4:04 p.m., resident #351 was in his room, sitting in a recliner with no call light within his reach. The call light was across room on the night stand. b. During an observation on 2/20/18 at 4:45 p.m., resident #5 was in her room, sitting in a recliner with no call light within her reach. c. During an observation on 2/20/18 at 4:25 p.m., resident #33 was sitting in a wheel chair and was not able to call for staff's assistance due to his call light lying on the floor to the left side of his wheel chair. d. During an observation on 2/20/18 at 5:07 p.m., resident #15 was in bed. She was not able to call for staff's assistance due to her call light lying on the fall mat, under a body pillow, which was on the floor. During an interview on 2/22/18 at 8:30 a.m. staff member Q stated the residents should always have their call light in place. A review of the facility policy Answering the Call Light showed, under General Guidelines . 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.",2020-09-01
721,FRIENDSHIP VILLA,275081,2300 WILSON,MILES CITY,MT,59301,2016-11-03,273,D,0,1,PCLL11,"Based on record review and interview, the facility failed to complete an Admission MDS by the 14th day after the resident's admission, for 1 (#12) of 12 sampled residents. Findings include: Record review of the resident's MDS, with the ARD of 6/2/16, showed a completion date of 6/10/16, which was completed on day 15 of the resident's stay, and one day late. During an interview on 11/3/16 at 9:00 a.m., staff member F stated non-compliance with time frames were related to her work load.",2020-09-01
722,FRIENDSHIP VILLA,275081,2300 WILSON,MILES CITY,MT,59301,2016-11-03,278,E,0,1,PCLL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to accurately reflect the current hearing abilities for 1 (#6); for the current height for 1 (#5); and for the current speech, communication, locomotion, and ADL abilities for 1 (#2) out of 12 sampled residents. Findings include: 1. Review of resident #2's Admission MDS, with an ARD of 4/12/16, showed the absence of speech, and total dependence for ADLs. Review of the Quarterly MDS, with an ARD of 7/12/16, showed resident #2 was able to participate in all of his ADLs, including eating and locomotion off and on the unit. Resident #2 had a [DIAGNOSES REDACTED]. Review of the resident's Care Plan, dated 4/07/16, showed the resident was dependent on staff for all care. During an interview and observation on 11/1/16 at 9:20 a.m., resident #2 was unable to follow commands, and was not able to participate in the transfer with the Hoyer lift. Staff member [NAME] stated he was dependent on staff for all care. During an interview on 11/2/16 at 3:40 p.m., staff member F stated she thought she had corrected that MDS, although it had not been completed. Review of resident #2's Quarterly MDS, with the ARD of 10/11/16, showed the resident had clear speech and was usually understood. During an interview on 11/1/16 at 9:30 a.m., staff member [NAME] and G stated they had never heard resident #2 say anything. During an observation on 11/2/16 at 10:05 a.m., resident #2 was unable to respond to simple yes/no questions. During an interview on 11/1/16 at 12:00 p.m., staff member I stated she received the communication ability for resident #2 from an interview with the resident's family member. She also stated she did not receive training for the completion of the MDS. Review of the resident's Quarterly MDS, with the ARD of 10/4/16, showed the resident was always understood and always understands. Review of the Brief Interview for Mental status showed the resident was rarely or never understood. During an interview on 11/2/16 at 9:00 a.m., staff member J stated she did not understand how to code that section, if the resident did not want to complete the interview. 2. A review of Resident #5's Annual MDS, with an ARD of 4/12/16, and the Quarterly MDS's, with ARD's of 7/12/16 and 10/11/16, showed a discrepancy in K0200-A, height - the resident went from being 74 inches to 68 inches. The staff member responsible for completion of the measurements on the MDS was not available to comment on the procedure she used to measure the residents. 3. Resident #7 had a [DIAGNOSES REDACTED]. Review of resident #7's Significant Change MDS, with an ARD of 3/4/16, showed the resident had highly impaired hearing. Review of the resident's Significant Change MDS, with an ARD of 7/12/16, showed the resident had moderately impaired hearing. Review of the resident's Quarterly MDS, with an ARD of 10/11/16, showed the resident had minimal hearing difficulty. Review of the resident's care plan for communication showed he used a dry erase board to communicate his needs to staff. During an interview on 11/2/16, at 3:40 p.m., staff member N stated the resident yelled when he needed something. During an interview on 11/3/16 at 9:23 a.m., staff member C stated the resident was not able to follow directions due to his hearing deficit.",2020-09-01
723,FRIENDSHIP VILLA,275081,2300 WILSON,MILES CITY,MT,59301,2016-11-03,279,D,0,1,PCLL11,"Based on interview and record review, the facility failed to update the comprehensive care plan to include current interventions and goals for 2 (# 2 and #7) of 12 sampled residents. Findings include: 1. Review of resident #2's Care Plan showed I receive my nutrition through a PEG tube. The goal showed I will maintain good nutrition and stable weights. Review of the Vitals section of the Electronic record showed resident #2 had experienced a significant weight gain. Review of the Care Plan did not show whether the weight gain was desired, or planned. During an interview on 11/2/16 at 3:30 p.m., staff member F stated she did not know the resident's care plan required a specific nutrition plan and goal. 2. Review of resident #6's Care Plan included the following interventions for falls: -Staff to ensure the resident's FWW is in good repair and available at all times. -Non slip strips in place in front of his recliner and bed to provide traction when rising. -Staff to ensure the resident is wearing adequate footwear. During an interview on 11/3/16 at 8:15 a.m., staff member C stated the staff used the sit-to-stand lift for the resident during transfers related to safety. Review of the resident's Care Plan did not show an intervention for the sit-to-stand lift. During an interview on 11/3/16 at 8:30 a.m., resident #6 stated he hasn't ambulated since his knee injury on 6/16/16.",2020-09-01
724,FRIENDSHIP VILLA,275081,2300 WILSON,MILES CITY,MT,59301,2016-11-03,318,D,0,1,PCLL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and observations, the facility failed to provide appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion by not walking resident to meals for one (#3) of 12 sampled residents. Findings include: Resident #3 was admitted with [DIAGNOSES REDACTED]. Review of resident #3's Quarterly MDS, with an ARD of 7/5/16, section G, showed that the resident was a one person assist to transfer, a one person assist to walk in room, and one person assist to walk in the corridor. Review of resident #3's Significant Change MDS, with an ARD, of 10/13/1, section G, showed that the resident was a two plus person assist to transfer, a two plus person assist to walk in room, and walking had not occurred in the corridor. Review of resident #3's Care Plan, dated 11/6/14, showed restorative nursing would work with resident #3 to maintain ROM in both shoulders, to dress, and perform ADLs independently, and decrease pain. Review of resident #3's Restorative Instructions from physical therapy showed that the resident was to walk to meals with staff. On 11/1/16 at 12:40 p.m., and at 5:10 p.m., a copy of resident #3's restorative instructions were requested but not provided by the facility. Review of resident #3's Walk to Dine activity notes showed resident #3 did not walk to the dining room as indicated on the resident's Restorative Instructions from physical therapy. On 11/1/16 at 12:40 p.m., and at 5:10 p.m., a copy of resident #3's Walk to Dine activity documentation was requested but was not provided by the facility. Review of the facilities' Restorative Nursing Program policy showed if a resident has a change in their ROM assessment and showed signs of decline, the resident would be referred to therapy for an evaluation of the need for a formalized therapy or the Restorative Nursing program. During an interview on 10/31/16 at 4:50 p.m., staff member L stated resident #3 did use the wheelchair to go to meals. During an observation on 10/31/16 at 4:55 p.m., resident #3 was in her wheel chair in the hall way. The resident wheeled herself in her wheel chair to the dining room without staff assistance. During an interview on 11/1/16 at 9:25 a.m., staff member G stated resident #3 normally wheeled to the dining room for meals and did not walk with staff. Staff member G stated resident #3 complained of shoulder pain most of the time. During an interview on 11/1/16 at 11:10 a.m., staff member C stated she did not know anything about restorative nursing care. Staff member C stated that staff member B did the restorative nursing program. During an interview and observation on 11/1/16 at 12:11 p.m., resident #3 stated she wheeled herself to the dining room in her wheel chair, and has been observed in the dining room just prior to the interview, in her wheelchair. During an interview on 11/1/16 at 11:15 a.m., staff member B stated she had a restorative binder that indicated which residents needed restorative nursing. Staff member B stated that PT and OT gave generalized layouts for her to train staff how to perform restorative nursing. Staff member B stated that she had three CNAs who were trained currently on restorative nursing care. Staff member B stated that the restorative nursing care book was reviewed monthly.",2020-09-01
725,FRIENDSHIP VILLA,275081,2300 WILSON,MILES CITY,MT,59301,2016-11-03,323,G,0,1,PCLL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and observation, the facility failed to prevent further falls with injury for 2 (#s 1 and 12) of 12 sampled residents. Findings include: 1. Resident #12 was admitted to the facility on [DATE] for physical therapy. Review of the Resident Incident Report, dated 7/18/16, showed resident #12 had a fall while attempting to sit on the bed. She stated she lost her balance when the lights went out. Review of the resident's Resident Incident Report, dated 8/22/16, showed she was found sitting on the floor in her room. The resident was ambulating, alone, and unattended, and may have become dizzy. The interventions documented were to use oxygen more and walker at all times. Review of the Progress Notes, dated 8/24/16, showed resident #12 had an x-ray of her left foot related to pain. No fracture was found. Review of the resident's Resident Incident Report, dated 9/10/16, showed she was found lying on floor, on her left side, in front of her bed. She stated she was going to sit in her rocking chair. The resident complained of right groin pain. The resident was not using her walker. Neither a root cause, nor any new interventions were identified or documented for the fall. Review of the resident's Vitals Summary, for the month of (MONTH) (YEAR), showed no pain from 9/1/16 through 9/4/16. From 9/5/16 to 9/16/16, the resident had pain every day, ranging from 1 to 10. Review of the Progress Notes, dated 9/6/16, showed the resident was complaining that her right knee was giving out and resident is complaining of severe pain shooting from right hip to knee and she is refusing to put any weight on it. Review of the Progress notes, dated 9/6/16, showed the resident was sent to the ER to rule out a DVT. A DVT was ruled out at the hospital. She was diagnosed with [REDACTED]. Review of the Progress Notes, dated 9/9/16, showed the resident had complained of leg pain, and Gabapentin was started. Review of the Progress Notes, dated 9/10/16, showed the resident had fallen. Review of the Progress notes, dated 9/10/16, showed the CNAs were now using a wheelchair as the resident was unable to move her legs. States she has pain in both legs and her left shoulder. Review of the resident Progress Notes, dated 9/11/1/6, showed the resident required two person assist when transferring with FWW. Resident complains of bilateral leg pain. Review of the resident Care Plan for resident #12, dated 6/10/16, showed one intervention for falls - Physical therapy to provide exercises and activities to improve ambulation. Review of the resident Progress Notes dated 9/12/16, showed the IDT had reviewed the fall and documented, Resident will use call light for all transfers until she returns to her baseline - is working with PT. Review of the resident Progress Notes dated 9/14/16, showed the resident has not ambulated at all today. Complained of pain in her right leg and requested Tylenol. Review of the resident Progress Notes dated 9/16/16, showed resident #12 had a CT ordered for the right hip by the MD. During an interview on 11/4/16 at 8:40 a.m., non-facility staff member NF1, stated he knew the resident was having pain, pretty severe pain, after the fall, and he did question it. She could no longer walk. During an interview on 11/2/16 at 9:20 a.m., staff member B stated the resident was diagnosed with [REDACTED]. 2. Review of the Progress Notes for resident #1, dated 12/28/15, showed the resident had left knee pain. She stated I fell yesterday and hurt my knee. An appointment was made for the resident to see her physician the next day. Resident is using a wheelchair. Review of the resident's Progress Notes, dated 12/28/15, which was a late entry, showed the resident stated she had twisted her knee when she was getting up from the bed and sat back down. The Resident returned from her appointment on 12/29/15 with a fractured ankle. Review of the Resident Incident Report, dated 12/28/16, showed the resident stated, Oh honey I didn't fall. Review of resident #1's Quarterly MDS, with an ARD of 10/4/16, showed the resident had short and long term memory impairments, and moderately impaired cognition. During an interview on 11/3/16 at 3:30, staff member O, the facility physician, stated the resident could have broken her ankle if she twisted her knee, because she had osteoporosis, and staff member A stated there was no further investigation, because they did not think a fall had occurred. Staff member B stated it would be hard to determine if a fall had occurred, without talking to both nurses, who no longer worked at the facility. Review of the Resident Incident Reports for resident #1 showed falls on: 1/6/15, resulted in a 1 inch gash on her head, which required 6 staples to her forehead. 1/21/16, stated she hit her head. 1/31/16, slid out of wheelchair when the brakes were not locked. 2/26/16, resulted in the resident hitting her head on a wall. 4/25/16, resulted in a large hematoma on right side of frontal lobe. 5/2/16, stated she did not use her walker, and fell . 10/23/16, stated I don't know. I just fell She reported she hit her head. Review of the resident's Care Plan for fall prevention, dated 7/30/16, showed Resident will wear shoes that properly fit; Staff to remind and assist to sit down and take breaks when she looks tired; Staff will encourage/remind resident to use four wheeled seated walker at all times when ambulating. During an observation on 11/2/16 and 11/3/16, while resident #1 was walking to the dining room with her walker, her heels were slipping out of her shoes as she took each step.",2020-09-01
726,FRIENDSHIP VILLA,275081,2300 WILSON,MILES CITY,MT,59301,2016-11-03,425,D,0,1,PCLL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff compared the narcotic blister card with the sign out log prior to administration of a narcotic for 2 (#s 13 and 14) of 14 sampled and supplemental residents. The facility failed to ensure staff signed out a narcotic on the sign out log prior to administration of the narcotic for 1 (#13) of 14 sampled and supplemental residents. Findings include: 1. Resident #13 had [DIAGNOSES REDACTED]. During an observation of medication pass, for resident #13, on 11/1/16 at 8:20 a.m., staff member C removed a blister card labeled oxycodone, 5 mg tablets, from the narcotic drawer, and removed two tablets from the card. Staff member C did not visually compare the amount of oxycodone on the blister card to the count on the narcotic sign out log. Staff member D did not sign out the oxycodone on the narcotic sign out log. On 11/1/16 at 9:30 a.m., review of the resident's narcotic sign out log for oxycodone 5 mg, did not show an entry for the administration time on 11/1/16 at 8:20 a.m. 2. Resident #14 had [DIAGNOSES REDACTED]. During an observation of medication pass, for resident #14, on 11/2/16 at 8:46 a.m., staff member D removed a blister card, labeled tramadol 50 mg tablets, from the narcotic drawer, and removed one tablet from the card. Staff member D did not visually compare the amount of tramadol on the blister card to the count on the narcotic sign out log. During an interview on 11/3/16 at 9:30 a.m., staff member B stated the protocol for signing out narcotics was the following: -Look in the drawer for the resident's narcotic blister card. -Remove the card from the medication cart. -Compare the blister card to the narcotic sign out log. -Sign out the narcotic from the log. Staff member B stated the narcotic count has been off, but the staff was able to track the missing narcotics from the resident's MARs.",2020-09-01
727,GOOD SAMARITAN SOCIETY - MOUNTAIN VIEW MANOR,275084,10 MOUNTAIN VIEW DR,EUREKA,MT,59917,2018-04-19,677,D,0,1,S69J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate and timely assistance for eating for 1 (#14) of 12 sampled residents. Findings include: During an observation and interview on 4/16/18 at 6:02 p.m., resident #14 was sitting reclined in her chair, with her head tilted to the left. She was attempting to pick up her adaptive silverware. Staff were assisting other residents. Resident #14 continued to sit, without eating or receiving staff assistance. At 6:30 p.m., resident #14 stated she would like to try the pasta salad and the green beans. She stated she would not eat the broccoli. Staff member D brought resident #14 the salad and green beans. She stated resident #14 could feed herself. At 6:46 p.m., resident #14 was attempting to spear the green beans with her utensil. She put the adaptive fork down and used her fingers. The temperature of the green beans was taken and found to be 80 degrees. Resident #14 stated the beans were not hot. Resident #14 sat in the dining room for 45 minutes watching other residents eat, without receiving any assistance with eating her meal. A review of resident #14's MDS, with an ARD of 2/2/18, showed the resident was coded as a 3/2, showing she needed extensive assistance of one person providing physical assistance, for meals. During an observation on 4/17/18 at 9:00 a.m., resident #14 was sitting in the dining room, reclined in her chair, head tilted to the left. Breakfast service had started at 7:30 a.m. She was attempting to spear a fried egg with her fork. She stated the egg should be cut up for her. She said, If you want to help me, that would be ok. Staff did not assist her, and she eventually used her fingers to eat the fried egg. Review of resident #14's Care Plan, dated 11/20/15, showed Provide assistance at meals as needed. Monitor for choking. During a dining observation on 4/16/18 at 6:46 p.m., resident #14, who had a [DIAGNOSES REDACTED]. No offers of assistance had been made to resident #14 by the staff.",2020-09-01
728,GOOD SAMARITAN SOCIETY - MOUNTAIN VIEW MANOR,275084,10 MOUNTAIN VIEW DR,EUREKA,MT,59917,2018-04-19,687,D,0,1,S69J11,"Based on observation, record review, and interview, the facility failed to provide toenail care for 2 (#s 14 and 18), and resident #18 had pain from the nail and nail damage, and resident #14 reportedly had a fungal infection and nail damage, of 12 sampled residents. Findings include: 1. During an interview and observation on 4/18/18 at 8:25 a.m. resident #18 had long, thick toenails. The right toenail had a black area underneath the nail. The resident stated it hurt when pressure was applied. She was unable to recall having her toenails clipped. During an interview and observation on 4/19/18, at 9:14 a.m., staff member B stated she had not been aware of the lack of toenail care in the facility. She was not aware whether a podiatrist from the community was available to the facility. Record review of resident #18's Nursing Progress Notes showed no documentation for nail care. 2. During an interview on 4/18/18 at 2:30 p.m., NF1 stated she was concerned that resident #14 was not receiving proper toenail care. During an observation on 4/19/18 at 10:40 a.m., resident #14 was observed to have damage to the big toenail on her left foot. The toenail was swollen, extending upwards approximately one centimeter beyond the height of a normal toenail. The toenail was observed to be discolored with black and yellow areas. The toenail was also observed to have rough edges, consistent with crumbling or tearing/chipping of the toenail. During an interview on 4/19/18 at 10:42 a.m., staff member B stated that she had been unaware of the state of resident #14's toenail. Staff member B said that the toenail had a fungal infection and that it could be filed so the protrusion of the nail could be minimized. On 4/19/18, at approximately 11:05 a.m., staff member B stated that the facility was working to get a podiatrist to visit the building once a month to see residents.",2020-09-01
729,GOOD SAMARITAN SOCIETY - MOUNTAIN VIEW MANOR,275084,10 MOUNTAIN VIEW DR,EUREKA,MT,59917,2018-04-19,689,E,0,1,S69J11,"Based on observation, interview, and record review, the facility failed to determine the root cause, implement new interventions, and evaluate and modify interventions for 11 falls, 2 with injuries to include a head injury and bloody nose, and the resident was frequently found incontinent immediately following the falls, for 1 (#26) of 12 sampled residents; and failed to ensure medications dispensed were secured for 8 (#s 10, 13, 14, 17, 20, 33, 37, and 40) of 31 sampled and supplemental residents. Findings include: 1. A review of resident #26's fall documentation showed: - Review of resident #26's Incident Report, dated 9/10/17, showed the resident was found lying on the floor of his room, in front of his recliner, which was turned around towards the wall. No root cause or interventions to prevent further falls were identified to determine why the resident fell from the recliner. - Review of resident #26's Incident Report, dated 9/12/17, showed the resident was found on the floor during routine rounding. He was found sitting upright to middle of the bed. Predisposing Physiological Factors were identified as incontinent and improper footwear. A direct root cause for the fall was not identified or measures taken to address the reasons why the resident was incontinent or why he had improper footwear on. During an interview on 4/19/18 at 9:40 a.m., staff member C stated the facility did conduct a team huddle after each fall, and did identify a root cause through an internal document. The documents were requested for resident #26's falls and were not provided. - Review of resident #26's Incident Report, dated 9/15/17, showed the resident was found lying on the floor of his room. His feet were towards the bed and his head was towards the door. Predisposing Physiological Factors were identified as incontinent, confused and impaired memory. A direct root cause was not identified, and the facility did not address the incontinence, for future prevention of falls. Interventions were not implemented for prevention of falls. The resident had two more falls, without injury, to include on 10/4/17, 11/9/17, which did not show further interventions were implemented for fall prevention. - Review of resident #26's Interdisciplinary Meeting note, dated 11/9/17, showed the fall was viewed on video. Resident entered the dining room and sat in multiple chairs. He pulled a rolling chair out and went to sit on it as it slipped out behind him, falling onto his back. Will purchase an alarm for the dining room door to monitor entrance after hours. - Review of resident #26's Incident Report, dated 11/13/17, showed the resident was found on the floor in the dining room. Resident had himself opened the dining room door after having removed the 'closed cone.' Predisposing Factors included furniture and confusion. How the furniture was related to the resident's fall was not explained. The investigation failed dot show a direct root cause was identified relating to why the resident fell specifically. The door alarm was not in place. The resident's falls continued to occur. - Review of resident #26's Incident Report, dated 11/22/17, showed the resident was found laying on the floor in the hallway. No conditions were identified as predisposing factors and no root cause or interventions to prevent further falls were identified. - Review of resident #26's Interdisciplinary Meeting note, dated 12/15/17 showed the resident was found on the ground next to his doorway in the hall. The fall was reviewed on video. He seemed to lose his footing and fell with arms stretched out to break his fall. Resident was wearing slippers at the time. Family felt the slippers may have been the cause; will have family bring slippers home. The facility did not address other factors for why the resident may have lost his footing. - Review of resident #26's Incident Report, dated 12/27/17, showed the resident was found on the floor in his room. It was obvious he hit his head as evidenced by a bump and 2 abrasions. A direct root cause for the fall was not identified and interventions were not implemented to address the variety of reasons why the resident had fallen. The resident had two more falls without injury, on - Review of resident #26's Incident Report, dated 2/27/18, for a fall on 2/13/18, showed the resident was found on the floor in his room. Resident was lying on the floor perpendicular to his recliner chair, with his right hand holding his head, elbow resting on the floor. There was no wet surface on the floor. The resident was incontinent of bowel. The facility failed to address the incontinence relating to fall management. - Review of resident #26's Incident Report, dated 2/27/18, for a fall on 2/18/18, showed the resident was found sitting on the floor in the hallway. Staff believe the resident caught his right foot on a lift parked in the area. The facility did not address the safety issue of lifts parked in the hallways. - Review of resident #26's Incident Report, dated 2/27/18, for a fall on 2/24/18, showed the resident was found on the floor in the room across from his room. Blood was dripping from his nose. No apparent unsafe conditions were identified. The facility did not identify a direct root cause or implement interventions for safety. During an interview on 4/18/18 at 2:40 p.m., staff member C stated resident #26's falls were not typical falls. She stated the facility had retrained the resident to use his wheelchair, instead of ambulating, and he was no longer falling. We still want him to walk to the dining room with assistance. During observations at dinner on 4/16/18, breakfast and lunch on 4/17/18, and breakfast on 4/18/18, resident #26 was brought to the dining room in a wheelchair. Resident #26 was not observed walking.",2020-09-01
730,GOOD SAMARITAN SOCIETY - MOUNTAIN VIEW MANOR,275084,10 MOUNTAIN VIEW DR,EUREKA,MT,59917,2018-04-19,693,D,0,1,S69J11,"Based on observation, interview, and record review, the facility staff failed to ensure 1 (#18) of 12 sampled residents had their head of the bed (HOB) elevated greater than 30 degrees while being administered a tube feeding, which caused the resident to cough during the feeding. Findings include: During an observation and interview on 4/18/18 at 1:28 p.m., resident #18 was administered a gravity bolus tube feeding by staff member K. The staff member stated the resident's head of the bed was elevated less than 30 degrees. When resident #18 began to cough, staff member K elevated the resident's HOB to 30 degrees. Resident #18 continued to cough, but when asked, stated she was okay. Staff member K stated resident #18's HOB should have been elevated greater than 30 degrees, but staff member K stated she was hesitant to do so because of the contractures to resident #18. Resident #18 stated she was okay when the head of her bed was elevated greater than 30 degrees, and stated she was in no discomfort from her contractures. During an interview on 4/18/18 at 1:37 p.m., staff member M stated resident #18 should have had the head of her bed elevated above 30 degrees while receiving a tube feeding. Staff member M states she provided range of motion therapy to resident #18, and knew the resident was able to tolerate the head of her bed greater than 30 degrees. During an observation on 4/18/18 at 2:22 p.m., resident #18's head of the bed was measured by staff member K using the facility's goniometer. She measured the resident's head of the bed and stated that it was at 22 degrees and should have been at 30 degrees. During an interview on 4/19/18 at 9:14 a.m., staff member B stated the head of the bed for resident #18 should have been elevated greater than 30 degrees. Staff member B stated she had heard resident #18's HOB was at 22 degrees the day before during a gravity tube feeding. Review of the facility's policy, Tube (Enteral) Feedings: General Information, read, 2. Head of Bed (HOB): Elevate HOB 30-45 degrees at all times during feeding and for at least 30-40 minutes after the feeding is stopped.",2020-09-01
731,GOOD SAMARITAN SOCIETY - MOUNTAIN VIEW MANOR,275084,10 MOUNTAIN VIEW DR,EUREKA,MT,59917,2018-04-19,758,D,0,1,S69J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide evidence of the resident's gradual dose reduction attempts for an antianxiety medication, for 1 (#40) of 12 sampled residents. Findings include: During an interview on 4/16/18 at 3:40 p.m., resident #40 stated he was not aware that he was on an antianxiety medication, or an antidepressant. Review of resident #40's current physician orders [REDACTED]. Review of the supporting [DIAGNOSES REDACTED]. Review of resident #40's Care Plan, dated 3/29/18, showed the resident used psychopharmacological medications related to depression and anxiety. The interventions included to consider dosage reduction when clinically appropriate, and to educate the resident and family about risks, benefits, and side effects. The Care Plan also showed the resident had a need for attention and affection. During an interview on 4/18/18 at 3:37 p.m., staff member B stated the facility did not have a [DIAGNOSES REDACTED]. She stated the Physician would review the medication. A physician order [REDACTED].",2020-09-01
732,GOOD SAMARITAN SOCIETY - MOUNTAIN VIEW MANOR,275084,10 MOUNTAIN VIEW DR,EUREKA,MT,59917,2018-04-19,761,D,0,1,S69J11,"Based on observation, interview and record review, the facility staff member failed to securely maintain medications when away from the medication cart, and keep the medications which were accessible in line of sight, which had the potential to affect any resident who had medications stored in the open drawers or on top of the cart when unattended, and specifically, for 6 (#s 10, 13, 14, 17, 37, and 40 ) of the residents in the dining room at the time of the medication pass. Findings include: During an observation on 4/18/18 at 7:53 a.m., staff member K passed medications to some residents seated in the dining room. Both medication carts for the 100 and 200 halls were left unlocked, and some medication drawers were left opened two to four inches. Containers with medication cassettes for resident #40 and resident #13 were left on top of the medication cart. The stock drawer for the medications on the 100 hall was left eight inches open. Staff member K walked away from both medication carts, to the far end of the dining room, and dispensed medication to a resident. Staff member K went to the sink on the opposite end of the dining room and washed her hands at the sink. The medication carts were not in her visual field, as her back was towards the medication carts. During an observation on 4/18/18 at 7:58 a.m., staff member G approached the medication cart for the 100 hall and attempted to push the drawer closed with her foot. The drawer did not completely close, and remained open three inches. Staff member K returned to the medication carts and put the container with medication cassettes for resident #17 on top of the medication cart. Staff member K walked away from the carts. The drawer on the back side of the medication cart for the 200 hall with medication for resident #14 was left open eight inches. During an observation on 4/18/18 at 8:03 a.m., staff member K administered medications to resident #20, and both medication carts remained unlocked. At 8:05 a.m., staff member K returned to the medication carts, and prepared medications for resident #17 and walked away to administer the medications to resident #17. At 8:07 a.m., staff member K removed the container with medication cassettes for resident #10 from the medication cart. She left the cassettes for resident #10 on top of the cart. Staff member K went to the sink on the opposite end of the dining room and washed her hands. The medication carts were not in her visual field, as her back was facing the medication carts. During an observation on 4/18/18 at 8:27 a.m., staff member K removed the container with medication cassettes for resident #37 from the medication cart and put the cassettes on the medication cart for 200 hall. Staff member K had removed the container with the medication cassettes and prepared medications for resident #33. Staff member K left the medication cassettes for resident #37 on top of the medication cart and walked away to dispense medications to resident #33. During an interview on 4/18/18 at 11:15 a.m., staff member K stated her system was to prepare medications for two residents, but administer one at a time. She stated she used two computers and felt this was a quicker system. Staff member K stated she would consider a different system to dispense medications and that she should not have left the medication carts without securing the medications first. Staff member K stated it was highly unlikely that any residents or staff would remove medications from the unsecured medication carts without her knowledge. During an interview on 4/19/18 at 10:12 a.m., staff member G stated she had advised staff member K to keep the drawers on the medication carts closed and to not leave medication cassettes on the medication cart. Staff member G stated staff member K had her own system and should have kept her medications more secure. Review of the facility's policy, Acquisition, Receiving, Dispensing and Storage of Medications, read, 4. Medications will be stored in a locked medication cart, drawer or cupboard. Only the person passing medication and the director of nursing services will be permitted to have access to the keys to the medication storage areas.",2020-09-01
733,GOOD SAMARITAN SOCIETY - MOUNTAIN VIEW MANOR,275084,10 MOUNTAIN VIEW DR,EUREKA,MT,59917,2018-04-19,803,E,0,1,S69J11,"Based on observation, interview, and record review, the facility failed to provide the planned meal on the daily menu to the residents who were receiving the meal. Findings include: During an observation and record review on 4/16/18 at 6:20 p.m., residents on a regular diet received fish, corn, and broccoli. The menu called for strawberries with whipped topping, but the facility served a strawberry jello cake instead. Residents receiving a pureed diet received pureed barbeque pork and green beans. They did not receive pureed pasta salad. The menu specified a three bean salad would be served, not green beans. Resident #26 received a large portion of the meat and salad. Staff member D stated resident #26 did not like green beans, and so the resident did not receive them. He was not provided a substitute for the beans. During an interview on 4/16/18 at 6:40 p.m., staff member D stated the facility did not have the strawberries to serve, and the cook unintentionally overcooked the broccoli. She stated the pasta salad did not puree well, so was not provided. She did not know why green beans were served instead of the three bean salad. During an interview on 4/17/18 at 11:15 a.m., staff member H stated she was warming up chopped, already cooked turkey for the roast turkey on the menu. Staff member D stated the facility did not have the turkey roll that would usually be served. During an observation on 4/17/18 at 12:35 p.m., the residents were eating turkey and mashed potatoes with gravy. The menu called for bread stuffing and zucchini. During an interview on 4/17/18 at 4:17 p.m., staff member D stated the facility did not have the ingredients for bread stuffing, and the zucchini had not been ordered.",2020-09-01
734,GOOD SAMARITAN SOCIETY - MOUNTAIN VIEW MANOR,275084,10 MOUNTAIN VIEW DR,EUREKA,MT,59917,2018-04-19,804,E,0,1,S69J11,"Based on observation, interview, and record review, the facility failed to provide palatable, appealing, and timely meals for 6 (#s 1, 4, 7, 8, 10, and 14) of 31 sampled and supplemental residents. Findings include: During an interview on 4/16/18 at 5:45 p.m., resident #10 stated having to wait for meals to be served was normal. He had become accustomed to the delay. Record review showed that the dinner service was to begin at 5:30 p.m. During a dining observation on 4/16/18 at 6:05 p.m., approximately 40% of the residents had not yet received their meals; 35 minutes after the meal was scheduled to start. When the meal was served, the broccoli was observed to be mushy and lacking structural integrity. It was unappealing in appearance, resembling a gelatinous substance, unlike broccoli. During an interview on 4/16/18 at 6:07 p.m., 37 minutes into the dinner, resident #7 stated that the meals were usually this late and the resident tried to make the best of the situation. During an interview on 4/16/18 at 6:11 p.m., resident #8 stated the hot food was not always served hot, and the cold food was not always served cold. During an interview and observation on 4/16/18 at 6:46 p.m., resident #14 stated the broccoli tasted bad as did the rest of the meal. Resident #14 stated that the whipped cream tasted sour. The green beans, which were temperature tested , were not hot at 80 degrees. During an interview on 4/18/18 at 10:02 a.m., resident #1 stated there is a lot of waiting for meals, usually at least 30 minutes. During an interview on 4/18/18 at 10:05 a.m., resident #4 stated that because the wait for food was so long at meal time, she would like some snacks or something to hold the residents over when they are so hungry. Resident #1 agreed with resident #4 that the delayed meal was a big issue. Resident #4 suggested that vegetable trays or something be brought out to the tables at the start of meal time so the residents didn't have to just sit there being hungry. Resident #1 stated that the problem of waiting is at its worst during evening meal time due to a decrease in the number of staff at the facility. During an interview on 4/17/18 at 9:38 a.m., staff member H stated serving time varied, depending on the amount of nursing staff available to assist the residents.",2020-09-01
735,GOOD SAMARITAN SOCIETY - MOUNTAIN VIEW MANOR,275084,10 MOUNTAIN VIEW DR,EUREKA,MT,59917,2018-04-19,805,E,0,1,S69J11,"Based on interview and record review, the facility failed to have a documented Dental soft diet, as ordered by the physician, for 5 (#s 6, 10, 15, 18, and 19) of 31 sampled and supplemental residents. Findings include: Review of the facility's Physician Ordered diets showed resident #s 6, 15, 18 and 19 had orders for a Dental soft diet. Review of the facility's Therapeutic Breakdown for diet textures, showed Mechanical/L3, Pureed/L1 and Dysphagia/L2 textures. It did not show a Dental soft diet the physician had ordered. During an interview on 4/18/18 at 3:05 p.m., staff member I stated she did not know what a dental soft diet was. She asked staff member D, who stated Everything must be soft. Staff member D said she was not aware it was not included in the Therapeutic Menu Breakdown. During an interview and observation 4/18/18 at 9:20 a.m., resident #10's diet card showed a dental soft diet. She received crisp bacon. She stated her diet had not been updated. On 4/19/18, the facility changed the dental soft diet orders for the residents to a Mechanical/L3.",2020-09-01
736,GOOD SAMARITAN SOCIETY - MOUNTAIN VIEW MANOR,275084,10 MOUNTAIN VIEW DR,EUREKA,MT,59917,2018-04-19,880,D,0,1,S69J11,"Based on observation, interview, and record review, facility staff failed to perform hand hygiene between resident to resident contact during medication administration, including eye drops, for 8 (#s 2, 3, 5, 9, 10, 12, 15, and 30) of 31 sampled and supplemental residents. Findings include: During an observation on 4/18/18 at 8:10 a.m., staff member K prepared and dispensed medications for resident #10. The staff member did not wash or sanitize her hands before or after the resident contact. At 8:12 a.m., staff member K prepared and dispensed medications to resident #2. Staff member K did not wash or sanitize her hands before or after the resident contact. During an observation on 4/18/18 at 8:16 a.m., staff member K prepared and administered medications for resident #5. The staff member placed her hand on the resident's back, explained the medications to the resident and handed resident #5 her drinking glass. Staff member K returned to the medication cart without washing or sanitizing her hands. At 8:18 a.m., staff member K administered medications to resident #30. The staff member handed resident #30 her drinking glass and straw. Staff member K returned to the medication cart without washing or sanitizing her hands. At 8:24 a.m., staff member K prepared and administered medications to resident #9. The staff member handed resident #9 his drinking glass and straw then returned to the medication cart without washing or sanitizing her hands. During an observation on 4/18/18 at 8:42 a.m., staff member K prepared and administered medications to resident #15. The medications were crushed and given to the resident with applesauce and a spoon. Staff member K sat beside resident #15 and spoon fed the resident her medications. Staff member K returned to the medication cart without washing or sanitizing her hands. During an observation on 4/18/18 at 8:46 a.m., staff member K administered eye drops to resident #12. The staff member did not wash or sanitize her hands prior to administering the drops. During an interview on 4/18/18 11:15 a.m., staff member K stated she does not use the hand sanitizer, and only uses the sink to wash her hands. During an observation on 4/19/18 at 7:44 a.m., staff member L administered oral medications and eye drops to resident #3. Staff member L did not wash or sanitize her hands prior to administering eye drops. During an observation on 4/19/18 at 8:06 a.m., staff member L prepared and administered medications for resident #2. The staff member touched the residents water cup, straw, and spoon fed resident #2 her medications. Staff member L did not wash or sanitize her hands prior to or after administering the medications. During an interview on 4/19/18 at 10:47 a.m., staff member L stated she should have washed her hands prior to and after administering medications to the residents. She stated it was important to perform hand hygiene practice, especially when having direct resident contact. Review of the facility's policy, Hand Hygiene and Handwashing (sic), read, 2. If hands are not visibly soiled or contaminated with blood or body fluids, use an alcohol-based hand rub for routinely cleaning hands: a. Before having direct contact with resident, patients and children. b. After having direct contact with another person's skin . d. After touching equipment or furniture near the resident/patient. e. After removing gloves.",2020-09-01
737,GOOD SAMARITAN SOCIETY - MOUNTAIN VIEW MANOR,275084,10 MOUNTAIN VIEW DR,EUREKA,MT,59917,2019-06-13,558,D,0,1,VX7011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a call light was within reach for a dependent resident with mobility deficits, on a consistent basis, for 1 (#30) of 19 sampled residents. Findings include: During an observation on 6/11/19 at 2:23 p.m., resident #30 was in her room, sitting up in her wheelchair. Her call light was wrapped around the bedrail at the head of the bed, and she was unable to reach it to call for assistance due to the positioning of the wheelchair. Resident #30 stated she could use the standard call light if it was placed directly in her hand. A record review of the facility's procedure guide titled, Call Light, showed, When leaving the room, place call light within easy reach of the resident if in bed. If out of bed, stretch call light cord across bed so resident is able to reach it. Review of resident #30's Care Plan, dated 5/15/19, showed a [DIAGNOSES REDACTED]. Review of resident #30's Care Plan did not show information related to the resident's difficulty accessing her call light based upon the positioning of her wheelchair and her impaired mobility. During an interview on 6/13/19 at 9:18 a.m., resident #30 stated she was unaware if she had ever been offered an adaptive call light at the facility to accommodate her difficulty reaching the call light. During an interview on 6/13/19 at 9:24 a.m., staff member C was unsure if resident #30 had ever been provided with an adaptive call light. During an interview on 6/13/19 at 12:13 p.m., staff member C stated resident #30 felt she had used an adaptive call light in the past and was willing to try it again.",2020-09-01
738,GOOD SAMARITAN SOCIETY - MOUNTAIN VIEW MANOR,275084,10 MOUNTAIN VIEW DR,EUREKA,MT,59917,2019-06-13,600,E,0,1,VX7011,"Based on observation, interview, and record review, the facility failed to protect 4 (#s 14, 18, 19, 25, and 37) of 22 sampled and supplemental residents from verbal and/or sexual abuse; failed to prevent and/or limit wandering of residents into other resident rooms, for 2 (#s 7 and 19), which lead to verbal altercations and threats of bodily harm for 4 (#s 7, 18, 32, and 40); and damage to personal property for 2 (#s 12 and 25). Findings include: 1. a. During an observation on 6/11/19 at 11:00 a.m., resident #19 was walking in the hallway near the nurse's station and sat directly next to resident #7, with their legs touching. Residents #19 and #7 were observed whispering to each other, leaving minimal space between their lips and ears. Staff member [NAME] intervened within 30 seconds and walked resident #19 to the bathroom. Staff member [NAME] stated, They both have memory issues. Intervening helps both of them forget. b. During an observation on 6/11/19 at 4:32 p.m., resident #7 was observed to have his arm around the shoulders of resident #19, and was rubbing her upper arm, very near her left breast. Staff member D was sitting next to them in a high back recliner, visiting with the residents, but did not separate the contact. Refer to F656 - Comprehensive Care Plan, for resident #7's behavior. Review of resident #19's Progress Note, dated 3/9/19, showed, At approximately 0500, resident (#19) came out of her room. normally she comes down to the nurses station and sits in one of the chairs. tonight another male resident was also up, sitting on the couch by the nurses station, resident stated I'm staying away from the guys. they push me in the corner and take my clothes off'. 'they need to keep their hands off or I will kick them.' resident directed to another chair, staff member with her, and she had a snack. will continue to monitor. (sic) Review of resident #19's Care Plan, revised 6/12/18, reflected, The resident has impaired cognitive function and impaired thought processes R/T dx of dementia E/B impaired decision making, Long-term memory loss; and lack of orientation to time and place. (sic) For interventions under this category, the care plan showed, resident needs supervision with all decision making. During an interview on 6/12/19 at 10:58 a.m., staff member C explained she had concerns about resident #7's wandering and sexually inappropriate behaviors. Staff member C stated, We keep (resident #7) in close sight because he doesn't have boundaries. (Resident #7) walked into a resident's room while care was being provided. (Resident #7) has definitely kissed (resident #19) on the cheek. Staff member C stated, Staff must take resident #19 by the hand and lead her away from situations that put her at risk. Both residents have severe dementia. Staff member C stated, It's a delicate situation, and the facility wanted to respect the resident's rights to have relationships. Staff member C stated, We had the Ombudsman come and conduct an in-service on sexuality. During an interview on 6/11/19 at 11:25 a.m., staff member D explained she did not know resident #7 was prone to aggressive and invasive behaviors prior to his admission into the facility, and (the staff) started noticing behaviors almost immediately. Staff member D explained staff had been checking on resident #7 every 15 minutes and stated, (The 15 minute check) intervention has been successful, but (resident #7) still likes to go into others' rooms. Staff member D stated resident #7 had not been physically agressive towards others, but he has threatened (physical aggression), and, he has kissed residents on the lips and touched their behinds. He'll ask them on dates; he asked a CNA to lay in the bed with him. Staff member D stated she was concerned about the safety of other residents now. During an interview on 6/11/19 at 11:51 a.m., staff member C stated she was unaware of resident #7's pattern of wandering and other aggressive behaviors at the time of admission. Staff member C stated resident #7's pattern of wandering has persisted and has been intrusive at times, and she is concerned for his safety and others. Staff member C stated that the facility's current interventions of frequent checks and knowing resident #7's whereabouts have been effective in that the wandering behaviors have decreased. Staff member C stated that resident #7 had tried to kiss female residents, but his behaviors has tamed, somewhat. Staff member C stated they were currently working on a discharge plan for resident #7. c. During an interview on 6/13/19 at 10:50 a.m., resident #18 stated resident #7 had entered his room on at least one occasion and had made threatening comments. Resident #18 stated, (Resident #7) has threatened me before, about a few weeks back. (Resident #7) said that he's going to pull my head off! Resident #18 stated he was concerned that resident #7 would enter his room again. d. During an interview on 6/12/19 at 11:17 a.m., resident #37 stated resident #7 had been in her room and was laying on her bed. The resident patted the bed beside him, encouraging her to lay down. She said she told him to get out of her room. Resident #37 stated resident #7 stated the room was his and was not leaving. Resident #37 had to have staff come and get him out. e. During an interview on 6/11/19 at 9:55 a.m., resident #25 stated resident #7 entered her room and stated he thought she .you need a little, I'll go slow with you . The resident told him to get out of her room. Resident #7 stated he did not have to get out, he owned the building. Review of resident #7's Progress Note, dated 4/26/19, showed, Resident has been wandering into other resident rooms. (Resident #7) has threatened to punch both (resident #40) and (resident #18). When staff attempts to remove (resident #7) from other resident rooms, (resident #7) states that this is 'my house,' get your hands off off me. will continue to monitor. (sic) Review of Facility Reported Incidents, dated 2/25/19 at 10:43 a.m., showed, (Resident #32) reported he had knowledge of two male residents on his hall whom sexually take advantage of women residents whom do not have the mental capacity to give consent. (Resident #32's) therapist met with (resident #40), whom told the therapist that (resident #19) comes into his room and that he has gotten her to do things for him sexually, that he is unable to fully perform sexually, but that he gets a rise out of it. Review of resident #32's interview with law enforcement, on 2/25/19 at 10:43 a.m., showed the resident told law enforcement he was upset with what he had seen in the hallway. Resident #32 reported that resident #40 had bragged about getting resident #19 to touch her private parts with her cold hands. Resident #32 stated resident #40 told him that resident #19 would not perform oral sex on him. Resident #32 stated he knew of two or three times that this had happened. Resident #19 would go into resident #40's room. Resident #32 stated resident #38, resident #36, and resident #40 were touching people. Resident #32 stated resident #40 stated he had only been successful with resident #19. Resident #32 stated resident #36 had patted resident #9 on the breast. Resident #32 stated he had heard resident #14 say I need a man and stated that resident #19 had stated that too. Review of an interview with resident #40, conducted by facility staff on 2/25/19 at 1:15 p.m., showed resident #40 stated resident #19 comes into his room all hours of all day and night. Resident #40 was asked if he had ever touched resident #19 inappropriately, and resident #40 stated, Heck ya I do. Resident #40 stated that resident #19 touched him too. Resident #40 stated he knew resident #19 was not capable of a relationship, there is nothing there. Resident #40 stated he had never gone into resident #19's room. Resident #40 stated, They need to keep them out of other peoples rooms. During an interview on 6/10/19 at 4:12 p.m., resident #40 stated, A lot of different residents are in and out of my room. They take stuff, there is really no way to stop it. I have had the stop sign forever. The wackos don't pay any attention to the stop sign. The walker in front of the resident's door is to help deter residents that wander. Resident #40 stated, I won't snitch on people, but I am doing pretty good right now. Resident #40 would not expand in detail on the incident that occurred in February. During an interview on 6/12/19 at 11:18 a.m., NF2 stated she was aware of the 2/25/19 incident and the allegations involving resident #19 and resident #40. NF2 stated the facility had told her they were going to contact the police, but she had not heard anything since. NF2 expressed wanting an update after the investigation had been completed; she stated, I just want to make sure there are interventions in place that will prevent this from happening in the future. NF2 continued, I'm pretty sure his room is close to hers . NF2 denied knowledge of any other incidents with male residents since 2/25/19. During an interview on 6/11/19 at 9:50 a.m. resident #12 stated she tried to stay in her room to protect her room from resident #7 wandering and taking her belongings. Resident #12 said she was unable to do many activities outside her room, related to having to watch her room. During an interview on 6/12/19 at 10:49 a.m., NF3 stated she was advised of male resident behaviors towards her family member earlier in the year. During an interview on 6/12/19 at 3:48 p.m., staff member C confirmed that resident #7's and resident #19's rooms were located directly across the hall from one another. Staff member C stated, (Staff) haven't had any issues with them living across the hall. (Staff) have not noticed (resident #19) wander into (resident #7's) room. (Resident #7) chooses to sleep out here by the main hallway. Review of resident #14's Progress Note, dated 2/25/19 at 4:26 p.m., showed LATE ENTRY Resident reported to LMSW that (resident #14) may have been taken advantage of sexually. Reporting individual (resident #32) said that other resident (resident #40) has tried to ger her to play with him but she won't. Resident assessed and no trauma noted to vulnerable areas. Resident has not exhibited acute change in emotions. She has advanced dementia and unable to be interviewed. Will observe for tearfulness, fear of other residents, change in behaviors. Care planned to redirect from entering othr (sic) residents room. Report has been submitted with APS, State Hotline, Law Enforcement, MD, family. Review of resident #14's Progress Notes, dated 3/20/19 at 5:30 p.m., showed (staff member H), reported to writer that Resident was found in DR standing in front of a male Resident's WC and he was touching her breast(s) over her clothing. Resident removed from situation. Facility Administrator, DON, MD, Ombudsman (attempted-VM to call facility), family and APS notified. Review of resident #7's Progress Note, dated 4/21/19 showed resident #7 was seen by facility staff kissing resident #14 on the couch in front of the nursing station. Staff was able to redirect resident #7 immediately. Review of resident #7's Progress Note, dated 4/21/19 showed at approximately 9:15 p.m., (Resident #7) was seen walking over to (resident #19). (Resident #7) asked (Resident #19) to look up at him, when she did, he kissed her on the lips. Staff quickly seperated (Resident #19) from (Resident #7) and walked him to his room. Will continue to monitor. Review of #7's Care Plan, with a revision date of 2/27/19, showed, The resident has impaired cognitive function/dementia or impaired thought process R/T Dementia, impaired decision making, long-term memory loss, short term memory loss, poor judgement. Under Interventions, the Care Plan showed, Monitor/document/report to health care provider any changes in cognitive function, specific changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty expressing others, level of consciousness, mental status. Resident needs assistance with all decision making. A review of the facility's policy titled, Abuse and Neglect showed under the heading .Policy .The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This is not limited to freedom of corporal punishment and involuntarry seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, location employees, other residents, consultants or volunteers, employees of other agencies serving the resident, family or legal guardians, friends, or other individuals .",2020-09-01
739,GOOD SAMARITAN SOCIETY - MOUNTAIN VIEW MANOR,275084,10 MOUNTAIN VIEW DR,EUREKA,MT,59917,2019-06-13,656,D,0,1,VX7011,"Based on interview and record review, the facility failed to develop a plan of care for inappropriate verbal and physical sexual behaviors towards female residents and implement interventions to assist in preventing further occurrences for 1 (#7) of 19 sampled residents. Findings include: During an interview on 6/11/19 at 11:25 a.m., staff member D stated resident #7 had been in the facility for a couple of months. Staff member D stated, The information was not given to us that (resident #7) had wandering or behavior issues; he was admitted to the facility from the hospital. Almost immediately we started seeing behaviors. (Resident #7) was exit-seeking and wandering, especially during the night. We started fifteen-minute checks, and 1:1 at night. We also got activities involved. Staff member D stated she felt like the interventions had been successful because resident #7 doesn't wander as much and has not had exit-seeking behaviors. (Resident #7) still does like to go into other resident rooms. He thinks the facility is his house, so he goes in rooms, and tries to shut off lights to save energy. Staff member D stated, (Management staff) brought (resident #7's guardian) in, and informed her about the behaviors and wandering, and that he needed a locked unit. (Resident #7's guardian) was receptive in understanding the behaviors the resident had been having. Staff member D stated, (Resident #7) has been sexually inappropriate, kissing female residents on the lips, and grabbing their bottoms. He will ask female residents out on dates and has asked a CNA to lay in bed with him. We are concerned about the safety of the other residents and that is why we called the discharge meeting. He is on the waiting list for the locked unit at another facility, and the facility said it would probably be late (MONTH) before they could get him admitted . During an interview on 6/11/19 at 11:47 a.m., staff member [NAME] stated (resident #7) is inappropriate with the (female residents), and he was getting chummy with (resident #19). During an interview on 6/11/19 at 11:51 a.m., staff member C stated, (Resident #7) has tried to kiss some of the female residents and has been inappropriate with the staff by asking them on dates. Staff member C stated the interventions in place to prevent the inappropriate behavior were knowing resident #7's whereabouts, and doing frequent checks. Review of resident #7's Care Plan, with a revision date of 2/27/19, lacked a behavioral care area with goals and interventions for sexually inappropriate behaviors. The Care Plan lacked documentation concerning #7's whereabouts and frequent checks.",2020-09-01
740,GOOD SAMARITAN SOCIETY - MOUNTAIN VIEW MANOR,275084,10 MOUNTAIN VIEW DR,EUREKA,MT,59917,2019-06-13,684,D,0,1,VX7011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to frequently assess and monitor a reddened area, located over a boney prominence of the spinal process, that was identified during the admission skin assessment, for 1 (#34) of 19 sampled residents. Findings include: During an interview and observation on 6/13/19 at 9:37 a.m., resident #34 stated she was independent with her cares, but staff would assist when she needed it. Resident #34 stated she was admitted to the facility because she fractured her back at home. Resident #34 lifted up the back of her shirt to show where she had fractured her back, revealing a bright reddened area to her upper spine. Resident #34 had a notable hump over the upper spine where the reddened area was located. Review of resident #34's Admit Data Collection Form, dated 5/20/19, showed the resident had red areas over spinous process [MEDICATION NAME] vertebrae (sic). During an observation and interview on 6/13/19 at 11:23 a.m., staff member B examined resident #34's back, and stated, That (the reddened area) does blanch, it is also the site of where the [MEDICATION NAME] is placed, in the meantime the physician gave me an order to apply skin prep over the (the reddened area on resident #34's boney prominence). Staff member B stated, (Resident #34) should be on a weekly skin check, but when she came in, redness was noted over the spinal processes. I think (facility staff) just didn't log (weekly skin checks) in. Well, (documentation of skin checks) should be in the nursing notes, but I don't see that information here. If (weekly skin checks) is put in the computer as an intervention, it will come up when (the skin check) is due. (The weekly skin checks for new admissions) will usually populate through the MDS and through the admission assessment, the skin check should generate. Staff member B randomly selected another resident on the computer who was currently in the facility. Staff member B selected the Assessments tab for the resident that was selected, and it was observed the resident had an intervention of skin observation. Review of resident #34's profile, under Assessments, on the facility's software program, lacked the skin observation intervention. Review of resident #34's Care Plan, with a revision date of 6/13/19, showed, The resident has the potential for pressure ulcer development R/T kyphotic posture with boney prominences, limited mobility. Red area [MEDICATION NAME] spine w/loose skin tag. The Care Plan did not show interventions to monitor or perform skin assessments for the reddened area on resident #34's [MEDICATION NAME] spine. A review of the facility's policy, titled, Skin Assessment, Pressure Ulcer Prevention and Documentation Requirements, showed under the heading .Purpose: -To systematically assess residents with regard to risk of skin breakdown, -To accurately document observations and assessments of residents, -To appropriately use prevention techniques and pressure redistribution surfaces on those residents at risk for pressure ulcers.",2020-09-01
741,GOOD SAMARITAN SOCIETY - MOUNTAIN VIEW MANOR,275084,10 MOUNTAIN VIEW DR,EUREKA,MT,59917,2019-06-13,867,D,0,1,VX7011,"Based on interview and record review, the facility failed to identify, plan, implement interventions, and monitor a quality deficient practice related to alleged verbal and sexual abuse for cognitively impaired residents. This failure had the potential to affect any resident at the facility. Findings include: During an interview on 6/13/19 at 8:10 a.m., when asked if abuse issues had been identified earlier in the year and added to QAPI, staff member C stated, Abuse training (was) offered, but (it's) not in QAPI as a defined plan. She stated they are going through the process and trying to protect resident rights during investigations. During an interview on 6/13/19 at 8:30 a.m., when asked how changes are monitored for sustainability, staff member C stated changes are reviewed monthly at QAPI to see if they are effective and if additional changes are needed. Staff member C stated facility specific issues of wandering and abuse had not been added into the facility's QAPI plan. During an interview on 6/13/19 at 8:50 a.m., staff member C stated, We didn't add abuse as a formal one in QAPI, but we should have and taken credit, since a lot of training has been completed. Review of the Facility's 2019 QAPI Plan, under the heading Data Monitoring Plan, showed adverse events/incidents were to be reviewed monthly by staff member C to identify and address high volume, high risk, and problem prone processes. The QAPI Plan showed the data will be communicated with the QAPI Committee Members through the QAPI Committee Meeting and the facility's standup meeting that is held weekly. The QAPI Plan did not address recent issues with alleged abuse or recurrent incidents of residents wandering into other residents' rooms. Refer to F600 - Abuse, related to alleged verbal and sexual abuse concerns.",2020-09-01
742,GOOD SAMARITAN SOCIETY - MOUNTAIN VIEW MANOR,275084,10 MOUNTAIN VIEW DR,EUREKA,MT,59917,2016-12-15,154,E,0,1,VOVS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents receiving [MEDICAL CONDITION] medications were fully informed of the risks versus benefits of the medications for 4 (#s 1, 2, 3, 4) of 10 sampled residents. Findings include: 1. Review of resident #3's (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the resident's medical record did not show evidence of the resident being informed of the potential side effects and benefits of receiving the medication. In an interview on 12/14/16 at 8:50 a.m., staff member B said they had not thought to address medications the resident was admitted on until now. 2. Review of resident #4's (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the resident's medical record did not show evidence of the resident being informed of the potential side effects and benefits of receiving the medication. In an interview on 12/14/16 at 5:15 p.m., staff member B said due to the resident being admitted on the medication we don't have evidence of the resident being informed of the risks and benefits of the medication. 3. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. She did not have a PO[NAME] A review of an Admission MDS, with an ARD of 5/10/16, reflected the resident had a BIMS score of 11; moderately impaired. Her speech was clear, she was able to make herself understood, and she was able to understand others. A review of a Quarterly MDS, with an ARD of 11/11/16, reflected the resident had a BIMS score of 11; moderately impaired. A review of the resident's (MONTH) (YEAR) MAR indicated [REDACTED]. A review of the resident's care plan, initiated on 5/6/16, page 6, read, The resident uses psychopharmacological medications R/T (sic) dx (sic) of [MEDICAL CONDITION] w/psychotic features and catatonia E/B quetiapine, [MEDICATION NAME] and [MEDICATION NAME] use. Interventions read, Discuss with health care provider, family re (sic) ongoing need for use of medication. Dose increased 11/29/16. Observe for decrease in paranoia, improved participation in self cares, improved appetite. A review of the resident's medical record did not include documentation that the resident received education regarding the risks and benefits of taking [MEDICATION NAME] or [MEDICATION NAME]. During an interview on 12/14/16 at 3:30 p.m., staff member C stated the facility had not provided education to the resident regarding the risks and benefits of treatment relating to [MEDICATION NAME] or [MEDICATION NAME]. 4. Resident #2 was admitted to the facility with a [DIAGNOSES REDACTED]. A review of an Annual MDS, with an ARD of 5/6/16, reflected the resident had a BIMS score of 11; moderately impaired. Her speech was clear, she was able to make herself understood, and she was able to understand others. A review of a Quarterly MDS, with an ARD of 11/4/16, reflected the resident had a BIMS score of 11; moderately impaired. She usually made herself understood and she was able to understand others. A review of the resident's (MONTH) (YEAR) MAR indicated [REDACTED]. A review of the resident's medical record did not include documentation that the resident received education regarding the risks and benefits of taking [MEDICATION NAME] and [MEDICATION NAME]. During an interview on 12/13/16 at 11:30 a.m., resident #2 stated she had not received education regarding the risks and benefits of taking [MEDICATION NAME] and [MEDICATION NAME]. During an interview on 12/14/16 at 3:30 p.m., staff member C stated the facility had not provided education to the resident regarding the risks and benefits of treatment relating to the use of [MEDICATION NAME] and [MEDICATION NAME]. On 12/15/16 at 8:50 a.m., an attempt was made to speak with the resident's PO[NAME] A message was left on the POA's voice mail but a return call was not received.",2020-09-01
743,GOOD SAMARITAN SOCIETY - MOUNTAIN VIEW MANOR,275084,10 MOUNTAIN VIEW DR,EUREKA,MT,59917,2016-12-15,280,D,0,1,VOVS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to revise the care plan in regards to the resident's falls for 1 (#4) of 10 sampled residents. Findings include: Review of resident #4's medical record showed the resident's [DIAGNOSES REDACTED]. Review of the resident's (name of facility) progress note dated 7/23/16 showed resident was found sitting on the floor of his room, next to his recliner and his wheel chair. resident (sic) stated that he got out of recliner, lost balance, and went to sit in his wheel chair. wheel (sic) chair rolled out from under him, and resident sat on the floor. possible (sic) bruise to left lower back area. no (sic) complaints of pain or discomfort voiced. will (sic) continue to monitor. Review of the (name of facility) progress note, dated 7/25/16, showed Discussed residents (sic) recent fall on 7/23 at risk management meeting. Resident was attempting to self transfer from recliner chair to wheelchair, when the wheelchair rolled back apparently. The group discussed anti-roll back bar, but due to his oxygen tank this is not a possibility. Staff will make sure wheelchair brakes are always locked and staff to be vigilant about using the tab alarm when in the recliner, wheelchair and bed. Review of the resident's (name of facility) progress note, dated 9/5/16. showed This nurse observed res (sic) sitting on foot pedals in front of his table in the DR. 3 person assist with gait belt to sit him back into chair. Assessed for injuries, Res (sic) continues to be confused but in good mood. Review of a (name of facility) progress note, dated 9/6/16, showed Residents (sic) recent falls on 9/4 and 9/5 discussed at risk management meeting .On 9/5 resident was seated in his wheelchair at the dinning (sic) room table. Resident stood from his wheelchair and pushed his wheelchair back slightly and lost his balance fell on to his bottom, landing sideways on his foot pedal of his wheelchair. No injuries or reports of pain. Care plan updated for both falls. The intervention for the fall on 9/5 is assure that the residents (sic) breaks (sic) are locked on his wheelchair while seated at the dinning (sic) table. Staff education provided on new interventions (sic) Review of the resident's care plan showed there was a Focus area for falls which included Interventions with a revision date of 9/9/16. The interventions showed Lock wheelchair breaks (sic) while seated at the dinning (sic) room table. Review of the care plan did not reflect evidence of the Risk Management's suggestion that wheelchair brakes always be locked 7/25/16. In an interview on 12/15/16 at 9:25 a.m., staff member B said it should have been carried forward from the risk management meetings that the wheelchair brakes be locked all the time.",2020-09-01
744,GOOD SAMARITAN SOCIETY - MOUNTAIN VIEW MANOR,275084,10 MOUNTAIN VIEW DR,EUREKA,MT,59917,2016-12-15,281,D,0,1,VOVS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to follow physician orders [REDACTED].#7), and continued to use a multi-dose vial of insulin past the expiration (opened) date for 1 (#8) of 10 sampled residents. Findings include: 1. Resident #7 was admitted to the facility with a [DIAGNOSES REDACTED]. During an observation on 12/13/16 at 9:50 a.m., staff member D administered eye drops to the resident. The staff member instilled one drop in each eye. A review of the directions printed on the medication box for the eye drops read, [MEDICATION NAME] Acetate 1% - instill 1 drop in right eye three times a day. A review of the resident's (MONTH) (YEAR) MAR indicated [REDACTED]. Start date 12/7/16 1000. The resident received 25 doses of [MEDICATION NAME] drops in both eyes by multiple facility staff members. During an interview on 12/13/16 at 9:57 a.m., staff member D stated the resident's orders for eye drops had changed last week. She stated the original order was for one eye drop in the right eye, but new orders were for one drop in each eye. During an interview on 12/13/16 at 12:01 p.m., staff member B stated a new order for eye drops had been received on 12/6/16. The order was for one eye drop to be administered to the right eye only. She stated all orders were to be reviewed and updated, if needed, every 24 hours by the night nurse. She stated the order update for the eye drops was missed during the 24 hour check. A review of the resident's Clinical Referral Physician orders, dated 12/6/16, read, (Continue) PA 1% QID OD x 2 wks then Taper (sic) by 1 gtt per wk F/U 1 month. Facility staff documented a 24-hour review had been conducted on 12/7/16 at 3:00 a.m. A review of the facility's 24-hour chart check procedure, provided on 12/13/16 at 12:19 p.m., read, .4. The 24-hour chart check is completed on night shift and all orders are doubled (sic) checked for accuracy. If a medication was discontinued, please make sure the medication is removed from the medication cart. 5. All medication with tapering doses, or stop date, will be checked against the MAR for accuracy of dosing. A review of the facility's Physician/Practitioner orders policy, revised 11/2016, read, Purpose: To provide individualized care to each resident by obtaining appropriate, accurate and timely physician/practitioner orders. To provide a procedure that facilitates the timely and accurate processing of orders. 2. Resident #8 was admitted to the facility with a [DIAGNOSES REDACTED]. During an observation on 12/13/16 at 10:50 a.m., staff member D collected a random blood glucose sample from the resident's right middle finger. The staff member stated the resident would require one unit of sliding scale insulin per the sliding scale. During an observation on 12/13/16 at 11:00 a.m., two multi-dose 10 milliliter bottles of insulin, one Humalog, and one [MEDICATION NAME], were in the medication cart. Each bottle had an opened date of 11/8/16. During an interview on 12/13/16 at 11:05 a.m., staff member D stated the opened date of 11/8/16 exceeded the 28-day expiration date for insulin. During an interview on 12/15/16 at 8:33 a.m., staff member [NAME] stated opened multi-dose vials of insulin, kept at room temperature, were to be dated, and used within 30 days after the opened date. The staff member stated the efficacy of the insulin, and the stability of the preservatives used, could be altered if used past 30 days. A review of the resident's (MONTH) (YEAR) MAR indicated [REDACTED]. These doses were administered by multiple facility staff members. A review of the facility's Insulin Administration procedure, revised 5/2016, read, .3. Check label on vial carefully to ensure correct type of insulin and date vial was opened.",2020-09-01
745,GOOD SAMARITAN SOCIETY - MOUNTAIN VIEW MANOR,275084,10 MOUNTAIN VIEW DR,EUREKA,MT,59917,2016-12-15,441,F,0,1,VOVS11,"Based on observation, record review and interview the facility failed to ensure the separation between dirty and clean linen during sorting to ensure prevention of infection transmission. This deficiency had the potential to affect all residents, staff and visitors in the facility. Findings include: During an observation on 12/14/16 at 7:55 a.m., staff member F removed clean laundry from the washer. There were two dryers and 3 washers in this room. A few feet away was the room with the soiled laundry. The door, between the washer and dryer room, and the sorting room, had an automatic hold open device but the door was blocked open with bags of soiled laundry. Staff member F left the clean wet laundry in a basket just outside the dryer. Staff member F then began sorting the laundry with the door open between the soiled sorting area and the clean laundry/linen side. The facility's policy and procedure for the laundry was attached to the bulletin board on the wall between the washers and dryers. Review of the policy and procedure showed Soiled linen should be handled as little as possible and with minimum agitation to prevent gross microbial contamination of the air .Wherever located, the soiled linen processing area must be separate from clean linen storage .clean supply and equipment storage. The laundry facility should be designed to enhance the separation of clean and soiled functions and be supported by appropriate ventilation to prevent mixing of air between these areas. Methods to achieve separation: Functional separation may be achieved by one or more methods, including physical barriers, negative air pressure systems in the soiled linen area, or positive airflow from the clean linen area to the soiled linen area. In an interview on 12/14/16 at 8:00 a.m., staff member G said following a discussion with a technician from [NAME]on Controls indicated the sorting area should have negative air flow and so it was shut off in the sorting area.",2020-09-01
746,POWDER RIVER MANOR,275087,104 N TRAUTMAN,BROADUS,MT,59317,2018-03-09,636,E,0,1,DHBE11,"Based on record review and interview, the facility failed to ensure nutrition assessments were completed with the annual or significant change MDS for 8 (#s 3, 7, 9, 12, 14, 17, 20, and 28) of 22 sampled and supplemental residents. Findings include: A review of the resident assessments for #s 3, 7, 9, 12, 14, 17, 20, and 28, showed: 1. Resident #7 had a Significant Change MDS with an ARD of 6/16/17. Review of resident #7's assessments in PCC failed to show a nutrition assessment had been completed for that Significant Change MDS. 2. Resident #28 had a Significant Change MDS with an ARD of 1/26/18. Review of resident #28's assessments in PCC failed to show a nutrition assessment had been completed for that Significant Change MDS. 3. Resident #14 had a Significant Change MDS with an ARD of 7/15/17. Review of resident #14's assessments in PCC failed to show a nutrition assessment had been completed for that Significant Change MDS. 4. Resident #12 had a Significant Change MDS with an ARD of 12/26/17. Review of resident #12's assessments in PCC failed to show a nutrition assessment had been completed for that Significant Change MDS. 5. Resident #3 had an Annual MDS with an ARD of 8/25/17. Review of resident #3's assessments in PCC failed to show a nutrition assessment had been completed for that Annual MDS. 6. Resident #20 had an Annual MDS with an ARD of 8/4/17. Review of resident #20's assessments in PCC failed to show a nutrition assessment had completed for that Annual MDS. 7. Resident #17 had an Annual MDS with an ARD of 7/21/17. Review of resident #17's assessments in PCC failed to show a nutrition assessment had been completed for that Annual MDS. 8. Resident #9 had an Annual MDS with an ARD on 6/23/17. Review of resident #9's assessments in PCC failed to show a nutrition assessment had been completed for that Annual MDS. During an interview on 3/8/18 at 1:57 p.m., staff member C said she would go into PCC weekly and check on which residents had nutrition assessments that were due. Staff member C said the residents who needed nutrition assessments showed up with red writing to alert her to the nutrition assessments that needed to be done. Staff member C opened PCC and went through each resident in the facility. No alerts in red writing were identified in PCC for nutrition assessments that needed to be completed. Staff member C said she did not understand what was going on. Staff member C said some of the residents in the facility would certainly be due to have nutrition assessments done. Staff member C said she had done nutrition assessments for the residents identified above but had no explanation why their nutrition assessments were not in PCC.",2020-09-01
747,POWDER RIVER MANOR,275087,104 N TRAUTMAN,BROADUS,MT,59317,2018-03-09,655,D,0,1,DHBE11,"Based on record review, observation, and interview, the facility failed to address oral care services on the base-line care plan for 1 (#7) out of 14 sampled residents. Findings include: During an observation on 3/8/18 at 9:05 a.m., resident #7 was transferred from her recliner with a Hoyer lift and two person assistance, to her bed. Resident #7 had her eyes closed and did not participate in the transfer process. She was not able to participate in any of the cares the staff assisted her with. Review of resident #7's Admission MDS, with an ARD of 11/13/17, showed she required total assistance of two persons physical assistance with transfers, hygiene, locomotion, and bathing. During an interview on 3/9/18 at 8:02 a.m., staff member G stated he followed the CNA Worksheet for resident #7. He stated resident #7 was NPO, and he had performed her oral care with a toothette. Review of resident #7's initial baseline care plan did not show the facility addressed the resident's oral care needs or level of assistance needed.",2020-09-01
748,POWDER RIVER MANOR,275087,104 N TRAUTMAN,BROADUS,MT,59317,2018-03-09,656,E,0,1,DHBE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure comprehensive care plans were completed for the following: for measurable goals for interventions regarding exhibited behaviors, and having those concerns addressed individually in a focus area for 1 (#4); for a goal, and interventions to address depression and [MEDICAL CONDITION] medication for 1 (#10); for a focus, goal, and interventions to address a significant weight loss for 1 (#19); and failed to have a care plan to address a resident's [DIAGNOSES REDACTED].#7) of 14 sampled residents. Findings include: 1. Resident #4 was admitted with [DIAGNOSES REDACTED]. Review of resident #4's Annual MDS, with an ARD of 8/25/17, reflected his cognitive skills for daily decision making were severely impaired. Behavioral symptoms reflected resident #4 exhibited physical behavioral symptoms directed towards others 1-3 days out of the seven day look back period. Rejection of care reflected resident #4's behaviors of this type occurred 1-3 days out of the seven day look back period. Resident #4's Functional Status reflected he required extensive two person physical assistance for bed mobility, transfers, locomotion, dressing, eating, and toileting. The Care Area Assessment Summary reflected Dementia and Behavioral Symptoms were included in the care planning process. Review of resident #4's Quarterly MDS, with an ARD of 2/23/18, reflected resident #4 continued to exhibit physical behavioral symptoms directed towards others 1-3 days out of the seven day look back period. Review of resident #4's care plan showed one focus area: I am unable to care for myself because of dementia and muscle weakness, they cause variances in mental and physical functioning throughout the day and night and also make me a high fall risk. Goals listed included: I will participate in at least part of my cares each day through next review, I will have no major injuries from falls through next review, and I will be active in facility outside of room at least once per day other then meals. There was neither a goal for behaviors and resisting care, nor a focus area to specifically address the issue of behaviors. Review of resident #4's current MAR indicated [REDACTED]. A gradual dose reduction, signed 12/15/17, by resident #4's provider, showed a do not taper as clinically contraindicated. Review of resident #4's Nursing Progress notes, titled Behavior Note, from 3/4/17 through 2/23/18, reflected several entries that described the resident exhibiting hitting and kicking staff during cares, and refusals to take his prescribed medications. The entries did not include the interventions staff tried according to resident #4's care plan to decrease the physical aggression and/or refusal of his medications. During an interview on 3/8/18 at 2:39 p.m., staff member B stated the facility did not have a formal IDT team or meeting. She stated staff meet for the care plan meeting only. She stated she reviewed the nurse's notes and other department notes and then wrote a comprehensive note for each scheduled MDS. She stated she could see where she should break down the interventions into a focus area with separate goals. 2. Review of resident #10's physician monthly orders, dated 10/1/17, showed the resident was started on [MEDICATION NAME] 50 mg every day for a [DIAGNOSES REDACTED]. Review of resident #10's Quarterly MDS, with an ARD of 9/29/17, showed the resident had received an antidepressant for all seven days of the look back period. The MDS also showed the resident had a [DIAGNOSES REDACTED]. Review of resident #10's Quarterly MDS, with an ARD of 6/30/17, did not show the resident had a [DIAGNOSES REDACTED]. Review of resident #10's care plan, with a revision date of 2/5/18, failed to show the facility had developed and implemented a care plan, to include a focus, goal, and interventions, to address resident #10's depression and his use of a [MEDICAL CONDITION] medication. During an interview on 3/9/18 at 8:13 a.m., staff member B said all goals and interventions were on the care plans for the residents. Staff member B said she did not break down the focus areas into specific areas. Staff member B said, I guess I'll have to start doing that. During an interview on 3/9/18 at 8:25 a.m., staff member A said the facility did not have a policy regarding care plan development, implementation, and revision. 3. Review of resident #7's Quarterly MDS, with an ARD of 12/1/17, showed the resident had a [DIAGNOSES REDACTED]. Review of resident #7's current care plan, with a revision date of 12/11/17, failed to show the facility had initiated a focus, goals, and interventions that addressed resident #7's dementia. During an interview on 3/9/18 at 9:45 a.m., staff member B said she did not know residents with a specific [DIAGNOSES REDACTED]. 4. Resident #19 was admitted with [DIAGNOSES REDACTED]. Review of resident #19's Significant Change MDS, with an ARD of 1/19/18, section K300, weight loss, showed resident #19 had a weight loss which was checked as not prescribed. Review of resident #19's care plan showed weight loss was not identified as a focus area, and did not have person centered goals or interventions. During an interview on 3/08/18 at 1:56 p.m., staff member C said she did not participate in care plan meetings for the residents. Staff member C said she interviewed residents and family members about the resident's food preferences, diet textures, and fluids, and she passed that information on to the MDS Coordinator. Staff member C said the MDS Coordinator added that information to the resident's care plan.",2020-09-01
749,POWDER RIVER MANOR,275087,104 N TRAUTMAN,BROADUS,MT,59317,2018-03-09,710,D,0,1,DHBE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to make sure that the primary physician was aware of a significant change in weight, which included gain and loss for 1 (#18), and for a loss of weight, for 1 (#19) of 14 sampled residents. Findings include: 1. Resident #19 had [DIAGNOSES REDACTED]. During an observation and interview on 3/6/18 at 4:52 p.m., resident #19 was sitting in a wheel chair in the activity room. Resident #19 stated he was not on a special diet and had no concerns regarding his weight loss. Resident #19 felt he was maintaining his weight. During an interview on 3/7/18 at 8:25 a.m., staff member [NAME] said resident #19 was eating better today. Review of resident #19's Weight Summary sheet for April, May, June, July, August, September, October, November, (MONTH) (2017), January, February, and (MONTH) (2018), showed the resident had a significant weight loss for January, February, and (MONTH) (2018). During an interview on 3/7/18 at 1:58 p.m., resident #19's NF1 stated resident #19 had lost weight. NF1 said resident #19 frequently ate only a couple of bites of food. The resident was offered other choices but he refused the food. NF1 was not sure about what the doctor knew. During an interview on 3/8/18 at 3:55 p.m., staff member F stated the administrator or the ADON would notify the physician and/or the family or the nursing staff would do this. Review of resident #19's Progress Note from the dietician on 2/27/18 at 1:53 p.m., showed the resident had a significant weight loss, but did not show the weight loss was discussed with the physician. No documentation was provided, prior to the end of the survey, to show the physician had been notified of resident #19's weight loss. 2. Resident #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of resident #18's Weight and Vitals Summary, dated 3/8/18, showed a weight loss of 10% in (MONTH) and another 10% in (MONTH) compared to September's weight of 152.8 pounds and July's weight of 153.2 pounds. The medical record for the resident showed: Review of resident #18's Progress Note, dated 7/27/17, showed the resident had gained weight since admission, and the plan was to give the resident smaller portions to stop the weight gain. No documentation was found to indicate the physician had been notified, by the facility, of resident #18's weight gain. Review of resident #18's Progress Note, dated 11/28/17, showed the resident had lost weight, which was 8-10 pounds, and to continue current care plan. No documentation was found to show the physician had been notified of resident #18's weight loss. Review of resident #18's Progress Note, dated 2/27/18, showed she was taken off the small portions diet and she was to be monitored for weight gain. Review of resident #18's Progress Note, dated 2/28/18, showed, per dietician small portions were discontinued and to monitor weight. Review of resident #18's Progress Note, dated 2/12/18, showed staff member B wrote resident #18 triggered a ten percent weight loss in (MONTH) (YEAR), and triggered another weight loss in (MONTH) (YEAR). There was no documentation the physician was notified of these weight losses. During an interview on 3/9/18 at 10:00 a.m., staff member A stated the facility did not have a policy and procedure for notification of physician and families when changes occur with residents. Staff member A said that information, such as weight changes, may have been passed on to the physician from the administrator's email. No documentation was provided prior to the end of the survey to show the physician was notified of the resident's significant weight changes.",2020-09-01
750,POWDER RIVER MANOR,275087,104 N TRAUTMAN,BROADUS,MT,59317,2018-03-09,908,E,0,1,DHBE11,"Based on observation and interview, the facility failed to ensure a suction machine, used for emergency code operations was maintained to ensure it was in working condition for any resident in need of suctioning. Findings include: During an observation and interview on 3/8/18 at 10:23 a.m., the facility suction machine, used for residents that were in a medical emergency status (respiratory arrest), was observed in the medication room, and it was covered with a plastic bag. Staff member F stated the staff checked the suction machine to ensure it was in working condition. She stated a log for the checks was kept in the medication room. Staff member F stated she was unable to find the log showing it had been checked to ensure it was in working order. A written request was made for the log. No documentation was submitted, prior to the end of the survey, that showed the suction machine was maintained and working.",2020-09-01
751,POWDER RIVER MANOR,275087,104 N TRAUTMAN,BROADUS,MT,59317,2019-05-02,600,D,0,1,YPC911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent elopements from the facility for 1 (#9) and; the facility failed to protect 1 (#9) of 14 sampled residents from verbal and physical abuse by another resident. Findings include: 1. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of nursing progress notes showed: -12/15/18 showed: (Resident name) told CNA that he was going out to move him (sic) pickup around so the sun would melt the frost off. (Resident name), in fact, left the Manor property. Sheriffs (sic) office was called and they checked on him. Message left on daughter (name) telephone and I did visit with daughter (name). (Daughter's name) stated she just talked to her Dad and asked him if he had received a package she mailed to him so she thinks he may be headed to the post office. (Resident name) returned to the facility moments later accompanied by Deputy Sheriff. -12/28/18 showed: Resident came to NS and spoke with this RN. Stated, 'I am going to check out here. I got to go to the bank and a couple other places. (Name) is going to go with me. It will be a little bit before I go because (name) has a doctor appt (sic) so Im (sic) guessing about an hour.' RN reported this to (name). Appox (sic) an hour later CNA and HR person reported to this RN that resident had got in his truck and drove off alone. Resident just returned to facility 20 mins (sic) ago in his truck. No one was with him. Reported this to (name) DON/Admin (sic). -1/13/19 showed: Resident got into his pickup and drove off of facility property. Staff did try to stop him and remind him that he is not to drive. He just waved them off and told them he is was (sic) just going to the arena. Sheriff's Office notified and will make contact with him. Attempted to contact daughter (name) via telephone, her husband answered and said she is on her way into town to visit her folks. Review of resident #9's Wandering Risk Scale, dated 8/17/18, showed the resident had a score of 9 which indicated the resident was at a risk to wander. Review of resident #9's baseline care plan, dated 8/17/18, showed, under the Safety heading, Will still be driving self even though poor eye sight. During an interview on 5/2/19 at 7:16 a.m., staff member A said the facility had not identified resident #9 leaving the facility as an elopement. Staff member A said the resident did not have a valid driver's license. Staff member A did not have an answer for why the facility had contacted the Sheriff's department when the resident left the facility in his pick-up. Staff member A said the family had allowed the resident to have his pick-up at the facility. The staff member said the family had taken resident #9's pick-up home several months ago. 2. Review of resident #12's behavior notes showed: - 9/1/18, resident #12 was hitting, kicking and yelling at resident #9, and - 12/4/19, resident #12 was verbally and physically abusive (slapping) to resident #9, and - 1/5/19, resident #12 was cursing resident #9, she grabbed him by the hand and arm, and would not let him go, and - 3/2/19, resident #12 was yelling at resident #9, and attempted to hit resident #9 prior to staff intervention, and -3/10/19, resident #12 slapped resident #9 in the face. During an interview on 5/2/19 at 7:16 a.m., staff member A said she did not think of resident #12 yelling, cussing, and slapping resident #9 as abusive because she had been like that to him all of their lives together. Staff member A said resident #9 did not think resident #12 was abusing him and would laugh at that if you were to ask him about it. Review of the facility's policy, Abuse Prevention, Investigation, and Reporting of Resident Abuse, dated (MONTH) (YEAR), showed: -Policy: Each resident had the right to be free from abuse, corporal punishment, and involuntary seclusion. Resident must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, . The facility's policy failed to address elopement as a concern.",2020-09-01
752,POWDER RIVER MANOR,275087,104 N TRAUTMAN,BROADUS,MT,59317,2019-05-02,604,D,0,1,YPC911,"Based on observation, interview, and record review, the facility failed to provide on-going monitoring and evaluation for the continued use of a physical restraint, failed to reassess the effectiveness of the intervention, and failed to review and revise the resident's care plan for the restraint showing the need for the restraint, and to ensure it was not utilized for staff convenience or discipline, for 1 (#12) of 14 sampled residents. Findings include: During observations on 4/30/19 at 9:00 a.m. and 4:10 p.m., resident #12 was observed in the activities room with a wander guard on her right wrist. The resident did not appear to be wandering at the time. During an observation on 5/1/19 at 8:04 a.m., resident #12 was eating breakfast. Her wheelchair had the the wander guard in place. During an observation on 5/1/19 at 2:28 p.m., resident #12 was observed sleeping in bed, and the wander guard was on her right wrist. During an interview on 5/1/19 at 8:35 a.m., staff member [NAME] stated the wander guard for resident #12 was used because the resident went to the end of the hallways, to the doors, but was too weak to open the doors herself. During an interview on 5/1/19 at 9:53 a.m., staff member D explained the wander guard was used for the resident's exit seeking behavior, and she had made it outside in the past. During an interview on 5/1/19 at 1:29 p.m., staff member C stated a risk assessment for elopement was completed when any new admission came into the facility. The information was then reflected on the resident's baseline care plan. She did not know of a set protocol regarding the on-going evaluation of efficacy for the wander guard, and she did not have a specific assessment to monitor the effectiveness of the restraint. She did not know why the wander guard was not documented on resident #12's MDS or care plan. No steps had been taken by the facility to minimize or eliminate the use of the restraint for the resident, to her knowledge. During an interview on 5/1/19 at 1:15 p.m., staff member A explained the wander guard for resident #12 was used because the resident was a wanderer, but did acknowledge there have been zero instances of elopement. The wander guard was placed at the time of admission. No formal assessment had been completed to monitor the ongoing need for the restraint, which the resident was wearing daily. However, if it had went off at any point, there was a need for it. There had been no efforts to minimize or eliminate the use of the restraint for the resident. Review of resident #12's progress notes showed no documentation to support the continued need for the device. No exit seeking behaviors or elopements had been documented. Review of resident #12's most current MDS, with an ARD of 02/15/19, showed no documentation of the resident having the restraint in place. Review of resident #12's most current care plan, dated 3/18/19, had no mention of the restraint. Review of the Wandering Risk Assessment, dated 8/17/18, for resident #12, showed in the instructions, Complete on admission, readmission, at 72 hours, and one month later, with change of condition and annually on all residents. For residents at risk or high risk to wander, update quarterly. The initial risk assessment for resident #12, dated 8/17/18, showed resident #12 was at high risk for wandering. The 72 hour assessment for resident #12 was completed on 8/20/18 and showed the resident was still at a high risk for wandering. No further assessments were completed. Review of Powder River Manor Patient Care Alarm Policy showed: -2. POA/Resident, Nursing, Medical Director, or Provider to verify the use of the alarm is appropriate and documented in the Care Plan. -6. If the patient care alarm is not serving the purpose of the prevention/safety for the resident, a care-plan meeting will be scheduled and the efficacy of the patient care alarm will be either altered or discontinued with agreement of resident/POA and Medical Director. During an interview on 5/1/19 at 3:30 p.m., staff member A, stated she did not have an updated abuse policy that included both physical and chemical restraints. Review of the facility's policy, Abuse Prevention, Investigation, and Reporting, dated (MONTH) (YEAR), showed: -Policy: Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. The policy identified the types of abuse as: verbal abuse, sexual abuse, physical abuse, mental abuse, involuntary seclusion, negligence, and misappropriation of resident property, but the use of restraints was not included in the policy.",2020-09-01
753,POWDER RIVER MANOR,275087,104 N TRAUTMAN,BROADUS,MT,59317,2019-05-02,609,D,0,1,YPC911,"Based on interview and record review, the facility failed to identify and report allegations of elopement and abuse for 1 (#9) and failed to report abusive behaviors exhibited by 1 (#12) of 14 sampled residents. Findings include: 1. Review of resident #9's nursing progress notes showed: -12/15/18: (Resident name) told CNA that he was going out to move him (sic) pickup around so the sun would melt the frost off. (Resident name), in fact, left the Manor property. Sheriffs (sic) office was called and they checked on him. Message left on daughter (name) telephone and I did visit with daughter (name). (Daughter's name) stated she just talked to her Dad and asked him if he had received a package she mailed to him so she thinks he may be headed to the post office. (Resident name) returned to the facility moments later accompanied by Deputy Sheriff. -12/28/18: Resident came to NS and spoke with this RN. Stated, 'I am going to check out here. I got to go to the bank and a couple other places. (Name) is going to go with me. It will be a little bit before I go because (name) has a doctor appt (sic) so Im (sic) guessing about an hour.' RN reported this to (name). Appox (sic) an hour later CNA and HR person reported to this RN that resident had got in his truck and drove off alone. Resident just returned to facility 20 mins ago in his truck. No one was with him. Reported this to (name) DON/Admin (sic). -1/13/19: Resident got into his pickup and drove off of facility property. Staff did try to stop him and remind him that he is not to drive. He just waved them off and told them he is was (sic) just going to the arena. Sheriff's Office notified and will make contact with him. Attempted to contact daughter (name) via telephone, her husband answered and said she is on her way into town to visit her folks. Review of resident #9's Wandering Risk Scale, dated 8/17/18, showed the resident had a score of 9 which indicated the resident was at a risk to wander. During an interview on 5/2/19 at 7:16 a.m., staff member A said the facility had not identified resident #9 leaving the facility as elopements. Staff member A said the facility did not report these incidents to the state agency since the facility had not identified them as elopements. 2. Review of resident #12's behavior notes showed: - 9/1/18, resident #12 was hitting, kicking and yelling at resident #9, and - 12/4/18, resident #12 was verbally and physically abusive (slapping) to resident #9, and - 1/5/19, resident #12 was cursing resident #9, she grabbed him by the hand and arm, and would not let him go, and - 3/2/19, resident #12 was yelling at resident #9, and attempted to hit resident #9 prior to staff intervention, and -3/10/19, resident #12 slapped resident #9 in the face. During an interview on 5/2/19 at 7:16 a.m., staff member A said she did not think of resident #12 yelling, cussing, and slapping resident #9 as abusive because she had been like that to him all their lives together. Staff member A said resident #9 did not think resident #12 was abusing him and would laugh if you were to ask him about it. Staff member A said the facility had not reported these incidents to the state agency because she did not think of them as abuse. 3. Review of resident #12's Behavior note, dated 9/1/18 at 3:24 p.m., showed resident #12 was yelling, hitting, kicking at staff and other residents. Review of resident #12's Monthly Summary, dated 10/3/18, showed resident #12 had been verbally and physically combative with staff and family, and has tried to attack other residents where staff had to get in between to keep her from hitting them but instead getting beat up themselves. Review of resident #12's Monthly Summary, dated 11/3/18 at 1:28 a.m., showed, resident has been combative, biting, verbally and physically abusive to staff and family on a daily basis. During an interview on 5/2/19 at 7:30 a.m., staff member F said abuse is reported to the nurse then the nurse tells the Director of Nursing. During an interview on 5/2/19 at 7:45 a.m., staff member D said the process for reporting alleged abuse was report allegation to the supervisor and give the supervisor a written account of the allegation of abuse. The supervisor would look it over and decide on a case by case if it was to be submitted to the state. Review of the facility's policy, Abuse Prevention, Investigation, and Reporting of Resident Abuse, dated (MONTH) (YEAR), showed: -Investigation: 2. The Administrator and/or Director of Nursing will notify immediately the State Department of Public Health and Human Services (Licensing and Certification) at . 6. The Administrator notifies the County Commissioners, Montana State Department of Public Health, the appropriate licensing agency, the family or responsible party, the local and State Ombudsman. -Reporting: 7. Notify the State Department of Public Health and Human Services of the results of all substantiated or unsubstantiated investigations within 5 working days of the incident.",2020-09-01
754,POWDER RIVER MANOR,275087,104 N TRAUTMAN,BROADUS,MT,59317,2019-05-02,623,D,0,1,YPC911,"Based on interviews and record review, the facility failed to provide a written explanation, to the resident's representative and the Office of the State Long-Term Care Ombudsman, of the reason for the facility initiated transfer, for 1 (#21) of 14 sampled residents. Findings include: During an interview on 5/1/19 at 4:45 p.m., staff member B stated written notification to the resident's representative and the Office of the State Long-Term Care Ombudsman was only required when the resident was discharged , not when they were transferred. Review of resident #21's nursing note, dated 3/13/19, showed a telephone notification of the transfer was provided to the resident's daughter, but there was no documentation regarding the reason for the transfer in resident #21's medical record.",2020-09-01
755,POWDER RIVER MANOR,275087,104 N TRAUTMAN,BROADUS,MT,59317,2019-05-02,657,D,0,1,YPC911,"**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 comprehensive care plan for 2 (#s 3 and 12) of 14 sampled residents. Findings include: 1. During an observation on 4/30/19 at 9:00 a.m., resident #3 could be heard repeatedly calling out ma'am, ma'am, ma'am . This repeated vocalization continued until a staff member entered the resident's room to assist her. Resident #3's call light was not on at the time of the observation. During an interview on 5/1/19 at 1:57 p.m., staff member D stated resident #3 had an increase in calling out for approximately two months. She also stated resident #3 was usually not able to identify what she needed assistance with. Staff member D stated resident #3 has had a decline in her functional abilities, and she had an increase in her falls over the past several months. Review of resident #3's Morse Fall Scale assessments, dated 6/27/18, 6/30/18, 9/21/18, 10/26/18, 1/18/19, 2/5/19, 2/12/19, and 3/25/19, all showed resident #3 was a High Fall Risk. The form, dated 10/26/18, showed resident #3 had a history of [REDACTED]. Review of resident #3's MDS, with an ARD of 10/26/18, showed she had sustained her first fall. This coincided with the Morse Fall Scale dated 10/26/18. Review of resident #3's activities of daily living care plan, showed an intervention, added 12/11/19, related to the use of a bed alarm, and she has . history of falls getting up from bed to go to the toilet . The current care plan did not address fall prevention strategies until 12/11/18. Review of resident #3's comprehensive care plan showed a Falls care plan was not initiated until 2/1/19, although the resident had fallen prior to this. 2. During an observation on 4/30/19 at 9:00 a.m., resident #12 was observed in the activities room with a wander guard on her right wrist. The resident also had a tabs alarm in place on the chair, and it was attached to her clothing, both considered restraints, if not utilized properly. During an interview on 5/1/19 at 1:29 p.m., staff member C said she did not know of a set protocol regarding the on-going monitoring and evaluation of efficacy regarding the Wanderguard for resident #12. She did not know why the wander guard was not documented on resident #12's MDS or care plan. Review of resident #12's most current MDS, with an ARD of 2/15/19, showed no documentation of the resident having a restraint, which was the Wanderguard, in place. Review of resident #12's Baseline care plan, dated 8/16/18, included the restraint, which was the wander guard, as part of the residents care regimen. Review of resident #12's care plans, dated 10/23/18, 12/7/18, and 3/18/19, did not show the restraint (Wanderguard) as being part of the resident's care. Review of Powder River Manor Patient Care Alarm Policy: -2. POA/Resident, Nursing, Medical Director, or Provider to verify the use of the alarm is appropriate and documented in Care Plan. -6. If the patient care alarm is not serving the purpose of the prevention/safety for the resident, a care-plan meeting will be scheduled and the efficacy of the patient care alarm will either be altered or discontinued with agreement of resident/POA and Medical Director.",2020-09-01
756,POWDER RIVER MANOR,275087,104 N TRAUTMAN,BROADUS,MT,59317,2019-05-02,690,D,0,1,YPC911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible, for 1 (#3) of 14 sampled residents. Findings include: During an observation on 4/30/19 at 11:00 a.m., resident #3 requested to leave activities in order to use the toilet. An unidentified activities staff member told her that she had gone 15 minutes earlier. The activities staff member continued to engage resident #3 in activities until 11:30 a.m. Resident #3 did not ask to use the toilet between 11:00 a.m. and 11:30 a.m. During an interview on 5/1/19 at 1:57 p.m., staff member D stated she was unaware of any order to monitor for [MEDICAL CONDITION] for resident #3. Staff member D stated if there was something to monitor, it would . pop up on PCC (electronic health record). Staff member D stated that she did not remember monitoring for [MEDICAL CONDITION] was the expectation for resident #3 after discontinuing the Myrbetriq (medication for overactive bladder). Staff member D stated when resident #3 called out or used her call light, she was unable to articulate her needs and ended up asking to use the toilet. Review of resident #3's physician progress notes [REDACTED]. Review of resident #3's nursing progress notes did not show any documentation for communication with the physician clarifying the need for monitoring the resident for [MEDICAL CONDITION] Review of resident #3's current care plan showed no interventions related to monitoring for [MEDICAL CONDITION].",2020-09-01
757,POWDER RIVER MANOR,275087,104 N TRAUTMAN,BROADUS,MT,59317,2019-05-02,758,D,0,1,YPC911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from PRN [MEDICAL CONDITION] medications that extended beyond 14 days for 2 (#s 4 and 20) of 17 sampled and supplemental residents. Findings include: 1. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #4's Medication Administration Record, [REDACTED]. The PRN Klonopin had not been limited to 14 days. A review of resident #4's medication administration records for (MONTH) 2019, (MONTH) 2019, (MONTH) 2019, (MONTH) 2019, and (MONTH) 2019, showed the resident had not received a dose of the PRN Klonopin for those months. During an interview on 5/1/19 at 8:57 a.m., staff member C said she did not understand why resident #4's PRN Klonopin was still on the medication administration record. Staff member C said the resident had been on a taper of his routine Klonopin and his PRN Klonopin was included in that taper. The staff member reviewed the original taper order for the routine Klonopin and said she would need to call the physician since it was not clear on the PRN Klonopin. Staff member C said the resident had been started on [MEDICATION NAME] and his anxiety had improved greatly, and that was why the physician had started the taper on the Klonopin. During an interview on 5/2/19 at 8:05 a.m., staff member B said resident #4 had not received a dose of his PRN Klonopin in a very long time. During an interview on 5/2/19 at 8:05 a.m., staff member A said the facility was not reviewing PRN [MEDICAL CONDITION] medications in the Quality Assurance and Performance Improvement meeting. 2. Resident #20 was admitted with an anxiety disorder. Review of resident #20's physician orders, dated 3/22/19, showed a PRN order for [MEDICATION NAME] 25 mg orally, every six hours, as needed for panic attacks. Review of resident #20's MAR, dated (MONTH) 2019, showed a PRN order for [MEDICATION NAME]. The order was not limited to 14 days. Resident #20 continued to receive the medication through the month of (MONTH) 2019. Review of all resident #20's physician progress notes [REDACTED]. During an interview on 5/2/19 at 8:05 a.m., staff member A said the facility had not reviewed [MEDICAL CONDITION] and antipsychotic PRN medications for being outside the 14-day time limit. Staff member A said the facility had not identified this as a concern, and it had not been added to the facility's QAPI program. Review of the facility policy Antipsychotic Medication Use, not dated, showed: -14. The need to continue PRN orders for [MEDICAL CONDITION] medication beyond the 14 days requires that the practitioner document the rationale for the extended order and the duration of the PRN order will be indicated in the order. -15. PRN orders for antipsychotic medications will not be renewed beyond the 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication.",2020-09-01
758,POWDER RIVER MANOR,275087,104 N TRAUTMAN,BROADUS,MT,59317,2019-05-02,883,E,0,1,YPC911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to offer or provide PSV-23 for 1 (#19); failed to offer or provide PCV-13 for 4 (#s 7, 17, 19, and 21) and; failed to document the provision of education on influenza, [MEDICATION NAME], and Prevnar vaccinations for 5 (#s 7, 11, 17, 19, and 21) of 17 sampled and supplemental residents. Findings include: During an interview on 5/2/19 at 8:49 a.m., staff member A stated there was no documentation, in the medical record, of vaccination education provided to the resident and/or the resident's representative prior to the administration of the influenza, PCV-13, and PSV-23 vaccines. During an interview on 5/2/19 at 8:49 a.m., staff member B stated she was aware there needed to be at least one year between the administration of the PCV-13 and PSV-23 vaccines. Review of resident #7's immunization record showed no PCV-13 had been offered or provided. The record showed [MEDICATION NAME] Dose 1 (PSV-23) had been given on 7/1/16. Therefore, PCV-13 should have been offered or provided after 7/1/17. Review of resident #17's immunization record showed no PCV-13 had been offered or provided. The record showed [MEDICATION NAME] Dose 2 (PSV-23) had been given 11/8/16. Therefore, PCV-13 should have been offered or provided after 11/8/17. Review of resident #19's immunization record showed no PCV-13 or PSV-23 had been given. Neither of these vaccinations were documented as offered or provided. Review of resident #21's immunization record showed no PCV-13 had been offered or provided. The record showed [MEDICATION NAME] Dose 1 (PSV-23) had been given on 12/22/16. Therefore, PCV-13 should have been offered or provided after 12/22/17. Review of resident #s 7, 11, 17, 19, and 21, records failed to show any documentation of education provided to the resident or resident's representative related to vaccinations.",2020-09-01
759,POWDER RIVER MANOR,275087,104 N TRAUTMAN,BROADUS,MT,59317,2016-11-03,226,E,0,1,9VHU11,"Based on interview and record review, the facility failed to ensure staff were trained on the necessary components of abuse, before allowing the staff to perform resident care. This occurred for 7 of 7 sampled employees (I, J, K, L, M, N, & O) hired between 3/1/16 and 10/14/16. This failure, directly affected 1 (#11) resident, who had a fall after being left alone on the commode; and this failure had the potential to affect all resident's who received care from these staff members. Findings include: During a review of personnel files for staff members I, J, K, L, M, N, & O, it was found that only three files contained employee signed copies of the facility's resident rights. None of the files included evidence that the new employees received abuse education prior to resident contact or performance of resident care. During an interview on 11/2/16 at 2:20 p.m., staff member A said that the facility did not require or provide abuse education to the new employees, to include the types of abuse, abuse reporting requirements, or investigation on abuse, before the new staff were allowed to work with the residents. New employees were educated concerning abuse when they completed their computer education requirements, and attended mandatory staff continuing education. The topic of abuse was covered once a year when the computer education modules were scheduled, and was one of the twelve topics covered in the monthly mandatory staff continuing education sessions. The employees may not have received the initial abuse education until the topic of abuse was scheduled, and taught during the year. Computer education was done on demand to accommodate individual employee schedules. New employees, who were contracted staff members, were not provided abuse education by the facility, and the facility had to contact the contracted staff vendors to determine if abuse education had been completed, and this had not occurred. During an interview on 11/2/16 at 4:00 p.m., staff member P described an unwitnessed fall by resident #11. On 9/16/16, the resident had been placed on the commode in his room bathroom and then left alone with the bathroom door closed. He was found later by another staff member on the floor, uninjured, in front of the commode at approximately 1:29 p.m. Staff member P stated the employees, staff members I and J, who placed the resident on the commode, were recent hired as nurse aides. Staff member P said new employees are not given abuse education by the facility during orientation or before initiation of resident contact or provision of resident care. A review of resident #11's progress note for 9/16/16, revealed charting for the investigation of an unwitnessed fall at 1:29 p.m. The charting indicated that the CNA's, staff I and J, were educated regarding not leaving resident #11 on the commode alone, and on the concept of abuse and neglect. A review of personnel files showed staff member I was hired on 3/15/16, and staff member J was hired 3/17/16. Both were hired to provide patient care, and neither personnel file included abuse education.",2020-09-01
760,POWDER RIVER MANOR,275087,104 N TRAUTMAN,BROADUS,MT,59317,2016-11-03,279,D,0,1,9VHU11,"**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 comprehensive care plan, in coordination with the Kardex Reports (facility care guide), and ensure the two documents accurately reflected the resident's status, and coordination of care, to ensure the resident's received the necessary care and services to reach their highest practicable level of well-being for 2 (#s 3 & 4) of 10 sampled residents. Findings include: 1. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. He had nutritional deficiencies and a gastrotomy PEG tube (percutaneous endoscopic gastrostomy tube) used to provide liquid feedings directly to the resident's stomach. a. During an observation on 11/2/16 at 12:30 p.m., of resident #4's room environment, it was noted that a MDS Kardex Report (care guide) for the resident was taped on the inside of the resident's closet door. The report was dated 6/10/16, and used as a quick access guide for staff for the provision of resident care. Review of resident #4's progress notes showed on 4/21/16 at 3:25 p.m., the resident was found in his room on the floor after an unwitnessed fall, with bruising to his left cheek and forehead, and an abrasion to his left elbow. A review of resident #4's physician hospitalization notes, dated 4/26/16 at 1:55 p.m., revealed that an x-ray of the resident's left hip on 4/29/16, done four days after resident #4's fall, showed a left femoral neck fracture. The resident underwent [REDACTED]. A review of resident #4's Physical Therapy Progress notes and Discharge Summary, dated 6/10/16, cautioned that the resident's hip should not be flexed over 90 degrees, that he should not cross his legs, and that he should not be positioned in excessive internal or external rotation. Staff member R stated in this report, Pt's (patient's) orthopedic physician reported that he would be unlikely to repair a hip dislocation if one were to occur, so that it is paramount that positions of dislocation and falls are prevented . A review of the resident's MDS Kardex Report, posted in the closet of the resident's room, showed the following concerns; - The document lacked evidence to show the resident was at risk for falls, or had experienced falls. - The document lacked evidence relating to the physical therapist's precautions to prevent a hip dislocation, which was from a prior left [MEDICAL CONDITION], or the physicians concerns with a potential future dislocation. b. A review of resident #4's care plan and nutrition progress notes showed the resident had a PEG tube, which had been in place since his admission to the facility. The medical record reflected in 2010 that the resident started taking small amounts of an oral pureed diet, and he had tolerated it well. A review of resident #4's (MONTH) (YEAR) MAR indicated [REDACTED]. Resident #4's Kardex Report did show the resident had a feeding tube but the report did not show the PEG tube was being utilized for nutrition. A handwritten entry on the Kardex showed an entry of pureed (diet texture) with honey to pudding thick liquid. The Kardex did not show that the resident received an oral intake of food. It was unclear upon review of the document if the pureed diet was to be given orally or through the feeding tube. The Kardex did not show that resident #4 had a [DIAGNOSES REDACTED]. c. A review of resident's #4's care plan, dated 9/12/16, showed the resident's PEG tube site often became irritated, and reflected a history [MEDICAL CONDITION] at the site. A review of resident #4's TAR (treatment administration record) for (MONTH) (YEAR), showed the resident's PEG tube site was ordered to be cleaned with warm soapy water, rinsed, and covered with dry drain gauze two times a day. A review of the resident's Kardex did not show that the resident was ordered to have his PEG tube site cleansed or dressed twice a day, or that the PEG site had been positively cultured [MEDICAL CONDITION]. There were no precautions documented on the Kardex for the potential spread [MEDICAL CONDITION] to the resident or others when the dressing changes occurred. 2. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. He came to the facility with a right artificial knee, bilateral artificial hip joints, and a cardiac pacemaker. During a review of resident #3's medical record, a copy of the resident's pacemaker wallet card was observed. A review of the resident's Kardex Report, located in the resident's closet, did not show the resident had a cardiac pacemaker or give precautions regarding resident care because he had a pacemaker. A review of resident #3's care plan, dated 7/16/16, did not show that the resident had a cardiac pacemaker. During an interview on 11/2/16 at 6:30 p.m., staff member P stated the Kardex Reports in the residents closets used to be correct, but now most of them had not been updated, and they do not show accurate information as to what cares and services were to be given to the individual residents. During an interview on 11/3/16 at 10:15 a.m., staff member S spoke about a book, which was kept at the nurses' station, that contained up to date care plans for all the residents. Staff were to review the book at shift change each day so they would be aware of changes made to individual care plans for the residents. The book was also available for new employees to learn specific resident care needs. Staff member S stated that the Kardex Reports had been removed from the residents room closets because they were not current or updated.",2020-09-01
761,POWDER RIVER MANOR,275087,104 N TRAUTMAN,BROADUS,MT,59317,2016-11-03,281,D,0,1,9VHU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility staff failed to use the five rights of drug administration to assure medication administration accuracy; specifically, when a staff member mixed a medication into a glass of juice, gave it to the resident with instructions to drink all of it, but failed to determine whether the resident actually swallowed any of the juice with medication in it, for 2 ( #6 and #8) of 10 sampled residents. Findings include: 1. During an observation and interview of a medication administration pass for resident #8 on 10/2/16 at 11:45 a.m., staff member Q used the appropriate MAR, and measured and poured [MEDICATION NAME] powder ,17 grams, into a glass of approximately 100 cc of fruit juice. She gave the drink and medication to the resident, and voiced instructions for her to be sure to drink the entire amount of juice. She told the resident she had mixed medication with the juice. She left the resident sitting at the dining room table eating her lunch. The resident did not drink any of the juice with medication but the resident finished her meal, drank all of her coffee, and left the table at 12:27 p.m. The glass of juice with medication remained on the table. Staff member Q was asked to come to the dining room at 12:29 p.m. She observed the full glass of juice on the table, and stated she would take it to resident #8 and make sure she drank it. Staff member Q later reported that resident #8 had taken all of the juice with [MEDICATION NAME] in it. She said she had not returned to verify the resident had taken the medication after she gave it to her initially. A review of resident #8's (MONTH) (YEAR) MAR's showed [MEDICATION NAME] was to be given to the resident at 12:00 p.m., and mixed in her coffee and not in juice. The correct dosage had been given in juice, but not coffee. The nurse documented it had been given within an appropriate timeframe for the 12:00 p.m. ordered time. 2. During an observation of a medication administration pass for resident #6 on 10/2/16 at 12:00 p.m., staff member Q used the appropriate MAR, measured, crushed, and poured [MEDICATION NAME]/APAP 10-325 tab, Metoclopram 5 mg tab, and [MEDICATION NAME] 10 mg tab, into a glass of approximately 100 cc of fruit juice. The nurse presented it to resident #6 who was eating. She placed it on the table near the resident, and told the resident she had mixed the medication for her in the juice. Staff member Q left the resident. The resident sipped the juice with the medication in it while eating her lunch. It was noted that staff member Q did not return to the resident to verify whether the juice had been swallowed before the empty glass the medication had been in was returned to the kitchen for washing. During the medication pass, staff member Q poured the medications, and checked that the drugs given were the right drugs ordered. She did not actually observe that the medications were swallowed by the residents she gave them to, that the entire amount of juice with the full dosage prescribed for the resident was taken, that the medication had been taken orally, or what time the medication was actually received by the resident's. REFERENCES: S. DeLaune & [NAME] Ladner, Fundamentals of Nursing, Standards and Practice, Albany, N.Y., 1998, pg. 237. Nurses are obligated to follow the orders of a licensed physician or other designated health care provider unless the orders would result in client harm. Ann Perry and [NAME] Potter, Clinical Nursing Skills and Techniques, 5th ed., Mosby, Inc., St. Louis-Missouri, 2002, pgs. 442, 445. Preparing and administering medications requires accuracy by the nurse .Accuracy is greatest when the nurse observes the five rights of administration. 1. The right drug. 2. The right dose. 3. The right client. 4. The right route. 5. The right time .Each time a drug dose is prepared the nurse refers to the MAR (medication administration record) .",2020-09-01
762,POWDER RIVER MANOR,275087,104 N TRAUTMAN,BROADUS,MT,59317,2016-11-03,363,D,0,1,9VHU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the approved menu was followed to meet the nutritional needs of all residents in the facility, and failed to ensure the meal met the consistency as prescribed and indicated on the plan of care for 1 (#1) out of 10 sampled residents. Findings include: 1. During an observation on 11/1/16 at 5:00 p.m., residents were served their supper meal. The meal included an 8 oz. cup of potato soup, an orange wedge, 4 crackers, and a serving of pineapple. Residents receiving a pureed diet received pureed apricots instead of the pineapple. Review of the menu submitted to the survey team reflected the RD had signed off on the menu, approving it, on 1/17/14. The menu reflected the supper meal was to be Canadian bacon pizza, cook's choice, cottage cheese, pineapple, and a beverage. During an interview on 11/3/16 at 8:55 a.m., staff member C stated she discovered the kitchen staff had been using the menu signed off in 2014, and not the current menu the registered dietician had approved and signed on 1/27/16. In an interview on 11/2/16 at 8:55 a.m., staff member C stated the registered dietician was comfortable with her picking the foods for the meal when serving the cook's choice. Staff member C stated the menu choices, and changes, were not reported to the dietician for approval before being served. Staff member C stated the supper meal of potato soup was the cook's choice, and probably should have included a sandwich to ensure it met all food group and nutritional needs. Review of the menu approved and signed by the registered dietician on 1/27/16, reflected residents were to receive Canadian bacon pizza, cottage cheese, pineapple, and a beverage. The cook's choice was not included on the menu. During an interview on 11/3/16 at 11:00 a.m., staff member B stated it was her understanding that cook's choice was preplanned, discussed, and approved by the registered dietician. Review of the facility Menu's policy, showed the menus would meet the nutritional needs of residents, be prepared in advance, and be followed. The policy reflected the dietician would review and approve all menus. 2. Resident #1 had a [DIAGNOSES REDACTED]. During an observation on 11/1/16 at 5:00 p.m., resident #1 was being assisted with her meal. Staff members D and H were confused regarding the resident's requirement for thickened liquids. Staff member D asked staff member H what resident #1 required for thickened liquids. Staff member H answered this was her first day back, and she was not sure. During an interview on 11/1/16 at 5:50 p.m., staff member D stated she could ask the kitchen what the resident was supposed to have for her thickened liquids. Staff member D stated she was a [MEDICATION NAME] (contracted employee), and was not accustomed to mixing the thickened liquids for residents. Staff member D stated she was used to the kitchen staff mixing the thickened liquids in other facilities she had worked at. Staff member D pulled out a resident pocket care plan and stated she could look on that. Staff member D showed the surveyor the resident's pocket care plan. The pocket care plan did not reflect what the resident's dietary needs were. Staff member G was seated next to staff member D and H. She stated she was not sure where the care plans were kept but each resident had one on the inside door of their closet. Staff member G stated she was not sure if it included the resident's dietary needs. During an interview on 11/2/16 at 8:55 a.m., staff member C stated the kitchen just started mixing the thickened liquids on 10/27/16. Staff member C stated she was not sure why the kitchen staff did not prepare the thickened liquids for the supper meal on 11/1/16. During an interview on 11/2/16 at 2:00 p.m., staff member C submitted a copy of the notice to kitchen staff dated 10/27/16 instructing the kitchen staff to prepare all the thickened liquids. Staff member C stated it was a new process and should have been done on 11/1/16 for the supper meal. During an interview on 11/3/16 at 11:00 a.m., staff member B stated information was shared in a CNA meeting on 10/27/16, notifying the nursing staff dietary staff would prepare the thickened liquids. Staff member B stated she was not sure if the staff that did not attend the meeting were notified but she would find out. Staff member B stated she would have staff that didn't participate in the training be trained that day.",2020-09-01
763,POWDER RIVER MANOR,275087,104 N TRAUTMAN,BROADUS,MT,59317,2016-11-03,365,D,0,1,9VHU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provided the correct diet textures, as ordered by the physician, for 2 of (#s 5 and 9) of 10 sampled residents. Findings include: 1. Resident #5 was admitted with [DIAGNOSES REDACTED]. During an observation on 11/1/16 at 11:37 a.m., resident #5 was served one half of a Reuben sandwich, and cole slaw. Resident #5 was observed drinking regular fluids. During a review of resident #5's clinical record, a written order stated the resident was to have a mechanical soft diet with nectar thick liquids. The order was dated 10/21/16. During an observation on 11/1/16 at 5:15 p.m., resident #5 was served a cup of potato soup, whole saltine crackers, and liquids that had been thickened. The resident had asked for a cup of coffee, and staff member D was observed pouring a white substance from a glass container into resident #5's cup of coffee. Resident #5 had stated that she did not want anything in her coffee. Staff member D was attempting to thicken resident #5's coffee with the white substance when another staff member told staff member D that it was not the Thicket in the glass jar but sugar. During an interview on 11/1/16 at 6:00 p.m., staff member D said she was a contracted staff member, and it had been awhile since she had worked at the facility. During an observation on 11/2/16 at 11:40 a.m., resident #5 was served chopped ham, whole cooked mixed vegetables, and German potato salad. All of resident #5's liquids had been thickened. During an interview on 11/2/16 at 11:45 a.m., staff member E, who was assisting resident #5, said she had been taught if a food item could be mashed with a fork, then it was mechanical soft. Staff member [NAME] said the mixed vegetables, and the potato salad could be mashed with a fork, but the ham could not be so that is why the ham was chopped. During an observation on 11/3/16 at 8:20 a.m., resident #5 was eating breakfast. Resident #5 had been served oatmeal, soft eggs, whole toast, and a whole hash brown patty. Resident #5's fluids were thickened. During an interview on 11/3/16 at 9:30 a.m., staff member C said the meat for the Reuben sandwiches, served on Tuesday for lunch, had been run through the food processor along with the sauerkraut. Staff member C said the Reuben sandwich was then grilled. Staff member C said the hash browns, served that morning for breakfast, were soft since they were baked rather than fried. Staff member C said resident #5 liked her toast in the morning, and that she wouldn't eat it if it was chopped up. Staff member C said resident #5 was not a person who would eat ground meat. Staff member C said she had never thought about having nursing staff contact the physician to clarify a diet order. 2. During an observation on 11/2/16 at 11:35 a.m., resident #9 was eating chopped ham, and her liquids were thickened. During an interview on 11/2/16 at 12:00 p.m., staff member F said resident #9's diet was mechanical soft, and the chopped ham should have some kind of gravy on it. During an interview on 11/2/16 at 12:05 p.m., staff member [NAME] said resident #5's food was chopped. Staff member [NAME] said the resident had chopped meat, chopped mixed vegetables, and chopped German potato salad. Staff member [NAME] could not explain why resident #5 and resident #9, who both had mechanical soft diets, had different textured foods on their plates. During on observation on 11/2/16 at 5:15 p.m., resident #9 was sitting in the activity room with two family members. Resident #9 had her dinner, and her family member was feeding her. Resident #9's food was a pureed hot dog and pureed beets. During an interview on 11/3/16 at 9:45 a.m., staff member C said resident #9 should have chopped meats, and thickened liquids as needed. Staff member C said resident #9 could drink thin liquids some days, and on other days she needed thickened liquids. Staff member C said resident #9's hot dog and beets should not have been pureed, and she would have to ask the cook why she had served resident #9 pureed foods. Staff member C said the cook would not come on shift until 11:00 a.m. that day. During an interview on 11/3/16 at 10:40 a.m., staff member C said she had talked to the cook and the cook stated she always pureed resident #9's food when family members were feeding her. Staff member C said the cook was fearful of the family members feeding resident #9 mechanical soft foods and causing the resident to choke. During a review of resident #9's clinical record, a written order stated the resident was to have a regular diet, mechanical soft texture, and regular fluid consistency. The order was dated 3/2/16. Another written order showed the resident was to have thicken (sic) liquids prn. The order was dated 9/6/16. During an interview on 11/3/16 at 11:25 a.m., staff member C said the registered dietician had provided a document that was to be followed for mechanically altered diets. Staff member C provided a copy of this document. Review of the document titled Dysphagia Level 2: Mechanically Altered, showed: -This diet consists of foods that are mechanically altered by blending, chopping, grinding, or mashing so that they are easy to chew and swallow. -Foods in large chunks or foods that are too hard to be chewed thoroughly should be avoided.",2020-09-01
764,POWDER RIVER MANOR,275087,104 N TRAUTMAN,BROADUS,MT,59317,2016-11-03,371,F,0,1,9VHU11,"Based on observation, interview and record review, the facility failed to ensure sanitary conditions were maintained for bulk foods by failing to ensure scoops were not stored in the bulk flour and the sugar bin. This had the potential to affect all residents the facility provided meals for. Findings include: During an observation on 11/1/16 at 8:57 a.m., scoops were stored inside of the bulk flour and sugar bin. During an interview on 11/1/16 at 9:05 a.m., staff member C stated the scoops would not continue to be stored in the bins. Review of the Food Receiving and Storage policy reflected all foods shall be stored in a manner that complied with safe food handling practice",2020-09-01
765,BEARTOOTH MANOR,275090,350 W PIKE AVE,COLUMBUS,MT,59019,2018-01-11,550,D,0,1,U25Y11,"Based on observation and interview, the facility failed to treat 1 (#1) of 14 sampled residents with dignity and respect, for a resident who had wanted to make a choice regarding a meal preference. Findings include: During an observation and interview on 1/8/18 at 6:00 p.m., resident #1 refused to eat the chicken salad sandwich she had ordered for the evening meal. Resident #1 said the chicken salad looked like runny baby food. Staff member A was observed speaking to resident #1. Resident #1 received a hamburger on a bun at 6:25 p.m. Resident #1 said the hamburger looked much more appetizing than the chicken salad sandwich she had received earlier. During an interview on 1/9/18 at 1:30 p.m., resident #15 spoke about an incident from 1/8/18, when resident #1 refused to eat her chicken salad sandwich. Resident #15 said resident #1 was approached by staff member A, who asked resident #1 if she had a problem with the chicken salad sandwich. Resident #15 said staff member A told resident #1 it was what she had ordered for dinner. Resident #15 said resident #1 told staff member A she could not eat the chicken salad sandwich because it looked terrible. Resident #1 told staff member A she wanted a hamburger. Resident #15 said staff member A was reluctant to give resident #1 something different to eat. Resident #15 said resident #1 started to cry because staff member A was insisting resident #1 eat what she had ordered. Resident #1 nodded in affirmation of what resident #15 had said. Resident #1 did not want to speak of the conflict she had with staff member A regarding the evening meal on 1/8/18.",2020-09-01
766,BEARTOOTH MANOR,275090,350 W PIKE AVE,COLUMBUS,MT,59019,2018-01-11,580,D,0,1,U25Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to notify the resident and his guardian, and consult with the physician, for a severe weight gain in one month, for 1 (#30) of 14 sampled residents. Findings include: Review of resident #30's physician visit note, dated 12/07/17, showed the resident had a decrease in his weight, and his extremities showed a trace of [MEDICAL CONDITION], but they actually look quite good. Review of resident #30's Weights and Vitals Summary showed he weighed 169.5 pounds on 12/5/17, and on 1/8/18, he weighed 190.5 pounds, a weight gain of 21 pounds in 1 month During an observation on 1/11/18 at 10:21 a.m., resident #30 had [MEDICAL CONDITION], on his lower legs and ankles. During an interview on 1/10/18 at 10:55 a.m., staff member H stated the resident's legs were swollen, and had 2+ or more [MEDICAL CONDITION]. She stated when he elevated his legs, the [MEDICAL CONDITION] improved. She looked through the Physician notification book, and stated the physician had not been notified of the [MEDICAL CONDITION] or severe weight gain of 21.5 pounds in one month. Review of resident #30's EHR lacked evidence the resident and his guardian were aware of the resident's change in status. Review of resident #30's nutrition note, dated 1/09/18, showed triggering for significant gain. Weight had declined to 169.5-176 pounds while he was sick. Now back to 190.5 pounds which is what he was weighing prior to becoming sick. He has had variable weight trends in the past with possibly some of this related to [MEDICAL CONDITION] ([MEDICATION NAME] on board), overall stable. Monitoring weights, and follow-up with additional interventions PRN.",2020-09-01
767,BEARTOOTH MANOR,275090,350 W PIKE AVE,COLUMBUS,MT,59019,2018-01-11,610,D,0,1,U25Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide evidence of a thorough investigation for an allegation of abuse for 1 (#22) of 14 sampled residents, and failed to protect residents from further potential abuse by allowing an alleged abusive employee to continue to work. Findings include: Review of a facility incident report, dated 7/12/17, showed a CNA was reported and witnessed to be physically and verbally abusive to a resident #22. Review of the facility investigation showed the allegation included the CNA yelling at the resident, stating he made her life more difficult, and forcibly placing his foot on the foot plate of the mechanical lift during a transfer. Resident #22 was reportedly saying please please. Review of the facility incident report, dated 7/17/17, showed Through our investigation and interview of cognitive residents and staff members, we have unsubstantiated the abuse allegation toward this resident. Review of the facility Notice of Discipline for the CNA, dated 7/13/17, showed the employee was suspended from 7/13/17 through 7/17/17. It was not documented that the CNA was removed from resident care on 7/12/17. Review of the facility Notice of Discipline for the CNA, dated 8/3/17, showed the employee was provided a Final Warning for rude or discourteous conduct towards a resident, and unacceptable treatment of [REDACTED]. The employee gave a two-week resignation notice, and was allowed to work until 8/15/17, when another allegation of abuse was reported. Review of resident #22's EHR showed he was discharged from the facility on 7/25/17. During an interview on 1/10/18 at 11:00 a.m., staff member A stated the facility did not have documentation to show how the abuse was not substantiated, and had no evidence of education provided to the CN[NAME] When asked why the CNA was given a final warning on 8/3/17, if the abuse was unsubstantiated, she stated corporate employees had conducted the investigation, and staff member A thought the physical abuse had been unsubstantiated, and maybe the verbal abuse had been substantiated.",2020-09-01
768,BEARTOOTH MANOR,275090,350 W PIKE AVE,COLUMBUS,MT,59019,2018-01-11,641,E,0,1,U25Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and observation, the facility failed to accurately reflect the communication and cognitive status for 2 (#s 29 and 30); and the use of anticoagulant medication for 3 (#s 3, 17, and 40) of 22 sampled and supplemental residents. Findings include: 1. Review of resident #30's Significant Change MDS, with the ARD of 12/4/17, showed the resident was always understood and always understands. The Brief Interview for Mental Status showed the resident was rarely/never understood, and was not completed with the resident. The Mood interview was not completed with the resident because it was coded as rarely/never understood. During an observation and interview on 1/9/18 at 9:40 a.m. resident #30 could answer simple questions, and use one word gestures. During an interview on 1/11/18 at 11:10 a.m., staff member [NAME] stated she had miscoded the communication section for resident #30. 2. Review of resident #29's Quarterly MDS, with the ARD of 12/01/17, showed the resident was sometimes understood, and sometimes understands. The cognition and mood sections were coded as rarely/never understands, and the interviews were not attempted for resident #29. During an interview on 1/11/18 at 11:08 a.m., staff member J stated she did not know she should attempt the interview for cognition and mood, and code 99 if the resident was unable to complete the interview. 3. During an interview on 1/9/18 at 1:30 p.m., resident #40 stated she was not receiving [MEDICATION NAME], but she was getting some type of blood thinner. Review of resident #40's (MONTH) (YEAR) MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Review of resident #40's Admission MDS, with an ARD of 12/26/17, showed, in Section N0410E, the resident had received an anticoagulant 7 of 7 days during the look-back period. During an interview on 1/9/18 at 2:48 p.m., staff member C stated she coded resident #40's Admission MDS to show the use of an anticoagulant due to the resident receiving [MEDICATION NAME] Bisulfate, aka [MEDICATION NAME]. She stated she had a reference tool she had received from the pharmacy to identify drugs in selected classifications. Staff member C referenced the document and stated that [MEDICATION NAME] was not on the list of anticoagulants. She stated she used the RAI coding manual as the guideline for coding. She accessed the manual via the facility software program and stated the instruction for N0410E specified that [MEDICATION NAME] was not to be coded as an anticoagulant. Staff member C stated she missed that part of the instructions. She said she does not look at the instructions if she believes she knows the coding for a question, but that she would review the instructions to improve accuracy. Staff member C stated she had coded the MDS inaccurately for resident #40, and she would complete a correction. Staff member C stated she completed this question inaccurately for resident #3, and others as well. 4. Review of resident #17's Quarterly MDS, with an ARD of 11/6/17, showed the use of an anticoagulant 7 of 7 days during the look-back period. Review of resident #17's (MONTH) (YEAR) MAR indicated [REDACTED] During an interview on 1/11/18 at 11:15 a.m., staff member C stated resident #17's MDS was coded inaccurately. 5. Review of resident #3's Quarterly MDS, with an ARD of 10/6/17, showed the resident was receiving anticoagulant therapy. Record review of resident #3's (MONTH) (YEAR) Medication Administration Record [REDACTED] During an interview on 1/10/18 at 10:25 a.m., staff member C said the resident was on [MEDICATION NAME], an anti-platelet medication, not an anti-coagulant. Staff member C said she had miscoded resident #3's Quarterly MDS. Staff member C said she would fix it and would file a corrected MDS.",2020-09-01
769,BEARTOOTH MANOR,275090,350 W PIKE AVE,COLUMBUS,MT,59019,2018-01-11,656,E,0,1,U25Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to develop a comprehensive care plan to describe an effective method of communication, and for a risk of choking, for 1 (#30); failed to address [MEDICAL CONDITION], visual loss, mood, and shortness of breath, for 1 (#40); failed to appropriately address dementia care and needs, for 1 (#14) of 14 sampled residents. Findings include: 1.a. During an interview on 1/8/18 at 1:45 p.m., staff member J stated the facility could communicate fairly well with resident #30, because he had lived at the facility for several years. The resident had a [DIAGNOSES REDACTED]. She stated the resident should be able to be interviewed, and would answer simple questions. She stated if he got frustrated, he would place his hand on his face. During an interview on 1/11/18 at 10:40 a.m., staff member [NAME] stated she had miscoded the communication section on the MDS. The miscoding resulted in the problem for communication not being triggered for development on the care plan. During an interview and observation on 1/9/18 at 9:41 a.m., resident #30 could use gestures and verbalize one word to communicate. He showed, using single words and gestures, that he had some stomach pain, was happy, and had no teeth. Review of resident #30's Care Plan, initiated on 2/11/14, did not include a concern with the resident's ability to communicate. b. Review of resident #30's progress note, dated 11/23/17, showed the resident coughed at breakfast while eating bacon and eggs. He was encouraged by the staff to eat lunch, and started to cough again. He started to vomit. He became more agitated. At 2:12 p.m., his lips turned blue, and he was sent to the ER, for respitory distress from choking. Review of resident #30's History and Physical Report from the hospital, dated 11/24/17, showed the resident had an [MEDICAL CONDITION] food impaction, which resulted in pneumonia. Review of resident #30's progress note, dated 12/15/17, showed he returned to the facility, but he did not have his dentures. Review of resident #30's Nutritional Status Care Plan, revised on 12/6/17, did not reflect the choking episode, the lack of dentures, or the risk of choking. 2. a. During an observation and interview on 1/9/18 at 1:33 p.m., resident #40 stated her legs were painful from being so swollen. She removed the sheet that was covering her lower body. [MEDICAL CONDITION] was visible to both legs. The skin on resident #40's legs was taut and shiny. There was visible redness to the distal portion of her lower legs. Resident #40 stated her legs felt tight, and she said it was difficult to walk. Review of resident #40's Initial Nursing Evaluation, dated 12/19/17, showed 3+ [MEDICAL CONDITION] to both lower extremities. Review of resident #40's nursing progress notes, dated 12/19/17-1/11/18, showed the following: -12/20/17- 5+ [MEDICAL CONDITION] in extremities. -12/21/17, 12/22/17, 12/25/17 and 12/26/17- 3+ bilat (bilateral) LE (lower extremity) [MEDICAL CONDITION]. -12/27/17- Bilateral LE's are extremely [MEDICAL CONDITION], 4+ pitting. -1/1/18- .Bilat LE's are 4+ pitting, red, shiny, warm to touch . -1/4/18- Lower extremity [MEDICAL CONDITION] was severe -1/5/18, 1/6/18, 1/7/18, 1/8/18, and 1/9/18 presence of 3+ bilateral lower extremity [MEDICAL CONDITION]. Review of resident #40's care plan, dated 1/5/18 as the last review date, showed no focus area to address the presence of the [MEDICAL CONDITION], the cause of the [MEDICAL CONDITION], or any interventions to manage the [MEDICAL CONDITION]. b. During an observation and interview on 1/9/18 at 1:51 p.m., resident #40 was sitting in a recliner, leaning forward, with her feet on the floor. She had an overbed table in front of her, and her elbows were on the table. Resident #40 occasionally rested her head in her hands during the conversation. Frequently, she had to stop mid-sentence to breathe or rest. She was using accessory muscles to breathe. She stated her shortness of breath interfered with everything she tried to do. Resident #40 said she could not eat due to her increased difficulty breathing while eating, and her lack of energy from working so hard to breathe. Review of resident #40's Initial Nursing Evaluation, dated 12/19/17, showed resident is SOB (short of breath) all the time, she has [MEDICAL CONDITION] and respirations are labored. Review of resident #40's (MONTH) (YEAR) MAR indicated [REDACTED]. Review of resident #40's (MONTH) (YEAR) MAR indicated [REDACTED]. The (MONTH) (YEAR) MAR indicated [REDACTED]. Review of resident #40's care plan, dated 1/5/18 as the last review date, showed no focus area to address the resident's shortness of breath, the cause of the shortness of breath, effect the shortness of breath had on resident #40's functional abilities, or interventions to treat the shortness of breath. During an interview on 1/11/18 at 8:41 a.m., staff member C stated she was responsible for developing and updating the nursing portions of resident #40's care plan. She stated she definitely needs to get something in her care plan about (resident #40's) shortness of breath and [MEDICAL CONDITION]. Staff member C said resident #40's shortness of breath interferes with her daily functioning. She stated the resident refused to elevate her legs, to manage her [MEDICAL CONDITION]. due to her breathing difficulty. Staff member C stated resident #40's care plan should show her rejection of treatment and alternate interventions. Staff member C stated she had been unable to complete and maintain resident #40's care plan because she was responsible for many tasks in the facility, and there was not enough time to do them all. c. During an interview on 1/9/18 at 1:35 p.m., resident #40 stated she was depressed because of the decline in her health status. She became tearful 3-4 times during the interview, stating she did not believe she would be able to return home. Review of resident #40's (MONTH) (YEAR) and (MONTH) (YEAR) MARs showed she received medication to treat her anxiety 23 times in (MONTH) and 14 times in January. Review of resident #40's care plan, dated 1/5/18 as the last review date, showed no focus area to address her mood. The care plan did not show resident #40 was feeling depressed. The care plan did not show resident #40 had anxiety that was treated with a psychoactive medication. During an interview on 01/10/18 at 4:14 p.m., staff member J stated she completed the mood section of resident #40's Admission MDS, with an ARD of 12/26/17. She stated she felt resident #40 was not open about her mood issues at that time. Staff member J stated she believed resident #40 was depressed, and should have been started on an antidepressant while she was in the hospital. Staff member J said resident #40's mood was not addressed on her care plan because it did not trigger on the MDS. Staff member J looked at resident #40's mood interview for the Admission MDS, and stated she scored a three (minimal depression). She stated she could write a care plan whether a problem was triggered or not, but she did not add mood to the care plan based on the assessment. Staff member J stated she would conduct a new assessment. Review of resident #40's Resident Mood Interview, dated 1/11/18, showed the depression score was 15 (moderately severe depression). Review of resident #40's updated care plan, provided by staff member J, showed a focus area for mood, dated 1/11/18, and specifically addressed depression. The updated care plan did not address resident #40's anxiety. d. During an interview on 1/9/18 at 1:38 p.m., resident #40 stated she was blind in one eye, and pointed towards her left eye. She said she managed alright using only her right eye, but was concerned about losing her remaining vision. Review of resident #40's care plan, dated 1/5/18 as the last review date, showed no focus area to address resident #40's left eye [MEDICAL CONDITION] or her need to compensate for her lost vision. During an interview on 1/11/18 at 10:30 a.m., staff member [NAME] stated she was responsible for completing the vision assessment and care plan for resident #40. Staff member [NAME] said she was aware resident #40 was blind in her left eye. She stated she did not add the issue to the care plan because the MDS did not trigger the area as a problem. Staff member [NAME] stated she did not think she needed to address the vision loss since resident #40 compensated for the loss on her own. She stated the visual loss and compensatory techniques should be included in the care plan. 3. Resident #14 was admitted to the facility with a major neurocognitive disorder due to dementia of Alzheimer's type. Review of resident #14's Quarterly MDS, with an ARD of 10/27/17, showed the resident's cognitive status to be severely impaired. Review of resident #14's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of resident #14's current care plan, initiated on 5/1/17, showed the focus on her cognition as I am cognitively impaired due to: Dementia. Her goal was I want to maintain my current level of cognition. and the interventions for her dementia was Staff will anticipate my social needs and provide for them and Staff will assist in decision making as instructed by the family or resident. During an observation and interview on 1/8/18 at 1:21 p.m., resident #14 was walking down the hallway with a four-wheeled walker. Resident #14 said she was on her way to play bingo. During an observation on 1/8/18 at 3:32 p.m., resident #14 was in her room with another resident. Resident #14 was seated in a chair facing a recliner, the other resident was seated in a recliner, there was bedside table in-between the two residents, and resident #14 was painting the other resident's fingernails. During an observation and interview on 1/8/18 at 5:45 p.m., resident #14 was walking down the hallway from her room. Resident #14 said she was on her way to the dining room for dinner. When resident #14 got to the dining room, she assisted other residents with putting on clothing protectors, positioning residents at their dining tables, and getting a few beverages for other residents. Resident #14 said she liked to help other people. During an observation on 1/9/18 at 7:17 a.m., resident #14 was sitting in her recliner watching television. During an interview on 1/11/18 at 10:04 a.m., staff member J said she does Hand in Hand dementia training for the staff. Staff member J felt she was knowledgeable about dementia. Staff member J felt resident #14 had blossomed since coming to the facility. Staff member J said resident #14 was doing a lot of things now and the resident's care plan should show everything the resident was doing. On 1/11/18 at 11:00 a.m., staff member J provided an updated copy of resident #14's cognitive care plan. The updated care plan, dated 1/11/18, showed an updated focus for #14 included; Although I have Dementia (sic) I am able to participate in tasks I enjoy doing such as helping others. I have several peers who ask me to paint their nails, (sic) help with small tasks such as placing shirt saver on peers and getting coffee. I am happy and content with my residence in this facility . The updated goals included; I want to safely perform small tasks for my peers. I want to maintain my current level of cognition The updated interventions included; I love to paint nails and have several peers who seek me out to do this for them and would like to contine with the activity, and I want to be able to visit with my new friend, (name), who visits and we are able to carry on a conversation in Spanish. The care plan was not updated for the areas of concern, until it was identified by the surveyor.",2020-09-01
770,BEARTOOTH MANOR,275090,350 W PIKE AVE,COLUMBUS,MT,59019,2018-01-11,758,D,0,1,U25Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure 1 (#14) of 14 sampled residents was free from an antipsychotic medication that was prescribed based on the resident's behaviors. Findings include: Review of resident #14's admission orders [REDACTED]. Review of resident #14's Psychopharmacological Drug Assessment form, dated 7/28/17, showed resident #14 was receiving [MEDICATION NAME], 2.5 mg, twice a day. The document showed resident #14's behaviors, mood, and psychiatric symptoms had improved. Review of resident #14's Antipsychotic Use For Residents With Dementia form, dated 10/27/17, showed the resident had no behaviors. Section 2e. related to prior life patterns and preferences and showed resident #14 had lived at home with her daughter, and the daughter had reported resident #14 had occasional wandering behaviors. This document noted resident #14 had not had any behaviors since admission to the facility. Review of resident #14's nursing progress notes from 4/19/17 to 1/07/18, did not show resident #14 had any behaviors since her admission to the facility. Review of resident #14's electronic health record did not show any behavior monitoring for resident #14. Review of resident #14's pharmacy consultation report, dated 8/3/17, showed the facility requested a dose reduction for resident #14's [MEDICATION NAME]. The [MEDICATION NAME] was decreased from 2.5 mg, twice a day, to 2.5 mg, once a day. The physician agreed with the request, and the [MEDICATION NAME] was decreased to 2.5 mg per day. Review of resident #14's pharmacy consultation report, dated 10/3/17, showed the facility requested the [MEDICATION NAME] be discontinued. The physician declined the recommendation. Review of resident #14's pharmacy consultation report, dated 12/04/17, showed the facility requested the [MEDICATION NAME] be discontinued. The physician accepted the recommendation. The [MEDICATION NAME] was discontinued on 12/5/17. Review of resident #14's nursing progress notes showed the facility contacted the daughter/POA on 12/5/17 at 9:26 a.m. to inform the daughter that resident #14's [MEDICATION NAME] had been discontinued on 12/5/17. The facility left a voice mail. Resident #14's daughter/POA contacted the facility at 10:27 a.m. on 12/5/17. The daughter/POA voiced she did not want the [MEDICATION NAME] discontinued, and requested the [MEDICATION NAME] be restarted, and increased to 7.5 mg. The nursing note showed staff member B tried to explain to the daughter/POA that resident #14 had no behaviors, and was participating in activities. During an interview on 1/10/18 at 4:25 p.m., staff member B said resident #14 was off [MEDICATION NAME] for several weeks. Staff member B said resident #14 went out of the facility with her daughter. When resident #14 and her daughter returned to the facility, the daughter insisted something happened and her mother needed to be on an anti-psychotic. Staff member B said the daughter was told the facility would not request resident #14 be restarted on [MEDICATION NAME]. Staff member B said she told the daughter to contact the physician, and discuss this with him. Staff member B said the facility received an order, on 12/12/17, from the physician, to restart resident #14's [MEDICATION NAME]. Staff member B said the facility had not had any behavior problems with resident #14. Staff member B said the facility did not feel they could argue with the physician and daughter, who was resident #14's DPO[NAME] Staff member B said the facility had not gotten the medical director involved in the situation regarding the medications. During an interview on 1/11/18 at 9:58 a.m., staff member C said resident #14 did not have any behaviors.",2020-09-01
771,BEARTOOTH MANOR,275090,350 W PIKE AVE,COLUMBUS,MT,59019,2018-01-11,759,E,0,1,U25Y11,"**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%, which affected 3 (#s 6, 8, and 20) residents, out of 22 sampled and supplemental residents, and the facility medication error rate was 12.9%. Findings include: 1. During an observation, interview, and record review, on 1/9/18 at 7:56 a.m., staff member F prepared medication for administration to resident #6. She poured a thick, orange-colored liquid into a plastic graduated medication cup. The graduated markings were in 2.5 ml increments. Review of the label on the bottle, and the order in the EHR, showed the medication was [MEDICATION NAME] (an anti-convulsant), and the dose to be administered was 3.5 ml. Staff member F stated she determined the correct dose by pouring the liquid [MEDICATION NAME] to a point in between the 2.5 ml marking and the 5.0 ml marking. She asked, how else could I do it? After hesitating briefly, staff member F asked, with a syringe? She then obtained a 1.0 ml syringe, withdrew 1 ml of the liquid [MEDICATION NAME] from the medication cup, and put it into a plastic drinking cup. After withdrawing 3 mls, there were a few drops of the medication left in the cup. Staff member F stated she did not have enough of the medication and poured more of the medication into the cup and withdrew the last 0.5 ml needed. The next medication prepared was a pinkish liquid. Review of the label on the bottle showed the medication was Felbamate (an anti-convulsant). Staff member F pointed out the dosage sticker which showed the dose was 1600 mg/ 13.3 ml. The label showed the suspension was 600 mg/ 5 ml. Staff member F stated she would use a graduated medication cup and a 1.0 ml syringe to measure the dosage. She filled the medication cup to 12.5 ml and stated she would add another 0.5 ml. She then stated she would add another 1.3 ml. She then stated she would add another 1.2 ml. Staff member F then calculated the dosage on a piece of paper and stated she would give 0.8 ml in addition to the 12.5 ml in the medication cup. She withdrew 0.8 ml from the bottle and added it to the cup. Staff member F stated it was not her normal process to measure resident #6's liquid medications with a syringe. She said she just eyeballs it clarifying that she uses the graduated medication cup and estimates. She prepared the remainder of resident #6's medications, and administered the two liquids, and the other medications. Review of resident #6's (MONTH) (YEAR) physician's orders [REDACTED]. The ordered dose for the breakfast administration was 1200 mg/ 10 ml. During an interview and record review on 1/9/18 at 10:17 a.m., staff member F stated the bottle showed 1600 mg/ 13.3 so that is what she gave. She stated she was going by the label and did not check the order dosage closely. Staff member M stated she would clarify the dosage. During an interview on 1/9/18 at 10:35 a.m., staff member B stated that liquid medications, not ordered at an amount marked on the medication cup, should be measured with a syringe. She stated she was new to the facility, but the facility audited the nursing staff during medication administration every few months. During an interview on 1/9/18 at 5:01 p.m., staff member M stated the Felbamate for resident #6 should have been 1200 mg/ 10 ml, not 1600 mg/ 13.3 ml. 2. During an observation and interview on 1/9/18 at 7:44 a.m., staff member F prepared medication for administration to resident #20. She referred to the EHR and stated the order was for digestive enzymes 500 mg. She pulled a bottle from the cart, labeled Essential Enzymes, and obtained 1 500 mg capsule. Staff member F stated the next order was Lactobacillus, and pulled a bottle from the cart, labeled Florastar 250 mg capsules. She stated the dose was 500 mg and obtained 2 capsules. She administered the medications to resident #20. Review of resident #20's (MONTH) (YEAR) physician orders [REDACTED]. During an interview on 1/9/18 at 10:17 a.m., staff member F stated the Essential Enzymes were given as Lactobacillus and the Florastar was given as the digestive enzymes. She stated that was wrong, it was the other way, and then reiterated her initial statement. Clarification, for which medication covered each order, was requested, and staff member M stated she would follow-up. During an interview on 1/9/18 at 5:01 p.m., staff member M stated the Florastar is given for the Lactobacillus order and should have been one capsule instead of two. She stated she added the product name to resident #20's orders for improved communication of what was to be administered. 3. a. During an observation on 1/11/18 at 7:31 a.m., staff member L prepared medication for administration to resident #8. Upon entering the room, staff member L handed resident #8 a bottle of [MEDICATION NAME] Nasal Spray. With staff member L present, the resident administered two sprays to each nostril. Staff member L offered no instruction to resident #8. Review of resident #8's (MONTH) (YEAR) physician orders [REDACTED]. During an interview on 1/11/18 at 7:57 a.m., staff member L stated she thought the order was for one spray to each nostril. She would have to instruct resident #8 to give one spray in each nostril. Staff member L stated Calcitonin is given one spray in each nostril. She stated she was aware that [MEDICATION NAME] and Calcitonin were different medications. Staff member L said she did not realize the order was for alternating nostrils, and she would do it for resident #8 instead of letting him do it himself. b. During an observation on 1/11/18 at 7:40 a.m., staff member L prepared cough syrup for administration to resident #8. She poured 5 ml of [MEDICATION NAME] AC into a plastic medication cup. She administered the medication to resident #8. Review of resident #8's (MONTH) (YEAR) physician order, showed an order for [REDACTED]. Review of resident #8's cough syrup label, which was on the bottle, showed the dose to be administered was 10 ml every 6 hours as needed for cough. During an interview on 1/11/18 at 7:44 a.m., staff member L stated, We've got a mistake there, when comparing resident #8's MAR order to the cough syrup bottle's label. She said she was going by the MAR and did not notice the label on the bottle. She stated she would clarify the order later, and moved on to administer medications to other residents. Review of resident #8's faxed physician order, dated 1/8/18, showed the order was for [MEDICATION NAME] AC 10 ml every 6 hours as needed for cough. During an interview and record review on 1/11/18 at 11:20 a.m., staff member A provided documentation of medication administration education and competency evaluations for the licensed nurses. Staff member A stated the documentation did not specifically show issues such as measuring liquids or clarifying discrepancies. The education was conducted in (MONTH) (YEAR). No audits of medication administration observations, after the (MONTH) (YEAR) competency evaluations, were provided.",2020-09-01
772,BEARTOOTH MANOR,275090,350 W PIKE AVE,COLUMBUS,MT,59019,2018-01-11,760,D,0,1,U25Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a medication, after not completing an ordered lab test designed to monitor the appropriate therapeutic dose of the medication, for 1 (#33) of 14 sampled residents. Findings include: Resident #33 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. During an interview on 1/8/18 at 5:02 p.m., resident #33 stated he did not believe he was receiving all his scheduled medications. Review of resident #33's (MONTH) (YEAR) MAR and TAR showed an order to monitor for adverse side effects related to the use of anticoagulant medication, but did not show the use of an anticoagulant medication. Review of resident #33's Nursing progress note, dated 12/20/17, showed an order had been received for a dose change of [MEDICATION NAME] (an anticoagulant medication), and for a PT/INR (a lab test to monitor therapeutic blood levels) to be drawn in ten days. Review of resident #33's physician orders, in the EHR, showed the [MEDICATION NAME] dose change, dated 12/20/17, but not the order for the lab test. Review of resident #33's lab results, in the EHR, did not show a PT/INR for 12/30/17, or any date following the order of 12/20/17. A written request was made, on 1/9/18, for the PT/INR results for 12/30/17. Review of resident #33's PT/INR lab report, dated 12/18/17, showed hand written orders that the physician requested the [MEDICATION NAME] dose be changed, and to recheck the PT/INR in ten days. The order was noted by two nurses. During an interview and record review on 1/9/18 at 3:06 p.m., staff member G looked at the orders in the EHR and said she did not see an order for [REDACTED]. She stated, It sure looks like we dropped the ball. She stated the facility routinely writes [MEDICATION NAME] orders with a stop date the day prior to the lab draw date, and after the lab results are received, the physician gives new orders based on the current values. Staff member G stated there was no process for monitoring if labs were completed, and the results were received. During an interview on 1/9/18 at 5:15 p.m., staff member M stated no PT/INR had been drawn for resident #33 on 12/30/17, and as a result, resident #33 had not received any [MEDICATION NAME] since 12/29/17. During an interview on 1/10/18 at 1:40 p.m., staff member B stated there was no process for tracking that an ordered lab had been completed. She said the facility had started a new process, in (MONTH) (YEAR), of two nurses noting an order so that no orders would be missed. Staff member B stated she had spoken to the Medical Director that morning and his direction was for [MEDICATION NAME] orders to be written with an end date, prior to the lab draw, and new orders would be written after the lab results were received. Written and signed confirmation of this plan was provided by the facility. Staff member M stated there was a PT/INR/[MEDICATION NAME] Flowsheet in use, but it was not followed through for resident #33. Review of resident #33's (MONTH) (YEAR) PT/INR/[MEDICATION NAME] Flowsheet showed the next PT/INR was due to be drawn on 12/30/17. It did not show any results that staff were aware the lab had not been drawn. The missed lab resulted in 10 days of resident #33 not receiving [MEDICATION NAME], a medication with a narrow therapeutic window. The facility had no process in place that had discovered the error. See F770 for additional details.",2020-09-01
773,BEARTOOTH MANOR,275090,350 W PIKE AVE,COLUMBUS,MT,59019,2018-01-11,770,D,0,1,U25Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a physician-ordered lab test for 1 (#33) of 14 sampled residents. Findings include: Review of resident #33's (MONTH) (YEAR) MAR and TAR showed an order to monitor for adverse side effects related to the use of anticoagulant medication, but did not show the use of an anticoagulant medication. Review of resident #33's progress note, dated 12/20/17, showed an order had been received for a dose change of [MEDICATION NAME] (an anticoagulant medication), and for a PT/INR (a lab test to monitor therapeutic blood levels) to be drawn in ten days. Review of resident #33's physician orders [REDACTED]. Review of resident #33's lab results in the EHR did not show a PT/INR for 12/30/17 or any date following the order of 12/20/17. A written request was made on 1/9/18, for the PT/INR results for 12/30/17. Review of resident #33's PT/INR lab report, dated 12/18/17, showed hand written orders to change the [MEDICATION NAME] dose, and to recheck the PT/INR in ten days. During an interview and record review 1/9/18 at 3:06 p.m., staff member G looked at the orders in the EHR and said she did not see an order in the EHR for the blood draw for PT/INR. She stated, It sure looks like we dropped the ball. During an interview on 1/9/18 at 5:15 p.m., staff member M stated no PT/INR had been drawn for resident #33 on 12/30/17, and as a result, resident #33 had not received any [MEDICATION NAME] since 12/29/17. During an interview on 1/9/18 at 5:24 p.m., staff member G stated a lab order should be put on the lab calendar, and that it was done for resident #33's PT/INR due on 12/30/17. Staff member G stated labs were not usually scheduled for Saturday, and a nurse would not likely look for it. She said it should have been passed on in the (nurse to nurse) shift report. Staff member G stated all the processes failed. See F760 for further details.",2020-09-01
774,BEARTOOTH MANOR,275090,350 W PIKE AVE,COLUMBUS,MT,59019,2018-01-11,804,E,0,1,U25Y11,"Based on observation and interview the facility failed to provide hot, attractive, and palatable food for 3 (#s 1, 3, 14) of 14 sampled residents. Findings include: 1. During an interview on 1/08/18 at 1:26 p.m., resident #3 said the food could be hotter. Resident #3 said he eats a lot of hot dogs and hamburgers, the alternate food choice, because he doesn't like what is being served as the main entree. Resident #3 said the main entree is frequently chicken or turkey, and he does not like poultry. Resident #3 said facility staff had never asked about his food likes and dislikes. 2. During an interview on 1/8/18 at 5:10 p.m., resident #1 said she had a breakfast tray in her room every morning. Resident #1 said her breakfast was always cold. During an observation and interview on 1/8/18 at 6:00 p.m., resident #1 refused to eat the chicken salad sandwich she had ordered for the evening meal. Resident #1 said the chicken salad looked like runny baby food. Resident #1 said everything else she had ordered for the evening meal was fine. 3. During an interview and observation on 1/08/18 at 6:16 p.m., resident #14 refused to eat the chicken salad sandwich, stating it did not look good. During an observation on 1/08/18 at 5:55 p.m., the alternate dinner item was a chicken salad sandwich, with the chicken salad being blended into a puree. During an interview on 1/08/18 at 6:07 p.m., staff member D stated the chicken salad did get a little too squishy with the machine she used to prepare the salad. 4. During an observation on 1/11/18 at 8:35 a.m., resident #141's breakfast tray, which included pureed pancake, egg, and sausage, had temperatures ranging from 90 to 97 degrees when the meal was provided to the resident. During an observation on 1/11/18 at 8:45 a.m., resident #21's breakfast tray showed the temperature of the food was 90 degrees, and the margarine was not melting on the pancake. The resident stated the eggs were too cold to eat. Review of the resident council minutes, for 11/7/17, showed the residents stated breakfast needed to be served hotter. During an interview on 1/11/18 at 9:15 a.m., staff member D stated she had not known about the resident complaints regarding cold breakfast. Therefore, she had not followed up on any of the concerns. She stated the facility did not have a plate warmer, and she did not know how well the food tray cart was insulated. The facility had not identified the concerns with the food temperatures prior to the survey.",2020-09-01
775,BEARTOOTH MANOR,275090,350 W PIKE AVE,COLUMBUS,MT,59019,2018-01-11,842,D,0,1,U25Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain a complete and accurate medical record for 1 (#14) of 14 sampled residents. Findings include. Resident #14 was admitted to the facility on [DATE] from a psychiatric unit. Resident #14 had been admitted to the psychiatric unit from home, and was at the psychiatric unit for three days. Review of resident #14's electronic health record failed to show the facility had any information regarding resident #14's admission to, and discharge from, the psychiatric unit. Resident #14's admission History and Physical, and the Discharge Summary from the psychiatric unit, was requested from the facility on 1/9/18. During an interview on 1/10/18 at 4:25 p.m., staff member B said the facility had no information from the psychiatric unit for resident #14. Staff member B was unable to answer any questions regarding resident #14's stay at the psychiatric unit. Staff member B did not know why resident #14 had been admitted to a psychiatric unit, she did not know any of the findings from resident #14's stay, and she did not know what behaviors, if any, resident #14 had exhibited during her stay at the psychiatric unit. Staff member B said the facility forgot to request the information from the psychiatric unit. Staff member B said she hadn't thought it was necessary because resident #14's physician was local to the facility, and he would have notified the facility of anything important.",2020-09-01
776,BEARTOOTH MANOR,275090,350 W PIKE AVE,COLUMBUS,MT,59019,2018-01-11,849,D,0,1,U25Y11,"Based on record review and interview, the facility failed to provide designated facility staff to communicate with Hospice Services, and failed to collaborate with a hospice representative in the care planning process, for 1 (#141) of 14 sampled residents. Findings include: Review of resident #141's Care Plan, dated 12/22/17, showed Please refer to my hospice plan of care located in this care plan for more details of my care. Review of the Care Plan showed no further Hospice Care Plan details. During an interview on 1/11/18 at 11:50 a.m., staff member C stated resident #141's Hospice Care Plan should be at the nurses' station in a binder. She also stated there was not a facility designated employee to communicate and coordinate with Hospice Services. Resident #141's Hospice Care Plan was not located in the binder at the nurses' station, per staff member C's interview.",2020-09-01
777,BEARTOOTH MANOR,275090,350 W PIKE AVE,COLUMBUS,MT,59019,2019-03-21,695,D,0,1,TRHL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to consistently monitor portable oxygen tank levels; failed to replace the empty portable tank with a full tank; and failed to have the necessary regulator available to deliver the prescribed amount of oxygen per minute for 1 (#20) of 17 sampled residents, which caused the resident to report feeling short of breath. Findings include: During an observation and interview, on 3/19/19 at 12:42 p.m., the oxygen tank on the back of resident #20's chair was empty. Resident #20 had the nasal cannula on. Resident #20 stated he had [MEDICAL CONDITION]. He stated he was supposed to be on three liters of oxygen. The regulator on the portable tank showed it was on two liters per minute. During an observation and interview on 3/19/19 at 2:50 p.m., resident #20's oxygen tank was observed to be empty. Staff member J looked at the portable oxygen tank on the back of the resident #20's wheel chair and stated, Oh your tank is empty. Staff member J stated, We check the tanks when we bring them back from meals. Staff member J stated the resident brought himself back from meals, And to be honest, I got busy and didn't think to check it. Staff member J asked resident #20 if he was having any trouble breathing, and the resident stated sometimes he gets short of breath. During an observation and interview on 3/21/19 at 9:57 a.m., K stated We have to check (resident name) oxygen constantly. Staff member K stated he thought the resident was to be on three liters of oxygen per minute. Staff member K and the surveyor looked at the regulator, which showed the dial was on two liters per minute. Staff member K asked staff member I how many liters of oxygen the resident was supposed to be on, and staff member I stated three and a half liters. Staff member K then went to turn the regulator up, but stated the regulator did not have a three and a half setting. Staff member K stated he was going to check to supply closet where the oxygen supplies were kept but came out a few minutes later and stated he did not see any regulators that had a three and a half setting on them. Staff member I went into the supply room and checked for herself, and stated she was unable to find a regulator that had the required settings for the resident per the physician's orders of three and a half liters per minute. During an observation on 3/21/19 at 8:41 a.m., resident #20's portable oxygen tank was empty. During an interview on 3/21/19 at 8:49 a.m., NF2 stated resident #20 needed oxygen when he ambulated, and he was always, always on three liters. During an interview on 3/21/19 at 10:05 a.m., staff member I stated staff should be checking resident #20's oxygen levels on the portable tank At least every shift, and when they are getting him in and out of the wheel chair. Staff member I was unable to identify how long the current regulator had been in place, but stated she thought resident #20 had a regulator in place that had the ability to deliver the three and a half liters ordered. Review of resident #20's Physician's Orders, dated 10/1/18, showed the resident was to receive three and a half liters of oxygen, per minute, via nasal cannula, related to [MEDICAL CONDITIONS]. A review of the facility policy titled, Oxygen Usage showed, under the procedures heading: 6. a. Licensed nurses shall be in charge of the administration of oxygen. b. A nursing assistant (when directed by a licensed nurse) may turn on/off an oxygen concentrator for those residents receiving oxygen on a regular basis, either continuously or PRN that are determined to be medically stable regarding oxygen usage. The nursing assistant is not to set the oxygen flow rate, initiate the use of oxygen or assess the need for usage .",2020-09-01
778,BEARTOOTH MANOR,275090,350 W PIKE AVE,COLUMBUS,MT,59019,2019-03-21,759,D,0,1,TRHL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to ensure the medication error rate was less than 5 percent, which affected 2 (#s 19 and 27) of 17 sampled residents. The facility medication error rate was 6 percent. Findings include: During an observation on 3/19/19 at 8:49 a.m., staff member H was observed giving insulin to resident #19 in her room. The nurse administered the dose in the resident's abdomen, at her request. Staff member H did not prime the insulin pen prior to administering the dose. Review of resident #19's medical record showed #19 had a [DIAGNOSES REDACTED].#19's MDS Annual Assessment, dated 10/3/18, and MDS Quarterly Assessment, dated 1/3/19, showed a [DIAGNOSES REDACTED].#19 had received Insulin for all seven days of the assessment period. During an observation and interview on 03/20/19 at 4:21 p.m., staff member H administered insulin to resident #27. Staff member H did not prime the insulin pen prior to administering the dose. Staff member H stated No, I did not prime the pen. I have not been instructed to do this. Review of resident #27's Care Plan, dated 1/24/19, showed a [DIAGNOSES REDACTED]. Review of the facility Policy, Number NS0667, Insulin and Non-Insulin Pen Delivery Systems, under Procedure number eight, showed .In order to assure each dose of insulin is administered completely and safely, air must be expelled from the cartidge by giving an airshot BEFORE EACH INJECTION",2020-09-01
779,BEARTOOTH MANOR,275090,350 W PIKE AVE,COLUMBUS,MT,59019,2019-03-21,804,E,0,1,TRHL11,"Based on observation, interview, and record review, the facility failed to prepare food that was palatable and attractive, and the residents reported the food was at times flavorless, awful, horrible, dry, did not look good or taste good, and was hard to chew. The failure affected 5 (#s 10, 12, 24, 25, and 32) sampled and supplemental residents. Findings Include: During an observation on 3/18/19 at 3:34 p.m., staff member G took corned beef out of the oven. The corn beef was on a baking sheet and appeared dark brown and dry. During an interview on 3/18/19 at 4:20 p.m., resident #24 stated the food at the facility was often times dry and flavorless. He stated the kitchen staff do not listen when they are given feedback on how the meals taste. During an interview on 3/18/19 at 5:33 p.m., resident #32 stated the appearance and the taste of the food was not good, saying, It doesn't look good. The resident stated, You know, you eat with your eyes first. Resident #32 stated They don't ask for feedback, and they don't push the alternative. During an observation and interview on 3/18/19 at 6:05 p.m., resident #12 left the dining room and was observed making a peanut butter and jelly sandwich in her room. Resident #12 stated the food was awful because it was often dry and had no flavor. She stated she had food in her room for the days when the meals were bad at the facility. Resident #12 stated today the corned beef was very over cooked, hard to chew, and dry. During an observation at 3/19/19 at 12:30 p.m., roasted pork loin was served with cauliflower for lunch. The roasted pork loin appeared dry and gray, and the cauliflower was mushy. During an interview on 3/19/19 at 1:27 p.m., NF1 stated the food at the facility had been horrible. He stated the food is always dry and hard to chew. He stated the resident (#25) is missing some teeth and it is hard for him to eat the meat the facility prepared. NF1 stated the pork was dry and had no flavor and the cauliflower was so mushy and over cooked he could not eat it. Resident #25 stated he had the alternate meal which was chicken and stated it was very dry and hard to chew. Review of a Grievances/Concern Report Form dated 1/17/19 showed, The food quality in the kitchen is not very good . During an interview on 3/21/19 at 8:57 a.m., resident #10 stated the food had not improved since she filed the grievance in January. She stated the food might be worse. Resident #10 stated the food did not have any flavor and the meat was usually really tough, which made it hard to chew.",2020-09-01
780,BEARTOOTH MANOR,275090,350 W PIKE AVE,COLUMBUS,MT,59019,2019-03-21,880,D,0,1,TRHL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to minimize the risk of infection by ensuring oxygen tubing is kept off the floor, and failed to replace the contaminated tubing that had been on the floor with clean tubing, for 1 (#20) of 17 sampled residents, which caused contaminated oxygen tubing to be placed in resident #20's nares. Findings include: During an observation on 3/19/19 at 12:42 p.m., resident #20's nasal cannula, connected to the concentrator, was laying on the floor. The concentrator was very dirty and had a brownish colored substance that had been spilled down the side and had dried. Staff member J was in the room with the resident, and was tending to his empty portable oxygen tank, and did not take note of the oxygen tubing laying on the floor, or address the tubing on the floor. During an observation on 3/21/19 at 8:41 a.m., resident #20's nasal cannula tubing for the portable tank was laying on floor. During an observation on 3/21/19 at 10:01 a.m., no labeling or date was observed on resident #20's oxygen tubing on the concentrator or portable tank. During an interview on 3/21/19 at 9:57 a.m., staff member K stated Every Sunday the tubing is changed. If the tubing is found on the floor we switch it out and date it. Review of resident #20's Care Plan, dated 10/22/18, showed I have SOB at times due to my [DIAGNOSES REDACTED]. Nursing will change my oxygen tubing every seven days as per facility policy.",2020-09-01
781,BEARTOOTH MANOR,275090,350 W PIKE AVE,COLUMBUS,MT,59019,2016-10-20,253,C,0,1,4EQE11,"Based on observation and interview, the facility failed to repair areas of the main tub and shower room, which was utilized by the residents, and maintain the cleanliness of the building which was also used by the residents who resided at the facility. Findings include: During on observation on 10/17/16 at 3:30 p.m., baseboards, which appeared to be wood-like, had missing areas or chunks broken out at the corners on Shady Lane and Sunnyside hallways. During an observation on 10/19/16 at 9:05 a.m., the tub room, on the Mountaintop hallway, was observed to have broken floor tiles around the tub chair lift, and an area where a toilet had been removed. On the right wall of the tub room, where the floor and wall met, the caulking was missing, and dirt was on the floor. A rubber mat was covering a floor drain, and the rubber mat had hard water build-up. During an interview on 10/19/16 at 9:15 a.m., staff member H said the broken floor tiles in the bathing room should be replaced. During an interview on 10/20/16 at 7:30 a.m., Staff member J said the broken floor tiles could not really be fixed without ripping out big sections of the tiles. Staff member J said the whole tub room needs to be remodeled. Staff member J said the wood-look baseboards that were missing chunks were of a foam/wood composition, and were on the schedule to be replaced in the future.",2020-09-01
782,BEARTOOTH MANOR,275090,350 W PIKE AVE,COLUMBUS,MT,59019,2016-10-20,275,D,0,1,4EQE11,"Based on record review and interview, the facility failed to complete the MDS assessment accurately, or within the required 14 day timeline for 1 (#7); and failed to complete an Annual MDS assessment for 1 (#8) of 11 sampled residents. Findings include: 1. During a review of resident #7's most current Annual MDS, with an ARD of 7/9/16, section G400, Range of Motion, showed No Assessment for the resident's range of motion. During a review of resident #7's most current Annual MDS, with an ARD of 7/9/16, section J1800, Falls Since Adm/Reentry or Prior Assessment showed No Assessment for the resident's falls. During a review of resident #7's nursing notes, the resident had a fall on 6/24/16 were she hit the back of her head, and the nurse identified a bump. Nursing notes showed neurological checks were completed, and the resident's family was notified. During a review of resident #7's most current Annual MDS, with an ARD of 7/9/16, showed section Z0500 B was not dated until 8/2/16. 2. A review of resident #8's clinical records showed Annual assessments had been completed by nursing, the dietary manager, and the activities director. A review of resident #8's MDSs showed the most current MDS to be a Quarterly, with an ARD of 6/16/16. Resident #8 had an Admission MDS, with an ARD of 9/21/15. Resident #8 did not have an Annual MDS in progress or available for review, showing the assessment had not been completed as required. During an interview on 10/18/16 at 5:45 p.m., staff member A said the last director of nursing completed all the MDS assessments and signed off on them. Staff member A said the employee left in (MONTH) of (YEAR). Staff member A said the facility had not had a consistent MDS coordinator since that time. Staff member A said the facility had hired an MDS coordinator two weeks ago, and she was receiving MDS training.",2020-09-01
783,BEARTOOTH MANOR,275090,350 W PIKE AVE,COLUMBUS,MT,59019,2016-10-20,276,D,0,1,4EQE11,"Based on record review and interview, the facility failed to complete the Quarterly MDS assessment accurately for 1 (#7); and failed to sign off the assessment was completed timely within the 14 day required timeline, for 1 (#9) of 11 sampled residents. Findings include: 1. A review of resident #7's most current Quarterly MDS, with an ARD of 10/7/16, section G400, Range of Motion, was blank. A review of resident #7's most current Quarterly MDS, with an ARD of 10/7/16, section H300, Bladder Continence was blank, and section H400, Bowel Continence was blank. During a review of resident #7's care plan, the care plan showed the resident had bowel and bladder incontinence. A review of resident #7's most current Quarterly MDS, with an ARD of 10/7/16, section J100, Pain Management was blank. During a review of resident #7's Medication Administration Record, [REDACTED]. The Medication Administration Record [REDACTED]. A review of resident #7's most current Quarterly MDS, with an ARD of 10/7/16, showed section Z0500 B was not dated. 2. Review of resident #9's Quarterly MDS showed an assessment reference date of 7/15/16, and a Z0500B date of 8/9/16. During an interview on 10/19/16 at 11:20 a.m., staff member A stated the staff member who was formerly completing the MDSs was also the DON, and was no longer employed at the facility. Staff member A stated she was aware the MDS assessments were not in compliance.",2020-09-01
784,BEARTOOTH MANOR,275090,350 W PIKE AVE,COLUMBUS,MT,59019,2016-10-20,280,E,0,1,4EQE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to update the resident care plan for falls with injury for 1 (#4); for severe weight loss for 1 (#5); and for respiratory status and oxygen use for 1 (#2) of 11 sampled residents. Findings include: 1. Resident #4 was admitted to the facility with anxiety disorder and dementia. Review of resident #4's Significant Change MDS, with an ARD of 1/25/16, and a Quarterly MDS, with and ARD of 7/19/16, showed a BIMS score was not documented. The assessment indicated in section C0100 that the resident was not recommended for a BIMS interview. Review of resident #4's Fall Risk Assessment, dated 11/24/16, showed the resident scored a 17. The score indicated a risk of falling. Review of resident #4's progress notes showed the resident fell on [DATE], 12/28/15, 1/14/16, and 6/29/16. The care plan lacked evidence for fall prevention protocols, and approaches to prevent falls. Refer to F323 for detailed fall and lack of care plan information. During an interview on 10/19/16, at 11:20 a.m., staff member A stated the former DON left employment, and the care plans got lost in the pieces. She said the plan was to revamp the care plans. 2. A review of resident #2's admission physician's orders [REDACTED]. The order was to be adjusted per facility protocol, and was e-signed by the resident's physician. A review of resident #2's medication administration records, dated (MONTH) of (YEAR), showed that oxygen had been ordered for resident #2 on 08/26/16. Three liters per minute were to be given at rest and five liters per minute were to be given with activity. It was documented with signatures that the resident had received it once per shift (three times a day) since 10/1/16. There were no recordings of oxygen saturation levels on the MARS for resident #2. During observations on 10/18/16 at 8:20 a.m. and at 12:32 p.m., resident #2 was observed in the dining room wearing her oxygen cannula in her nose at three liters per minute. A review of resident #2's nursing progress notes showed a lack of evidence for the respiratory status assessments, or use of oxygen. A review of the care plan for resident #2 did not show the resident had been ordered to be on oxygen or that the resident had a respiratory problem for which oxygen would be an appropriate treatment. 3. A review of resident #5's Significant Change MDS, with an ARD of 10/22/15, showed a weight of 166 pounds. A Quarterly MDS, with an ARD of 7/22/16, showed a weight of 121 pounds. This showed a 27.2% weight loss in 9 months, which was a severe weight loss of greater than 10% in 6 months. Review of resident #5's care plan, dated 4/2/16, showed the resident was on an NAS diet, regular texture, regular liquids, and would receive Boost supplement BID, to help with weight maintenance. It showed a goal of her weight to be maintained at 121.1 pounds. The care plan interventions showed to monitor and document weight and report a weight loss greater than 5 pounds to the dietitian. The care plan showed that the staff were to allow the resident time to comfortably complete her meals and provide access and assistance to eat pleasure foods. During an interview on 10/19/16, at 4:24 p.m., staff member F reported that he did not look at the care plan or attend the care plan meetings. He was unable to answer why additional interventions had not been trailed with resident #5's severe weight loss. Review under the Care Planning section in the Weight Assessment and Intervention policy showed the following: 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietitian, the Consultant Pharmacist, and the resident or resident's legal surrogate. 2. Individualized care plans shall address, to the extent possible: a. The identified causes of weight loss b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment.",2020-09-01
785,BEARTOOTH MANOR,275090,350 W PIKE AVE,COLUMBUS,MT,59019,2016-10-20,281,D,0,1,4EQE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to verify and/or request a change or clarification in the unusual dosage of a physician prescribed medication. This resulted in a medication error with potential harm for 1 (#14) of 15 sampled and supplemental residents, when the resident was given the medication from the facility's stock medications in a dose other than what was prescribed for the resident. Findings include: During a medication pass observation on 10/18/16 at 7:45 a.m., [MEDICATION NAME] 325 mg, one tablet, was poured from a stock medication container by staff member K, and administered to resident #14. A review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The record showed the medication had been ordered to start on 10/14/16. Twice daily doses had been signed off by the nurses as given for the last five days. During an observation and interview on 10/18/16 at 6:10 p.m., staff member K reviewed resident #14's physician's orders [REDACTED]. Staff K then verified the 325 mg dosage of the stock medication bottle of [MEDICATION NAME] on her medication cart, as used for resident #14. She stated she had probably given the wrong dose of [MEDICATION NAME] to resident #14 at 7:45 a.m. She also said that she had never heard of [MEDICATION NAME] coming in a 140 mg dose, and stated that she would check the dosage with the resident's physician. During an interview on 10/19/16 at 9:35 a.m., staff member C stated she had noted the difference in the dose of [MEDICATION NAME] ordered for resident #14 and the dose of the stock medication she had available on her medication cart to give to the resident. She said she had sent a fax requesting a dosage change from the physician because the dosage of 140 mg ordered was unavailable to the facility. The physician had not yet responded to the fax. A review of resident #14's Medication Administration Record [REDACTED]. It was not determined if this dosage had actually been given, and if so where it had come from. REFERENCES: S. DeLaune. & [NAME] Ladner, Fundamentals of Nursing, Standards and Practice, Albany, N.Y., 1998, p. 237. Nurses are obligated to follow the orders of a licensed physician or other designated health care provider unless the orders would result in client harm. Ann Perry and [NAME] Potter, Clinical Nursing Skills and Techniques, 5th ed., Mosby, Inc., St. Louis-Missouri, 2002, pgs. 442, 445. Preparing and administering medications requires accuracy by the nurse .Accuracy is greatest when the nurse observes the five rights of administration. 1. The right drug. 2. The right dose. 3. The right client. 4. The right route. 5. The right time .Each time a drug dose is prepared the nurse refers to the MAR (medication administration record) .Drugs are not always dispensed in the unit of measure in which they are ordered .Dose calculations are necessary when the dose on the drug label differs from the dose ordered.",2020-09-01
786,BEARTOOTH MANOR,275090,350 W PIKE AVE,COLUMBUS,MT,59019,2016-10-20,323,G,0,1,4EQE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement interventions, and provide assistance for a resident who: had severe cognitive deficits, was unable to comprehend fall prevention efforts, and had repeated falls for self-transferring; failed to show the resident's care plan was reviewed to ensure the fall interventions were successful, or that the plan was modified for falls; and failed to complete neurological assessments after falls. This included a fall with a hip fracture, which required surgery, for 1 (#4) of 11 sampled residents. Findings include: Resident #4 was admitted to the facility with anxiety disorder and dementia. Review of resident #4's Fall Risk Assessment, dated 11/24/16, showed the resident scored a 17. This score indicated a risk of falling. Review of resident #4's progress notes showed the resident fell on [DATE], 12/28/15, 1/14/16, and 6/29/16. Fall details included: - Fall #1: The progress note, dated 11/28/15, showed resident #4 was found on the floor under the table in the small parlor. The fall was unwitnessed by staff. The note showed there was no injury. When the resident was found, one wheelchair break was locked and the other was not. The note showed it was uncertain if the resident had unlocked one of the brakes. Review of the resident's progress notes for 11/29/15-12/2/15, failed to show the facility completed neurological assessments for the resident after an unwitnessed fall. Neurological assessment records were requested on 10/19/16, for this fall, but were not received prior to the end of the survey. Review of the facility falls log for the resident showed the care plan was reviewed and updated. Review of the resident's care plan did not show any updates or modifications had been made for the 11/28/15 fall, or to address the root cause of the fall. - Fall #2: The resident's progress note, dated 12/28/15, showed resident #4 was found in the hallway on the floor, lying on her left side. She had been previously sitting in the small parlor in her wheelchair. The note showed there were no apparent injuries, but the neurological assessments were not documented in the progress notes. Neurological assessments were requested on 10/19/16, for this fall, but were not received. - Fall #3: The progress notes, dated 1/14/16, showed resident #4 was found lying on the floor of the small parlor on her left side. The note showed that she was assessed, and cried out when her left leg was touched. The doctor was notified, and gave the facility a telephone (verbal) order to send the resident to the emergency room , per ambulance, for further evaluation. Neurological assessment records were requested on 10/19/16, for the fall that occurred on 1/14/16, but the facility failed to provide the records. The following progress note for the resident, dated 1/17/16, showed resident #4 was still in the hospital recovering from surgery which related to her fall on 1/14/16. Review of the resident's discharge instructions from the hospital, dated 1/18/16, showed the resident was to engage in activities as tolerated, bear weight as tolerated, and utilize PRN pain medications for her fractured hip. Review of the resident's nursing notes, dated 1/18/16, showed the resident was returned to the facility with a [DIAGNOSES REDACTED]. The note showed she went under ORIF (open reduction internal fixation) on 1/15/16. New orders were received and noted. Review of resident #4's care plan showed two new interventions were added to her care plan in (MONTH) on the day the resident fell : 1) If resident is anxious after lunch, please toilet and lay down. This intervention was started on 1/14/16, but was created on 2/9/16. 2) Try to assist resident when she is attempting to ambulate self. This intervention was initiated on 1/14/16, and created on 1/14/16. Review of resident #4's progress notes, dated 1/14/16 - 1/18/16, showed she was taken in the ambulance to the hospital, and was re-admitted to the facility on [DATE] after undergoing surgery to repair a hip fracture. The facility had not implemented fall prevention interventions on the care plan upon her return to the facility on [DATE], after the fracture or surgery. - Fall #4: Review of resident #4's progress notes, dated 6/9/16, showed the resident had a fall while a CNA was pushing her down to supper in a wheelchair. The staff member had stopped to help another resident, and resident #4 stood up from her wheel chair, started walking, and fell . This fall was a witnessed fall, and the resident had no injury. Neurological assessments were requested on 10/19/16, but not received for the fall. Review of the facility fall log showed the care plan was reviewed for the resident, which showed: Staff will seat resident #4 at the table while unattended. The intervention was started on 6/9/16, but created on 6/14/16. The facility failed to implement an intervention for the direct root cause of the fall as the resident was not eating at the time of the fall, but was transferring to the dining room to eat dinner and was assisted by staff at the time. Review of the facility's Fall Prevention policy showed the facility was to implement and/or update fall precautions for residents after falls. The policy showed incident logs were to be reviewed, and the care plans were to be updated after a fall. There were no recommendations listed on the fall log for interventions for resident #4's fall. The policy showed the fall incident reports were to be completed after every fall, but although requested, the fall incident reports were not provided by the facility. During an interview with staff members A and B on 10/19/16, at 8:45 a.m., and again at 10:00 a.m., staff members A and B stated incident reports had not been completed for resident #4's falls. The facility policy showed neurological assessments were to be completed for falls. Review of resident #4's progress notes, dated 11/28/15, 12/28/15, 1/14/16, and 6/29/16, showed the resident did not have neurological assessments initiated for any of her four falls. During an interview on 10/19/16, at 10:05, staff member B stated all the neurological assessments were under the assessment section in the electronic health record. Review of resident #4's assessment records in the electronic health record, as of 10/19/16 at 10:20 a.m., lacked evidence of the completion of any of the neurological assessments for the falls noted above.",2020-09-01
787,BEARTOOTH MANOR,275090,350 W PIKE AVE,COLUMBUS,MT,59019,2016-10-20,325,G,0,1,4EQE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement new nutritional interventions in order to prevent severe weight loss for 1 (#5) of 11 sampled residents. Specifically the resident had 20.2% severe weight loss in six months (4/19/16 to 10/20/16). The facility failed to utilize their policies to address the resident's severe weight loss. Findings include: During an observation on 10/18/16 at 8:20 a.m., resident #5 was seated for breakfast in the dining room. She was observed feeling around for her silverware with her hand. She put an unopened container of jelly in her hot tea, and then rested her fingers in her hot tea. At 8:35 a.m., staff member A sat down next to the resident and commented on her ring. The resident woke up, took her hand out of the hot tea, took the jelly packet out of her tea, and placed it back with the other unopened jelly. She had not eaten any of her food, and the staff did not assist the resident. At 8:40 a.m., staff member L offered to cut the resident's food and then brought the resident a full bowl of cereal and stated, I want to see you eat. The resident placed her fingers on top of her food, and did not attempt to take any bites. Staff had not assisted her at this point with eating her food. At 8:45 a.m., staff member [NAME] asked the resident how she was doing. The resident pushed the new bowl of cereal away, but alternative were not offered, or assistance with the meal. At 8:55 a.m., the resident was finished with her meal, and had not received assistance, but had only eaten 5% of her breakfast. She was not offered a supplement at this meal. During an interview on 10/18/16 at 8:20 a.m., staff member [NAME] stated resident #5 was offered Boost Breeze BID at lunch and evening meals not at her breakfast meals. Record review of the P[NAME] Response History (resident intake record) showed resident #5 had refused the supplement at breakfast on 10/17/16 and 10/18/16, although she had not been offered the item during the 10/18/16 meal. During an observation on 10/18/16, at 12:25 p.m., resident #5 was seated in the dining room for the lunch meal. She appeared to be more alert. She had her supplement of orange Boost Breeze. At 12:55 p.m. the resident took her first bite of food, and used two hands to hold her fork. She reached for her water and was unable to pour the water for herself. The resident who sat next to resident #5 poured a glass of water for the resident. At 1:15 p.m., the resident took one bite of her lunch meal. The resident did not consume anymore at that meal. During an interview on 10/18/16 at 1:20 p.m., resident #5 reported liking her orange Boost Breeze. Also during the interview with resident #5, her table mate stated that resident #5 had not been eating very much lately. The resident was observed to have a supplement drink, which she had not consumed. During an interview on 10/18/16 at 1:20 p.m., staff member [NAME] stated she would report any weight loss to nurse management, and in the previous 4-6 weeks had faxed the weight loss to the MD to increase MD communication. Staff member [NAME] stated staff member I consulted at the facility monthly, and his last visit was (MONTH) 5th. Staff member [NAME] stated that resident #5 had acted different lately, and had been in the hospital six months ago, lost weight, but then the resident gained it back. During an interview on 10/18/16 at 1:45 p.m., resident #5 stated that she doesn't feel like she could ask for other food, and would have liked to ask for a chicken sandwich. During an interview on 10/18/16 at 2:00 p.m., staff member G, stated he followed whatever the regulation was for being notified about weight loss but did not know what the regulation was or when he should be notified about a weight loss. He stated he would authorize a supplement when the resident had lost weight, and then stated he had to discontinue the supplements after the residents gained weight. During a follow-up interview on 10/20/16 at 8:02 a.m., staff G stated he was aware of resident #5's weight loss. He stated he did receive a list, once per month, of residents with weight loss. A review of the resident's physician progress notes [REDACTED]. During an interview on 10/18/16 at 2:05 p.m., staff member H reported that she reported to the nurse any weight change of three pounds. The staff member stated staff member [NAME] had always been on top of residents' weight changes. If the weight was a big change from the previous week, she would zero out her scale and re-weigh the residents. Although staff H stated she did reweigh the resident, the re-weigh was not documented on the resident's Weights and Vital Summary. During an interview on 10/18/16 at 4:50 p.m., staff member B stated there was not a policy on how and when the nursing staff should assist the residents in the dining room if additional assistance was needed, and she had not provided education to her staff on providing the resident's more assistance if needed. During an interview on 10/19/16 at 4:24 p.m., staff member F reported that he did not look at the resident's care plan or attend the care plan meetings. He stated he looked at the outcomes of the meetings, the Quarterly MDS schedule, weight issues, and skin issues. He implemented a protocol for staff member [NAME] to follow and use as a guide with any weight loss or skin issues. Staff member F was unable to answer why additional interventions had not been trialed with resident #5's severe weight loss. A review of resident #5's Progress Notes showed the following dates, weights, and interventions: - 4/19/16: 132.2 pounds, 20.2% weight loss at 6 months, Boost BID - 4/26/16: 133.2 pounds, 19.8% weight loss at 6 months, Boost BID - 4/29/16: 132.1 pounds, 13.9% weight loss at 6 months, Boost BID - 5/12/16: 132.2 pounds, 10.1% weight loss at 6 months, Boost BID - 6/15/16: 125.2 pounds, 10.2% weight loss at 6 months, Boost BID - 7/9/16: 125.7 pounds, 10.2% weight loss at 6 months, Boost BID - 8/5/16: 121.1 pounds, 8.3% weight loss at 6 months, Boost BID - 9/17/16: 114.4 pounds, 14.1% weight loss at 6 months, Boost BID (8% weight loss in 1 month, 9% weight loss in 3 months) - 9/22/16: 119.1 pounds, 10.4% weight loss at 6 months, Boost BID - 10/10/16: 128.2 pounds, 12.1% weight loss at 6 months, Boost BID - 10/10/16: 127.4 pounds, 11.4% weight loss at 6 months, Boost BID This represents a severe (greater than 5% in 1 month, 7.5% in 3 months, and 10% in 6 months) weight loss. A review of resident #5's Significant Change MDS, with an ARD of 10/22/15, showed a weight of 166 pounds. A Quarterly MDS, with an ARD of 7/22/16, showed a weight of 121 pounds. This reflected a 27% weight loss in 9 months, which was a severe weight loss of greater than 10% in 6 months. The resident's RD Nutrition Follow-up assessment was completed on 2/2/16, 5/3/16, and 8/9/16. Each assessment showed inadequate oral intake as evidenced by intakes of 0-25%. Boost BID was implemented on 2/2/16. The RD Assessment Follow-up dated 8/9/16 showed an intervention to trial cookies and ice cream for the resident. No additional interventions were recommended during the past 8 month time frame. Review of staff member F's progress note, dated 10/4/16, showed weight loss secondary to a recent illness, but staff member F did not address the overall weight loss. The documentation showed to continue with Boost BID. Review of resident #5's Care Plan, dated 4/2/16, showed the resident was on a NAS diet, regular texture, regular liquids, and would receive Boost supplement BID, to help with weight maintenance. It showed a goal weight to be maintained at 121.1 pounds. The care plan interventions showed to monitor and document weight and report a weight loss greater than 5 pounds to the dietitian. The care plan showed that the staff were to allow the resident time to comfortably complete her meals, and provide access and assistance to eat pleasure foods. Record review of the P[NAME] Response History (resident intake record) for the resident, dated for 10/18/16 at 12:59 p.m., showed that the resident consumed 0-30cc of the supplement, and 0-25% consumed of the lunch meal. Review of the Nutrition Department Policy and Procedure showed the following: 3. Evaluate meal intake for achieving at least 75% of meals and substitutes offered. If less than 75% consider one or more of the following, as tolerated by the resident: serve larger food portions especially protein foods (meats, fish, poultry, eggs, dairy: such as adding grated, melted or sliced cheese to vegetable or main dish, cottage cheese as a side dish, and/or yogurt). 9. Implement fortifications as tolerated, such as: a. Super cereal b. Super hot chocolate c. Super juice d. Super mashed potatoes e. Super pudding f. Super shake g. Super soup h. Fortified ice cream i. Daily two fluid ounces of half & half for breakfast cereal, unless specified otherwise on individual tray card. Gravy is added to appropriate items at lunch and supper. j. Daily breakfast serve an extra egg, as tolerated. k. Other items may be considered, as tolerated: skim milk powder may be added to scrambled eggs; soups; casseroles; meat loaf or meat balls; cookies and muffin recipes; also add grated or melted cheese to vegetables, casseroles or soups; also peanut butter on bread, crackers, celery, apples, and bananas. 10. Consider commercial supplements if above approaches continue to be inadequate, such as house supplement (a 1 calorie per cc such as boost or ensure, a 2 calorie per cc product such as Plus 2 or Shake Plus). Review of the Weight Assessment and Intervention policy showed the following: 3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will notify the Physician. 4. The Dietitian will review the unit Weight Record to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. 6. If the weight change is desirable, this will be documented and no change in the care plan will be necessary. Review under the Care Planning section of the policy showed the following: 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietitian, the Consultant Pharmacist, and the resident or resident's legal surrogate. 2. Individualized care plans shall address, to the extent possible: a. The identified causes of weight loss b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment.",2020-09-01
788,BEARTOOTH MANOR,275090,350 W PIKE AVE,COLUMBUS,MT,59019,2016-10-20,332,D,0,1,4EQE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to administer the physician prescribed dosage of medication for 2 residents (#s 14 & 15) of 15 sampled and supplemental residents. The two medication errors made, out of a total 38 opportunities, were not significant but resulted in an unacceptable facility medication administration error rate of 5.2%. Findings include: 1. During a medication pass observation on 10/18/16 at 7:45 a.m., [MEDICATION NAME] 325 mg, one tab was poured from a stock medication container by staff member K and administered to resident #14. A review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. During an observation and interview on 10/18/16 at 6:10 p.m., staff member K reviewed resident #14's physician's orders [REDACTED]. Staff member K then verified the 325 mg dosage of the stock medication bottle of [MEDICATION NAME] on her medication cart as used for resident #14. She said she had probably given the wrong dose of [MEDICATION NAME] to resident #14 at 7:45 a.m. 2. During an observation of a medication pass on 10/18/16 at 8:17 a.m., staff member K brought [MEDICATION NAME] suspension nasal spray to resident #15 in her room and set it down in front of the patient. The resident picked it up, and without receiving instructions, gave herself one spray in each nostril. Staff member K gave resident #15 additional oral medications and then left the room. Review of the resident's medication review report, signed on 10/11/16 by resident #15's physician, showed [MEDICATION NAME] was ordered on [DATE] as [MEDICATION NAME] Suspension ([MEDICATION NAME] Propionate), 2 sprays in both nostrils one time a day for allergies [REDACTED].>During an observation and interview on 10/18/16 at 6:10 p.m., staff member K reviewed resident #15's physician's orders [REDACTED].",2020-09-01
789,BEARTOOTH MANOR,275090,350 W PIKE AVE,COLUMBUS,MT,59019,2016-10-20,371,E,0,1,4EQE11,"Based on observation, interview, and record review, the facility failed to label, for proper storage, one food item brought into the facility for resident use, and failed to discard 3 items that were stored beyond their manufacturer's expiration dates. This had the potential for harm to residents or staff members who would have consumed the items. Findings include: During an observation survey of the facility's medication storage room, on 10/17/16 at 3:25 p.m., a plastic container of what appeared to be chicken and noodles was found in the medication room refrigerator, undated, and without the name of the person for whom it was being stored. At the same time a yogurt was found with a manufacturer's expiration date of 7/23/18, and 2 protein shakes were found to have manufacturer's expiration dates of 8/29/16. All four items were removed from the refrigerator and disposed of at the time of the survey by staff member I. Staff member I stated none of the items should have been in the refrigerator. During an interview on 10/19/16 at 11:45 a.m., staff member [NAME] stated there was no policy for the labeling of food held in the food refrigerator in the medication storage room. She said the kitchen food labeling policy applied to foods in the medication room refrigerator. A review of the facility's policy entitled USE BY DATE/Discard Date, Food Labeling Guide as revised 5/6/15, showed the manufacturer's expiration date, when available, is the use by for unopened items. Cooked leftovers have a use by date of 3 days after the original cooking date.",2020-09-01
790,BEARTOOTH MANOR,275090,350 W PIKE AVE,COLUMBUS,MT,59019,2016-10-20,425,E,0,1,4EQE12,"Based on observations, interview, and record reviews, a facility staff member failed to dispose of an over-the-counter medication in a safe manner for 1 (#1); failed to ensure a medication was available to a resident (#9); and, failed to maintain direct control of medications given to resident's by walking away from the resident's prior to medications being consumed, once they had been given to the resident's, for 2 (#s 8 and 9) of 9 sampled residents. Findings include: During an observation on 12/27/16 at 12:25 p.m., staff member C had passed medications to resident #8 in the dining room. Staff member C had placed the resident's medications in front of him and walked back to her medication cart to continue her medication pass. The staff member had not observed the resident consume the medications, prior to leaving the resident. During an observation on 12/27/16 at 12:27 p.m., staff member C was observed disposing of an over-the-counter medication (acetaminophen), which belonged to resident #1. The medication had dropped on the floor, and the nurse put the pill in the garbage. During an observation on 12/27/16 at 12:35 p.m., staff member C had passed medications to resident #9 in the dining room. Staff member C had placed the resident's medications in front of him and walked back to her medication cart to continue her medication pass. The staff member had not observed the resident consume the medications prior to leaving the resident. During the observation on 12/27/16 at 12:35 p.m., staff member C had passed medications to resident #9. The resident's Medication Administration Record [REDACTED]. The medication was out of stock and unavailable, and the resident had not received her dose of carafate. During an interview on 12/27/16 at 1:00 p.m., staff member C stated the following: - The residents' in the facility had not had orders to self-administer their medications. She also stated she had not watched the resident's take their medications, but she was supposed to. - Resident #9 had the medication, carafate, 1 gram, to be given at the noon medication pass. The medication was not administered because the shipment had not arrived. Resident #9 had missed one dose of carafate at noon that day, but the facility had not ordered, and obtained the medication prior to the missed dose occurring. - Staff member C stated that the proper disposal method for medications which had dropped on the floor would include putting the medication in a sharps container to secure it, but only if it was a narcotic medication. She stated she had thrown the medication in the garbage because the pill was an over-the-counter medication. Review of the facility's Medication Administration and Ordering policy, dated (MONTH) (YEAR), showed that medication administration and re-ordering of medications should be completed consistently. Review of the facility's Medication Destruction policy, dated (MONTH) (YEAR), showed tablets unless otherwise instructed should be flushed down the sewer nearest the medication room.",2020-09-01
791,BEARTOOTH MANOR,275090,350 W PIKE AVE,COLUMBUS,MT,59019,2016-10-20,441,F,0,1,4EQE11,"Based on observation, interview and record review, the facility failed to: Maintain a cleanable surface for a bathing tub located on the Mountaintop hallway, which had the potential to affect all resident's how used the tub and area; and failed ensure oxygen tubing, oxygen cannula, and nebulizer changes were completed in a manner to prevent bacterial contamination and spread of potential infection, and document the change of the equipment, for 4 (#s 2, 10, 12, and 13) of 15 sampled and supplemental residents. Findings include: 1. During an observation on 10/19/16 at 9:05 a.m., the fiberglass tub in the Mountaintop tub room was observed to have five areas on the inside edges of the tub where the protective coating had been broken or chipped away, creating uncleanable surfaces. The rubber surround on the outside of the tub was missing or broken in three areas, creating uncleanable surfaces. The area of the tub surround, above the key lock, had a crack approximately one inch long, creating an uncleanable surface. The floor to the tub room was observed to have multiple missing or broken floor tiles which created an uncleanable surface. A touch control panel at the front of the tub had a plastic film covering it, the film was bubbled and ridged, creating an uncleanable surface. During an interview on 10/19/16 at 9:15 a.m., staff member H said 41 of the 43 residents in the facility used the tub weekly. Staff member H said the broken floor tiles in the bathing room should be replaced. Staff member H said she knew about the chips in the tub's surface, the missing rubber pieces of the tub surround, and the crack above the key lock. Staff member H said she used chemicals to clean the inside of the tub, including the tub jets, but she did not clean the outside of the tub. Staff member H said the staff had been trying to get the tub replaced for at least the last eight months. During an interview on 10/20/16 at 7:30 a.m., staff member J said the control panel on the tub could not be replaced. Staff member J said the tub was too old and replacement parts could no longer be ordered. Staff member J said the broken floor tiles could not really be fixed without ripping out big sections of the tiles. Staff member J said the broken floor tiles, and the chips in the surface of the tub were probably uncleanable. Staff member J was aware that facility staff were trying to come up with ways to replace the tub in the Mountaintop tub room. Staff member J said the whole tub room needed to be remodeled. 2. During an observation of oxygen concentrators on 10/19/16 at 4:00 p.m., the oxygen tubing, cannula's, and nebulizers were found to be unlabeled, and without documentation showing when the items were last changed for residents #2, #10, #12, and #13. Resident's #2's oxygen tubing and cannula were found on the floor. A record review of the medication and treatment administration records for residents #2, #10, #12 and #13, showed a lack of evidence for the times or dates oxygen equipment had been changed. During an interview on 10/19/16 at 11:30 a.m., staff member B stated that one staff member had been changing all of the residents' oxygen equipment and tubing on a weekly basis for a long period of time. She said that by policy the changes were to be documented on the medication administration record. She said the nurses, not the person who changed the equipment, would have been responsible to sign for the changes made. A review of the facility's oxygen concentrator policy, last revised as of (MONTH) 2014, showed that for intermittent use, equipment was to be stored so as not to touch the floor when not in use. It was to be changed weekly, and so noted on the medication administration record. For continuous use, the oxygen equipment (tubing, cannula, and nebulizer) were to be changed weekly, and so noted on the medication administration record. During an interview, on 10/18/16 at 3:50 p.m., staff member C read the facility's policy for oxygen concentrator use, which showed the date of the tubing change was to be documented on the resident's medication administration record. She said she had never seen documentation of the oxygen tubing change on any of the residents' medical administration records or the resident's treatment administration records. She said that she would not have documented an equipment change if she had not completed the task herself. REFERENCE [NAME] L, Wilkins, [NAME] K. Stoller, and Craig [MI] Scanlan, Egan's Fundamentals of Respiratory Care, 8th ed., St. Louis-Missouri, 2003, pg. 51. Oxygen therapy and pulmonary function equipment are also implicated as potential sources of nosocomial infections .Large-volume nebulizers are the worst offenders .Small-volume medication nebulizers (SVNs) can also produce bacterial aerosols. SVNs have been associated with nosocomial pneumonia, including Legionnaires' disease, resulting from either contaminated medications or contaminated tap water used to rinse the reservoir. [NAME] [MI] Wilkins, [NAME] K. Stoller, and Craig L Scanlan, Egan's Fundamentals of Respiratory care, 8th ed., St. Louis-Missouri, 2003, pgs. 42, 51. Equipment handling procedures that help prevent the spread of pathogens include maintenance of in-use equipment, processing of reusable equipment, the application of one-patient-use disposables, and fluid and medication precautions The plastic industry now makes sterilized, prepackaged, single patient-use, and inexpensive respiratory equipment, which has caused infections associated with respiratory care equipment to decrease significantly .",2020-09-01
792,BEARTOOTH MANOR,275090,350 W PIKE AVE,COLUMBUS,MT,59019,2016-10-20,456,F,0,1,4EQE11,"Based on observation and interview, the facility failed to maintain essential equipment in the correct working order for 41 of 43 residents. Findings include: During an observation on 10/19/16 at 9:00 a.m., of the tub room on the Mountaintop hallway, an object appeared to be stuck in a hole at the front of the tub. The object appeared to be a turkey baster. A touch control panel at the front of the tub, were the turkey baster was located, had a plastic film covering it which was bubbled and discolored. During an interview on 10/19/16 at 9:15 a.m., staff member H identified the object as an actual turkey baster and stated it was a replacement for the on/off switch that controlled the water flow into the tub. Staff member H said a lot of the residents in the facility liked to use the tub to soak in because it helped with their aches and pains. Staff member H said 41 of the 43 residents in the facility used the tub to bathe, as it was the only tub in the facility. During an interview on 10/20/16 at 7:30 a.m., staff member J said the control panel, and the on/off switch on the tub could not be replaced. Staff member J said the tub was too old, and replacement parts could no longer be ordered.",2020-09-01
793,VALLEY VIEW HOME,275091,1225 PERRY LN,GLASGOW,MT,59230,2020-01-09,558,D,0,1,ZMML11,"Based on observation, interview, and record review, the facility failed to provide an accessible grab bar for 1 (#6) of 19 sampled residents, which created a higher risk for the resident to lose her balance or fall. Findings include: During an interview on 1/7/20 at 10:05 a.m., resident #6 stated she need more stable bars in her bathroom to help her stand. Resident #6 stated she had put in a work order for it a month or two ago, but the maintenance department had a backlog of orders. During an observation on 1/7/20 at 10:10 a.m., resident #6's bathroom had one grab bar behind the toilet and horizontal grab bars on either side of the toilet. While the grab bar behind the toilet was fixed to the wall, the ones on either side of the toilet were not fixed to the floor and came up off the floor when an upward force was applied. When exerting a downward force on the bars, the bars would wobble. During an interview on 1/8/20 at 9:33 a.m., resident #6 stated she had lived in another room in the facility where there was a fixed grab bar to the side of the toilet, which allowed her to stand on her own. In her new room, though, the grab bar was behind the toilet and she was unable to reach it. Resident #6 explained she was unable to use the horizontal grab bars on either side of the toilet: I have the strength in my arms to pull myself up, but (the bars) move. During an interview on 1/8/20 at 10:04 a.m., staff member C stated resident #6 preferred to use the bars next to the toilet, but, They move, so she can't use them. Staff member C stated staff had put in a work order already, but could not recall the exact date. Work orders for the past three months were requested from the facility. There were no work orders for resident #6. Review of resident #6's Care Plan, revised 1/7/20, showed: I need assistance in performing and maintaining my ADL activities. My ADL strengths include: able to voice my needs and use limited upper arm and hand coordination . ADL approaches will meet my needs to maintain my most independent function possible.",2020-09-01
794,VALLEY VIEW HOME,275091,1225 PERRY LN,GLASGOW,MT,59230,2020-01-09,577,C,0,1,ZMML11,"Based on observation and interview, the facility failed to post the results of the most recent State Health Survey, which rendered it inaccessible to all residents, family members, and residents' legal representatives. Findings include: During an observation on 1/9/20 at 7:42 a.m., the State Health Survey CMS Form-2567 was not included in the facility's State Survey Results binder. The binder was located on one of the main hallways by the nurses' station and included the Life Safety Code Form-2567 only. During an interview on 1/9/20 at 7:50 a.m., staff member A stated he would add the Health Survey CMS Form-2567 to the binder today. During an interview on 1/9/20 at 8:08 a.m., resident #6 stated she was unsure where to find the State Survey results, but she could ask a staff member about its location. During an interview on 1/9/20 at 8:15 a.m., staff member [NAME] stated the survey results were usually held in the binder close to the nurses' station so residents could access it. During an interview on 1/9/20 at 8:16 a.m., resident #46 stated he was unsure where to find the State Survey results.",2020-09-01
795,VALLEY VIEW HOME,275091,1225 PERRY LN,GLASGOW,MT,59230,2020-01-09,585,C,0,1,ZMML11,"Based on observation, interview, and record review, the facility failed to ensure all residents had ready access to grievance information through postings in prominent locations throughout the facility; and the facility failed to provide the contact information of the grievance official either individually, or through postings in prominent locations throughout the facility. This deficient practice had the potential to affect any resident wanting to file a grievance. Findings include: During an observation on 1/8/20 at 8:45 p.m., the main bulletin board near the nurse's station showed a single blank grievance form tacked to the right side of the board at eye level. A copy of the first page of the Resident Grievance Process policy was tacked in the upper right corner of the bulletin board. No posting of the name and contact information of the grievance official was found. During an observation on 1/8/20 at 8:50 p.m., the wall letter boxes to the right of the Social Services/Activities joint office, contained a box with blank grievance forms. The label on the box was approximately half an inch high, and the box was at standing eye level height. No other signage or posting was present. During a group interview on 1/8/20 at 11:44 a.m., members of the Resident Council group were asked if they knew how to file a formal grievance. None of the members present felt confident they knew how to file a formal grievance, or where to find the necessary information. When asked where to find the grievance policy posting or the blank grievance forms, several of the members said they thought there were forms by the bulletin board near the nurse's desk. However, none of the residents could recall any posting related to the policy. None of the residents were able to name the grievance official. During an interview on 1/8/20 at 3:40 p.m., staff member K stated she facilitated the Resident Council meetings per the residents' request. She stated that when a resident brought up an issue in a meeting, she handled it. Staff member K stated this process was separate from the grievance process, and did not overlap in any way. During an interview on 1/8/20 at 4:13 p.m., staff member J stated she had been the grievance official since December of 2018. Staff member J stated she was responsible for instructing new residents about the grievance process. Staff member J stated the grievance process was part of the admission agreement, and she brought this up at every care conference. Staff member J did not know why the residents in the group interview stated they were unaware of the process. A review of the facility's policy titled, Resident Grievance Process, dated 12/27/18, showed, Information on how to file a grievance or complaint will be available to the resident. The contact information of the grievance official with whom a grievance can be filed, including his or her name, business address (mailing and email) and business phone number. A review of the facility's current admission packet showed a single paragraph describing the right to file a grievance. No information about the name or contact information of the grievance official was seen.",2020-09-01
796,VALLEY VIEW HOME,275091,1225 PERRY LN,GLASGOW,MT,59230,2020-01-09,600,G,1,1,ZMML11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to protect 1 (#70) of 19 sampled residents from several incidents of physical and verbal abuse from family members, which resulted in emotional and mental anguish for the resident. Findings include: During an interview on 1/8/20 at 9:31 a.m., staff member B stated resident #70 was no longer residing in the facility, but when he was a resident, staff had some concerns with his family being aggressive, but (it was) nothing serious. Staff member B explained that when staff had concerns about the way resident #70's family was interacting with him, staff would require the family to meet in the common area so staff could observe them. During an interview on 1/8/20 at 10:48 a.m., staff member E recalled interactions she had observed between resident #70 and his family. Staff member E stated resident #70's father would raise his voice and sometimes a hand at resident #70. Staff member E explained when staff observed this aggressive behavior, they would ask resident #70's father to leave the facility, and he would comply. Staff member E added staff required resident #70's family to have supervised meetings. Staff member E stated resident #70 had started yelling out and screaming a lot, but only a month or so after he had been admitted to the facility. Staff member E explained resident #70's yelling would irritate his family, who would then tell him to shut up. During an interview on 1/8/20 at 11:02 a.m., staff member A stated staff had to constantly monitor resident #70 because he would act out and yell for no apparent reason. Staff member A stated staff could not figure out what resident #70 needed. Staff member A continued to explain staff had witnessed resident #70's parents hitting, yelling, and threatening him, and forcing food into his mouth. Staff member A stated he witnessed resident #70's parents grab his hands and shake him, or grab resident #70's side while holding up a fist and telling him to shut up. Staff member A stated he had spoken with resident #70's parents to inform them that staff needed family visits to happen in the common area and to ask that they please keep their hands off of him. Staff member A stated requiring family visits in the common area alleviated a lot of the aggression, but he did witness resident #70's parents grab his wrists on either side following that intervention. Staff member A stated resident #70 was very difficult, loud, and would use a lot of foul language; staff tried every intervention they could think of to help him stay calm. During an interview on 1/8/20 at 11:51 a.m., staff member A stated the progress notes would clarify how this was a complicated case. Staff member A stated, We were going back and forth trying to decide if it was abuse. During an interview on 1/8/20 at 12:33 p.m., staff member A stated the facility protected resident #70 by implementing an intervention of ensuring family visits occurred in the common area. This intervention was put in place 11/2/18. Review of a Nursing Progress Note, dated 8/19/18, showed: Only yelling during cares and while family here to visit. Review of a Nursing Progress Note, dated 9/1/18, showed: Family here this afternoon, they were getting frustrated with (resident #70's) yelling and were telling him to be quiet and grabbing his face. There was no mention in the progress note of staff removing resident #70 from his family. Review of a Nursing Progress Note, dated 9/3/18, showed: Resident yelled out with parents throughout lunch time. Family members grabbed resident by shoulders several times trying to get him to stop yelling, family very short tempered overall today. There was no mention in the progress note of staff removing resident #70 from the situation. Review of a Nursing Progress Note, dated 10/4/18, showed resident #70 would yell out and (his father) would open hand pat his face. As (resident #70's) behavior increased the force of the 'pat' appeared to increase as well. (Resident #70) would glare at his father and attempt to elbow him and even rose a fist to him in a threatening manner. (Resident #70's father) responded by restraining (resident #70's) wrist. The note added no reddened skin from the face pats or wrist grab were noted. There was no mention of staff removing resident #70 from the situation. Review of a Nursing Progress Note, dated 10/6/18, showed resident #70 was yelling and spitting at his parents. Both mom and dad smacked resident in the face several times. Staff removed resident #70 immediately. Review of Social Services Progress Notes, dated 10/24/18, showed resident #70 admitted to the facility [DATE]. The note showed: (Resident #70) has been historically observed acting out more frequently and louder than his normal baseline when his father is around. He normally continues this behavior for quiet (sic) some time after his family departs the facility as well. (Resident #70's) behavior appear (sic) on the defensive around his father due to the possibility of his father placing a hand over (resident #70's) mouth to attempt to stop him from yelling at times .family stated that they may decline the amount of trips to visit with (resident #70) in order to see if time away may help. This writer informed them that (resident #70) frequently acts out even on days they are not visiting so although that could be a possible type of help it may not too. Review of a Quarterly Activities Note, dated 11/14/18, showed: Family comes to visit frequently but do have tendencies to become aggressive . Review of a Restorative Nursing Note, dated 11/14/18, showed: When family is close to resident he hollers out but when at distance he calms down. Resident was moved to recliner a distance away from dad and sister and resident was then quiet. Dad moved closer to recliner where resident was sitting and resident started hollering again. Resident was spitting and cursing at dad. Review of a Nursing Note, dated 12/2/18, showed: Today this nurse and CNA witnessed the dad grabbing resident's wrist which increased the volume on yelling. There was not mention of staff removing resident #70 from the situation. Review of resident #70's Care Plan, dated 10/30/18, showed: My family becomes aggressive at times while they are here to visit me .I will be safe while residing (in the facility). Interventions for this goal included: floor staff will report any negative behavior from family members to upper management immediately; staff will ensure all family visitation occurs in a common area; staff will separate resident from harm immediately upon witnessing. Review of resident #70's [DIAGNOSES REDACTED]. Review of the facility's policy, Abuse Prevention and Management Program, dated 4/25/19, showed: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse.Ensuring the health and safety of each resident with regard to visitors such as family members or resident representatives, friends, or other individuals subject to the resident's right to deny or withdraw consent at any time and to reasonable clinical and safety restrictions. Additionally, the policy showed, following an allegation of abuse, the facility would: Respond to the needs of the resident and protect him/her from further incident. The facility failed to proactively protect resident #70 from physical and verbal abuse by family members; and failed to remove resident #70 from situations in which family members became aggressive. After implementing an intervention of requiring supervised family visits, staff members continued to observe aggressive behavior by family members towards resident #70, without intervening at all times. A review of resident #70's final MDS showed resident #70 discharged the facility on [DATE], and he did not return to the facility.",2020-09-01
797,VALLEY VIEW HOME,275091,1225 PERRY LN,GLASGOW,MT,59230,2020-01-09,609,D,1,1,ZMML11,"> Based on interview and record review, the facility failed to report all incidents of abuse within 24 hours to the State Survey Agency; and failed to report the results of the facility's investigations following the incidents to the State Survey Agency within five working days, for 1 (#70) of 19 sampled residents. Findings include: During an interview on 1/8/20 at 11:02 a.m., staff member A stated he was unsure if any of the abuse incidents involving resident #70 were reported to the State Survey Agency. During an interview on 1/8/20 at 12:33 p.m., staff member A stated the facility did not have any documentation showing they had reported incidents of abuse to the State Survey Agency. During an interview on 1/9/20 at 8:04 a.m., staff member F stated if she saw a visitor grab a resident's hands aggressively, she would assume it would be possible abuse and report it to the DON right away. During interview on 1/9/20 at 8:08 a.m., staff member B stated possible abuse needed to be reported immediately to the charge nurse, ADON, or DON, who would then report it to the State Survey Agency in order to prevent recurring incidents of abuse. Staff member B stated, Our residents need to trust us with their care. Review of the facility's policy, Abuse Prevention and Management Program, dated 4/25/19, showed: Immediately report all alleged violations to the Administrator, state agency, adult protective services .within specified timeframe's.",2020-09-01
798,VALLEY VIEW HOME,275091,1225 PERRY LN,GLASGOW,MT,59230,2020-01-09,610,D,1,1,ZMML11,"> Based on interview and record review, the facility failed to provide documentation to show they had completed a thorough investigation for all abuse incidents; and failed to report the results of their investigations to the State Survey Agency within five working days for 1 (#70) of 19 sampled residents. Findings include: During an interview on 1/8/20 at 2:21 p.m., staff member A stated he thought the previous Social Services Director had submitted all abuse reports, and all of the facility's investigations to the State Survey Agency, but there was no record of these documents maintained by the facility. Review of the facility's policy, Abuse Prevention and Management Program, dated 4/25/19, showed: Within five (5) working days of the alleged incident, the facility will give the resident .state survey and certification agencies a written report of the findings of the investigation and a summary of corrective action taken to prevent such incidents from recurring.",2020-09-01
799,VALLEY VIEW HOME,275091,1225 PERRY LN,GLASGOW,MT,59230,2020-01-09,623,D,0,1,ZMML11,"Based on interview and record review, the facility failed to notify the resident, and the resident's representative, of the reason for a transfer out of the facility, in writing, for 1 (#28) of 19 sampled residents. Findings include: During an interview on 1/7/20 at 12:50 p.m., resident #28 stated she did not remember being hospitalized during (MONTH) or (MONTH) of 2019. Resident #28 was able to converse effectively about her care and treatment. During an interview on 1/7/20 at 3:56 p.m., staff member J stated she had been working on the process for providing written notice related to the reason for transfer out of the facility. She stated that in the past, the facility had provided verbal notice of the reason for transfer, and that written notice had not been provided consistently. A review of the facility's policy titled, Resident Transfer/Discharge Process, dated 12/27/18, only addressed transfers and discharges which were resident-initiated or against medical advice. The policy failed to mention transfers and discharges which were facility-initiated, or any written notice provided to the resident or the resident's representative. A request was made for transfer notice documentation for hospitalization s for resident #28, which occurred on 8/30/19, 9/18/19, and 9/21/19. No additional documentation was received prior to the end of the survey.",2020-09-01
800,VALLEY VIEW HOME,275091,1225 PERRY LN,GLASGOW,MT,59230,2020-01-09,625,D,0,1,ZMML11,"Based on interview and record review, the facility failed to provide the resident, and the resident's representative, with written bed hold information prior to a transfer out of the facility, for 1 (#28) of 19 sampled residents. Findings include: During an interview on 1/7/20 at 3:56 p.m., staff member J stated she had been working on the process for providing written bed hold information when residents transfer out of the facility. She stated in the past, the facility had provided the bed hold information when residents admit to the facility on ly. Staff member J stated she was not sure under what circumstances it was necessary to provide this information other than upon admission. A review of the facility's policy titled, Bed Holds, which was not dated, showed the facility provided the resident and the representative with written information related to bed holds on admission, prior to therapeutic leave, and prior to transfer to a hospital. A request was made for bed hold information provided to resident #28, and her representative, prior to her hospitalization s, which occurred on 8/30/19, 9/18/19, and 9/21/19. No additional documentation was received prior to the end of the survey.",2020-09-01
801,VALLEY VIEW HOME,275091,1225 PERRY LN,GLASGOW,MT,59230,2020-01-09,640,D,0,1,ZMML11,"Based on interview and record review, the facility failed to complete a discharge assessment; encode the subset upon a resident's discharge within 7 days; and transmit the resident's assessment within 14 days of completing the assessment for 1 (#1) of 20 sampled and supplemental residents. Findings include: During an interview on 1/8/20 at 4:43 p.m., staff member N stated no MDS was done upon discharge. She stated it was, A computer glitch, but it is done now. Staff member N stated she has reminders set on her calendar for discharges, along with other milestones. Staff member N was not able to identify any specific circumstances which led to the assessment being missed. A review of resident #1's closed medical record showed he had been discharged to home on 8/31/19. The medical record failed to show an MDS had been completed at the time of resident #1's discharge.",2020-09-01
802,VALLEY VIEW HOME,275091,1225 PERRY LN,GLASGOW,MT,59230,2020-01-09,657,D,0,1,ZMML11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to review and revise a resident's care plan related to ADL needs and mobility, for 1 (#28) of 19 sampled residents. Findings include: During an observation and interview on 1/7/20 at 12:50 p.m., resident #28 was lying in bed watching television. She stated the staff had to help her with all cares she received. Resident #28 stated she was not able to reposition herself, and had limited movement of her arms and legs, due to her [MEDICAL CONDITION]. Resident #28 stated she enjoyed getting up for bingo. During an interview on 1/9/20 at 8:40 a.m., staff member O stated when care conferences were due, she gathered information from the front-line staff, and direct care staff. She asked questions about what care approaches had been working and what had not been working. If something was truly not working, the interdisciplinary team would have considered revising the care plan. When asked specifically about resident #28, staff member O stated she had been refusing restorative services for several months. Staff member O was not able to explain why these refusals were not documented. Staff member O stated resident #28's representative was a staff member at the facility, and there had been many verbal conversations about resident #28's plan of care. Staff member O stated, We talked about it many times, there just wasn't a documentation trail. Staff member O stated the interdisciplinary team was hesitant to revise the care plan until they were sure the intervention was not going to work. During an interview on 1/9/20 at 8:55 a.m., staff member N stated in (MONTH) 2019, the interdisciplinary team initiated a one-week evaluation of resident #28, related to how she responded to requests to get out of bed. Staff member N stated this evaluation took place from 11/14/19 through 11/21/19. When asked what the evaluation revealed, she stated no analysis of the documentation was done. Staff member N was not able to provide any care plan changes that were implemented as a result of this observation. A review of resident #28's Quarterly Restorative Care Assessment, dated 6/7/19, showed gentle passive range of motion to both lower extremities to be done daily in order to maintain current functioning. A review of resident #28's Progress Notes, dated 6/8/19, showed a single encounter in (MONTH) with active range of motion to lower extremities. A review of resident #28's Nursing Rehab Time Log, dated (MONTH) 2019, showed no encounters for passive range of motion documented. There was no documentation of refusals, or deferrals due to condition. A review of resident #28's Nursing Rehab Time Log, dated (MONTH) 2019, showed one refusal on 8/3/19, and one encounter of 15 minutes on 8/26/19. Encounters of five to ten minutes were documented on five other days during the month. A review of resident #28's Nursing Rehab Time Log, dated (MONTH) 2019, showed encounters for passive range of motion four days out of month. Resident #28 was hospitalized three different times from August-September of 2019. Deferrals due to condition were documented on 9/9-9/11/19. A review of resident #28's Quarterly Restorative Care Assessment, dated 10/7/19, showed continue passive range of motion to lower extremities daily. A review of resident #28's Nursing Rehab Time Log, dated (MONTH) 2019, showed 15-minute encounters for passive range of motion eight days out of the month. There was a 10-minute encounter documented on 10/16/19. A review of resident #28's Nursing Rehab Time Log, dated (MONTH) 2019, showed 10-minute encounters three days; a refusal was documented on 11/5/19; and 15-minute encounters were documented on two days during the month. These were all for passive range of motion. A review of resident #28's Nursing Rehab Time Log, dated (MONTH) 2019, showed 10-minute encounters for passive range of motion occurring on three days during the month. A review of resident #28's Care Plan, dated 3/11/19, showed a problem with ADL's. The restorative plan approach was initiated on 5/17/19. No revisions to the restorative approach have occurred since 5/17/19. On 11/15/19, one day after the observation period started, an approach was added to encourage and assist resident #28 to get out of bed in the morning. No other revisions to the care plan were noted.",2020-09-01
803,VALLEY VIEW HOME,275091,1225 PERRY LN,GLASGOW,MT,59230,2020-01-09,761,E,0,1,ZMML11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to remove expired pain medications from medication carts for two (#s 61 and 30) of 19 sampled residents. Expired medications may be less potent; therefore, these expired medications had the potential to be less effective at reducing both residents' pain levels. Findings include: [NAME] During an observation on 1/7/20 at 3:23 p.m., resident #61's [MEDICATION NAME] had expired in (MONTH) of 2019 and was still in the medication cart. Two tablets were remaining in the 62-pill package. During an interview on 1/7/20 at 3:25 p.m., staff member I stated resident #61 had medication packets of [MEDICATION NAME] that were not expired. This was confirmed upon observation on 1/7/20 at 3:36 p.m. Review of resident #61's MAR indicated [REDACTED]. It was unclear if the tablets that were administered came from the expired packet. B. During an observation on 1/7/20 at 3:53 p.m., resident #30's [MEDICATION NAME] had expired on 10/31/19 and was still in the medication cart. During an interview on 1/7/20 at 3:54 p.m., staff member H stated resident #30 had not taken the [MEDICATION NAME] in months. Review of resident #30's MAR indicated [REDACTED]. During an interview on 1/7/20 at 3:16 p.m., staff member B stated one staff member on the night shift was assigned to review stock medications and supplies weekly to ensure nothing had expired. During an interview on 1/7/20 at 3:26 p.m., staff member G stated staff check for expired medications and supplies once per month, if not more often. Staff member G stated it had become a habit for staff: We just look at (the expiration date) whenever we pull out a medication. Review of the facility's policy, Medication Storage and Security Checklist, included a check box, which showed: Controlled substances are properly labeled and in date. Review of the facility's policy, Mosby's Pocket Guide to Nursing Skills and Procedures, showed: Check expiration date on all medications and return outdated medication to pharmacy.",2020-09-01
804,VALLEY VIEW HOME,275091,1225 PERRY LN,GLASGOW,MT,59230,2020-01-09,812,E,0,1,ZMML11,"Based on observation, interview, and record review, the facility failed to ensure proper food storage and labeling, in accordance with professional standards for food service safety. This deficient practice had the potential to affect all residents who consumed food or beverages from the kitchen and food storage areas. Findings include: During an observation on 1/8/20 at 9:01 a.m., the following items were found: Freezer directly inside main kitchen door: -angel food cake in zip lock bag, no date Cooler in main kitchen area: -half a red onion dated 1/1/20 -shredded parmesan cheese in large plastic bag closed with twist tie, open, no date -blueberries, raspberries, and strawberries, open, no date -large bottle of salsa, open, no date Cooler near main entrance to kitchen: -bottle of prune juice, open, no date -bottle of tomato juice, open, no date -gallon of milk, open, no date -pitcher of tea colored liquid, no label, no date -pitcher of clear liquid with lemony smell, no label, no date -carton of soy milk, open, no date -carton of Boost Breeze, open, no date -carton of chocolate dessert sauce, open, no date -bottle of Gatorade, open, no date -carton of half and half, open, no date Dry Storage: -three not labeled and not dated, plastic, resealable containers with what appeared to be breakfast cereal -crispy onions in zip lock packaging, open, no date Freezer in the back: -bag of mini butterscotch chips, open, no date During an interview on 1/8/20 at 9:30 a.m., staff member P stated all opened items should be dated. Staff were supposed to discard some items after five days, and others on the use-by date. A review of the facility's policy titled, Food Receiving, Storing, Preparing, & Distributing, dated 8/26/19, showed any food removed from its original container must be labeled clearly with the contents of the container. The policy showed, Any potentially hazardous, ready to eat refrigerated food must be clearly marked at the time of preparation with a 'use by' date .All foods must be used within 4 days of preparation or opening.",2020-09-01
805,VALLEY VIEW HOME,275091,1225 PERRY LN,GLASGOW,MT,59230,2020-01-09,883,D,0,1,ZMML11,"Based on interview and record review, the facility failed to determine if a resident had the Pneumococcal vaccine and failed to offer the vaccine if needed, for 1 (# 35) of 19 sampled residents. Findings include: During an interview on 1/8/20 at 7:35 a.m., staff member M stated due to Medicare/Medicaid changes, immunizations could not be given here anymore, and they have had to rely on the clinic. Staff member M also stated there was a delay in getting consents back from POAs, and there was a changeover of DON. Staff member M did not know the status of resident #35's immunizations. During an interview on 1/8/20 at 2:06 p.m., staff member L stated resident #35 had been here so long, staff had to look through paper charts in the basement to see if there was a record of her vaccines. Staff member L also stated she would call resident #35's daughter to see if she knew (about resident #35's vaccination status). Review of resident #35's vaccination record did not show resident #35 had received or declined a pneumococcal vaccine.",2020-09-01
806,VALLEY VIEW HOME,275091,1225 PERRY LN,GLASGOW,MT,59230,2017-05-25,274,E,0,1,DP9Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately record an MDS assessment to reflect a significant change in a resident's condition. This deficiency affected three (#s 5, 6, and 7) of 13 sampled residents. Findings included: 1. Review of resident #5's Annual MDS, with an ARD of 8/24/16, was compared to the most recent Quarterly MDS assessment with an ARD of 2/22/17. Three areas showed a significant change in status for resident #5 from 8/24/16 to 2/22/17, which were: - Cognitive Patterns: The ARD of 8/24/16, showed resident #5 had a BIMS of 10; moderately impaired. Whereas, the ARD of 2/22/17, showed the resident had improved with a BIMS of 14; cognitively intact. - Behavior: The ARD of 8/24/16, showed resident #5 did not exhibit behaviors. Whereas, the ARD of 2/22/17, showed a decline as the resident had other behaviors identified one to three days. - Loss of Bowel and Bladder Control: The ARD of 8/24/16, showed resident #5 was occasionally incontinent of urine and continent of bowel function. Whereas, the ARD of 2/22/17, showed a decline as the resident was frequently incontinent of bladder and bowel function. During an interview on 5/24/17 at 4:13 p.m., staff member C stated at least two care areas changed for resident #5. Therefore, a significant change MDS should have been completed in place of the most recent quarterly assessment. 2. Review of Resident #6's Annual MDS, with an ARD of 6/8/16, was compared to the most recent Quarterly MDS assessment with an ARD of 3/8/17. Two areas showed change for resident #6 from 6/8/16 to 3/8/17, which were: - Behavior: The ARD of 6/8/16, showed resident #6 did not exhibit presence or frequency in rejection of care. Whereas, the MDS with an ARD of 3/8/17, showed the presence of rejected care for the resident, with the behavior occurring one to three days. - Bladder: The ARD of 6/8/16, showed resident #6 was continent of bladder function. Whereas, the MDS with an ARD of 3/8/17, showed the resident was occasionally incontinent of bladder function. During an interview on 5/24/17 at 4:10 p.m., staff member C stated a significant change MDS needed to be completed when two or more care areas have changed due to factors related to disease or the aging process and could not resolve to the previous condition on their own. During an interview on 5/24/17 at 4:20 p.m., staff member C stated at least two care areas changed for resident #6. Therefore, a significant change MDS should have been completed in place of a recent quarterly assessment. During an interview on 5/24/17 at 5:20 p.m., staff member C stated she reviewed MDS coding information to look for possible errors. Staff member C stated the information the floor staff recorded might not be in conjunction with the requirements of the RAI. The CNAs could have recorded information different than how the RAI information was interpreted. 3. Resident #7 was diagnosed with [REDACTED]. Review of resident #7's Annual MDS, with an ARD of 8/31/16, a Quarterly MDS, with an ARD of 11/30/16, and a Quarterly MDS, with an ARD of 3/1/17, showed resident #7 had a decline in five areas: Depressive symptoms, behavioral symptoms, ADLs, urinary continence, and weight change. The assessments showed: Annual MDS - 08/31/16: -Depression score was coded as 7; mild depression -Behavior symptoms were coded as 0; behavior not exhibited -Bed mobility was coded as 0; independent with setup help -Dressing was coded as 2; limited assist of 1 person -Toilet use was coded as 2; limited assist with setup help only -Personal hygiene was coded as 3; extensive assist with setup help only -Urinary continence was coded as 1; occasionally incontinent -Weight was coded as 132 lbs. Quarterly MDS - 11/30/16: -Depression was score coded as 8; mild depression -Behavior symptoms were coded as other/1; behavior occurred 1 to 3 days -Bed mobility was coded as 2; limited assist of 1 person -Toilet use was coded as 2; limited assist of 1 person -Personal hygiene was coded as 2; limited assist of 1 person -Weight was coded as 130 lbs. Quarterly MDS - 03/01/17: -Depression score was coded as 11; moderate depression -Behavior symptoms were coded as other/2; behavior occurred 4 to 6 days, but less than daily -Bed mobility was coded as 3; extensive assist of 1 person -Dressing was coded as 3; extensive assist of 1 person -Toilet use was coded as 3; extensive assist of 1 person -Personal hygiene was coded as 4; total assist of 1 person -Urinary continence was coded as 2; frequently incontinent -Weight was coded as 118 lbs. which reflected a 10.6% weight change During an interview on 05/24/17 at 2:00 p.m., staff member C stated that a significant change MDS should be completed when there was a decline in three or more areas, unless it is a weight loss. Staff member C also stated that the changes would have had to impact more than one area. Having reviewed the changes for resident #7, staff member C said there should have been a significant change MDS completed.",2020-09-01
807,VALLEY VIEW HOME,275091,1225 PERRY LN,GLASGOW,MT,59230,2017-05-25,309,D,0,1,DP9Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately and timely assess a resident for swallowing, choking, and possible aspiration related to dysphagia; and they also did not provide the appropriate diet and thickened liquids for 1 (#1) resident, in an attempt to maintain the resident's highest practicable well being, of 13 sampled residents. Findings included: Record review of the Resident Progress Notes for resident #1 showed the following: -4/23/17: Resident #1 fell and sustained a laceration to her head. She received stitches at the (Hospital) emergency room . -4/26/17: (Family) reported normal behaviors but reports new loose cough. -5/1/17: Resident was sent back to (Hospital) emergency room related to cognitive decline and to have a brain scan. -5/1/17: Resident was flown to (Hospital) Clinic Hospital for a positive brain bleed. She declined surgery and chose to be on comfort care. -5/3/17: Resident transported back to nursing home for comfort cares. Resident cannot swallow very well and the doctor there says that 'she probably only has weeks left.' -5/5/17: Resident reclining in bed holding a cup of tea and sipping it. Resident indicates she is swallowing and it appears so to this writer. Resident denies pain. Family reports resident has spoken her first name and swallowed tea, water, Gatorade, and jello. -5/5/17: Reports resident having problems breathing. No follow-up records noted. -5/7/17: Family requested to speak with this writer regarding their mother's status. As she is now able to drink, they are concerned that she may be aspirating if she is not swallowing properly. They agree to nursing staff evaluating her lung sounds and vitals daily to determine if any potential aspiration has occurred. -5/9/17: Order received to start resident on honey thick liquids due to coughing with thin liquids. -5/8/17: Resident cough noted when drinking thin liquids, resident trialed for honey thick liquids and did well, no cough noted. MD faxed to switch resident to honey thick liquids. -5/11/17: Resident is now taking some clear liquids as well as ensure supplement. No follow-up record noted. -5/11/17: Reported resident had coughing fit and requested [MEDICATION NAME]. Attempted to cleanse mouth with sponge after admin but resident had another coughing fit with one wet sponge. -5/16/17: Family fed resident yogurt with large fruit chunks and (Resident) ate and chewed with no choking problems. Call to (doctor) requesting to advance diet per family's request. -5/17/17: .did eat jello, feeding self with a spoon. Jello propped in left hand. Spilled off spoon some, but advancing in physical abilities. -5/19/17: (Resident #1) and family are requesting to be removed from comfort care. There was no record of a bedside swallow evaluation, or speech therapist evaluation, after the resident was witnessed coughing, choking, or requesting to advance her diet post brain bleed. Review of resident #1's Physician order [REDACTED]. -5/3/17: Clear liquid diet -5/9/17: Clear liquid diet, honey thick -5/16/17: Full liquid diet, honey thick -5/16/17: mechanical soft diet, honey thick liquids Review of the (Hospital) Clinic Discharge Instructions, dated 5/3/17, showed the following: -Severe dysphagia. Patient was evaluated by speech therapy and noted to have significant dysphagia. -Swallowing difficulty: Thin liquids -Severe dysphagia due to her subdural hematoma. Review of resident #1's Physician Summary, dated 5/10/17, showed the following: -(Resident) not speaking but is doing great with yes and no, little other expressions. She denies pain, agrees with some choking with swallowing and requests nutritional supplementation. -She has requested nutritional support which will need to be in the form of thick liquids. She should have thickened liquids to honey consistency due to dysphagia of thin liquids. Review of a fax sent to the physician, dated 5/19/17, showed the following: -Message: (Resident #1) and family are requesting to be removed from comfort care. They are asking to restart [MEDICATION NAME], Milk of Magnesium, Tylenol, [MEDICATION NAME], Tiger Palm, trimo-San, Asprin, and potassium. -Action Taken: I am not sure she really needs all those meds. Certainly Milk of Magnesium, as needed, is fine and start Trimo-san. Review of resident #1's Nutritional Status Care Plan showed the following: Problem: Start Date: 5/9/16: I have a regular fortified mechanical soft diet. -This problem does not say why the resident is on a mechanical soft diet. Approach start date: 5/11/17: I am on honey thick liquids. -Honey thick liquids were originally ordered on [DATE]. This approach also does not discuss her ensure or what she is at risk for. The approach does not address how staff should assist the resident and what do if she experiences choking or swallowing issues. -The care plan also does not show were the resident was assessed to help with possible improvements in her swallowing. Review of resident #1's ADL Functional/Rehabilitation Potential Care Plan showed the following: Problem Start Date: 5/30/15: I am limited in ability to transfer myself related to past cardiovascular disease and weakness. -This problem was not updated since her most recent cognitive decline and change to comfort care. The care plan, again, does not address her rehabilitation related to dysphagia and her recent [MEDICAL CONDITION]. During an observation on 5/23/17 at 8:25 a.m., resident #1 was served the following for breakfast; scrambled eggs, toast, and cold cereal. She had a divided plate and drinks that were covered. Toast and cold cereal were not recommended for a mechanical soft diet per the facility's policy. During an interview and observation on 5/23/17 at 10:30 a.m., resident #1's family member stated the resident had been drinking her ensure without thickenup, and the resident sometimes coughed. The resident was observed picking up the unthickened ensure, had drank it with a straw, and spilled the majority of the ensure out of her mouth, and onto her bottom lip and food protector. The food protector had chocolate ensure all down the front. There was no staff monitoring the resident in the room at this time. During an interview on 5/23/17 at 11:00 a.m., staff member D stated the helping hands are facility volunteers who help between meals, and they provide snacks to the residents. The volunteers had not been educated on what foods were not recommended for specific therapeutic diets. A staff member made a list of diets for each resident, which the helping hands used as a guide when they decided what items they could offer to residents. During an observation on 5/23/17 at 12:00 p.m., staff member [NAME] asked resident #1's family, who had given the resident an unthickened ensure. The family member could not remember the staff members name. She stated they gave her mother an unthickened ensure yesterday (5/22/17) as well, she wondered if her mother still needed the thickened liquids. She stated her mother coughed sometimes when drinking the ensure. Staff member [NAME] stated that's something that we would have to watch at bedside. During an observation on 5/23/17 at 2:15 p.m., a helping hand offered resident #1 an afternoon snack, which included an apple bar. This item was not recommended on the mechanical soft diet per the facility's policy. Record review of the facility's Diet and Nutrition Care Manual showed the following items were Foods to Avoid on a mechanical soft diet: -Dry/crunchy cereals such as granola, shredded wheat, bran, or raisin bran cereal. Dry or chewy cakes, cookies, coconut, nuts, large edible seeds, popcorn . -Yogurt with nuts, coconut, or large chunks of fruit. -Any dry, tough, or crusty bread (such as French bread, biscuits, focaccia bread), crackers, toast, etc. Record review of the facility's Diet and Nutrition Care Manual showed the following items were examples of thin liquids: -Tea -Gelatin -Nutritional supplements (ensure) During an interview on 5/23/17 at 3:15 p.m., staff member A stated the facility did not have a speech therapist. She stated they had never had to use one in the past and that residents would probably have to go to Billings for the service. She stated she checked Google for a speech therapist in the area and didn't find any therapists. During an interview on 5/23/17 at 3:30 p.m., resident #1's family stated the care conference, she requested to have, went well. She stated they told her the nursing staff could watch the resident drink at her bedside, or send her to the hospital for an expensive test ([MEDICATION NAME] swallow exam). She stated she encouraged her mom to continue to drink the thickened liquids for safety. During an interview on 5/23/17 at 3:45 p.m., staff member C stated a nurse completed a bed-side swallow evaluation, if ordered by the physician. The nurse would provide food and if the resident didn't choke, advance the diet. She stated the doctor preferred to do this, rather than complete an expensive test at the hospital, which would a [MEDICATION NAME] swallow exam. During an interview on 5/23/17 at 4:30 p.m., staff member A stated the facility did not have a policy or procedure on what to do if a resident needed an evaluation from a speech therapist. During an interview on 5/24/17 at 8:45 a.m., staff member C stated she had a discussion with the family on risks and benefits of thickened liquids. She stated she would discuss restarting all the resident's medications with the nurse practitioner today. Review of resident #1's risk and benefits, dated 5/23/17, showed a signed consent by the resident's family member (not her POA). The form did not address any risks or benefits but simply stated what liquids should be thickened. The risk factors for drinking thin liquids and refusing the need of the [MEDICATION NAME] swallow test, was not identified on the form. During an interview on 5/24/17 at 11:00 a.m., staff member C stated resident #1 received a bedside swallow evaluation by the nurse practitioner. She stated the resident choked on thin liquids but did not choke when drinking ensure (which is a thin liquid). Staff member C stated the nurse practitioner ordered the resident to remain on thickened liquids except for the ensure. The resident could have ensure without thickener. The nurse was unaware of the four different types of thickened liquids (thin, nectar, honey, and spoon). She stated the bedside swallow evaluation would not capture if the resident was silently aspirating. During an interview on 5/24/17 at 2:45 p.m., staff member G stated the facility did not have a speech therapist, but swallow studies could be performed at the hospital. If she felt a resident was at risk for swallowing or choking, she would recommend a swallow study. She stated the nurses do perform a bedside swallow evaluation by offering different textured foods to residents, and then watched what textures they could tolerate. Record review of Nursing Progress notes, dated 5/24/17, showed the nurse practitioner performed a bedside swallow study and orders to continue the order, as is for thickened liquids, and may have ensure plus unthickened. Nurse practitioner wants the (physician) to perform another bedside swallow study during rounds next week. During an interview on 5/24/17 at 4:00 p.m., staff member C stated the doctor did not like to order a [MEDICATION NAME] swallow evaluation at the hospital. He stated why order a [MEDICATION NAME] swallow when the residents just have to go on thickened liquids, hate it, and request to be off of the thickened liquids, and then end up spending a ton of money.",2020-09-01
808,VALLEY VIEW HOME,275091,1225 PERRY LN,GLASGOW,MT,59230,2017-05-25,371,F,0,1,DP9Y11,"Based on observation, interview, and record review, the facility failed to ensure food was stored in a safe manner. The facility did not complete temperature logs for the refrigerators and freezers in the kitchen and throughout the facility. The facility did not store employee food seperate from the residents food. Also, expired food products were observed in the residents refrigerator. This deficiency had the potential to affect all residents receiving food from the kitchen and food stored in the other refrigerators. Findings included: 1. During an observation and interview on 5/22/17 at 3:00 p.m., the refrigerator, in the kitchen, next to the food preparatory area, had a temperature of 55 degrees Fahrenheit. This refrigerator contained the milk and juices for the residents. Staff member D stated the walk-in cooler and freezer were the only ones that had a temperature log. She also stated that this refrigerator was new and she did not think to keep a temperature log. She was not sure what the staff did when the refrigerators were out of range. Staff member J stated the facility got the refrigerator about 1-3 years ago. Review of the facility's Daily Freezer/Refrigerator Temperature Log dated (MONTH) (YEAR), showed the following: -Instructions: This log will be maintained for each refrigerator and freezer (both walk-in and reach-in units) in the facility. A designated food service employee will record the time, air temperature and their initials. If corrective action is required on any day, circle the date in the first column and explain the action taken on the back of the chart or on an attached sheet of paper. Refrigerators should be between 36 F and 41 F. Freezers should be between -10 F and 0 F. -11 out of 22 days were completed for the walk-in refrigerator. Eight temperatures recorded were out of range. There was no documentation of what actions the facility took, for those temperatures that were out of range. -9 out of 22 days were completed for the walk-in refrigerator. Three temperatures recorded were out of range. There was no documentation of what actions the facility took, for those temperatures that were out of range. Review of the facility's Refrigerators and Freezers policy showed the following: 1. Acceptable temperature ranges are 35 F to 40 F for refrigerators and less than 0 F for freezers. 2. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures. 3. Monthly tracking sheets will include time, temperature, initials, and 'action taken.' The last column will be completed only if temperatures are not acceptable. 4. Food Service Supervisors or designated employees will check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening. 5. The supervisor will take immediate action if temperatures are out of range. Actions necessary to correct the temperatures will be recorded on the tracking sheet, including the repair personnel and/or department contacted. 2. During an observation on 5/24/17 at 2:45 p.m., staff member H opened the door of the refrigerator in the North-West Kitchenette, pulled out a bottle of diet soda, took a drink from the bottle, and replaced it in the refrigerator. During an observation on 5/24/17 at 2:58 p.m., unlabeled and expired food items were observed in the North-West Kitchenette refrigerator, which were: - 1 undated cheeseburger in a wrapper. - 1 undated half consumed 20-ounce diet soda. - 2 expired protein supplements, 2.5 fluid ounces, with use by dates of 4/8/17. During an observation on 5/24/17 at 3:20 p.m., a refrigerator with a sign identifying that it was used for staff food storage, was observed in the Physical Therapy room adjacent to the North-West Kitchenette. The refrigerator was empty. During an interview on 5/24/17 at 3:30 p.m., staff member I, stated staff food was not supposed to be stored in the refrigerator with residents food. Employees were supposed to store their food in the break room or in the staff refrigerator, in the old physical therapy room. Expired food should be discarded. Review of the North-West Kitchenette Refrigerator Temperatures Log, dated (MONTH) (YEAR), showed the following: - Instructions: Please record daily, fridge temps at 40 degrees and freezer at 0 or below, contact maintenance if temps are abnormal - 11 days out of 24 had refrigerator and freezer temperatures recorded. No outdating or cleaning had been done. A review of the facility's policy, Storage of employee food and beverage, reflected, Employees store their food and beverage in the refrigerator located in the employee break room. Employees are not allowed to store food or beverage in any resident's refrigerator or in medication room's. The contents of the refrigerator are checked weekly by the housekeeping supervisor for any outdated items, and are discarded in the appropriate manner. A review of the facility's policy, Refrigerators and Freezers, reflected All medications and foods shall be appropriately dated to ensure proper rotation by expiration dates. Expiration dates on unopened food will be observed and use by dates indicated once food is opened.",2020-09-01
809,VALLEY VIEW HOME,275091,1225 PERRY LN,GLASGOW,MT,59230,2017-05-25,406,D,0,1,DP9Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide services with a qualified speech therapist for 1 (#1) out of 5 residents on a dysphagia diet were at risk for swallowing and choking concerns. Findings include: Record review of Valley View Home Snack Charting, showed 5 total residents on a dysphagia diet. Two residents also had an order for [REDACTED].>During an interview on 5/23/17 at 3:15 p.m., staff member A stated the facility did not have a speech therapist. She stated they had never had to use one in the past and stated residents would probably have to go to (Hospital) for the service. She stated she checked Google for a speech therapist in the area and didn't find any therapists. During an interview on 5/23/17 at 3:45 p.m., staff member C stated a nurse completed a bed-side swallow evaluation, if ordered by the physician. The nurse would provide food and if the resident didn't choke, advance the diet. She stated the doctor preferred to do this, rather than an expensive test ([MEDICATION NAME] swallow exam), at the hospital. During an interview on 5/23/17 at 4:30 p.m., staff member A stated the facility did not have a procedure on what to do if a resident needed an evaluation from a speech therapist. During an interview on 5/24/17 at 11:00 a.m., staff member C stated resident #1 received a bedside swallow evaluation by the nurse practitioner. She stated the resident choked on thin liquids but did not choke when drinking ensure (which is a thin liquid). Staff member C stated the nurse practitioner ordered the resident to remain on thickened liquids except for the ensure. The resident could have ensure without thickener. The nurse was unaware of the four different types of thickened liquids. She stated the bedside swallow evaluation would not capture if a resident was silently aspirating. During an interview on 5/24/17 at 2:45 p.m., staff member G stated the facility did not have a speech therapist but swallow studies could be performed at the hospital. If she felt a resident was at risk for swallowing or choking, she would recommend a swallow study. She stated the nurses do perform a bedside swallow evaluation by offering different textured foods to residents, and watch what textures they could tolerate. Record review of Nursing Progress notes, dated 5/24/17, showed the nurse practitioner performed a bedside swallow study, and orders to continue order as is for thickened liquids, and may have ensure plus unthickened. Nurse practitioner wants the (physician) to perform another bedside swallow study during rounds next week.",2020-09-01
810,VALLEY VIEW HOME,275091,1225 PERRY LN,GLASGOW,MT,59230,2018-08-09,585,E,0,1,PQ0P11,"Based on interview and record review the facility failed to provide information to 3 (#s 1, 4, and 48) of 28 sampled and supplemental residents how to file a formal grievance with the facility. Findings include: During a resident group interview on 8/7/18 at 8:59 a.m., residents #s (1, 4, and 48) stated, they were never shown how to file an official grievance with the facility. During an interview on 8/8/18 at 10:50 a.m., staff member I stated, we have the official grievance book but there has not been any grievances filed since (YEAR). During an interview on 8/8/18 at 10:54 a.m., staff member H stated she was not sure if the residents knew how to file an official grievance and stated, Some of them might know how to do it. She stated she had never gone over how to file a grievance with the residents. She stated that is something I should go over in the next resident council meeting. Review of the grievance book showed no grievances had been filed since (YEAR).",2020-09-01
811,VALLEY VIEW HOME,275091,1225 PERRY LN,GLASGOW,MT,59230,2018-08-09,658,D,0,1,PQ0P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff did not pre-pour a Scheduled II controlled medication prior to administration for 1 (#34) of 17 sampled residents. Findings include: During an observation on 8/7/18 at 8:25 a.m., staff member F was observed administering medications to resident #34. Staff member F had pre-poured the resident's medications and could visually identify all medications in the cup. The medications in the cup were: [MEDICATION NAME] 150 mg, [MEDICATION NAME] 10 mg, [MEDICATION NAME] (a Schedule II controlled substance) 5/325 mg, magnesium 400 mg, and [MEDICATION NAME] 17 grams. During an interview on 8/7/18 at 2:55 p.m., staff member F stated she did not usually pre-pour Schedule II medications, and was not sure of the rules for pre-pouring Schedule II medications. During an interview on 8/9/18 at 8:15 a.m., staff member A stated pre-pouring of controlled substances was acceptable as long as they were under lock and key in the med cart, and the nurse who poured the medications was the one who administered the medications. Review of the facility policy titled Medication Administration/Pre-pouring of medication(s) showed, under item e, pre-pouring of Schedule II medications was not acceptable as the controlled substance was no longer secured in a separately locked, permanently affixed compartment.",2020-09-01
812,VALLEY VIEW HOME,275091,1225 PERRY LN,GLASGOW,MT,59230,2018-08-09,660,D,1,1,PQ0P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure discharge plans were identified and updated regularly throughout a resident's stay, ensuring the family was aware of the identified needs and services when or if there was a discharge from the facility, for 1 (#205) of 28 sampled and supplemental residents. Findings include: During an interview on 8/8/18 at 1:13 p.m., NF1 stated the resident's family was not aware the facility was going to send resident #205 out of town to a behavioral unit, until the facility was ready to send the resident. During an interview on 8/9/18 at 8:30 a.m., staff member A stated resident #205's discharge plan, on admit, was that the resident was going to be a long term stay at the facility. During an interview on 8/9/18 at 8:01 a.m., staff member A stated the facility staff had contacted the family 11/8/17, after resident #205 had hit a staff member. The behavior unit out of town was discussed. The family said they would think about transferring the resident. Review of resident #205's nursing progress note, dated 8/18/17 at 11:04 a.m., showed the resident was admitted to the facility. Review of resident #205's physician progress notes [REDACTED].#205 after the resident was admitted to the facility. The facility staff were reporting the resident had increased bad behaviors. Review of resident #205's progress notes, dated 9/6/17 at 10:46 a.m., showed social services spoke to resident #205's wife, stating the possibility of a stay at an out of town hospital's behavioral unit to try and stabilize the resident's behavior. Review of resident #205's progress notes, dated 9/6/17 at 1:27 p.m., showed social services staff had contacted the out of town hospital's BHU, stating the facility would first monitor the resident for effects of the added [MEDICATION NAME] (a medication) before a behavioral unit stay. There was no documentation that the resident's wife or the POA was notified. There was no update on resident #205's discharge plan. Review of resident #205's care plan, with a date of 9/12/17, showed no documentation that the facility had any plans in place for discharge. Review of resident #205's nursing progress note, dated 10/11/17 at 3:33 p.m., showed resident #205's physician saw the resident for his 60 day evaluation at the facility. The resident's wife was there. The resident's wife was made aware of the resident's behaviors. Review of resident #205's progress notes, dated 11/8/17 at 3:46 p.m., the family and physician were notified that resident #205 had punched a staff member in the eye. There was no documentation that discussed the inability for the facility to care for the resident. Review of resident #205's fax cover sheet from the out of town hospital BHU, dated 11/8/17, showed communications had occurred between the facility and the hospital. Review of resident #205's progress note, dated 11/9/17 at 10:09 a.m., after resident #205 had struck the staff member, the IDT (interdisciplinary team) discussed options with the resident's care. A call was placed to the out of town hospital behavioral unit. The BHU had a bed open. Family gave approval to take the resident there. The resident was transported by the director of nursing and a nurse. The resident's physician was notified and voiced approval. No discussion had occurred with the family prior to this about the impending transfer, although it had been considered and worked on by the facility. Review of resident #205's out of town hospital emergency room report, dated 11/9/17, showed resident #205 was presented to the emergency room in Great Falls, Montana, by a private vehicle, with facility care staff, for evaluation of his behavioral problems. The facility did not have a plan in place for discharge started on admission or updated when resident #205's behaviors increased. There was no documentation in resident #205's medical record showing the facility met or discussed the discharge and plan with the family, as the events occurred. On the day of the discharge, the facility informed the family of the plan, and then requested the family's agreement of the plan. There were no other options offered for discharge.",2020-09-01
813,VALLEY VIEW HOME,275091,1225 PERRY LN,GLASGOW,MT,59230,2018-08-09,689,D,0,1,PQ0P11,"Based on observation, interview, and record review, the facility failed to provide adequate supervision for 1 (#53) of 17 sampled residents. Findings include: During an observation on 8/8/18 at 1:16 p.m., resident #53 was seated in his wheel chair, at the nurses station, unattended. The resident was bent over, and was playing with the leg rests on his wheel chair. During an interview on 8/9/18 at 9:00 a.m., staff member A stated resident #53 was on the Red Falling Star Prevention Program. She stated a red star was placed on the outside of the resident's door and triggered staff to stop and look at the resident. Staff member A stated the red star meant the resident was not to be left alone, in his wheel chair, in his room. Staff member A stated the staff tried to keep the resident out of his room as much as possible. Review of the facility's Red Star Falling Program showed Never leave resident in their wheelchair alone in any room. Offer a 1:1 visit, take them for a walk, offer meaningful distraction, ensure their needs are met, or sit them at the nurse's station (someone must be at the nurse's station), assist to bed if certified. Review of resident #53's nurse's notes for July, (YEAR) showed the following: -7/20/18: Unwitnessed fall in room. No injuries, -7/22/18: Unwitnessed fall out of wheel chair. No injuries, -7/30/18: Unwitnessed fall from wheel chair in room. one inch laceration to the right side of his head was sustained, -8/2/18: Resident was found on floor. No injuries. Review of resident #53's care plan, dated 7/26/18 showed the resident was on the red star fall prevention program and was not to be left alone in his room when in his wheel chair. The care plan was not updated to reflect recent falls.",2020-09-01
814,VALLEY VIEW HOME,275091,1225 PERRY LN,GLASGOW,MT,59230,2018-08-09,725,E,0,1,PQ0P11,"Based on interview and record review, the facility failed to respond to call lights in a timely manner for 4 (#s 1, 4, 47, and 48) of 28 sampled and supplemental residents. Findings include: During resident interviews on 8/7/18 at 8:59 a.m., residents #s 1, 4, 47, and 48 stated they often had to wait a long time for the staff to answer their call lights. During an interview on 8/7/18 at 8:15 a.m., resident 48 stated she had to wait 42 minutes a few days prior after she pushed her call light button. She stated she was upset by this because she often is incontinent when she has to wait a long time. During an interview on 8/7/18 at 8:20 a.m., resident 47 stated he had to wait 30 minutes after he pushed his call light button. During an interview on 8/8/18 at 9:26 a.m., staff member G stated the facility had a lack of staff around two months prior, around the time administration changed. He stated There can still be issues at night when people call out. For nights there were four staff working, at a minimum, when there were typically six in the past, showing a decrease. Review of Resident Council minutes, dated 4/30/18, showed: Old Business: - Call light time has gotten a little better. Hall one and two residents are still complaining about times Open Discussion: - Call lights take a while but staff also come in turn the light off and don't come back (sic) Review of Resident Council minutes, dated 5/29/18, showed: Old Business: -Sometimes it takes a long time to get help from CNAs New Business: - The council feels like every once in a while they don't see change on what is discussed in resident council (sic)",2020-09-01
815,VALLEY VIEW HOME,275091,1225 PERRY LN,GLASGOW,MT,59230,2018-08-09,744,D,0,1,PQ0P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care and services by failing to assess and determine the underlying cause(s) of behaviors for a resident with dementia, for 1 (#53) out of 17 sampled residents. Findings include: During an observation on 8/7/18 at 8:15 a.m., resident #53 was lying in bed with his eyes closed. The resident did not go to the dining room for the morning meal. During an observation on 8/7/18 at 12:00 p.m., resident #53 was observed lying in bed with his eyes closed. The resident did not go to the dining room for lunch. During an interview on 8/9/18 at 9:00 a.m., staff member A stated the facility attempted to learn where residents are at and what they did prior to admit. Staff member A stated resident #53 enjoyed taking things apart and wheeling around the facility in his wheel chair. Staff member A stated the resident displayed aggressive behaviors such as punching and kicking staff. Staff member A stated the facility had not figured out why the resident was having behaviors. Review of resident #53's Admission MDS, with an ARD of 7/29/18, showed disorganized thinking. Section [NAME] did not show signs or symptoms of [MEDICAL CONDITION], and the resident did have physical behaviors toward others. Section G showed the resident needed extensive assistance with ADLs. Section C showed the resident had a BIMS score of 2, which indicated severe cognitive impairment. Review of resident #53's nurse's notes, dated 7/18/18 through 8/8/18, showed the following behaviors, however did not address any underlying causes: -7/18/18: admitted to facility. Confused and agitated with care at times. -7/19/18: Up in the morning with assist of two staff. Seemed content in wheel chair. No agitation noted. Resident agitated in the evening and became physically aggressive with staff. Resistive to redirection and care. -7/20/18: Resident had a pleasant morning. Words garbled after lunch. Content to wander the facility in his wheel chair. Unwitnessed fall in room. -7/21/18: Resident had baseline behavior. Wife reported pajamas brought in were untouched. Staff report the resident was in T-shirt and brief only, in the morning. -7/22/18: Found on floor with wheel chair tipped over. -7/24/18: Family gave general information regarding the resident's likes and dislikes. Taken to special care unit for closer supervision. -7/25/18: Resident cooperative, but at times restless. Placed in special care unit for closer monitoring for a few hours. -7/26/18: Staff report the resident started slapping CNA's leg and grabbed her leg while seated on the toilet. Taken to special care unit for closer observation. -7/28/18: No further aggression. -7/30/18: Resident in wheel chair in his room, staff hear loud crash. Resident was found on the floor. Resident was brought to the TV room to allow for closer supervision. -7/31/18: Resident was resistive to assistance from staff. Ate his lunch on the special care unit. Behavior remained baseline. A baseline of the resident's behaviors was not evident in the medical record. -8/1/18: Resident up and out of room either in the TV common area or in the hall. -8/2/18: Resident found on the floor of his room. -8/3/18: Resident increasingly striking out at staff during care since admit. MD informed and [MEDICATION NAME] ordered to start when pharmacy can supply. -8/4/18 at 2:55 p.m.: Resident up for breakfast, but leaned in chair and ate poorly when fed. Resident had been sleeping in the recliner in the TV room since 9:30 a.m. Incontinent of urine and changed. -8/5/18: CNA reported that the resident had been awake most of the night. Rested in bed. HS [MEDICATION NAME] 10 mg was held due to new medication [MEDICATION NAME] with resident sleeping most of the day yesterday. -8/6/18: Resident has not had any behaviors noted at this time. He has slept off and on most of the day. -8/6/18 at 3:39 p.m.; Wife concerned that resident was sleeping too much and requested that practitioner change medication or stop the medication. -8/7/18: CNAs noted to the nurse yesterday that the resident was incontinent of urine completely due to lethargy and weakness. He had not left the bed. Staff was repositioning and assisting with feeding. Resident had been sleeping in the am and did respond with opening his eyes when spoken to. The resident did not follow commands very well such as drinking water when instructed to drink. Family would like [MEDICATION NAME] discontinued after doing research. [MEDICATION NAME] discontinued and [MEDICATION NAME] 25 mg to be started 8/8/18. -8/8/18: Resident was up in recliner with family at side. He was alert, but appeared tired. Speech was garbled. As the evening went on the resident was more alert and understandable. [MEDICATION NAME] held at HS due to resident's condition. Review of resident #53's care plan showed the resident needed assistance with ADLs related to dementia, needed encouragement to eat, was not able to express needs appropriately, and had combative behaviors during cares and towards the staff. Interventions included avoiding over-stimulation, maintain a calm environment and approach, consistent routine, staff to explain their wishes slowly and more than once if needed, monitor pain, give simple directions, and anticipate the resident's needs. The facility failed to assess the resident's behaviors for underlying causes. The MDS showed the resident had behaviors, and the care plan showed the resident had behaviors, however failed to address the underlying causes of the behaviors.",2020-09-01
816,VALLEY VIEW HOME,275091,1225 PERRY LN,GLASGOW,MT,59230,2018-08-09,758,D,0,1,PQ0P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an antipsychotic medication had an adequate indication for use, for 1 (#53) of 17 sampled residents. Findings include: During an interview on 8/9/18 at 8:00 a.m., staff member A stated resident #53 was receiving an antipsychotic for punching and kicking staff. Staff member A stated the resident was strong and aggressive towards staff. Staff member A stated the facility had been trying to educate the physicians on trying different things for behaviors. Review of physician orders [REDACTED]. -8/3/18: [MEDICATION NAME] 0.5 mg started. The order did not contain an indication for the use of an antipsychotic medication. -8/7/18: [MEDICATION NAME] discontinued. [MEDICATION NAME] 25 mg started due to sedation and family request. Review of nursing notes for 8/3/18 through 8/8/18 showed the following: -8/3/18: Resident increasingly striking out at staff during care since admit. MD informed and [MEDICATION NAME] ordered to start when pharmacy can supply. -8/4/18 at 2:55 p.m.: Resident up for breakfast, but leaned in chair, and ate poorly when fed. Resident had been sleeping in the recliner in the TV room since 9:30 a.m. Incontinent of urine and changed. -8/5/18: CNA reported that the resident had been awake most of the night. Rested in bed. HS [MEDICATION NAME] 10 mg was held due to new medication [MEDICATION NAME] with resident sleeping most of the day yesterday. -8/6/18: Resident has not had any behaviors noted at this time. He has slept off and on most of the day. -8/6/18 at 3:39 p.m., wife concerned that resident was sleeping too much and requested that practitioner change medication or stop medication. -8/7/18: CNAs noted to this nurse yesterday the resident was incontinent of urine completely due to lethargy and weakness. He has not left bed. Staff was repositioning and assisting with feeding. Resident had been sleeping this am and did respond with opening his eyes when spoken to. Did not follow commands very well such as drinking water when instructed to drink. Family would like [MEDICATION NAME] discontinued after doing research. [MEDICATION NAME] discontinued and [MEDICATION NAME] 25 mg to be started 8/8/18. During an observation on 8/7/18 at 8:15 a.m., resident #53 was lying in bed with his eyes closed. The resident did not go to the dining room for the morning meal. During an observation on 8/7/18 at 12:00 p.m., resident #53 was observed lying in bed with his eyes closed. The resident did not go to the dining room for lunch. -8/8/18: Resident was up in recliner with family at side. He was alert, but appeared tired. Speech was garbled. As the evening went on the resident was more alert and understandable. [MEDICATION NAME] held at HS.",2020-09-01
817,VALLEY VIEW HOME,275091,1225 PERRY LN,GLASGOW,MT,59230,2018-08-09,812,F,0,1,PQ0P11,"Based on observation, interview, and record review, the facility failed to clean and maintain the kitchen to ensure sanitation in the kitchen areas, creating a potential for food-borne illness for all residents who consume facility food. Findings include: 1. During an initial tour through the main kitchen on 8/6/18 at 4:13 p.m., areas of concern were identified: -The filters in the hood vent, above a range grill and burners, a steamer, and a three container steam table, were covered with greasy dust. A kettle with soup was heating on the stove top, below the hood vent. -Twelve medium to large sized kettles were stored above a preparation table. The kettles were facing up and open to dirt and debris. No guard covered the kettles. Eight soup ladles were on the rack, above the preparation table. The ladles were also facing up and open to dirt and debris. -Two raw turkey breasts, sealed in a plastic package, and two rolls of raw hamburger, sealed in plastic, were sitting together in a plastic tub. Two packages of raw beef stew meat were sealed in a plastic wrap were sitting next to two raw pork roasts, in a plastic package, on the same sheet pan. The practice of storing the different meats together on the same pan may result in cross contamination of blood and juices. -The top of the dish machine had wet food, crumbs, and debris, which had not been cleaned by staff. -The circulating fans, inside the three door refrigerator, had greasy dust dangling off the fan covers which had not been cleaned, and this was just above stored food. During an interview on 8/6/18 at 4:13 p.m., staff member [NAME] stated the kettles and soup ladles always hung on the rack above the preparation table, and she did not realize the possibility of contamination, with the kettles and spoons uncovered and stored in the manner they were. The staff member stated maintenance cleaned the hood filters; she thought weekly. The staff member stated she was aware of the meat in the same tub and on the same rack in the walk in. Review of the facility's Sanitization policy, with a revision date of (MONTH) 2008, showed all kitchen areas would be kept clean. Staff would be trained to maintain cleanliness throughout their work areas. Procedures for daily cleaning duties included the hood vent, wiping down the entire surface, completely. The policy did not identify to cover openings of kettles and ladles, or wash the outside of the dishwasher, to protect from contamination. The policy was not current and did not follow current standards of practice. During an interview on 8/7/18 at 8:15 a.m., staff member D stated she supervised the cleaning of the kitchen. The staff member stated she would talk with maintenance to work out a plan for cleaning the hood vent. The staff member stated understanding the different types of meat, thawing on the same tray, but did not realize the possibility of contamination. Review of a non dated letter, addressed to the dietary manager, from the administrator, showed the administrator was to conduct weekly random inspections of the kitchen. The administrator showed he was responsible for the kitchen being in compliance with regulations, and the dietary manager was responsible to delegate the work and ensure the kitchen was clean. There was no documentation showing the administrator had conducted weekly inspections.",2020-09-01
818,VALLEY VIEW HOME,275091,1225 PERRY LN,GLASGOW,MT,59230,2018-08-09,865,F,0,1,PQ0P11,"Based on interview and record review, the facility failed to implement and operationalize an effective QAPI program by failing to follow through on identified concern areas, for planning, monitoring, and evaluation of the concerns, for corrective action and improvement, which may affect all residents residing at the facility. Findings include: During an interview on 8/9/18 at 8:03 a.m., staff member H stated, We try to complete Performance Improvement Project Worksheets for the tasks each department is working on, however it does not always get done. She stated, the departments are in charge of keeping track of QAPI information and what they are working on, quarterly. During an interview on 8/9/18 at 9:20 a.m., staff member H stated they needed to improve on documentation of what they were doing for QAPI and the steps they are taking for improvement as well as follow through. She stated, We are still learning. Review of QAPI Meeting minutes dated 1/17/18 showed there was no documentation of Performance Improvement Projects or the Worksheets to show evaluation, root cause analysis, monitoring, or evaluation of the following issues: MDS Coordinator - From (MONTH) we have an increase proxy score in ADLS & incontinence - pressure ulcers - one reoccurring and was recently admitted to the hospital for bleed Maintenance - Worked to get the heaters to function correctly. Review of QAPI Meeting minutes dated 5/17/18, showed there was no documentation of Performance Improvement Project Worksheets to show evaluation and root cause analysis of the following issues: Resident Care Coordinator - Oxygen in use signs, where to place signs, who's role to put up sign when O2 is started. - Progress notes being received in a timely manner or consistently after doctor visit - Bed rails, did not have a process for putting bed rails on Housekeeping - Housekeeping staff not cleaning under furniture as reported by family and residents. Dietary - Walk in Fridge Door does not work properly. - Floor drain, does not drain properly. - Cooking steamer does not work. - Need for food wash sink. Nursing - Med review - labels on medications do not consistently match orders or progress notes provided by the doctor - Staff not aware of the fall protocol - infection control - developing an antibiotic stewardship - working on getting a new bath tub",2020-09-01
819,VALLEY VIEW HOME,275091,1225 PERRY LN,GLASGOW,MT,59230,2018-08-09,881,F,0,1,PQ0P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement an antibiotic stewardship program to track antibiotic use, for 1 (#22) of 17 sampled residents. This had the potential to affect those residents receiving antibiotics as the program was not implemented for all residents. Findings include: During an interview on 8/8/18 at 4:17 p.m., staff member B stated she was currently in the process of taking a class on antibiotic stewardship, however had not fully implemented the program. Staff member B stated the physicians went over antibiotic use when they came to the facility, and they reviewed the medications. The Pharmacist conducted monthly medication reviews. Staff member B stated the facility followed CDC guidelines for antibiotic use and surveillance. The facility failed to track and trend antibiotic use to determine if antibiotic use was appropriate. Review of a Facility Event Summary Report showed resident #22 was started on an antibiotic, [MEDICATION NAME] 400 mg daily for ten days, on 7/11/18 for a UTI. On 7/12/18, the antibiotic was changed to [MEDICATION NAME] 500 mg two times daily for ten days as E-coli was present. The facility failed to monitor antibiotic use for appropriateness and failed to obtain lab data prior to initiation of an antibiotic.",2020-09-01
820,ST LUKE COMMUNITY NURSING HOME,275093,107 6TH AVE S W,RONAN,MT,59864,2018-02-08,656,E,0,1,5XLH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to include on the resident's care plan: the indications for use, mood triggers, and non-pharmacological interventions for use of an antianxiety medication for 1 (#35); bladder incontinence and interventions to prevent complications of incontinence for 1 (#20); and, the need for interventions to prevent complications related to impaired mobility for 1 (#30) of 15 sampled residents. Findings include: 1. Review of resident #20's Significant Change of Status MDS, with an ARD of 12/7/17, showed the resident was frequently incontinent of bladder. The MDS showed resident #20 received limited assistance for toileting. Review of resident #20's quarterly bladder evaluation, completed in the timeframe of the most recent MDS, showed occasional incontinence at night. Review of resident #20's (MONTH) (YEAR) ADL flowsheets showed the resident was frequently incontinent of bladder at night. Review of resident #20's care plan did not show a focus problem for bladder incontinence, the level of assistance needed for toileting, interventions to minimize incontinent episodes, or the risk for complications from the incontinence. During an interview on 2/8/18 at 9:25 a.m., staff member I stated she developed the nursing portions of the care plans. She said she tried to make sure resident needs are included in the care plan, but she missed the bladder incontinence for resident #20. 2. During an interview and observation on 2/05/18 at 3:23 p.m., NF3 stated resident #30 had limited mobility to his joints, and specifically to his right hand. Resident #30's right hand was noted to be closed. NF3 stated resident #30's right hand had a contracture. She opened his hand to demonstrate the effort required to extend resident #30's fingers. She stated the staff usually opened his hand and washed his skin, and that she does it as well. Review of resident #30's care plan did not show the impaired mobility in the right hand, or the need for care to prevent complications. During an interview on 2/08/18 at 9:25 a.m., staff member I stated staff provided care to resident #30's right hand to prevent complications. She said staff will sometimes place a carrot (soft carrot-shaped device used to prevent complications from contractures), or a rolled wash cloth in resident #30's right hand, and that the hand is opened and washed by the staff. She stated the impaired mobility and interventions were not on the care plan and would be added. Staff member I stated she did not know how newly hired staff would know to provide these services for resident #30 if they were not on his care plan. 3. Review of resident #35's (MONTH) (YEAR) physician's orders [REDACTED]. Review of resident #35's care plan showed a problem for potential discomfort or side effect related to the use of the antianxiety medication. The care plan had as a listed intervention that the resident has a tendency to get nervous. The care plan did not show the indication for use of the medication, any known triggers for the panic attacks/anxiety, or any non-pharmacological measures to use to alleviate the anxiety. During an interview on 2/8/18 at 9:25 a.m., staff member I stated the care plan showed the resident tended to get nervous, but did not show the physician's indication for use of the medication, the triggers for the anxiety, or possible non-pharmacological interventions. She stated she did not realize that much detail was needed, and she would update the care plan.",2020-09-01
821,ST LUKE COMMUNITY NURSING HOME,275093,107 6TH AVE S W,RONAN,MT,59864,2018-02-08,657,D,0,1,5XLH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to include a behavior plan on the resident's care plan for 1 (#6) resident out of 15 sampled residents. Findings include: Resident #6 was admitted with the [DIAGNOSES REDACTED]. Reports for allegations of inappropriate sexual behavior were submitted to the State Survey Agency. One allegation, dated 8/21/17, was reported by another resident to facility staff, and one on 1/1/17, that alleged resident #6 was kissing other female residents. Both allegations were investigated and unsubstantiated. Review of resident #6's Quarterly Minimum Data Set, with an assessment reference date of 11/8/17, reflected the resident was not cognitively impaired, and was able to make himself understood and understand others. Section [NAME] reflected resident #6 had no inappropriate behaviors. Review of the monthly nursing summary, dated 1/4/18, reflected, will occ (sic) say sexual innuendos to staff or want to hug female staff etc . Listed under the question, How often did staff intervene showed, 1:1 as needed. LIsted under Outcome of intervention showed, beh (sic) has decreased. During an interview on 2/8/18 at 9:30 a.m., staff member D stated resident #6 did not exhibit inappropriate behaviors during the look back period for his assessment, so behavior was not triggered as a care plan area to consider. Review of resident #6's care plan did not include a problem, goal, or interventions, to address sexually inappropriate behaviors. During an interview on 2/8/18 at 9:50 a.m., staff member O stated resident #6's behaviors had decreased in the last three months. She stated she redirected him approximately three weeks ago regarding a sexually inappropriate comment he made to her. Staff member O stated it would be helpful to have resident #6's behaviors addressed on his care plan so that everyone is aware, so they know how often it is happening. During an interview on 2/8/18 at 10:15 a.m., staff member P stated resident #6 received his showers from male staff because he might be inappropriate with female staff. During an interview on 2/8/18 at 10:25 a.m., staff member Q stated resident #6 hadn't exhibited sexually inappropriate behaviors for a long time. Staff member Q stated if he did, she would report the behavior to the nurse and would redirect him.",2020-09-01
822,ST LUKE COMMUNITY NURSING HOME,275093,107 6TH AVE S W,RONAN,MT,59864,2018-02-08,658,E,0,1,5XLH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to meet professional standards of quality by documenting and/or administering incorrect dosages of insulin to 1 (#14); failed to intervene or notify the physician when blood glucose levels exceeded the physician's specified parameters for 1 (#14); failed to document the efficacy of PRN medications for 3 (#s 14, 22, and 27); and failed to document the administration of insulin and the blood glucose results for 1 (#25) of 15 sampled residents. Findings include: Insulin 1. Resident #14 was admitted to the facility with [DIAGNOSES REDACTED]. a. Review of resident #14's physician's orders [REDACTED].>300 GIVE 6 UNITS [MEDICATION NAME], NOTIFY MD FOR BS >400. Review of resident #14's (MONTH) and (MONTH) (YEAR) Medication Administration Record (MAR) showed: - 1/4/18 at 11:00 a.m., resident #14 had a blood glucose of 222. The resident was administered 2 units of [MEDICATION NAME] insulin. Resident #14 should have been administered 4 units of insulin. - 1/17/18 at 11:00 a.m., resident #14 had a blood glucose of 241. The resident was administered 2 units of [MEDICATION NAME] insulin. Resident #14 should have been administered 4 units of insulin. - 2/3/18 at 11:00 a.m., resident #14 had a blood glucose of 289. The resident was administered 2 units of [MEDICATION NAME] insulin. Resident #14 should have been administered 4 units of insulin. During an interview on 2/7/18 at 1:06 p.m., staff member A stated she must have accidentally written the wrong dosages of insulin administered to resident #14. Staff member A stated all nursing staff members were required to double check dosages of insulin with another nurse prior to administering insulin to the residents. Staff member A stated she could not recall which nurse had double checked the insulin dosage for resident #14. b. Review of resident #14's (MONTH) and (MONTH) (YEAR) MAR and nurse's notes showed: - 1/2/18 at 7:00 a.m., resident #14 had a blood glucose of 43. No staff interventions were documented, neither was the resident's physician notified. - 1/12/18 at 6:45 a.m., resident #14 had a blood glucose of 50. Staff administered 4 ounces (oz) of orange juice, but did not recheck the resident's blood sugar, neither did staff notify the resident's physician. - 1/19/18 at 6:00 a.m., resident #14 had a blood glucose of 47. Staff administered 4 oz of orange juice. At 6:35 a.m., resident #14's blood sugar was 65. Staff administered 4 oz of apple juice. At 7:05 a.m., resident #14's blood sugar was 91. The resident's physician was not notified. - 1/21/18 at 7:00 a.m., resident #14 had a blood glucose of 55. No staff interventions were documented, neither did staff notify the resident's physician. - 1/22/18 at 7:00 a.m., resident #14 had a blood glucose of 50. No staff interventions were documented, neither was the resident's physician notified. - 1/25/18 at 7:00 a.m., resident #14 had a blood glucose of 48. No staff interventions were documented, neither was the resident's physician notified. - 1/27/18 at 6:30 a.m., resident #14 had a blood glucose of 50. Staff documented they administered prune juice, did not recheck the resident's blood sugar, neither did anyone notify the resident's physician. - 1/28/18 at 7:00 a.m., resident #14 had a blood glucose of 47. Staff documented they administered apple juice with 3 sugar packets. The staff did not recheck the resident's blood sugar, neither did staff notify the resident's physician. - 1/29/18 at 7:00 a.m., resident #14 had a blood glucose of 41. No staff interventions were documented, neither did staff notify the resident's physician. - 2/1/18 at 6:00 a.m., resident #14 had a blood glucose of 48. Staff documented they administered prune juice, did not recheck the resident's blood sugar, neither notify the resident's physician. Staff documented they would be monitoring the resident's status. - 2/3/18 at 7:00 a.m., resident #14 had a blood glucose of 55. No staff interventions were documented, neither was the resident's physician notified. - 2/4/18 at 6:00 a.m., resident #14 had a blood glucose of 36. Staff documented they gave the resident 120 cc of orange juice. At 8:20 a.m., resident #14's blood sugar was 76. The resident's physician was not notified. Nurse's notes, dated 2/4/18 at 4:00 p.m., read, Resident at 7:55 (a.m.) could not stay sitting up byself (sic), and could not stand, speech wasn't understandable. BS 36. During an interview on 2/8/18 at 8:58 a.m., staff member F stated she had contacted resident #14's physician in the past when her blood glucose levels were outside the parameters of 60-400. Staff member F stated these notifications were not always documented in the resident's MARs or nurse's notes. During an interview on 2/8/18 at 10:41 a.m., staff member K stated she had given the resident orange juice when her blood glucose levels were less than 60. Staff member K stated she would inform the oncoming staff in report, and would document the results in the log book. Staff member K stated the facility did not have an on-call physician on staff, and therefore she did not contact anyone regarding blood glucose levels less than 60. During an interview on 2/8/17 at 11:06 a.m., staff member H stated she had not contacted resident #14's physician when her blood glucose levels were below 60. Staff member H stated, juice with extra sugar packets was offered to the resident when her blood glucose levels were in the 40's. The staff member stated she should have informed the next nursing shift of the resident's blood glucose results with any interventions provided. Staff member H stated she should have documented hypoglycemic events, and interventions provided on the resident's MAR. On 2/8/18 at 11:49 a.m., staff member J hand delivered a letter signed by (physician name) which read, 1/11/18- Nursing does not have to notify myself, (physician's name), of blood sugars below 60. Please address each blood sugar individually with carbohydrates and recheck accordingly. During an interview and record review on 2/8/17 at 11:50 a.m., staff member I stated the physician letter, dated 1/11/18, should have been added to the resident's MAR upon receipt. Staff member I stated the letter, dated 1/11/18, had not been documented in resident #14's (MONTH) or (MONTH) MAR. An interview with resident #14's primary care physician was attempted on 2/8/18 at 12:07 p.m., and on 2/13/18 at 8:42 a.m. The physician returned the phone call on 2/8/18, and left a message after the survey team had exited the facility. An interview with resident #14's physician was not conducted regarding her episodes of [DIAGNOSES REDACTED]. c. Review of resident #14's physician's orders [REDACTED].>300 GIVE 6 UNITS [MEDICATION NAME], NOTIFY MD FOR BS >400. Review of resident #14's (MONTH) (YEAR) MAR and nurse's notes showed: - 2/4/18 at 9:00 p.m., resident #14 had a blood glucose of 405. No staff interventions were documented, neither was the resident's physician notified. A written request was made on 2/7/18 at 9:26 a.m., to staff member [NAME] for a copy of the facility's policy and procedure on Physician notification of blood glucose levels. This policy was not submitted to the survey team prior to exiting the facility on 2/8/18. During an interview on 2/8/18 at 11:10 a.m., staff member H stated she had contacted the emergency room physician regarding resident #14's blood glucose of 405 on 2/4/18. The staff member stated she had been told to just monitor the resident's blood glucose levels. Staff member H stated she did not document the phone call or instructions in the resident's medical record or MAR. 2. Resident #25 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #25's (MONTH) (YEAR) MAR, for the date of 2/4/18, was blank for the scheduled blood glucose check, and for the 5:30 p.m. administration of insulin. During an interview on 2/8/18 at 11:50 a.m., staff member R stated normally she gets the blood sugar and documents that. Staff member R stated she wrote the blood sugar value on a yellow sticky note. Staff member R stated she verified the insulin she gave with another nurse, but forgot to document the blood sugar value and the insulin administration on the MAR. A review of the facility's policy, Safe Medication Preparation, read, Right Documentation: Accurate documentation allows nurses and other health care providers to communicate with one another and improves medication safety. Many medication error results (sic) from inaccurate documentation .Medication Preparation .2. The right to have the correct drug route and dose dispensed. Efficacy of PRN medications 3. Review of resident #14's (MONTH) and (MONTH) (YEAR) MAR and nurse's notes showed: a. A physician's orders [REDACTED]. - 1/12/18 at 7:30 p.m., resident #14 was administered [MEDICATION NAME] 10/325. Staff did not document the dosage given, reason it was given, nor did staff follow-up with the documentation of efficacy. - 1/15/18 at 11:30 a.m., resident #14 was administered [MEDICATION NAME] 10/325 for pain with ambulation. Staff did not document the dosage given, nor did staff follow-up with the documentation of efficacy. b. A physician's orders [REDACTED]. - 1/22/18 at 8:00 a.m., resident #14 was administered [MEDICATION NAME] 7.5/325 for pain with standing. Staff did not follow-up with documentation of efficacy. c. A physician's orders [REDACTED]. TOPICAL TID PRN REDNESS. - From 1/2/18 to 1/30/18, staff administered [MEDICATION NAME] cream to resident #14. Staff did not follow-up with the documentation of efficacy eight times. - On 2/5/18 at 10:00 p.m., resident #14 was administered [MEDICATION NAME] cream. Staff did not follow-up with the documentation of efficacy. During an interview on 2/8/18 at 9:00 a.m., staff member F stated efficacy of PRN medication should have been documented in the resident's MAR one hour after being provided. 4. Resident #22 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #22's (MONTH) Treatment Administration Record (TAR), dated 3/21/17, a physician's orders [REDACTED]. TOPICAL BID PRN. - 1/13/18 at 9:00 p.m., resident #22 was administered [MEDICATION NAME] powder. Staff did not follow-up with the documentation of efficacy. - 1/15/18 at 9:00 p.m., resident #22 was administered [MEDICATION NAME] powder. Staff did not follow-up with the documentation of efficacy. 5. Resident #27 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #27's (MONTH) and (MONTH) (YEAR) MAR and nurse's notes showed: a. A physician's orders [REDACTED]. - 1/9/18 at 6:00 a.m., resident #27 was administered [MEDICATION NAME] 50 mg. Staff did not follow-up with the documentation of efficacy. - 1/22/18 at 10:00 a.m., resident #27 was administered [MEDICATION NAME] 50 mg. Staff did not follow-up with the documentation of efficacy. - 2/2/18 at 12:00 p.m., resident #27 was administered [MEDICATION NAME] 50 mg. Staff did not follow-up with the documentation of efficacy. - 2/3/18 at 4:00 p.m., resident #27 was administered [MEDICATION NAME] 50 mg. Staff did not follow-up with the documentation of efficacy. During an interview on 2/7/18 at 1:12 p.m., staff member B stated the efficacy of PRN medication should always be documented in the resident's MAR within one hour of being given. She stated the efficacy would ensure a resident's PRN medication use is being monitored appropriately. During an interview on 2/7/18 at 1:16 p.m., staff member C stated efficacy of PRN medication should have been documented in the resident's MAR within one hour after being provided. Review of the facility's policy, Post-administration Activities, read, 2. Document data pertinent to patient's (sic) response. This is especially important when giving PRN drugs. References: http://care.diabetesjournals.org/content/41/Supplement_1/S119 1. Call provider immediately: in case of low blood glucose levels (=70 mg/dL (3.9 mmol/L)). Low finger-stick blood glucose values should be confirmed by laboratory glucose measurement.",2020-09-01
823,ST LUKE COMMUNITY NURSING HOME,275093,107 6TH AVE S W,RONAN,MT,59864,2018-02-08,661,D,0,1,5XLH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a discharge summary with a recapitulation of the resident's stay for 1 (#41) of 1 closed discharge record. Findings include: Review of resident #41's Focus Charting progress notes, dated 7/25/17, showed the resident was receiving hospice services. A progress note, dated 7/29/17, showed a [DIAGNOSES REDACTED]. A progress note, dated 11/12/17, showed resident #41 had a fall and was transferred to the emergency room . The note showed a [DIAGNOSES REDACTED]. Progress notes, dated 11/23/17 and 11/24/17, showed resident #41 displayed inappropriate behavior. Review of resident #41's closed record showed no document with a discharge summary or recapitulation of stay. Review of resident #41's Patient Transfer Form showed a discharge plan, and documentation of current ADL status. During an interview and record review on 2/7/18 at 3:36 p.m., staff member [NAME] stated the Patient Transfer Form was resident #41's discharge summary and recapitulation of stay. Staff member [NAME] stated the Patient Transfer Form was the only document used as a recapitulation of stay by the facility, and usually included more information regarding the care received in the facility. She stated the form did not show resident #41 had previously been receiving hospice services, which ended in Sept (YEAR), and did not reflect concerns for the infection, the fall with injury, or the behaviors noted in resident #41's clinical record.",2020-09-01
824,ST LUKE COMMUNITY NURSING HOME,275093,107 6TH AVE S W,RONAN,MT,59864,2018-02-08,695,D,0,1,5XLH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide necessary respiratory care by not cleaning respiratory equipment as directed by the manufacturer's guidelines for 2 (#s 36 and 39 ) of 18 sampled and supplemental residents. Findings include: 1. During an observation and interview on 2/5/18 at 1:50 p.m., a machine with tubing and an attached face mask was observed in resident #39's room. He stated it was a sleep apnea machine. Observation of the machine showed significant soiling on the tubing, mask, and filter compartment that could be scraped off with a fingernail. Resident #39 stated no one cleaned the mask or tubing. He stated the mask and tubing had not been replaced during his stay in the facility because the machine was so old that replacement parts were no longer available. Review of resident #39's (MONTH) (YEAR) physician's orders [REDACTED]. Review of resident #39's care plan showed a BIMS score, updated 1/30/18, of 14 (cognitively intact). The care plan showed a problem for alteration in activities of daily living. An intervention for the problem showed, [MEDICAL CONDITION] as ordered. The care plan did not include any instruction for the cleaning or maintenance of the machine or components. During an interview on 02/8/18 at 9:50 a.m., staff member N stated staff notify her when a resident had a [MEDICAL CONDITION] or [MEDICAL CONDITION], and they were added to a list for routine cleaning and maintenance. She said the respiratory therapy staff rounded monthly to replace the machine's white filter, and perform other services on a scheduled basis. During an observation and interview on 2/8/18 at 10:00 a.m., staff member N briefly inspected the sleep apnea machine. With the filter cover removed, she looked in the filter compartment and stated the machine and filter were not clean. The tubing was inspected, and staff member N stated it was not clean. She stated it was an older model, and had not been supplied by the facility. She stated resident #39's machine was not on the list to be serviced by the respiratory therapy team, and had not been serviced. During an interview on 2/8/18 at 10:25 a.m., staff member C stated the night shift set up the machine and removed the mask in the morning. She said she provided no service to the device. During an observation and interview on 2/8/18 at 10:40 a.m., staff member C briefly inspected the machine and stated it was not clean. Using an alcohol swab, she swabbed an area of the tubing and removed some of the visible soil. She removed the filter and rinsed it. During an interview on 2/8/18 at 12:30 p.m., staff member N stated resident #39's machine was not up to facility standards. She said the expectation was for nursing staff to complete the daily cleaning of the mask unit. Review of resident #39's (MONTH) and (MONTH) (YEAR) MARS/TARS and care plan showed no evidence of cleaning of the mask unit. A written request was made for evidence of the cleaning of the mask. No evidence was provided. 2. During an observation and interview on 2/5/18 at 2:20 p.m., a [MEDICAL CONDITION] machine was observed in resident #36's room. He stated he used it at night. Review of resident #36's care plan showed a BIMS score of 15, cognitively intact. The care plan did not show the use of the [MEDICAL CONDITION] or include any instruction for the cleaning or maintenance of the machine or components. Review of resident #36's (MONTH) (YEAR) physician's orders [REDACTED]. Check/fill with distilled water (every) HS. Review of the manufacturer's instructions, provided by the facility, showed the following: -It's important to clean your equipment as specified in your product instructions. Poor maintenance can make your sleep therapy ineffective and damage your equipment. - Daily cleaning directions for the mask and tubing; -Weekly cleaning of the gray/black foam filter, headgear, machine, and humidifier. During an observation on 2/8/18 at 10:50 a.m., resident #36's [MEDICAL CONDITION] mask showed visible debris which could be removed with a gloved finger. After putting on his glasses, the resident stated the mask had visible debris clinging to the inside. He stated he had not noticed it before because he doesn't wear his glasses when he used the mask. Resident #36 stated no one washed his mask. To his knowledge, the mask had not been cleaned during his stay in the facility. Review of resident #36's (MONTH) and (MONTH) (YEAR) MARS/TARS and care plan showed no direction to clean the mask unit daily and no evidence of cleaning. During an interview and record review on 2/8/18 at 12:30 p.m., staff member N stated the therapy department did not complete the routine daily and weekly cleaning tasks for the [MEDICAL CONDITION]. She stated as far as she knew, there was no evidence the tasks were being completed. Verbal and written requests were made for evidence of the cleaning of the [MEDICAL CONDITION] and the components. No evidence was provided.",2020-09-01
825,ST LUKE COMMUNITY NURSING HOME,275093,107 6TH AVE S W,RONAN,MT,59864,2019-03-07,695,D,0,1,LYH411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to consistently monitor a resident's oxygen saturations per physician order [REDACTED].#11) of 16 sampled residents. Findings include: During an observation on 3/4/19 at 1:36 p.m., resident #11 was in bed with his eyes closed. An oxygen concentrator was next to the window and not running. The concentrator had a nasal cannula attached to it and was not applied to the resident. Resident #11 was observed to have an occasional dry cough. During an observation on 3/4/19 at 3:57 p.m., resident #11 was in bed with his eyes closed and did not have oxygen applied while he was in bed. During an observation and interview on 3/5/19 at 9:34 a.m., staff member A stated she checked resident #11's oxygen saturation and it was at 81%. Staff member A reported the low oxygen saturation to staff member D. Staff member D answered staff member A and stated resident #11's oxygen saturation goes back into the 90's as soon we place him back on it. Staff member D took resident #11 to his room and placed him in bed and applied his oxygen via nasal cannula on 2 liters per minute. Review of resident #11's physician's orders [REDACTED]. Review of resident #11's Vital Signs, Weights, I and O Summary form, showed on 3/1/19 on the 6-2 shift, his oxygen sats were 84%. There were no oxygen sat entries for the 2-10 p.m. evening, or the 10-6 a.m. night shift recorded on the form. Review of resident #11's Treatment Administration Record showed he had been administered oxygen on 3/4/19 at 2.5 liters ( the prescribed order was 2 liters for oxygen sats below 89%) with an oxygen sat of 93%, and on 3/5/19 at 2 liters with no oxygen sat documented. There were no entries for 3/1/19-3/3/19. Review of the Nurse's note, dated 3/1/19 at 3:30 a.m., showed resident #11's oxygen sats were 96% at 3 liters per minute (the prescribed order was 2 liters per minute). Review of the Nurse's notes, dated 3/1/19 at 12:00 p.m., showed oxygen sats were 84% with a late entry timed at 10:00 a.m. that showed O2 applied for O2 sat of 84%. Review of resident #11's Nurse's note, dated 3/4/19 at 2:40 a.m., showed oxygen sats at 82% on room air and 96% with oxygen at 3 liters per minute (the prescribed order was for 2 liters per minute). Review of resident #11's Nurse's note, dated 3/5/19 with no time entered, showed oxygen sats 99% on 2 [MI] O2 removed to reassess need. O2 while lying in bed was 84% OR[NAME] Reapplied oxygen via NC. 93% on 2.5 [MI] (the prescribed order was for 1--2 liters per minute). During an interview on 3/5/19 at 11:02 a.m., staff member D stated the CNAs check resident #11's oxygen every shift and they tell the nurse the result. She stated the nurses documented in the Treatment Administration Record what the oxygen sat percent was and if oxygen was administered. Review of the Treatment Administration Record for (MONTH) did not reflect results charted by CNAs for the dates of (MONTH) 1-3. Staff member D stated they could get an order to check resident #11's oxygen sats every shift. Review of resident #11's Nurse's note, dated 3/5/19 at 3:15 p.m., showed O2 sat at 81% on R[NAME] O2 placed at 2 L per NC & O2 sat (increased) to 93% . Review of a Nurse's Order, dated 3/5/19, showed change nebulizer tubing & reservoir Q month. Rinse filter Q month (on the 10th) check O2 sat Q shift. The Nurse's Order was placed on the Treatment Administration Record and included specific times the nursing staff was to check resident #11's oxygen sats at 8:30 a.m. and 8:00 p.m. During an observation on 3/06/19 at 8:00 a.m., resident #11 did not have oxygen on during his breakfast meal. During an observation and interview on 3/6/19 at 11:30 a.m., staff member A transferred resident to his wheelchair to take him to the dining room for lunch. Resident #11 did not have his oxygen on after staff member Staff member A placed him in his wheelchair. Staff member A stated she checked his oxygen sats after breakfast and he was at 84%, so she put his oxygen on after breakfast. Staff member A stated the nurse would check his sats again after he was done with lunch to see if he needed to have his oxygen back on. While staff member A was wheeling resident #11 to the dining room she was instructed to put his oxygen on. Staff member A obtained an oxygen tank and a carrier and placed resident #11 on oxygen at 2 liters per minute via nasal cannula. Resident #11 was on the oxygen continuously during his lunch meal. During an interview on 3/6/19 at 11:42 a.m., staff member C stated she would not know if resident #11's oxygen sats were below 89% unless he was tested continuously. Staff member C stated resident #11 should be on oxygen continuously. She stated he had been on vital sign monitoring recently because of a recent illness of a urinary tract infection. She stated he was not eating well, and in the last week he had not been able to keep his oxygen sats up. She stated she would place him on the oxygen in his room, and he would end up staying in bed with the oxygen on the whole time. Staff member C stated since he had become ill at the end of (MONTH) he had needed the oxygen. She stated she noticed this morning at breakfast he was getting very sleepy, so when I took him down to his room, I checked his sats and they were 84%, so I put his oxygen on at 2 liters per minute. On 3/06/19 at 2:06 p.m., a record review of resident #11's Treatment Administration Record showed new entries to check O2 sat q shift, and O2 at 2lpm per nc continuously. Document if resident refuses. During an interview on 3/07/19 at 7:58 a.m., staff member [NAME] stated, if an oxygen order is prn for sats to be 89% we should have another part of that order that would say check q shift.",2020-09-01
826,ST LUKE COMMUNITY NURSING HOME,275093,107 6TH AVE S W,RONAN,MT,59864,2019-03-07,880,D,0,1,LYH411,"Based on observation, interview, and record review the facility failed to ensure staff cleaned a glucometer properly exposing residents who received testing with the glucometer to bloodborne pathogens for 1 (#40); and failed to ensure staff changed gloves between a dirty and clean procedure placing residents at risk for infection for 2 (#s 7, and 10) of 16 sampled residents. Findings include: 1. During an observation on 3/6/19 at 11:30 a.m., staff member C checked resident #40's blood glucose. Staff member C obtained the glucometer and the supply tray and entered resident #40's room. Staff member C washed her hands and applied gloves. Staff member C conducted the blood glucose check with the glucometer. After staff member C was done with procedure she wiped the glucometer with a Sani-wipe disinfecting wipe and set the glucometer on a clean paper towel to dry. The instructions on the Sani-wipe container instructed the user to ensure the item being cleansed remained wet for 2 minutes to be effectively disinfected. Staff member C stated she was trained to use the Sani-wipe to wipe down the glucometer, and then place it on a paper towel to dry. She stated the glucometer was placed back into the wall mount in the med room once it had dried. Staff member C stated she was not aware the Sani-wipe instructions were to ensure the object remained wet for two minutes to ensure disinfection. During an interview on 3/7/19 at 7:58 a.m., staff member [NAME] stated, some of us were cleaning the glucometer incorrectly. She stated apparently, the little cards made up for cleaning it said let dry for two minutes when actually the container says to keep wet for two minutes. We called over to the hospital and asked about their policy, and they said they keep it wet for two minutes. Staff member [NAME] stated the administrative staff are discussing and are planning to change the process for cleaning to ensure the device remains wet for the two minutes. 2. During an observation and interview on 3/5/19 at 1:25 p.m., staff members A and B assisted resident #10 with toileting. Staff member A and B washed their hands and applied gloves. Staff member A and B assisted resident #10 from her Broda chair to the toilet with the use of a Hoyer lift. When resident #10 was done with toileting staff member A used the lift to raise resident #10, and staff member B provided perineal care. Resident #10 had a bowel movement. Staff member B used her contaminated glove to pull additional cleansing wipes from the package. Staff member B applied perineal barrier cream, a clean brief and then removed her contaminated gloves. Staff member B stated she should have removed her gloves after she was done providing perineal care. Staff member B threw away the contaminated brief and obtained a new brief and applied to resident #10 and pulled up her pants. During an observation on 3/5/19 at 1:40 p.m. staff member A assisted resident # 7 with toileting and perineal care. Resident #7 had a bowel movement. Staff member A cleansed resident #7's perineal area with cleansing cloths, and then used her contaminated gloves to apply a clean brief, pull up the resident's pants, and move the resident out of the room touching the handles of the lift and then removed her gloves. Staff member A stated she should have removed her gloves after she provided perineal care and sanitized her hands. During an interview on 3/7/19 at 7:58 a.m., staff member [NAME] stated facility CNAs were trained to use gloves when doing perineal care, and should change their gloves after the perineal care, sanitize, put clean gloves on, and then put the clean brief on. She stated the facility's last training was the annual PPE training last fall. She stated she usually does hand hygiene audits and floor observations weekly. Review of the facility policy, titled Use of Gloves in the Nursing Home, showed .Gloves should be changed immediately if they become wet, worn, soiled, or torn.",2020-09-01
827,ST LUKE COMMUNITY NURSING HOME,275093,107 6TH AVE S W,RONAN,MT,59864,2016-10-06,157,D,0,1,KSTH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to notify a resident's physician and care plan team members of the resident's unplanned weight loss of 8.5% of total body weight for 1 (#12) of 14 sample and supplemental residents. Findings include: Resident #12 was admitted [DATE] with [DIAGNOSES REDACTED]. A review of Focus Charting showed resident #12 had a loss of 8.5% of her total body weight over a period of 9 days between 9/17/16 and 9/26/16. A review of the (YEAR) CNA Weekly Weight Records for resident #12 showed the resident also had a loss of 9.4% of total body weight over the last four months (June to September). During an interview on 10/4/16 at 11:10 a.m., staff member [NAME] said she was not notified by any of the nurses regarding resident #12's weight loss, as determined on 9/26/16. She said that she was usually notified regarding resident weight loss with a call from the resident's nurse or by one of the care team managers. She also stated that resident #12 was due to have an updated diet assessment completed as of the date of the interview,10/4/16. A record review of resident #12's 60 day visit with her physician, dated 9/8/16, showed the resident's weight at the time of the appointment was 131.6 lbs. Under the heading of Chronic diastolic (congestive) heart failure the physician notes on the record showed: increased diuresis (sic) appears to have stabilized pt (patient) nicely. The record did not list weight loss as a problem. No other records were found to indicate that the resident's physician had been notified of the resident's weight loss determined on 9/26/16. During an interview on 10/6/16 at 11:10 a.m., staff member C said the nursing staff knew about the weight loss. She said it was the facility's policy that if resident weight loss was greater than three pounds the nurse was to notify the care team. A review of the Focus Charting nursing notes for resident #12, from 9/17/16 through 9/27/16, showed no evidence that resident #12's physician, dietician, or family members had been notified of the resident's weight loss. There was no charting showing the nursing staff considered the resident's weight loss a significant problem. The charting did not show whether the DON or care team members had been made aware of the resident's weight loss. A review of the facility's policy, Changes in Resident Condition/Notification, showed Nursing services will notify the resident, his or her next-of-kin, or representative (sponsor), as each case may apply, when: There is a significant change in the resident's physical, mental, or psychosocial status, or when there is a need to alter the resident's treatment significantly. A review of the facility's policy, Weight Loss or Gain, showed All resident weights will be monitored at least on a weekly basis, and excessive weight loss or gain will be evaluated on an individual basis, and necessary steps will ensue. For procedures to follow, the listing included: 4. If a weight problem is identified, the staff nurse will notify the DON. 5. The interdisciplinary care planning team will be notified of the problem by the DON and will meet to investigate the problem and identify possible solutions. The supervisor will notify the physician if weight gain or loss continues and will convey the recommendation of the interdisciplinary team. 6. In compliance with the physician's plan of care, the plan will be placed in the resident's care plan.",2020-09-01
828,ST LUKE COMMUNITY NURSING HOME,275093,107 6TH AVE S W,RONAN,MT,59864,2016-10-06,221,D,0,1,KSTH11,"Based on observation, interview, and record review, the facility failed to keep 1 (#3) of 11 sampled residents free from a physical restraint when in bed, which was used for staff convenience, which restricted the resident's freedom of movement, and was not used for the resident's medical symptoms. Findings include: During an observation on 10/5/16 at 7:50 a.m., resident #3 was lying in bed. Her bed was placed against the wall, the mattress was a scoop mattress, and a 10 inch wedge was placed underneath the scoop mattress. The resident had minimal room to move in bed. During an interview on 10/5/16 at 8:18 a.m.,staff member M stated the mattress and wedge were in place to prevent the resident from getting out of bed. During record review, no assessment was found for the use of the mattress or wedge. During an interview on 10/5/16 at 8:40 a.m., staff member B stated the facility did not complete written assessments for equipment use, but met as a team and put it on the care plan. She stated the mattress and wedge were to prevent the resident from rolling out of bed.",2020-09-01
829,ST LUKE COMMUNITY NURSING HOME,275093,107 6TH AVE S W,RONAN,MT,59864,2016-10-06,222,G,0,1,KSTH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility utilized multiple [MEDICAL CONDITION] medications for one resident to treat behaviors which were identified as pain related for staff convenience for 1 resident (#3) out of 11 sampled residents; the effect resulted in significant lethargy for the resident who had cognitive and communication deficits. Findings include: Review of a Pharmacy Recommendation for resident #3, dated 4/21/16, showed RN's and I talked about her crying etc. They think she is worse. Could be decrease of [MEDICATION NAME] or [MEDICATION NAME] needs increased. Could go back up with [MEDICATION NAME] and get [MEDICATION NAME] to therapeutic dose. Review of the physician's reply, which was in the medical record, showed Increase [MEDICATION NAME] to 150 mg daily, and no change in [MEDICATION NAME]. Review of the resident's Physician order [REDACTED]. [MEDICATION NAME] was increased in dose to .5 mg, 4 times a day, for anxiety and comfort. Review of the resident's Focus Charting notes showed [MEDICATION NAME] was discontinued on 5/9/16. The reason was not provided. Review of the resident's Hospice not on 5/19/16 showed the resident was agitated and trying to climb out of her chair. The resident cried through the visit and talked about home. She was given [MEDICATION NAME] and [MEDICATION NAME] for back pain. Review of the resident's Focus Charting notes on 5/20/16 showed Dr. here new order to DC [MEDICATION NAME] and consider taper of narcotics. Review of the resident's Hospice note on 5/23/16 showed staff reported the patient seemed to have an increase in agitation with use of [MEDICATION NAME], and the last week was the worst. No signs and symptoms of pain, and the MD decreased [MEDICATION NAME] to three times a day, and the [MEDICATION NAME], from 10 mg four times a day to 5 mg three times a day. Review of the resident's Physician Orders, dated 5/26/16, showed to discontinue [MEDICATION NAME] and start [MEDICATION NAME] for the resident's depression. Review of the resident's (MONTH) Medication Administration showed ([MEDICATION NAME]) dated 4/18/16, 100 mg PO at HS. The administration record was blank, and said see page 3. Page 3 showed ([MEDICATION NAME]) 150 mg po daily. The administration record was blank. Review of the resident's Focus Charting on 5/28/16 showed the resident had a fall in her room. She was taken to the dining room for closer observation. She was given an extra [MEDICATION NAME] with her scheduled one at 1400. A reason was not provided. Pain was not addressed for the resident. Review of the resident's medical record did not show the monitoring for affects from the reduction in pain and anti anxiety medication, and discontinued use of the [MEDICATION NAME] on 5/23/15. Review of the resident's Focus Charting noted on 6/2/16 showed the resident had a rash, and the [MEDICATION NAME] was on hold. The documentation showed, Resident restless, crying, today at lunch. Pain was not addressed, although the resident had exhibited pain symptoms. Review of the resident's Focus Charting note on 6/2/16 showed the resident was restless and moaning. A PRN [MEDICATION NAME] and [MEDICATION NAME] was given, showing a positive outcome. Although the medication was beneficial to treat the restless and moaning, the facility did not consistently utilize this information when the resident exhibited future pain symptoms, but rather her pain symptoms were treated with behavior altering medications. Review of the resident's Focus Charting on 6/9/16 showed Clinical Pharm (sic) called about acute [MEDICAL CONDITION]/agitation. The recommendation given was for [MEDICATION NAME] 2 - 5 mg every hour as needed. Staff report the resident needs 1 to 1 care due to falling out of bed, agitation, and not sleeping for 48 hours. The resident's medical record lacked an assessment for possible pain and medication withdrawal as a potential cause for the [MEDICAL CONDITION]. Review of the resident's Focus Charting note, dated 6/9/16, showed a new order to increase the [MEDICATION NAME] to 10 mg, three times a day. Review of the resident's Focus Charting note on 6/10/16 showed the resident was crying and stating she was in pain. She was given 3 mg of [MEDICATION NAME], and 10 mg of [MEDICATION NAME] with a positive effect. Again, this showed the benefits of treating the resident's pain, rather than her behavior symptoms. Review of the resident's Focus Charting note on 6/11/16 showed the resident was awake most of shift and prn [MEDICATION NAME] and [MEDICATION NAME] was given. The nurse documented, Needing one on one care to keep her from climbing out of bed or off her chair. Review of the resident's Focus Charting note on 6/12/16 showed Became restless given [MEDICATION NAME], .5 mg and [MEDICATION NAME] 3 mg and [MEDICATION NAME] 10 mg. Wedge cushion used on mattress. At 1400, restlessness continue at time. Resident presents with tremor/shakes - possible side effect from [MEDICATION NAME]. Review of the Focus Charting notes dated 6/13/16 showed a fall out of bed; and, call placed to hospice - concerns of noted tremors and shakes. Review of the resident's Care Plan shows the resident's bed was placed against the wall, with a scoop mattress, and a 10 wedge on the outside of the mattress was in place to keep the resident from getting out of bed. Review of the resident's Focus Charting note on 6/16/16 showed the resident was extremely restless. The Hospice nurse advised to give 2 mg [MEDICATION NAME] and titrate up to 5 mg, if needed. At 2300, [MEDICATION NAME] 10 mg was given for pain. Gave her an increase 2 mg of [MEDICATION NAME] at 2255 - then increased dose to 3 mg, at 2355 now - much quieter now but awake. This note indicated the resident was given 6 mg of [MEDICATION NAME]. Review of the resident's Focus Charting Note on 6/17/16 showed a new order for [MEDICATION NAME] 50 mg, may titrate to 100 mg in 1 week, and [MEDICATION NAME] 1 mg every 2 hours as needed for comfort. The resident exhibited verbal complaints of pain, and 10 mgs of [MEDICATION NAME] was given. Review of the resident's Focus Charting Note on 6/18/16 showed the resident crying and complaining of pain. PRN [MEDICATION NAME] given. The documentation in the medical record lacked evidence for how the facility attempted to alter the resident's pain prior to her exhibiting the crying, or complaining of pain in an attempt to anticipate her needs due to her impaired cognition. Review of the resident's Hospice note on 6/20/16 showed Staff reported patient is a bit calmer since [MEDICATION NAME] and [MEDICATION NAME] med (sic) dose changes. Pt (sic) will get her first dose of [MEDICATION NAME] tonight. (ordered 6/17/16) Review of a Hospice note dated 6/28/16 showed Staff report patient typically becomes agitated when transferred to bed, appears fearful and trying to pull herself up out of bed. (Hospice) did note a pattern throughout nurses notes of increased agitation at night and calm during day when up in Broda chair. Review of the resident's medical record lacked evidence the facility assessed the resident's increase in pain when in bed, or the physical restriction placed on the resident while in bed, as possible contributing factors for the resident's increased agitation. Review of the resident's Focus Charting on 6/30/16 showed a new order for an increase in [MEDICATION NAME] from 1 mg to 2 mg, three times a day, for agitation. Review of the Significant Change MDS, with the ARD of 7/13/16, showed resident #3 had signs and symptoms of pain 3 to 4 days out of the 7 day look back period. This showed the facility had identified the pain concerns, but had not adequately assessed, or addressed the pain contributors. Review of the resident's Pharmacy Review and Recommendation, dated 7/7/16, showed She is doing well on the increase in [MEDICATION NAME], can we decrease [MEDICATION NAME] to 1 mg every 6 hours while awake, and keep the prn dose 1mg, four times a day. The physician agreed, and the order was changed on 7/15/16. Review of the resident's (MONTH) MAR, (YEAR), showed the [MEDICATION NAME] was decreased on 7/29/16, back to 1 mg, three times a day, related to an increase in lethargy, and having to wake the resident up for meals. Review of the resident's Focus Charting on 8/29/16 showed the resident continued to be lethargic frequently, and often slept though meals and medications. During an interview on 10/5/16 at 8:20 a.m., staff member N stated that it was difficult to keep the resident comfortable, but functional. Staff member N stated, She is more sleepy and talking less. She can get really emotional. During observations on 10/3/16, resident #3 was sleeping at the nurses station in her Broda chair at 1:40 p.m., 2:40 p.m., 3:00 p.m., with no position change. At 4:30 p.m., staff member O took the resident to her room, and changed her incontinent brief as resident #3 was lying in the Broda chair. Staff member O stated She's calmed down a lot. At 5:30 p.m., resident #3 was sleeping soundly, while snoring, in the day room. During observations on 10/4/16, resident #3 was by the nurses station at 6:60 a.m., asleep. At 7:45 a.m. she was still sleeping. At 8:20 a.m., she was sleeping by the dining room. At 8:55 a.m. resident #3 was sitting at the table for breakfast, dozing, as her eyes opened and closed occasionally. During an observation on 10/4/16 at 9:05 a.m., resident #3 was sleeping while the staff member attempted to feed her. Staff member N stated She's really sleepy, maybe we shouldn't feed her. During an observation at 10:20 a.m., resident #3 was in bed sleeping, and remained in bed sleeping at 11:20 a.m., and 12:00 p.m. Resident #3 was up in dining room for lunch at 12:50 p.m. During an interview on 10/4/16 at 3:40 p.m., resident #3's sister stated She sleeps a lot. What causes that? During an observation on 10/4/16 at 4:00 p.m., resident #3 was sleeping at the nurses station, after the visit from the sister. During an observation on 10/5/16 at 8:40 a.m., 9:33 a.m., and at 10:20 a.m., resident #3 was sleeping in a dark room. During an observation on 10/5/16 at 11:20 a.m., resident #3 was in the beauty shop, getting a hair cut, with her head back and eyes closed, sleeping. During all observations, resident #3 was asked simple yes/no questions, and was not able to verbalize a response. Review of the resident's Activity Record for (MONTH) (YEAR) showed resident #3 slept through 30 activities, and attended 16. During an interview on 10/6/16 at 9:40 a.m., staff members B and D stated the goal was to discontinue the [MEDICATION NAME] and continue to taper the [MEDICATION NAME] for resident #3. Staff member D stated the resident was inconsolable, and the facility did not know what else to do for her. Review of the resident's medical record showed resident #3 experienced 15 medications changes from 4/21/16 through 7/29/16. Review of the resident's (MONTH) and (MONTH) (YEAR) MARS showed her pain level and effectiveness of pain medications were not monitored.",2020-09-01
830,ST LUKE COMMUNITY NURSING HOME,275093,107 6TH AVE S W,RONAN,MT,59864,2016-10-06,279,D,0,1,KSTH11,"Based on record review and interview, the facility failed to develop an adequate care plan for unplanned weight loss for 1 (#12) of 14 sampled and supplemental residents. Findings include: A review of the resident's Focus Charting showed a loss of 8.5% of her total body weight over a period of 9 days, between 9/17/16 and 9/26/16. A review of the resident's (YEAR) CNA Weekly Weight Records for resident #12 showed the resident lost 5 lbs. in June, gained 5 lbs. in July, lost 2 lbs. in August, and lost 10.6 lbs in September. This was a loss of 9.4% of total body weight over the four months. During an interview on 10/4/16 at 11:10 a.m., staff member [NAME] said she was not notified by any of the nurses regarding resident #12's weight loss as determined on 9/26/16. A record review of an Estimation of Nutritional Needs, dated 4/12/16 showed resident #12 had gained weight over the past year, which was desirable. A record review of an Estimation of Nutritional Needs, dated 7/12/16, showed resident #12 had returned from a hospitalization for low blood pressure and was determined to have experienced a 4.4% decrease in weight over the prior month. The record showed the plan was to monitor intakes and weight trends, and make further nutritional recommendations as appropriate. It also showed Nutrition P[NAME] (plan of care) updated. A review of the resident's care plan showed the resident had a potential for aspiration and weight loss related to wearing only upper dentures and provided a list of interventions for aspiration and weight loss concerns on 4/17/15. Actual resident weights were handwritten on the care plan for the following dates: 10/5/15, 1/12/16, 4/12/16, and 7/12/16. Other than these dates, no other alterations or additions to the care plan had been made since 4/17/15. The resident's care plan was reviewed again on 10/6/16, after staff member [NAME] had been made aware of resident #12's weight loss. It showed no new alterations or additions had been made to the care plan since 10/4/16, which was when staff member [NAME] was made aware of resident #12's weight loss. A review of the facility's Weight Loss or Gain policy showed All resident weights will be monitored at least on a weekly basis and excessive weight loss or gain will be evaluated on an individual basis, and necessary steps will ensue. The procedure included the steps: - The interdisciplinary care planning team will be notified of the problem by the DON and will meet to investigate the problem and identify possible solutions. The supervisor will notify the physician if weight gain or loss continues and will convey the recommendation of the interdisciplinary team. - In compliance with the physician's plan of care, the plan will be placed in the resident's care plan.",2020-09-01
831,ST LUKE COMMUNITY NURSING HOME,275093,107 6TH AVE S W,RONAN,MT,59864,2016-10-06,315,D,0,1,KSTH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure the position of a catheter bag was dependent, and promoted the flow of urine into the bag for 1 (#6) of 11 sampled residents. Findings include: Resident #6 was readmitted to the facility on [DATE], and a review of the resident's medical history showed a concern with [MEDICAL CONDITION] which was considered chronic, despite treatments. The resident wore a catheter on a continual basis, and had a history of [REDACTED]. During an observation on 10/3/16 at 4:20 p.m., resident #6 was sitting in the common area in a chair. His catheter bag was placed in a cover that had been tied to his walker. As the resident was sitting, the level of the catheter bag was above the level of his bladder, and urine was not able to drain down the tube and into the bag. During an observation on 10/3/16 at 5:15 p.m., resident #6 was sitting at the end of the east/west hall near the dining room. The catheter bag was tied to his walker. The level of the catheter bag was above the level of his bladder. The bag was not in a dependent position, and urine could not drain into the catheter bag. During an observation on 10/5/16 at 2:50 p.m., resident #6 was sitting in a side chair in the common area. The tubing from his catheter was lying above the level of his legs and bladder as he sat. The catheter bag was tied to the walker and was not in a dependent position. The urine could not drain into the bag. During an interview on 10/5/16 at 4:45 p.m., staff member K said the urine could drain when resident #6 stood up. She then lowered the bag on the walker so the catheter would be in a dependent position and the urine could drain. A review of the Procedural Guideline 18.3, Care of an Indwelling Catheter, provided by the facility, showed the drainage bag should be kept below the level of the bladder.",2020-09-01
832,ST LUKE COMMUNITY NURSING HOME,275093,107 6TH AVE S W,RONAN,MT,59864,2016-10-06,325,D,0,1,KSTH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to recognize the loss of 8% total body weight over a period of nine days coupled with the loss of 9.4% body weight over four months, which was significant, as a problem requiring resident reevaluation, update of care interventions, and failed to adequately address the resident's ill fitting dentures, and diet concerns relating to choking and swallowing for 1 (#12) out of 14 sample and supplemental residents. Findings include: Resident #12 was admitted with [DIAGNOSES REDACTED]. Weight During an observation on 10/5/16, at 08:40 a.m., resident #12 refused the oatmeal she had ordered, requested, and received, dry toast. Jelly was spread on the toast by an assisting staff member. The resident was observed to experience coughing and difficulty swallowing with each bite of toast taken. She was observed to take four bites of the toast before she licked the jam off the toast and then stopped eating the meal. A review of Focus Charting for resident #12, dated 9/17/16, showed VS: 98/58, 16, 97.7, 52, 97% wt. 132.2 and stable. A review of Focus Charting for resident #12, dated 9/26/16, showed VS: 111/69. 98.1, 62, 22, 90%, wt: 121. This was a loss of 11.2 lbs or 8% of total body weight, over a period of nine days. A review of the (YEAR) CNA Weekly Weight Records for resident #12 showed the resident to have lost 5 lbs. in June, gained 5 lbs. in July, lost 2 lbs. in August, and lost 10.6 lbs in September. This was a loss of 9.4% of total body weight over a period of four months. A review of the Focus Charting nursing notes for resident #12, from 9/17/16 through 9/27/16, showed there was a lack of evidence that resident #12's physician, dietician, or family members had been notified of the resident's weight loss. There was no charting showing the nursing staff considered the resident's weight loss a significant problem. The charting did not show whether the DON or care team members had been made aware of the resident's weight loss. Refer to F157 Notification of Changes. During an interview on 10/4/16 at 11:10 a.m., staff member [NAME] said she was not notified by any of the nurses regarding resident #12's weight loss as determined on 9/26/16. She said that she was usually notified regarding resident weight loss with a call from the resident's nurse or by one of the care team managers. She also stated that resident #12 was due to have an updated diet assessment completed as of the date of the interview, 10/4/16. A review of resident #12's medical records, showed that the resident's last nutritional assessment was completed on 7/12/16, and the resident's food intake had decreased over the previous three months. It showed a greater number of lab values indicating a decline in general resident nutritional status were found abnormal during the same three months. A record review of an Estimation of Nutritional Needs, dated 4/12/16, showed resident #12 had gained weight over the past year, which was desirable. A record review of an Estimation of Nutritional Needs, dated 7/12/16, showed resident #12 had returned from a hospitalization for low blood pressure, and had experienced a 4.4% decrease in weight over the prior month. The record showed the plan was to monitor intakes and weight trends, and make further nutritional recommendations as appropriate. It also showed Nutrition P[NAME] (plan of care) updated. A review of the care plan for resident #12, showed that the resident had a potential for aspiration and weight loss related to wearing only upper dentures and the plan provided a list of interventions documented for aspiration and weight loss concerns on 4/17/15. Resident weights were documented on the plan but no other alterations or additions to the care plan had been made since 4/17/15, showing the weight changes had not been addressed on the plan. The resident's care plan was reviewed again on 10/6/16, after staff member [NAME] had been made aware of resident #12's weight loss on 10/4/16, but no changes had been made to the care plan. During an interview on 10/6/16 at 11:10 a.m., staff member C said We (the nursing staff) knew about the weight loss. The weight loss was thought to have occurred because resident #12 was receiving diuretics and leg wrapping treatments for her lower extremity [MEDICAL CONDITION]. She said it was the facility's policy that if a resident's weight loss was greater than three pounds, the nurse was to notify the resident's care team, which had not occurred. A review of the Medical Administration records showed that resident #12 received [MEDICATION NAME] and Spirolactone for lower extremity [MEDICAL CONDITION], prior to and during (MONTH) and (MONTH) of (YEAR). Both medications had been discontinued on 7/12/16. [MEDICATION NAME] was restarted on 7/15/16, and Spirolactone was restarted on 8/16/16. Both medications were continued and given to resident #12 during (MONTH) (YEAR). No dose changes were ordered for either medication during (MONTH) (YEAR), when resident #12 experienced a 10.6 lb weight loss over a nine day period. A record review of resident #12's 60 day visit appointment with her physician, dated 9/8/16, showed that the resident's weight at the time of the appointment was 131.6 lbs. Under the heading of chronic diastolic (congestive) heart failure the physician notes show: increased dieresis appears to have stabilized pt (patient) nicely. The record does not list weight loss as a problem. No other records were found to indicate that the resident's physician had been notified of the resident's weight loss determined on 9/26/16. A review of the facility's policy entitled Weight Loss or Gain, showed All resident weights will be monitored at least on a weekly basis and excessive weight loss or gain will be evaluated on an individual basis, and necessary steps will ensue. The procedure included in the policy lists the following: 1. Weekly weights will be taken and recorded both in the weight book and on the individual resident record on the CN[NAME] flow sheet. 2. Staff nurses will evaluate and act upon weight gain or loss on their weekly summary, documenting the weight and indicating if there is a problem. 3. Each individual resident demonstrating weight loss or gain of more than three pounds per week will be re-weighed. 4. If a weight problem is identified, the staff nurse will notify the DON 5. The interdisciplinary care planning team will be notified of the problem by the DON and will meet to investigate the problem and identify possible solutions. The supervisor will notify the physician if weight gain or loss continues and will convey the recommendation of the interdisciplinary team. 6. In compliance with the physician's plan of care, the plan will be placed in the resident's care plan. 7. Weight problems will be monitored and evaluated weekly by the staff nurse until the problem is solved. The resident's weight concerns were not addressed using the procedures, or policies established by the facility to address the resident's weight loss, which was significant. Swallowing/Choking, and Dentures During an observation on 10/04/2016 at 08:05 a.m., resident #12 was eating breakfast in her room. The resident had coughed each time after taking a bite of pancake. The resident stated she usually coughed after she took bites of food. It was observed that the diet card had pureed foods circled for the resident, and the food being served to the resident was not a pureed diet. During an interview on 10/04/2016 at 08:05 a.m., staff member F stated the resident usually ate a mechanical soft diet, not pureed. At this time the resident stated her dentures do not fit right in her mouth, so she eats without the dentures. During an interview on 10/4/16 at 11:10 a.m., staff member [NAME] stated the resident should be on a pureed diet but she could pick a mechanical soft diet if she chose to. A review of the resident's Physician Orders, showed on 5/2/15 the diet was changed to reflect a pureed diet, but the resident could choose a mechanical soft diet. Because of this, the resident should have been served a pureed diet initially, and then given the option to choose a mechanical soft diet if she preferred. During an observation on 10/05/2016 at 08:40 a.m., the resident was eating breakfast in her room. The resident had taken four bites of toast and had coughed each time she took a bite. The resident stated she did not have any teeth, and it was hard for her to eat. The diet card had pureed food circled for the resident, but the food being served was not pureed. A review of the residents Care Plan interventions, dated 4/17/15 to 07/12/16, showed chewing problems, referral to speech therapy if indicated, potential for aspiration and weight loss related to wearing only upper dentures. The care plan showed staff were to monitor for coughing with meals. The plan lacked evidence to show what staff should do if she is coughing, or that it had been identified as an issue from the time the plan was initiated. A review of the residents Nutritional Assessment, dated 09/25/13, showed chewing difficulties and dentures. A review of the resident's CAA Analysis Report, under dental care report, and dated 04/14/2016, showed resident #12 triggered for not using her dentures, dentures loose, and currently on pureed diet with occasional mechanical soft every now and then. A review of the resident's dietitian notes, dated 07/12/16, showed dentition filled in as own-good and the Plan of Care updated. A review of the resident's Quarterly MDS, section K0100, with an ARD of 07/09/16, showed that the resident had no problems with chewing difficulty, or problems with her dentures. The medical record lacked documentation for how the diet and choking was addressed, as it was actively occurring, and failed to address the resident's ill fitting dentures, which hindered her eating.",2020-09-01
833,ST LUKE COMMUNITY NURSING HOME,275093,107 6TH AVE S W,RONAN,MT,59864,2016-10-06,329,G,0,1,KSTH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to adequately assess and monitor for adverse affects of multiple medication changes, which did not promote the quality of life, for 1 (#3) resident, who had cognitive and communication deficits, out of 11 sampled residents. Findings include: Review of a Pharmacy Recommendation for resident #3, dated 4/21/16, showed RN's and I talked about her crying etc. They think she is worse. Could be decrease of [MEDICATION NAME] or [MEDICATION NAME] needs increased. Could go back up with [MEDICATION NAME] and get [MEDICATION NAME] to therapeutic dose. Review of the physician's reply, which was in the medical record, showed Increase [MEDICATION NAME] to 150 mg daily, and no change in [MEDICATION NAME]. Review of the resident's Physician order [REDACTED]. [MEDICATION NAME] was increased in dose to .5 mg, 4 times a day, for anxiety and comfort. Review of the resident's Focus Charting notes showed [MEDICATION NAME] was discontinued on 5/9/16. The reason was not provided. Review of the resident's Hospice not on 5/19/16 showed the resident was agitated and trying to climb out of her chair. The resident cried through the visit and talked about home. She was given [MEDICATION NAME] and [MEDICATION NAME] for back pain. Review of the resident's Focus Charting notes on 5/20/16 showed Dr. here new order to DC [MEDICATION NAME] and consider taper of narcotics. Review of the resident's Hospice note on 5/23/16 showed staff reported the patient seemed to have an increase in agitation with use of [MEDICATION NAME], and the last week was the worst. No signs and symptoms of pain, and the MD decreased [MEDICATION NAME] to three times a day, and the [MEDICATION NAME], from 10 mg four times a day to 5 mg three times a day. Review of the resident's Physician Orders, dated 5/26/16, showed to discontinue [MEDICATION NAME] and start [MEDICATION NAME] for the resident's depression. Review of the resident's (MONTH) Medication Administration showed ([MEDICATION NAME]) dated 4/18/16, 100 mg PO at HS. The administration record was blank, and said see page 3. Page 3 showed ([MEDICATION NAME]) 150 mg po daily. The administration record was blank. Review of the resident's Focus Charting on 5/28/16 showed the resident had a fall in her room. She was taken to the dining room for closer observation. She was given an extra [MEDICATION NAME] with her scheduled one at 1400. A reason was not provided. Pain was not addressed for the resident. Review of the resident's medical record did not show the monitoring for affects from the reduction in pain and anti anxiety medication, and discontinued use of the [MEDICATION NAME] on 5/23/15. Review of the resident's Focus Charting noted on 6/2/16 showed the resident had a rash, and the [MEDICATION NAME] was on hold. The documentation showed, Resident restless, crying, today at lunch. Pain was not addressed, although the resident had exhibited pain symptoms. Review of the resident's Focus Charting note on 6/2/16 showed the resident was restless and moaning. A PRN [MEDICATION NAME] and [MEDICATION NAME] was given, showing a positive outcome. Although the medication was beneficial to treat the restless and moaning, the facility did not consistently utilize this information when the resident exhibited future pain symptoms, but rather her pain symptoms were treated with behavior altering medications. Review of the resident's Focus Charting on 6/9/16 showed Clinical Pharm (sic) called about acute [MEDICAL CONDITION]/agitation. The recommendation given was for [MEDICATION NAME] 2 - 5 mg every hour as needed. Staff report the resident needs 1 to 1 care due to falling out of bed, agitation, and not sleeping for 48 hours. The resident's medical record lacked an assessment for possible pain and medication withdrawal as a potential cause for the [MEDICAL CONDITION]. Review of the resident's Focus Charting note, dated 6/9/16, showed a new order to increase the [MEDICATION NAME] to 10 mg, three times a day. Review of the resident's Focus Charting note on 6/10/16 showed the resident was crying and stating she was in pain. She was given 3 mg of [MEDICATION NAME], and 10 mg of [MEDICATION NAME] with a positive effect. Again, this showed the benefits of treating the resident's pain, rather than her behavior symptoms. Review of the resident's Focus Charting note on 6/11/16 showed the resident was awake most of shift and prn [MEDICATION NAME] and [MEDICATION NAME] was given. The nurse documented, Needing one on one care to keep her from climbing out of bed or off her chair. Review of the resident's Focus Charting note on 6/12/16 showed Became restless given [MEDICATION NAME], .5 mg and [MEDICATION NAME] 3 mg and [MEDICATION NAME] 10 mg. Wedge cushion used on mattress. At 1400, restlessness continue at time. Resident presents with tremor/shakes - possible side effect from [MEDICATION NAME]. Review of the Focus Charting notes dated 6/13/16 showed a fall out of bed; and, call placed to hospice - concerns of noted tremors and shakes. Review of the resident's Care Plan shows the resident's bed was placed against the wall, with a scoop mattress, and a 10 wedge on the outside of the mattress was in place to keep the resident from getting out of bed. Review of the resident's Focus Charting note on 6/16/16 showed the resident was extremely restless. The Hospice nurse advised to give 2 mg [MEDICATION NAME] and titrate up to 5 mg, if needed. At 2300, [MEDICATION NAME] 10 mg was given for pain. Gave her an increase 2 mg of [MEDICATION NAME] at 2255 - then increased dose to 3 mg, at 2355 now - much quieter now but awake. This note indicated the resident was given 6 mg of [MEDICATION NAME]. Review of the resident's Focus Charting Note on 6/17/16 showed a new order for [MEDICATION NAME] 50 mg, may titrate to 100 mg in 1 week, and [MEDICATION NAME] 1 mg every 2 hours as needed for comfort. The resident exhibited verbal complaints of pain, and 10 mgs of [MEDICATION NAME] was given. Review of the resident's Focus Charting Note on 6/18/16 showed the resident crying and complaining of pain. PRN [MEDICATION NAME] given. The documentation in the medical record lacked evidence for how the facility attempted to alter the resident's pain prior to her exhibiting the crying, or complaining of pain in an attempt to anticipate her needs due to her impaired cognition. Review of the resident's Hospice note on 6/20/16 showed Staff reported patient is a bit calmer since [MEDICATION NAME] and [MEDICATION NAME] med (sic) dose changes. Pt (sic) will get her first dose of [MEDICATION NAME] tonight. (ordered 6/17/16) Review of a Hospice note dated 6/28/16 showed Staff report patient typically becomes agitated when transferred to bed, appears fearful and trying to pull herself up out of bed. (Hospice) did note a pattern throughout nurses notes of increased agitation at night and calm during day when up in Broda chair. Review of the resident's medical record lacked evidence the facility assessed the resident's increase in pain when in bed, or the physical restriction placed on the resident while in bed, as possible contributing factors for the resident's increased agitation. Review of the resident's Focus Charting on 6/30/16 showed a new order for an increase in [MEDICATION NAME] from 1 mg to 2 mg, three times a day, for agitation. Review of the Significant Change MDS, with the ARD of 7/13/16, showed resident #3 had signs and symptoms of pain 3 to 4 days out of the 7 day look back period. This showed the facility had identified the pain concerns, but had not adequately assessed, or addressed the pain contributors. Review of the resident's Pharmacy Review and Recommendation, dated 7/7/16, showed She is doing well on the increase in [MEDICATION NAME], can we decrease [MEDICATION NAME] to 1 mg every 6 hours while awake, and keep the prn dose 1mg, four times a day. The physician agreed, and the order was changed on 7/15/16. Review of the resident's (MONTH) MAR, (YEAR), showed the [MEDICATION NAME] was decreased on 7/29/16, back to 1 mg, three times a day, related to an increase in lethargy, and having to wake the resident up for meals. Review of the resident's Focus Charting on 8/29/16 showed the resident continued to be lethargic frequently, and often slept though meals and medications. During an interview on 10/5/16 at 8:20 a.m., staff member N stated that it was difficult to keep the resident comfortable, but functional. Staff member N stated, She is more sleepy and talking less. She can get really emotional. During observations on 10/3/16, resident #3 was sleeping at the nurses station in her Broda chair at 1:40 p.m., 2:40 p.m., 3:00 p.m., with no position change. At 4:30 p.m., staff member O took the resident to her room, and changed her incontinent brief as resident #3 was lying in the Broda chair. Staff member O stated She's calmed down a lot. At 5:30 p.m., resident #3 was sleeping soundly, while snoring, in the day room. During observations on 10/4/16, resident #3 was by the nurses station at 6:60 a.m., asleep. At 7:45 a.m. she was still sleeping. At 8:20 a.m., she was sleeping by the dining room. At 8:55 a.m. resident #3 was sitting at the table for breakfast, dozing, as her eyes opened and closed occasionally. During an observation on 10/4/16 at 9:05 a.m., resident #3 was sleeping while the staff member attempted to feed her. Staff member N stated She's really sleepy, maybe we shouldn't feed her. During an observation at 10:20 a.m., resident #3 was in bed sleeping, and remained in bed sleeping at 11:20 a.m., and 12:00 p.m. Resident #3 was up in dining room for lunch at 12:50 p.m. During an interview on 10/4/16 at 3:40 p.m., resident #3's sister stated She sleeps a lot. What causes that? During an observation on 10/4/16 at 4:00 p.m., resident #3 was sleeping at the nurses station, after the visit from the sister. During an observation on 10/5/16 at 8:40 a.m., 9:33 a.m., and at 10:20 a.m., resident #3 was sleeping in a dark room. During an observation on 10/5/16 at 11:20 a.m., resident #3 was in the beauty shop, getting a hair cut, with her head back and eyes closed, sleeping. During all observations, resident #3 was asked simple yes/no questions, and was not able to verbalize a response. Review of the resident's Activity Record for (MONTH) (YEAR) showed resident #3 slept through 30 activities, and attended 16. During an interview on 10/6/16 at 9:40 a.m., staff members B and D stated the goal was to discontinue the [MEDICATION NAME] and continue to taper the [MEDICATION NAME] for resident #3. Staff member D stated the resident was inconsolable, and the facility did not know what else to do for her. Review of the resident's medical record showed resident #3 experienced 15 medications changes from 4/21/16 through 7/29/16. Review of the resident's (MONTH) and (MONTH) (YEAR) MARS showed her pain level and effectiveness of pain medications were not monitored.",2020-09-01
834,ST LUKE COMMUNITY NURSING HOME,275093,107 6TH AVE S W,RONAN,MT,59864,2016-10-06,364,D,0,1,KSTH11,"Based on record review, interview and observation, the facility failed to provide food that was palatable and attractive for 1 (# 9) resident, who was on a modified diet, of 11 sampled residents. Findings include: During an observation on 10/4/16 at 9:05 a.m., resident #9 was encouraged to drink her liquid pancake in a mug. She stated, It tastes like water, how come it is liquid? Is that a pancake? If it is, its a new one on me. During an observation on 10/4/15 at 12:30 p.m., resident #9 was encouraged to drink liquid beef. She stated, I don't like the taste of it. Staff member N then encouraged her to try the liquid vegetables. The resident stated, This is kind of odd, I don't think I like it. The resident's meal due to her dislike for it, was not changed. The mug for the liquid beef did not feel hot, and the temperature measured to be low and 92 degrees. If beef is precooked, and held on a warming table for meal service, at a minimum the temperature for holding must be 135 degrees. Review of resident #9's diet card showed she was on a regular pureed diet, although she was being served a liquid diet. During an interview on 10/4/16 at 12:35 p.m., staff member N stated the resident had been spitting out the pureed food, so they changed the resident's diet to a liquid diet. During an interview on 10/4/16 at 3:35 p.m., staff member D stated she thought the diet card had been corrected to match the liquid diet order. It was determined the diet order had not been changed on the diet card.",2020-09-01
835,ST LUKE COMMUNITY NURSING HOME,275093,107 6TH AVE S W,RONAN,MT,59864,2016-10-06,367,E,0,1,KSTH11,"Based on observation, record review, and interview, the facility failed to provide pureed food, as ordered by the physician, for 4 (#s 3, 4, 8, and 13) of 14 sampled and supplemental residents. Findings include: 1. During an observation on 10/4/16 at 8:10 a.m., residents' #s 3, 4 and 13 had been served regular pancakes for breakfast. Review of the residents' diet orders showed they should have received a pureed diet, but had not. During an observation on 10/5/16 at 8:20 a.m., the same three residents had regular textured waffles which had been served to them, rather than pureed. During an interview on 10/5/16 at 7:50 a.m., staff member A looked at the waffles and stated they were soft, and the facility had attempted to make the waffles look like regular waffles, which they did. During an interview on 10/4/16 at 4:00 p.m., staff member D stated the pancakes had apple juice and syrup on them to make them soft, and agreed they were not pureed. 2. During an observation on 10/4/16 in the morning, resident #8 had a cup of thin brown liquid with sediment at the bottom for his meal. Staff member P was asked what the liquid mixture was, and he replied liquid toast to go through a straw. Review of resident #8's physician ordered diet showed her food should be nectar thick consistency. The toast appeared and stirred like water, rather than a nectar thick consistency.",2020-09-01
836,ST LUKE COMMUNITY NURSING HOME,275093,107 6TH AVE S W,RONAN,MT,59864,2016-10-06,431,D,0,1,KSTH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to label two Cyanocobalamin 1000 mcg/ml vials when opened; and failed to ensure expired or opened dressings were not available for use on residents. This practice had the potential to cause adverse consequences for residents utilizing the medication or supplies. Findings include: During an observation of the East medication cart, on [DATE] at 11:45 a.m., two Cyanocobalamin 1000 mcg/ml vials were opened and not dated. One vial had visible puncture marks where it had been accessed by a needle. Also, found in the South medication cart was an opened 3M Steri Strip package, which would have expired on ,[DATE] were it not opened; a Mesalt Sodium Chloride Dressing, which expired ,[DATE]; and three Allevyn adhesive 7.5 cm by 7.5 cm dressings, which expired ,[DATE]. None of the items had been dated when opened. During an interview on [DATE] at 11:45 a.m., staff member G said that normally the nurses date the bottles when they are opened. She said they are supposed to date them when they are opened. She removed the expired supplies and undated vials from the medication carts. During an interview on [DATE] at 3:45 p.m., staff member B said, They were supposed to look through those and get rid of them.",2020-09-01
837,ST LUKE COMMUNITY NURSING HOME,275093,107 6TH AVE S W,RONAN,MT,59864,2016-10-06,441,E,0,1,KSTH11,"Based on record review, observation, and interview, a facility staff member failed to practice adequate infection control measures when handling a resident's catheter bag for 1 (#6) of 11 sampled residents; failed to develop and operationalize an infection control program that included all the necessary elements of an infection control program, which increased the risks and limited the benefits of the program related to antibiotic use for the residents; and the facility failed to provide, and staff failed to utilize, personal protective gear when soiled laundry was being sorted and rinsed. This practice had the potential to spread infection through out the facility, and potentially affect all residents receiving services from the laundry area, or who came into contact with the employees who sorted the soiled laundry. Findings include: 1. During an observation on 10/3/16 at 1:00 p.m., resident #6's catheter bag was lying on the floor by the bed in his room, and was not covered with a protective [NAME]et. Blood tinged urine could be seen through the bag. During an observation on 10/4/16 at 7:45 a.m., resident #6 was in bed sleeping. The catheter bag was lying on the floor, uncovered. A housekeeper was observed in resident #6's room mopping the floor. During an interview on 10/4/16 at 7:45 a.m., staff member H said they (housekeepers) just mop if they (residents) are not up. If they are mobile I wait until they are down eating. Staff member H did not comment on the catheter bag being on the floor when it was shown to her. During an observation on 10/5/16 at 8:30 a.m., resident #6's catheter bag was on the floor, uncovered, and leaning against the garbage can. During an interview on 10/5/16 at 8:30 a.m., staff member F said they always hang the bag on the side of the bed. She checked the bag, found it on the floor, and attached it to the bed. During an interview on 10/5/16 at 11:30 a.m., staff member I said the facility did not use a disinfecting floor cleaner when mopping the floors. She said the floor cleaner used by the facility was considered a neutral cleaner, and would not have a kill-sheet associated with the product. 2. During an interview on 8/5/16 at 8:30 a.m., staff member B said the facility was not using any kind of specific infection control criteria, such as McGeer's, to monitor infections and antibiotic use. A review of the Infection Control Surveillance Log showed the facility had not used a criteria to assist in identifying active infections, such as McGeer's. The facility had not distinguished nosocomial from non-nosocomial infections. The facility failed to consistently conduct an antibiotic review when antibiotic treatment was utilized. Statistical data was gathered for overall infection rate in the facility, and did separate out statistical data for urinary tract infections, but did not delineate other types of infections. 3. During an interview on 10/5/16 at 11:30 a.m., staff member I said the CNAs were responsible for sorting the laundry upstairs in the soiled utility rooms. During an observation of the south hall soiled utility room, on 10/5/16 at 11:30 a.m., used by the CNAs to sort laundry, with staff member I, there was no protective gowns or goggles available in the room to be utilized by the staff when sorting laundry. The soiled utility room, which served the east and west halls, also did not contain personal protective gowns or goggles. During an observation on 10/5/16 at 11:30 a.m., of the soiled utility room which served the east and west halls, a pair of wet pants was observed, which had been rinsed in the hopper, and was hanging off the faucet on the back of the hopper. During an interview on 10/5/16 at 1:35 p.m., staff member J said that personal items of clothing were taken to the soiled utility rooms to be placed into hampers, or rinsed in the hopper and placed in the hampers. After the clothing was rinsed, it was put into a bag and sent down to the laundry. She said she does not always put personal clothing into a bag before taking them out of the resident room and bringing the laundry to the soiled utility room. Staff member J said the laundry personnel picked up the laundry from the soiled utility room, put it into a larger cart, and transported the laundry downstairs. She said the hoppers in the soiled utility rooms were used to rinse soiled items (feces, emesis, etc.) that is not from an isolation room. She said about using the hopper to rinse clothes, I wear gloves and stand way back when I spray. A review of the Laundry Policy and Procedure showed that staff were instructed to bag laundry in the resident's room, or tub room, and sort the laundry into separate hampers in the dirty utility room. During an interview and observation on 10/6/16 at 10:30 a.m., staff member F demonstrated how she would put laundry into a plastic bag and place it in a hamper. She then took the hamper to the soiled utility room. She demonstrated and stated she would take plastic bags out of the hamper, remove soiled clothes from the plastic bag, rinse the soiled clothes in the hopper, spray pooh off the clothes, ring out the clothes, and place the clothes into the plastic bag for the laundry to pick up. She said she wears gloves when she rinses items in the hopper. Staff member F said she did not wear a gown, and stood with her body away from the hopper so she didn't get any pooh on her. She said she had experienced getting feces on her clothes when she was new, but now she had learned to stand further back.",2020-09-01
838,LAKE VIEW CARE CENTER,275094,1050 GRAND AVE,BIGFORK,MT,59911,2017-05-11,278,E,0,1,4IN411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately reflect resident's height and weight status in regards to whether or not a resident had a significant weight loss. This deficiency affected 3 (#s 4, 6, and 7) out of 13 sampled residents. Findings include: Record review for residents #4 and 6 showed: 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #4's Admission MDS, dated [DATE], reflected the resident was 66 inches tall and weighed 138 pounds. Review of resident #4's Quarterly MDS, dated [DATE], reflected the resident was 130 pounds and was coded with a significant weight loss which was not prescribed by a physician. Review of resident #4's MDS reflected the resident weighed 134 pounds. This would calculate to a 2.9% weight loss in six months, which was not a significant weight loss. 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #6's Annual MDS, dated [DATE], reflected the resident was 61 inches tall and weighed 108 pounds. Review of the 3/13/17 Quarterly MDS reflected the resident was 104 pounds and was coded with a significant weight loss which was not prescribed by a physician. Review of resident #6's MDS, dated [DATE], reflected the resident weighed 115 pounds. This would calculate to a 7.8% weight loss in six months, which is not a significant weight loss. During an interview regarding resident #4 and #6, on 5/10/17 at 10:05 a.m., staff member H stated the weights for resident #4 and #6, did not trigger significant weight loss and we are going to have to do some training on that. 3. Resident #7 was admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #7's Admission MDS, with an ARD of 1/30/17, reflected the resident was 63 inches tall and weighed 223 pounds. The record reflected resident #7 had a weight loss that was not physician prescribed, although this was the initial assessment, and no previous assessment had been completed. Review of resident #7's Admission MDS, with an ARD of 4/19/17, reflected the resident was 70 inches tall and weighed 216 pounds. The record reflected resident #7 had a weight loss that was not physician prescribed. Review of resident #7's Weights and Vitals Summary, dated 5/9/17, reflected the resident was 70 inches tall and had various recorded weights: - 1/24/17: 233.8 lbs. (standing) initial admission weight - 1/27/17: 222.6 lbs. - 2/17/17: 216 lbs. - 3/16/17: 214 lbs. - 4/12/17: 232 lbs. (wheelchair) re-admission weight - 4/17/17: 216.4 lbs. - 4/22/17: 208.6 lbs. - 4/28/17: 204.6 lbs. - 5/5/27: 204 lbs. During an interview on 5/10/17 at 10:00 a.m., staff member H stated The accuracy of the MDS was in question from a recent mock survey conducted at the facility. Staff member H stated the facility staff must have taken the recorded discharge weights from the hospital as the resident's admission weight to the facility which was not accurate. Resident #7 does not have weight loss issues, his diet has been fortified to prevent weight loss and promote skin healing. The resident had lower extremity [MEDICAL CONDITION] at the time of admission and had not lost significant weight while in the facility. Staff member H stated the resident's recorded height was also incorrect and would not fluctuate seven inches if the resident's height was measured accurately at the facility on admission.",2020-09-01
839,LAKE VIEW CARE CENTER,275094,1050 GRAND AVE,BIGFORK,MT,59911,2017-05-11,281,D,0,1,4IN411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide services that met professional standards of quality when administering medications for 2 (#s 14 and 16) of 21 sampled and supplemental residents. Findings include: 1. During an observation and interview on 5/9/17 at 7:55 a.m., staff member D prepared an [MEDICATION NAME] Diskus for administration to resident #16. Staff member D handed the Diskus to the resident and instructed her to inhale deeply. The resident completed the inhalation and proceeded to go to the dining room for breakfast. Staff member D stated the only special instruction regarding the administration of [MEDICATION NAME] is to inhale. Staff member D stated she was not aware of any instruction to rinse the resident's mouth. During an observation on 5/10/17 at 8:12 a.m., staff member D prepared the [MEDICATION NAME] Diskus for administration to resident #16. Staff member D handed the Diskus to the resident and instructed her to inhale deeply. Upon completion of the inhalation, staff member D offered the resident a glass of water and encouraged resident #16 to take a drink. The resident took a drink and swallowed the water. Staff member D did not instruct the resident to rinse her mouth and then spit out the water. During an interview on 5/10/17 at 8:30 a.m., staff member A stated that after [MEDICATION NAME] is administered, resident #16 should rinse her mouth. Review of the manufacturer's package insert showed: [MEDICATION NAME] can cause serious side effects, including: .fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using [MEDICATION NAME] to help reduce your chance of getting thrush. 2. During an observation on 5/10/17 at 7:28 a.m., staff member F prepared a medication for administration to resident #14. The medication was ordered to be inhaled orally (given via a nebulizer). Staff member F poured the medication into the reservoir cup, applied an inhalation mask to the resident and turned on the nebulizer to start the administration. She returned to the medication cart parked in the hallway near the resident's room. While working at the cart, her back was towards the resident. During an observation on 5/10/17 at 7:32 a.m., staff member F performed a blood glucose test on resident #15, in his room, and returned to the cart to prepare insulin. She went to resident #15's room to administer the insulin. Staff member F returned to the cart and prepared medications for resident #15. She re-entered his room and administered the medications. During an observation and interview on 5/10/17 at 7:48 a.m., a CNA entered resident #14's room and turned off the nebulizer. Staff member F went into the room to confirm the medication administration was completed. Staff member F stated she did not believe resident #14 had an order to self-administer the nebulizer and there was no intent for resident #14 to self-administer medications. The staff member stated that she was standing by, and did not believe leaving the resident unattended during inhalation met the criteria of self-administration. The staff member had not returned to resident #14's room during the nebulizer administration, had gone into resident #15's room three times, and was positioned with her back to resident #14 when at the medication cart. Staff member F did not observe the resident completing the administration. Review of resident #14's physician's orders [REDACTED]. Review of resident #14's care plan, completed review date of 3/29/17, did not show an indication for self-administration. Review of resident #14's assessments did not show an assessment for self-administration of medication. Review of resident #14's Annual MDS, with an ARD of 3/9/17, showed a BIMS of 7, severe impairment. During an interview on 5/10/17 at 8:30 a.m., staff member A stated that residents left unattended to complete a nebulizer administration, after set-up, should have a self-administration of medication assessment. Staff member A stated that self-administration would not apply to (resident #14), she is not capable. The nurse should be there to do it. According to Kozier and Erb's, the standard of practice for medication administration requires the licensed nurse to remain with the resident until all medications have been swallowed (completed). Bermin, [NAME], Snyder, S., Kozier, B., & Erb, [NAME] (2002). Kozier & Erb's techniques in clinical nursing (5th ed.) New Jersey: Pearson Education.",2020-09-01
840,LAKE VIEW CARE CENTER,275094,1050 GRAND AVE,BIGFORK,MT,59911,2017-05-11,318,D,0,1,4IN411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure a resident wore a splint for a contracture of her left wrist in accordance with the occupational therapist's recommendation for 1 (#2) of 13 sampled residents. Findings include: 1. Review of a document in resident #2's record entitled Splint Wear and Care with the date 12/28/16, hand written at the bottom of the page, showed the splint was used for contracture prevention and had the following on/off schedule for when the splint was to be worn by the resident: -1 hr on 1 hr off day one -2 hr on 1 hr off day two -4 hr on 1 hr off day three -6 hr on 1 hr off day four -8 hr day & at at night During observations on 5/8/17 from 4:12 p.m. to 5:00 p.m., 5/9/17 from 7:30 a.m. to 9:00 a.m., and 5/9/17 from 12:50 p.m. to 3:00 p.m., resident #2 did not wear a splint on either her left or right wrist or hand. Review of resident #2's care plan and treatment record did not show any information regarding the splint for resident #2, who had a [DIAGNOSES REDACTED]. In an interview on 5/10/17 at 7:20 a.m., staff member A said the resident had worked up to wearing the splint eight hours a day. It should have been worn during waking hours. It was discussed with staff member B and she learned the splint was not being furnished to the resident or being documented on.",2020-09-01
841,LAKE VIEW CARE CENTER,275094,1050 GRAND AVE,BIGFORK,MT,59911,2017-05-11,322,D,0,1,4IN411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to verify location of a feeding tube, prior to administration of medication through the tube, for 1 (#18) of 21 sampled and supplemental residents. Findings include: During an observation on 5/11/17 at 8:15 a.m., staff member G prepared medications for administration, through a gastrostomy (feeding) tube, to resident #18. Staff member G checked for residual stomach contents by attaching a 60 ml syringe to the tube and drawing back on the plunger. No residual was returned. Staff member G proceeded to administer the medications through the tube. Correct placement of the tube was not confirmed prior to the administration of medication. During an interview on 5/11/17 at 8:30 a.m., staff member G stated there was no need for placement check since he had done a residual check. He stated that since he had not received any residual, the check did not confirm placement. Review of policy titled, Confirming Placement of Feeding Tubes, with a revision date of [DATE], showed the following four methods to check placement of a gastrostomy tube: 1. Observe for changes in the external tube length marked at the time of initial insertion . 2. Observe for signs of respiratory distress . 3. Use the auscultory method. (Steps defined) 4. Check pH of aspirate (Steps defined) The next direction showed, If any of the above suggests improper tube positioning, do not administer feeding or medication. Notify the Charge Nurse or Physician. A review of the Enteral Nutrition Practice Recommendations, referred to in the Protocols for Long Term Care (regulatory guidance), showed potential complications related to the use of a feeding tube. Included in this section was the potential risk for aspiration. The following information was from the article, included in the Protocols for facility reference as needed, and showed: Maintenance Considerations After feedings have been started, it is necessary to assure that the tube has remained in the desired location (either the stomach or small bowel). Among the methods that may be useful are: determining if the external length of the tubing has changed, observing for negative pressure when attempting to withdraw fluid from the feeding tube, observing for unexpected changes in residual volumes, and measuring pH of the feeding tube aspirates. In adult patients, do not rely on the ausculatory method to differentiate between gastric and respiratory placement. Do not rely on the ausculatory method to differentiate between gastric and small bowel placement. Mark the exit site of a feeding tube at the time of the initial radiograph; observe for a change in the external tube length during feedings. If a significant increase in the external length is observed, use other bedside tests to help determine if the tube has become dislocated. If in doubt, obtain a radiograph to determine tube location. Bankhead, R. et al. [NAME]S.P.E.N. Enteral Nutrition Practice Recommendations, Journal of [MEDICATION NAME] and Enteral Nutrition, Volume 33: Number 2, March/April 2009. Page 144-145",2020-09-01
842,LAKE VIEW CARE CENTER,275094,1050 GRAND AVE,BIGFORK,MT,59911,2017-05-11,329,D,0,1,4IN411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to develop behavioral interventions for the resident's aggression to self and others for which the resident was receiving medications for 1 (#2) of 13 sampled residents. Findings include: 1. Review of resident #2's Medication Administration Record [REDACTED]. Additionally, the resident had received [MEDICATION NAME] .5 mg prn for agitation on (MONTH) 5th. This was all in addition to the routine scheduled dose of [MEDICATION NAME] of 1 mg twice a day. Review of resident #2's Order Summary Report, dated 5/3/17, showed [MEDICATION NAME] Give 1 mg by mouth two times a day for Aggression, self injury. Review of the telephone order dated 12/22/16, showed [MEDICATION NAME] 0.25 mg PO Q4-6 PRN agitation/anxiety/abusive behavior/disruptive behaviors . Review of resident #2's Quarterly MDS, with an ARD of 2/17/17, showed in Section E0200 the resident was demonstrating physical behavioral symptoms directed towards others, verbal behavioral symptoms directed toward others and other behavioral symptoms not directed toward others (such as self injurious behavior) occurring 4 to 6 days. Review of the resident #2's Weekly Progress Notes, dated 3/7/17 and 3/14/17, showed behaviors included the resident hitting/ punching herself (especially in her face) and staff and biting herself and staff. During an observation on 5/9/17 at 11:10 a.m., as staff propelled the resident in her wheelchair, the resident struck herself with her hand, two times. Staff continued to propel the resident in the wheelchair. In an interview on 5/10/17 at 7:20 a.m., staff member A said I know they try different things, like walking and redirection, but there are no non-pharmacological interventions in her care plan nor could I find documentation in her record of things they have tried.",2020-09-01
843,LAKE VIEW CARE CENTER,275094,1050 GRAND AVE,BIGFORK,MT,59911,2017-05-11,367,D,0,1,4IN411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure a resident received the prescribed therapeutic diet for 1 (#2) of 13 sampled residents. Findings include: 1. Review of resident #2's record showed [DIAGNOSES REDACTED]. Review of the resident's Order Summary Report dated 5/3/17, showed the resident's diet order was mechanical soft texture, thin consistency, and ground meat. During an observation on 5/9/17 at 8:40 a.m., resident #2 was served bacon that was not ground. During an interview on 5/10/17 at 7:20 a.m., staff member A stated the resident should have received ground bacon.",2020-09-01
844,LAKE VIEW CARE CENTER,275094,1050 GRAND AVE,BIGFORK,MT,59911,2017-05-11,425,E,0,1,4IN411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assure that medication was provided in the correct dose, and failed to modify a medication label when the order had changed, for 3 (#s 8, 16, and 17) of 21 sampled and supplemental residents. Findings include: 1.a. During an observation on 5/9/17 at 4:28 p.m., staff member C prepared medication for administration to resident #8, using the (MONTH) (YEAR) eMAR which showed an order for [REDACTED]. Review of the manufacturer's product information showed that Ocuvite was available in multiple dosages, with the leutin dose ranging from 10 to 50 mg. b. During an observation on 5/9/17 at 4:28 p.m., staff member C prepared medications for administration to resident #8, using the (MONTH) (YEAR) eMAR which showed an order for [REDACTED]. Review of resident #8's Order Summary Report, dated 4/26/17, and signed by the physician, showed the same orders for Ocuvite-Lutein and Probiotc, without a dose, as were on the eMAR. During an interview on 5/9/17 at 4:38 p.m., staff member C stated that both the Ocuvite-Lutein and the Probiotic are over-the-counter medications. She said the family supplied the Ocuvit-Lutein for resident #8 and the Probiotic was house stock. Staff member C stated that she gave whatever dose was on hand. 2. During an observation on 5/9/17 at 7:50 a.m., staff member D prepared medications for administration to resident #16. The eMAR showed an order for [REDACTED]. Review of resident #16's Order Summary Report dated 5/3/17, showed the same order, without a dose, as was on the eMAR. During an interview on 5/9/17 at 7:55 a.m., staff member D stated that the docusate sodium capule was a stock item, and she gave one capsule from the bottle in the cart. Staff member D stated the docusate capsules were available in more than one strength. Review of manufacturer's information showed docusate sodium was available in capsule strengths of 50 mg, 100 mg, and 250 mg. 3. During an observation on 5/10/17 at 7:19 a.m., staff member F prepared medication for administration to resident #17. The order on the eMAR showed Hydrocodone-Acetaminophen 5-325 mg 1 tablet po (by mouth) tid, may have 1-2 tabs in the am. The order was dated 8/10/16. The order on the bubble pack card containing the medication showed Give 1-2 tablets orally 3-4 times a day as needed. Following the directions on the eMAR, resident #17 had the potential to receive a total of four hydrocodone-acetaminophen tablets in a day. Following the directions on the medication card, the resident had the potential to receive eight tablets in a day. During an interview on 5/10/17 at 7:20 a.m., staff member F stated that resident #17's hydrocodone-acetaminophen order had been changed. During an interview on 5/10/17 at 11:50 a.m., staff member A stated the medication card was incorrect and the eMAR order reflected the current intent of the order. She said a change of direction sticker should have been applied to the card. A review of resident #17's hydrocodone-acetaminophen card, on 5/11/10, showed a change of direction sticker had been applied.",2020-09-01
845,LAKE VIEW CARE CENTER,275094,1050 GRAND AVE,BIGFORK,MT,59911,2017-05-11,441,E,0,1,4IN411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an environment to prevent the development or spread of infection by not disinfecting a glucometer between uses when being used for more than one resident for 2 (#s 20 and 21); and failed to follow hand hygiene and glove use procedures for 6 (#s 14, 15, 18, 19, 20, and 21) of 21 sampled and supplemental residents. Findings Include: 1. Disinfecting glucometer During an observation on 5/9/17 at 7:30 a.m., staff member D, completed a blood glucose check for resident #19. The glucometer was wiped with an alcohol swab for less than ten seconds. Staff member D used the same glucometer to complete a blood glucose check for resident #20 at 7:37 a.m. After the procedure, staff member D wiped the glucometer with an alcohol swab for less than 10 seconds. Staff member D used the same glucometer to complete a glucometer check on resident #21. The nurse returned to the medication cart and cleaned the glucometer with a Micro-Kill One disinfectant wipe and then wrapped the glucometer with a second Micro-Kill One disinfectant wipe. During an interview on 5/9/17 at 7:48 a.m., staff member D stated the procedure for cleaning the glucometer was to use an alcohol wipe between residents and sanitize the glucometer when all the blood glucose checks scheduled for that time have been completed. Staff member D demonstrated wrapping the glucometer and stated the wrapping was done to make sure the disinfectant had enough contact time on the glucometer. Staff member C was standing at a medication cart parked next to staff member D's medication cart and stated that staff member D was correct. Staff member C stated that alcohol was used between residents and the Micro-Kill One disinfectant wipes were used when the task is completed. Review of the glucometer manufacturer's information booklet, page 46, section titled, Cleaning and Disinfecting Your Meter and Lancing Device, showed point 4. To disinfect your meter, clean the meter with one of the validated disinfectant wipes listed below. Other EPA registered wipes may be used for disinfecting the (glucometer), however these wipes have not been validated and may affect the performance of your meter .Wipe all external areas of the meter or lancing device including both front and back surfaces until visibly clean. Avoid wetting the meter test strip port. Allow the surface of the meter or lancing device to remain wet at room temperature for the contact time listed on the wipe's directions for use. During an interview on 5/9/17 at 1:30 p.m., staff member A stated the Micro-Kill One cloth was to be used to wipe down the glucometer between use on every resident so that it was wet or moist for one minute. Review of the facility policy titled, Blood Glucose Monitor Disinfection, with a revision date of Sept (YEAR) showed: Purpose: To implement a safe and effective process for disinfecting blood glucose monitors. Micro-Kill One, a wipe that is EPA registered; .will be utilized to clean the monitor. If a product (Micro-Kill One) is not available, a 1:10 bleach solution may be substituted. Policy: The blood glucose monitor (glucometer) will be cleaned and disinfected with wipes following use on each resident when monitors are shared by multiple residents. 2. Hand hygiene and glove use a. During an observation on 5/9/17 at 7:30 a.m., staff member D gathered supplies at the medication cart, knocked on the door of resident #19 and entered the room. Staff member D put on gloves without performing hand hygiene, completed a blood glucose check, then removed and discarded the gloves. Staff member D left the room without performing hand hygiene. Staff member D knocked on a resident room next door to #19 and spoke to a CNA who was in the room. Staff member D then pressed a button to enter the secured care unit. Staff member D went to the room of resident #20, knocked on the door and entered the room. She put on gloves she took from her pocket, without performing hand hygiene. Staff member D then completed a blood glucose check, removed and discarded the gloves. Staff member D left the room without performing hand hygiene. Staff member D then went to the dayroom, on the secured care unit, and washed her hands at the sink. Resident #21 was sitting in the dayroom. Staff member D put on gloves, completed a blood glucose check, and removed and discarded the gloves. She left the dayroom without performing hand hygiene. As she walked back to the medication cart, she entered a code on a keypad to exit the secured care unit. The staff member then opened the door with her hands, which had not been washed or sanitized after performing a blood glucose check. During an interview on 5/9/17 at 7:48 a.m., staff member D stated the reason she had not washed or sanitized her hands before applying gloves and after removing them, was because she did not have a bottle of sanitizer in her pocket. She stated she should have washed her hands. b. During an observation on 5/10/17 at 7:28 a.m., staff member F put on gloves in the hallway and entered the room of resident #14. Staff member F opened the night stand drawer with a gloved hand, moved some items within the drawer, placed the gloved hand on resident #14's wheelchair and clothing, and picked up a facemask used to administer an inhaled medication. Staff member F touched the outside and inside surfaces of the mask while adding the medication to the reservoir cup and applying the mask to resident #14. The nurse removed and discarded the gloves and left the room without performing hand hygiene. During an observation on 5/10/17 at 7:32 a.m., Staff member F put on gloves at the medication cart in the hallway, knocked on resident #15's door and entered. The nurse completed a blood glucose check. Staff member F picked up a urinal that was hanging by the handle on the resident's trash can. She returned the urinal, removed one glove and returned to the medication cart. Staff member F took keys from her pocket and unlocked the medication cart. She used one disinfectant wipe to clean the glucometer and another to wrap it. She set the meter aside and removed the remaining glove. Staff member F used alcohol based hand sanitizer on her hands. She prepared insulin for administration to resident #15 and applied gloves at the cart, in the hallway. Staff member F knocked on resident #15's door and entered the room. After the administration, staff member F returned to the cart, removed gloves and used alcohol based hand sanitizer on her hands but had failed to remove gloves and wash or sanitize hands prior to leaving resident #15's room. During an interview on 5/10/17 at 8:30 a.m., staff member A stated that staff receive annual training and competency testing in infection control. Staff member A stated gloves should be applied in the room and removed prior to exiting the room, and hand hygiene should occur in the room. She said gloves should not be worn in the hallway unless needed in the hallway for a specific purpose. c. During an observation on 5/11/17 at 8:15 a.m., staff member G was wearing gloves and administering crushed medications into a feeding tube for resident #18. During the procedure, staff member G touched the bed linens and the resident's skin, he handled the feeding tube and opened the port for access. Water was added to the medications to dissolve them and aid administration. While wearing the same gloves that had touched the resident, the linens, and the tube, staff member G picked up a spoon, by the handle, that was in a cup on resident #18's bedside stand. He used the handle end of the spoon, which was potentially contaminated, to stir the mixture in the cup to loosen the residual medication. He administered the medication from the cup into the resident's feeding tube. During an interview on 5/1/17 at 8:30 a.m., staff member G stated he should not have used the spoon since he could not know if it was clean and should bring a spoon with him, to use if needed. Review of the facility policy titled, Glove Use, showed the following points: -Used gloves should be discarded into the nearest waste receptacle inside the room. -Perform hand hygiene after removing gloves. Review of the facility policy titled, Handwashing/Hygiene, showed the following points: -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. -Employees must wash their hands for at least twenty seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: . The conditions included, before and after direct resident contact for which hand hygiene is indicated by acceptable professional practice; before and after performing any invasive procedure (e.g., fingerstick blood sampling); after removing gloves. -In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% [MEDICATION NAME] or [MEDICATION NAME] for all the following situations: The situations included, before and after direct contact with residents; after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; after removing gloves.",2020-09-01
846,LAKE VIEW CARE CENTER,275094,1050 GRAND AVE,BIGFORK,MT,59911,2018-07-26,565,E,0,1,7GJC11,"Based on observation, interview, and record review, the facility failed to limit disruptive noises in the facility, or maintain the noises at an acceptable level for the residents, for 6 (#s 5, 10, 13, 14, 20, and 39) of 24 sampled and supplemental residents. Findings include: During an observation on 7/24/18 and 7/25/18 at 7:15 a.m., the 200 hall was very loud. Staff were speaking loudly to one another and the residents, equipment was being moved and banged around, and a vacuum was being used in the hall. During a resident group meeting, on 7/24/18 at 11:00 a.m., resident #s 5, 10, 13, 14, 20, and 39 stated the noise in the building was too loud for them, especially on halls 200 and 300, in the early morning, when staff were changing shift. More than half the residents in the group meeting stated they were unable to go back to sleep after the noise was so loud during shift change. The group stated the concern had been brought up to the administrator in the past. Review of the resident council minutes showed on 4/25/18 the loud noise at night had not been resolved, and a new grievance form for a noise complaint had been completed. Review of the 6/27/18 resident council meeting minutes showed new concerns of noise at the morning shift change, noise at the beginning of the afternoon shift, staff talking while charting, resident televisions being loud, and the staff being loud after the dinner meal. During an interview on 7/25/18 at 3:31 p.m., staff member A stated he was aware of the noise at shift change in the morning. The staff member stated he had audited the noise level a couple times and had inservice's, but the noise must still be happening.",2020-09-01
847,LAKE VIEW CARE CENTER,275094,1050 GRAND AVE,BIGFORK,MT,59911,2018-07-26,578,D,0,1,7GJC11,"Based on interview and record review, the facility failed to update a resident's Care Plan for 1 (#47) of 13 sample residents, and the resident had a full code status identified on the POLST advanced directive form, within specifications, but the care plan did not reflect the same information. This had the potential to result in staff failing to follow the resident's wishes. Findings include: A review of resident #47's POLST, signed by the resident's wife on 5/7/18, showed in Section A, that the resident was not to be resuscitated, if the resident did not have a pulse and was not breathing. In Section B, the POLST showed if the resident had a pulse and was breathing, only limited additional interventions were to be conducted. Intubation, advanced airway interventions, and or mechanical ventilation were not to be done. In Section C the POLST showed the resident was not to be given nutrition by tube. A review of resident #47's Care Plan, last reviewed on 7/20/18, had an Advanced Directives Focus initiated on 5/7/18. It showed I have a full code status. Staff will intervene appropriately if I should need cardiac resuscitation. The focus had been dated as revised on 5/29/18 but did not show any further interventions or updates to the resident's POLST information. In an interview on 7/26/18 at 11:15 a.m., staff member B was shown both resident #47's POLST of 5/7/18, and the resident's Care Plan focus for Advance Directives. Staff member B said she was not aware that any changes had been made by the resident or his wife to the resident's 5/7/18 POLST. Staff member B she would make the necessary changes to the resident's Care Plan to have it accurately reflect the resident's POLST.",2020-09-01
848,LAKE VIEW CARE CENTER,275094,1050 GRAND AVE,BIGFORK,MT,59911,2018-07-26,623,B,0,1,7GJC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide written notification to resident #47, and to all other residents, and/or resident representatives, and the facility ombudsman, regarding the reason for resident transfers from the facility between the dates of 1/1/18 and 7/26/18. Findings include: A review of the facility's infection control investigations showed resident #47, had been hospitalized for [REDACTED]. On 7/26/18, the facility was requested to provide evidence it had provided resident #47 written notification of the reason for his transfer from the facility to the hospital on [DATE]. At the time of the request, staff members B and [NAME] voiced that they did not understand the reason for the request. During an interview on 7/26/18 at 11:27 a.m., staff member [NAME] said she had read the resident transfer notice regulation tag, and understood what the facility was being requested to provide. She stated the facility had not yet begun to provide written transfer notices to residents prior to their transfer from the facility. She said residents had been informed of the reason for their transfer but said no written transfer notices had been given to any residents transferred from the facility in (YEAR).",2020-09-01
849,LAKE VIEW CARE CENTER,275094,1050 GRAND AVE,BIGFORK,MT,59911,2018-07-26,758,D,0,1,7GJC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to discontinue or renew physician's orders for PRN [MEDICAL CONDITION] medications 14 days after the medication had been originally ordered for 2 (#6 and 30); and failed to conduct a gradual dose reduction without a rational for 2 (#s 15 and 40) of 13 sampled residents. Findings include: 1. During an interview on 7/24/18 at 4:00 p.m., staff member D said the facility was aware of the 14 day order limit for PRN [MEDICAL CONDITION] medications. She said the facility had been working to get PRN [MEDICAL CONDITION] medications discontinued, and were working on educating the physicians regarding the regulations. She said this had been difficult because so many of the patients on hospice were deliberately ordered PRN [MEDICAL CONDITION] medications as soon as they went on hospice, so they would be available for administration to the residents when they needed them. She said she was not sure whether hospice staff were aware of the need for the PRN [MEDICAL CONDITION] medications to be reordered every 14 days. A review of resident medical records showed the following: a. A review of resident #30's (MONTH) (YEAR) Order Summary Report, signed by the resident's provider on 6/27/18, showed the resident was ordered to receive [MEDICATION NAME] Tablet 0.5 mg by mouth every 4 hours as needed for anxiety/sob 1-2 tablet as needed. A review of resident #30's MARS for (MONTH) (YEAR), showed the resident was ordered to receive [MEDICATION NAME] Tablet 0.5 mg by mouth every 4 hours as needed for anxiety/sob 1-2 tabs PO/SL on 5/21/18 at 12:15 p.m. The MARS showed resident #30 had been administered [MEDICATION NAME] on 7/7/18 at 7:52 p.m. This was 47 days after the PRN [MEDICAL CONDITION] medication had been ordered. The [MEDICATION NAME] had been due to be reordered or discontinued on 6/5/18. b. Review of resident #15's current Physician orders showed the resident had been prescribed [MEDICATION NAME], an antipsychotic, for [MEDICAL CONDITION], since 4/4/17. Review of the facility fax to the physician for a request of a gradual dose reduction, dated 6/9/18, showed the physician declined to attempt the GDR. No rational, or risk verses benefit was provided to the resident. c. Review of resident #6's Medication Administration Record [REDACTED]. The order was not reviewed, reordered, or discontinued every 14 days.",2020-09-01
850,LAKE VIEW CARE CENTER,275094,1050 GRAND AVE,BIGFORK,MT,59911,2018-07-26,759,D,0,1,7GJC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to conduct medication pass without error greater than 5%, when it failed to have medication available for administration for 2 (#s 4 and 17) of 24 sampled and supplemental residents. This resulted in a medication administration error rate of 7.4%. Findings include: 1. During an observation of the medication pass on 7/24/18 at 8:27 a.m., staff member H was observed looking through all of the drawers of the medication cart for the resident hall. She voiced frustration at not being able to find a stock bottle of [MEDICATION NAME] 20 mg capsules as prescribed for resident #17. She looked for the drug in the facility's medication storage room and did not find any. She said she would have to order the [MEDICATION NAME] from the facility pharmacy. She said it would take time and resident #17 would not get her [MEDICATION NAME] as scheduled. Staff member H said she would give the medication as soon as it came from the pharmacy. A review of resident #17's (MONTH) (YEAR) MAR indicated [REDACTED]. The resident was scheduled to be given the medication at 8:00 a.m. every morning. Further review of resident #17's MAR, on 7/24/18 at 4:00 p.m., showed staff member H had initialed resident #17's 7/24/18 8:00 a.m. dose as having been given. The record did not show the time the [MEDICATION NAME] had been administered. The incident was determined a medication error based on observation of the [MEDICATION NAME] not having been administered within the time period for which it had been scheduled and prescribed. 2. During an observation of the medication pass on 7/24/18 at 8:35 a.m., staff member H was unable to find Calcium [MEDICATION NAME] 600 mg tablets on the facility's medication cart. None was found in the medication storage room. When resident #4 became aware of this, she spoke to staff member H, and told her to give her TUMS 1,000 mg Antacid Tablets instead. Resident #4 said she had been receiving TUMS for the last week or so because other nurses had also been unable to find Calcium [MEDICATION NAME] 600 mg tablets as the resident's physician order [REDACTED]. She said she would have to order Calcium [MEDICATION NAME] 600 mg from the pharmacy, and the resident's ordered 9:00 a.m. dose would be delayed. A review of resident #4's MARS showed the resident was ordered to receive Calcium-Carb 600 Tablet (Calcium [MEDICATION NAME]) Give 2 tablet (sic) by mouth in the morning for gastric upset unrelieved with PPI (proton pump inhibitor). The medication had been started on 1/17/17. The resident's MARS showed the resident had been administered the medication every day (MONTH) 1st through the 23rd. It was scheduled to be given every morning at 9:00 a.m. During an interview on 7/24/18 at 3:40 p.m., staff member H said she had ordered Calcium [MEDICATION NAME] 600 from the pharmacy, but it had not yet been received by the facility. Review of resident #4's MARS, on 7/25/18, showed staff member H had initialed resident #4's 9:00 a.m. dose of calcium carb 600 mg as having been administered on 7/24/18. It did not show the specific time it was administered. Further review also showed that resident #4's previously ordered Calcium [MEDICATION NAME] 600 had been ordered discontinued on 7/25/18 at 9:18 a.m., and Calcium [MEDICATION NAME] Antacid Tablets had been ordered to be given 2 tablet (sic) by mouth one time a day for acid indigestion/stomach upset. Give 2 750 mg tablets. The antacid tablets (TUMS) were scheduled to be given at 8:00 a.m. each morning starting 7/26/18. The incident was determined a medication error on 7/24/18 based on observation of the Calcium [MEDICATION NAME] 600 Tablet not having been administered within the scheduled time period for which it had been scheduled and prescribed.",2020-09-01
851,LAKE VIEW CARE CENTER,275094,1050 GRAND AVE,BIGFORK,MT,59911,2018-07-26,761,E,0,1,7GJC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, medication stored in the medication storage refrigerator were not dated with an open date, for 1 (#40), of 13 sampled residents; and medications were not discarded when expired or when they did not have an open date documented on the medication, which had the potential to affect any resident using expired medications. Findings include: During an observation on 7/24/18 at 4:00 p.m., inspection of the facility's medication refrigerator in the medication storage room was conducted with staff member D present. One vial of [MEDICATION NAME] purified protein derivative (diluted) [MEDICATION NAME] 5 TU/0.1 ml was found in the refrigerator. The medication, was a vial that would be used by several nurses, and the medication administered to different residents. The vial had been previously opened and some of the contents were missing. It was not labeled with an open date but had a manufacturer's expiration date of 11/19. Staff member D said this was because the medication had not been labeled with an open date, the medication's use by date could not be determined. She removed it from the refrigerator stating she planned to dispose of it. During an observation on 7/24/18 at 4:35 p.m., inspection of the facility's medication cart medications for the 300 hall was conducted with staff member I. The following items were found: -[MEDICATION NAME] Lubricant Eye drops, labeled for resident #40, opened 6/10/18, with manufacturer's expiration date of 2019/10. Staff member I stated that the eye drops were good for 30 days after the open date and were overdue for discard. -Potassium Cl 10% solution 20 mEq/15 ml, labeled for resident #40, with an open date of 4/2018. The vial was open and a portion had been used. Staff member I stated the potassium should have been discarded after being opened for 30 days. -Milk of Magnesia 16 fl oz., with manufacturer's expiration date of 9/15, labeled as opened 4/7/18. Opened with portions missing. Outdated per manufacturer's expiration date. During the interview on 7/25/18 at 10:00 a.m., staff member B also provided a sheet titled Recommended Minimum Medication Storage Parameters (based on manufacturer guidance) Ophthalmic, Otic, and Topical Medications. It consisted of two pages of recommended storage temperatures and expiration dates for specific eye medications. Staff member B said she did not know if the facility staff nurses had access to this form on a regular daily basis. It did not give information for resident #40's [MEDICATION NAME] Lubricant Eye drops. During an interview on 7/26/18 at 7:45 a.m., staff member B said she had called the pharmacy and was told resident #40's [MEDICATION NAME] Eye drops were good until the manufacturer's expiration date, even after the container was opened. A review of the facility's policy titled Storage and Expiration of Medications, Biologicals, Syringes and Needles from LTC Facility Pharmacy Services and Procedures Manual and copyrighted in (YEAR), showed the following on page two: Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. Facility staff may record the calculated expiration date based on date opened on the medication container. Medications with a manufacturer's date expressed in month and year (e.g. May, 2019) will expire on the last day of the month.",2020-09-01
852,LAKE VIEW CARE CENTER,275094,1050 GRAND AVE,BIGFORK,MT,59911,2018-07-26,812,D,0,1,7GJC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement and utilize the facility's policy for labeling and dating food stored in the facility's resident food refrigerator. Staff were unable to determine when foods were expired or when the food was required to be discarded. Findings include: During an observation and interviews on [DATE] at 4:00 p.m, contents of the facility's resident food refrigerator were checked for dates and labeling with staff members D and F present. The following was found in the refrigerator: -One glass of thick chocolate brown liquid covered in plastic without a date or resident's name. Staff member D said she had placed this, a nutritional food supplement, in the refrigerator several days earlier for a resident who was no longer at the facility. She discarded it. -Several chocolate and strawberry 4 oz. Imperial Sysco shakes in previously frozen cartons, now thawed, but not labeled for thaw dates. Staff member F said that when the shakes had been first placed in the refrigerator they had been frozen. -There were a variety of snacks, prepared by the facility, and available for residents, which were dated with dates prior to [DATE]. -The resident food refrigerator had a sign on the front of the door that showed Nurses-Please check all contents of fridge to ensure 72 hr state expiration standard is met. (i.e.- if predated from manufacturing fine as dated. If our dating 72 hr max.) During an interview at the time of the refrigerator observation on [DATE] at 4:00 p.m., staff member D said, the dates on the food in the refrigerator were the dates the foods had been placed in the refrigerator. She said food was to be discarded 72 hours after the labeled dates. The Sysco shakes did not have a labeled date or a manufacturer's discard date on them and she said she was not sure when they expired. During an interview at the time of the refrigerator observation, on [DATE] at 4:00 p.m., staff member F said the Sysco shakes were supposed to be dated with the date the shakes were thawed, and were to be disposed of 72 hours after they had been thawed. On [DATE] at 4:50 p.m., a policy titled Food Storage-Residents was provided by the facility. It was labeled with an effective date of Aug (YEAR), and a revised date of (MONTH) (YEAR). It showed All food belonging to residents must be labeled with the resident's name and the 'use by' date if there is no manufacturer's expiration date. According to the policy, all of the above facility prepared resident snacks and foods, dated prior to [DATE], and without manufacturer's expiration dates, had expired. On [DATE] at 4:00 p.m., staff member D was given the facility's Food Storage-Residents Policy to read. She voiced concern that the staff had not been dating the resident's food items according to the policy. She said staff were dating food with the date it was placed in the refrigerator. They were not labeling the food with use by dates. During an observation on [DATE] at 4:02 p.m., further inspection of the resident refrigerator showed the Sysco shakes and facility prepared resident snacks observed on [DATE] had been removed. New facility prepared resident snacks had been placed in the refrigerator. The snacks were all labeled with dates showing [DATE]. According to the facility policy, all of the new resident snacks were considered outdated, due to the use by date noted in the policy, therefore, the snacks needed to be discarded. During an interview on [DATE] at 4:05 p.m., staff member A was notified of the labeling of the new snacks found in the resident refrigerator. He said he would make changes to assure the food date labels were corrected to reflect the use by/discard date of the food items, according to the facility policy.",2020-09-01
853,LAKE VIEW CARE CENTER,275094,1050 GRAND AVE,BIGFORK,MT,59911,2017-08-16,280,D,1,0,ENOM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to review and revise the care plan to include the resident and representative's goal of trailing the use of a Dynovax communication board. The resident was not exposed to the use of the board on a consistent trail basis, and no data regarding the use of the communication device was collected for evaluation. This practice affected 1 (#1) of 1 residents trialing a Dynovax communication board. Findings include: Resident #1 was admitted to the facility on [DATE], with multiple diagnoses, including encephalitis, [MEDICAL CONDITIONS] and traits similar to autism. Review of resident #1's Admission MDS, with an ARD of 11/17/16, showed communication was identified as a needed care area, and the MDS showed communication would be care planned. Review of resident #1's care plan showed, impaired communication, and this was last updated on 11/20/16. Use of the Dynavox communication board, had not been included in the care plan at any time. A review of the facility's policy, Care Planning, reflected, 2.The care plan is broken down into separate focus areas: Psycho-Social, Quality of Life, Comfort/Pain/Sleep, Death & Dying, Behavior, Communication . Review of resident #1's (in-house) therapy note, dated 12/23/16, showed, .Per case manager, pt is being evaluated for a Dynavox ACC device and requires a communication evaluation to start the process. Pt has evaluation next month to start the process. Pt would benefit from ST to address communication to better express wants and needs to staff. Review of resident #1's (in-house) therapy note, dated 1/13/17, showed, Patient was evaluated for a Dynavox on Monday, contacted the ST for results. Continue P[NAME]. Review of resident #1's (in-house) therapy note dated 2/1/17, showed, resident #1 was discharged from speech therapy, as having not met her communication goal, secondary to participating in speech therapy at another location (hospital speech therapy), with increased resources for Alternative/Augmentative Communication technology. Observations conducted on 8/15/17 at 7:33 a.m., 8/15/17 at 8:50 a.m., 8/15/17 at 10:25 a.m., 8/15/17 at 12:03 p.m., 8/15/17 at 12:15 p.m., 8/15/17 at 12:20 p.m., and throughout the remainder of the survey, showed resident #1 did not have PECC cards, or the Dynavox communication device available, at any time, for use during communication. Review of resident #1's IDT note, dated 11/30/16, showed, Resident .She (resident #1) is unable to communicate, but may yell so that staff knows she needs something. She easily becomes frustrated and often aggressive at the caregivers .And, (Guardian) looking into (resident #1's) past use of Dynavox for communication . Review of resident #1's IDT note, dated 3/7/17 showed, under the category Restorative Care/PT/OT summary, the IDT notes showed, Speech Pathology: reinforcing picture exchange communication .Goal is to progress toward more functional communication systems. Review of resident #1's nursing notes, from 3/7/17 to 8/15/17, showed no further documentation for the application of the Dynavox communication device. Review of resident #1's IDT note, dated 5/31/17, lacked any evidence communication was reviewed. Review of resident #1's speech therapy notes showed in-house speech therapy was provided, for a needed swallowing evaluation, between the dates of 11/18/16 and 2/1/17. The speech therapy notes showed, a local hospital speech therapist was working with resident #1, to help provide a communication board (Dynavox.) During an interview on 8/16/17 at 7:40 a.m., staff member B said, There was no order for the Dynavox, therefore there was no care plan for it. A lot of these things were just brought in by the guardian for the staff to use. Review of resident #1's nursing notes, dated 6/17/17, at 2:11 p.m., showed, Dr. (sic) regarding communication device; Patient continues to benefit from participation in communication. Use device to target functional communication for expression of needs and wants. (Guardian) brought this form to this nurse. During an interview on 8/15/17 at 1:30 p.m., NF1 said that the Dynavox was on loan to resident #1 for a trial period, and Medicaid would not pay for the Dynavox if she could not show she could utilize the device. She said The speech therapist (from the local hospital) offered to come train staff on how to use the communication device. NF1 said that they (speech therapy from the local hospital), Tried to work with the speech therapist at the facility, but no one cared. NF1 said the documentation form she had given the nursing staff was a form that outlined the use of the Dynavox. During an exit conference interview on 8/16/17 at 10:30 a.m., staff member's A and B said they could not offer more input regarding the Dynavox, as neither of them had been employed at the facility when the communication device was in use for resident #1. They said the (in-house) Speech Therapist may have been able to provide input, but was on a leave from the facility, and they were unable to make contact.",2020-09-01
854,LAKE VIEW CARE CENTER,275094,1050 GRAND AVE,BIGFORK,MT,59911,2017-08-16,310,D,1,0,ENOM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to identify, care plan, and work with the resident adequately for the trial-use of a Dynavox Communication System, leading to a missed opportunity for the resident to utilize the system, to improve communication, and failed to evaluate the effectiveness of this device for the resident, for 1 (#1) of 3 sampled residents. Findings include: Resident #1 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #1 had also sustained a [MEDICAL CONDITION] due to encephalitis at the age of 14 days. Review of resident #1's Admission MDS, with an ARD of 11/17/16 showed resident #1 had an intellectual disability, had no speech, and was sometimes understood. Communication was identified as a needed care area, and the MDS showed communication would be care planned. Review of resident #1's care plan showed, impaired communication, had last been updated on 11/20/16. Use of the Dynavox communication board, had not been included in the care plan at any time. Review of the in-house speech therapy dates, 11/18/16 - 2/1/17, showed the in-house therapist had a working knowledge of the incoming Dynavox, and had been working with Resident #1 utilizing OPEC cards. Review of resident #1's CAA, dated 11/22/16, showed the following: -What are the triggering MDS items: (Nature of the problem.) I triggered for communication due to my impaired ability to talk; -What are the complications and risk factors?: not having my needs or communicate what I am wanting met making my behaviors escalate (sic); -Was there a need for a referral?: not needed at this time; and, -Will you proceed to care plan and why or why not?: yes to address the problem and possible interventions. A review of the facility's policy, Care Planning, reflected, 2.The care plan is broken down into separate focus areas: Psycho-Social, Quality of Life, Comfort/Pain/Sleep, Death & Dying, Behavior, Communication . Review of resident #1's (in-house) Speech Therapy notes, between 11/18/17 and 2/1/17, provided by the facility, showed therapy had been provided for swallowing difficulties, OPEC cards were trialed with resident #1, and the Speech Therapist was aware a communication board was being acquired for resident #1. Review of resident #1's (in-house) therapy note, dated 12/23/16, showed a new goal, Patient will effectively communicate basic wants/needs with verbal, tactile and visual instruction/cues. Under Analysis of Functional Outcome/Clinical Impression, .Due to her decreased communication skills, pt demonstrates increased behaviors. Per case manager, pt is being evaluated for a Dynavox ACC device and requires a communication evaluation to start the process. Pt has evaluation next month to start the process. Pt would benefit from ST to address communication to better express wants and needs to staff. Review of resident #1's (in-house) therapy note, dated 1/13/17 showed, Patient was evaluated for a Dynavox on Monday, contacted the ST for results. Continue P[NAME]. Review of resident #1's (in-house) therapy note, dated 2/1/17, showed, resident #1 was discharged from speech therapy, as having not met her communication goal, secondary to participating in speech therapy at another location (hospital speech therapy), with increased resources for Alternative/Augmentative Communication technology. Observations conducted, 8/15/17 at 7:33 a.m., 8/15/17 at 8:50 a.m., 8/15/17 at 10:25 a.m., 8/15/17 at 12:03 a.m., 8/15/17 at 12:15 p.m., and 8/15/17 at 12:20 a.m., and throughout the survey showed resident #1 did not have PECC cards, or the Dynavox communication device available, at any time, for use in communication. Review of resident #1's IDT note, dated 11/30/16, showed, Resident .She (resident #1) is unable to communicate, but may yell so that staff knows she needs something. She easily becomes frustrated and often aggressive at the caregivers .And, (Guardian) looking into (resident #1's) past use of Dynavox for communication . Review of resident #1's IDT note dated 3/7/17 showed, Resident . She is unable to verbally communicate, but may utter/yell so that staff may perceive a desire, need, or unpleasantry (sic). She is currently able to touch a staff member's hand to alert staff to bring food/drink to her mouth at a meal. She becomes frustrated and is often aggressive at her caregivers. Under the category Restorative Care/PT/OT summary, the IDT notes showed, Speech Pathology: reinforcing picture exchange communication .Goal is to progress toward more functional communication systems. Review of resident #1's IDT note, dated 5/31/17, lacked any evidence communication was reviewed. Review of resident #1's nursing note, dated 6/17/17 at 2:49 p.m., showed, (Resident) .Difficult to read needs. Has not been willing to use communication computer with staff regularly to help staff understand her needs and wants . Review of resident #1's nursing notes, from 3/7/17 to 8/15/17, showed no further documentation for the application of the Dynavox communication device, or the application of PECC communication cards on a consistent basis, or the response of the resident to the use of the communication devices. During an interview on 8/16/17 at 7:40 a.m., staff member B said, There was no order for the Dynavox, therefore there was no care plan for it. A lot of these things were just brought in by the guardian for the staff to use. There were no orders for them. She would bring them in and take them back out, like the Dynavox. Review of resident #1's nursing notes, dated 6/17/17, at 2:11 p.m., showed, Dr. (sic) regarding communication device; Patient continues to benefit from participation in communication. Use device to target functional communication for expression of needs and wants. (Guardian) brought this form to this nurse. During an interview on 8/15/17 at 1:30 p.m., NF1 said she had talked to the facility about not allowing resident #1 to have more than one tablet, with which to watch movies, at a time. She said that the Dynavox was on loan to resident #1 for a trial period, and Medicaid would not pay for the Dynavox if she could not show she could utilize the device. She said The speech therapist (from the local hospital) offered to come train staff on how to use the communication device. NF1 said that they (speech therapy from the local hospital), Tried to work with the speech therapist at the facility, but no one cared. NF1 said the documentation form she had given the nursing staff was a form that outlined the use of the Dynavox. During an interview on 8/15/17, staff member C said, She (resident #1) was not receptive to the communication board. She throws things. She got frustrated with the Dynavox. During an interview on 8/15/17 at 9:20 a.m., staff member D said, (Another resident) and resident #1 often require one-on-one care. We don't have the time to give her (resident #1) the one-on-one she needs. She doesn't get the time she needs, like with the communication tablet. There is no one there to teach her. Staff member D said she did not receive any training on the use of the Dynavox. During an interview on 8/15/17 at 9:30 a.m., staff member [NAME] said, It's hard to take care of all the residents when one person needs one-on-one. She (resident #1) cannot get the care she needs here because of the needs of the other residents. Staff member [NAME] said she did not receive any training on the use of the Dynavox. Review of resident #1's in-house speech therapy information showed the resident was provided services for a needed swallowing evaluation between the dates of 11/18/16 and 2/1/17. Review of the in-house speech therapy notes showed, the therapist was also trialing the use of PECC cards to communicate with resident #1. The speech therapy notes also showed a local hospital speech therapist was working with resident #1, to help provide a communication board (Dynavox.) The hope was to increase resident #1's ability to communicate, and subsequently decrease aberrant behaviors. The facility speech therapist was unavailable through-out the survey to clarify the (in-house) treatment plan, the use of PECC cards, or the expectation that a communication board would be acquired by the hospital based Speech Therapist. The (local hospital) Speech Therapist was on vacation and not available to clarify the intended collaboration between providers, for the use of the Dynavox, to meet the communication needs of resident #1. During an exit conference interview on 8/16/17 at 10:30 a.m., staff member's A and B said they could not offer more input regarding the Dynavox, as neither of them had been employed at the facility when the communication device was in use for resident #1. They said the (in-house) Speech Therapist may have been able to provide input, but was on a leave from the facility, and they were unable to make contact.",2020-09-01
855,MONTANA VETERANS HOME N H,275100,400 VETERANS DR,COLUMBIA FALLS,MT,59912,2017-02-23,322,E,0,1,GTM611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to check for the placement of an enteral feeding tube, check for gastric content to assess for gastric emptying, failed to administer each medication separately and flush the tubing between administrations, and failed to adhere to fluid restrictions while administering enteral feeding and medications for 2 (#s 3 and 7) of 20 sampled residents. Findings Include: 1. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. [NAME] Enteral Tube Placement and Gastric Residual Check: During an observation on 2/22/17 at 12:00 p.m., staff member [NAME] prepared 300 ml of water, and placed it by the bedside. The staff member opened the post on the feeding tube and attached a 100 ml syringe to the port. She administered 300 ml of water, via a bolus feeding. The staff member then attached the feeding tube lumen to the enteral nutrition via a continuous feeding machine at 250 ml to be administered over an hour. Staff member [NAME] failed to check for the residual of gastric content and tube placement prior to the administration of the tube feeding. During an observation on 2/22/17 at 3:50 p.m., staff member F administered resident #3's tube feeding, water flush, and medications. The staff member checked for residual and returned the gastric contents. Staff member F then administered the resident's medications, flushed the tube with approximately 150 ml of water, then attached the continuous enteral feeding to the feeding tube port. Staff member F failed to check for the feeding tube placement prior to administering medications. The staff member failed to flush the gastric tubing prior to administering medications. A review of resident #3's Order Summary Report, signed by the physician on 1/27/17, showed, [MEDICATION NAME] Tube Feeding 125 ml (1/2 can), continue 250 ml Bolus [MEDICATION NAME] 2.0 TID, total formula 875 ml, provides 1750 KCal and 74 G Protein, continue water flushes as ordered one time a day for nutrition check residual at each feeding. If greater than 60 cc hold x 1 hour, than recheck if less then 60 cc to start feeding. Provide 75 ml H20 Flush pre/post medication administration three times a day and feedings four times a day. A review of resident #3's TAR, dated 2/1/17 -2/28/17, showed: Check residual tube feeding two times a day. A review of resident #3's MAR, dated 2/1/17 - 2/28/17, showed: -[MEDICATION NAME] Tube Feeding: continue 250 ml Bolus [MEDICATION NAME] 2.0 TID, total formula 875 ml, provides 1750 KCal and 74 G Protein, continue water flushes as ordered one time a day for nutrition. Check residual at each feeding. If greater than 60 cc hold x 1 hour, than recheck if less than 60 cc to start feeding. Provide 75 ml H20 Flush pre/post medication administration three times a day and feedings four times a day. During an interview on 2/22/17 at 12:20 p.m., staff member [NAME] stated she did not feel the need to check for tube placement since the resident had the tube feeding for a long time. She stated the resident had in the past unhooked his own tube feedings when he felt he was starting to gain too much weight from the nutrition. She stated the residual was only checked twice daily as ordered on the resident's MAR. Staff member [NAME] stated she did not check for residuals or tube placement, and was not aware of the facility's policy on checking either. The staff member could not remember the last training she received from the facility on tube feeding procedures or protocols. During an interview on 2/22/17 at 4:20 p.m., staff member F stated she would check placement on the tube feeding if the feeding tube was new, or had been replaced recently. She stated she might check for feeding tube placement once a week. Staff member F stated resident #3 had a history of [REDACTED].#3's feeding tube. She stated she did not flush the tubing prior to administering the medication because she had checked for residual. Staff member F stated she could not remember the last time the facility had provided education or training on enteral feeding. During an interview on 2/22/17 at 2:53 p.m., staff member B stated it was her expectation for the nurses to check the resident's stomach contents for residual, and hold back on the tube feeding if a large amount of gastric content was noted on the residual. Staff member B stated the staff could check for placement by pushing an air bolus through the feeding tube, and listening with a stethoscope for bowel sounds. The staff member stated it was the standard of care to check for residual and tube placement between tube feedings. Staff member B was not sure when the last training was completed for the nursing staff on enteral feeding. She stated staff member C, provided the enteral feeding tube training for nursing staff. During an interview on 2/23/17 at 10:20 a.m., staff member C stated she was responsible for training the nursing staff on enteral feeding. She stated it was the expectation of staff to check for tube placement and residual prior to every feeding and medication administration. She stated it was also the expectation to flush the tubing prior to medication administration as well as after. Staff member C stated resident #3 was able to disconnect his own tube feeding and had in the past when he felt as if he was gaining too much weight. Due to his psychiatric issues, associated with his tube feeding, the staff member stated it would be a good idea to check for tube placement on every administration for resident #3. She stated resident #3 had a physician order to mix together the resident's medications and administer together due to his psychiatric issues and fluid restriction. Staff member C stated she had not provided the nursing staff with recent education and training on the facility's policy and procedure for enteral training. B. Fluid Restriction: During an observation on 2/22/17 at 12:00 p.m., staff member [NAME] prepared 300 ml of water and placed by the bedside. The staff member opened the feeding tube port and attached a 100 ml syringe to the port. She administered 300 ml of water via a bolus feeding. The staff member then attached the feeding tube lumen to the enteral nutrition via a continuous feeding machine at 125 ml to be administered over an hour. During an interview on 2/23/17 at 9:53 a.m., staff member [NAME] stated she was not aware the resident was on a fluid restriction. She stated it would be important to follow the physician orders for fluid administration on a resident that was on a fluid restriction. The staff member stated during the medication administration for resident #3, she stated she would use the 30 ml to flush meds, and an extra 10 ml if pills were dry, usually using a small med cup. She stated the small med cup was approximately 60 ml, but it might have been closer to 75 ml. Staff member [NAME] could not give what the amount of fluid the white cardboard cups held. She stated it would be important to measure, and be concise on the amount of water administered for a resident on a fluid restriction. During an observation on 2/22/17 at 3:50 p.m., staff member F prepared resident #3's tube feeding and medications. Staff member F crushed and mixed all medications together and placed them into a white cardboard cup and added water. Staff member F failed to measure the amount of fluid added to the white cardboard cup. Staff member F administered the medications after checking for residual. Staff member F stated during the administration she usually tried to give the resident a little more water, but this time she only administered about 120 ml's of fluid. The staff member failed to measure the amount of water given with the medication administration. During an interview on 2/22/17 at 4:20 p.m., staff member F stated she did not measure the amount of water given with resident #3's medications. She stated she guessed the white cardboard cup contained about 150 ml of water. She stated she also gave an additional amount of water since the crushed medications stuck in the syringe, she stated she thought it was about 30 ml of water. The staff member stated she was not aware resident #3 was on a fluid restriction. A review of the packaging for the white cardboard cups showed, Solo, single sided poly paper hot cups. 8 fl oz /236 ml. A review of resident #3's Physician Orders, dated 8/28/16, showed, Tube feeding clarification, free water restriction increased to 1800 ml per day. Provide 75 ml of water flush pre and post medication administration three times daily, and feedings, four times daily. A review of resident #3's MAR, dated 2/1/17 - 2/28/17, showed: -water flushes with medications. Free water restriction 1800 ml per day. Provide 75 ml water flush pre and post medication administrations three times daily and feedings four times daily, every shift due to [MEDICAL CONDITION] please indicate water amount. During an interview on 2/22/17 at 2:10 p.m., staff member NF1 stated resident #3 received 4 boluses daily. Three enteral feedings at 250 ml, and an additional enteral feeding at 125 ml bolus of [MEDICATION NAME] 2.0. She stated that was a total of 925 ml of formula containing 640 ml free water. She stated he also received 75 ml of water pre and post feedings, four times daily, as well as pre and post medication administration three times daily, for a total of 1050 ml daily. NFI stated with resident #3's water flushes, plus the water content of his formula, resident #3 received 1690 ml of free water daily. She stated an annual review for resident #3, in (MONTH) (YEAR), showed a clarification of an order written [REDACTED]. She stated the water restriction was increased from 1200 ml to 1800 ml at that time. During an interview on 2/22/17 at 2:53 p.m., staff member B stated it was the expectation of the staff to follow the physician orders and the MAR indicated [REDACTED] During an interview on 2/23/17 at 10:20 p.m., staff member C stated resident #3 was on fluid restriction related to his [MEDICAL CONDITION]. She stated it was the expectation of the staff to follow the physician orders and the MAR indicated [REDACTED]. 2. Resident #7 was admitted with a [DIAGNOSES REDACTED]. During an non-medication pass observation, on 2/22/17 at 4:45 p.m., staff member F prepared for resident #7, one [MEDICATION NAME] 20 mg tablet, and one risperdone 1 mg tablet. The two medications were crushed together and mixed into 5 ml's of liquid [MEDICATION NAME] syrup, and poured into a clear graduated medication cup. The staff member added water from the tap to the graduated medication cup for a total of 30 mls. She checked the resident for gastric content and then administered the medications. The staff member did not flush the tubing with a water flush prior to administering the medication. The staff member failed to administer the medications separately with a water flush between medications. A review of resident #7's MAR, dated 2/1/17 - 2/28/17, showed: -[MEDICATION NAME] 1.5 to 1 can at 1230 and 2100 two times daily with 150 cc H20 before and after every feeding. -[MEDICATION NAME] 1.5 calorie liquid 12 oz, at 0830 and 1700, two times daily with 150 ml water flush pre and post feeds. During an interview on 2/22/17 at 4:45 p.m., staff member F stated she was not aware of the need to administer medications individually with a water flush prior to the medication administration, between medications, and after the administrations. The staff member stated she had no previous training on this technique. During an interview on 2/22/17 at 3:16 p.m., staff member B stated it was the expectation of staff to administer each medication separately and flush feeding tube between each medication. During an interview on 2/23/17 at 10:20 a.m., staff member C stated resident #7 did not have an order to mix all of his evening medications together, and administer at the same time. She stated the professional standard was to administer each medication separately with a fluid flush between each administration. A review of the facility policy titled, Tube Feedings, showed the Tube feedings implementation as follows: - Check placement of the feeding tube to be sure it hasn't slipped out since the last feeding. -To check tube patency and position, remove the cap or plug from the feeding tube, and use the syringe to infect 5 to 10 ml of air through the tube to clear the tube. Then, aspirate gastric contents to be sure the tube is in the stomach. Look at the appearance of the aspirate. -To assess gastric emptying, aspirate and measure residual gastric volume. Reinstall any aspirate obtained. Hold feedings if residual volume is greater than 500 ml. - Flush the feeding tube with 30 ml of water; use sterile water if immunocompromised or critically ill patient. - After administering the appropriate amount of formula, add 30 ml of water to the gauge bag or bulb syringe or manually flush the feeding tube using a barrel syringe. Flushing maintains the tube's patency by removing excess formula, which could occlude the tube. - Flush the feeding tube with 30 ml of water before and after medication administration to help prevent tube occlusion.",2020-09-01
856,MONTANA VETERANS HOME N H,275100,400 VETERANS DR,COLUMBIA FALLS,MT,59912,2017-02-23,371,E,0,1,GTM611,"Based on observation, interview, and record review, the facility failed to ensure proper hand hygiene was maintained when food was being served in the 40 bed wing dining room. This deficient practice had the potential to affect all residents being served in the 40 bed dining room or those residents who received room trays. Findings include: During an observation on 2/22/17 at 9:06 a.m., staff member H was putting food on resident plates at the steam table in the 40 bed wing dining room. Staff member H left the steam table area, opened a door behind the steam table, touching the door knob. Staff member H was gone from the steam table 45 seconds. When staff member H returned to the steam table, she continued handling resident plates, toast, and serving utensils. Staff member H did not wash and re-glove her hands prior to restarting the plating of food for the residents. During this observation, staff member H leaned forward, reaching toward the front of the steam table, staff member H's identification badge was observed rubbing on top of the stainless steel ledge where resident plates were being set. During an observation on 2/22/17 at 9:10 a.m., staff member H went through the door behind the steam table, again touching the door knob. This door was later identified as a door opening into a mini kitchen where food, plates, silverware, paper goods, and food items were stored. Staff member H returned to the serving line. Staff member H did not wash or re-glove her hands prior to restarting the plating of food for the residents. During an observation on 2/22/17 at 9:17 a.m., staff member H dropped a piece of toast on the floor. Staff member H picked the piece of toast up and put it in the garbage can. Staff member G reminded staff member H to change gloves. Staff member H changed gloves, but did not wash her hands. Staff member H changed gloves again at 9:28 a.m., and 9:31 a.m. She did not wash her hands either time, prior to putting new gloves on. During an interview on 2/22/17 at 1:40 p.m., staff member H said hands should be washed or sanitized between glove changes. During an interview on 2/22/17 at 1:50 p.m., staff member G said all dietary staff should be washing their hands between glove changes. Staff member G said, Hand sanitizers do not take the place of hand washing. Review of the facility's policy, titled Hand Hygiene, showed: 2. Appropriate hand hygiene must be performed under the following conditions: h. After handling items potentially contaminated with blood, body fluids, excretions, or secretions. j. Before gloving and after de-gloving.",2020-09-01
857,MONTANA VETERANS HOME N H,275100,400 VETERANS DR,COLUMBIA FALLS,MT,59912,2017-02-23,441,E,0,1,GTM611,"Based on observation, interview and record review, the facility failed to ensure proper hand hygiene was followed during medication administration, which had the potential to affect 14 of 14 residents on the SCU. Findings include: During an observation of medication pass on 2/23/17 at 8:10 a.m., staff member I dispensed medications from bottles into his hand, then placed the medications into a small medication cup. Staff member I made frequent glove changes during the observation of medication administration for one resident. Staff member I did not sanitize hands between glove changes. At 8:15 a.m., staff member I answered the phone with gloves on, then returned to dispensing medications. Staff member I did not change gloves or sanitize hands. During an interview on 2/23/17 at 12:45 p.m., staff member C stated the expectation was for nursing staff to sanitize hands between glove changes, and to pour medications into the cap of the bottle and then into the medication cup. Review of the facility's policy, titled Hand Hygiene, showed the following: 2. Appropriate hand hygiene must be performed under the following conditions: . d. before preparing or handling medications .and . j. before gloving and after de-gloving .",2020-09-01
858,MONTANA VETERANS HOME N H,275100,400 VETERANS DR,COLUMBIA FALLS,MT,59912,2018-06-14,554,D,0,1,B8CU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess a resident, and obtain an order for [REDACTED].#38) of 29 sampled and supplemental residents. Findings include: During an observation on 6/12/18 at 9:09 a.m., resident #38 was sitting at a dining table with seven pills, on a napkin, to the right of her breakfast plate. During an observation and interview on 6/12/18 at 9:10 a.m., staff member H was preparing medications and placing them in packages. She had one package prepared, and was working on the second package. She was using the MAR and the medication cards and bottles to confirm the correct medications were prepared. Staff member H stated she had delivered the medications to resident #38. She stated the resident preferred to take her pills with her oatmeal. Staff member H said she did not know if resident #38 had orders to self-administer those medications. She checked the orders on the MAR, and stated resident #38 had orders to self-administer [MEDICATION NAME] and her nebulizer treatment, but not other medications. She said residents needed an assessment and an order to be permitted to take medications unattended. Staff member H stated the facility policy says we can observe, without being with the resident. During the interview, staff member H completed the second medication package and prepared a third package of medications. Staff member H stated she was preparing and packaging pills for three residents going on an outing. She said her attention was on packaging the medications. Review of resident #38's physician's orders [REDACTED].#38 may self-administer [MEDICATION NAME], Tylenol, and [MEDICATION NAME] nebulizer solution, in the resident's room, after set-up by nursing. The orders did not show other medications were approved for self-administration. Review of resident #38's (MONTH) (YEAR) MAR showed, under the heading Unscheduled Other Orders, the physician approval for the self-administration of [MEDICATION NAME] and Tylenol, in the resident's room, after set-up by the nurse. Review of a document from resident #38's clinical chart, titled, Assessment For Self-Administration Of Medications After Set-Up by Nursing, showed the resident had been approved to self-administer [MEDICATION NAME] and [MEDICATION NAME] nebulizer solution. The form was signed by a nurse. There was no evidence of interdisciplinary review or approval, and the Tylenol was not addressed. Review of a policy titled, Medication - Self-Administration, showed a requirement for interdisciplinary team to .ensure that he/she has the cognitive, physical, and visual ability to perform the task. The policy showed the following: - the members of the interdisciplinary team; - the need to determine the specific medications to be self-administered; - the need to determine the location of the self-administration; and, - The resident must be pre-authorized both by the Interdisciplinary team and have a physician's orders [REDACTED].",2020-09-01
859,MONTANA VETERANS HOME N H,275100,400 VETERANS DR,COLUMBIA FALLS,MT,59912,2018-06-14,623,D,0,1,B8CU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written notification of transfer to the hospital for 1 (#10) of 23 sampled residents. Findings include: During an interview on 6/12/18 at 3:48 p.m., resident #10 stated he had a supra pubic catheter, had frequent bladder infections, and had been hospitalized on ce for a bladder infection. Review of resident #10's hospital admission and discharge summary, showed the resident was admitted to the hospital on [DATE] [MEDICAL CONDITION] due to urinary tract infection. Resident #10 was given antibiotics and was discharged back to the facility on [DATE]. Review of resident #10's Interdisciplinary Progress Notes, dated 12/15/17 through 12/31/17, did not show that written notification was given to the resident or his representative for transfer, before he was transferred, when he was in the hospital, or after he returned to the facility. During an interview on 6/14/18 at 12:00 p.m., staff member C said she was not aware of written notification to resident, representative, or the ombudsman for transfers or discharges. During an interview on 6/14/18 at 12:16 p.m., staff member D said he was not aware of written notifications for the resident, resident's representative, or the ombudsman with transfers or discharges. Staff member D said, We always notify the representative by phone if I need to send a resident to the hospital.",2020-09-01
860,MONTANA VETERANS HOME N H,275100,400 VETERANS DR,COLUMBIA FALLS,MT,59912,2018-06-14,656,D,0,1,B8CU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to include use of a [MEDICAL CONDITION] device in the comprehensive care plan for 1 (#65); and failed to implement use of compression stockings for 1 (#65) of 23 sampled residents. Findings include: 1. During an observation and interview on 6/11/18 at 3:32 p.m., [MEDICAL CONDITION] was noted to resident #65's lower extremities. Both legs were weeping. There was Allevyn adhesive dressing on each leg. Resident #65 stated he had [MEDICAL CONDITION], and his legs wept. He stated he had open wounds to his legs at times. Wet spots were noted on the sheet under resident #65's legs. No [MEDICATION NAME] elastic compression bandages or compression stockings were in use. Review of resident #65's physician's orders [REDACTED]. During an observation on 6/12/18 at 2:55 p.m., resident #65 was sitting in his wheelchair. He was not wearing [MEDICATION NAME] elastic compression bandages or any type of compression stockings. During an observation and interview on 6/14/18 at 8:34 a.m., resident #65 stated he had not been wearing [MEDICATION NAME] elastic compression bandages or any type of compression stockings for over a week. He picked up the [MEDICATION NAME] from a pile of items stacked next to his bed. He stated no one had asked him about wearing them or offered to assist him. Resident #65 stated he could not put them on himself, and that he must have help. He stated he would wear them if someone told him he should, and helped him put them on. Resident #65 stated he knew he should wear them but no one offered to put them on. He stated he was off the radar. Resident #65 said he meant that he was expected to do things for himself, and that help was not offered. Review of resident #65's care plan showed a focus area for skin. The problem statement showed the resident was at very high risk for further vascular wounds due to [MEDICAL CONDITION]. An intervention, dated 12/20/17, showed [MEDICATION NAME]. The care plan did not show when [MEDICATION NAME] was to be applied, where [MEDICATION NAME] was to be applied, or how often. The care plan did not show if the [MEDICATION NAME] was being used for compression (to treat [MEDICAL CONDITION]), or to secure a dressing. During an interview and record reviewed on 6/14/18 at 10:04 a.m., staff member I reviewed resident #65's care plan, and stated the care plan should show more information regarding the [MEDICATION NAME] elastic compression bandages, such as when, where, and why to apply. 2. During an interview and observation on 6/11/18 at 3:33 p.m., there was a [MEDICAL CONDITION]/[MEDICAL CONDITION] device noted on resident #65's bedside stand. Resident #65 stated the facility had issued the device to him. Review of resident #65's physicians orders, dated 6/6/18, showed an order to, Encourage [MEDICAL CONDITION] with Sleep. During an interview and record review on 6/13/18 at 5:25 p.m., staff member F asked staff member J if resident #65 was using his [MEDICAL CONDITION]/[MEDICAL CONDITION], and staff member J stated he used it regularly. Staff member F stated it should be on the CNA daily worksheet. Review of a document titled, CNA Care Plan Sheet, showed a designated row with information regarding the care of resident #65. The form did not show the use of a [MEDICAL CONDITION] or [MEDICAL CONDITION]. During an interview on 6/14/18 at 11:36 a.m., resident #65 stated he had not used the device consistently for weeks, due to a wound on his face. He stated he did use it occasionally for brief periods when he was short of breath, and he would infrequently fall asleep and leave it on all night. During an interview and record review on 6/14/18 at 10:04 a.m., staff member I reviewed resident #65's care plan, and stated the use of a [MEDICAL CONDITION]/[MEDICAL CONDITION] was not on the resident's care plan, and it should be. She stated the care plan should show if the device was not being used.",2020-09-01
861,MONTANA VETERANS HOME N H,275100,400 VETERANS DR,COLUMBIA FALLS,MT,59912,2018-06-14,657,D,0,1,B8CU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure care plans were reviewed and revised to show [MEDICAL CONDITION] drug use for 2 (#s 16 and 52) of 29 sampled and supplemental residents. Findings include: 1. a. Review of resident #16's current Order Summary Report, dated 5/25/18, showed the resident was receiving [MEDICATION NAME] 10 mg at bedtime and [MEDICATION NAME] 0.5 mg every six hours as needed. The [MEDICATION NAME] was ordered 1/25/17, and the [MEDICATION NAME] was ordered 11/2/17. Review of resident #16's current [MEDICAL CONDITION] care plan did not show the care plan had been updated to include the [MEDICATION NAME] or the as-needed [MEDICATION NAME]. b. Review of resident #52's current Order Summary Report, dated 5/25/18, showed the resident was receiving [MEDICATION NAME] 0.25 mg in the morning, [MEDICATION NAME] 0.5 mg at bedtime, [MEDICATION NAME] 1 mg every 6 hours as needed, [MEDICATION NAME] 12.5 mg every morning, and [MEDICATION NAME] 25 mg at 3 p.m. Review of resident #52's current [MEDICAL CONDITION] care plan did not show the care plan had been updated to include the [MEDICATION NAME]. Review of resident #52's current [MEDICAL CONDITION] care plan showed the resident was receiving [MEDICATION NAME]. Resident #52's current Order Summary Report, dated 5/25/18, did not show the resident was receiving [MEDICATION NAME]. During an interview on 6/14/18 at 11:00 a.m., staff member G said all residents receiving [MEDICAL CONDITION] medications should have that information on their care plans.",2020-09-01
862,MONTANA VETERANS HOME N H,275100,400 VETERANS DR,COLUMBIA FALLS,MT,59912,2018-06-14,658,D,0,1,B8CU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow manufacturer's instructions to instruct the resident to rinse his mouth after the administration of an inhaled steroidal medication for 1 (# 1) of 29 sampled and supplemental residents. This failure increased the resident's risk for developing thrush. Findings include: During an observation on 6/12/18 at 4:32 p.m., staff member O prepared medication for administration to resident #1. He gathered pills and a [MEDICATION NAME] metered dose inhaler. The inhaler package had the name of resident #1 and instructions to take two puffs twice a day. Staff member O proceeded to resident #1's room, and administered the inhaler as resident #1 held the aero chamber and followed staff member O's instructions to take a deep breath. After the administration of the inhaler and pills was completed, staff member O left the room. He did not instruct resident #1 to rinse his mouth, and spit out the water. Review of the manufacturer's instructions for the use of [MEDICATION NAME] showed to have the patient rinse his mouth with water, without swallowing, following inhalation to help reduce the risk of oropharyngeal candidiasis (thrush). During an interview on 6/12/18 at 5:15 p.m., staff member O said he should have had resident #1 rinse his mouth and spit after administration of the [MEDICATION NAME]. He stated he usually gave the inhaler to the resident in the hall, and had the rinse cup ready. He stated he forgot the rinse because giving the inhaler in resident #1's room disrupted the routine.",2020-09-01
863,MONTANA VETERANS HOME N H,275100,400 VETERANS DR,COLUMBIA FALLS,MT,59912,2018-06-14,661,D,0,1,B8CU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a discharge summary that included a reconciliation of the resident's medications, and a post-discharge plan of care for 1 (#96) of 29 sampled and supplemental residents. Findings include: Review of resident #96's closed record showed the resident was admitted on [DATE], and was discharged on [DATE]. Review of resident #96's closed record showed a discharge summary, dated 5/2/18, was written by the resident's medical provider which included a recapitulation of resident #96's stay at the facility. No reconciliation of medications or post-discharge plan of care was included in the summary or found in the record. During an interview on 6/14/18 at 9:57 a.m., staff member I stated she was responsible to complete the post-discharge plan of care, and none was completed for resident #96. She stated the receiving facility completed a care plan on admission. Staff member I stated there was no reconciliation of medication completed. She said a medication list was not provided to the resident, but one was given to the receiving facility. Staff member I stated she did not know why these required elements of the discharge were not done.",2020-09-01
864,MONTANA VETERANS HOME N H,275100,400 VETERANS DR,COLUMBIA FALLS,MT,59912,2018-06-14,684,D,0,1,B8CU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement the use of compression stockings for 1 (#65) of 23 sampled residents. Findings include: 1. During an observation and interview on 6/11/18 at 3:32 p.m., [MEDICAL CONDITION] was noted to resident #65's lower extremities. Both legs were weeping. There was Allevyn adhesive dressing on each leg. Resident #65 stated he had [MEDICAL CONDITION], and his legs wept. He stated he had open wounds to his legs at times. Wet spots were noted on the sheet under resident #65's legs. No [MEDICATION NAME] elastic compression bandages or compression stockings were in use. Review of resident #65's physician's orders [REDACTED]. During an observation on 6/12/18 at 2:55 p.m., resident #65 was sitting in his wheelchair. He was not wearing [MEDICATION NAME] elastic compression bandages or any type of compression stockings. During an observation on 6/13/18 at 5:35 p.m., resident #65 was not wearing [MEDICATION NAME] elastic compression bandages or any type of compression stockings. During an observation and interview on 6/14/18 at 8:34 a.m., resident #65 stated he had not been wearing [MEDICATION NAME] elastic compression bandages or any type of compression stockings for over a week. He picked up the [MEDICATION NAME] from a pile of items stacked next to his bed. He stated no one had asked him about wearing them or offered to assist him. Resident #65 stated he could not put them on himself, and that he must have help. He stated he would wear them if someone told him he should, and helped him put them on. Resident #65 stated he knew he should wear them but no one offered to put them on. He stated he was off the radar. Resident #65 said he meant that he was expected to do things for himself, and that help was not offered. Review of resident #65's care plan showed a focus area for skin. The problem statement showed the resident was at very high risk for further vascular wounds due to [MEDICAL CONDITION]. An intervention, dated 12/20/17, showed [MEDICATION NAME]. The care plan did not show when [MEDICATION NAME] was to be applied, where [MEDICATION NAME] was to be applied, or how often. The care plan did not show if the [MEDICATION NAME] was being used for compression (to treat [MEDICAL CONDITION]), or to secure a dressing. During an interview and record reviewed on 6/14/18 at 10:04 a.m., staff member I reviewed resident #65's care plan, and stated the care plan should show more information regarding the [MEDICATION NAME] elastic compression bandages, such as when, where, and why to apply. During an interview on 6/14/18 at 10:47 a.m., staff member H stated [MEDICATION NAME] was applied by the nurse if it was part of a dressing change. She said resident #65's dressings were changed by the night shift nurse. Staff member H then said, The aide must put those on. During an interview on 6/14/18 at 10:52 a.m., staff member N stated nurses usually put on the [MEDICATION NAME] stockings. She said she had never applied the [MEDICATION NAME] for resident #65, and had not applied them that day, but she thought he was wearing them. During an observation on 6/14/18 at 11:00 a.m., resident #65 was seated in his wheelchair. He was wearing socks, but was not wearing the [MEDICATION NAME]. Review of the (MONTH) (YEAR) TAR showed an order for [REDACTED]. During an interview on 6/14/18 at 11:40 a.m., staff member H stated the criteria for signing off, on the TAR, that a treatment was completed, was trust. She further stated, Trust and verify. She stated the TAR should be signed off and then the resident should be checked to be sure the task was done. Staff member H stated the [MEDICATION NAME] treatment was signed off as done, when it was not done, was due to lack of follow-through and communication. During an interview on 6/14/18 at 11:48 a.m., staff member B stated the [MEDICATION NAME] did not provide adequate compression to treat resident #65's [MEDICAL CONDITION], but they were ordered to treat his [MEDICAL CONDITION]. She stated staff should offer to apply the [MEDICATION NAME] as ordered and document if refused by the resident.",2020-09-01
865,MONTANA VETERANS HOME N H,275100,400 VETERANS DR,COLUMBIA FALLS,MT,59912,2018-06-14,695,D,0,1,B8CU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to clean a [MEDICAL CONDITION]/[MEDICAL CONDITION] device according to the manufacturer's guidelines for 1 (#65) of 23 sampled residents, which could increase the resident's risk for respiratory infection. Findings include: During an interview and observation on 6/11/18 at 3:33 p.m., there was a [MEDICAL CONDITION]/[MEDICAL CONDITION] device noted on resident #65's bedside stand. Resident #65 stated the facility had issued the device to him. He stated he cleaned the tubing, mask, and device himself about every two weeks, or less. He stated the mask and tubing did not get wiped daily. Resident #65 stated the staff have never cleaned the device or the mask and tubing. He stated the tubing and mask have never been replaced. Review of resident #65's physician's orders [REDACTED]. During an interview and record review on 6/13/18 at 5:25 p.m., staff member F stated the use of the [MEDICAL CONDITION]/[MEDICAL CONDITION] was not on the (MONTH) (YEAR) MAR indicated [REDACTED]. She asked staff member J if resident #65 was using his [MEDICAL CONDITION]/ [MEDICAL CONDITION], and staff member J stated he used it regularly. Staff member F stated it should be on the CNA daily worksheet. Review of a document titled, CNA Care Plan Sheet, showed a designated row with information regarding the care of resident #65. The form did not show the use of a [MEDICAL CONDITION] or [MEDICAL CONDITION], or instructions for cleaning the device. Staff member J stated she did not know where cleaning of a [MEDICAL CONDITION]/[MEDICAL CONDITION] device was documented. She stated the cleaning of the device was done by the night shift staff. Staff member F stated the device should be cleaned by the day shift after the device was removed, and should be cleaned according to the manufacturer's instructions. She stated a review of resident #65's care plan did not show use of the [MEDICAL CONDITION]/[MEDICAL CONDITION], or the need for routine cleaning. The facility later provided a copy of resident #65's TAR which showed, under the heading, Unscheduled Other Orders, Please encourage resident to use [MEDICAL CONDITION] with sleep once his facial sore completely heals - FYI. The TAR did not show instructions for cleaning or an area to sign for completion of the cleaning. During an interview on 6/14/18 at 11:36 a.m., resident #65 stated he has not used the device consistently for weeks, due to a wound on his face. He stated he did use it occasionally for brief periods when he was short of breath, and he would infrequently fall asleep and leave it on all night. Review of the manufacturer's instructions for cleaning, provided by the facility, showed the following: - Unplug the device, and wipe the outside of the device with a cloth slightly dampened with water and a mild detergent. - Hand wash the tubing and mask adaptor before first use and daily in a solution of warm water and liquid dish soap. Rinse thoroughly. Directions for cleaning the mask were requested but not provided by the facility. A written request was made on 6/13/18, for a policy regarding [MEDICAL CONDITION]/[MEDICAL CONDITION] cleaning. Review of a facility policy titled, [MEDICAL CONDITION] Equipment Care and Maintenance, provided by the facility, showed the cleaning protocol of the manufacturer would be followed, if available. The policy showed a cleaning schedule for various components of the device, mask, and tubing, to be used when the manufacturer's instructions were not available. The mask was on the list for daily cleaning. The tubing was on the list for weekly cleaning. Evidence of the cleaning of the mask, tubing, and device was not provided. During an interview and record review on 6/14/18 at 10:04 a.m., staff member I reviewed resident #65's care plan, and stated the use of a [MEDICAL CONDITION]/[MEDICAL CONDITION] was not on the resident's care plan, and it should be. She stated the care plan should show if the device was not being used.",2020-09-01
866,MONTANA VETERANS HOME N H,275100,400 VETERANS DR,COLUMBIA FALLS,MT,59912,2018-06-14,756,E,0,1,B8CU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the pharmacist was monitoring residents receiving PRN [MEDICAL CONDITION] medications in excessive duration for 6 (#s 19, 22, 52, 73, 78, and 80) of 29 sampled and supplemental residents. Findings include: 1. a. Review of resident #19's Medication Administration Record, [REDACTED]. This was an active prescription written on 12/19/17. b. Review of resident #22's current Order Summary Report, dated 5/25/18, showed [MEDICATION NAME] 0.5 mg by mouth as needed for anxiety every six hours PRN. This was an active prescription written on 5/17/17. c. Review of resident #52's current Order Summary Report, dated 5/25/18, showed [MEDICATION NAME] 1 mg by mouth as needed for agitation/anxiety PO/IM every six hours PRN. This was an active prescription written on 4/21/18. d. Review of resident #73's Medication Administration Record, [REDACTED]. This was an active prescription written on 3/1/18. e. Review of resident #78's Medication Administration Record, [REDACTED]. This was an active prescription written on 7/28/16. f. Review of resident #80's current Order Summary Report, dated 5/25/18, showed [MEDICATION NAME] 0.5 mg by mouth as needed for agitation TID PRN. This was an active prescription written on 5/8/18. Review of the facility's Medication Regimen Review, from 6/1/18 to 6/7/18, showed a lack of monitoring for PRN [MEDICAL CONDITION] medications. - #19 No problems noted, - #22 No problems noted, - #52 No problems noted, - #73 No problems noted, - #78 No problems noted, - #80 No problems noted. During an interview on 6/14/18 at 8:03 a.m., staff member [NAME] said she did not review PRN [MEDICAL CONDITION] medications for the 14-day time limit when she did the Drug Regimen Review. She said she was under the impression the director of nursing was reviewing and tracking them.",2020-09-01
867,MONTANA VETERANS HOME N H,275100,400 VETERANS DR,COLUMBIA FALLS,MT,59912,2018-06-14,758,E,0,1,B8CU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure PRN [MEDICAL CONDITION] medications were limited to 14 days, and failed to ensure monitoring for adverse drug reactions and efficacy of [MEDICAL CONDITION] medications were completed for 9 (16, 19, 22, 28, 41, 52, 73, 78, and 80) of 29 sampled and supplemental residents. Findings include: 1. a. Review of resident #16's current Order Summary Report, dated 5/25/18, showed the resident was to receive [MEDICATION NAME] 0.5 mg by mouth as needed for anxiety every four hours PRN. This was an active prescription written on 11/2/17 with no expiration date. Review of resident #16's record contained no monitoring for adverse drug reactions or efficacy for [MEDICAL CONDITION] medications the resident had received. b. Review of resident #19's Medication Administration Record, [REDACTED]. This was an active prescription written on 12/19/17 with no expiration date. Review of resident #19's record contained no monitoring for adverse drug reactions or efficacy for [MEDICAL CONDITION] medications the resident had received. c. Review of resident #22's current Order Summary Report, dated 5/25/18, showed the resident was to receive [MEDICATION NAME] 0.5 mg by mouth as needed for anxiety every six hours PRN. This was an active prescription written on 5/17/17 with no expiration date. Review of resident #22's record contained no monitoring for adverse drug reactions or efficacy for [MEDICAL CONDITION] medications the resident had received. d. Review of resident #52's current Order Summary Report, dated 5/25/18, showed the resident was to receive [MEDICATION NAME] 1 mg by mouth as needed for agitation/anxiety PO/IM every six hours PRN. This was an active prescription written on 4/21/18 with no expiration date. Review of resident #52's record contained no monitoring for adverse drug reactions or efficacy for [MEDICAL CONDITION] medications the resident had received. e. Review of resident #73's Medication Administration Record, [REDACTED]. This was an active prescription written on 3/1/18 with no expiration date. Review of resident #73's record contained no monitoring for adverse drug reactions or efficacy for [MEDICAL CONDITION] medications the resident had received. f. Review of resident #78's Medication Administration Record, [REDACTED]. This was an active prescription written on 7/28/16 with no expiration date. Review of resident #78's record contained no monitoring for adverse drug reactions or efficacy for [MEDICAL CONDITION] medications the resident had received. g. Review of resident #80's current order summary report, dated 5/25/18, showed the resident was to receive [MEDICATION NAME] 0.5 mg by mouth as needed for agitation TID PRN. This was an active prescription written on 5/8/18 with no expiration date. Review of resident #80's record contained no monitoring for adverse drug reactions or efficacy for [MEDICAL CONDITION] medications the resident had received. During an interview on 6/14/18 at 11:00 a.m., staff members F and G said they were not aware of the 14-day limit for PRN [MEDICAL CONDITION] medications. During an interview on 6/14/18 at 11:00 a.m., staff member F said the facility was not monitoring for the adverse reactions and efficacies of [MEDICAL CONDITION] medications, routine or PRN. 2. a. Review of resident #28's Order Summary Report, dated 5/25/18, showed the resident was to receive [MEDICATION NAME] Tablet 0.5 mg by mouth as needed for anxiety SL/IM (sic) or Q1-2H PRN - Quantity: 30 Refill: 5. This was an active prescription written on 4/4/18 with no end date. b. Review of resident #41's order summary report, dated 5/25/18, showed the resident was to receive [MEDICATION NAME] Tablet 0.5 MG ([MEDICATION NAME]) Give 0.5 mg by mouth as needed for Anxiety PO, SL or IM (sic) Q4H PRN - Quantity: 30 Refill: 5. This was an active prescription written on 10/12/16 with no end date. During an interview on 6/13/18 at 9:48 a.m., staff member K stated she was not aware of the 14 day limit on [MEDICAL CONDITION] medications. During an interview on 6/14/18 at 11:50 a.m., staff member B stated she believed the 14 day limit was only on antipsychotic medications and not on [MEDICAL CONDITION] medications so they had not been following 14 day limit for [MEDICAL CONDITION] medications.",2020-09-01
868,MONTANA VETERANS HOME N H,275100,400 VETERANS DR,COLUMBIA FALLS,MT,59912,2018-06-14,842,D,0,1,B8CU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to keep a complete medical record for 1 (#61) of 23 sampled residents. Findings include: During an interview on 6/13/18 at 10:04 a.m., staff member K stated resident #61 currently had a suprapubic catheter, and had one for a couple of months. Review of resident #61's records did not show an order for [REDACTED]. During an interview on 6/14/18 at 12:21 p.m., staff member M stated all my residents that have a catheter are shown on the Order Summary Report. I have never seen one that does not and I think it would be important to have that on the order summary when reviewing the Order Summary Report.",2020-09-01
869,MONTANA VETERANS HOME N H,275100,400 VETERANS DR,COLUMBIA FALLS,MT,59912,2019-08-08,583,E,0,1,0QGC11,"Based on observation, interview, and record review, the facility staff failed to protect residents' protected health information (PHI) for 16 (#s 6, 7, 13, 23, 25, 26, 30, 41, 45, 51, 68, 70, 76, 78, 82, and 84) of 41 sampled and supplemental residents, which had the potential to affect all residents in the facility. Findings include: 1. During an observation on 8/7/19 at 2:56 p.m., a clear plastic bucket was placed under the desk at the nursing station in the SCU, which contained PHI information for residents 6, 7, 13, 23, 25, 26, 30, 41, 45, 51, 68, 70, 78, 82, and 84. There were forms titled SCU Report SHEET and faxes to physician offices. During an observation on 8/8/19 at 9:58 a.m., the clear plastic bucket and PHI for residents 6, 7, 13, 23, 25, 26, 30, 41, 45, 51, 68, 70, 78, 82, and 84 paperwork remained under the desk at the nursing station in the SCU. A paper that documented FULL CODE status for residents, dated 6/27/19, was displayed on the cork board at the nurse's station in the SCU. All facility residents were listed by wing: there were three residents listed for the east wing, seven residents listed for the west wing, and one resident listed for the SCU. There was a list hanging at the SCU nurse's station, dated 7/30/19, which included fifteen resident names and their birthdays. During an interview on 8/7/19 at 2:56 p.m., staff member A stated the clear plastic bucket under the desk at the nurse's station was the shred bin. She stated she thought staff emptied it at night but was not sure. A request was made on 8/7/19 at 3:15 p.m., for a policy/procedure for shredding of residents PHI. No information was provided by the facility at exit. During an observation on 8/7/19 at 10:45 a.m., a pile of paper documents containing patient information and medical details was observed face side up in an open plastic box. The box was on the floor next to the garbage can, under the desk at the 500 hall nurses' station. The box was approximately one-third full of papers. During an interview on 8/7/19 at 10:48 a.m., staff member L stated papers to shred are disposed of in the open box, on the floor beside the garbage can, under the desk at the 500 hall nurses' station. During an observation on 8/7/19 at 3:46 p.m., a cardboard box with an open top was observed on the floor, under the left side of the desk at the 400 hall nurses' station. The box was approximately one-third full of paper documents containing patient information and medical details. During an interview on 8/7/19 at 3:48 p.m., staff member B stated the shred box under the desk at the 400 hall nurses' station was emptied by the mail room, where there was a large shredder. During an observation on 8/8/19 at 8:05 a.m., a pile of paper documents containing confidential patient information and medical details was observed face side up in an open plastic box. The box was on the floor next to the garbage can, under the desk at the 500 hall nurses' station. The box was approximately one-third full. Documents belonging to resident #76 were on top of the papers in the box and included: an admission record face sheet (containing resident name, address, SSN, birthday, contact details, diagnosis), Medicare identification card, and MAR. During an observation on 8/8/19 at 8:08 a.m., a cardboard box with an open top was observed on the floor under the left side of the desk at the 400 hall nurses' station. The box was approximately one-third full of documents face side up that contained resident and medical information. During an interview on 8/8/19 at 8:09 a.m., staff member M stated she puts papers with resident information that need to be disposed of into the shred box at the nurses' station. She stated she did not know how often the boxes were emptied at the nurses' stations, but the shred gets collected at the big shredder in the mail room and disposed of.",2020-09-01
870,MONTANA VETERANS HOME N H,275100,400 VETERANS DR,COLUMBIA FALLS,MT,59912,2019-08-08,609,D,0,1,0QGC11,"Based on interview and record review, the facility failed to report an incident within 24 hours to the State Survey Agency; and failed to report the results of the facility's investigation following the incident to the State Survey Agency within five working days for 1 (#293) of 32 sampled residents, which had the potential to affect all resident reports of abuse and/or neglect. Findings include: Review of the facility's report of the incident for resident #293 showed the incident occurred on 7/15/18 and 7/16/18. According to the incident report, the facility contacted the State Survey Agency and submitted their report on 7/25/18. The results of the facility's investigation were not included in the 7/25/18 report. During an interview on 8/7/19 at 2:55 p.m., staff member B confirmed she was aware of the allotted time frames for reporting incidents and stated the facility did not report the incident or investigation to the State Survey Agency within five working days.",2020-09-01
871,MONTANA VETERANS HOME N H,275100,400 VETERANS DR,COLUMBIA FALLS,MT,59912,2019-08-08,610,D,0,1,0QGC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide documentation to show that they had completed a thorough investigation for 1 (#293) of 32 sampled residents; and failed to report the results of their investigation to the State Survey Agency within five working days, which had the potential to affect all resident reports of abuse and/or neglect. Findings include: Review of the facility's report of the incident regarding resident #293 showed the incident occurred on 7/15/18 and 7/16/18. According to the incident report, the facility contacted the State Survey Agency and submitted their report on 7/25/18. The results of the facility's investigation were not included in the 7/25/18 report. During an interview on 8/7/19 at 10:04 a.m., staff member B stated she did not have documentation from staff about resident #293 bringing a suspicious object into the building. Staff member B stated there were no progress notes for resident #293 between the time he brought the item into the facility on [DATE], and when the facility started their investigation the morning of 7/16/18. During an interview on 8/8/19 at 11:17 a.m., staff member I stated she had interviewed both staff member H, who had been present when resident #293 brought an item wrapped in a towel into the facility, and staff member J to whom staff member H reported the incident. Staff member I stated she did not request written statements from staff member H or [NAME] Staff member I stated she did not take notes on either interview. Staff member I stated she understood the importance of documenting interviews and that the facility has started documenting their investigations more thoroughly since the 7/15/18 incident. Staff member I stated they had no other documentation to show the facility had completed a thorough investigation of the incident.",2020-09-01
872,MONTANA VETERANS HOME N H,275100,400 VETERANS DR,COLUMBIA FALLS,MT,59912,2019-08-08,689,D,0,1,0QGC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident at risk for elopement was supervised, placing the resident at further risk for elopement for 1(#81) of 32 sampled residents, which has the potential to affect all residents who are an elopement risk; and failed to maintain a safe environment for all residents by allowing 1(#293) access to his vehicle, in which a .454 caliber handgun, ammunition, and a hatchet were stored; and failed to investigate an item that 1(#293) of 32 sampled residents had brought into the facility immediately upon entry, which had the potential to affect all residents in the facility. Findings include: Incident and Resident Background Review of the facility's incident report, which was submitted to the State Survey Agency on 7/25/18 showed: 07/16/2018 - I received a voicemail from (staff member J) working yesterday afternoon. She reported that (resident #293) went to his truck which is parked in our lot to sit in it. (Staff member J) said when (resident #293) returned he had an item wrapped in a towel and would not show or disclose to (staff member J) what he had brought back into the facility. This morning (staff member G) went and spoke with (resident #293) who voiced suicidal thoughts. (Staff member G) then asked to speak with myself and staff member C. Due to all concerns myself, staff member C and male nurse went to search (resident #293's) nursing room. We did find a 454-revolver unloaded wrapped in a towel in a wash basin next to (resident #293's) recliner. There was no ammunition found in the room. (Resident #293) was present the entire room search and resistant to offer any information when asked about the hand gun. (Resident #293) gave permission for us to search his truck. I called the (local) police department to come in and take the hand gun into their possession due to (resident #293) has no emergency contact, no next of kin, no power of attorney and no guardian. Detective (detective's last name) came to the facility and did speak briefly with (resident #293) and got (resident #293's) truck keys. Detective (detective's last name) and I searched the truck and found the ammunition and a hatchet. The officer took the gun and ammunition and the hatchet is locked in our facility safe. I then called the Mental Health Professional hotline and spoke with (staff member) who spoke with the psychiatrist on call (staff member) who said to send (resident #293) to the ER for an (sic) mental health evaluation. The floor RN told (resident #293) that he would be going to the ER and (resident #293) said he would not be going and proceeded to walk to the back of the building. I called Detective (detective's last name) back and he returned to the facility and assisted in getting (resident #293) into the ambulance to the ER. (Resident #293) was seen in the ER and transferred on an emergency status hold to (a different facility). I have spoke (sic) with the (facility's) social worker and with (resident #293). (Resident #293) does not wish to return to our facility. I have talked with (State Survey Agency supervisor) from QAD about this and she has advised me to report this due to the potentials that could have happened. The incident report was written by staff member B. During an interview on 8/6/19 at 3:25 p.m., staff member B stated she had received a voicemail on 7/16/18 from staff member J, which was left on 7/15/18. Staff member B stated the voicemail explained resident #293 had brought an unidentified object wrapped in a towel into the facility and the resident would not show staff its contents. Staff member B stated facility staff initiated an investigation as soon as she received the voicemail on the morning of 7/16/18. Staff member B stated she had performed a room search and found a .454 caliber handgun wrapped in a towel. During an interview on 8/6/19 at 3:30 p.m., regarding resident #293's mental health, staff member B stated resident #293 did not have regular mental health assessments done; only every 90 days when completing the BIMS assessment. Staff member B stated after resident #293's wife passed away, he would often tell staff member B that he just wanted to fall over. Staff member B explained resident #293 had moved from the domiciliary to the nursing home due to a decline in his physical health and ability to care for himself. During an interview on 8/7/19 at 10:02 a.m., staff member B stated resident #293 had moved from the domiciliary to skilled nursing care on 2/16/18. Staff member B stated resident #293 was just a very difficult person in that he did not have anyone else; no family or PO[NAME] During an interview on 8/7/19 at 10:41 a.m., staff member I stated resident #293 had a [DIAGNOSES REDACTED]. Staff member I explained resident #293 was a very closed person and tended to be verbally mean and aggressive towards others, but not physically. During an interview on 8/7/19 at 10:54 a.m., staff member G stated resident #293 was first admitted to the domiciliary unit in 2010 from an out-of-state facility. Staff member G stated resident #293 tended to refuse medications, procedures, and treatments throughout his stay. Staff member G stated in (MONTH) of (YEAR), resident #293 had seemed more cheerful than usual, but in (MONTH) of (YEAR) he had had an acute status change and was diagnosed with [REDACTED]. An ultrasound had revealed a mass in his liver, and he was placed on comfort care. Staff member G stated, during resident #293's hospital stay, it was determined resident #293 was not competent to make decisions regarding his medical care. Staff member G stated when resident #293 returned to the facility from his stay in the hospital, he continued to refuse mental health exams and BIMS assessments, but this was a pattern with him. Review of resident #293's BIMS showed he had refused to participate in the assessment on 2/20/18 and 5/18/18; however, a BIMS was completed on 5/2/18, and he scored 6/15, indicating a severe cognitive impairment. Resident #293's care plan, dated 5/4/18, showed resident #293 has a dx of dementia .(and) impaired short term memory. Review of resident #293's Social Service Assessment with dates 2/20/18, 5/2/18, and 5/18/18 indicated resident #293 used foul language in daily conversation, was physically or verbally threatening with staff/residents, and exhibited avoidance of staff and/or residents. The assessment also showed resident #293 was isolating daily or consistently; and was observed making negative statements and withdrawing from activities. Resident's Access to Vehicle During an interview on 8/6/19 at 4:05 p.m., staff member O stated residents can have a vehicle on the facility's grounds only if they live in the domiciliary. If a resident were to move from the domiciliary to the skilled nursing facility, the vehicle must be removed from the facility's grounds. During an interview on 8/7/19 at 9:45 a.m., staff member B stated resident #293 still had his vehicle on the facility's property after moving from the domiciliary on 2/6/18. Staff member B stated the facility's policy states nursing home residents are not allowed vehicles on the property. Staff member B also stated resident #293 had the keys to his vehicle throughout his stay in the nursing home. Staff member B stated she thought resident #293 was unable to drive the vehicle because it was an old pick-up. Staff member B stated the interdisciplinary team did not determine whether resident #293 was capable of driving; it was just known when folks are in nursing they cannot drive. Staff member B was unsure if there were any interdisciplinary team notes that provided evidence of an assessment of resident #293 regarding whether he was able to leave his vehicle on the facility's grounds upon moving to the nursing home due to extenuating circumstances (i.e. lack of a guardian, relative, or POA). During an interview on 8/7/19 at 9:55 a.m., staff member B stated residents do not have to check-out with staff prior to leaving the facility if the residents stay on facility grounds. Staff member B stated the facility sits on 130 acres of property. Staff member B could not provide an answer when asked how staff monitor residents' comings and goings when they leave the building itself and stay on the facility's 130 acres of property. Review of the facility's policy titled, Rules - General Residents, revised 6/4/18 and 4/16/19, showed, Nursing home residents will not be permitted to have a motorized vehicle on the grounds .Domiciliary residents may have a vehicle on grounds .The interdisciplinary care planning team may, in conjunction with the Medical Director, determine a resident's ability to drive a vehicle. Day of Incident During an interview on 8/6/19 at 3:53 p.m., staff member C stated the facility's policy prohibited weapons in the facility. Staff member C stated the facility began an investigation as soon as staff member B received the voicemail, and we did not know the gun was there until we found it. Staff member C stated the facility did not assume it was a weapon at first; it was only until staff member G assessed resident #293 and informed the appropriate staff that resident #293 was experiencing suicidal ideation that staff began the room search. During an interview on 8/6/19 at 4:54 p.m., staff member J stated she worked on 7/15/18, the day the incident occurred, but she did not see resident #293 walk in the door with an object wrapped in a towel. Staff member J stated staff member H had observed resident #293 walk in the door with a concealed object. Staff member J explained resident #293's vehicle was in the parking lot; resident #293 did not drive it, but did have access to it. Staff member J stated staff member H had informed her resident #293 had brought something in that was wrapped in a towel. Staff member J stated she had left a voicemail for staff member B explaining staff member H's observation. During a follow-up interview on 8/7/19 at 2:34 p.m., staff member J explained she had observed resident #293 walk out of the facility with his walker. Staff member J stated she had asked him where he was going, and resident #293 responded, Leave me alone! Staff member J stated her .concern was, 'Oh, I hope he does not think he is driving.' Staff member J stated staff member H offered to keep an eye on resident #293 because he was not going anywhere, and that he just wanted to sit in his truck. Staff member J did not see staff member H come back into the facility with resident #293. Staff member H reported to staff member J that resident #293 had taken something in a white towel into his room. Staff member J went to look at it and saw that resident #293 had already put it in a cabinet. Staff member J did not unwrap the towel at that time since, residents are allowed to have their own personal items. Staff member J stated she was never concerned it was something harmful. She recommended social services check in with him the following day, 7/16/18. Staff member J stated she did not have a reason to search resident #293's room then, and she did not know that that was something staff could do. Staff member J stated she has since learned that staff can search residents' rooms if there is reasonable suspicion to do so. Staff member J stated if she had been concerned about the item in resident #293's posession, she would have contacted the supervisor on-call. During an interview on 8/7/19 at 10:54 a.m., regarding the incident on 7/15/18, staff member G stated staff alerted her that resident #293 had brought something in from his vehicle that was concealed. Upon assessing resident #293 on 7/16/18, resident #293 stated he had had a plan to kill himself with a gun, and that it would be a noble way to go, but then denied that he had a gun. Staff member G stated at that point, staff members B and C performed a room search and found the unloaded firearm. Staff member G stated the facility immediately scheduled a mental health professional evaluation but had difficulty convincing resident #293 to go to the emergency room . Staff member G stated resident #293 ran out of the facility but he was unable to get very far because he was too weak. Eventually, they were able to convince him to go to the emergency room with law enforcement. After resident #293 left with law enforcement, an officer searched his vehicle and found ammunition and a hatchet. During an interview on 8/7/19 at 1:50 p.m., staff member C stated staff member B would be the person to contact in situations such as the one that occurred on 7/15/18, and that it was acceptable to leave a voicemail because, we did not know (the item wrapped in the towel) was a gun until we found the gun .it could have been a huckleberry muffin. Staff member C stated, I'm not (staff member H or J) so I cannot say if (the item wrapped in a towel) was concerning. Staff member C stated if staff were to report an abuse or neglect allegation, they would contact the nursing supervisor or whomever was on-call. Depending on who was in the facility at the time, the nursing supervisor would then contact staff member C, if necessary. During an interview on 8/7/19 at 2:13 p.m., staff member C stated he thought if anyone had suspected it was a gun, things would have gone differently because there would have been more of a sense of urgency. During an interview on 8/7/19 at 2:56 p.m., staff member H stated she had walked out to resident #293's vehicle around lunchtime on 7/15/18, where resident #293 was sitting. Staff member H stated resident #293 handed her an object wrapped in a towel. When staff member H asked what was in the towel, resident #293 stated nothing you need to worry about. Staff member H stated she thought the object might be a gun because of its weight, but she could not be sure. After bringing the object into resident #293's room with him, staff member H stated she immediately reported her thoughts to staff member J, who told staff member H she would look into it. Staff member H stated the facility's policy is to report any concerns to the floor nurse, who will then report it to the shift supervisor. During an interview on 8/8/19 at 11:17 am, staff members B, C, and I all stated staff member H did not report she thought it was a gun at the time of the incident; however, the facility failed to provide written statements from staff members H and J during the investigation. Staff member I stated she personally interviewed staff members H and J, and from what staff member I gathered during her verbal interview with staff member H, staff member H had no idea what the concealed item was. Staff member I stated, why would you have a gun in a towel wrapped in your hands and give it back to the resident? .I know (staff member H) and she would not have done that if she had felt like it was a gun. She always has the resident's best interest in mind. The facility provided two policies titled, Rules - General Residents, one with a revision date of 4/16/19 and the other with a revision date of 6/4/18. Both policies showed, residents are prohibited from keeping any instruments designed to do bodily harm, including but not limited to a gun, knife, razor blade, stick other than a cane, and sharp scissors. The 6/4/18 version showed staff is authorized to inspect a resident's room .if there are signs of .materials that might be harmful to the health and welfare of the residents or others. The 4/16/19 version added, the inspection/search may also include the personal vehicle(s) of a resident that is kept on the facility grounds. Review of the facility's policy, titled, Suicide Prevention/Plan of Action, and not dated, showed, when a nursing home resident has a car on the premises, social services will have the keys to the vehicle, and when staff suspects a resident has a weapon or has suicidal ideation, staff will: report to the nurse; notify a supervisor; search the room with two staff members present; notify the resident; notify the resident's representative; call the police for assistance; notify the medical doctor on call; offer support to the resident; 1:1 supervision if needed or freqent checks; and report incident to State/Ombudsman as necessary. Staff member B had stated the document had been created on 8/2/18. 2. During an observation and interview on 8/7/19 at 8:29 a.m., resident #81 was in his wheelchair and ambulating independently to the dining room for breakfast. He was well groomed and interactive with staff. Staff member D stated resident #81 was able to transfer himself and would go to the smoke shack at 10:30 a.m. During an observation on 8/7/19 at 9:48 a.m., resident #81 was in the smoke shack sitting in his wheelchair. There were other residents sitting in the smoke shack with him waiting for a staff person to assist them. The smoking area was observed. The smoke shack was contained in a courtyard with the facility building on two sides and fencing that enclosed the rest of the area. On one side of the courtyard was a chain link fence with a chain link gate. The gate had a u-shaped closure and was not locked. On the gate was a red sign that showed ''gate must be closed at all times'', and a white sign that showed ''do not open emergency exit, maintenance use only, visitors staff and residents use other entrances. The gate led directly into the parking lot. Resident #81 was observed to have a wanderguard bracelet on his right wrist. The gate did not have a sensor to alert staff if resident #81went out of the gate and into the parking lot. Resident #81 was sitting in the smoke shack without staff supervision and had access to the unlocked gate. A staff member arrived at 10:00 a.m. to assist the residents in the smoking shack. Resident #81 ambulated independently back into the building when he had finished smoking. No staff were observed supervising resident #81 while he was outside of the building and out of range of the wanderguard system. During an interview on 8/7/19 at 10:00 a.m., staff member D stated resident #81 takes himself outside and waits for the smoke shack staff several times per day. She stated the gate was locked in the past. She stated she was not aware the gate was not locked. She stated when nursing staff and non-nursing staff heard the wanderguard alarm they let (resident #81's name) out, but they don't go out with him. During an interview on 8/7/19 at 10:32 a.m., with staff member [NAME] and F, staff member [NAME] stated several weeks ago, resident #81 was confused, went out the gate, and was found in the parking lot, so they locked the gate. Staff member F stated the life safety code surveyor had told the facility three weeks ago, the gate had to be unlocked because it was an emergency exit. Staff member F stated the lock was removed. Review of the facility Alleged Incident/Accident report, dated 7/12/19 at 2:40 p.m., showed, received a phone call from front office staff that (resident #81's name) was outside of the building by OLD MAIN (couple hundred feet from building) Staff escorted back to Nursing Unit. (Resident name) had been in smoke shack for 1400ish smoke. Unknown what time he left, but did not return to nursing unit. Intervention: (resident name) will be taken to/From smoke shack by staff. Review of resident #81s Annual MDS, with an ARD of 4/7/19, showed resident #81 was cognitively impaired, and independent with locomotion. Review of resident #81's MDS care plan showed a concern for elopement, dated 7/12/19, with interventions to assist resident #81 back from smoking, and wanderguard to wheelchair. Review of resident #81's Care Plan, with dates under the focus section of 1/19 and 6/10/19, showed a focus area SMOKIN[NAME] Interventions included supervision at the smoke shack. The focus area COGNITION showed a date of 7/11/19 at 5:25 p.m., assisted to smoke shack- (resident's name) went thru gate found by vehicle with an intervention of lock to gate by smoking area 7/11/19. Review of the facility policy and procedure titled Elopement showed .3. Start wanderguard monitoring program until individualized interventions for the resident can be care planned and implemented.",2020-09-01
873,MONTANA VETERANS HOME N H,275100,400 VETERANS DR,COLUMBIA FALLS,MT,59912,2019-08-08,925,F,0,1,0QGC11,"Based on observation and interview, the facility failed to maintain an effective pest control program to ensure the facility remained free of flies in the food preparation, service, and storage areas. This had the potential to affect all residents that ate food prepared in the facility kitchen. Findings include: During an observation on 8/5/19 at 1:54 p.m., four flies were observed flying in the air in the dishwashing room, outside the kitchen area. During an interview on 8/7/19 at 11:11 a.m., staff member K stated the facility has a contract with a pest control service company to spray for bugs, monitor for rodents, and also for any other special needs. During an observation and interview on 8/8/19 at 8:19 a.m., residents and staff were heard complaining about a fly bothering them in the 500 dining room. Staff member N stated she had only seen flies in the dining room that day, and staff were not allowed to smash the flies. During an observation on 8/8/19 at 9:56 a.m., a fly was observed flying in the area around the 500 hall nurses' station. During an observation and interview on 8/8/19 at 11:11 a.m., three flies were observed flying in the air in the dishwashing area. Clean glasses were noted to be stored upside down, stacked in racks in the area. During an observation on 8/8/19 at 11:13 a.m., one fly was observed flying in the air above the kitchen prep counter where 2 large pans of jello were being made. During an observation and interview on 8/8/19 at 11:14 a.m., staff member B stated the facility had placed a screen on the heat escape vent above the ovens in the kitchen, as a means to attempt to eliminate the flies coming into the kitchen. Staff member K stated the County Health Department had recommended that the facility address the fly situation with fly tape or bug zappers. One fly tape was observed hanging above the hand washing sink and toaster/bread stand area in the kitchen. Staff member K stated the VA won't allow a bug zapper in the facility, due to the possibility of a fly being partially zapped in the bug zapper and then flying out and dying, and landing on some food.",2020-09-01
874,VALLEY VIEW ESTATES HEALTH & REHABILITATION,275101,225 N 8TH ST,HAMILTON,MT,59840,2016-08-18,164,D,0,1,BECW11,"Based on observation, interview, and record review, the facility failed to protect personal and confidential information from public exposure for 1 (#13) of 14 sampled and supplemental residents. Findings include: During an observation on 8/16/16 at 8:58 a.m., residents #13 and #14 were seated in the dining room eating breakfast. Staff member D approached resident #13 and asked how the resident was settling in to the facility. Staff member D asked resident #13, How are your bowels working, pretty good? Staff member D spoke in a voice that could be heard 20 feet from the table where the residents were seated. During an interview on 8/17/16 at 11:15 a.m., resident #13 stated it was not the best time to be asked about her bowels, but if he has to know, I guess I'll tell him. During an interview on 8/17/16 at 10:35 a.m., resident #14 stated that discussing a residents bowel movements over breakfast was a poor subject. Resident #14 said I don't think it's a table subject. I can't remember anyone asking me such a private question in a public area. During an interview on 8/16/16 at 8:59 a.m., Staff member D stated he would usually talk with a resident in the privacy of their room. Review of Residents Rights and Responsibilities provided by the facility showed the residents have a right to privacy in accommodation, medical treatment, personal care and visits.",2020-09-01
875,VALLEY VIEW ESTATES HEALTH & REHABILITATION,275101,225 N 8TH ST,HAMILTON,MT,59840,2016-08-18,274,D,0,1,BECW11,"Based on record review and interview, the facility failed to complete a Significant Change MDS assessment for 1 (#3) of 12 sampled residents. The resident experienced a decline in condition , warranting the completion of a Significant Change MDS assessment. The findings include: Review of resident #3's most recent Annual MDS assessment, dated 7/4/16, with a most recent comparative Quarterly assessment, dated 4/7/16, showed more than two care area categories with marked decline. The areas included: Vision, Activities of Daily Living, Range of Motion, Bowel Continence, and Weight. - The Annual MDS assessment, dated 7/4/16, showed the resident was coded as having impaired vision. The Quarterly assessment, dated 4/7/16, showed the resident had adequate vision. - The Annual MDS assessment, dated 7/4/16, showed the resident's ADL self-performance required extensive assistance, and one person assistance with most mobility needs such as: bed mobility, transfers, dressing, and toilet use. The comparative Quarterly assessment, dated 4/7/16, showed for all categories previously mentioned, the resident's self-performance required only supervision and setup help only. - The Annual MDS assessment, dated 7/4/16, showed the resident had a functional limitation in range of motion, which affected the resident's upper and lower extremities bilaterally. The comparative Quarterly assessment, dated 4/7/16, showed no functional or bilateral limitation in range of motion. - The Annual MDS assessment, dated 7/4/16, showed the resident's bowel movements as incontinent. The comparative Quarterly assessment, dated 4/7/16, showed the resident was continent with bowel movements. -The Annual MDS assessment, dated 7/4/16, showed the resident weighed 126 lbs., the comparative Quarterly asessment, dated 4/7/16, showed the resident weighed 138 lbs. During an interview on 8/17/16 at 3:50 p.m., staff members A and [NAME] stated a significant change MDS would be initiated for a resident when two or more care areas have changed from the previous MDS assessment for that resident. A significant change MDS would be initiated immediately if a resident was placed on hospice care. The facility's Interdisciplinary Team discussed all of the resident's change in status at the weekly IDT meeting.",2020-09-01
876,VALLEY VIEW ESTATES HEALTH & REHABILITATION,275101,225 N 8TH ST,HAMILTON,MT,59840,2016-08-18,323,E,0,1,BECW11,"Based on observation, interview, and record review, the facility failed to provide a safe environment, free from potential accident hazards to residents and staff. Specifically, 3 (#'s 2, 7, and 8) out of 12 sampled residents had portable liquid oxygen tanks unsecured and unfastened to the backs of their wheelchair's. Findings Include: During an observation on 8/17/16 at 7:30 a.m., a portable oxygen tank with a single strap was discovered draped over the handles of a wheel chair in resident #7's bedroom. The tank was not secured to the wheel chair, was hanging dependently, and was not stored in an approved stand or holder. During an observation on 8/17/16 at 7:40 a.m., a portable oxygen tank with a single strap was discovered draped over the handles of a wheel chair in resident #2's bedroom. The tank was not secured to the wheel chair, was hanging dependently, and was not stored in an approved stand or holder. During an observation on 8/17/16 at 11:15 a.m., a portable oxygen tank with a single strap was discovered draped over the handles of a wheel chair in resident #7's bedroom. The tank was not secured to the wheel chair, was hanging dependently, and was not stored in an approved stand or holder. During an interview on 8/17/16 at 8:05 a.m., staff member N stated CNAs check the oxygen tanks each time they switch a resident from the wall concentrator to a portable concentrator. Staff member N showed the process of checking the tank's oxygen level by holding one side of the strap, and then placed the strap over the handles of the wheelchair in a dependent position. No securements or fasteners were used to hold the tank to the chair. During an interview on 8/17/16 at 11:20 a.m., staff member B stated there were no specifics taught to the direct care staff related to safety measures for portable oxygen tanks. Staff member B then spoke with staff member F, and discussed if safety precautions related to oxygen tanks was covered in training or orientation. Staff member F stated safety precuations for oxygen tanks was not covered in the training. During an interview on 8/17/16 at 11:25 a.m., staff member A stated she would order secured oxygen tank holders for oxygen dependent residents with portable oxygen tanks as soon as possible. A review of the facility's Oxygen Safety Policy and Procedure showed under General Guidelines that oxygen cylinders must be stored in racks with chains, sturdy portable carts and/or approved stands. The policy also showed oxygen cylinders may not be left free standing. They must be securely fastened at all times.",2020-09-01
877,VALLEY VIEW ESTATES HEALTH & REHABILITATION,275101,225 N 8TH ST,HAMILTON,MT,59840,2016-08-18,325,D,0,1,BECW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to recognize, assess and implement interventions in response to severe unplanned weight loss, for 2 months, for 2 (#'s 3 and 5) of 12 sampled residents. Findings include: 1. Review of Resident #5's Nutritional Recommendations, by staff member L, dated 12/15/15, reflected the residents weight was stable at 127 pounds. The recommendations were to continue with the care plan and nutrition interventions, cater to the resident's food preferences, try to maintain weight within IBW range of 117-143 pounds, and note that the resident was at risk for weight loss due to a [DIAGNOSES REDACTED]. A review of the resident's weights showed the weight was 123 lbs. on 1/22/16 and 108 lbs. on 1/29/16. This was a 12% weight loss in 7 days. The resident was reweighed on 1/30/16 at 108 lbs., and 2/1/16 at 110 lbs. A review of Resident's Clinical Notes, dated 1/29/16 at 3:06 p.m., showed There was a weight discrepancy this week. Resident was weighed with the Hoyer, 108.2 lbs. Will re-weigh resident for 5 days. Further review include: - 1/30/16 at 3:19 p.m., weight today is 108.2. - 2/2/16 at 3:24 p.m., Pt. weighed today. 110.9 lbs. - 2/4/16 at 10:08 a.m., Dietary, SS, LE, MDS, DON and daughter on phone for care conference. Dietary-weight stable, appetite maintain. - 2/9/16 at 8:40 a.m., Staff need to record properly and weigh weekly. - 2/18/16 at 1:17 p.m., reflected the resident's physician was in to see the resident, and no new orders were given. Review of the resident's Physician's Notes, completed by staff member S on 3/2/16 at 10:54 a.m., reflected the resident was being seen for a routine checkup, and no recent concerns from the nursing staff. The note showed the resident's weight was stable, and the resident's general appearance was normal, except chronically ill appearing. No height or weight was noted in the documentation. Review of Resident #5's Nutritional Assessment, completed by staff member L, dated 3/22/16 at 6:06 p.m., reflected the resident weighed 106 pounds on 3/18/16, and to place resident on weight monitoring. If the weight was valid, the staff should notify the physician and the PO[NAME] The resident's goal body weight was 117-143 pounds. The assessment noted the resident had a 5% or more weight loss in the last month or a 10% weight loss or more in the last 6 months that was not physician prescribed. Nutrition interventions and recommendations were to incorporate: -240cc of honey thick fluids 3 times a day at snack time -morning snacks and supplement for afternoon snack -extra fats 3 times a day -assist resident with meals -super cereal every morning -avoid high purine foods -check with doctor for Kemp's, or equivalent, supplement at medication pass Monitoring and evaluation for the interventions included: -labs as available -weigh the resident weekly -monitor intake supplements -monitor skin status -monitor intake for food and fluids -follow up quarterly or as needed Review of Resident #5's Nutritional Recommendations, completed by staff member L, and dated 3/22/16, reflected that the resident's weight was 106 pounds, the resident's weight was down 18% in 6 months, and 13% in 3 months, which was significant. The resident's weight was stable for the last month. The BMI was 17.1. Recommendations were to continue with the care plan and nutrition interventions, cater to the resident's food preferences, include super cereal every morning, place resident on weight monitoring, and if the weight was accurate notify the doctor and POA, provide assistance at meals to increase oral intake, and check with the doctor to see if the resident might benefit from Kemp's at medications pass due to weight loss and low BMI. A review of the resident's Clinical Notes showed: - 3/24/16 at 2:22 p.m., reflected the facility received an order for [REDACTED]. Review of Resident #5's Physician/Nurse Communication sheet, dated 3/24/16, reflected that the dietitian wanted a supplement for the resident due to a low BMI, resident's weight was stable at 106-107, the resident appears thin and contracted, and the resident may benefit from Kemp's at medication pass. The physician responded ok to Kemp's on 3/24/16. - 3/26/16 at 10:22 a.m., reflected the resident was up for meals, and her appetite was fair. The note stated the resident will eat what she wants, and does not allow staff to assist with meals. - 3/27/16 at 6:46 p.m., reflected the resident's appetite was poor but did drink most fluids that were offered. - 4/7/16 at 7:15 p.m., reflected the resident's physician was in to see the resident, and no new orders were given. - 4/8/16 at 11:01 a.m., reflected that the resident's weight was stable for one month, and the resident had significant weight loss for 3 and 6 months. Review of Resident #5's Physician Notes, completed by staff member S, and dated 4/19/16 at 9:20 a.m., reflected the resident's weight was 109 pounds, the resident was losing weight, and the resident had a general appearance that was normal except being chronically ill appearing, confused, and lashed out at everyone who attempted to help her. Review of the resident's Clinical IDT Note, dated 6/28/16 at 11:54 a.m., reflected the resident had a history of [REDACTED]. The resident's weight was down 17% in the last 6 months but had been stable for the last 3 months. Interventions in place for weight loss were health shakes, Kemp's, and a regular mechanical soft diet. Review of the resident's Clinical Notes, dated 8/11/16 at 10:00 a.m., reflected the resident was seen by the physician, and no new orders were given. Review of Resident #5's Care Plan reflected the resident had a history of [REDACTED]. The care plan reflected that the resident could be resistive with encouragement, and assist to increase her intake. The goal of this focus problem was to keep the resident's weight stable with no sign of dehydration over the next 90 days with a goal date of 9/20/16. During an interview on 8/16/16 at 12:52 p.m., staff member R stated resident #5 was on weekly weights. If a weight was off more than 2 pounds the resident was reweighed every week. Staff member R stated resident #5 was being weighed with the Hoyer lift and with the wheelchair, giving some discrepancy to the weights. The facility changed out their scales in (MONTH) around the time this resident lost weight. Staff member R stated all staff members were now weighing residents the same way. Staff member R stated when someone loses weight staff will implement health shakes or ensure, and request the doctor order a supplement or extra protein. Staff member R stated the care plans were updated as needed. Staff member R stated the supplement was ordered, for resident #5, in (MONTH) (YEAR) because the resident had stopped eating as much. During an interview on 8/16/16 at 2:35 p.m., staff member I stated the facility had no Nutritional Recommendation notes from (MONTH) and (MONTH) (YEAR). During an interview on 8/16/16 at 3:30 p.m., staff member L stated she would have to look at the chart to see if any interventions were completed for resident #5 from (MONTH) to (MONTH) (YEAR). Staff member L stated that the facility did change scales in (MONTH) (YEAR) but would look for more information on weight loss for resident #5. During an interview on 8/17/16 at 10:50 a.m., staff member L stated she had no other documentation for resident #5 for the weight change in January. Staff member L stated resident #5's weight was stable now. Staff member L stated the facility has an IDT meeting every week to discuss skin and weight, and she would attend the meeting every 2 weeks. Staff member L stated once staff were aware of a weight change they would review the resident, see what interventions were in place, and notify the doctor. Staff member L stated she would look at the diet order, foods the resident was accepting and preferences, review the nursing notes and oral intake, and update the care plan. If a resident was not accepting meals staff would offer a snack and shakes, and try to offer again at a later time when the resident may be more accepting. During an interview on 8/17/16 at 11:20 a.m., staff member I stated the facility completed a weekly weight report. If a weight was off by 3 pounds one way or the other, staff reweighed the resident. Every Tuesday the facility has a skin and weight meeting where they discussed the weights and interventions. The dietician wound attend the meeting every 2 weeks. Staff member I stated she provided the weight sheet to the dietician through her mailbox on weeks she was not coming to the skin and weight meeting. If there was a weight discrepancy the dietician would take the information and write a Nutrition Recommendation with suggested interventions. This process was done quarterly or as needed with any weight changes. Staff member I stated after receiving the Nutrition Recommendation staff would implement the suggested interventions. To monitor the interventions, for weight loss, the staff would record the resident's appetites, and if anyone ate less than 50% of the meal staff would offer something else. The facility offered 3 snacks a day for all residents. A review of the Weight Monitoring policy showed based on the resident's comprehensive assessment; the facility will ensure the resident maintains acceptable parameters of nutritional status, such as body weight, unless the resident's clinical condition demonstrates that this is not possible. The policy showed staff should inform the physician of a significant weight change, and may order nutritional interventions. The physician should be encouraged to document the [DIAGNOSES REDACTED]. Meal consumption information should be recorded, and may be referenced by the interdisciplinary care team as needed. The Registered Dietitian or Dietary Manager should be consulted to assist with interventions, and recorded in the nutrition progress notes. 2. Review of resident #3's Admission MDS, with an ARD of 7/23/15, showed the resident weighed 145 lbs. A Quarterly MDS, with an ARD of 4/7/16, showed the resident weighed 138 lbs., and an Annual MDS, with an ARD of 7/4/16, showed the resident weighed 126 lbs. Resident #3 had an avoidable significant weight loss of 8.7% of her body weight in the three month span from the Quarterly assessment to the Annual assessment. The Annual MDS, with an ARD of 7/4/16, identified the weight loss as greater than 5% and it was not physician prescribed, however the record reflected a lack of nutritional interventions to prevent further weight loss from occurring. During an observation and interview on 8/16/16 at 9:10 a.m., resident #3 was seated at a dining room table. Resident #3 was not eating breakfast which included a fried egg, biscuit, super cereal, with fiber fortified juice, and a cup of milk. Resident #3 stated she was worried about her husband, and didn't want to eat any of the food because it was cold. Staff member N then went to the table and offered to heat the bowl of super cereal for the resident. Staff member N stated You'll eat for him (the surveyor) but you won't eat for me. Staff member N brought back the bowl of super cereal after she had microwaved it, and the resident stated it was too hot to eat and pushed it away. During an observation and interview on 8/16/16 at 9:45 a.m., a dietary staff member took resident #3's meal tray away because resident #3 stated she was finished. Resident #3 did not eat her egg, biscuit, she only had a few bites of the super cereal (which was re-heated), drank 2 oz. of her 4 oz. fiber juice, and a few drinks of 2% milk. The resident consumed less than 10% of what was offered. Resident #3 stated she knew she had lost a lot of weight. No alternative meal choice or snack was offered when the resident's tray was removed. During an interview on 8/17/16 at 10:55 a.m., staff member L stated when resident #3 ate less than 50% of a meal an alternative meal choice or snack was supposed to be offered. Staff member L stated resident #3's weight was stable, and that she had an elevated BMI and did not want the resident to gain weight. Staff member L stated resident #3 had anxiety issues which caused her not to eat, and was the causitive factor of the resident's weight loss. A review of resident #3's Care Plan showed resident #3 may be at risk for weight loss, and had a problem with constipation. A care plan goal was established to maintain weight and hydration over the next 90 days with the goal date of 10/11/16. No Interventions listed on the weight loss care plan offered the resident supplemental nutritional support. The interventions on the care plan only identified the resident's diet as regular with textures as tolerated, (for staff to) offer and encourage a variety of fluids throughout the day to encourage good hydration, high fiber juice (in the) AM, (to) provide finger foods with meals, (and resident #3) needed a cup for hot cereal and soup. The care plan showed the resident was at risk for weight loss, but did not address the weight loss the resident was experiencing. A review of resident #3's ADL Verification Worksheet, from 6/1/16 - 8/16/16, showed the staff documented 213 meals, and resident #3 ate less than 50% for 64 of those meals. The ADL Verification Worksheet failed to show reasons the meals were not consumed, and if or what alternative meal choices or snacks were offered to the resident. A review of resident #3's Physician order [REDACTED]. The resident received medications to promote bowel motility and for [MEDICAL CONDITION]. A diet order, which began on 6/6/16, showed the resident on a regular diet with texture as tolerated. The resident could request one can of Ensure. There was not a record of super cereal being added to the resident's orders. A review of the facility's Nutrition Recommendations from the Registered Dietician showed: - (MONTH) 6, (YEAR): resident #3's weight was 135.6 lbs. The recommendations showed the resident's weight was stable, BMI was 31.5, to continue with care plan and nutrition interventions, cater to resident's food preferences, and to try and avoid weight gain. - (MONTH) 21, (YEAR): resident #3's weight was 122.6 lbs. The recommendations showed the resident's weight was down 9% x 6 months - significant, resident weight was down 9% x 3 months - significant, the resident's weight was down 10% x 1 month - significant, the resident's BMI was 28.4, the doctor would be faxed regarding the weight loss, diet order was regular, a can of Ensure could be offered, provide the resident with one can of Ensure daily, offer snacks TID, include super cereal every morning, and cater to the resident's food preferences. - (MONTH) 28, (YEAR): resident #3's weight was 126.2 lbs. The recommendations showed the resident's weight was down 6% x 1 month - significant, the resident's BMI was 29.3, the physician was notified regarding weight loss last week, (to) continue with care plan and nutrition interventions, cater to resident food preferences, and encourage oral food and fluid intake. The resident's record reflected a lack of evidence that nutrition recommendations were made in (MONTH) (YEAR) or by the date of the survey.",2020-09-01
878,VALLEY VIEW ESTATES HEALTH & REHABILITATION,275101,225 N 8TH ST,HAMILTON,MT,59840,2017-11-08,201,D,1,1,2DHO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to permit 1 (#2) of 10 sampled residents to remain in the facility. The facility failed to demonstrate that the transfer/discharge was necessary. Findings include: Resident #2 was admitted to the facility on [DATE], and the resident resided on the special care unit. Review of resident #2's Significant Change in Status MDS, with an ARD of 6/1/17, showed resident #2 had a BIMS score of 3, severely impaired. Review of resident #2's Quarterly MDS, with an ARD of 8/22/17, showed resident #2 had a BIMS score of 3, severely impaired. Review of resident #2's clinical notes, dated 9/11/17, showed the resident was sent to the ER after being seen by staff, sitting in his wheelchair, hitting a female resident who was on the floor in his room. The clinical notes showed staff member B told resident #2's daughter that he would not be permitted to return to the facility. During an interview on 11/6/17 at 1:10 p.m., NF2 stated she was aware of resident #2's behavior, regarding physical altercations, in the facility. She stated no one from the facility had told her the behavior of resident #2 could potentially lead to the resident being transferred or discharged from the facility. NF2 stated she was reassured on several occasions, after being notified of an altercation, the facility would manage resident #2's behavior. She stated other residents wandering into resident #2's room was what caused the resident to become upset and act out. She stated the facility put up a Velcro stop sign on resident #2's door, but she was not aware of other efforts to keep residents out of resident #2's room or his personal space. Review of resident #2's clinical notes dated 3/2/17-9/12/17, showed resident #2 had 11 physical altercations with other residents prior to 9/11/17. Review of events reported, by the facility, to the SA, during the same time period, showed the same altercations. The event reports showed resident #2, prior to 9/11/17, hitting, kicking, grabbing, pushing, and pulling on other residents. None of these events had resulted in the resident being transferred or discharged , except when resident #2 required medical treatment. During an interview on 11/6/17 at 5:36 p.m., staff member M stated the stop signs on the doorway of some of the rooms are attached with Velcro. She said the stop signs were documented on the resident's care plan and meant to keep the wandering residents out of his room. Staff member M stated resident #3 was a wanderer, and he did not understand verbal commands to leave a room, and staff needed to provide assistance. She said resident #3 would enter resident #2's room and he would escalate (become agitated) Staff member M stated the stop sign was not effective to keep resident #3 out of resident #2's room. She said the staff tried to redirect the residents away from each other, but she did not know of any other interventions. Staff member M stated over time,8 resident #2 became upset when he saw resident #3. She said resident #2 became angry and violent, but the staff could redirect him. During an interview on 11/7/17 at 4:35 p.m., NF3 stated there was no reason for resident #3 to be admitted to (local hospital) on 9/11/17. He stated the resident was admitted on ly because the facility refused to take him back when notified that he was ready for transport. NF3 stated the facility conveyed to the hospital that resident #2 had exhibited aggressive behaviors, and because of that report, 1:1 was provided to resident #2 throughout the 11-day hospital stay. He said resident #2 had no adverse behaviors during the hospitalization . During an interview on 11/7/17 at 5:24 p.m., staff member A stated prior to transferring the resident to the hospital on [DATE], there was no plan for the resident's discharge. She stated the plan was for the resident to remain in the facility. During this interview, staff member A stated she had discussed the possible need for transfer or discharge, of resident #2, with NF2 on one occasion. She stated the possible need was related to resident #2's aggressive behavior. Staff member A stated she did not know the date of this conversation, and would need to look for the documentation of the notification. Staff member B said she spoke to the physician on 9/11/17, and the physician was going to go to the hospital ER to facilitate having resident #2 admitted to the hospital. Staff member A stated the goal was for resident #2 to have a psychiatric evaluation. She stated a physician's orders [REDACTED]. Staff member A said the events of 9/11/17, led to a transfer when other events had not, because on 9/11/17, resident #2 was hitting. Staff member A stated the decision to refuse to accept the resident back into the facility was made after admission to the hospital. During an interview on 11/8/17 at 9:36 a.m., staff member L stated resident #2 did not exhibit agitated or aggressive behaviors when 1:1 was utilized, but it was done sporadically, not on a continuous basis. She said there were long periods when resident #2 was calm, but when resident #3 entered resident #2's room it was a trigger for agitation. Staff member L stated near the end of resident #2's stay, just seeing resident #3 in a common area sometimes caused aggression. She stated resident #2 had struck another resident at least once prior to 9/11/17. During an interview on 11/8/17 at 10:03 a.m., staff member J stated the facility IDT had discussed resident #2's behavior many times. He stated resident #2 was agitated by wandering residents coming into his room and would yell at them. Over time, resident #2 became more physically aggressive with the wandering residents. Staff member J said the interventions used were a doorway stop sign, pulling his privacy curtain, and staff observation. He stated the interventions were not always effective. Staff member J said the staff wanted to send resident #2 to (behavioral treatment facility) but the only way to do so was for a hospital to send the resident directly to the treatment facility. He stated he had contacted the behavioral treatment facility to inquire about placement for resident #2, and had been advised transfer directly from the nursing home was not an option. Staff member J stated the facility had developed a plan in conjunction with the physician, to have resident #2 admitted to the local hospital and refuse to accept him back. He said that to get resident #2 to the treatment facility, it would have to be a dump. Staff member J clarified the term dump as meaning refusing to accept the resident back from the hospital. He stated the physician had provided an order to facilitate the process about two weeks prior to resident #2 being sent to the ER. Staff member J stated the same process was used previously with a female resident, (name). He said after she was treated at a behavioral health facility, she was able to return to the nursing home. During the same interview, staff member J stated he was present on the special care unit on 9/11/17, and was monitoring the situation regarding resident #2. He stated a CNA had witnessed resident #2 hitting another resident (#3). Staff member J said he arrived on the unit shortly after the altercation, and the resident was being provided 1:1 monitoring and was calm. He stated law enforcement was called to the facility and interviewed resident #2, who calmly told the officer what had happened. Staff member J stated resident #2 had no altercations with staff or residents after resident #3 was removed from his room. He stated resident #2 was calm until staff prepared to transport him to the ER. Staff member J stated resident #2 began to exhibit agitation, but the law enforcement and EMS staff were able to perform the transfer and no further adverse behavior occurred. Staff member J said 1:1 was provided from the time the altercation was observed until the resident left the facility and there was no immediate danger to others during that time. He said resident #2 required transfer to theER on [DATE], because He was at the max point and was not going to come off this high. Staff member J clarified by saying resident #2 was becoming more easily agitated when resident #3 was nearby. He said the IDT had discussed moving resident #2 to another room, but had not done so. He said the IDT had discussed moving resident #2 off the secured unit but did not because he was a flight risk. He stated 1:1 was provided as a diversion and was effective. Staff member J stated he did not know why 1:1 was not provided on a consistent basis. He stated staff member A and resident #2's physician (facility medical director) made the decision that the resident would not be accepted back on 9/11/17 and he was advised of the decision that same day. He said the IDT reviewed the decision on Tuesday (9/12/17), but it was just confirming the decision made on 9/11/17. During an interview on 11/8/17 at 1:45 p.m., staff member A stated the facility had no documentation NF2 had been notified of the possible need for transfer. During an interview on 11/8/17 at 2:27 p.m., staff member C stated he was aware of prior altercations between residents #2 and #3. He said on one occasion he witnessed resident #3 in resident #2's room, and resident #2 was reaching out towards resident #3. Staff member C believed resident #2 would hit or grab resident #3 and he stepped between them and took resident #3 from the room. Staff member C stated he was aware of another event when resident #2 was sent to the hospital after an altercation with resident #3. The altercation occurred after resident #3 entered resident #2's room. He said there was discussion of not accepting the resident back to the facility. Staff member C stated it was near the time when an order was received to send resident #2 to the ER if he became aggressive. He said the understanding was that resident #2 would be sent out and not allowed to return. He said it was about two weeks from when the order was received until resident #2 was sent out to the ER. Staff member C stated there had been discussion of providing 1:1 for resident #2 or resident #3, but there was not enough staff to do it. Review of a document titled, Provider Communication Form, dated 4/3/17, showed the physician was notified of resident #2 being involved in two physical altercations when a female resident entered resident #2's room, twice, on 4/2/17. The document showed staff were trying to keep the residents apart and asked if the provider had any suggestions. The section titled, Provider response showed, Keep other residents out of room, and was signed by resident #2's physician. Review of resident #2's Care Plan Report, dated 3/2/17, showed an intervention to redirect other residents away form Resident #2's room. It did not show the need for 1:1 monitoring at all times, or during periods of agitation. Review of resident #2's electronic health record showed a physician's orders [REDACTED]. if resident becomes agitated/aggressive send to ER R/T being a danger to self/others (sic). Staff members C, J, L, and M stated, during the above referenced interviews, resident #2 was agitated by other resident entering his room, and 1:1 was shown to be an effective intervention, but was not added to resident #2's care plan and was not consistently provided. The facility failed to provide evidence of assessment of resident #2's behavior, consistent interventions, evaluation of the interventions, and adjustment of care plan to meet the resident's needs. This failure led to behaviors that put resident #2 and other residents at risk of injury, which caused the facility to transfer the resident to the ER and refuse to allow him to return.",2020-09-01
879,VALLEY VIEW ESTATES HEALTH & REHABILITATION,275101,225 N 8TH ST,HAMILTON,MT,59840,2017-11-08,202,D,1,1,2DHO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to include documentation, in the resident's medical record from a physician to show why a transfer or discharge was necessary for 1 (#2) of 10 sampled residents. Findings include: Review of resident #2's electronic health record showed a physician's orders [REDACTED]. if resident becomes agitated/aggressive send to ER R/T being a danger to self/ others (sic). Review of resident #2's clinical notes and events reported by the facility, to the SA, dated 3/2/17-9/12/17, showed resident #2 had 11 physical altercations with other residents prior to 9/11/17, and none of these events had resulted in the resident being transferred or discharged , except when resident #2 required medical treatment for [REDACTED]. Review of resident #2's (MONTH) (YEAR) and Sept (YEAR) clinical notes and care plan, dated 3/2/17-present, showed no evidence of new non-pharmacological interventions to manage the adverse behaviors that lead to discharge and showed no plan to discharge resident #2 to a behavioral treatment facility or other care setting. The most recent update to resident #2's care plan for behavioral interventions was on 7/17/17. The care plan showed staff were to remind the resident not to touch or attempt to hurt other residents. The care plan showed the resident would require multiple reminders due to dementia. The facility failed to recognize resident #2 was severely cognitively impaired as evidenced by initiating the intervention of cognitive reminders. Review of resident #2's physician's notes did not show documentation of why the transfer was necessary and or why the resident could not return to the facility.",2020-09-01
880,VALLEY VIEW ESTATES HEALTH & REHABILITATION,275101,225 N 8TH ST,HAMILTON,MT,59840,2017-11-08,203,D,1,1,2DHO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to provide the resident or responsible party with appropriate notice before the resident was transferred for 1 (#2) of 10 sampled residents. Findings include: Resident #2 was admitted to the facility on [DATE], and resided on the special care unit. Review of resident #2's electronic health record showed a physician's orders [REDACTED]. if resident becomes agitated/aggressive send to ER R/T being a danger to self/ others (sic). Review of resident #2's clinical notes and census information for (MONTH) (YEAR), in the electronic health record, showed the resident was transferred to a localER on [DATE], following a physical altercation with another resident (#3). The clinical notes for 9/11/17, showed NF2 was told that resident #2 would not be permitted to return to the facility. During an interview on 11/6/17 at 1:10 p.m., NF2 stated she was aware of resident #2's behavior in the facility. She stated no one from the facility had told her the behavior of resident #2 could potentially lead to the resident being transferred or discharged from the facility. NF2 stated she was reassured on several occasions, after being notified of an altercation, the facility would manage the resident's behavior. Review of resident #2's clinical notes and events reported, by the facility, to the SA, dated 3/2/17-9/12/17, showed resident #2 had 11 physical altercations with other residents prior to 9/11/17, and none of these events had resulted in the resident being transferred or discharged , except when resident #2 required medical treatment for [REDACTED]. During an interview on 11/7/17 at 5:24 p.m., staff member A, stated that prior to transferring the resident to the hospital on [DATE], there was no plan for discharge. She stated the plan was for the resident to remain in the facility. Staff member A stated she had discussed the possible need for transfer or discharge, of resident #2, with NF2. She stated the possible need was related to resident #2's aggressive behavior. Staff member A stated she did not know the date of this conversation, and would need to look for the documentation of the notification. During an interview on 11/8/17 at 1:45 p.m., staff member A stated the facility had no documentation NF2 had been notified of the possible need for transfer.",2020-09-01
881,VALLEY VIEW ESTATES HEALTH & REHABILITATION,275101,225 N 8TH ST,HAMILTON,MT,59840,2017-11-08,205,D,1,1,2DHO11,"> Based on interview and record review, the facility failed to provide a bed-hold notice to 1 (#2) of 10 sampled residents. Findings include: During an interview on 11/6/17 at 1:10 p.m., NF2 stated no bed-hold notice was provided in writing or explained to her verbally. She stated she was advised on 9/11/17, resident #2 would not be accepted back into the facility. Review of resident #2's electronic health record did not show evidence that a bed-hold notice was provided to the resident or the responsible party. No electronic copy was found within the record. Review of resident #2's clinical notes for 9/11/17, and following, showed no documentation that a bed-hold notice was provided. A clinical note, dated 9/11/17, showed NF2 was informed resident #2 would not be accepted back into the facility. Review of a facility policy titled, Transfer and Discharge, dated 2/5/15, showed, in Section 5. Notice of Bed-Hold Policy and Readmission: b. Before the facility transfers a resident to a hospital or allows a resident to go on therapeutic leave, the social service designee or other designated staff member should provide written information to the resident and a family member or legal representative of the bed-hold and admission policies. c. In cases of emergency transfers, the notice of the bed-hold policy should be provided to the resident or resident's representative within 24 hours of the transfer. This may be sent with other papers accompanying the resident to the hospital.",2020-09-01
882,VALLEY VIEW ESTATES HEALTH & REHABILITATION,275101,225 N 8TH ST,HAMILTON,MT,59840,2017-11-08,223,D,0,1,2DHO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent abuse for 1 (#3) of 10 sample residents when it did not intervene to prevent the resident from wandering into other resident rooms. Residents had previously responded with physical abuse towards resident #3 when she was encountered by them in their rooms. Findings showed: Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. Her room was on a secured unit for memory care residents. Review of resident # 3's most recent Quarterly MDS, with an ARD of 10/5/17, showed that the facility had been unable to interview the resident for the BIMS score. She experienced both short term and long term memory deficits. She was coded as having moderate depression, and experienced intermittent moods and behaviors. She was coded as ambulatory with the assist of one staff member, and supervision for both walking in her room and walking the facility corridors. She was also coded for daily wandering that included intrusion on others. During an observation on 10/7/17 at 3:30 p.m., resident #3 was seen wandering into other resident rooms across the hall from hers. She wandered into one room through the hall door and went through the bathroom to go into the next room. In each room, at each bed, she laid her upper body with her head on the pillow, and her feet on the floor, for about a minute. She would then get up and go to the next bed and do the same. When housekeeping staff appeared in the doorway she quickly left the room and went into the hall. Residents were not in the rooms she entered. No staff appeared to be supervising her. During an interview on 10/8/17 at 2:33 p.m., staff member C said resident #3 had a wandering problem and that she was always in and out of other residents' rooms. He stated that resident #3 and resident #2 had a history of [REDACTED].#3 wandered. He stated resident #3 could be difficult to divert at times. He said the facility had placed a stop sign on resident #2's room door to hinder #3 from entering, but resident #2 often removed the sign, or raised it high, and resident #3 would walk under it and into resident #2's room. He said the best thing that could have been done was to provide resident #3 with one to one supervision to prevent her from wandering. He said but of course that will never happen because the facility has never had enough staff to be able to provide one to one supervision for any length of time. During an interview on 10/7/17 at 4:00 p.m., staff member A said the staff put up stop signs across residents' doors and it usually worked to keep resident #3 from going into other resident rooms. The staff had also been offering snacks and playing music to divert resident #3 from wandering. She said that resident #2 would take his room's stop sign down or raise it up real high so resident #3 couldn't see it and she would wander into his room. She said that resident #2 and resident #3 had many altercations - too many. She said she had been concerned when resident #2 was still a resident in the facility that resident #3 could be hurt or injured during an altercation with resident #2. She did not mention any use of one to one supervision for either resident #2 or resident #3 as a means of protecting either resident from potential abuse. A review of resident #3's Clinical Notes showed the following, on the following dates: -7/10/17 Goes into other residents rooms and frequently will lay on or kneel down and have top half of her body on other's beds. -7/10/17 Observed to go into others rooms and get on there (sic) beds can be difficult to redirect at times. -7/18/17 Resident continues to wander during the day and evening. She does not speak, nor does she seem to comprehend when spoken to. She has some scratches to her left upper arm from being grabbed by another male resident. (The resident) seems unaware of the other residents' agitation at her being near his room. She easily breaks free of his grasp but later examination revealed some scratches. -7/24/17 Staff heard a male resident yelling from his room and entered to find (resident #3) lying on a bed in his room. Male resident was holding onto her right arm with both hands and trying to pull her off the bed. Removed (resident#3) from his room and redirected her to social room. Note (sic) several reddened areas at right elbow and lower arm, will monitor for bruising . -8/31/17 Resident was grabbed by both arms by male resident . -9/11/17 Resident was hit per a male resident. No injuries noted at this time. -9/14/17 Pacing halls and in and out of rooms all evening. A review of incident reports sent by the facility to the state provided further details surrounding the events concerning the preceding statement documentation. A review of incident reports, sent by the facility to the state agency, showed that resident #3 had been involved in 12 altercations from 1/11/17 to 10/21/17. In eight of the reported incidents, resident #3 had wandered by or into another resident's room. Seven of the incidents were altercations with resident #2. They occurred from 5/30/17 to 9/11/17. Of those seven incidents, resident #3 had wandered into resident #2's room, where the altercations occurred, five times. Two other altercations occurred as resident #3 wandered by resident #2's room. A review of a report sent to the State Agency, by the facility, on 9/14/17, substantiating abuse, showed: Based on investigation of 9/11/17, IDT believes (resident #3) to be a trigger for (resident #2). It was determined that resident #2 was intentionally attempting to injure resident #3. A review of a report sent to the State Agency, by the facility, on 9/14/17, showed on 9/11/17, resident #3 was hit by resident #2, and resident #2 was removed from the facility. The facility did not plan for resident #2 to be able to return to the facility. During an interview on 11/7/17 at 4:00 p.m., staff member A said, after resident #2 had left, the facility calmed down. She said resident #2 had triggered other residents to have anxiety over the drama he created during his altercations with resident #3. No evidence was found to show the facility intervened to prevent resident #3 from wandering either before, during, or after the altercation events substantiating abuse. Nothing was found in the resident's medical records to indicate that her wandering into other resident's room may have placed her in a position for potential abuse.",2020-09-01
883,VALLEY VIEW ESTATES HEALTH & REHABILITATION,275101,225 N 8TH ST,HAMILTON,MT,59840,2017-11-08,241,E,1,1,2DHO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and interview, the facility failed to maintain resident privacy from a wandering resident for 1 (#2) of 10 sampled residents; and failed to maintain dignity, due to not adequately grooming female residents' hair, for 9 (#s 5, 7, 8, 10, 11, 12, 13, 14, and 15) of 15 sampled and supplemental residents. Findings include: 1. Resident #2 was admitted with a [DIAGNOSES REDACTED]. Review of resident #2's Significant Change in Status MDS, with an ARD of 6/1/17, showed resident #2 had a BIMS score of 3, severely impaired. Review of resident #2's Quarterly MDS, with an ARD of 8/22/17, showed resident #2 had a BIMS score of 3, severely impaired. During an interview on 11/6/17 at 1:10 p.m., NF2 stated she was aware of resident #2's behavior, regarding physical altercations, in the facility. She stated other resident's wandering into resident #2's room was what caused him to become upset and act out. She stated the facility put up a Velcro stop sign on resident #2's door but she was not aware of other efforts to keep residents out of resident #2's room or his personal space. During an observation on 11/6/17 at 4:36 p.m., resident #3 wandered in and out of resident rooms. Resident #3 was seen entering a room, walking through the bathroom and into the next room. During an interview on 11/6/17 at 5:36 p.m., staff member M stated the stop signs on the doorway of some of the rooms are attached with Velcro. She said the stop signs are in the resident's care plan and are meant to keep the wandering residents out of the room. Staff member M stated resident #3 was a wanderer and did not understand verbal commands to leave a room and staff needed to provide assistance. She said resident #3 would enter resident #2's room and he would escalate (become agitated). Staff member M stated the stop sign was not effective to keep resident #3 out of resident #2's room. She said the staff tried to redirect the residents away from each other, but she did not know of any other interventions. Staff member M stated over time, resident #2 became upset when he saw resident #3. She said resident #2 became angry and violent, but the staff could redirect him. Refer to F223 for further detail on resident #2 and #3. During an interview on 11/7/17 at 5:24 p.m., staff member A stated she did not know if resident #3 entered resident #2's room when the stop sign was on the doorway of resident #2's room. During an interview on 11/8/17 at 10:03 a.m., staff member J stated resident #2 was agitated by wanderers in his room, from the beginning (of his stay in the facility). He said that in the beginning, resident #2 would yell at residents who wandered into his room. Staff member J said as time went by and residents continued to wander into resident #2's room he became more physically aggressive. He said the staff used a Velcro stop sign across his doorway and pulled his privacy curtain, to maintain his privacy and keep wandering residents out of his room. He said these efforts were not always effective. Review of a document, provided by the facility, titled, Provider Communication Form, dated 4/3/17, showed the physician was notified of resident #2 being involved in two physical altercations when a female resident entered resident #2's room, twice, on 4/2/17. The document showed staff were trying to keep the residents apart and asked if the provider had any suggestions. The section titled, Provider response showed, Keep other residents out of room, and was signed by resident #2's physician. At the time of discharge, resident #2 had been in the facility over six months, and even though the staff were aware of escalating behavior by resident #2, when other residents entered his room, the resident's privacy was not maintained. 2. Review of resident #7's current MDS, a Quarterly, with an ARD of 11/3/17, showed resident #7 needed extensive assistance of one staff for personal hygiene needs. During an observation on 11/6/17 at 12:50 p.m., resident #7 was seated at a table in the main dining room. Staff member G was feeding resident #7 some mixed fruit. Resident #7's hair was flattened to the back of her head, and uncombed. Review of resident #7's current plan of care showed resident #7 was an extensive assist of one with her ADLs. Resident #7's current plan of care did not show the resident's preferences for how her hair was to be groomed by staff assisting. During an observation on 11/7/17 at 8:32 a.m., resident #7 was seated at a table in the main dining room. Resident #7's hair was flattened to the back of her head, and uncombed. During an observation on 11/7/17 at 8:47 a.m., staff member H was sitting at the table with resident #7 and three other residents. Resident #7's hair was flattened to the back of her head. During an observation on 11/7/17 at 9:40 a.m., resident #7 was sitting in her room. Resident #7's hair was pressed flat to the back of her head, and uncombed. During an interview on 11/7/17 at 10:15 a.m., NF1 said resident #7 had a standing appointment on Thursdays to have her hair washed and styled. NF1 said resident #7's family would come to her, NF1, and complain about the way the resident's hair looked. NF1 said she had told the family members repeatedly, I fix her hair, the CNAs don't comb it out. NF1 said the CNAs have told her, NF1, We're not beauticians, and we don't know how to fix hair. During an observation on 11/7/17 at 5:00 p.m., resident #7 was seated at a table in the main dining room, and her hair continued to be pressed flat to the back of her head and appear uncombed. During an observation on 11/8/17 at 10:00 a.m., resident #7 was in the main seating area of the facility participating in an activity. Resident #7's hair was parted on the right back side, and pressed flat to the back of her head Observations relating to resident hair included: 3. During an observation 11/7/17 from 5:15 p.m. to 5:45 p.m., residents' #5 and #13 were brought to the main dining room by staff. Both residents were observed to have snarled, messy hair on the backs of their heads. The hair appeared uncombed. 4. During an observation on 11/8/17 from 8:30 a.m. to 9:00 a.m., residents #8, #10, #11, #12, #14, and #15 were seated in the main dining room waiting for breakfast to be served. All six residents' hair had not been groomed. Their hair was pressed flat to their heads in back, and snarled in other areas. 5. During an observation on 11/8/17 at 10:00 a.m., an activity was taking place in the main sitting area of the facility. Resident #s 10, 13, 14, and 15 were participating in the activity. All four residents had snarled and messy hair. During an interview on 11/8/17 at 10:01 a.m., staff member I said she did not like the female residents having bed head hair. Staff member I said the female residents hair was frequently snarled and messy. Staff member I said this had been an ongoing problem for a long time. During an interview 11/7/17 at 10:15 a.m., NF1 said most of the female residents come to her for haircuts, perms, and sets. NF1 said the female residents never have their hair brushed. NF1 said she had given hair picks to all the female residents with permed hair so the CNAs could pick their hair out. NF1 said the CNAs tell her, We're not hair dressers. NF1 said family members had come to her and complained about the female residents' hair not being brushed or styled. NF1 said she had told family members that she does their hair, but the CNAs do not brush it out. During an interview on 11/8/17 at 10:30 a.m., staff member H said she had been a CNA for two months. Staff member H said, I brush all my female residents' hair when I get them up. Staff member H thought resident #7's hair was supposed to be flattened and parted down the right side of the back of her head. Staff member H said she did not know how to brush permed hair. A review of the resident care plans failed to show how the resident's preferred their hair to be fixed by staff. During an observation on 11/8/17 at 1:00 p.m., all the female residents, seated in the main dining room appeared to be well groomed with their hair [MEDICATION NAME] and in place.",2020-09-01
884,VALLEY VIEW ESTATES HEALTH & REHABILITATION,275101,225 N 8TH ST,HAMILTON,MT,59840,2017-11-08,246,D,0,1,2DHO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to address a resident's call light needs adequately to ensure the light was able to be used by the resident, and the resident's communication and physical limitations was a barrier in using the call light, for 1 (#6) of 10 sampled residents. Findings include: Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation and interview on 11/6/17 at 4:30 p.m., resident #6 was in bed watching television. Resident #6 was covered with a blanket that was pulled up to her chin. Her call light was clipped to the top of her blanket. NF4 and other family members were visiting with her. NF4 said resident #6 would like to be interviewed sometime in the next couple of days. During an observation and interview on 11/7/17 at 7:40 a.m., resident #6 was in bed. She was covered with a blanket, and her touch pad call light was clipped to the top of her blanket. Resident #6's television was on. Resident #6's hands were observed to be clenched into fists and pulled up on her chest. Resident #6 had a pillow under her head and two pillows along her right side, propping her up. Resident #6 had difficulty with speaking and making herself understood. She was soft spoken and slurred her words. Resident #6 indicated, by a head nod, she had just had a shower. Resident #6 said she missed living at her previous facility, but moving to this facility allowed her family members to visit with her every day. Resident #6 said the CNA staff were good, and they repositioned her frequently. Resident #6 was difficult to understand. Her voice was very soft, and her speech was not very clear. During an observation and interview on 11/7/17 at 8:23 a.m., NF5 was in the resident's room. NF5 was brushing and braiding resident #6's hair. NF5 said she or another family member would come in on resident #6's bath days, and fix resident #6's hair. Review of resident #6's Annual MDS, with an ARD of 8/15/17, showed she had impaired range of motion of her upper and lower extremities on both sides. The Annual MDS also showed resident #6 needed extensive assistance of two staff for transfers, dressing, and personal hygiene needs. Review of an OT discharge summary, dated 8/23/17, showed resident #6 to have ataxic limb movement. During an interview on 11/7/17 at 5:45 p.m., NF4 voiced a concern about the functionality of resident #6's call light. NF4 said the resident had told her, I can't tell when my call light is on. NF4 also voiced resident #6's concern that it takes staff forever to come to her room when she pushes the call light. During an observation and interview on 11/8/17 at 9:36 a.m., resident #6 was in her bed. She appeared to be calling out and appeared to be crying. Resident #6 was red-faced, her nose was runny, and she had tears on her cheeks. Resident #6, by moving her head from side to side, indicated she needed something, but could not express what her concern was. Resident #6 attempted to demonstrate the use of her touch pad call light. Resident #6's hands were clenched into fists and drawn up on her chest. She was covered with a blanket. The touch pad call light was on top of her blanket, at waist level, and clipped to the blanket. Resident #6 was unable to get her hands down to her waist to push the flap on the touch pad. The flap on the touch pad was pressed down and released. The light in the hallway was observed not to be lit up. Several more attempts were made to get the light in the hallway to light up, none were successful. One CNA was found and brought to resident #6's room. Staff member H and another CNA then entered resident #6's room and attempted to understand what resident #6 needed. The other CNA left the room and staff member G entered the room to assist staff member H in communicating with resident #6. Staff member I enter resident #6's room. Staff member I did determine, by head shakes or nods, that resident #6 wanted her window blinds open. Staff member G said she would put the touch call light under the resident's blankets, close to her hands, so she could depress the flap. Staff member G said when the call light was placed on top of resident #6's blankets and her hands were underneath the blankets, resident #6 could not reach the call light. When demonstrated to staff member G that a person had to keep a steady pressure on the flap for the hallway light to stay on, staff member G said she didn't know that. Staff member G said resident #6 would probably not be able to keep a steady pressure on the call light due to the contractures of her hands and arms. Review of resident #6's Annual MDS, with an ARD of 8/15/17, showed resident #6's speech to be unclear due to slurred or mumbled words. Review of resident #6's social service notes from 9/20/16 through 11/7/17, showed the resident to be very soft spoken. Review of resident #6's care conference notes, dated 7/20/17, showed staff were having a hard time communicating with the resident. The interdisciplinary team had determined two staff present would provide better understanding of wants and needs. Review of resident #6's nursing note, dated 6/12/17, showed, Speech is quiet with a lot of unclear words. Review of resident #6's current plan of care showed under Communication, the resident had difficulty speaking. During an observation on 11/8/17 at 10:00 a.m., resident #6 was seated in her wheelchair in her room, covered with a blanket to her chin. Her hands were under the blanket at chest level and she was facing the interior of her room, looking toward her television. The touch pad call light was clipped on top of the blanket and was at lap level. Resident #6 attempted to push the flap on the call light. As resident #6 moved her hands under the blanket, the touch pad fell over and resident #6 could not reach it. During an observation and interview with staff member A on 11/8/17 at 10:30 a.m., resident #6 was in bed and covered with a blanket. Resident #6's hands were clenched and drawn up to her chest. The touch pad call light was clipped on top of the blanket at waist level. Staff member A observed resident #6 attempt to move her hands to reach the touch pad call light. Staff member A observed resident #6's blankets bunch up on top of her stomach and the resident was unable to access the call light. Resident #6 had tears running down her cheeks during this observation. Staff member A stepped into the hallway and observed the light in the hallway would not stay lit unless constant pressure was maintained on the flap of the touch pad call light. Staff member A was not aware the hallway light would not stay lit unless a steady pressure was maintained on the touch pad call light. Staff member A said the facility had tried many different call lights since the resident's admission, but none had proved satisfactory to the resident or her family. Staff member A said the therapy department had made recommendations for an appropriate call light for the resident to use. Staff member A said therapy had, in the past, written work orders for the maintenance department to address the resident's call light. Review of maintenance records showed therapy did two Maintenance Department Work Request for resident #6's call lights on: - OT wrote on 7/31/17; Please look into adapting patients (sic) call light to include a light and buzzer. Comment by maintenance: Blank - OT wrote on 10/12/17; Light outside of room reflecting call light is on is not working. Comment by maintenance: Completed at 12:30 p.m. as soon as I came back. Light bulb was burnt out outside room, however call board still worked and secondary bell still in place. During an observation interview on 11/8/17 at 9:00 a.m., NF4 was in the facility to take resident #6 to a dental appointment. NF4 said resident #6 was glad that someone had listened to her (resident #6) and gotten to the root of the problem with her (resident #6) call light. Resident #6 nodded her head in agreement with NF4's statement. During an interview on 11/8/17 at 12:20 p.m., staff member A said the maintenance man was on his way to town to get a new adaptive call light for resident #6, and an electrician would be coming to the facility to install the proper outlet for it. During an interview on 11/8/17 at 1:05 p.m., staff member N said she had worked extensively with resident #6 since her admission. Staff member N said resident #6 had a limited range of motion due to the contractures caused by her [MEDICAL CONDITION]. Staff member N said resident #6 had ataxic limb movement (muscle spasms) that limited the functionality of her hands and arms.",2020-09-01
885,VALLEY VIEW ESTATES HEALTH & REHABILITATION,275101,225 N 8TH ST,HAMILTON,MT,59840,2017-11-08,278,B,0,1,2DHO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to correctly code MDSs for 5 (#s 1, 3, 4, 5, and 7) of 10 sampled residents. Findings include: 1. During an observation on 11/6/17 at 12:50 p.m., resident #7 was at a table in the main dining room. The resident was seated in a wheelchair, and was wearing glasses. Review of resident #7's Quarterly MDS, with an ARD of 11/3/17, showed the resident did not have glasses. Review of resident #7's Annual MDS, with an ARD of 2/22/17, showed the resident did have glasses. Review of resident #7's nursing notes showed the resident received a [MEDICATION NAME] immunization outside the facility (MONTH) of (YEAR). Resident #7's currently Quarterly MDS, with an ARD of 11/3/17, showed the resident had not received a [MEDICATION NAME] immunization. During an interview on 11/7/17 at 3:50 p.m., staff member K said she had reviewed the resident's most recent MDS, dated [DATE], and her annual MDS dated [DATE]. Staff member K said she had reviewed resident #7's nursing notes from (MONTH) (YEAR), and the resident had received a [MEDICATION NAME] immunization outside the facility. Staff member K said the coding on the Quarterly MDS, with an ARD of 11/3/17, was incorrect. Staff member K said she would correct and resubmit the information to CMS. During an observation on 10/7/17 at 10:40 a.m., the facility's medication room refrigerator was noted to hold a quantity of flu vaccine. Staff member L stated the facility had not yet begun to administer the (YEAR) flu season vaccine to residents. 2. A review of resident's #1's Annual MDS, with an ARD of 11/1/17, inaccurately showed the resident had received an influenza vaccine for the current (YEAR) flu season. In section O0250B, it correctly showed the resident had been given flu vaccine on 12/8/16. Section O0250C was inaccurately left empty and should have showed the (YEAR) flu vaccine had not been offered yet. 3. A review of resident #3's Annual MDS, with an ARD of 10/5/17, inaccurately showed, in section O0250A, the resident had received an influenza vaccine for the current (YEAR) flu season. In section O0250B, it correctly showed the resident had been given flu vaccine on 11/10/16. Section O0250C remained empty and should have showed the (YEAR) flu vaccine had not been offered yet. 4. a. Review of resident #5's Annual MDS, with an ARD of 11/2/17, showed, in Section L, the resident had no dental issues including loose or broken teeth, obvious cavities, abnormal mouth tissue, mouth pain, or bleeding or inflamed gums. Review of resident #5's Care Plan Report, with an effective date of 2/8/16 to present, showed a focus area of the resident's need for ADL assistance. The focus area showed, Teeth in poor repair. Review of resident #5's assessment titled, Clinical Admission Documentation, dated 2/9/16, showed a section for an Oral and Dental evaluation with eight optional answers, and instructions to check all that apply. The only option marked showed, Obvious or likely cavity or broken natural teeth. Review of resident #5's assessment titled, Clinical Admission Documentation, dated 7/18/16, showed a section for an Oral and Dental evaluation with eight optional answers, and instructions to check all that apply. The only option marked showed, Obvious or likely cavity or broken natural teeth. During an interview on 11/7/17 at 1:35 p.m., staff member K stated she gathered data for MDS coding from the record and conducted observations, interviews, and assessments. She said she was unsure why Section L was coded as none of the above. Staff member K stated she would look into it. No further information was provided prior to the end of the survey. During an interview on 11/7/17 at 5:17 p.m., staff member L stated resident #5 has missing teeth, broken teeth, and at least one tooth that appears to have a cavity. She stated resident #5 had no mouth pain or difficulty eating. During an interview on 11/8/17 at 10:48 a.m., resident #5 stated she had missing and broken teeth. She used her tongue to point to one of her teeth, stating the tooth being indicated was one of them. b. Review of resident #5's Annual MDS, with an ARD of 11/2/17, showed the resident had received the influenza vaccination for this year's influenza vaccination season. The date the vaccine was received showed as 11/20/16. 5. Review of resident #4's Significant Change in Status MDS, with an ARD of 10/27/17, showed the resident had received the influenza vaccination for this year's influenza vaccination season. The date the vaccine was received showed as 11/23/16. During an interview on 11/7/17 at 11:08 a.m., staff member B stated the influenza vaccinations had not yet been given, in the facility, for this year's influenza vaccination season. She stated the vaccine had been received, and the facility had a plan to begin the immunizations. Staff member B stated that influenza vaccines given during the (YEAR)-2017 influenza season would not be current for this year's influenza vaccination season. During an interview on 11/7/17 at 1:35 p.m., staff member K stated the influenza vaccine coding for residents #3, #4, and #5, could be considered as accurate (incorrect) because she coded for the last flu shot given, regardless of when that was. Staff member K stated she used the RAI Manual as the resource for coding instructions. Review of the RAI Manual instructions for coding the influenza vaccination showed: Steps for Assessment 1. Review the resident's medical record to determine whether an influenza vaccine was received in the facility for this year's influenza vaccination season. If vaccination status is unknown, proceed to the next step. 2. Ask the resident if he or she received an influenza vaccine outside of the facility for this year's influenza vaccination season. If vaccination status is still unknown, proceed to the next step. 3. If the resident is unable to answer, then ask the same question of the responsible party/legal guardian and/or primary care physician. If influenza vaccination status is still unknown, proceed to the next step. 4. If influenza vaccination status cannot be determined, administer the influenza vaccine to the resident according to standards of clinical practice. Coding Instructions for O0250A, Did the resident receive the influenza vaccine in this facility for this year's influenza vaccination season? Code 0, no: if the resident did NOT receive the influenza vaccine in this facility during this year's influenza vaccination season. Code 1, yes: if the resident did receive the influenza vaccine in this facility during this year's influenza season.",2020-09-01
886,VALLEY VIEW ESTATES HEALTH & REHABILITATION,275101,225 N 8TH ST,HAMILTON,MT,59840,2017-11-08,281,D,0,1,2DHO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide medication according to a physician's prescribed order when the facility staff failed to administer a dose of scheduled narcotic medication, and failed to provide medications at the physician prescribed time intervals, for 1 (#3) of 10 sample residents. Findings include: A review of resident #3's September, October, and (MONTH) (YEAR) MARs, showed the resident had been ordered to receive [MEDICATION NAME] 7.5 mg-[MEDICATION NAME] 325 mg tablet, one tablet four times daily, starting 6/17/17. The resident was scheduled to receive one tablet at 8:00 a.m., 12:30 p.m., 5:30 p.m., and 9:30 p.m. A review of resident #3's (MONTH) (YEAR) MARs, showed the record was signed off, and the resident had received [MEDICATION NAME] 7.5 mg-[MEDICATION NAME] 325 mg at 12:30 p.m. on 10/31/17. A review of the facility's narcotic stock reconciliation records showed on 10/31/17, a dose of [MEDICATION NAME] 7.5 [MEDICATION NAME] 325 mg was not signed out for resident #3, corresponding to the 12:30 p.m. prescribed administration time. During an interview and record review on 10/8/17 at 11:48 a.m., staff member B was shown resident #3's narcotic reconciliation records. She stated that if the medication had not been signed out, it probably had not been given. A review of resident #3's September, October, and (MONTH) (YEAR) MARs were compared to the facility's corresponding narcotic reconciliation records for resident #3's prescribed [MEDICATION NAME] 7.5 mg [MEDICATION NAME] 325 mg scheduled doses. The process revealed the following medication errors: On 9/2/17 resident #3 was scheduled to receive [MEDICATION NAME]/[MEDICATION NAME] at 5:30 p.m., she received it at 4:00 p.m., one hour and 30 minutes early. This medications concerns included: -9/2/17 5:30 p.m. given at 4:00 p.m., 1 hr 30 mins early. -9/2/17 9:30 p.m. given at 7:00 p.m., 2 hrs 30 mins early. -9/3/17 5:30 p.m. given at 4:00 p.m.,1 hr 30 mins early. -9/3/17 9:30 p.m. given at 7:00 p.m., 2 hrs 30 mins early. -9/11/11 8:00 a.m. given at 10:00 a.m., 2 hrs late. -9/12/17 8:00 a.m. given at 9:30 a.m.,1 hr 30 mins late. -9/15/17 9:30 p.m. given at 8:00 p.m.,1 hr 30 mins early. -9/16/17 9:30 p.m. given at 7:30 p.m., 2 hrs early. -9/17/17 9:30 p.m. given at 7:00 p.m., 2 hrs 30 mins early. -9/24/17 9:30 p.m. given at 12:05 a.m. on 9/25/17, 2 hrs 35 mins late. -9/28/17 5:30 p.m. given at 4:00 p.m., 1 hr 30 mins early. -9/28/17 9:30 p.m. given at 7:00 p.m., 2 hrs 30 mins early. -10/15/17 9:30 p.m. given at 12:01 a.m., on 10/16/17, 2 hrs 31 mins late. -10/23/17 8:00 a.m. given at 9:46 a.m.,1 hr 46 mins late. -10/23/17 5:30 p.m. given at 4:00 p.m.,1 hr 30 mins early. -10/28/17 9:30 p.m. given at 11:00 p.m.,1 hr 30 mins late. During an interview and record review on 10/8/17 at 11:48 a.m., staff member B was shown resident #3's narcotic reconciliation records. She stated that nurses were not allowed to wait until residents were awake to be given evening scheduled medications. She said medications were to be given as scheduled in the MARs at the times designated and prescribed by the resident's physician. DeLaune, S.& Ladner, S ., Fundamentals of Nursing, Standards and Practice, Albany, NY., (1998), pg. 237. Nurses are obligated to follow the orders of a licensed physician or other designated health care provider unless the orders would result in client harm.",2020-09-01
887,VALLEY VIEW ESTATES HEALTH & REHABILITATION,275101,225 N 8TH ST,HAMILTON,MT,59840,2017-11-08,371,E,0,1,2DHO11,"Based on observation, interview, and record review, the facility failed to ensure all equipment in the kitchen was cleaned in a manner to prevent contamination of food while food was being prepared. This deficient practice had a potential to affect residents who received food from the kitchen when staff used the soiled equipment. Findings include: During an observation on 11/6/17 at 12:10 p.m., the Globe mixer was observed to be uncovered, and the mixing bowl was in the upright position. A wire whip was observed in the bottom of the mixing bowl. Unidentified, dried, crusty substances were adhered to the mixer arm, splash guard, and wire safety screen. During an interview on 11/6/17 at 12:12 p.m., staff member [NAME] said he did not know the last time the mixer had been used. Staff member [NAME] had staff member F cover the mixer with a clear plastic bag. The unidentified dried substances were not removed before being covered by staff member F. During an observation on 11/7/17 at 8:25 a.m., the Globe mixer still had unidentified, dried, crusty substances adhered to the mixer arm, splash guard, and wire safety screen. During an interview on 11/7/17 at 10:20 a.m., staff member D said the Globe mixer should be cleaned after every use. Staff member D said splashes from food being mixed should not be left on the mixer guards and housing. Staff member D said she would have someone do a deep clean on the mixer. During and interview on 11/7/17 at 12:10 p.m., staff member D said she had deep cleaned the Globe mixer herself. Record review showed the Globe mixer was not on the weekly kitchen equipment cleaning schedule.",2020-09-01
888,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2018-02-07,689,D,1,0,D4YN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and interview, the facility failed to use a gait belt when transferring a resident from wheel chair to bed, and bed to wheel chair for 1 (#6) of 6 sampled residents. Findings include: Resident #6 had a [DIAGNOSES REDACTED]. During an observation on 2/6/18 at 11:00 a.m., staff members D and [NAME] transferred resident #6 from her wheel chair to the bed with the use of a slider board. Staff members D and [NAME] placed the slider board under the resident's bottom, grabbed the resident's pants by the waistband, and pulled her across the slider board to the bed. After they had performed personal care, staff members D and [NAME] sat the resident up on the edge of the bed, placed the slider board under the resident's bottom, grabbed the resident's pants by the waistband, and pulled her across the slider board to the wheel chair. Staff members D and [NAME] did not use a gait belt to transfer the resident. The resident was not able to slide herself across the slider board without staff assistance. Review of resident #6's Quarterly MDS, with an ARD of 11/8/17, section G 0110 B showed the resident was an extensive assist of two staff persons for transfers. Review of resident #6's care plan, dated 10/12/17, showed staff were to use a slide board for transfers. During an interview on 2/6/18 at 11:18 a.m., staff member D stated she did not use a gait belt because she was trained to transfer the resident using her pants to pull her over the slider board. During an interview on 2/6/18 at 12:00 p.m., staff member B stated the expectation was for staff to use a gait belt when transferring a resident. During an interview on 2/6/18 at 5:11 p.m., staff member B stated the resident would be evaluated by therapy for a different transfer technique. Review of the policy and procedure for Transfers: Sliding Board, showed the following: .9. Instruct/assist the patient to shift weight and slide across the board using extremities as able .",2020-09-01
889,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2018-02-07,880,D,1,0,D4YN11,"> Based on observation and interview, the facility failed to ensure staff changed gloves when moving from a dirty task to a clean task, during provision of ADL care, for 1(#6) of 6 sampled residents. Findings include: During an observation on 2/6/18 at 11:00 a.m., staff members D and [NAME] performed personal care for resident #6. Staff members D and [NAME] washed their hands and donned clean gloves. Staff members D and [NAME] assisted the resident to lie down on the bed. Staff members D and [NAME] then removed the residents pants and soiled undergarment. Staff members D and [NAME] performed personal care by wiping from the front to the back. Staff member [NAME] then applied protective cream to the resident's bottom. Staff members D and [NAME] did not change their gloves or sanitize their hands. Staff members D and [NAME] then placed a clean undergarment on the resident and pulled her pants up. Staff members D and [NAME] then removed their gloves and washed their hands. Staff members D and [NAME] did not change gloves or sanitize their hands when moving from a dirty task to a clean one. During an interview on 2/6/18 at 11:18 a.m., staff member D stated they should have changed gloves. During an interview on 2/6/18 at 12:05 p.m., staff member B stated it was the expectation for staff to wash/sanitize their hands and change gloves when moving from a dirty to a clean task. During an interview on 2/7/18 at 1:25 p.m., staff member G stated the following should occur for incontinence care: -get all supplies -wash hands -put on clean gloves -position the resident -remove soiled clothing -perform peri care -discard gloves -sanitize hands -put on clean gloves -put clean clothing on -discard gloves -wash hands During an interview on 2/7/18 at 1:45 p.m., staff member F stated the following for incontinence care: -wash hands -put gloves on -roll the resident and remove the brief -wash front to back -if gloves are dirty, take off and sanitize hands -put clean gloves on",2020-09-01
890,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2019-04-10,760,D,1,0,OT4G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, a nurse failed to follow the correct medication administration process, and administered another resident's pain medication to a fell ow resident who had an allergy to the specific kind pain medication given, and this resulted in a negative outcome and the resident experienced nausea and vomiting. This was considered a significant medication error, for 1 (#1) of nine sampled residents. Findings include: During an interview on 4/10/19 at 7:48 a.m., NF1 said resident #1 received the wrong medications about three and a half weeks ago. NF1 said the facility had contacted him about the medication error. NF1 said resident #1 received Tylenol #3 which contained [MEDICATION NAME]. NF1 said resident #1 experienced vomiting three times because she had an allergy to [MEDICATION NAME]. NF1 said the resident's allergy to this medication was well documented. During an interview on 4/10/19 at 11:47 a.m., resident #1 said she did remember getting sick several weeks prior when she was given someone else's pills. The resident said she had never been given the wrong medications before. Resident #1 said she thought a nurse had given her a pill to help her when she was throwing up. During an interview on 4/10/19 at 2:46 p.m., staff member F said she had recently received training on the five rights of the medication pass, per nursing professional standards. During an interview on 4/10/19 at 2:48 p.m., staff member G said an in-service had been conducted by staff member B, who went over the five rights of medication administration. During an interview on 4/10/19 at 2:54 p.m., staff member C said she was aware staff member B had conducted in-service training's with the floor nurses in relation to a medication error that had happened for resident #1. Staff member C said she knew about this because it had been discussed in the morning management meetings, and an incident report had been completed on the medication error. During an interview on 4/10/19 at 3:00 p.m., staff member A said a medication error had occurred for resident #1. The staff member said an incident report had been done for this. Staff member A said the facility had completed a root cause analysis of the medication error and had identified the nurse, who was new, and the nurse failed to follow the five rights of a medication pass. The failure was caused due to the nurse failing to clarify the resident's last name. Staff member A said the nurse had asked the resident her first name, but did not ask the resident's last name, and at the time the incident occurred, the facility had two residents with the same first name. Staff member A said staff member B had completed an in-service training on passing medications with all nursing staff. Staff member A said he thought staff member B had given the new nurse additional education in the medication pass process by assigning him to another nurse to observe additional medication administrations. Staff member A said he did not feel this medication error was a system problem, as this was the first time this had occurred since he had started working in the facility in (MONTH) (YEAR). Staff member A said the facility had not had a QAPI meeting since the incident, but one was scheduled for 4/24/19, when the medical director would be in the facility. Staff member A said medication errors and outcomes had been added to the next QAPI agenda. During an interview on 4/10/19 at 4:25 p.m., staff member B said she had completed in-service training for all the floor nurses on medication administration, and the five rights of a medication pass. Staff member B said newly hired floor nurses went through a three week orientation, where they were supervised and trained by an experienced floor nurse in the medication pass process. Staff member B said the nurse who had the medication error for resident #1 was a new nurse who had completed the three week orientation. Staff member B said the nurse, after the medication error happened, received additional verbal and visual training, and was supervised by an experienced floor nurse for an additional three months. Staff member B said medication errors in the facility had not been identified as a problem. Due to resident #1 having three episodes of vomiting, and the physician prescribing antiemetics for resident #1, it was considered a significant medication error, and this would be added to QAPI. Review of the facility's Medication Error Report, dated 3/16/19, and revised on 3/27/19, showed resident #1 had received another resident's medications, including Tylenol #3, which contained [MEDICATION NAME]. The report showed the resident had three episodes of vomiting. The report also showed One on One' education was given to the nurse who had given the medication the resident was allergic to. The report also showed re-education was provided to all nurses. Review of resident #1's nursing notes, dated 3/16/19, showed the resident had vomiting episodes three times that day. The physician was notified of the medication error, and the resident's condition; including her emesis. The physician prescribed [MEDICATION NAME] 4 mg for the nausea and vomiting for the resident. Review of resident #1's medical record showed the resident had an allergy to [MEDICATION NAME]. Review of the facility's In-service Sign-In Sheet, dated 3/22/19, showed the nurse who administered the [MEDICATION NAME] received 1-1 training with staff member B, related to the importance of the five rights of medication administration, and using two forms for resident identification. Review of the facility's In-service Sign-In Sheets, dated 3/22/19, showed all the floor nurses, on all shifts, received training on the importance of the five rights of medication administration. Review of the facility's policy, Adverse Consequences and Medication Errors, revised (MONTH) 2014, showed: .6. Examples of medications (sic) errors include: b. Unauthorized drug - a drug is administered without a physician's orders [REDACTED].>12. In the even of a significant medication-related error or adverse consequence, immediate action is taken, as necessary, to protect the resident's safety and welfare. Significant is defined as: d. Requiring treatment with a prescription medication .",2020-09-01
891,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2017-06-22,244,E,0,1,07DD11,"Based on record review and interview, the facility failed to resolve and provide feedback on the steps taken to assist with resolution of the resident council concerns. This failure had the potential to affect the residents involved in the resident council group and those residents who followed the council's actions. Findings include: During an interview on 6/20/17 at 3:45 p.m., the group members stated the concerns were not being followed up on by department heads of the facility or the departmental staff. The group members stated they had repeated concerns with missing laundry, activities, food and kitchen concerns. Review of the resident council minutes for (MONTH) 4, (YEAR) showed the following concerns were listed: 1. Meals were not being served on time. 2. Food was cold and the staff were not waiting to see if the residents would like seconds on their meals. 3. Staff not staying in the A wing dining room during meals. 4. Missing laundry. 5. Rooms not being cleaned completely and just having the garbage taken out. 6. Long waits for call lights. Review of the resident council minutes for (MONTH) 2, (YEAR) showed the following concerns were listed: 1. Call lights not being answered. 2. Missing laundry. 3. Rooms not being cleaned well. 4. Cold meals served and all the staff not waiting for residents to get seconds before leaving the dining room. Review of the resident council minutes for (MONTH) 6, (YEAR) showed the following concerns were listed: 1. Getting woke up early to be checked on. 2. Loud TV's at night. 3. Missing laundry. 4. Food continues to be cold. Review of facility documentation, on 6/20/17, showed the facility failed to document any follow-up to the resident council concerns. During an interview on (MONTH) 20, (YEAR) at 3:00 p.m., Staff member A stated he was unable to find any follow-up documentation to the resident council concerns. He stated there were some repeated issues listed on the resident council minutes and due to the lack of follow-up documentation, he assumed the issues were still present with the council group.",2020-09-01
892,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2017-06-22,252,D,0,1,07DD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide a homelike environment for 3 (#s 4, 12, and 17) of 18 sampled and supplemental residents. During an observation on 6/19/17 at 8:45 a.m., resident #4, 12, and 17 had minimal decorations on their walls. Resident #4 and #17 shared a room and did not have any personal items in their room. Resident #4 did not have anything on her walls. She did not have a roommate, and the room was bare and had an institutional-like appearance. Record review of resident #4's medical record showed an admitted [DATE]. He was a prisoner of war during World War II and was in a concentration camp. He was admitted with dementia, stroke, unmanageable behaviors, and heart disease. His Quarterly MDS with and ARD of 4/1/17, showed a BIMS of 5 (severely impaired). During an interview on 6/20/17 at 2:15 p.m., staff member J stated she was not sure why there were no decorations in resident #4 and resident #17's room. She stated she was not sure if resident #4's brother just didn't put any decorations up, and resident #17 was new to the room. During an interview on 6/20/17 at 3:00 p.m., staff member [NAME] stated he does not set up the rooms with nay decorations. He stated families oversee decorating resident rooms. He was not sure who was responsible for decorating resident rooms when the resident is unable to decorate independently. During an interview on 6/20/17 at 3:55 p.m., staff member J stated it was a team effort to decorate the resident rooms. If family did not decorate the resident rooms, the staff would contact the family to see what the residents liked and then decorate the room. He stated he was unaware of this prior to the survey, and there were several residents who had rooms like resident #4 and resident #17. During an interview on 6/20/17 at 4:10 p.m., resident #4 stated his room was so-so. During an interview on 6/21/17 at 11:40 a.m., resident #12 stated her room was not too great. She stated she did not want to talk about what will make it better, because it would not happen. She stated they don't let you hang pictures around here. Resident #12 stated she liked not having a roommate, but it made her room feel lonely and bare. During an interview on 6/22/17 at 10:45 a.m., resident #17's family member stated the resident had pictures on his wall in his old room, but the facility had not hung them up since he had moved rooms. Record review of the facility's policies failed to show who was responsible for ensuring resident rooms were homelike and did not provide an institutional-like appearance.",2020-09-01
893,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2017-06-22,253,D,0,1,07DD11,"Based on observation, interview, and record review, the facility failed to clean handrails on the C-Wing, and failed to manage urine and fecal odors, also on the C-Wing. This failure had the potential to affect the residents who were residing on the C-Wing. Findings include: Handrails: During observations 6/19/17 - 6/22/17, the wooden handrails located on the C-Wing were noted to be sticky and had food like substances on the rails. Review of the deep cleaning schedule For (MONTH) and May, up to (MONTH) 22, (YEAR), failed to show documentation that the handrails had been cleaned on the C-Wing unit. During an interview with NF1 on 6/22/17 at 10:00 a.m., NF1 stated that sometimes the handrails did not get cleaned because she had to try to utilize her time the best she could and that meant at times certain tasks did not get completed. She stated that she did not have training on cleaning the handrails, but when she got extra time, she tried to wipe them down. A review of the contracted housekeeping services policy, Job To Be Done: Elevator Floors, Walls, Doors, Tracks, showed the housekeepers were to wipe down the hand rails. Odor: During observations on the C-Wing, a pungent odor of urine was evident at the following times: - 6/19/17 at 8:15 a.m., 2:55 p.m., and 3:35 p.m. - 6/20/17 at 8:00 a.m., 2:30 p.m., and 2:49 p.m. - 6/21/17 at 9:15 a.m. During an observation and interview on 6/19/17 at 3:00 p.m., staff member H stated she smelled a foul odor down the hallway on C-Wing. She thought they had found the cause of the smell and cleaned a resident up that had a bowel movement. During an observation of the C-Wing Unit, 35 minutes after the conversation with staff member H, the odor down the C-Wing unit was still strong of urine and fecal matter. During an interview on 6/19/17 at 4:00 p.m., staff member C stated the odor down the C-Wing hallway was one resident who struggled with a mental illness, and his bedroom always smelled of urine. She stated housekeeping was supposed to deep clean the resident's room three times per week (due to urinating on the heater and other places in the room), and the facility was changing the mattress every two days. Staff member C stated there was another resident down the C-Wing hallway that was not clean and struggled with the smell of urine in their room, but that the facility was unsure of how exactly to handle the strong urine smell down the C-Wing hallway. During an interview on 6/20/17 at 8:00 a.m., staff member I stated a resident down the C-Wing hallway was urinating in the heater on occasion. Staff member I also stated the resident placed his urine soiled clothes in the garbage can and continuously spilled his urinal in his room. She stated the resident would be picky about letting staff change him or at times would lay in bed, soiled, and would not allow staff to change his bedding. Staff member I stated the resident struggled from a mental illness and was at times hard to interact with because he did not trust many people. During an interview on 6/20/17 at 3:45 p.m., the resident group members (two of whom reside on the C-Wing) stated the urine smell was terrible on the C-Wing. A review of the contracted housekeeping services policy, Job to Be Done: Complete Room Cleaning, showed the following instructions for complete room cleanings: 1. Set up room calendar outlining what rooms are to be cleaned on certain days. 2. Coordinate with Charge Nurse at the start of shift to have the room ready. 3. If room is not ready, Supervisor must make adjustment to clean sometime during the day. 4. Nursing Assistants should strip beds and empty closets and drawers. 5. Clean rooms using a 5-step method. 6. Additional work: a. Clean and sanitize mattress, bed frame, springs and rails. b. Clean and sanitize closet and drawers. 7. Coordinate complete room cleanings with exterminator visit. During an interview on 6/22/17 at 10:00 a.m., NF1 stated she used to deep clean resident rooms one time each week, but recently a specific resident's room was requiring a deep clean three times a week. She stated when she deep cleaned, she moved the bed around and dusted around the room. She stated she was required to sweep and mop all around the room. NF1 stated she tried to clean the blinds and move everything. She stated she had not been given any special instructions on how to clean up or manage any urine odor that was in a specific resident's room. During an interview on 06/22/17 at 10:12 a.m., staff member Q stated the odor was very hard to keep up with on the C-Wing hallway. She stated that the resident, who she believed was responsible, changed his clothes two to three times per day and would throw his clothes in the trash can. Staff member Q stated that the resident would change clothes if he was encouraged. He did not let anyone know what he did with his soiled clothes, resulting in the odor filling up the room and hallway.",2020-09-01
894,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2017-06-22,278,E,0,1,07DD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately complete the pain assessment on the MDS for 3 (#s 8, 9, and 14) of 15 sampled residents. This deficiency had the potential to affect the residents in the facility who suffer from pain and require pain assessments. Findings include: 1. Resident #8 had a [DIAGNOSES REDACTED]. Review of the residents Annual MDS, with an ARD date of 8/8/2016, showed the following information in section J: - J0100: Patient didn't receive a scheduled pain medication or a PRN pain medication. - J0300, J0400, J0500, J0600A, J B, J0800, J0850: Not assessed. Review of resident #8's MAR, dated (MONTH) (YEAR), showed the resident was being monitored for pain, and that she could communicate. She was assessed for pain three times per day on all the days of the month, except the afternoon of the 5th and morning of the 6th. During an interview on 6/22/17, at 09:00 a.m., resident #8 stated she was assessed for pain daily, although she didn't experience much pain. 2. A review of the following resident records showed: a. Resident #9 had a [DIAGNOSES REDACTED]. Review of the resident #9's Admission MDS, with an ARD date of 5/31/17, showed the following information in section J: - J0100: Patient did not have any scheduled pain medication but was receiving PRN pain medications. - J0300, J0400, J0500, J0600A, J B, J0800, J0850: Not assessed. Review of the residents MAR, dated (MONTH) (YEAR), showed resident #9 was on pain monitoring. The MAR indicated [REDACTED]. Review of the PRN Pain Management Flow Sheet, dated (MONTH) 25-30, (YEAR), showed the resident was experiencing pain in her arm on 5/25, 26, 27, 28, 29, and 30, (YEAR). She was receiving PRN medications and non-pharmacological treatment approaches. b. Resident #14 had a [DIAGNOSES REDACTED]. Review of the resident #14's Quarterly MDS, with an ARD date of 3/10/17, showed the following information for section J0300, J0400, J0500, J B, J0800, J0850: not assessed. Review of resident #14's MAR, dated (MONTH) (YEAR), showed resident #14 was on pain monitoring. The MAR indicated [REDACTED]. The resident also received pain medication on the following dates: -3/2/17 -3/8/17 -3/9/17 During an interview on 6/20/17 at 12:00 p.m., staff member J stated she was unsure why the pain assessments were triggering as not assessed because they assessed for the resident's pain every day. During an interview on 6/20/17 at 8:50 a.m., staff member P stated when she completed the MDS's for pain, she would look to see if the nursing staff completed a pain assessment based on if the UDA was completed by the nursing staff. She was unsure what UDA stood for but it was an online assessment the nursing staff completed.",2020-09-01
895,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2017-06-22,279,D,0,1,07DD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to update the care plan for 1 (#8) out of 15 sampled residents, and the resident had a supra pubic catheter placed, which was new. Findings include: Resident #8 had a [DIAGNOSES REDACTED]. Review of resident #8's Nursing Progress Notes, dated 6/1/17, showed the resident had a change of condition. The resident had a subrapubic tube placement. The note showed, per physician progress notes [REDACTED]. Review of the resident's procedure discharge instructions, dated 6/1/17, showed the following: 1. Keep tube secured at all times. 2. Dress the supra pubic skin site with gauze and tape as needed. 3. (MONTH) shower with the tube in place, no need to cover. 4. Stay hydrated to ensure urine is clear and any residual blood clots are washed out. Review of resident #8's physician orders, dated 6/1/17, showed the following instructions for the supra pubic placement: 1. Keep tube secured at all times. 2. (MONTH) dress supra pubic skin with gauze and tape. 3. Take Tylenol, 650 mg, oral, every 6 hours, PRN for pain. 4. Take [MEDICATION NAME], 5 mg, oral every 4 hours, PRN for pain. 5. Follow up with the clinic next week. 6. Please call physician with any issue in the mean time. Review of the resident's care plan showed the following: Focus: Resident requires indwelling catheter due to: [MEDICAL CONDITION] bladder. Created on 8/10/16. Goal: Resident will have no signs and symptoms of urinary tract infection or complications of indwelling catheter throughout this quarter. Created on 8/10/16 and target date of 3/22/17. Interventions: 1. Monitor for signs and symptoms of infection and report to the physician. Created on 8/10/16. 2. Catheter care twice a day and PRN. Created on 8/10/16. 3. #16 Foley 10 cc balloon. Created on 12/20/16. 4. Keep catheter off floor. Date created 8/10/16. 5. Leg bag when appropriate. Date created: 10/13/16. 6. Provide privacy bag. Date created 12/20/16. 7. Encourage resident to consume fluids on meal trays, between meals, and nourishments provided. Date created: 8/10/16. The facility failed to update any information on the care plan to reflect the supra pubic catheter placement that occurred on 6/1/17. During an interview on 6/20/17 at 04:00 p.m., staff member C stated they were not sure how the subrapubic catheter was not placed on the care plan. She stated typically it was the unit manager who updated those documents.",2020-09-01
896,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2017-06-22,281,E,0,1,07DD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to meet professional standards of nursing practice when facility staff did not clarify and write in the medication administration record whether medications were to be given by mouth or through a gastrostomy tube for 1 (#10), and staff failed to administer resident #10's medication one at a time, with tap water flushes between medications, when medications were administered through the resident's gastrostomy tube. This had the potential to expose the resident to nonabsorption of medication and possible negative medication interactions, of 15 sampled residents. The facility failed to assure the administration of PRN medications by facility staff was followed by an evaluation and written record of the efficacy of the PRN medication received for 4 (#s 1, 2, 3, and 11); and facility staff also failed show the physician's orders [REDACTED].#s 1, 2, 3, 4, 5, 7, 8, 9, 11, and 13) out of 15 sampled residents. Findings include: Gastrostomy Tube Medications: 1. Resident #10 was admitted to the facility 6/7/17 with [DIAGNOSES REDACTED]. He had a gastrostomy tube on admission with orders for continuous tube feeding, per pump. During an interview on 6/21/17 at 9:00 a.m., staff member I stated that she was aware resident #10 had recently requested to taste food, and had been allowed limited oral intake. He had tolerated it well. She stated that despite this, she had verified with other staff that the resident was to continue to receive his medications through his gastrostomy tube. During an observation of medication administration on 6/21/17 at 9:00 a.m., staff member I used resident #10's MAR and placed the following medications in one medication cup: -vitamin C 500 mg, 1 tab -vitamin D 1000 IU, 2 tabs -doccusate sodium 100 mg, 1 tab -[MEDICATION NAME] sulfate 325 mg, 1 tab -[MEDICATION NAME] 10 mg, 1 tab -gilenya 0.5 mg, 1 cap -[MEDICATION NAME] 4 mg, 1 tab -[MEDICATION NAME] 20 mg, 1 tab -potassium chloride liquid 20 MEQ/15 ml (10%), 15 cc Staff member I crushed each medication and mixed all the medications together with tap water into one container cup. In the resident's room, with the resident resting in bed, with the head of the bed elevated, staff member I used a toomey syringe to aspirate the resident's gastrostomy tube without return. She flushed the tube slowly with approximately 50 cc tap water without meeting resistance. After the tap water flush she administered the medication solution to the resident pushing it in slowly through the gastrostomy tube using the syringe and plunger. She followed the medication solution with a final flush of approximately 50 cc tap water before reconnecting the resident's gastrostomy tube to an ordered continuous tube feeding pump. A review of resident's #10's MAR, after the administration of the above medications, showed that all of the medications, except for the potassium chloride liquid, had been written as ordered to be given by mouth. The potassium chloride liquid was ordered to be given via the PEG tube. During an observation of medication administration preparation on 6/22/17 at 9:20 a.m., staff member K used resident #10's MAR to gather the resident's ordered 9:00 a.m. medications in one medication cup. She proceeded to crush each medication and mixed all of them together in a liquid solution. During an interview on 6/22/17 at 9:25 a.m., staff member K stated she was planning to use a syringe and flush the mixed medication solution through resident #10's gastrostomy tube all at once. She stated she had not read the facility's policy for administering medication through a gastrostomy tube. She said she had spoken to other nursing staff that morning, and had been told to mix all the medications together, and then, to give them to the resident through his gastrostomy tube. When she was told the facility policy showed medications were to be administered one at a time with flushes between, she discarded the crushed combination of medications she had prepared, and proceeded to pour the same medications into individual med cups. A review of resident #10's MAR on 6/22/17, showed that the resident's ordered 9:00 a.m. medications remained written as ordered to be given by mouth, except the potassium chloride liquid was ordered to be given via the PEG tube. A review of the facility's policy, titled Medication Administration: Enteral, showed the following procedure steps to administer medications through a gastrostomy tube: 1. Gather supplies. 2. Prepare for administration of medication. 3. Assemble medicine cups to transport into patient's room. 4. Verify tube placement. Under #2 the policy shows Prepare each medication in individual medication cups. Under #4 the policy shows the following steps when the resident has a gastrostomy tube: - Place stethoscope over patient's epigastric region. Inject 10 ml air into the tube while listening for whooshing sound. If no whooshing sound is heard, stop procedure and notify physician . - Check for residual using syringe to: Aspirate stomach contents. Measure amount of residual. Follow specific physician/APN/PA orders regarding residuals. Re-instill residual formula. - Disconnect syringe, remove plunger from syringe, and place it upright on bedside table. - Draw up at least 50 mls tap water into syringe. - Attach syringe to end of tube. - Instill tap water into the tube through the syringe, allow to flow by gravity. - Administer medications individually. - Flush with 5 mls tap water in between each medication. After administering all medications, flush with at least 50 mls of tap water. - Reconnect tube or champ as indicated. The following concerns were identified relating to the completed and documented medications and treatments ordered by the physician: 2. A review of resident #1's MARS showed the resident received [MEDICATION NAME] HCl 50 mg by mouth at 6:00 p.m. on 6/12/17, 6/14/17, and 6/16/17. Pain levels were recorded for the times that the medication were given on the resident's MAR. The MAR did not have a PRN Pain Management Flow Sheet and efficacies for the medication given were not provided. 3. A review of resident #2's MARS showed the resident received [MEDICATION NAME] 5 mg by mouth, as a PRN pain medication, at 9:00 p.m. 6/3/17. No pain level assessments were recorded on the MARS at the time of the medication administration. Pain monitoring on the MARS did not show a change in pain status. The MAR did not have a PRN Pain Management Flow Sheet and efficacy for the medication given, and this documentation was not provided. 4. A review of resident #3's MARS showed the resident received [MEDICATION NAME] 5-325 mg tab by mouth as a PRN pain medication a total of 21 times on various shifts between 6/1/17 and 6/19/17. For five of the administrations, pain levels were recorded at the time the medication was given. The MARS did not have a PRN Pain Management Flow Sheet and efficacies for all the medications given were not found. 5. A review of resident #11's MARs showed the resident received [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg by mouth, as a PRN medication, 16 times on various shifts between 6/1/17 and 6/19/17. A review of resident #11's PRN Pain Management Flow Sheet did not show documentation of pain evaluations or efficacies of the [MEDICATION NAME]-[MEDICATION NAME] given to resident #11 at: - 6/3/17 at 2:00 p.m. - 6/4/19 at 2:45 p.m. - 6/5/17 at 12:00 noon - 6/12/17 at 9:30 a.m. - 6/14/17 at 8:00 p.m. During an interview on 6/22/19 at 7:30 a.m., staff member P stated that when PRN pain medications were given, pain assessments were done after the medication had taken effect, and were to be recorded on the PRN Pain Management Flow Sheet, as part of each resident's MAR. The following concerns were identified relating to MARs and nursing signatures, and the facility staff failed to sign off on the resident MAR's for medications given for the following residents: 6. A review of resident #1's MARs, done on 6/19/17, for the month of (MONTH) (YEAR), did not show nursing staff signed the MAR or TAR, showing physician orders [REDACTED]. Concerns were identified with: [MEDICATION NAME] Nebulization Solution (2.5 mg/3 ml) 3 ml to be inhaled orally via nebulizer was not signed as given on 6/2/17 at 11:00 p.m., 6/6/17 at 2:00 p.m., 6/8/17 at 11:00 p.m., on 6/11/17 at 2:00 a.m. and 6:00 a.m., on 6/12/17 at 2:00 a.m. and 6:00 a.m., on 6/13/17 at 2:00 a.m., 6:00 a.m., 2:00 p.m., and 11:00 p.m., on 6/14/17 at 2:00 a.m. and 6:00 a.m., on 6/15/17 at 2:00 a.m., 6:00 a.m., and 11:00 p.m., on 6/16/17 at 2:00 a.m. and 6:00 a.m., on 6/17/17 at 2:00 a.m. and 6:00 a.m., on 6/18/17 at 2:00 a.m., 6:00 a.m., and 2:00 p.m. Further concerns were identified relating to the lack of documentatin by nursing staff for the [MEDICATION NAME] 650 mg, Vitamin D3 5000, [MEDICATION NAME] Sodium 100 mg, House Supplement frozen treat 4oz., and Senna Plus 8.6-50 mg/tab. Concerns on the resident's TAR included: -Pain monitoring was not always signed off, per physician's orders [REDACTED].>-Ordered respiratory assessments were not all signed off as completed. -Numerous bed alarm function checks were not signed off as performed. -Chair alarm function checks were not always signed off as performed. -Resident use of the Wanderguard alarm was not always signed off as completed. 7. A review of resident #2's MAR/TAR, done on 6/19/17, for the month of (MONTH) (YEAR), did not show signatures of nursing staff for if all of the medication or treatments ordered by the physician were given for the following: -[MEDICATION NAME] tablet 1000 units -[MEDICATION NAME] HCl 75 mg -[MEDICATION NAME] HCl 100mg -A house nutrition supplement -Oxygen saturation and pulse rates -Oxygen per nasal cannula at 2 L/min -Ordered pain monitoring 8. A review of resident #3's (MONTH) (YEAR) MAR did not show signatures of medication administration or treatments given for the following dates and times: Humalog OG Solution 100 units/ml 2 units did not show signatures as given for a recorded blood sugar of 171 per ordered sliding scale coverage on 6/5/17 at 7:30 a.m. Oxygen per nasal cannula at 3 L/min was not signed off as given on 6/2/17, 6/13/17, and 6/14/17 on the 11:00 p.m. to 7:00 a.m.shift, and on 6/5/17 and 6/15/17 on the 7:00 a.m. to 3:00 p.m. shift. 9. A review of resident #10's (MONTH) (YEAR) MAR/TAR did not show all the signatures of medication administration or treatments given for the following: -[MEDICATION NAME] acid 500 mg -[MEDICATION NAME] 2000 units/tab -[MEDICATION NAME] 100 mg one cap -[MEDICATION NAME] 325 mg -Gilenya 0.5 mg one cap -[MEDICATION NAME] 10 mg one tab -[MEDICATION NAME] 10 mg one tab -[MEDICATION NAME] 40 mg one tab -Potassium Chloride Liquid 20 MEQ/15 ml -Thera-M one tab -[MEDICATION NAME] 4 mg -[MEDICATION NAME] 20 mg -Daily cleansing of gastrostomy site was not signed off as performed on 6/15/17 on the 7:00 a.m. to 3:00 p.m. shift. -[MEDICATION NAME] 1.2CAL at 75 ml/hr continuous enteral feeding was not signed off as given on 6/16/17 on the 7:00 a.m. to 3:00 p.m.shift and on 6/20/17 on the 3:00 pm to 11:00 p.m.shift. -Checking the gastrostomy tube for residual, keeping the head of the bed elevated at 30-45 degrees, checking for proper tube placement, and flushing the tube with 100 cc of water, were not signed off as performed on 6/20/17 on the 3:00 p.m. to 11:00 p.m. shift. -Pain monitoring was not signed off as performed on 6/15/17 on the 7:00 a.m. to 3:00 p.m. shift, and on 6/20/17 on the 3:00 p.m. to 11:00 p.m.shift. 10. A review of resident #11's (MONTH) (YEAR) MAR/TAR did not show all signatures of medication administration or treatments given for the following: -Aspercreme lotion as applied to left knee -[MEDICATION NAME] Gel 1% as applied to the lips -Fingerstick blood glucose test -Weights were not signed off as taken on the days the resident was to receive [MEDICAL TREATMENT] treatment. Only one weight was recorded as taken out of the nine times the weights were ordered to be done. -None of the resident's post [MEDICAL TREATMENT] treatment vital signs were recorded for the month of June. -Bruit or thrill checks and assessment of the [MEDICAL TREATMENT] fistula site were not signed off as checked, and Wanderguard and bed sensor alarms were not signed off as performed on 6/4/17, 6/12/17, and 6/13/17 on the 7:00 a.m. to 3:00 p.m. shift, on 6/3/17, 6/4/17, and 6/6/17 on the 7:00 a.m. to 3:00 p.m. shift, and on 6/2/17 on the 11:00 p.m. to 7:00 a.m. shift. -[MEDICAL TREATMENT] site dressings were not signed off as removed on 6/13/17 and 6/20/17 on the 7:00 a.m. to 3:00 p.m. shift. 11. Review of resident #7's MAR, dated 6/2017, did not show all nursing signatures of medication administration or assessments completed for the following dates and times: - Ciclodan Solution 8%, apply typically in the evening, 6/6/17 at 7:00 p.m. - [MEDICATION NAME] Tablet Chewable, 100 mg x 2 per day, 6/18/17 at 10:00 p.m - [MEDICATION NAME] Sodium Capsule, 100 mg x 2 per day, 6/16/17 at 1:00 p.m. and 6/18/17 at 10:00 p.m - [MEDICATION NAME] Tablet, 2.5 mg x 2 per day, 6/18/17 at 10:00 p.m - Tylenol Tablet, 500 mg x 2 per day, 6/12/17 at 9:00 p.m. and 6/18/17 at 9:00 p.m - Acidophilus/L-Sporogenes Tablet, 6/10/17 at 12:00 p.m., 6/12/16 at 10:00 p.m., 6/14/17 at 10:00 p.m., and 6/18/17 at 10:00 p.m - [MEDICATION NAME] Capsule, 100 mg, 6/10/17 at 12:00 p.m., 6/12/17 at 10:00 p.m., and 6/18/17 at 10:00 p.m -Pain Assessment, to be completed every shift daily, 6/12/17 on the afternoon shift, 6/17/17 on the afternoon shift, 6/18/17 on the afternoon shift. 12. Review of resident #8's MAR's and TAR's, dated 6/2017, showed a lack of signatures for the completion of the following medications and treatments: - [MEDICATION NAME] Tablet, 3 MG - [MEDICATION NAME] Tablet, 10 mg - Pain monitoring - Subrapubic catheter post placement care (catheter was placed on 6/1/17 with instruction for follow-up care). Details and instructions are included in tag F279. 13. Review of resident #9 MARs, dated 6/2017, showed a lack of nursing signatures, to show the physician's orders [REDACTED]. - [MEDICATION NAME] Tablet, 40 mg given x 1 per day, 6/15/17 at 1:00 p.m., 6/16/17 at 1:00 p.m., 6/17/17 at 1:00 p.m., 6/18/17 at 1:00 p.m., and 6/19/17 at 1:00 p.m - Observe cast to left wrist area per shift for swelling, discoloration and sensation, 6/12/17 on afternoon shift, and 6/18/17 on afternoon shift. - Pulse oxygen every shift to keep oxygen saturation greater than or equal to 90% every shift, 6/3/17 on the morning shift, 6/6/17 on the afternoon shift, 6/8/17 on the night shift, 6/9/17 on the night shift, 6/10/17 on night shift, 6/12/17 on the afternoon shift, 6/15/17 on the morning shift, and on 6/15/17 on the afternoon shift. - [MEDICATION NAME] Suspension, 0 unit/ml, give 5 ml by mouth four times per day for thrush, 6/6/17 at 10:00 p.m., 6/7/17 at 11:00 a.m., and 4:00 p.m., 6/8/17 at 4:00 p.m., and 6/10/17 at 11:00 a.m. - [MEDICATION NAME] Tablet, 1 mg given at bedtime, 6/11/17 at 9:00 p.m., and 6/12/17 at 9:00 p.m. - [MEDICATION NAME] Tablet, 8 mg x 3 per day, 6/5/17 at 9:00 p.m., 6/6/17 at 9:00 p.m., and 6/12/17 at 9:00 p.m. -Pain monitoring to be completed every day, on every shift, 6/6/17 on the afternoon shift, and 6/16/17 on the night shift. - [MEDICATION NAME]-[MEDICATION NAME] Solution .5-2.5 (3) mg/3 ml, 1 vial inhale orally four times per day, 6/5/17 at 11:30 a.m., 6/7/17 at 11:30 a.m., 6/11/17 at 6:30 a.m., 6/12/17 at 4:30 p.m., and 9:00 p.m., 6/17/17 at 6:30 a.m., 4:30 p.m., and 9:00 p.m., and 6/18/17 at 4:30 p.m. and 9:00 p.m. 14. Review of resident # 13's MAR's, dated 6/2017, showed no signatures that the medications were given for the following: - [MEDICATION NAME] Solution .2-.5%, instill 1 drop in both eyes x 2 per day, 6/16/17 at 9:00 a.m. - [MEDICATION NAME] Tablet, 2 mg, given x 2 per day, 6/9/17 at 9:00 p.m - [MEDICATION NAME] Tablet, 50 mg, given x 3 per day, 6/10/17 at 1:00 p.m., 6/11/17 at 1:00 p.m., 6/12/17 at 1:00 p.m., 6/13/17 at 1:00 p.m., 6/17/17 at 1:00 p.m., and 6/20/17 at 1:00 p.m - [MEDICATION NAME] Tablet, 100 mg, given x 3 per day, 6/7/17 at 1:00 p.m., 6/10/17 at 1:00 p.m., and 6/14/17 at 1:00 p.m 15. Review of resident #4's MARs, dated 6/2017, showed no signatures for completion of the folloowing: -Aspirin Tablet, 81 mg, one time a day, 6/7/17 at 9:00 a.m., and 6/14/17 at 9:00 a.m -[MEDICATION NAME] Sprinkles Capsule Delayed Release, 125 mg, at bedtime, 6/17/17 at 9:00 p.m., 6/18/17 at 9:00 a.m. -[MEDICATION NAME] Sprinkles Capsule Delayed Release, 125 mg, three times a day, 6/6/17 at 1:00 p.m., 6/7/17 at 9:00 a.m., 6/9/17 at 1:00 p.m., 6/10/17 at 1:00 p.m., 6/14/17 at 9:00 a.m., 6/14/17 at 1:00 p.m., 6/17/17 at 5:00 p.m., 6/18/17 at 5:00 p.m. -[MEDICATION NAME] Tablet, 40 mg, one time daily, 6/7/17 at 9:00 a.m., 6/14/17 at 9:00 a.m -DycoLax Powder, 17 gm one time a day, 6/7/17 at 9:00 a.m., 6/14/17 at 9:00 a.m. -[MEDICATION NAME] Tablet, 5 mg at bedtime, 6/16/17, 6/17/17, 6/18/17 at 9:00 p.m. -[MEDICATION NAME] Suspension Reconstituted, 40 mg/5 mL, one a day, 6/7/17 at 9:00 a.m -[MEDICATION NAME] Sodium Tablet, 220 mg, two times per day, 6/7/17 at 9:00 a.m., 6/14/17 at 9:00 a.m., 6/11/17 at 4:00 p.m., 6/12/17 at 4:00 p.m., 6/17/17 at 4:00 p.m., 6/18/17 at 4:00 p.m -Senna Tablet, 2 tablets, two times per day, 6/7/17 at 9:00 a.m., 6/11/17 at 9:00 p.m., 6/12/17 at 9:00 p.m., 6/14/17 at 9:00 a.m., 6/17/17 at 4:00 p.m., 6/18/17 at 4:00 p.m 16. Review of resident #5's MARs, dated 6/2017, showed no signature on the date and times for scheduled medications for the following: -[MEDICATION NAME] Tablet, 15 mg, at bedtime, 6/1/17 at 9:00 p.m., 6/5/17 at 9:00 p.m. -[MEDICATION NAME] Tablet, 20 mg, three times a day, 6/7/17 at 1:00 p.m., 6/8/17 at 9:00 p.m., 6/13/17 at 1:00 p.m., 6/14/17 at 1:00 p.m., 6/15/17 at 9:00 p.m., 6/17/17 at 1:00 p.m During an interview on 6/20/17 at 3:15 p.m., staff member O stated she had missed some spots on the MAR. She stated that no one checked the MAR to see if it was completed. During an interview on 6/20/17 at 4:15 p.m., staff member C stated she did not review the MARs for signatures and was not sure if medical records reviewed the MARs. Ann Perry and [NAME] Potter, Clinical Nursing Skills and Techniques, 5th ed., Mosby, Inc., St. Louis-Missouri, 2002, pg.449. After administering a drug, record the following information on the MAR or other appropriate form required by the institution: -Drug name -Dose -Route of administration -Time of administration -Any expected client responses -Pertinent data or assessment collected at the time of administration -Signature and title of nurse administering drug Once a medication is administered, the nurse is responsible for critically evaluating what is known about the client's condition, how the drug is looking for therapeutic effects as well as adverse outcomes. Should adverse outcomes develop, the nurse recognizes the clinical signs and responds quickly.",2020-09-01
897,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2017-06-22,309,D,0,1,07DD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure there was an exchange of information between the [MEDICAL TREATMENT] clinic and the facility following [MEDICAL TREATMENT] treatment as required for 1 (#11) of 15 sampled residents. The facility also failed to provide for ongoing physical assessment and monitoring of the resident after the resident returned to the facility following [MEDICAL TREATMENT] treatment. Findings include: Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She had been receiving [MEDICAL TREATMENT] at the local [MEDICAL TREATMENT] clinic every Monday, Wednesday, and Friday. The resident's MDSs, with ARD dates of 3/6/17 and 6/6/17, both showed resident #11's BIMS scores reflected she was cognitively intact. A review of resident #11's care plan, showed that the resident was at risk for impaired renal function and for complications related to [MEDICAL TREATMENT] on 3/21/15. It did not include use of the [MEDICAL TREATMENT] communication form or the establishment and maintenance of information flow regarding the resident's tolerance of [MEDICAL TREATMENT] treatment between the facility and the [MEDICAL TREATMENT] clinic. During an interview of 6/21/17 at 4:45 p.m., resident #11 stated she had completed a [MEDICAL TREATMENT] treatment and returned from the [MEDICAL TREATMENT] clinic to her room, at the facility, at approximately 3:30 p.m. The resident stated that she had taken a completed facility [MEDICAL TREATMENT] communication record form to the [MEDICAL TREATMENT] clinic that morning and gave it to the clinic staff. She said she had not been given a communication form by the clinic to return to the facility, when she left the clinic after her treatment. She said she was resting in bed because she had been more tired than usual following the completion of her [MEDICAL TREATMENT] treatment. Resident #11 denied having been seen or assessed by the facility staff since her return to the facility from the clinic. She said no one had taken her blood pressure or pulse rate since she had returned. The resident continued to say that at one time she brought back a form with [MEDICAL TREATMENT] information to the facility after receiving treatments. She still continued to take a communication form to the [MEDICAL TREATMENT] clinic from the facility on the days she had [MEDICAL TREATMENT], but that the [MEDICAL TREATMENT] clinic had not given her anything to bring back from the facility in a long time. She also said that facility staff did not usually take her vital signs or assess her [MEDICAL TREATMENT] when she returned to the facility after completing a [MEDICAL TREATMENT] treatment. During an interview of 6/21/17 at 5:00 p.m., staff member L stated she had not yet received a [MEDICAL TREATMENT] communication record form from the [MEDICAL TREATMENT] clinic for resident #11, following her [MEDICAL TREATMENT] treatment. She said normally the [MEDICAL TREATMENT] clinic faxed the form to the facility after they completed it, following the resident's [MEDICAL TREATMENT] treatment. She denied having taken resident #11's vital signs or having done a nursing assessment on resident #11, since her return to the facility following her [MEDICAL TREATMENT] treatment. She said that normally the facility, and the [MEDICAL TREATMENT] clinic, did not communicate by phone on a regular basis following the resident's routine [MEDICAL TREATMENT] appointments. A review of resident #11's MARs for (MONTH) (YEAR), showed (on page 2) that resident #11 received nine [MEDICAL TREATMENT] treatments between 6/1/17 and 6/22/17. Pretreatment vital signs had been taken for the purpose of completing the [MEDICAL TREATMENT] communication form sent to the [MEDICAL TREATMENT] clinic for eight of the nine [MEDICAL TREATMENT] treatments received. The resident's pretreatment weight had only been provided to the clinic once for the nine treatments the resident received. None of the spaces for post treatment vital signs were completed for any of the nine [MEDICAL TREATMENT] treatments received by resident #11 in the month of June. A review of resident #11's MARS for (MONTH) (YEAR), also showed that the resident's [MEDICAL TREATMENT] site was not checked for bruit or thrill eight times out of the scheduled 61 times it was scheduled to be done. It also showed the resident's arteriovenous fistula had not been evaluated for infection and/or bleeding eight times out of the 61 times it was scheduled to be done. It showed that resident #11's post treatment fistula site dressing had not been removed for 2 of the 9 [MEDICAL TREATMENT] treatments received by the resident. A review of the facility's policy, titled [MEDICAL TREATMENT] Communication and Documentation showed the following: 1. Prior to leaving the Center for outpatient [MEDICAL TREATMENT] treatment, a licensed nurse will complete the top portion of the [MEDICAL TREATMENT] Communication Record or the state required form and send with the patient to his/her out-patient [MEDICAL TREATMENT] center visit. 2. Following completion of the out-patient [MEDICAL TREATMENT] treatment, the [MEDICAL TREATMENT] nurse should complete the form and return it or other communication to the Center with the patient. 3. Upon return of the patient to the Center, a licensed nurse will: -Review the [MEDICAL TREATMENT] center communication: -Evaluate/observe the patient; and -Document the evaluation/observation on the [MEDICAL TREATMENT] Communication Record or state required form. 4. Notify the [MEDICAL TREATMENT] center if the form is not returned with the patient and ask that it be faxed to the Center. Document notification of [MEDICAL TREATMENT] center regarding return of form or other communication. 5. Maintain the [MEDICAL TREATMENT] Communication Record or state required form in the patient's medical record. During an interview on 6/22/17, at 7:30 a.m., staff member M stated, We were doing so well with the [MEDICAL TREATMENT] communication forms for a good while but we haven't been doing so well lately.",2020-09-01
898,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2017-06-22,371,E,0,1,07DD11,"Based on observation, record review, and interview, the facility failed to ensure food was served and stored in a sanitary manner, and non-food contact surfaces were kept clean in the main kitchen and kitchen units throughout the facility. Cleaning schedules were developed for the kitchen, but they were not comprehensive, and did not include all of the areas that required regular cleaning. Food stored in the kitchen units, throughout the facility, had incorrect expiration dates. This deficiency could affect all residents whom received food from the kitchen. Findings include: During an observation on 6/19/17 at 8:00 a.m., the following concerns were observed in the main kitchen, in the presence of staff member N: - At the base of the kitchen floors, including the door entry into the kitchen, the walk-in coolers, and freezers, was a heavy accumulation of dirt and black matter. -The walls throughout the kitchen had splattered food on them. -The walk-in freezer had approximately 12-inch-long icicles hanging down over boxes of food. During an interview on 6/19/17 at 8:15 a.m., staff member N stated that housekeeping was supposed to come in weekly to deep clean the kitchen floors but had not cleaned the floors for the past several months. During an interview on 6/20/17 at 8:40 a.m., NF2 stated the housekeeping staff was supposed to clean in the kitchen once per week, and they did not clean for the past several months because of staff turnover. She stated she had not learned how to use the new machine. She stated her staff was also responsible for sweeping and mopping the kitchen units on the floors. She stated the kitchen was responsible for cleaning the refrigerators and freezers. During an observation on 6/21/17 at 8:30 a.m., the following concerns were observed in the Solona kitchen unit, in the presence of staff member G: -A buildup of ice in the bottom of the freezer that was approximately four inches in diameter. -Sugar spilled on clean trays that were stored in the unit. -Water-like stains on the stainless steel counter, under the ice machine, that was not cleaned. -Food on floors of the kitchen, and in between refrigerators and counters. The floors were also sticky from spilled juice. -There was food stains on the tile walls in numerous areas of the unit. -The refrigerator had food stains on the inside of the doors, and the inside the refrigerator. -A container of yogurt was dated, 6/15/17 with black ink, but the containers used by date showed 7/7/17. It was unclear what the 6/15/17 date represented. During an interview, during the observation, staff member G stated the staff were supposed to write the received by date, opened date, and used by date on items. During an observation on 6/21/17 at 9:00 a.m., the following concerns were observed in the C-wing kitchen unit, in the presence of staff member G: -There was a juice stain on the kitchen floor. -There was food on the floors and in between the refrigerators and the counters. The floors were also sticky from spilled juice. -There was food stains on the tile walls. -The refrigerator had food stained on the inside of the doors and inside the kitchen. -There was a gallon of 2% milk in the refrigerator, without a date. -The freezer had homemade popsicles labeled with a resident name, but these were not dated. Review of the kitchen's Weekly Zone Cleaning Chart showed they did not have the kitchen units listed as a part of the cleaning schedule. Staff member G stated staff marked off completed items on the list as the staff cleaned the items week-to-week, but he did not keep weekly copies. Review of the facility's (Contracted Agency for cleaning) performance evaluation, completed by the administrator, dated 5/31/17, did not show where the kitchen units had been evaluated by the administrator. They were not apart of the cleaning log. During an observation on 6/19/17 at 4:30 p.m.,the facility's rehabilitation unit kitchenette was found to have the following: -One refrigerated 8-10 oz facility container, holding a dark brown thick liquid with labeling showing it was soy sauce, had been opened on 4/14/12, and had expired on 4/20/17. -One refrigerated 96 fl. oz container of Western Family 100% apple juice, half empty, with a resident's name on it, unexpired, but without a label indicating the container's opened date. -One refrigerated half empty container of brown liquid, labeled prune juice, without lid, and without any labeling of opened date or expiration date. During an observation on 6/19/17 at 4:40 p.m., the facility's acute care wing kitchenette was found to have the following: -Five refrigerated small containers of various fruit juices with lids, all unopened, with expiration dates of 4/28/17. -Two refrigerated small unopened containers of orange juice, one with an expiration date of 6/9/17, and the other with an expiration date of 6/15/17. -One refrigerated, opened, carton of 1% low fat Dairy Pure milk, with a resident's name on it and an expiration date of 6/3/17. During an observation on 6/19/17 at 4:45 p.m., an observation of the facility's kitchenette on the dementia care unit found the following: -One refrigerated, opened, 46 fl oz Sysco carton of thickened orange juice, unlabeled as to opened date. -Two un-refrigerated loaves of wheat bread, one bag had been opened, both with best if used by dates of 6/7/17. -One uncovered ice cream sundae did not have a name or date labeling. -Three facility filled pudding containers with unreadable smudged labeling. These were discarded. Staff member G accompanied the surveyor during the kitchenette observations and discarded or removed from patient access unlabeled and expired food as it was found. During this time, staff member G stated that the dietary department had the responsibility to check food expiration dates and remove outdated food items from the facility kitchenettes. He expressed that not having control over nursing staff, who use the areas, and facility residents frequently leaving food, which was stored in the kitchenettes, but not labeled by staff with names, opened dates made it difficult. No signs were observed to direct staff or residents to label or date food items.",2020-09-01
899,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2017-06-22,490,E,0,1,07DD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility administration failed to identify and implement a system to monitor outdated medical supplies, stored in the facility's medication store room. This had the potential to prevent or delay ordered medical treatment for [REDACTED].#24 IV administration needles, and unexpired Natural Fibertherapy medication for constipation. Findings include: During an observation of the facility's medication storage room on 6/19/17, at 4:00 p.m., a review of the expiration dates on the following items found in unlocked drawers and shelves, showed them to be outdated: -Two Bard-Dickinson lab vacutainer tubes with sterile urine specimen cup sets, outdated (MONTH) of (YEAR). -One opened box of #24 g, 0.75 in. Bard-Dickinson intravenous Insyte Autoguard needles, outdated (MONTH) of (YEAR). -Two unopened 13 oz. containers of Natural Fibertherapy Medication, original texture and regular flavor, outdated (MONTH) of (YEAR). During an interview on 6/19/17 at 10:00 a.m., staff member L stated she was responsible to restock medical supplies for the facility. She said she normally reviewed the expiration dates on the supplies when she checked items for re-stocking and discarded those that were expired. During an observation of the medication room supplies on 6/19/17 at 4:00 p.m., staff member R stated she didn't know who was assigned to do checking for supply and medication outdates. She did not know if the task was assigned to be done on a scheduled basis. During an interview on 6/21/17 at 7:30 a.m., staff member L stated she was unaware of any facility policy that assigned responsibility for checking and disposing of outdated medical supplies in the medication room. She said the nurses frequently restocked the medication room medical supplies at night, but she didn't know if anyone was checking for expiration dates when they restocked. A review of the facility's policy titled Storage and Expiration Dating of Drugs, Biologicals, Syringes, and Needles, showed the following: -Drugs and biologicals that have an expired date on the label or are after manufacturer/supplier guidelines/recommendations, or if contaminated or deteriorated, are stored separately, away from use, until destroyed or returned to the provider. A review of the facility's policy titled Disposal/Destruction of Refused, Discontinued, and Expired Medications, showed the following: -If destruction cannot occur immediately, outdated or discontinued medications in packaging from the pharmacy are stored in a double-locked cabinet/drawer/area until such time as destruction can occur. -The consultant pharmacist, nurse, or other appropriate pharmacy personnel inspects nursing station storage areas for proper storage compliance on a regularly scheduled basis. Neither policy addressed specifcally who had the responsibility for checking for outdated medications and medical supplies in the facility medication room. The facility was asked to provide any other facility policies that would have addressed this. None was provided to the survey team. No documentation of scheduled or completed dates when the medication room was checked for outdates of medications or supplies, was provided.",2020-09-01
900,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2018-08-23,561,D,1,1,4NKL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to ensure staff facilitated a resident's right to choose his preferred method of toileting for 1 (#115); failed to ensure a resident was given his pain medication as requested before his therapy sessions, and failed to review the resident's medications with him at the time of administration for 1 (#116) of 25 sampled residents. Findings include: 1. Resident #115 was admitted with [DIAGNOSES REDACTED]. During an observation and interview on 8/21/18 at 4:06 p.m., resident #115 asked staff member A and B to use the bathroom as he needed to have a bowel movement. Staff member A stated they placed resident #115 on the bed pan in his bed. She stated they could not transfer him into the bathroom to sit on the toilet because the lift would not fit in the bathroom. Resident #115 stated he would prefer to sit on the toilet and not use the bedpan to have a BM. Staff member A and B assisted resident #115 with a transfer to his bed. Staff member A and B applied a lift sling to resident #115 to assist him with the Sit to Stand lift. Resident #115 was able to lift his legs and placed them on the lift base. Staff member A locked the wheelchair brakes. Staff member B positioned the lift in front of resident #115. Staff member A and B applied the sling to the Sit to Stand lift. Staff member B slowly lifted resident #115 with the lift. Resident #115 held onto the lift handles and was able to bear full weight on both of his legs and stand in the lift. He was lowered onto his bed. Resident #115 was able to assist staff and lifted his legs off of the lift base to get into his bed. Staff member A and B stated resident #115 could use a commode in his room. Staff member A and B stated resident #115 was doing good with the Sit to Stand lift. Staff member A and B log rolled resident #115 and placed him onto the bed pan. During an interview on 8/21/18 at 4:06 p.m., staff member C stated resident #115 could not bear weight since return from the hospital but staff was going to order a sling, and care plan him to use a commode. She stated it was not safe for him or the staff to use a Sit to Stand lift. Review of resident #115's care plan, with a review date of 8/21/18, showed no interventions for staff to use a lift for transfers. Interventions listed showed resident #115 required limited assistance with toileting and was independent at times. The care plan showed under the focus area of .at risk for falls, with a revision date of 6/6/18, resident #115 required limited to extensive assistance when getting in and out of bed. The care plan showed under the focus area of .[MEDICAL CONDITION] ., with a revision date of 6/6/18, that staff was to encourage resident #115 to use the toilet upon awakening, after meals, HS and prn. Another intervention included was, offer and or assist resident with urinal/commode as requested/needed. Review of the facility task list, for bowel movements, recorded for resident #115, showed he had a medium sized bowel movement, on 8/22/18 at 12:47 p.m., and was assisted by staff member O. During an interview on 8/23/18 at 12:15 p.m., staff member O stated she used the Sit to Stand lift on 8/22/18 to transfer resident #115 onto the toilet in his bathroom. Staff member O stated the Sit to Stand did fit in resident #115's bathroom so he could use the toilet to have a BM. Staff member O stated if staff was not able to get the lift into the resident's bathroom, they could use other bathrooms in the facility that the lift would fit into allow him to sit on the toilet to have a BM. 2. Resident #116 was admitted to the facility for a short-term stay for therapy with [DIAGNOSES REDACTED]. During an interview on 8/21/18 at 9:47 a.m., resident #116 stated, in his opinion, he thought the facility was understaffed. Resident #116 stated if he asked someone a question it may or may not get taken care of right away, or the first time. He stated no one took notes. Resident #116 stated his main concern was he had to question everything regarding his medications because he did not get the medications he was supposed to, or when he asked for them. Resident #116 explained he had a history over several years of working with his provider to get his [MEDICATION NAME] as low as it could be to maintain his [DIAGNOSES REDACTED]. Resident #116 stated if he didn't get his correct dose of [MEDICATION NAME] he would be in too much pain to do his therapy. Resident #116 stated (staff member C's name) brought in his medications, and she did not bring all four tablets of [MEDICATION NAME], only one. He stated he told her he was supposed to have four. Staff member C was observed to go back to the medication cart and bring back the additional three [MEDICATION NAME] tablets. Resident #116 stated he wanted his pills removed from the container in front of him so he could ensure he was getting the correct medications. During medication administration observation on 8/22/18 at 8:40 a.m., staff member P was asked by the resident if the nurse would bring in his medication cards so he could observe them to make sure he was getting the correct medications. Staff member P stated she could not bring in all of resident #116's cards because it would be an infection control issue. Staff member P did agree she could bring a copy of resident #116's Medication Administration Record [REDACTED]. Resident #116 stated he would like a copy to mark off his medications when they brought them. Resident #116 stated, So today was not good because I have to have the right amount of [MEDICATION NAME]. It is frightening because I want to get well and if they don't give me the right amount it could take me out of remission. If I wasn't checking and asking about what they are giving me, I would not have had the right dose of my [MEDICATION NAME] today. I would have gotten 1 mg instead of 4 mgs. I don't trust them now. To solve the problem I want to see her get the pills out of the package, like they do at the hospital, so I can see what it is. I don't want to be a target either and make people mad. Review of resident #116's medication physician orders [REDACTED]. Request for pain medication administration prior to therapy sessions: During an interview on 8/21/18 at 9:47 a.m., resident #116 stated he was taking 5 mg of [MEDICATION NAME] for the pain in his right foot every four hours. He stated he now made it a point to ask for it so he knows he will get it on time. He stated when it was scheduled it was always late and they would bring it when he did not need it. Resident #116 stated he had told staff he wanted his pain medication before his therapy sessions. He stated the pain medication took about 30-45 minutes to kick in, and it helped him have a more productive therapy session. He stated he asked the nurse today to bring his pain medication at 10:00 a.m., so he could take it before his therapy appointment at 11:00 a.m. Resident #116 stated today, at 6:00 a.m., he requested his pain medication so he could go to therapy at 11:00 a.m. He stated the nurse did not bring him his pain medication until 7:00 a.m. Resident #116 stated the nurse told him she was sorry she did not get it to him until 7:00 a.m. Resident #116 stated the nurse told him she had been pulled from one end to the other. Resident #116 stated the nurse told him he would not get his next dose until 11:00 a.m. Resident #116 stated he told her that was not acceptable because he had set it up yesterday. Resident #116 stated the nurse told him she would let the therapist know that she didn't get his pain medication to him at 10:00 a.m., and she would reschedule his therapy for 12:00 p.m. Resident #116 stated that happened on a regular basis. He stated if his medications were on time it was more by accident than on purpose. He stated getting his medications on time doesn't seem to be a priority with staff, because it kept happening. He stated the staff always apologize and state they have been tied up.",2020-09-01
901,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2018-08-23,583,D,0,1,4NKL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to protect protected health information for 3 (#s 13, 51, and 53) of 25 sampled residents. Findings include: 1. During an observation on 8/20/18 at 12:45 p.m., staff member R was sitting with resident #13, who was having a hard time eating. Staff member R stated, (Resident) has to go through the VA to get his dentures approved, and he does not have any now and that is why he is having a hard time eating. This was said loud enough for other residents sitting at resident #13's table to hear. During an interview on 8/22/18 at 9:31 a.m., staff member R stated she should not of divulged resident #13's protected health information. She stated she should talk quietly when referring to residents protected health information to make sure no residents can hear her. 2a. During an observation on 8/21/18 at 7:48 a.m., the opened trash bin attached to the medication cart of the Memory Care Unit (MCU) contained an empty medication bubble card with Protected Health Information (PHI) for resident #51. The discarded medication card for resident #51 was for the benzodiazepine, [MEDICATION NAME], a controlled medication. The discarded medication bubble card had clearly visible PHI for resident #51. b. During an observation on 8/21/18 at 8:00 a.m., the opened trash bin attached to the medication cart of the MCU contained empty medication bubble cards with PHI for resident #53. One of the discarded medication cards for resident #53 was for the blood pressure medication, Altenolol, and the second was for the antidepressant, [MEDICATION NAME]. The discarded medication bubble cards had clearly visible PHI for resident #53. During an observation and interview on 8/21/18 at 10:25 a.m., the open trash bin attached to the medication cart of the MCU still contained the three discarded medication bubble cards for residents #51 and #53. Staff member F stated the medication cards had been in the trash bin when she arrived for her shift that morning. Staff member F stated the PHI from the discarded medication cards should have had the PHI removed and put in the shredder or the PHI blacked out with a marker prior to going into the trash can. Staff member F removed the PHI from the discarded medication cards and put them into the shredder. During an observation and interview on 8/23/18 at 11:20 a.m., staff member F stated anything discarded should not have any visible PHI. Staff member F held up three discarded medication cards with resident PHI blackened out with a black marker. Review of the facility's policy, Privacy Rights: Patient (sic), read, The patient (sic) has a right to personal privacy and confidentiality of his/her personal and medical records. Personal privacy includes accommodations, medical treatment, written, telephone and electronic communications, personal care, and meetings of family and patient (sic) groups .",2020-09-01
902,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2018-08-23,625,D,0,1,4NKL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a bed-hold notice when the resident was transferred to the hospital for 3 (#s 23, 62, and 64) of 25 sampled residents. Findings include: During an interview on 8/21/18 at 9:32 a.m., staff member D stated the facility did not provide bed hold forms to the resident, POA, or ombudsman if they were transferred to the hospital. He stated the facility did not charge the resident while in the hospital. 1. Review of resident #23's record showed the resident was transferred to the hospital on [DATE], due to [MEDICAL CONDITION] and possible urinary tract infection, and returned to the facility on [DATE]. 2. Review of resident #62's record showed the resident was transferred to the hospital on [DATE], for [MEDICAL CONDITION] and returned to the facility on [DATE]. Resident #62 was transferred to the hospital again on 6/24/18 for chest pain and returned to the facility on [DATE]. 3. Review of resident # 64's record showed the resident was transferred to the hospital on [DATE], for [MEDICAL CONDITION], and returned to the facility on [DATE].",2020-09-01
903,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2018-08-23,657,D,0,1,4NKL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to revise a resident's care plan to reflect the use of a Sit to Stand lift for 1 (#115); and failed to revise a resident's care plan to include the practice for a resident to not be in her wheelchair for more than two hours at one time for 1 (#20) of 25 sampled residents. Findings include: 1. Resident #115 was admitted with [DIAGNOSES REDACTED]. During an observation and interview on 8/21/18 at 4:06 p.m., resident #115 asked staff member A and B to use the bathroom. Staff members A and B assisted resident #115 with a transfer to his bed. Staff members A and B applied a lift sling to resident #115 to assist the resident #115 with the Sit to Stand lift. Resident #115 was able to lift his legs and placed them on the lift base. Staff member A locked the wheelchair brakes. Staff member B positioned the lift in front of resident #115. Staff members A and B applied the sling to the Sit to Stand lift Staff member B slowly lifted resident #115. Resident #115 held onto the lift handles, and was able to bear full weight on both of his legs and stand in the lift. Resident #115 was lowered onto his bed. Resident #115 was able to assist staff and lifted his legs off of the lift base to get into his bed. Staff members A and B stated resident #115 was doing good with the Sit to Stand lift. Review of resident #115's care plan, with a revision date of 6/6/18, showed a focus area that he required assistance with transfers. Listed in the interventions was, resident requires limited assistance with toileting. Is independent at times with toileting. Review of resident #115's care plan did not include an intervention that showed staff used a Sit to Stand lift for his transfers. 2. Resident #20 was admitted with [DIAGNOSES REDACTED]. During an observation on 8/22/18 at 10:34 a.m., staff member H provided wound care for resident #20. Signs above resident #20's bed showed she was not to be positioned on her back, and staff were to change her position every two hours. Review of resident #20's Medication Administration Record [REDACTED]. Review of resident #20's care plan, with a revision date of 6/20/18, showed a focus area that addressed she was at risk for skin breakdown. Interventions listed included resident #20 required assistance with repositioning while she was in bed, and to follow positioning recommendations made by the wound clinic. Resident #20's care plan did not include the interventions that staff reposition her every hour in her wheelchair, and that she should be in her wheelchair no more than two hours at a time.",2020-09-01
904,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2018-08-23,658,E,1,1,4NKL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to provide medications in a timely manner for 1 (#64); and failed to accurately show documentation of services completed on the Treatment Administration Record (TAR) twice during the survey, when the nurse documented the dressing changes were completed, but the dressing changes were not completed for, for 1 (#35) of 39 sampled and supplemental residents. Findings include: 1. During an observation on 8/22/18 at 7:40 a.m., staff member [NAME] was observed passing morning medications. Staff member [NAME] prepared medications for resident #64 which included, [MEDICATION NAME] 40 mg BID. Review of the MAR indicated [REDACTED]. Staff member [NAME] stated the night nurse was supposed to give the medication at 6:00 a.m., but since the night nurse did not sign the medication as given, she would give the medication to the resident. Staff member [NAME] gave the medication past the one hour time limit. 2. Review of resident #35's Treatment Administration Record (TAR) showed orders for the 3:00 p.m. to 11:00 p.m. shifts to Apply [MEDICATION NAME] (sic) dressing to coccyx area every evening shift for skin care until healed. Start date 7/17/18. On 8/21/18 at 9:39 a.m., staff had initialed in the TAR for that day, reflecting wound care to resident #35's coccyx had been completed. During an observation and interview on 8/21/18 at 10:33 a.m., staff member H cleansed resident #35's coccyx area with normal saline and applied an [MEDICATION NAME] dressing. Resident #35's coccyx pressure ulcer did not have a dressing covering the ulcer. Staff member H stated she had inadvertently signed off on resident #35's TAR prior to the dressing change being conducted. Staff member H stated she was called away after signing off on the TAR, which reflected the wound care had already been provided. Staff member H stated the TAR should only be signed when a procedure had been completed. During an interview on 8/21/18 at 1:55 p.m., staff member F stated she would have done the dressing change to the coccyx for resident #35, but the resident's TAR had already been signed when it was reviewed. Staff member F stated there had been some confusion regarding who would complete the dressing changes. Staff member F stated the confusion has only been a problem for a few months, and prior to that, everyone knew who was doing dressing changes and when the dressing changes were due. A review of resident #35's TAR, on 8/23/18 at 9:20 a.m., showed staff had initialed the TAR for 8/22/18, reflecting wound care to resident #35's coccyx had been completed. During an observation and interview on 8/23/18 at 10:23 a.m., staff member Q removed the serosanguineous saturated dressing from resident #35's coccyx area, dated 8/21/18. Staff member Q stated the dressing change had not been done on 8/22/18. During an interview on 8/23/18 at 10:55 a.m., staff member S stated she had initialed on the TAR on 8/22/18 that a dressing change had been done for resident #35's coccyx pressure ulcer. Staff member S stated she should have done it (the dressing change), but got busy and missed it, after documenting in the TAR that the dressing change and skin assessment had been completed. Staff member S stated she should have never documented a procedure was done prior to doing it because it could be easily forgotten. Staff member S stated the TAR should only be signed when a procedure had been completed. Review of the facility's policy, Wound Dressings: Aseptic, read, 1. Verify order and review Skin Integrity Report .19. Cleanse or irrigate wound as ordered .30. Document: 30.1 Patient's response to treatment .30.3 Treatment on Treatment Administration Record. Review of the facility's policy, Skin Integrity Management, read, .11. Document daily monitoring of ulcer site, with or without dressing .11.2 For wounds requiring daily dressing change or wounds without a dressing, monitor for signs of decline in wound status. 11.2.1 REFERENCE: [NAME] [NAME] Stokowski, Timely Medication Administration for Nurses: Fewer Wrong-Time Errors? - Medscape - [DATE], Medscape Nurses C 2012 WebMD, LLC, pg. 2 1. The window is extended to 1 hour for medications scheduled between every 4 hours and every 24 hours.",2020-09-01
905,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2018-08-23,676,D,1,1,4NKL11,"> Based on record review, interview, and observation, the facility failed to provided timely incontinence care, leaving the resident feeling ignored and smelling of urine for 1 (#46) of 25 sampled residents. Findings include: During an observation on 8/20/18 at 3:15 p.m., resident #46's room smelled like urine. During an interview on 8/21/18 at 1:56 p.m., staff member J stated the CNA staff would usually do a early morning check and change for resident #46, and then an end of shift check and change. During an observation on 8/21/18 at 1:57 p.m., resident #46 smelled strongly of urine. She stated she just peed her pants, and sometimes the staff just ignore me. I can't walk and can't use the bathroom. During an observation on 8/21/18 between 2:00 p.m. and 4:23 p.m., resident #46 remained in the wet brief, and still smelled of urine. During an observation on 8/22/18 at 9:31 a.m., resident #46 was transferred to the shower chair for a shower. Her brief was heavy and saturated with urine. During an observation on 8/22/18 at 1:42 p.m., resident #46 had a strong odor of urine. She stated she had probably wet her pants. Review of resident #46's incontinence flow sheets, dated 8/10/18, showed the resident was provided incontinent care at 9:14 a.m., and at 9:41 p.m., in a 24 hour day. The flow sheets from 8/11/18 through 8/22/18, showed the resident was provided incontinent care three times a day. During an interview on 8/23/18 at 10:55 a.m., staff member L stated staff must not be documenting enough, because resident #46 was a heavy wetter. Review of resident #46's Quarterly MDS, with the ARD of 7/30/18, showed the resident was extensive assist of two for toileting. Review of a facility Complaint/Incident Investigation Report, dated 5/15/18, showed resident #46 has to go around smelling like urine and feces, because the CNA's don't have time to change her. Review of a facility facsimile regarding resident #46, from a nurse practitioner, dated 7/20/18, showed Pt has a very strong urine odor today. Please provide adequate perineal care every time she is checked and changed. She needs to be checked and changed every 2-3 hours for incontinent episodes. During an interview on 8/21/18 at 12:20 p.m., staff member I stated the order was just a reminder for the staff.",2020-09-01
906,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2018-08-23,684,G,1,1,4NKL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure a resident received treatment and care to avoid obstipation resulting in the resident being sent to the emergency department to be evaluated for fecal impaction, and the resident admitted to the hospital, for 1 (#61) of 25 sampled residents. Findings include: During an interview on 8/22/18 at 3:16 p.m., staff member M stated the facility did not have a policy and procedure for a bowel protocol. She stated she received a report every morning from the Dash Board on the EHR, and she gave it to the nurses if a resident did not have a BM within 72 hours. She stated staff were to start with MOM and then a suppository. She stated if the suppository did not work within two hours, then the nurse called the doctor and would give a Fleets enema or other prescribed orders. Staff member M stated the admission physician's orders [REDACTED]. Resident #61 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #61's medical record showed she had a discharge to the hospital on [DATE], and was readmitted to the facility on [DATE]. Review of resident #61's emergency room medical records, dated 8/12/18, showed she presents by ambulance from a local nursing home with complaint of 'not feeling well' and not having a bowel movement for 9 days. The patient is very confused and when I asked how long her abdomen has been hurting she said 'forever.' She also thought it was 1988. According to nursing home she has had vomiting a couple times in the past 24 hours. She states she has been passing gas. The emergency room Exam notes showed resident #61 had, liquid stool at the anus and on digital exam there is hard impacted stool in the rectal vault. Documented under the heading Final Impression was, 1. Fecal impaction 2. Acute kidney injury. Resident #61 was admitted to the hospital from the Emergency Department. Review of resident #61's hospital Discharge Summary, dated 8/15/18, under the heading Hospital Course, showed resident #61, Presented from the nursing home in which she lives for complaining of not feeling well and not having a bowel movement for 9 days. On admission she was very confused and could not give an adequate history. She was nauseated and was vomiting frequently, so he (sic) was placed while aggressive bowel protocol was undertaken, and patient had several large bowel movements. At that point the NG was removed and patient was able to tolerate an oral diet. She was also diagnosed with [REDACTED]. Finally, she had significant [MEDICAL CONDITION] on presentation likely secondary to hypovolemia with vomiting, and this progressively improved during the course of her stay. On the day of discharge, the patient had returned to her mental baseline. She was ambulating, tolerating oral diet, and having multiple bowel movements . Review of resident #61's nurse's notes, dated 8/11/18 at 11:37 p.m., showed, Resident had x 3 episodes of emesis this evening. VS: 99.7, 92 HR, 14 RR, 168/80. Resident has hypoactive bowel sounds, last BM charting was 8/2. Digital rectum exam done and felt hard stool. Suppository given to resident. Resident resting at this time, no further episodes of emesis at this time. Review of resident #61's nurse's note, dated 8/12/18 at 3:33 a.m., showed, Resident with no results from previous [MEDICATION NAME] suppository -Fleet enema administered as per protocol. Rectal check with hard, firm stool noted. Review of resident #61's nurse's note, dated 8/12/18 at 4:51 a.m., showed, No results from Fleet Enema- resident had moderate dark brown liquid emesis. Abdomen soft, non distended, hypoactive BSx1 in left upper quadrant only. Resident C/O not feeling well. Dr (name) notified- order to send to ER for evaluation. Daughter (name) called and made aware. Review of resident #61's EHR task for bowel incontinence showed resident #61 had no BM from 7/27/18-8/2/18 then a medium BM was recorded on 8/2/18. The record showed resident #61 did not have a recorded BM from 8/3/18 until her discharge on 8/12/18. Resident #61 did not have a recorded BM for ten days, including the day she was sent to the emergency department for nausea and vomiting and hard stool in the rectum. During an interview on 8/23/18 at 2:40 p.m., staff member M stated the facility started a new process for concerns that will show on the dashboard for residents who did not have a BM for 72 hours. She stated the CNAs can not go back and look at the BM record on their EHR entries to see a history of events. She stated the facility realized resident bowel records were not being tracked and they needed to find another process to track residents' BMs to avoid what happened to resident #61.",2020-09-01
907,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2018-08-23,686,G,1,1,4NKL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to prevent the development and worsening of a coccyx pressure ulcer, and the pressure ulcer caused the resident pain, affecting 1 (#35) of 25 sampled residents. Findings include: During an observation and interview on 8/21/18 at 10:19 a.m., staff members R and U provided perineum care to resident #35. Resident #35 had an opened area, the size of a quarter, to the coccyx. The skin had a grayish appearance and resident #35 complained of pain when staff cleansed the area with wipes. Staff member R stated resident #35's coccyx area looked worse. Staff member U stated the coccyx ulcer should have had a dressing covering the area to provide protection and comfort. Staff members R and U stated they would inform the unit nurse. Review of resident #35's facility record showed, the resident was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. A BRADEN skin assessment was conducted at the time of admission with a result of 14; at moderate risk for developing a pressure ulcer. Admission skin assessment notes did not mention concerns with the skin on resident 35's coccyx. Review of resident #35's Admission MDS, with an ARD of 6/25/18, showed no in section M 0210; unhealed pressure ulcers. Review of resident #35's Treatment Administration Record (TAR) showed orders for the 3:00 p.m. to 11:00 p.m. shifts to Apply [MEDICATION NAME] (sic) dressing to coccyx area every evening shift for skin care until healed. Start date 7/17/18. During an observation and interview on 8/21/18 at 10:33 a.m., staff member H cleansed resident #35's coccyx area with normal saline and applied an [MEDICATION NAME] dressing. Resident #35 complained of pain when the coccyx pressure ulcer was touched. Staff member H stated the pressure ulcer appeared to have worsened, and that she would inform staff member Q so the wound could be reassessed and remeasured by a wound certified staff member. During an observation and interview on 8/23/18 at 8:33 a.m., staff members N and T provided perineum care to resident #35. There was a 4 x 4 [MEDICATION NAME] dressing, dated 8/21/18, on resident #35's coccyx. The dressing edges had begun to roll up, and were saturated with serosanguineous fluids, the dressing was no longer covering the coccyx pressure ulcer. Resident #35 hollered out because of pain when staff members N and T attempted to cleanse the coccyx area with wipes. There was an odiferous smell coming from the coccyx area, which had not been present during the observation on 8/21/18. Staff member N stated she would have the pressure ulcer reassessed and remeasured. Staff member T stated the pressure ulcer appeared worse and the smell was new. During an observation and interview on 8/23/18 at 10:23 a.m., staff member Q removed the serosanguineous saturated dressing, dated 8/21/18 from resident #35's coccyx area. Staff member Q stated the area looked worse from the previous assessment performed on 8/18/18. Staff member Q cleansed the area with normal saline and resident #35 complained of severe pain. Staff member Q stated resident #35's physician would be informed of the worsening pressure ulcer and treatment would begin immediately. Staff member Q stated she would ensure resident #35 was given pain medication for the severe pain experienced during the pressure ulcer assessment and dressing. Staff member Q stated she had not been informed on 8/21/18, that resident #35's coccyx area looked worse. During an interview on 8/23/18 at 10:55 a.m., staff member S stated she had not changed the dressing to resident #35's coccyx pressure ulcer on 8/22/18. Staff member S stated she should have done it, but it got busy and I missed it. During an interview on 8/23/18 at 1:11 p.m., staff member Q stated resident #35 had a worsening Stage II pressure ulcer that should have been treated more aggressively since resident #35 had not been admitted to the facility with any open areas to the coccyx. A review of resident #35's nurse's notes reflected the following: - 7/2/18 at 3:09 a.m., Note: This is a follow-up from the change in condition-medical that occurred on 7/2/18. Status of condition: no change. Data: dressing to coccyx area intact; slept this shift. Action: will continue to monitor. Response: no s/s of pain noted. - 7/2/18 at 8:47 a.m., .Pressure Area(s): Location(s): Blister to coccyx, fluid filled, purplish. Area cleansed and opti-foam gentle (sic) applied . - 7/3/18 at 3:09 a.m., Data: blister intact. - 7/8/18 at 10:02 a.m., Observations: Wound to coccyx c/d/I (clean, dry, intact) and good granulation noted. pink (sic) margins . - 7/10/18 at 1:41 p.m., Note: treatment to coccyx and both legs, all are improved turned and repositioned. Will on occasion turn self back on to back. - 8/5/18 at 10:00 p.m., Observations: [MEDICATION NAME] to coccyx area looking better . - 8/6/18 at 7:20 a.m., MASD: Location(s): Coccyx improved, healing. - 8/23/18 at 12:53 p.m., resident c/o pain upon cleansing of wound but does display decreased pain upon cessation of wound care. Wound measures 2 cm x 1.3 cm x 0.2 cm. Wound has macerated edging and visualized sloughing in wound bed. Notified MD at approximately 1050 (sic) awaiting further instruction. Also notified residents (sic) husband (his name) of residents change of condition/wound worsening. A review of a Skin Integrity Reports for resident #35 showed: - 7/16/18: a 50% granulated, 1.7 cm x 0.3 cm wound draining serous fluids with healthy surrounding tissue and wound edges. The wound was not odorous. - 7/24/18: stage zero, 50% granulated, 1.3 cm x 0.2 cm wound draining serous fluids with healthy surrounding tissue and wound edges. The wound was not odorous. - 8/1/18: stage zero, 75% granulated, 1 cm x 1 cm wound draining serosanguineous fluids with healthy surrounding tissue and wound edges. The wound was not odorous. - 8/10/18: stage zero, 75% granulated, 0.5 cm x 0.5 cm wound draining serosanguineous fluids with healthy surrounding tissue and wound edges. The wound was not odorous. - 8/18/18: non-staged, 50% granulated, 1.2 cm x 1.0 cm wound draining serosanguineous fluids with healthy surrounding tissue and wound edges. The wound was not odorous. A review of Verbal Orders from resident #35's physician, dated 8/23/18 at 2:10 p.m., read, Cleanse affected area (coccyx) with NS/WC (normal saline/wound cleanser), pat dry, apply silver alginate to wound bed, cover with foam dsg. every evening shift for wound care for 14 days. Cleanse affected area (coccyx) with NS/WC, pat dry, apply silver alginate to wound bed, cover with foam dsg. Review of the facility policy, Skin Integrity Management, read, The implementation of an individual patient's (sic) skin integrity management occurs within the care delivery process. Staff continually observes and monitors patients (sic) for changes and implements revisions to the plan of care as needed. Notify Medical Director, Center Nurse Executive, and Center Executive Director if deviation from protocol is requested by physician/advanced practice provider, managed care company, or others .3.4. Perform daily monitoring of wounds or dressings for presence of complications or declines and document .11. Document daily monitoring of ulcer site, with or without dressing .11.2 For wounds requiring daily dressing change or wounds without a dressing, monitor for signs of decline in wound status. 11.2.1 If unanticipated decline in wound, surrounding tissue, or new or increased wound pain, complete the Skin Integrity Report and notify physician/APP (sic).",2020-09-01
908,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2018-08-23,689,E,0,1,4NKL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify the direct or underlying root causes for multiple falls for a resident who had dementia, was on an antipsychotic, had limited mobility, and was a high fall risk; and failed to identify and implement interventions to prevent ongoing falls in which minor injuries occurred, or evaluate the care plan fall interventions to determine if the interventions were beneficial to the resident's safety, for 1 (#48); and failed to identify the root cause, and implement and monitor interventions for effectiveness, to include, providing adequate supervision, for the prevention of falls, for 1 (#13) of 25 sampled residents. Findings include: a. During an observation on 8/23/18 at 1:30 p.m., resident #48 stood up from his wheel chair and appeared unsteady. He stood and looked around for about 15 seconds before staff member P noticed him standing up. Staff member P was behind the nurse's station working on the computer. She quickly went over to the resident and stated (Resident) what are you doing, can you sit down for me please? The following concerns were identified related to resident #48's falls: 1. Lack of Evaluation of Hazards and Risk: Review of Resident #48's Progress Notes showed his admitted to the facility was 7/18/18. A review of resident #48's Progress Note for 7/18/18 read admitted from the hospital in wc/ Alert very confused poor safety awareness. Resident was living alone and had fallen many times. He had a fall risk assessment score of 21 indicating he was a high risk for falls. Review of resident #48's Progress Notes showed he had ten falls from 7/18/18 - 8/8/18. Review of resident #48's Order Summary Report showed an order date of 7/18/18, [MEDICATION NAME] Tablet 0.5 MG Give one tablet by mouth one time a day for Dementia. There was not an end date listed on the Order Summary Report, but it showed the order status was discontinued. Review of resident #48's Progress Notes on 7/18/18 showed, [MEDICATION NAME] increased to 1 mg in the evening. This occurred after the fall that occurred that day. The record did not reflect why specifically the [MEDICATION NAME] was needed, or attemps to utilize alternate interventions other than [MEDICATION NAME]. Review of resident #48's Care Plan showed Focus: Resident at risk for falls: cognitive loss, lack of safety awareness and [MEDICAL CONDITION] drug use and hx of falls occurring on 7/18/18, 7/19/18, 7/24/18; 8/2 resulting in ST; 8/5/18. Fall 8/08/18. This area of the care plan was not initiated until 7/26/18. The facility initially identified the resident had a history of [REDACTED]. He had already had four falls prior to 7/26/18, while residing at the facility. Review of resident #48's facility RMS (Risk Managment System) Event Summary Reports showed he had three falls with an injury (one head injury and two skin tears). Five falls were at the nursing station. b. Lack of - Evaluation/Fall Analysis: Review of resident #48's Progress Notes for the fall events showed a lack of identification for the location of the falls, four out of ten times. For seven of the falls, the facility did not identify the direct or underlying root cause of the falls, therefore, interventions implemented, were not beneficial for the prevention of the root causes. Review of resident #48's Progress Notes showed the resident's fall on 7/31/18 was due to the residents increased agitation from searching for a cigarette, which was believed to be the largest impact in his impulsiveness that had resulted in his documented falls. Review of resident #48's Progress Notes showed falls on the dates of 7/18/18, 7/19/18 (2), 7/24/18, 8/5/18 (2), 8/6/18, and 8/8/18, did not have the direct root cause of the falls documented. Review of resident #48's Order Summary Report and Progress Notes, showed an order date of 7/18/18, [MEDICATION NAME] Tablet 0.5 MG Give one tablet by mouth one time a day for Dementia. There was not an end date listed on the Order Summary Report but it showed the order status was discontinued. Review of resident #48's Progress Notes showed resident #48 fell on [DATE]. The progress note then showed [MEDICATION NAME] increased to 1 mg in the evening. Review of resident #48's Progress Notes, showed he had a fall on 7/19/18 at 12:20 p.m., the day after he had the [MEDICATION NAME] increased. Documentation failed to show if the increase in [MEDICATION NAME] was a consideration for an increased risk factor for falls. Review of resident #48's Progress Notes, dated 8/6/18 at 7:43 p.m., showed In bed this shift, drowsy. Review of resident #48's Progress Notes dated 8/7/18 at 9:00 a.m., showed Continues confused drowsy; and at 11:11 a.m. Is very lethargic remains in bed not taking food, liquid or meds, unable to sit in wc. c. Lack of - Interventions and monitoring: Review of resident #48's Admission MDS, with an ARD of 8/1/18, showed he had a BIMs of 3.0 - Severe Impairment. Section B., Inattention, showed Did the resident have difficulty focusing attention, for example being easily distracted or having difficulty keeping track of what was being said? The question was marked with a 1 meaning Behavior continuously present, does not fluctuate. Review of resident #48's Progress Notes shows no evaluation of the effectiveness of interventions from admission to the date of the survey. For the fall dated 7/18/18, the medical record showed interventions identified included the bed in low position and monitoring every 30 minutes. Review of resident #48's care plan showed the intervention of lowering the bed, from the fall on 7/18/18, was not added on the care plan until 7/26/18. The intervention of monitoring every 30 minutes was not added to the resident's care plan. For the fall dated 7/19/18 at 3:38 a.m., the record showed no new interventions were put in place for the prevention of future falls. The care plan was not updated until 7/26/18. Review of resident #48's Medication Administration Record, [REDACTED]. Resident #48 had an order for [REDACTED]. -7/28/18 at 11 p.m. - 7 a.m. -7/29/18 at 11 p.m. - 7 a.m. -7/30/18 at 7 a.m. - 3 p.m -7/31/18 at 7 a.m. - 3 p.m. - 8/2/18 at 7 a.m. - 3 p.m. -8/2/18 at 3 p.m.-11 p.m. - 8/6/18 at 7 a.m. - 3 p.m. -8/15/18 at 3 p.m. - 11 p.m. Review of resident #48's Progress Notes showed he had a fall on 8/2/18 at 11:50 p.m. His pain was not monitored on 8/2/18 during the 3p-11 to determine if pain was a potential contributor to the resident's comfort, agitation, or fall risk. The resident's medical record showed back pain was a concern for the resident, which may be a contributing factor to the resident's comfort if he was seated for long periods, or became agitated. The back pain was not consistently documented as a concern related to his falls, or a potential contributing factor. d. Lack of supervision: During an observation on 8/23/18 at 1:04 p.m. resident #48 was not monitored by staff, sitting behind the nurses station, looking at a newspaper. Review of resident #48's Progress Note, dated 7/20/18, showed needs constant supervision. During an interview on 8/23/18 at 9:25 a.m., staff member P stated the resident had dementia, and he should be on a one-on-one for supervision because he wanders, but they do not have enough staff for that. She stated that they try to sit him at the desk, and give him magazines to look at to keep him busy. e. Smoking: Review of resident #48's Progress Note, dated 7/18/18, showed resident #48 was admitted from the hospital and Family states resident is a chain smoker hasn't smoked since hospitalization nicotine patches are ordered here. (sic) Review of resident #48's Progress Notes showed on 7/20/18, Resident has been occasionally agitated, cursing at staff tonight. Resident resting/sleeping for approximately 3 hours. Asking to smoke and trying to solo transfer, has removed his oxygen. Review of resident #48's Progress Notes, dated 8/1/18, showed Upon investigation resident has dx of dementia with behavioral symptoms. Since resident admission on 7/18/18 his confusion has significantly increased, he continually attempted to stand despite staffs attempts to both redirect him and provide distraction. Resident does have strong hx of Smoking with 70yr 3 pk a day cigarette smoking hx he continues to reach and search for them as a result he had noted increased agitation that is believed to be the largest factor in his impulsiveness that has resulted in documented falls. No interventions were identified or added to the care plan related to smoking and the risk this included related to falls. The resident's lack of smoking increased his agitation and desire to stand and go smoke. 2. During an interview on 8/23/18 at 10:42 a.m., staff member I stated the facility looked at the 5 whys for falls, drew a picture of the fall, and put interventions into effect immediately. She stated this process began after resident #13's falls. Review of resident #13's Care Area Assessment, dated 6/7/18, and Event Summary Reports, showed the resident fell seven times in the last four months: 4/14/18, 4/17/18, 5/28/18, 5/30/18, 6/10/18, 6/12/18, and 6/18/18. All falls were in the residents's room. One fall was witnessed. Review of the resident #13's Event Summary Reports for each fall, showed no root cause was identified, and no monitoring for the effectiveness of interventions was completed. Review of resident #13's Progress Note, dated 6/1/18, showed the resident had poor safety awareness along with mild behavior issues. On 5/30/18 resident unsafely stood from wheelchair with brakes unlocked, and on 5/28 attempted to transfer without assistance. Safety cues and reminders to lock brakes and ask for assistance using call light and frequent safety checks. During an interview on 8/23/18 at 12:30 p.m., staff member L stated she thought the resident fell intentionally for attention. Review of resident #13's Progress note, dated 6/1/18, showed the resident had an increase in [MEDICATION NAME] despite multiple falls. There was no rationale provided for the increase of the [MEDICATION NAME]. Review of resident #13's Progress note, dated 6/18/18, showed Wife here and talked to DON about [MEDICATION NAME] dosage, they are checking into it. Currently 1 mg QID, speech is slurred, multiple falls. Review of resident #13's Antipsychotic Care Area Assessment, dated 6/7/18, showed adverse consequences of Anxiolytics exhibited by this resident included sedation and disturbances of balance and gait. Review of resident #13's Annual MDS, with the ARD of 6/6/18, showed the resident received a daily antipsychotic, antianxiety, and antidepressant, which all three medication side effects can contribute to falls. During an interview on 8/23/18 at 12:56 p.m., staff member M said the facility had no other documentation regarding the fall investigations. She stated the facility had initiated a new fall policy and procedure, recently. Review of resident #13's Fall Care Plan, showed: 1. Encourage resident to wear proper foot wear prior to ambulation or transfer (fell on ,[DATE]). 2. Re-educate and remind resident to ask for assistance to transfer and ambulate. Frequent check for safety. 3. Reminders to lock brakes. 4. Safety cues and reminders for safety. 5. Place call light within reach while in bed or close proximity to bed. 6. Remind resident to use call light. 7. Monitor for and assist toileting needs. The root cause for the falls was not established, and the interventions were not specific to resident #13. The fall on 8/1/18 was not documented in the electronic record or on the fall log.",2020-09-01
909,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2018-08-23,692,E,1,1,4NKL11,"> Based on observation, record review, and interview, the facility failed to provide sufficient fluid to maintain proper hydration for 1 (#003); and failed to offer fluids to the residents on the C wing. Findings include: During an observation and interview on 8/21/18 at 9:10 a.m. resident #003 did not have water in a cup in her room. She stated her lips were chapped often because she did not get enough water. During an interview on 8/23/18 at 12:05 p.m. Staff member O stated that staff do not go around to rooms and pass water routinely at the facility. She said they just fill water cups if they think of it, or if a resident asks. During an observation on 8/20/18 at 3:37 p.m., room numbers' 136, 147, 149A and B, and 139A and B did not have blue water pitchers in the rooms available with fluid for the resident. Review of the facility Complaint/Incident Investigation report, dated 5/15/18, showed, The residents do not get fresh water because they do not have a water cooler and staff do not feel like they have the time to pass ice and water. During an interview on 8/21/18 at 10:06 a.m., staff member J stated it was up to the CNAs to pass water to the residents. During an observation and interview on 8/22/18 at 2:53 p.m., a large water container was in the C hall, filled with ice and water. Staff member [NAME] stated there had been some big to do when the weather was hot, and the water jugs had just appeared. She also stated there were supposed to be enough blue water pitchers to cover two shifts. During an observation and interview on 8/23/18 at 9:16 a.m., the nursing hydration room contained no blue water pitchers. Staff member [NAME] stated she was concerned about resident hydration, and she always gave the residents water with their medications. During an observation on 8/22/18 at 4:07 p.m., room numbers 141 and 142 had no water pitchers in their room the entire day. During an observation and interview on 8/23/18 at 3:46 p.m., the water jug in the hallway was still full from the day prior. Staff member [NAME] stated the water jugs were probably used by staff more than residents. During an observation on 8/22/18 at 1:53 p.m., resident #46 had a bottle of water on her bedside table. She stated her family brought it in so she would drink more water. Review of the facility Hydration Policy, dated 3/01/16, showed: 1. Provide clean containers for water at patient's bedside. 2. Rinse and refill containers with ice and water each shift, and as necessary. 3. Keep pitcher within patient's reach. 4. If disposable cups/containers are used, replace daily. The Purpose: to promote adequate hydration for our patients. Surveyor: Burns, Ellen",2020-09-01
910,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2018-08-23,755,D,0,1,4NKL11,"Based on observation, interview, and record review, the facility failed to waste a controlled substance during a medication administration for 1 (#002) out of 39 sampled and supplemental residents. Findings include: During a medication administration observation on 8/22/18 at 9:40 a.m., staff member P administered resident #002 her morning medications that included the Schedule IV benzodiazepine controlled drug Clobazam. Staff member P unlocked the narcotic drawer in the medication cart and removed the bubble pack card of Clobazam. Staff member P removed one tablet from a closed bubble in the card. Another bubble in the card had a Clobazam pill broken in half and placed back in the bubble pack with tape on the back to hold it in the bubble. Staff member P stated she asked about that this morning and she thought the pharmacy should be putting them in the bubble pack for them. She stated her concern for taking two out and placing another 1/2 tablet back in the package was the drug could be substituted for another drug, and the controlled drug diverted. She stated she has never had to do this before with a controlled medication. The bubble pack contained one pill in each bubble. She stated she and the other nurse discussed the issue this morning during report. Review of resident #002's Medication Administration Record [REDACTED]. During an interview on 8/23/18 at 3:43 p.m., staff member V stated staff should not do that (return 1/2 pill to the bubble pack). He stated the half pill should be destroyed with two nurses and recorded in the narcotic book. Staff member V stated, We have addressed the issue, and they should have destroyed the 1/2 tablet, and documented with another nurse. Review of the facility policy and procedure titled Controlled Drugs: Management of, with an effective date of 8/1/18, showed nursing staff who administer medication will safeguard controlled drugs. Under the heading Destruction, the policy and procedure showed two licensed professionals are required to destroy and document the destruction of controlled drugs.",2020-09-01
911,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2018-08-23,757,D,0,1,4NKL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to evaluate the effectiveness of a [MEDICAL CONDITION] medication, [MEDICATION NAME], which caused sedation, confusion, and excessive drowsiness, and increased the risk for fall, and the resident had repeated falls, for 1 (#48) of 25 sampled residents. Findings include: During an interview on 8/23/18 at 9:25 a.m., staff member P stated the reason resident #48 is on [MEDICATION NAME] is because he has dementia and was aggressive. Resident #48 really should be a one-on-one for supervision because he wanders, we tried to sit with him at the desk when we can and give him magazines to look at. We have to watch him constantly and we do not have the staff . Review of resident #48's Order Summary Report, dated 7/18/18, stated [MEDICATION NAME] Tablet 0.5 MG give one tablet by mouth one time a day for Dementia. There was not an end date listed on the Order Summary Report, but it showed the order status was discontinued. Review of resident #48's Progress Notes showed resident #48 fell on [DATE]. The progress note showed, [MEDICATION NAME] increased to 1 mg in the evening. The Progress Note failed to reflect why the medication was increased, the need for it, or monitoring for the use of the medication. Review of resident #48's Order Summary Report showed [MEDICATION NAME] Tablet 1 MG Give 1 tablet by mouth in the evening related to unspecified dementia with behavioral disturbance. Review of resident #48's Progress Notes showed he had a fall on 7/19/18 at 12:20 p.m. The fall occurred after the increase of [MEDICATION NAME] to 1 mg on 7/18/18. Review of resident #48's Progress Notes dated 8/6/18 at 7:43 p.m., showed In bed this shift, drowsy. Review of resident #48's Progress Notes, dated 8/7/18 at 9:00 a.m., showed Continues confused drowsy. On 8/7/18 at 11:11 a.m., Is very lethargic remains in bed not taking food, liquid or meds, unable to sit in wc. Review of the Change of Condition Medication Regimen Review Report, dated 8/22/18, from the Pharmacy, showed (Resident #48) was noted to be experiencing new onset or worsening of falls, dizziness or impaired coordination as indicated on a change of condition medication regimen review request completed by the facility. He is receiving [MEDICATION NAME] 1 mg daily, and this can cause sedation, postural [MEDICAL CONDITION], dizziness and falls. Please evaluate above noted medications as contributing to this change in status, and consider any clinically appropriate dosage reductions. The Change of Condition Medication Regimen Review Report, dated 8/22/18, was not filled out by a doctor accepting or denying the recommendations.",2020-09-01
912,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2018-08-23,759,E,1,1,4NKL11,"**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 3 (#s 40, 64 and 116) of 39 sampled and supplemental residents. The facility medication error rate was 6.5%. Findings include: 1. During an observation on 8/22/18 at 7:40 a.m., staff member [NAME] was observed passing morning medications. Staff member [NAME] prepared medications for resident #40, which included [MEDICATION NAME] 10 mg BID for seven days. There were three pills left in the bubble pack after staff member [NAME] popped out the one pill she gave the resident that morning. There should have been one pill left after giving the resident her morning dose. The order on the resident's MAR indicated [REDACTED] Staff member [NAME] prepared medications for resident #64 which included [MEDICATION NAME] 40 mg BID. Review of the resident's MAR indicated [REDACTED]. Staff member [NAME] stated the night nurse was supposed to give the medication at 6:00 a.m., but since the night nurse did not sign the medication reflecting it had been given, she would give the medication to the resident. Resident #64 had a physician's orders [REDACTED]. Review of the resident's MAR for (MONTH) (YEAR) showed the medication was signed off as given. Review of the resident's (MONTH) (YEAR) MAR indicated [REDACTED]. Staff member [NAME] stated she would need to get clarification from the physician. The physician discontinued resident #64's [MEDICATION NAME] on 8/22/18 while at the facility. Resident #64 did not receive the medication for twenty-two days. 2. Resident #116 was admitted to the facility for a short-term stay for therapy with [DIAGNOSES REDACTED]. Review of resident #116's medication administration showed he was prescribed [MEDICATION NAME] 125 mcg give one tablet by mouth in the morning related to his [DIAGNOSES REDACTED]. Review of resident #116's (MONTH) and (MONTH) (YEAR) Medication Administration Record [REDACTED]. During a medication administration observation and interview on 8/22/18 at 9:00 a.m., staff member P administered resident #116 his prescribed medications. Staff member P administered resident #116's [MEDICATION NAME] 125 mcg and did not check his pulse prior to administering the [MEDICATION NAME]. Staff member P stated she did not check his pulse because there was no indication on the Medication Administration Record [REDACTED]",2020-09-01
913,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2018-08-23,761,E,0,1,4NKL11,"**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 and insulin pens, being administered to residents, were dated when opened, and not being used past the open-expiration date of 28 days; and failed to ensure irrigation solution and liquid [MEDICATION NAME] were dated when opened for 8 (#s 001, 7, 11, 17, 28, 47, 52, 60, and 117) of 39 sampled and supplemental residents. Findings include: 1. During an observation of the medication cart for rooms ,[DATE], at [DATE] at 1:30 p.m., the following items were observed to be open and without an opened date: - two opened [MEDICATION NAME] flex pens for resident #17 - two opened 1000 cc bottles of Acetic Acid 0.25% irrigation solution for resident #7 During an observation of the medication cart for rooms ,[DATE], at [DATE] at 1:40 p.m., the following items were observed to be open and without an opened date: - one opened [MEDICATION NAME] flex pen for resident #47 - one opened vial of [MEDICATION NAME]for resident #47 - one opened vial [MEDICATION NAME] for resident #11 - one opened vial [MEDICATION NAME] for resident #47 (dated [DATE], which was past the 28 day use after opening date) During an observation of the medication room on [DATE] at 1:50 p.m., staff member Q stated she was not sure but thought the night nurses checked the medication room for outdated medications. The refrigerator contained an opened bottle of liquid [MEDICATION NAME] for resident #001 with 17 milliliters in the bottle. There was no open date on the bottle and staff member Q stated resident #001 was deceased . She stated when someone passed away the medications are usually destroyed after twenty-four hours. Staff member Q stated the [MEDICATION NAME] must have been missed. There was one box of Tylenol Cold +Flu Severe opened with an expiration date of [DATE]. There were six caplets left in the box of twenty-four caplets. During an observation of the medication cart for rooms ,[DATE] on [DATE] at 2:00 p.m., the following items were observed to be open, and without an opened date: - one opened Tresiba flex pen for resident #60 - one opened [MEDICATION NAME] R 500 pen with no name on it During an observation of the medication cart for rooms ,[DATE], on [DATE] at 2:10 p.m., the following items were observed to be open and without opened date: - one opened [MEDICATION NAME] pen for resident #117 - one opened Toujeo pen for resident #52 - one opened [MEDICATION NAME] pen for resident #60 During an interview on [DATE] at 1:30 p.m., staff member [NAME] stated she had used one of the [MEDICATION NAME] flex pens that morning to give resident #17 twenty-five units of insulin. During an interview on ,[DATE] at 1:50 p.m., staff member Q stated she was not sure but thought the night nurses checked the medication room for outdated medications. Staff member Q stated resident #001 was deceased . Staff member Q stated the [MEDICATION NAME] must have been missed. She stated when someone passed away the medications are usually destroyed after twenty-four hours. During an interview on [DATE] at 2:00 p.m., staff member P stated she had used the Tresiba flex pen that morning for resident #60. She stated the pen should have been dated. Staff member P stated she did not know who the [MEDICATION NAME] RU 500 pen belonged to. Review of the pharmacy policy titled, 6.0 General Dose Preparation and Medication Administration, that the facility used showed in section 6.1, Document necessary medication administration/treatment information (e.g., when medications are opened, when medications are given, . 2. During an observation and interview on [DATE] at 9:19 a.m., staff member F stated resident #28 was the only resident on the Memory Care Unit (MCU) to be receiving insulin with a multi-dose pen. An opened, undated, [MEDICATION NAME] 100 units/ml insulin pen for resident #28 was in the top drawer of the medication cart. Staff member F stated resident #28 had been transferred to the MCU from another area of the facility a few weeks prior. Staff member F stated the [MEDICATION NAME] pen had not been dated, and that she had given resident #28 his dose of insulin that morning at 8:00 a.m., from that [MEDICATION NAME] pen. Resident #28 had been admitted to the facility with [DIAGNOSES REDACTED]. A review of resident #28's MAR indicated [REDACTED]. During an observation and interview on [DATE] at 9:05 a.m., staff member F administered 25 units of [MEDICATION NAME] to resident #28 using the undated [MEDICATION NAME] pen. The pen had not been replaced and had not been dated when opened. Staff member F stated the [MEDICATION NAME] pen had been the same pen from the day before, and that she had planned on replacing the undated pen with a new insulin pen, and had planned to date it when opened.",2020-09-01
914,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2018-08-23,804,E,0,1,4NKL11,"Based on observation, records review, and interview, the facility failed to provide palatable pureed food, prepared according to the menu, without a recipe; and failed to serve pureed food at an appealing temperature for 2 (#s 11 and 43) of 25 sampled residents. Findings include: During an observation on 8/21/18, resident #43 received pureed ham, carrots, and potatoes, instead of the pureed Shepherd's pie on the menu. During an interview on 8/21/18 at 1:10 p.m., staff member W stated the Shepherd's pie was not ready to be pureed so they chose to puree another meat. During an observation on 8/22/18 at 12:35 p.m., resident #43 received pureed soup, and pureed beef and a vegetable. The menu call for tuna salad sandwich and a cucumber and tomato salad. The resident stated he did not know what the foods were, and they tasted awful. I have to put sugar on all my food. During an interview on 8/22/18 at 2:50 p.m., staff member X stated resident #43 always puts sugar on his food. During a sample tray on 8/22/18 at 12:56 p.m., the pureed food was cold. The pureed food was not in the steam table, but sitting on top of the steam table rather than being maintained with a heat source. During an interview on 8/23/18 at 1:02 p.m., staff member X stated he did not know the pureed items should be in the steam table. He also stated the pureed food had been prepared cold, and then warmed up. During the lunch observation on 8/20/18 at 12:43 p.m., the alternate meal choice was chicken fricassee. The alternate provided was ground chicken instead of whole chicken. Resident #11 said the ground chicken tasted awful. During an observation on 8/23/18 at 11:51 p.m., staff member X pureed the chicken into a thin pancake-like consistency. When he was asked if that was the final product, he stated he would have to thicken it with a thickener. He stated, There's no way to get pudding or mashed potato consistency without thickener. When asked if he had a recipe for the pureed foods, he stated the facility did not have pureed recipes.",2020-09-01
915,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2018-08-23,880,D,1,1,4NKL11,"> Based on observation, interview, and record review, the facility staff failed to perform proper hand hygiene after removing their gloves for 1 (#7) out of 25 sampled residents; and failed to perform hand hygiene prior to providing assistance to those residents in the the dining room. Findings include: 1. During an observation on 8/22/18 at 10:04 a.m., staff members H and J provided perineal and wound care for resident #7. Staff member J placed gloves on her hands, while staff member H opened the wound cleaning supply packages, and then donned gloves. Resident #7 rolled to her left side while staff member J assisted her to stay on her right side. Staff member H provided perineal care as the resident was incontinent of stool. Staff member H wiped from the resident from front to the back with an incontinent wipe, and placed the wipe in the garbage. The staff member then pulled out more wipes from the package and cleaned the resident and placed those wipes in the garbage. The staff member then pulled more wipes out of the package. BM dropped from the soiled wipe onto the bed and the package. Staff member H wiped the stool off the bed and wipe package with a wipe and placed the wipe in the garbage. Staff member H removed her gloves, walked over to the wall by the door, grabbed a box of gloves, sanitized her hands, and placed the gloves on the resident's bed. Staff member H applied new gloves, and assisted the resident to roll over onto her back and cleansed the residents suprapubic catheter tubing. Staff member H removed her gloves, sanitized and placed new gloves on her hands. Staff members H and J assisted the resident to roll onto her left side and staff member J provided perineal care, removed the soiled incontinent brief, and placed it in the garbage. Staff member J removed her gloves after providing perineal care, then placed a new draw sheet under resident #7, and then donned a new pair of gloves. Staff members H and J assisted in placing a new incontinent brief on resident #7. Staff members H and J removed their gloves and sanitized their hands. Review of the facility policy titled Personal Protective Equipment showed .6.3 Change gloves after contact with each individual resident or after contact with contaminated articles. 6.4 Wash hands after removing gloves . Review of the facility policy titled Hand Hygiene showed . Perform hand hygiene: 1.1 Before patient care; 1.2 Before aseptic procedure; 1.3 After any contact with blood or other body fluids, even if gloves are worn; 1.4 After patient care; 1.5 After contact with the patient's environment . 2. During an observation on 8/21/18 at 8:47 a.m., while in the dining room, staff member Y placed her index finger in her nose and when she removed her finger she wiped it on the front of her shirt. Staff Y did not wash or sanitize her hands. During an observation on 8/21/18 at 8:50 a.m., staff member Y rubbed her face with both of her hands in the dining room. Staff Y had not sanitized or washed her hands. During an observation at 8/21/18 at 8:56 a.m., staff member Y touched a resident's walker handle and proceeded to put a gait belt on the resident. During an interview on 8/21/18 at 9:04 a.m., staff member Y stated she completed a hand hygiene course at orientation about two years prior. She stated that they do monthly training on hand hygiene as well. She stated she also had a hand hygiene training that she needed to do by the end of the month.",2020-09-01
916,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2018-08-23,883,E,0,1,4NKL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have a system in place for tracking the administration of the pneumococcal vaccines PCV13 and PPSV23 for 5 (#s 20, 23, 38, 46 and 49) of 25 sampled residents. Findings include: During the infection control interview on 8/23/18 at 10:21 a.m., staff member N stated the facility did not have a process in place currently for ensuring residents had both the PCV13 and the PPSV23. She stated she was not sure what the process would be for ensuring residents had been offered, and if consented, received the [MEDICATION NAME]. Review of the facility Immunization Report did not include all residents who currently resided in the facility. Review of sampled residents #s 20, 23, 38, 46 and 49's medical records failed to show a consistent pattern for the documentation of the history of prior administration of the vaccine, the administration of the vaccine at the facility, tracking of the vaccines, or the type of vaccine received. A review of the CDC Guidelines for [MEDICATION NAME] Vaccination schedule included: One dose of PCV13 is recommended for adults [AGE] years or older who have not previously received PCV13 followed by PPSV23 at least one year after the PCV13. One dose of PPSV23 is recommended for adults [AGE] years or older, regardless of previous history of vaccination with pneumococcal vaccines. Once a dose of PPSV23 is given at age [AGE] years or older, no additional doses of PPSV23 should be administered.",2020-09-01
917,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2019-10-17,609,D,0,1,NKQ311,"Based on interview and record review, the facility failed to report the results of an abuse investigation to the State Survey Agency within five working days of the incident for 2 (#s 4 and 33) of 22 sampled and supplemental residents. Findings include: During an interview on 10/16/19 at 10:25 a.m., resident #33 stated he only had issues with one resident. This resident cussed at him, and flipped him off. Resident #33 thought the reason resident #4 was upset with him was because he used to live in the room that resident #33 currently lived in. Resident #33 felt resident #4 was upset about losing the extra space, and a bed by the window. Resident #33 stated the interactions had been happening for about a year. During an interview on 10/17/19 at 8:15 a.m., staff member [NAME] stated resident #33 was surly, and frequently made negative comments to a number of residents. Staff member [NAME] stated he remembered an altercation between resident #33 and resident #4, in which the residents exchanged words, and resident #33 hit resident #4 on the arm four times. Staff member [NAME] stated the residents were separated, resident #4 agreed to move to a room on A wing, and to have his meals in a different dining room. Staff member [NAME] stated these interventions had prevented any further altercations between the two residents. During an interview on 10/17/19 at 10:15 a.m., resident #4 stated he and resident #33 had been having words on and off for at least six months, and the only physical altercation was in (MONTH) of 2019, when resident #33 had struck him (resident #4) four times on the left arm. Resident #4 denied any injury and stated avoiding resident #33 was an effective way to prevent any further problems. Review of the Facility Reported Incident documentation, dated 6/26/19, showed the initial incident occurred on 6/17/19 at 8:30 a.m., and was reported on 6/17/19 at 12:12 p.m. The results of the investigation were due by 6/25/19 at 12:12 p.m. The results of the investigation were submitted on 6/26/19. During an interview on 10/17/19 at 8:00 a.m., staff member A stated the incident occurred prior to his arrival, and he could not explain why the findings were not submitted before the five-day deadline.",2020-09-01
918,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2019-10-17,623,E,0,1,NKQ311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident or the resident's representative of the transfer, and the reasons for the transfer, in writing, for 3 (#s 1, 11, and 45) of 14 sampled residents. Findings include: 1. During an interview on 10/17/19 at 9:16 a.m., staff member N stated when a resident was transferred to ER, the transfer documentation was in the Assessment section of the electronic medical record. During an interview on 10/16/19 at 9:56 a.m., resident #1 did not remember receiving anything in writing when he was transferred to the hospital on [DATE]. Resident #1 stated the nurses gave paperwork to the ambulance people, but nothing to him. Review of resident #1's Quarterly MDS, with an ARD date of 7/12/19, showed a BIMS of 15, no cognitive impairment. Review of resident #1's Assessment section, for the date 9/3/19, failed to show any transfer documentation. Review of resident #1's hard copy medical record failed to show any transfer documentation for 9/3/19. A request was made for transfer documentation related to resident #1's 9/3/19 hospitalization . No documentation was received prior to the end of the survey. 2. Review of resident #11's Quarterly MDS, with an ARD of 7/29/19, showed a BIMS of 10, impaired cognition. Review of resident #11's Assessment section, dated 7/15/19, showed transfer documentation related to the hospitalization for pneumonia [MEDICAL CONDITION] from 7/15/19 to 7/22/19. No documentation was found which showed the resident's representative was given the reason for the transfer in writing. The transfer documentation shows the resident's daughter was notified by phone. Review of resident #11's Assessment section, dated 8/19/19, showed transfer documentation related to the hospitalization for pneumonia from 8/16/19 to 8/23/19. No documentation was found which showed the resident's representative was given the reason for the transfer in writing. The transfer documentation showed the resident's daughter was notified by phone. A request was made for documentation showing resident #11's representative received written documentation identifying the reasons for the transfers which occurred on 7/15/19 and 8/16/19. No documentation was received prior to the end of the survey. During an interview on 10/17/19 at 9:43 a.m., staff member B stated there has been a lot of confusion about which transfer notification form was used. This was due to new company ownership. 3. During an interview on 10/16/19 at 9:53 a.m., resident #45 stated he had a recent hospitalization where he stayed overnight in the hospital. Review of resident #45's Nurses Note, dated 8/23/19, showed, Call placed to ER, (resident #45) to be admitted for [MEDICAL CONDITION]. During an interview on 10/17/19 at 9:43 a.m., staff member B stated there was not a transfer form for resident #45's hospitalization on [DATE], but technically there should have been a transfer notification given to the resident. A request for resident #45's transfer notification form for 8/23/19 was requested on 10/16/19 at 4:26 p.m. No documentation was provided by the facility. Review of facility policy titled Transfer or Discharge, Emergency, revised (MONTH) (YEAR), showed no requirement for written notification of the reason for the transfer to the resident and/or the resident's representative.",2020-09-01
919,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2019-10-17,625,D,0,1,NKQ311,"Based on interview and record review, the facility failed to provide written bed-hold information for 2 (#1 and #11) of 14 sampled residents. Findings include: During an interview on 10/16/19 at 9:56 a.m., resident #1 stated he did not remember receiving any information about a bed-hold when he was hospitalized in early (MONTH) of this year. Review of resident #1's electronic medical record failed to show any documentation related to bed hold information provided to resident #1. Review of resident #11's electronic medical record failed to show any documentation related to bed hold information provided to resident #11 or his representative. A request was made for documentation showing bed hold information was given to resident #1 and resident #11's representative. No documentation was received prior to the end of the survey. A request for the facility's Bed Hold Policy was made, but no documentation was received prior to the end of the survey.",2020-09-01
920,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2019-10-17,656,D,0,1,NKQ311,"Based on interview and record review, the facility failed to develop and implement a nutrition care plan for 1 (#45) of 14 sampled residents. Findings include: During an interview on 10/17/19 at 2:50 p.m., staff member I stated she did not know why resident #45 did not have a nutrition care plan as she was new to her role and had not had time to check or update the care plans. Review of the facility'sTherapeutic Diet list, showed resident #45 was on a carbohydrate controlled diet. Review of resident #45's care plan, dated 10/14/19, showed no care plan for nutrition. A request for resident #45's nutrition care plan on 10/17/19 was not provided by the facility.",2020-09-01
921,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2019-10-17,676,D,0,1,NKQ311,"Based on observation, interview, and record review, the facility failed to provide a necessary functional communication system, in the form of communication boards or cards, for 1 (#11) of 14 sampled residents. Findings include: During an observation on 10/15/19 at 5:00 p.m., resident #11 was resting on his left side, staff were heard talking to him. Resident #11's voice was not audible. No staff was noted to be using any alternative communication devices. During an observation and attempted interview on 10/17/19 at 8:45 a.m., resident #11 was laying on his left side. Resident #11's lips were dry and flaky. This surveyor was unable to understand resident #11's breathy speech, and no picture cards were available. Staff member C was asked to figure out what resident #11 wanted. Staff member C stated she had a hard time understanding him (resident #11), but she would try. During an interview on 10/17/19 at 1:52 p.m., staff member M stated he had been at the facility for five months and had not seen any communication cards for resident #11. Staff member M stated he sometimes had trouble understanding resident #11, and would just sit with him and watch television. Review of resident #11's Communication care plan, dated 1/15/19, showed a focus of impaired communication due to difficulty making self understood. Interventions included attentive listening, encouraging resident to speak slowly, encourage use of gestures, and use of a communication board or word cards. During an interview on 10/17/19 at 1:57 p.m., staff member O stated she had been at the facility for over two years, and had not seen communication cards for at least six months. Staff member O was not sure why the cards were no longer being used. During an interview on 10/17/19 at 2:33 p.m., staff member D stated she thought the cards were still being used. She stated staff who had difficulty understanding resident #11 should be using the cards, and was not sure why the cards were not being used to communicate with resident #11.",2020-09-01
922,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2019-10-17,677,D,0,1,NKQ311,"Based on observation, interview, and record review, the facility failed to provide the necessary ADL services to a dependent resident for 1 (#11) of 14 sampled residents, in order to maintain oral care and the resident had discomfort related to this. Findings include: During an observation and attempted interview on 10/17/19 at 8:45 a.m., resident #11 had dry, flaking lips. Staff member C did oral care with pink toothettes. During an interview on 10/17/19 at 1:48 p.m., resident #11 shook his head indicating no when asked if the staff bushed his teeth. Resident #11 nodded his head yes when asked if he would like the staff to brush his teeth. During an interview on 10/17/19 at 1:52 p.m., staff member M stated he had not brushed resident #11's teeth. He had only used pink toothettes, and a small amount of mouthwash. Staff member M did not know why resident #11's teeth had not been brushed. Staff member M stated the CNAs only do oral care once a shift. Staff member M did not think once a shift was too infrequent, even though resident #11 experienced having discomfort from dry mouth. During an interview on 10/17/19 at 1:57 p.m., staff member O stated she used to brush resident #11's teeth. However, his gums began to bleed, so they stopped. Staff member O stated she did not remember how long ago this happened. Staff member O stated she had done oral care once a shift to remove the, gunky stuff, from resident #11's mouth. She stated she had not really thought about his mouth and lips being dry. Staff member O stated it would probably be a good idea to do it more often for resident #11's comfort, as he could not do it himself. Review of resident #11's ADL care plan, dated 5/15/19, showed resident #11 was totally dependent on staff for oral care, and used mouth swabs or toothettes for mouth moistening for comfort.",2020-09-01
923,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2019-10-17,688,D,0,1,NKQ311,"Based on observation, interview, and record review, the facility failed to provide appropriate services to prevent or improve a reduction in range of motion for 2 (#s 11 and 28) of 14 sampled residents. Findings include: 1. During an observation on 10/16/19 at 7:52 a.m., resident #11 was resting on his right side with his eyes open. Resident #11's arms were pulled up towards his chest. During an observation on 10/16/19 at 10:12 a.m., resident #11 was on his right side with his eyes open. Resident #11's arms were pulled up toward his chest. During an interview on 10/17/19 at 9:55 a.m., staff member M stated resident #11 had no formal ROM program. The only exercises done were during dressing, undressing and other personal cares. Staff member M stated it was not specifically documented as range of motion. During an interview on 10/17/19 at 1:57 p.m., staff member O stated resident #11 used to have a ROM program; but it had stopped about six months ago. Staff member O was not able to say why this had occurred. During an interview on 10/17/19 at 2:35 p.m., staff member Q stated she was new to her position in the rehabilitation department and was unsure how often the restorative plans were reviewed. During an interview on 10/17/19 at 2:45 p.m., staff member D stated when a resident is admitted to the hospital, all orders must be renewed. Staff member D stated the admitting nurse, charge nurse, or Director of Nursing was responsible for ensuring these types of orders are continued when a resident returns from a hospital stay. If the CNAs are not doing range of motion for resident #11, staff member D stated, it was probably because it got missed after one of his hospitalization s during the summer. Review of the Restorative Nursing Care Plan, dated 12/19/18, and found in a binder in the Rehabilitation Department, showed a goal to maintain left upper extremity shoulder, elbow, wrist, and hand range of motion. The document also specified the description, frequency, and duration of the exercises to be completed. 2. During an interview on 10/16/19 at 10:11 a.m., resident #28 stated the staff does not do anything for her contractures. Resident #28 stated she would like to get range of motion on her legs. During an interview on 10/17/19 at 8:36 a.m., staff member K stated restorative cares were hard to do with current staffing levels. During an interview on 10/17/19 at 8:43 a.m., staff member M stated resident #28 received range of motion at least twice a day, and it was documented in Point Click Care. During an observation and interview on 10/17/19 at 8:48 a.m., resident #28 was laying in bed and stated she had not received any range of motion. During an interview on 10/17/19 at 9:32 a.m., staff member B stated the restorative program was something the facility was working on back in June, but with the company change over, the plans to designate one certified nursing assistant to the restorative cares for residents was put aside. Staff member B stated the restorative cares have been an issue. Review of resident #28's Physical Therapy Evaluation and Plan of Treatment dated 10/15/19, showed the following: - Reason for referral: .long term resident of this facility who is unable to move independently due to progressive MS. For this reason a restorative ROM program has been established in the past with poor follow-through. Current staff are likely unfamiliar with this program, so the goal is to train staff to properly perform stretches to hips, knees, and ankles to improve quality of life, decrease stiffness and decrease pain. -Clinical impressions: The patient is not currently being assisted with her restorative stretching/ROM program, and the goal of therapy interventions is to train staff to properly assist the patient with this program to re-establish its performance. Review of resident #28's Restorative Range of Motion careplan, dated 10/9/19, showed the goal to, prevent contractures and maintain skin integrity. A request for resident #28's Restorative/Range of Motion documentation for the last three months was requested on 10/17/19. No documentation was provided by the facility.",2020-09-01
924,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2019-10-17,759,D,0,1,NKQ311,"**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 less than 5% which affected 2 (#s 3 and 33) of 22 sampled and supplemental residents. The observed error rate was 6.45%. Findings include: 1. During a medication administration observation on 10/16/19 at 8:14 a.m., staff member P prepared and administered medications to resident #3. Resident #3 was hesitant, but did take all of the [MEDICATION NAME] prepared for her. Review of resident #3's MAR, dated (MONTH) 2019, showed the 10/16/19 morning dose had been circled. During an interview on 10/17/19 at 12:10 p.m., staff member P stated the resident had only tasted the [MEDICATION NAME] and then refused. After a brief discussion regarding the sequence of events, staff member P stated she had made a mistake and corrected the documentation to show the medication had been given. 2. During a medication administration observation on 10/17/19 at 8:37 a.m., staff member N prepared and administered medications to resident #33. One of the medications required a blood pressure to be taken prior to administration. The automatic blood pressure cuff was not functioning; therefore, the nurse took a manual blood pressure. The [MEDICATION NAME] 10 mg, and the blood pressure result, were not documented at this time. Review of resident #33's MAR, dated (MONTH) 2019, showed the medication had not been signed out, and the blood pressure result had not been documented as of 12:25 p.m. on 10/17/19. During an interview on 10/17/19 at 12:25 p.m., staff member N stated, Oh, I forgot to sign out my treatments from this morning.",2020-09-01
925,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2019-10-17,812,D,0,1,NKQ311,"Based on observation, interview, and record review, the dietary staff failed to wear a hairnet while serving food off of a steam table in the dining room, and failed to maintain a clean convection oven. These practices have the potential to affect all of the residents served food from the facility. Findings include: 1. During an observation on 10/16/19 at 8:22 a.m., staff member H was serving food off the steam table without a hairnet on. During an interview on 10/16/19 at 8:37 a.m., staff member H stated he had forgot to put on a hairnet before serving breakfast, but he was suppose to wear one when serving food. During an interview on 10/17/19 at 9:06 a.m., staff member J stated dietary staff should always be wearing a hairnet when serving food. Review of the facility's policy on Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices dated (MONTH) (YEAR), showed, 12. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. Review of the facility's kitchen training, dated, 10/3/19, included handwashing, glove use, clean uniforms, hairnets, cross contamination, wash/rinse/sanitize, cleaning logs, temperature logs, and when to temp food. 2. During an observation on 10/15/19 at 1:45 p.m., there was charred burnt matter covering the entire bottom of the convection oven. During an observation on 10/16/19 at 4:32 p.m., there was charred burnt matter covering the entire bottom of the convection oven. During an interview on 10/16/19 at 4:35 p.m., staff member L stated the convection oven is cleaned monthly and wiped down weekly. Staff member L stated she believed the last time the convection oven was cleaned was about 2 weeks ago. During an interview on 10/17/19 at 9:08 a.m., staff member J stated the convection ovens were to be cleaned once a week and the last time it was cleaned was on the 12th of October. Review of the facility's Weekly Nutrition Services Cleaning Schedule for (MONTH) 2019, showed the convection oven had not been cleaned in the month of October. A request on 10/17/19 for the last three months of documentation of kitchen cleaning was not provided for (MONTH) or (MONTH) of 2019 by the facility.",2020-09-01
926,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2019-10-17,880,F,0,1,NKQ311,"Based on interview and record review, the facility failed to maintain a facility-wide infection prevention and control program. This deficient practice had the potential to affect all residents in the facility. Findings include: During an interview on 10/16/19 at 1:06 p.m., staff member B stated there had not been an infection control nurse since (MONTH) of 2019. She stated due to the changes in ownership, this had been very difficult to manage. Staff member B stated no surveillance, mapping, or any other analysis of data had occurred since (MONTH) of 2019. Staff member B stated she had come to the facility to perform MDS duties. However, her position had evolved into the interim DON. The current ownership had been in place since (MONTH) of 2019. Staff member B was not able to provide any specific reasons for the absence of the program other than the previous nurse quit, and the facility could not keep up until someone was hired. Review of the surveillance log, dated (MONTH) 2019, showed that no resident infections were logged after early June. The months of July, August, September, and (MONTH) 2019 were blank.",2020-09-01
927,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2019-10-17,881,F,0,1,NKQ311,"Based on interview and record review, the facility failed to establish and maintain an antibiotic stewardship program which included antibiotic use protocols and a system for monitoring antibiotic use. This deficient practice had the potential to affect all residents in the facility. Findings include: During an interview on 10/16/19 at 1:06 p.m., staff member B stated there had not been an active infection control program since (MONTH) of 2019. Due to to a number of factors including multiple changes in facility ownership, changes in facility leadership, exodus of staff, and the lack of a dedicated Infection Control nurse, the program had been dormant. Antibiotic usage has been driven by provider choice in the past. Staff member B stated the antibotic use reports have been filed in the binder. However, no review, analysis, or quality discussions have occurred to date. During an interview on 10/17/19 at 10:00 a.m., staff member A stated the facility was developing an Antibiotic Stewardship program, but it was not in place yet. Review of the Antibiotic Stewarship Log, showed antibotic order reports, by month, through (MONTH) 2019. No additional documentation indicating analysis, discussions, or other work was identified in the binder from (MONTH) 2019 to (MONTH) 2019.",2020-09-01
928,CONTINENTAL CARE AND REHABILITATION,275103,2400 CONTINENTAL DR,BUTTE,MT,59701,2019-10-17,883,D,0,1,NKQ311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 2 (#s 14 and 46) of 22 sampled and supplemental residents. Findings include: 1. During an interview on 10/17/19 at 1:10 p.m., staff member B stated an audit of all residents to determine what the immunization needs were, had not been done. Staff member B stated she was unaware that resident #14 was due to received [MEDICATION NAME]-23 any time after 7/23/19, and that it had not been scheduled yet. Review of resident #14's immunization records, dated 1/23/19, showed Prevnar-13 was administered. Review of the facility policy titled Pneumococcal Program, not dated, showed, .a. Adults aged > or =[AGE] years who have not previously received pneumococcal vaccine or whose previous vaccination history is unknown should receive a dose of PCV13 first, Followed by a dose of PPSV23. The dose of PPSV23 should be given 6-12 months after a dose of PCV 13 . 2. During an interview on 10/17/19 at 1:10 p.m., staff member B stated when a resident is admitted , the nurse is responsible for gathering the resident's immunization history. Staff member B could not remember who admitted resident #46. Staff member B stated she believed the resident could not remember if, or when, she may have had any vaccinations. Staff member B agreed staff should be attempting to determine the resident's immunization history on admission. Review of resident #46's immunization records, not dated, showed Influenza was documented as given on 10/14/19. No other immunizations were documented. Review of resident #46's electronic medical record showed she was initially admitted on [DATE]. Review of the facility policy titled Vaccination of Residents, revised (MONTH) (YEAR), showed, All new residents shall be assessed for current vaccination status upon admission.",2020-09-01
929,GLACIER CARE CENTER,275104,707 3RD ST SE,CUT BANK,MT,59427,2017-07-07,371,F,0,1,ZJT211,"Based on observation, record review, and interview, the facility failed to ensure food was served and stored in a sanitary manner, and non-food contact surfaces were kept clean in the main kitchen. Cleaning schedules were developed for the kitchen, but they were not comprehensive. This deficiency could affect all residents whom received food from the kitchen. Findings include: During the observation and interview, on 7/5/17 at 10:30 a.m., the following concerns were observed in the main kitchen, in the presence of staff member C: - At the base of the door frame's edges, at both door entries into the kitchen, and the dry food storage, there was a heavy accumulation of dirt and black matter that could be scraped off with a tip of a pen. Staff C stated staff was supposed to remove the build-up with a mop, otherwise maintenance came in once per year to strip the floors. -Staff member C was in the process of putting away boxes, which were from the food truck delivery, from Tuesday, the day before. Boxes remained on the floors in the walk-in cooler, walk-in freezer, and dry store room. She swept the walk-in cooler, which had wilted lettuce, dried out blueberries, and food crumbs on the floor. She stated it was the responsibility of the person who put away the food from the food truck to sweep the floor and it had not been completed. Because of recent staff turnover, staff member C was the staff responsible for putting away the boxes and had not had the time to complete the task. -In the walk-in freezer, on the right on the first rack, there were boxes covered in frost. The frost was approximately one inch thick and removable with a pen. There was an old pickle on the floor that was covered in frost. One of the fans was not working, and there was no visible thermometer in the freezer to show the temperature of the food was maintained at an acceptable level. -The shelves in the walk-in cooler and freezer where covered with a rust-like substance, along with a thick, black, buildup, which was removable with a pen. Staff member C stated the shelves had not been cleaned since she started in (MONTH) (YEAR), but that she was going to have maintenance power wash the racks. -There was sausage thawing on top of a box of frozen vegetables in the freezer. Staff member C stated the sausage was not supposed to be there. The sausage was improperly stored and could cause cross contamination to the frozen vegetables. -There were dried food stains and splatters on the majority of the walls in the kitchen and dry food storage area. -There was a counter that ran from the dirty dish room to the clean dish room, with a kitchen pass through, built into the wall. Staff member C stated the staff passed the dirty and clean dishes back and forth on the counter. The facility had not designated which side of the counter was for clean or dirty dishes. Both clean and dirty dishes were transferred through the pass through, increasing the risk for cross contamination between clean and dirty items. During the observation and interview on 7/6/17 at 8:00 a.m., the following concerns were observed in the main kitchen, in the presence of staff member C: -At the base of the door frame's edges, at both door entries into the kitchen and the dry food storage area, there remained a heavy accumulation of dirt and black matter that could be scraped off with a tip of a pen. The areas remained dirty, although staff member C was aware of the concerns during the initial observation. -There were food stains and splatters of food all around the back wall of the hand-washing sink ,and the counter next to the sink. -Storage racks, in the walk-in cooler and freezer, remained covered in a a rust-like substance, along with a black colored buildup, which was removable with a pen. The black colored buildup was observed the day prior. -The pipes and fans in the walk-in cooler were also covered in dust, and a black colored buildup that was removable with a pen. -There was a zip-lock bag containing raw chicken that was sitting on top of a box of cantaloupe. Staff member C stated the chicken should be on the bottom shelf, when thawed. The chicken was improperly stored and provided a potential cause for cross contamination. -There was grease and food buildup on the side of the steamer, on the top of the grill, and the side of grill. There was visible buildup of dust behind the grill, on the electronic hook-ups. During the observation and and interview, on 3/7/17 at 10:00 a.m., the following concerns were observed in the main kitchen, in the presence of staff member C: -The stains on the wall and counter behind the hand washing sink, remained. Staff member C wiped away the food stains with a wet kitchen towel. -The side of the stove, steamer, and grill, continued to have food and grease buildup on the sides, and the shelf above the stove. The visible buildup of dust behind the grill, on the electronic hook-ups, was still there from the previous day. Staff member C sprayed the stove with citru-D and wiped it down with a cloth, but not all of the grease build up was removed. -The sprayer connected to the grill had food particles built-up in the head of the sprayer and grease and dust buildup on the coils along the hose. -There was ham sitting on a box of melons. Staff member C stated the ham should not be stored on the melons and she would visit with her staff. The ham was improperly stored and provided a potential cause for cross contamination. Review of the facility's Daily Cleaning Tasks, showed a list of jobs to be completed daily. The record did not show specific staff assignments and did not track who had completed these daily assignments. Review of the facility's Weekly Cleaning Check List, showed a list of tasks that needed to be completed by each staff member daily. The cleaning list for Tuesday, showed the following items were to be cleaned: [NAME] 1: Clean wall behind rococo, prep sink, mixer & slice. E2: Clean hand sink, wall under hand sink and glove holders. During an interview on 7/5/17 at 10:45 a.m., staff member C stated she did not have a deep clearing schedule for the kitchen. She also did not currently track when clearing was completed. She stated she was going to work on a cleaning schedule with the business office. She stated she had some staff turnover in the kitchen, which has caused several of the cleaning tasks and unloading of the food truck to get missed.",2020-09-01
930,GLACIER CARE CENTER,275104,707 3RD ST SE,CUT BANK,MT,59427,2018-09-20,552,D,0,1,SCS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's right to be informed of the risks and benefits of the use of psychoactive medications for 2 (#s 25 and 22) of 22 sampled residents. Findings include: 1. During an interview on 9/18/18, at 7:46 a.m., resident #25 stated he did not know if he signed consents for the medications that he took for his [MEDICAL CONDITION]. He was not aware of the side effects and did not remember if the doctor or staff had discussed this with him, but he thought they would help him fall asleep better. Record review of resident #25's medical chart showed that he was admitted to the facility on [DATE]. He had current orders for [MEDICATION NAME] HCI tablet, give 2 tablets by mouth in the afternoon for [MEDICAL CONDITION], and [MEDICATION NAME] 1mg tablet, to be given by mouth as needed for anxiety TID PRN. Record review of resident #25's care plan showed he took 1mg [MEDICATION NAME] every eight hours as needed for anxiety/[MEDICAL CONDITION]. The care plan did not reflect the use of [MEDICATION NAME] to treat [MEDICAL CONDITION]. Record review of resident #25's medical chart showed that he had signed consents for the use of [MEDICAL CONDITION] medications [MEDICATION NAME](no dosage or frequency listed) for [MEDICAL CONDITION], dated 8/10/18, and [MEDICATION NAME] 1mg, by mouth three times a day for anxiety, dated 8/13/18. No consent was on file for the use of [MEDICATION NAME] for [MEDICAL CONDITION], and the facility did not provide a signed consent for the use of psychoactive medications for the administration of [MEDICATION NAME] for resident #25. 2. During an interview on 9/20/18 at 8:30 a.m., staff member [NAME] stated that she did not have the signed consent for resident #22's use of [MEDICATION NAME], but she was able to get it signed on 09/19/18 by the resident. Resident #22 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of resident #22's medical chart shows that she did not have a signed consent for the administration of [MEDICATION NAME] HCI. The facility provided a signed Consent for use of Psychoactive Medications for [MEDICATION NAME] for resident #22 on 9/20/18, which was signed by the resident on 9/19/18.",2020-09-01
931,GLACIER CARE CENTER,275104,707 3RD ST SE,CUT BANK,MT,59427,2018-09-20,582,D,0,1,SCS711,"Based on interview and record review, the facility failed to provide the NOMNC (CMS ) to 1 resident (#32) out of 23 sampled and supplemental residents. Findings include: Review of SNF Beneficiary Protection Notification Review for resident #32 showed Medicare Part A Skilled Services Episode Start Date: 3/14/18 and Last covered day of Part A Service: 5/6/18. The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. On the form the question that stated Was a NOMNC (CMS ) provided to the resident? The facility checked the box Other and stated Did not realize it was necessary. During an interview on 9/18/18 at 11:00 a.m., staff member B stated the facility did not provide the NOMNC (CMS ) form to the resident because they did not know that it was necessary, but the facility will start providing the form from now on.",2020-09-01
932,GLACIER CARE CENTER,275104,707 3RD ST SE,CUT BANK,MT,59427,2018-09-20,602,D,0,1,SCS711,"Based on interview and record review, the facility failed to complete a thorough investigation for a missing necklace for 1 (#34) of 22 sampled residents. Findings include: During an interview on 9/17/18 at 2:39 p.m., NF1 stated concerns regarding a missing necklace for resident #34 when the family received his belongings following his demise. NF1 stated the necklace was a gold chain with a cross. During an interview on 9/19/18, at 2:58 p.m., staff member B stated no internal investigation was done for missing property. Staff member B stated once the information was turned over to the police, the investigation was done by the police department. Review of an incident report, dated 8/2/18, showed the family of resident #34 reported the missing necklace to staff member [NAME] The incident report showed the police department was notified, however did not show the facility conducted an investigation. Review of the facility's witness summary report, dated 8/20/18, showed two CNAs were interviewed. The facility failed to conduct a thorough investigation into the missing necklace. Review of the facility Abuse Prevention Plan showed the following under investigation: -The facility will investigate all incidences . - .If alleged allegation was reported to law enforcement as a reasonable suspicion of a crime committed against a resident, the facility will still conduct its own internal investigation to the extent possible, in consultation with the law enforcement authority .",2020-09-01
933,GLACIER CARE CENTER,275104,707 3RD ST SE,CUT BANK,MT,59427,2018-09-20,641,D,0,1,SCS711,"Based on interview and record review, the facility failed to assure that each resident receives an accurate assessment that is reflective of the resident's status at the time of the assessment, for 1 (#25) of 22 sampled residents. Findings include: During an interview on 9/18/18, at 7:46 a.m., resident #25 stated that when he came to the facility, he told the nurse that they must puree his food because most of his teeth are missing and the ones present are rotted out and broken. Resident #25 stated that he has an upcoming appointment with the VA to have the remainder of his teeth removed and he is looking forward to not having to eat grinded up food. Record review of resident #25's Physical Examination form, dated 8/09/18, section: Nose/Throat, showed: Poor dentition, multiple dental carries, and broken teeth. Record review of resident #25's Speech Therapy Plan of Care, dated 8/25/18, showed that resident #25 is being referred to therapy, due to reports from nursing of swallowing difficulties. Section titled Precautions, stated that the resident has poor dentition with poor appetite. The resident's diet may need modified due to medical/dental status. Under section Underlying Impairments, it showed that the resident had the following: missing teeth, and due to dentition, possible infection, and pt reported pain in the back molars, he uses his tongue to smash food to the roof of his mouth. Record review of resident #25's OBRA Admission Assessment, Section L- Oral/Dental Status, dated 8/16/18, showed None of the above were present,",2020-09-01
934,GLACIER CARE CENTER,275104,707 3RD ST SE,CUT BANK,MT,59427,2018-09-20,655,D,0,1,SCS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours upon a resident's admission for 1 (#25) of 22 sampled residents. Findings include: During an interview on 9/18/18, at 7:46 a.m., resident #25 stated that he was recently admitted to the facility, and he did not recall having a care plan meeting. Resident #25 stated that he was at the facility because he passed out in his home and was found on the floor several days later. During an interview on 9/18/18, at 2:42 p.m., staff member B stated, whatever is in EHR electronically was what the facility used to create and generate base line care plans. Staff member B stated, the facility did not start a base line care plan for resident #25 within forty-eight hours. Record review of resident #25's medical record showed that resident #25 was admitted to the facility on [DATE]. An initial 48-hour base line care plan was not developed or implemented until 8/13/18.",2020-09-01
935,GLACIER CARE CENTER,275104,707 3RD ST SE,CUT BANK,MT,59427,2018-09-20,657,D,0,1,SCS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to update a care plan to include [MEDICAL CONDITION] medications for 1 (#14), failed to update the care plan to include a current feeding tube schedule for 1 (#8), failed to update a resident's care plan following the development of one, stage II coccyx pressure ulcer, and two unstageable pressure ulcers to the residents left and right heel for 1 (#10), and failed to update the care plan to include multiple UTIs for 1 (#28) of 22 sampled residents. Findings include: 1. During an interview on 9/19/18 at 3:06 p.m., staff member B stated the care plans were updated by the interdisciplinary team and each department updated their part of the care plan. During an interview on 9/20/18 at 9:50 a.m., staff member [NAME] stated resident #8's care plan did not include her current tube feeding regimen. Review of resident #8's physician orders [REDACTED]. Review of resident #8's care plan did not show the resident was to receive tube feedings five times daily. 2. During an interview on 9/19/18 at 3:07 p.m., staff member B stated the care plans were updated by the interdisciplinary team and each department updated their part of the care plan. During an interview on 9/20/18 at 9:53 a.m., staff member [NAME] stated resident #14's care plan did not include psychoactive medications. Review of resident #14's physician order [REDACTED]. Review of resident #14's care plan did not show the resident was taking two antidepressants. 3. During an interview on 9/19/18 at 3:08 p.m., staff member B stated the care plans were updated by the interdisciplinary team and each department updated their part of the care plan. During an interview on 9/20/18 at 9:55 a.m., staff member [NAME] stated resident #28's care plan did not include ongoing UTIs. Review of resident #28's Physician order [REDACTED]. -7/21/18; the resident was started on [MEDICATION NAME] 300 mg by mouth, two times daily for UTI, -8/21/18; the resident was started on [MEDICATION NAME], intramuscular every 36 hours for a UTI, -9/2/18; the resident was started [MEDICATION NAME] mg by mouth, two times daily for UTI, -9/5/18; the resident was started on [MEDICATION NAME] 875 mg by mouth, two times daily for UTI. Review of resident #28's care plan did not show updated interventions for the UTIs on 9/2/18 and 9/5/18. 4. During an observation and interview on 9/17/18, at 4:35 p.m., resident #10 was observed lying on his back in his bed. His bed was in the low position and he had a mat placed next to his bed on the floor. Resident #10 did not have shoes on, nor were his heels elevated. Two bunny boots were observed to be sitting on the chair in his room, which was in place at the end of his bed. Resident #10 stated that he had been lying in bed for a while. He said that staff repositions him about twice a day and he thinks they need to do it more often. A review of resident #10's Care Plan was completed on 9/18/18, and showed the resident is at risk for skin breakdown due to being incontinent and decreased mobility due to [MEDICAL CONDITION]. Resident #10's last Care Plan revision date for this focus area was on 4/24/2017, and staff interventions showed, Transfer sling to be lefted under me when I am up in broda chair. Review of Wound documentation for resident #10's coccyx showed the following: -7/3/18; Initial Wound Documentation, Pressure wound to coccyx, 0.6cm x 0.5cm, depth of 0.1cm, Stage II. -7/9/18; Weekly Wound Documentation, Pressure wound to coccyx resolved. Review of Wound documentation for resident #10's right heel shows the following: -5/10/18; Initial Wound Documentation, Pressure wound to right heel, 2.5cm x 3.0cm, depth N/[NAME] -5/24/18; Weekly Wound Documentation, Pressure to right heel, 2.8cm x 3.0cm, depth N/A -5/31/18; Weekly Wound Documentation, pressure to right heel, 2.6cm x 2.9cm, depth N/A -6/7/18; Weekly Wound Documentation not on file. -6/14/18; Weekly Wound Documentation, pressure area to right heel resolved. Review of Wound documentation for resident #10's left heel shows the following: -5/7/18; Initial Wound Documentation, Pressure wound to left heel, 3.4cm x 4.9cm, depth N/[NAME] -5/24/18; Weekly Wound Documentation, Pressure to left heel, 3.4cm x 4.3cm, depth N/A -5/31/18; Weekly Wound Documentation, pressure to left heel, 3.4cm x 4.6cm, depth N/A -6/07/18; Weekly Wound Documentation, pressure to left heel, 3.4cm x 4.8cm, depth N/A -6/14/18; Weekly Wound Documentation, pressure area to left heel resolved. Review of resident #10's Care Plan did not reflect the development of pressure ulcers on the residents coccyx or his left and right heels. During an interview on 9/19/18 at 2:12 p.m., staff member R stated, staff are supposed to reposition resident #10 every two hours and when he's in bed we put his feet in bunny boots to protect his heels. Staff member R stated, I just worked with him on Monday. She said, I can't remember if his pressure sores are healed or not, but the nurse would tell us if there were any changes. During an interview on 9/19/18 at 2:15 p.m., staff member C stated, staff repositions resident #10 every two hours. She stated that staff had a documentation sheet that we use. Staff member C stated that she was assigned to work with resident #10 the day before. She stated that all staff are required to put his bunny boots on him while he's in bed. Review of resident #10's progress notes showed on 5/7/18, orders were given to offload heels two degrees to deep tissue injury of left heel and bunny boot to left foot at all times. On 6/14/18, his order for bunny boots was discontinued. No update was made to the resident's care plan to reflect this information, or the ongoing use of the resident's bunny boots.",2020-09-01
936,GLACIER CARE CENTER,275104,707 3RD ST SE,CUT BANK,MT,59427,2018-09-20,658,D,0,1,SCS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to adhere to accepted standards of quality by administering medications for 1 (#25), when the accepted standards of quality dictate that the medication should not have been provided; and the facility withheld medications for 1 (#25) of 22 sampled residents when the accepted standards of quality dictate that the medications should have been provided. Findings include: During an interview on 9/19/18, at 3:20 p.m., staff member S stated resident #25 was admitted to the facility with orders for [MEDICATION NAME] 250mcg daily at bedtime, and [MEDICATION NAME] 25mg, 0.5 tablet three times a day. Staff member S stated that [MEDICATION NAME] should have been held if the resident's pulse was below 60, and [MEDICATION NAME] should be held if the resident's systolic blood pressure was below 120 and his pulse was below 50. Staff member S said that resident #25's order for [MEDICATION NAME] was updated on 9/4/18 to reflect Hold dig if pulse 60 or below. Staff member S stated that the [MEDICATION NAME] was reduced to 0.125mg daily on 9/10/18, and new orders were given to hold if pulse is below 50 beats per minute. Staff member S stated that the resident's [MEDICATION NAME] orders were updated on 9/5/18 to [MEDICATION NAME] 12.5mg by mouth two times a day and were to be held if pulse below 50 or systolic BP below 100 or diastolic below 40. Staff member S reviewed the Medication Administration Record [REDACTED]. Staff member S stated for the month of August, nursing should have held [MEDICATION NAME] on six days that the medication was administered, and nursing should not have held [MEDICATION NAME] for seven days that the medication was held. In September, the [MEDICATION NAME] should have been held for two days that the medication was administered. Staff member S stated all of these occurrences were medication errors. Review of Resident #25's MAR indicated [REDACTED] -8/7/18; pulse 54 bpm -8/24/18; pulse 56 bpm -8/28/18; pulse 58 bpm -8/29/18; pulse 55 bpm -8/30/18; pulse 57 bpm -8/31/18; pulse 48 bpm Review of resident #25's MAR indicated [REDACTED] -9/4/18; pulse 60 bpm Review of resident #25's MAR indicated [REDACTED] -9/10/18; pulse 59 bpm Review of Resident #25's MAR indicated [REDACTED] -8/23/18; pulse 63 bpm, blood pressure 111/63 -8/24/18; pulse 56 bpm, blood pressure 116/64 -8/26/18; pulse 55 bpm, blood pressure 125/63 -8/26/18; pulse 80 bpm, blood pressure 111/64 -8/27/18; pulse 51 bpm, blood pressure 126/66 -8/27/18; pulse 61 bpm, blood pressure 103/60 -8/29/18; pulse 55 bpm, blood pressure 98/57 Review of Resident #25's MAR indicated [REDACTED] -9/1/18; pulse 75 bpm, blood pressure 105/67 -9/1/18; pulse 58 bpm, blood pressure 106/55 -9/2/18; pulse 66 bpm, blood pressure 115/68 During an interview on 9/20/18, at 9:05 a.m., staff member A stated the facility has a low amount of medication errors. Staff member A stated that she was not aware of these medication errors for resident #25. During an interview on 9/20/18, at 9:05 a.m., staff member B stated the administration of [MEDICATION NAME] and the withholding of [MEDICATION NAME] on the above referenced dates were medication errors which could have resulted in unnecessary side effects for the resident.",2020-09-01
937,GLACIER CARE CENTER,275104,707 3RD ST SE,CUT BANK,MT,59427,2018-09-20,679,D,0,1,SCS711,"Based on observeation, interview, and record review, the facility failed to provide an ongoing program to support residents in their choice of activities for 1 (#2), and failed to include outside walks as part of the residents daily activity wishes for 1 (#14) of 22 sampled residents. Findings include: 1. During an interview on 9/17/18, at 1:13 p.m., resident #2 was observed in his room, lying on his bed, with his eyes open, and the lights off. Resident #2 stated that he recently moved to the facility from the hospital. He did not remember having a care plan meeting and he wants to move out, but the nursing home says no. Resident #2 stated that he did not participate in activities, as it is, too hard to get around, and staff would not, take him outside. Review of resident #2's Care Plan showed resident #2 liked gardening, going outdoors, and reading. Staff Interventions include: -Staff will encourage and invite me to activities, -Staff will monitor me for self-isolation and depression, -Staff will provide me with a monthly activity calendar. During an interview on 9/19/18 at 9:19 a.m., resident #2 was observed lying in his bed in the dark. When asked what activities he liked to participate in, resident #2 stated that he enjoyed reading and being outside. Resident #2 stated, staff don't take me outside, and if he wanted to go outside, he would have to have a friend come and take me for a walk around the block. He stated that sometimes the staff would ask him if he wanted to participate in activities, but not every day. Resident #2 stated the facility does not have a garden and they do not provide him with reading materials. He stated he, gets books from his friends to read. During an interview on 9/20/18 at 10:23 a.m., staff member H stated she wrote goals and objectives for resident activity needs within their care plans. Staff member H stated resident #2 often refused activities and he had refused gardening and walks with staff. Staff member H stated resident #2 goes out with a family member or friend who comes early. Staff member H stated resident #2 should be asked every day if he wants to go for a walk, and he should have activities every day. When asked if resident #2 is provided with reading materials, staff member H stated that all residents are offered the daily chronicle Monday through Friday, and resident #2 refused those too. She stated resident #2 had a friend who brought him things when he came in. Staff member H stated, four activities in a month is not sufficient. Staff member H stated, all resident refusals for activities are documented in EHR, and she just re-trained her aide because she was not documenting refusals. Review of resident #2's Documentation Survey Report v2, showed: -For the months of July, August, and (MONTH) of (YEAR), there was no documentation pertaining to resident #2 isolating himself or exhibiting symptoms of depression. -For the month of (MONTH) (YEAR) there was no documentation for participation or refusal of activities. -For the month of (MONTH) (YEAR), resident #2 participated in an individual 1:1 activity on three occasions; 8/09/18, 8/26/18, and 8/27/18. Resident #2 participated in movies on two occasions; 8/11/18 and 8/26/18. Resident #2 participated in special events on four occasions; 8/09/18, 8/16/18, 8/26/18, and 8/30/18. No documentation was provided regarding refusal of activities, or resident #2 isolating himself or exhibiting symptoms of depression. -For the month of (MONTH) (YEAR), resident #2 participated in special events on two occasions; 9/04/18 and 9/06/18. No documentation was provided regarding refusal of activities. 2. During an interview on 9/17/18 at 2:33 p.m., resident #14 stated she is depressed because she cannot go outside when she wants to. The resident appeared tearful and anxious. The resident had a wanderguard on her left ankle. During an interview on 9/17/18 at 3:06 p.m., staff member B stated the facility would consult activities for potential outings. During an interview on 9/20/18 at 9:58 a.m., staff member H stated the resident will attend some activities, and had some 1:1 activities. Staff member H stated the staff sometimes would take her outside, but she would not stay out for long. Review of resident #14's activity documentation for September, (YEAR) showed the resident was taken on a walk one time, and had 1:1 activities two times. Review of resident #14's care plan showed the following: -Focus: The resident would like to participate in group activities such as BINGO, weekly socials, listening to music, and occasional outings. -Interventions: Activity department will provide a monthly activity calendar and staff were to encourage and invite the resident to activities available. -Focus: Displaying signs of depression, exhibiting tearfulness, irritability, and lonesome for her animals. -Interventions: Teach effective coping strategies per abilities and as able to tolerate; problem solving, socialization, offer opportunities to express feelings, and teach relaxation skills. Encourage social and leisure activities. Make referral for psychological services-currently participating. Assess for appropriateness of adjustments to medications or medical treatment to alleviate symptoms per physician care team. The care plan failed to address the resident's desire to go outside. The care plan failed to address inability to go outside as a sign of depression.",2020-09-01
938,GLACIER CARE CENTER,275104,707 3RD ST SE,CUT BANK,MT,59427,2018-09-20,689,E,0,1,SCS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to use a gait belt for 1 (#5) when transferring from wheel chair to recliner, failed to lock the wheel chair breaks when transferring a resident from wheel chair to bed and from bed to wheel chair for 1 (#10), transfered a resident to and from the dining room for 1 (#13), and failed to complete a smoking assessment and provide adequate supervision during smoking for 1 (#22) of 22 sampled residents. Findings include: 1. During an observation on 9/17/18 at 1:59 p.m., staff members D and I transferred resident #5 from his wheel chair to his recliner. Staff member D grabbed the resident's hands. Staff member I grabbed the resident by the waist band of his pants. Staff members D and I pulled the resident up from his wheel chair, pivoted him, and lowered him into his recliner by holding onto his arms and the waist band of his pants. During an interview on 9/19/18 at 3:06 p.m., staff member B stated gait belts should be used anytime staff do a transfer or walk someone. During an interview on 9/20/18 at 9:06 a.m., staff member D stated a gait belt should be used if the resident is not independent in ambulating. Review of the Transfer Belt Policy showed, It is the policy of this facility that all Associates utilize a transfer (gait) belts with residents during transfers, ambulation and gait training. 2. During an observation on 9/19/18 at 9:30 a.m., staff members J and K transferred resident #10 from his wheel chair to his bed via a hoyer lift to perform peri care. The resident was lifted out of his wheel chair in a sling hooked to the hoyer lift. The wheel chair brakes were not locked and the wheel chair was observed to move when the resident was lifted up, out of the wheel chair. Staff members J and K performed peri care and transferred the resident back to his wheel chair via a hoyer lift. The wheel chair brakes were not locked when the resident was lowered into his wheel chair. During an interview on 9/19/18 at 9:45 a.m., staff member K stated she would normally lock the wheel chair brakes. During an interview on 9/19/18 at 9:46 a.m., staff member J stated the wheel chair brakes were usually locked while transferring a resident. 3. During an observation on 9/18/18 at 8:03 a.m., staff member C assisted resident #13 into the dining room with a gait belt fastened around his ribs, up past his navel. Staff member C walked in front of resident #13, holding the gait belt in a shoulder press stance to assist the resident. During an interview on 9/18/18 at 9:52 a.m., staff member C stated a gait belt was used anytime a resident was transfered. Staff member C stated the gait belt should be fastened up above the resident's navel around his chest area and should be not too tight but not too loose, either. She stated that she had not had any formal training on gait belt use at this facility; however, her co-workers have showed her how to properly use a gait belt and she learned how to in her CNA classes. During an observation on 9/20/18 at 7:57 a.m., staff member C assisted resident #13 into the dining room without using a gait belt. During an observation on 9/19/18 at 12:50 p.m., staff member D was assisting resident #13 out of his dining room chair after lunch. Staff member D fastened the gait belt around resident #13's waist. Staff member D pulled up on resident #13's arm/armpit to help him into a standing position without using the gait belt. The gait belt was not used to help resident #13 up from his chair. 4. During an interview on 9/17/18 at 1:19 p.m., resident #22 stated that she had been a resident of the facility for a couple of months. Resident #22 stated she smokes cigarettes daily, which she puts on her bedside table when not in use. She stated she relied on her husband to take her outside. Resident #22 stated, she cannot smoke on the facility property, so she leaves the building and goes across the street. When asked if she signed out of the building to smoke, resident #22 stated that she did not. During an observation on 9/17/18 at 2:14 p.m., resident #22 was observed exiting the front door of the facility with her husband to cross the street and smoke a cigarette. During an interview on 9/17/18 at 2:36 p.m., staff member A stated there were no residents in the facility who smoke. Staff member A stated, the facility is a non-smoking facility and if a resident who smoked was admitted to the facility, the facility would give the resident a patch or gum to assist with smoking cessation. Review of the facility policy, Smoking Policy Residents, showed: All residents who smoke will be assessed for their ability to safely smoke with or without supervision .the Smoking or E-cigarette Assessment will be completed at admission. Review of the facility sign-out sheet, Temporary Absence Release, showed resident #22 had not signed out of the building since 2:30 p.m. on 9/08/18. Review of resident #22's record showed she was admitted to the facility on [DATE]. No smoking assessment was completed for the resident upon admission. Review of resident #22's physician orders, dated 7/30/18, showed orders to: Encourage no tobacco use on wc rides outside-interferes with bone healing. Review of resident #22's Smoking or E-cigarette Assessment, completed at 2:57p.m. on 9/17/18, showed that resident #22 required one-on-one assistance with smoking cigarettes, which was provided by her husband.",2020-09-01
939,GLACIER CARE CENTER,275104,707 3RD ST SE,CUT BANK,MT,59427,2018-09-20,758,E,0,1,SCS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to review PRN [MEDICAL CONDITION] medications every 14 days for 2 residents (#s 20 and 25) out of 22 sampled residents. Findings include: 1. During an observation on 9/17/18 at 1:30 p.m., resident #20 was sleeping in her room in her recliner. During an observation on 9/17/18 at 3:30 p.m., resident #20 was sleeping in her room in her recliner. During an interview on 9/18/18 at 10:00 a.m., resident #20 stated she had been very tired lately and had a lot of pain. Review of resident #20's medical record showed a Consulation Report dated 2/1/18 (Resident's Name) has a PRN order for an anxiolytic, which has been in place for greater then 14 days without a stop date: [MEDICATION NAME] 5 mg Q 6 hrs PRN. CMS requires that PRN orders for non-antipsychotic [MEDICAL CONDITION] drugs be limited to 14 days unless the perscriber documents the diagnosed specific contition being treated, the rationale for the extended time period, and the duration for the PRN order. There was not another Consulation Report in resident #20's medical record. During an interview on 9/18/18 at 1:45 p.m., staff member F stated resident #20 is on a PRN order for [MEDICATION NAME]. Staff member F stated Im going to guess physician reviews are not being done for PRN [MEDICAL CONDITION] medications every 14 days. During an interview on 9/18/18 at 2:27 p.m., staff member B stated, the physician is not reviewing [MEDICAL CONDITION] medications every 14 days, but we are working on that. 2. During an interview on 9/18/18 at 7:46 a.m., resident #25 stated he is having a hard time sleeping and staff are, giving him pills for it. Record review of resident #25's Care Plan showed that resident #25 took 1mg [MEDICATION NAME] every eight hours as needed for anxiety/[MEDICAL CONDITION]. During an interview on 9/19/18 at 3:20 p.m., staff member S stated she reviewed medications for all residents at least monthly and she documented her resident assessments in the physician progress notes [REDACTED]. She was aware that several residents under her care were prescribed PRN [MEDICAL CONDITION] medications, and she felt that the resident's of the facility benefited from the medications and they offered improved quality of life. Staff member S stated she was not aware of the CMS regulations which state that PRN medications are limited to fourteen days and she will work with staff member T to make sure that this is done in the future. Record review of Resident #25's medical chart showed: -Resident #25 had an order for [REDACTED]. -No documentation regarding the continued use for [MEDICATION NAME] was found in the resident's physician progress notes [REDACTED].",2020-09-01
940,GLACIER CARE CENTER,275104,707 3RD ST SE,CUT BANK,MT,59427,2018-09-20,761,D,0,1,SCS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure an insulin pen was labeled with an open date for 1 of 2 medication carts. Findings include: During an observation on 9/20/18 at 8:30 a.m., the medication cart was inspected. The following was observed with no open date: -One [MEDICATION NAME]pen. During an interview on 9/18/18 at 10:16 a.m., staff member F stated supplies were checked monthly for expired medications and outdated supplies. During an interview on 9/20/18 at 8:40 a.m., staff member G stated the medication room and cart were checked monthly for outdated medications. During an interview on 9/20/18 at 8:45 a.m., staff member B stated the facility would dispose of the insulin pen.",2020-09-01
941,GLACIER CARE CENTER,275104,707 3RD ST SE,CUT BANK,MT,59427,2018-09-20,803,E,0,1,SCS711,"Based on observation, interview, and record review, the facility failed to have the dietitian sign off on a dinner meal menu change. This failure had the potential to affect all residents who consumed dinner on 9/17/18. Findings include: During an interview on 9/17/18 at 4:15 p.m., staff member L stated we are having a menu change, a veggie for a veggie; instead of green beans we are having cauliflower. We sent in a request to the dietitian to approve the change. During an interview on 9/19/18 at 10:10 a.m., Staff member B stated, we have not been able to get a hold of the dietitian all week this week, I'm not sure what is going on. During an interview on 9/19/18 at 10:28 a.m., staff member L stated, we are told to send an email to the dietitian to see if it was ok to change food items on the menu. Staff member L stated the dietitian was emailed to approve the change to switch green beans to cauliflower on Monday night's dinner. Staff member L stated he was not sure if she signed off to approve the menu change. He stated she often does not sign off on menu changes that are requested. Staff member L stated, there was usually a 50/50 chance she would reply with an approval. Staff member L stated even if the facility did not hear from her, they still make the menu change. Staff member L stated staff member M would know if the change was approved by the dietitian or not. During an interview on 9/19/18 at 10:32 a.m., staff member M stated the facility did not get the substitution for green beans to cauliflower approved by the dietitian for Monday night, (9/17/18).",2020-09-01
942,GLACIER CARE CENTER,275104,707 3RD ST SE,CUT BANK,MT,59427,2018-09-20,812,E,0,1,SCS711,"Based on observation and interview, the facility failed to properly date, label, and store food items in the kitchen. This failure had the potential to affect anyone who ate from the facility kitchen. Findings include: During an observation on 9/17/18 at 12:22 p.m., the following items were not properly dated: - What appeared to be cornbread on a plastic tray covered with saran wrap, not labeled or dated in the dry storage room. - A 1 gallon container of prepared yellow mustard that was opened with less than 1/4 used, with only a RD (received date), located in the dry storage room. - Unlabeled and undated four quart container 1/4 full, of what appeared to be sliced ham, in the walk-in refrigerator. During an interview on 9/17/18 at 12:35 p.m., staff member L stated, when the truck gets here we put an RD (received date) on the food and then when its opened we put a date on it. During an observation and interview on 9/17/18 at 12:37 p.m., staff member L was observed taking a container of gravy out of the walk-in refrigerator and stated, the gravy was made on the tenth so that needs to be tossed out. During an observation on 9/17/18 at 12:45 p.m., five pans on the shelf below the steam table were stored in a face-up position, as was a metal craft. There was what appeared to be dried food particles on the shelf. During an observation on 9/17/18 at 4:24 p.m., plastic blue bowls located on a top shelf in the kitchen were stored face-up, and open to debris. Plates in the plate warmer were stored uncovered, face-up, by the preparation table. Scoops were stored in a clear container on a bottom shelf, uncovered, and pulled half way out of under the shelf. During an interview on 9/17/18 at 4:28 p.m., staff member L stated, we usually store the plates uncovered face up in the plate warmer.",2020-09-01
943,GLACIER CARE CENTER,275104,707 3RD ST SE,CUT BANK,MT,59427,2018-09-20,880,F,0,1,SCS711,"Based on observation, interview, and record review, the facility failed to ensure the infection control program included suveillance of the increase in UTIs, and education for staff on infection control topics which included hand hygiene, which has the potential to affect all resident's of the facility. Findings include: 1. During an interview on 9/19/18 at 4:12 p.m., staff member B stated no formal education had been documented. Staff member B stated the facility reminded staff about infection control topics at daily shift change huddles; however, had not documented the training. Staff member B stated the facility had not determined why the rate of UTIs was up, and had not identified a trend in the amount and location of UTIs. Review of the facility maps showed the following: -In April, (YEAR) there were five UTIs, four of which were on the same hall, -In May, (YEAR) there were four UTIs, two on each hall of the facility, -In June, (YEAR) there were three UTIs, two of which were on the same hall, -In July, (YEAR) there were four UTIs, three of which were on the same hall, -In August, (YEAR) there were five UTIs, three on one hall and two on the other hall, -In September, (YEAR) there were four UTIs, three of which were on the same hall. The facility failed to investigate and determine a trend in the location of UTIs and act on the information. Review of the facility infection control binder showed the facility was tracking UTIs on a map of the facility; however, failed to show a potential correllation between the location of the UTIs and possible deficient infection control practices. 2. During an observation on 9/17/18 at 5:44 p.m., scoops were laid on top of the steam table lids, without a barrier between the lids and the scoops during dinner service. During an observation on 9/17/18 at 5:46 p.m., staff member N had gloved hands and grabbed a bag of hamburger buns, then touched the saran wrap covering the lettuce and tomatoes. With the same gloved hands, he picked up the lettuce and tomato, a bun, and placed it on a plate to be served. During an observation on 9/17/18 at 5:58 p.m., staff member N was serving potatoes with gloved hands. He touched several serving utensil handles, then proceeded to touch the potatoes with the same gloved hands. During an observation on 9/17/18 at 6:00 p.m., staff member N was digging through the scoop drawer without gloves on. During an interview on 9/18/18 at 10:44 a.m., staff member N stated he had not worked at the facility very long, it had been about two weeks. He stated he had completed hand washing classes before, but had not taken a hand washing class or had training on hand washing at this facility. During an interview on 9/18/18 at 10:48 a.m., staff member L stated staff member N was the first person he had ever hired and he was not sure if he would be involved in his training, and was uncertain about the training process. He stated he assumed staff member M would be involved in training. Review of staff member N's Healthcare Services Group handbook showed staff member N received the PPE and Hazard Assessment Inservice Dining Services Policy, and received the Handwashing Procedure guide. He also took a Dining Services Quiz that was unfinished and was signed by staff member N.",2020-09-01
944,GLACIER CARE CENTER,275104,707 3RD ST SE,CUT BANK,MT,59427,2019-10-16,610,E,1,0,JUJ511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to protect residents from ongoing abuse and neglect and failed to provide two person assistance causing: verbal and physical abuse for 3 (#s 2, 5, and 9); verbal and emotional abuse for 2 (#s 1 and 10); neglect for 2 (#s 6 and 7) of 10 sampled residents. Findings include: 1. Review of NF2's Counseling Form, dated 2/18/19, showed the staff member transferred three residents without assistance, and the residents were a two-person transfer. We want to make it clear that your way of transferring is not acceptable and will not be allowed. The Hoyer lift requires two people to assist when transferring a resident. No education was provided. The form further showed We believe you have violated Staff treatment of [REDACTED]. The staff member neglected resident safety. It was also reported and witnessed by (CNA name) that you were rough with two residents. Resident #5 said you were rude and rough. Another resident, who cannot communicate, was having his private parts wiped by you and his privates were flopping all over. There is no reason to be aggressive or rough when cleaning/caring for residents. You should never cause a resident pain or discomfort. This can be considered resident abuse. During an interview on 10/16/19 at 9:26 a.m., staff member A stated NF2 was not provided additional education or supervision, after the event. She was unable to explain why this did not occur. She stated the facility had recently been through four DONs. Review of the facility Abuse Prevention Plan, dated (MONTH) 2019, showed The accused abuser must be separated from all dependent adults and either suspended, terminated or reassigned to a position where the accused abuser is not in contact with dependent adults. Increase Supervision if needed. The facility did not follow the policy for resident protection. Review of resident #1's Grievance/Concern Report Form, dated 6/2/19, showed the resident stated to a nurse I want to file a grievance. He pointed to NF2 and stated the staff member was very rude. (Resident #1) had a tear in his eye. A resident fell while resident #1 was reporting and NF2 stated to the resident When are you ever gonna stop falling? Resident #1 whispered - That's what I mean. The action taken to address the grievance showed NF2 will not care for (resident #1) alone. Counseling was conducted on using proper approach when addressing residents. No further documentation was provided by the facility regarding the incident, counseling, training, or increased supervision for NF2 and resident protection. During an interview on 10/16/19 at 12:57 p.m., staff member G stated NF2 did not work on the third of (MONTH) 2019, and she was not sure if she was suspended. Staff member A was looking at NF2's time sheet for verification, which was not conclusive, and so did not show the residents were protected from abuse. Review of NF2's Employee Counseling Form, dated 6/6/19, showed We have had several reports of inappropriate conduct between you and residents. On (MONTH) 2, 2019, resident #1 filed a grievance against you for being very rude. On (MONTH) 5, 2019, (staff member H) witnessed you treating (resident #9) inappropriately. You were yelling in (resident #9's) face because he stiffened out on the two of you when you were laying him down after breakfast. NF2 then flicked her finger against the resident's face or chest. NF2's Employee Counseling Form continued with Physical abuse is never acceptable no matter how frustrated you may get. Review of the facility Abuse Prevention Plan, dated (MONTH) 2019, showed the policy had not changed. During an interview on 10/16/19 at 12:10 p.m., staff member A stated the facility had a no tolerance philosophy for abuse, but sometimes the facility was not backed up by the corporate Human Resources. Review of NF2's Employee Counseling Form, dated 6/6/19, also showed Later you and staff member H went in to care for (resident #10). (Resident #10) had an accident and had spilled the urinal all over himself. NF2 started yelling at resident #10, You have to start getting up to pee and don't be peeing all over anymore. (Resident #10) looked really embarrassed. Review of NF2's Employee Counseling Form, dated 6/6/19, showed NF2 continued to work on 6/5/19, after physical abuse had been witnessed earlier on that day, which failed to protect the residents. NF2 was no longer working at the facility as of 6/6/19. 2. Review of NF3's Employee Counseling Form, dated 5/22/19, showed resident #6's call light was not answered for 20 minutes. Resident #6 wanted to get into his recliner. NF3 stated she would put him to bed, but not in his recliner. NF1 stated she did not appreciate the my way or the highway approach of NF3. NF1 stated she did not believe resident #6 should have to go to bed at the convenience of the staff. Review of NF3's Employee Counseling Form, dated 7/21/19, showed NF3 was providing one person assist for resident #9, who required two person assistance, neglecting the resident's safety. She was in the room with NF4, who was also providing care. Resident #2 was cussing at NF4. You (NF3) heard a loud thump against the wall. NF4 had pushed resident #2 against the wall. She was talking loudly. You walked over to NF4 and resident #2. You noticed his bloody knees. You pointed out there was blood on the wall. The counseling form continued with,Since you were in the room, you could have reminded her that both residents were two person assist. The abuse may have been prevented if you had intervened. Review of NF4's Employee Counseling Form, dated 7/21/19, showed she was no longer working at the facility. 3. During an interview on 10/16/19 at 9:41 a.m., NF1 stated she would assist one CNA with the stand lift 2 person transfer for resident #6. She stated she had no training, but learned by watching. She said the timeliness for transfers depended on the day and shift, and what else was happening. She stated she would assist with the transfers any where from one time per week, to four times a week, usually because there was not a second CNA available. She stated the facility had recently changed the CNA schedule to 12 hour shifts, which increased staff coverage. Review of NF2's Counseling Form, dated 2/18/19, showed the staff member transferred three residents without assistance, and the residents were a two-person transfer, neglecting resident safety. During an interview on 10/16/19 at 8:50 a.m., staff member A stated she had counseled a CNA in (MONTH) 2019, for providing one person assist for care and transfers, when the resident was a two person assist. She said she had terminated two CNA's for not providing two person transfers, as specified on the care plan. Review of NF3's Employee Counseling Form, dated 7/30/19, showed NF3 had been treating resident #7 poorly. You have insisted she go to bed at 8:00 p.m. When she refuses, you tell her she will have to wait then until the next shift as you have other things to do. She stated she was afraid to say anything as you would get mad at her for speaking to administration. Review of NF3's Employee Counseling Form showed she was no longer working at the facility. The facility failed to protect the residents when abuse occurred, and staff failed to intervene when abuse was occurring.",2020-09-01
945,GLACIER CARE CENTER,275104,707 3RD ST SE,CUT BANK,MT,59427,2019-10-31,583,C,0,1,TXBD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain the confidentiality of all residents residing in the facility by publicly posting their first and last names, along with corresponding room numbers, in the vestibule attached to the facility's main entrance, and the residents had not provided permission for their information to be posted. Findings include: During an observation on [DATE] at 12:25 p.m., all 27 residents' first and last names, along with corresponding room numbers, were posted on a bulletin board in the vestibule attached to the main entrance. During an interview on [DATE] at 12:32 p.m., staff member F stated the bulletin board had been there at least one year. Staff member F stated, I guess anyone could walk in and look at it. During an interview on [DATE] at 12:35 p.m., staff member G stated she assumed residents had given their consent to have their full names and room numbers posted in a public area. Staff member G stated visitors were supposed to sign in at the front desk. The front desk was located past the bulletin board and through another door, after a visitor would have seen residents' names and room numbers. During an interview on [DATE] at 12:50 p.m., staff member C stated the facility had a photography release form they required residents to sign, but she was not sure there was something explicitly stating residents' names and room numbers would be posted publicly. Staff member C stated she understood the concern that residents' information was posted in a public location. During an interview on [DATE] at 1:35 p.m., staff member A stated residents were safeguarded from unwanted visitors by requiring visitors to sign in at the front desk. Staff member A stated residents' names were added to the board after they signed the admission packet. Staff member A stated residents were not explicitly told that their names would be posted in the vestibule. Review of the facility's policy titled, Photograph, Video and Publicity Release Form, updated in (MONTH) (YEAR), showed: Permission to use my name, likeness, image, voice, and/or appearance as such may be embodied in any pictures, photos, video recordings, audiotapes, digital images, and the like . The policy did not include information that a resident's name and room number would be visible to all visitors who entered the facility prior to signing in at the front desk.",2020-09-01
946,GLACIER CARE CENTER,275104,707 3RD ST SE,CUT BANK,MT,59427,2019-10-31,761,E,0,1,TXBD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to dispose of two expired medications and [MEDICATION NAME] alcohol, which were located in the medication storage room. This had the potential to affect all residents who were prescribed those medications, and all residents whose staff used the expired [MEDICATION NAME] alcohol. Findings include: During an observation on 10/28/19 at 3:45 p.m. with staff member E, the following expired medications were found in the medication storage room: --Folic Acid 400 mcg, expired on 9/2019 --UltraTuss DM, expired on 9/2019 --[MEDICATION NAME] Alcohol 70%, expired on 2/2019 During an interview on 10/29/19 at 9:15 a.m., staff member I vocalized that she usually reviewed medications to check for expiration dates every week. Expired medications were then removed and taken to the nurse. During an interview on 10/29/19 at 9:50 a.m., staff member B stated, while referring to the Night Nurse Duties Check List, staff checked expiration dates in medication carts, and the medication room once every month. Review of the facility's policy titled, Night Nurse Duties Check List, showed: 25th of the month, check the med cart & fridge, for items expiring at the end of the month . 26th of the month check the stock items, and treatment supplies, including dressings for items expiring at the end of the month. Initials were noted on the 25th and 26th of (MONTH) and (MONTH) of 2019. Two medications and the [MEDICATION NAME] Alcohol were found expired on 10/28/2019.",2020-09-01
947,HOLY ROSARY EXTENDED CARE UNIT,275106,2600 WILSON ST,MILES CITY,MT,59301,2018-04-04,550,D,0,1,N5YU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 1 resident (#22) of 15 sampled residents was treated with respect and dignity by not using the term feeders for a resident whom needed assistance with eating. Findings include: Resident #22 was admitted to the facility with a [DIAGNOSES REDACTED]. A review of the resident's Admission MDS, with an ARD of 2/5/18, showed the resident had a BIMS of 7; severe impairment. Review of resident #22's Care Plan, with a goal date of 5/7/18, showed the resident had an ADL deficit, and was unable to complete his ADLs without assistance. The plan was to have the resident eat meals in the main dining room, at an assisted table, since he needed assistance with eating meals. During an interview on 4/2/18 at 6:46 p.m., staff member M was standing in a full dining room next the table were resident #22 was sitting. She referred to resident #22 as a feeder, and stated he sat on the side of the dining room with the rest of the feeders. The staff member was unable to explain why the term feeders may have been inappropriate. During an interview 4/4/18 at 8:43 a.m., staff member D stated the nurses would check for the meal preferences of the residents at the feeder table for preferences of likes and dislikes. Staff member M stated CNAs were responsible for the meal preferences for residents seated at the feeder tables. Staff member D stated she would not call a resident a feeder in front of the resident or the other residents. She stated it was fine to use the term away from resident care areas. A review of the facility's policy and procedure titled, Resident Rights and Responsibilities, showed, The resident has the right to a dignified existence, self-determination, and communication with and access to persons inside and outside the facility. Federal and State laws guarantee certain basic rights to all residents of this facility. these rights include the right to: a. A dignified existence. b. Be treated with respect, kindness, and dignity.",2020-09-01
948,HOLY ROSARY EXTENDED CARE UNIT,275106,2600 WILSON ST,MILES CITY,MT,59301,2018-04-04,554,D,0,1,N5YU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to assess and obtain a physician order [REDACTED]. Resident #45 was admitted to the facility with [DIAGNOSES REDACTED]. A review of resident #45's Annual MDS, with an ARD of 3/5/18, showed the resident was independent with her ADLs, but required supervision and minimal assistance with bathing and dressing. Resident #45 had a BIMS of 15; cognitively intact. During an observation and interview on 4/4/18 at 7:48 a.m., staff member B administered medications to resident #45 in the resident's room. Resident #45 put several capsules into a small white plastic bottle for later. Staff member B stated resident #45 liked to take some of her medications in the dining room when she was having breakfast. She stated resident #45 did not have a self-medication assessment, or a physician's orders [REDACTED].#45 liked to take part of her enzymes capsules during her meal, in the dining room. During an interview on 4/4/18 at 12:20 p.m., staff members D and F stated resident #45 did not have an order to self-administer medications. Staff member F stated resident #45 should not have been given medications to take with her to the dining room. Staff member F stated staff should have ensured all of resident #45's medications that were provided, were taken, at that time they were dispensed. Staff member F stated she would ensure resident #45 had a self-administration medication assessment in the resident's medical record prior to letting the resident take more medications in a container into the dining room. Review of resident #45's Care Plan, dated 4/4/18 at 2:41 p.m., showed resident #45 had passed self-administration evaluation and that the resident likes to split her enzymes and take them a few at a time before, during and after her meal. An IDT assessment was completed on 4/4/18 at 2:50 p.m. Review of the facility's policy, Self-Administration of Medications, dated 12/1/17, read, An assessment will be completed by the Interdisciplinary Team to determine the ability of the resident to self-administer medications and whether it is clinically appropriate to honor the resident's (sic) request. A resident may self-administer medications after the Interdisciplinary Team has determined which medications may be safely self-administered .",2020-09-01
949,HOLY ROSARY EXTENDED CARE UNIT,275106,2600 WILSON ST,MILES CITY,MT,59301,2018-04-04,676,D,0,1,N5YU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident wore hearing aids, for 1 (#22) of 15 sampled residents. Findings include: During an observation on 4/2/18 at 5:34 p.m., a note written on the dry erase board in resident #22's room showed, put hearing aids in every day. Resident #22 was admitted to the facility with a [DIAGNOSES REDACTED]. Review of resident #22's Care Plan, with a goal date of 5/6/18, showed the resident had a communication deficit related to altered hearing, which was evidenced by his inability to hear conversation adequately in areas with increased background noise. The approach was to speak slowly, clearly, in simple, short messages. Review of resident #22's Care Plan, with a goal date of 5/7/18, showed the resident had an ADL deficit, related to his inability to complete ADL's without assistance. The approach required staff to assist the resident in placing his hearing aid in his left ear, placing it in morning, and removing it in evening when sleeping. The hearing aid was noted to be kept at the nurses' station. Review of the facility's Hearing Aid N[NAME] Check Off sheet, showed resident #22 did not have his hearing aid on the following dates: - 3/31/18 - 4/1/18 - 4/2/18 - 4/3/18 During an observation on 4/2/18 at 5:40 p.m., resident #22 was sitting in his wheelchair by the front foyer, the resident did not have in his hearing aid. During an observation on 4/3/18 at 9:00 a.m., resident #22 was sitting in the dining room, he was not wearing his hearing aid. During an interview on 4/3/18 at 9:01 a.m., staff member H stated it was important for the resident to have his hearing aid in so he could hear. The staff member stated it was the responsibility of the night shift aides to assist the resident in the morning, and to put his hearing aid in his ear daily. The staff member stated she was not sure where the resident's hearing aid was, and stated she could not find it at the nurses' station or in the resident's room. During an interview on 4/3/18 at 9:08 a.m., staff member G stated she had picked up resident #22's hearing aid from the audiologist on Thursday, and it should have been working and available for the resident. The staff member looked in the nurses' station, and stated she could not find the resident's hearing aid. During an interview on 4/3/18 at 9:20 a.m., staff member G stated she had found the resident's hearing aid, at the nurses' station, and that she had been looking in the wrong spot. She stated the aide went to place the hearing aid in the resident's ear. During an interview on 4/3/18 at 2:00 p.m., resident #22's family member stated they expected the resident had help putting in his hearing aid every day, and felt it was important for this to be completed daily. During an interview on 4/4/18 at 10:00 a.m., staff member F stated hearing aids were kept for safe keeping at the nurses' station when the residents were not wearing their hearing aids. She stated for the less cognitive residents, the nurse was to sign in and out when the hearing aids were placed. She said it was the expectation, unless the hearing aid was being fixed, for the residents to have their hearing aids placed daily. A review of the facility's procedure titled, Hearing Aid Care, showed, A hearing aid is helpful to some patient in regaining some of their lost hearing .Patients generally wear hearing aids only during the day. At night and at times of rest, most patients remove their hearing aids.",2020-09-01
950,HOLY ROSARY EXTENDED CARE UNIT,275106,2600 WILSON ST,MILES CITY,MT,59301,2018-04-04,806,D,0,1,N5YU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide food according to a resident's preference for 1 (#21) of 15 sampled residents. Findings include: Resident #21 was admitted to the facility with a [DIAGNOSES REDACTED]. A review of resident #21's Initial MDS, with an ARD of 2/5/18, showed the resident had a BIMS of 99; the facility was unable to complete the resident's BIMS at the time of the interview. Review of resident #21's Nutrition Assessment, dated 1/26/18, showed no food dislikes. During an observation on 4/2/18 at 6:14 p.m., the resident was seated at the dining room table, with a plate of chopped roast beef, mashed potatoes with gravy, and a glass of ice water. The resident was not offered the green beans as on the menu. During an interview on 4/2/18 at 6:17 p.m., staff member M stated the CNA's would ask the residents what they wanted for their meal, and she would prepare what the CNA's told her what the residents wanted. She stated they worked to provide the resident with their preference. She stated if the resident was not able to express their needs, the CNAs would go based on a previous request. During an interview on 4/2/18 at 6:30 p.m., staff member N stated the CNA's told the dietary aides what the residents wanted for their meal. She stated if the resident was not able to communicate their needs, they would go by their care planned preferences. During an interview on 4/2/18 at 6:38 p.m., resident #21 stated green beans may not have been is favorite choice, but he would have eaten them had they been offered. He stated he liked his chocolate drink, but did not remember being offered one. During an interview on 4/3/18 at 10:20 a.m., resident #21's wife stated green beans were one of resident #21's favorite veggies, and since his appetite had improved, she felt he would have eaten them. During an interview on 4/4/17 at 8:43 a.m., staff member D stated it was the expectation of the nurses to ensure the resident's received meal items based on their food preferences. She stated if the resident was not able to communicate, the nurses would determine what they may want for dinner based on previous experience and knowledge of the resident, and their likes and dislikes.",2020-09-01
951,HOLY ROSARY EXTENDED CARE UNIT,275106,2600 WILSON ST,MILES CITY,MT,59301,2018-04-04,810,D,0,1,N5YU11,"Based on observation, interview, and record review, the facility failed to provide a resident with the required assistive devices used during meals, for 1 (#22) of 15 sampled residents. Findings include: During an observation on 4/2/18 at 6:45 p.m., resident #22 was feeding himself dinner. He was using built up silverware with a red foam handle. His plate did not have a food guard attached to it. Review of resident #22's Care Plan, with a goal date of 5/7/18, showed the resident had an ADL deficit, and was unable to complete his ADLs without assistance. The plan was to have resident #22 eat meals in the main dining room at an assisted table, since he needed assistance with eating meals, and provide the resident with built up silverware-red foam. During an observation on 4/3/18 at 8:52 a.m., resident #22 was feeding himself. He had a plate shield attached to the left side of his plate, and he was using regular silverware to eat with his right hand. The resident did not have the silverware available for use which was modified and built up with the red foam. During an interview on 4/3/18 at 8:55 a.m., staff member O stated she was not sure if the resident needed assistive eating utensils, and asked staff member N. Staff member N stated she did not know because she did not assist the residents at his table. During an interview on 4/3/18 at 8:57 a.m., staff member N stated it was the responsibility of the dietary aides to put out the assistive devices, because the aides did not have access to those utensils (the modified utensils). Staff member N retrieved a list from a cork board and explained resident #22 should have been given the built up (modified) red foam silverware. Review of the facility's list of Assistive Devices for Meals, showed, resident #22 was to be provided built up silverware (red foam). During an interview on 4/4/18 at 8:43 a.m., staff member D stated it was the expectation for the nurses and the dietary aides to ensure the resident's received the proper assistive devices during meal service. A review of the facility's policy and procedure titled Adopting Sites, showed, Various feeding devices can help a resident who has limited arm mobility, grasp, range of motion, or coordination.",2020-09-01
952,HOLY ROSARY EXTENDED CARE UNIT,275106,2600 WILSON ST,MILES CITY,MT,59301,2018-04-04,812,E,0,1,N5YU11,"Based on observation, interview, and record review, the facility staff failed to use proper hand hygiene during food preparation and going from dirty to clean tasks in the kitchen. This failure had the potential to affect all residents who consumed food from the kitchen. Findings include: During an observation on 4/3/18 at 7:46 a.m., staff member L washed dirty dishes with gloved hands. The staff member then left the dishwashing station and took her gloves off. She then picked up a clean cutting board without washing her hands and grabbed a colander of fresh tomatoes. During an interview on 4/3/18 at 7:55 p.m., staff member L stated she recalled attending orientation when she started working at the facility three and a half years prior, but could not remember if the facility taught hand hygiene at that time. She did not recall taking any hand hygiene classes from the facility but stated she knew proper hand hygiene. During an interview at 4/4/18 1:15 p.m., Staff member P stated she was not aware of infection control concerns regarding hand hygiene in the kitchen. Staff member P stated that random hand hygiene audits should be done, and managers should be recognizing hand hygiene concerns. The QAA had been working with all kitchen staff to improve infection control hand hygiene practices. The last infection control audit with the kitchen staff was compliant, so it was not brought to staff member K; this was around 1/2018. During an interview on 4/4/18 at 3:00 p.m. staff member K stated the expectations for staff to perform hand hygiene was to change gloves between dirty and clean tasks as well as washing hands between glove changes. He stated staff were to only use gloves in the kitchen area. Staff member K stated the kitchen staff must complete TOPs (sic) orientation training in the first 90 days of their hire date; however, they were required to complete hand hygiene training on day one. He stated staff complete hand hygiene training every year. Review of the facility's hand hygiene documentation showed staff member L completed the training on 3/23/18. A review of the facility's policy and procedure titled, When to Wash Hands, showed, Wash hands thoroughly and always: after using the restroom, before starting to work and when returning from the restroom or from breaks, after eating, drinking and smoking, after handling raw meat, poultry, seafood and produce, before working with ready-to-eat foods, before handling different types of food, after touching your hair, face, nose or any other part of your body, after coughing, sneezing and blowing your nose, after cleaning, after handling chemicals, after handling dirty equipment, after handling trash or other contaminated objects.",2020-09-01
953,HOLY ROSARY EXTENDED CARE UNIT,275106,2600 WILSON ST,MILES CITY,MT,59301,2018-04-04,925,E,0,1,N5YU11,"Based on observation, interview, and record review, the facility failed to maintain an adequate pest control program to prevent ants in the kitchen. This deficient practice had the potential to affect all residents who received food from the kitchen. Findings include: During an observation on 4/2/18 at 3:00 p.m., multiple ants were observed in the dishwashing room on the kitchen floor. During an interview on 4/4/18 at 3:05 p.m., staff member K, who worked in the kitchen regularly, stated he did not know there were ants and therefore had not reported the problem to maintenance. Staff member K stated the kitchen had not had ants for 6 to 8 months. During an interview at 4/4/18 at 1:15 p.m., staff member P stated she was not aware of the ant concern in the kitchen area currently. Staff member P stated she discussed the ant concern with staff member Q a few months ago. Staff Q contacted Eco lab (contractor for pest control) at that time. Staff member P stated she thought the problem was taken care of at that time. Both staff members P and K were unaware that there were ants currently in the kitchen. A review of the facility's policy and procedure titled, Pest Control Management Plan, showed, Purpose: to maintain high standards of cleanliness and to prevent the transmission of disease throughout the facility, Food Service will: 1. Routinely inspect premises for pests and if sighted report incident to Facilities Department by work order system (TMS), 2. Inspect all deliveries for pest and refuse and deliveries containing them (sic) 3. Eliminate all conditions conducive to pest inhabitance, Environmental Services will: 1. Have a licensed pest control operator routinely inspect the premises for evidence of pests, 2. Contact contractor if pests are found to arrange for elimination treatment, 3. Maintain documentation of all inspections, treatments and recommendations, 4. Eliminate all conditions conducive to pest inhabitance.",2020-09-01
954,HOLY ROSARY EXTENDED CARE UNIT,275106,2600 WILSON ST,MILES CITY,MT,59301,2019-05-16,655,D,0,1,GJZ811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to initiate a baseline care plan, including the use of oxygen, within 48 hours of admission for 1 (#45) of 23 sampled residents. Findings include: During an observation on 5/14/19 at 12:40 p.m., resident #45 had oxygen on via nasal cannula at a rate of 3 L/min. Resident #45 was noted to have a harsh cough. Resident #45 was not able to say why he was wearing oxygen. During an interview on 5/15/19 at 1:45 p.m., staff member [NAME] stated she was not sure why resident #45 was on oxygen. Staff member [NAME] reviewed the resident's medical record and was not able to locate a [DIAGNOSES REDACTED]. Resident #45 was admitted with [DIAGNOSES REDACTED]. Review of resident #45's physician orders, dated 4/22/19, showed no order for oxygen. Review of resident #45's hospice admission orders [REDACTED]. a. O2 at 1-3 L/min per nasal canual (sic) prn comfort. O2 sat. prn. Review of resident #45's baseline care plan, dated 4/22/19, did not show oxygen use. Review of resident #45's initial hospice care plan, dated 4/22/19, showed an order for [REDACTED].",2020-09-01
955,HOLY ROSARY EXTENDED CARE UNIT,275106,2600 WILSON ST,MILES CITY,MT,59301,2019-05-16,656,D,0,1,GJZ811,"**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 comprehensive care plan for 2 (#s 26 and 45) of 23 sampled residents. Findings include: 1. During an observation and interview on 5/13/19 at 4:06 p.m., resident #26 was sitting in her room, in her wheelchair, with her right foot elevated on a foot stool. Resident #26 stated the nurses remind her to elevate her foot as much as possible. Resident #26 stated she had no pain, and the elevation helped with the redness and swelling of her right lower leg. During an interview on 5/15/19 at 1:45 p.m., staff member [NAME] stated she believed resident #26 was receiving [MEDICATION NAME] for leg pain. During an interview on 5/15/19 at 3:55 p.m., staff member H stated she did not know why there was not documentation on resident #26's care plan related to pain management. Staff member H stated It was an oversight on my part. During a follow-up interview on 5/16/19 at 8:57 a.m., resident #26 stated the nurses sometimes used a heating pad for her leg pain. She stated they (the nurses) also gave her Tylenol or [MEDICATION NAME] for leg pain. Review of resident #26's physician order, dated 7/2/18, showed an order for [REDACTED]. Review of resident #26's physician progress notes [REDACTED]. Review of resident #26's current comprehensive care plan, dated 3/15/19, did not show any problems, goals, or approaches related to pain management. 2. During an observation on 5/14/19 at 12:40 p.m., resident #45 had oxygen on via nasal cannula at a rate of 3 L/min. Resident #45 was noted to have a harsh cough. Resident #45 was not able to say why he was wearing oxygen. During an interview on 5/15/19 at 1:45 p.m., staff member [NAME] stated she was not sure why resident #45 was on oxygen. Staff member [NAME] reviewed the resident's medical record in this surveyor's presence and was unable to locate a [DIAGNOSES REDACTED]. Review of resident #45's current hospice care plan, not dated, showed DME/Supplies: . O2 Concentrator. No other documentation of respiratory status or the use of oxygen was found. Review of resident #45's current comprehensive care plan, dated 4/30/19, showed Resident on O2 on the problem titled Assist w/ ADL's, risk for falls, Skin Risk. No goals or approaches related to respiratory status or oxygen use were found.",2020-09-01
956,HOLY ROSARY EXTENDED CARE UNIT,275106,2600 WILSON ST,MILES CITY,MT,59301,2019-05-16,679,D,0,1,GJZ811,"Based on observation, interview, and record review, the facility failed to provide an in-room activity program, per resident preference, for 1 (#28) of 23 sampled residents. Findings include: During an observation on 5/14/19 at 10:42 a.m., resident #28 was sitting in her recliner. She stated she was sleepy, but was willing to visit. She stated she did not watch TV or play bingo, but would rather be lazy. During an observation on 5/15/19 at 2:30 p.m., resident #28 was sitting in her recliner. The TV was not on, and a large plant and stuffed animals were in front of the TV. During an observation on 5/15/19 at 3:25 p.m., resident #28 was sitting in her recliner, looking at her fingernails. Review of resident #28's Significant Change MDS, with the ARD of 3/25/19, showed the resident was cognitively impaired. Review of resident #28's Care Plan, dated 3/26/19, showed she preferred in-room activities, would read the [NAME] newspaper, and was able to use the TV remote. Watches TV in her room when awake. The approaches included: - Deliver newspaper and magazines to room when extras are available. - Invite to scheduled music groups in the dining room. - Please turn TV or music on during the day. - Encourage out of room activities for social interactions. - Invite to scheduled bingo groups on Thursday and Saturday afternoon, and Monday evenings. During observations on 5/14/19 at 10:42 a.m., 5/15/19 at 2:30 p.m., and 5:10 p.m., and 5/16/19 at 7:47 a.m., resident #28 did not have newspapers in her room, and the TV was not on. Her room did not include a radio for music. During an interview on 5/16/19 at 9:03 a.m., staff member I said she had been able to persuade resident #28 to come out to activities in the past, but not recently. She stated it was everyone's responsibility to turn on the TV for resident #28, and she thought the family had been bringing in the newspaper. She stated the activity staff would start to do more 1:1 visits with the resident, since she preferred to be in her room. She stated she probably had not charted all of resident #28's activity refusals. Staff member I stated, we need to be more proactive with her. Review of resident #28's Activity Report for (MONTH) 1, to (MONTH) 16, showed she attended one activity on 5/8/19. No in-room activities were provided. Review of resident #28's Activity Report for (MONTH) showed she attended two activities, and had no in-room activities. Review of resident #28's Activity Report for (MONTH) showed she had two 1:1 visits. Review of resident #28's Significant Change MDS, with the ARD of 3/25/19, showed it was very important to the resident to have books and newspapers, and to listen to music.",2020-09-01
957,HOLY ROSARY EXTENDED CARE UNIT,275106,2600 WILSON ST,MILES CITY,MT,59301,2019-05-16,693,D,0,1,GJZ811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff followed physician orders [REDACTED].#s 1 and 14); and failed to properly label enteral formula container for a pump administered enteral tube feeding for 1 (#14) of 23 sampled residents. Findings include: 1. Free Water Flushes a. During an observation and interview on 5/15/19 at 2:00 p.m., staff member C prepared resident #1's enteral tube feeding of [MEDICATION NAME] 2.0, 250 ml. She then filled the calibrated measuring cup with 210 ml of free water. Staff C then flushed the resident's feeding tube with 35 ml of free water. She then administered the resident's prepared enteral feeding. She then administered the remaining 175 ml of free water through the resident's feeding tube. Staff member C stated she liked to give the resident a bit more water so she did not get dehydrated. During an interview on 5/15/19 at 2:23 p.m., staff member C stated she thought the resident was to get a required amount of water each day, but was not sure how much. She stated the resident may develop reflux if she was given too much water in addition to her tube feeding. She stated she would review the resident's order before the next tube feeding. Review of resident #1's Physician Orders, dated (MONTH) 2019, showed, Enteral Nutrition: [MEDICATION NAME] 2.0, 1 carton, 3 times per day. 60 ml of free water flush before and after bolus TID. Staff member C administered a total of 210 ml of free water during the resident's tube feeding. The physician order [REDACTED]. During an interview on 5/15/19 at 3:15 p.m. staff member [NAME] stated nursing staff were provided Healthstream training upon hire and annually on the administration of gastric enteral tube feedings. She stated nursing staff were then provided a nursing buddy to show them how to administer a resident's tube feeding for the first time. She stated staff were expected to follow the physician's orders [REDACTED]. During an interview on 5/15/19 at 3:48 p.m., staff member D stated resident #1 had issues with fluid overload in (MONTH) of (YEAR). Resident #1 was then switched to [MEDICATION NAME] 2.0 which contained less water and ensured she was provided less free water during the day. She stated she monitored resident #1's weights closely to ensure she was receiving adequate fluid balance. She said they did not have the resident on a current fluid restriction but wanted to ensure she did not receive more than 1500 ml of free water per day. b. During an observation on 5/15/19 at 4:45 p.m., staff member C flushed resident #14's feeding tube with a bolus of 35 ml of water, prior to the initiation of the tube feeding, via a pump. During an interview on 5/15/19 at 3:30 p.m., staff member D stated all residents in the facility were to receive a minimum of 1500 ml of fluids daily. This amount included flushes with medications and enteral fluids. Staff member D stated resident #14's sodium level was monitored, and she received free fluids during the day and before and after her tube feedings. During an interview on 5/15/19 at 4:45 p.m., staff member C stated resident #14 was to have a 30 ml bolus of water prior to the initiation of the tube feeding. Review of resident #14's MAR, dated 5/1/19 through 5/14/19, showed, 200 ml flushes QID and 30 ml flushes pre and post nocturnal feeding pump on a daily basis. Review of resident #14's Physician Orders, dated (MONTH) 2019, showed, 30 ml of free water flush before and after tube feeding connection/disconnection. 200 ml free water flush QID (sic). Staff member C administered 35 ml of free water at the initiation of the resident's tube feeding. The physician ordered 30 ml of free water, prior to initiation of tube feedings. A review of the facility's Lippincott Procedures titled, Enteral Tube Feeding, Gastric, showed, .Verify the practitioner's order, including the patient's identifiers, prescribed route based on the enteral tube's tip location, enteral feeding device, prescribed enteral formula, administration method, volume and rate of administration, and type, volume, and frequency of water flushes . 2. Enteral Bag Labeling During an observation on 5/13/19 at 5:24 p.m., a tube feeding bag was hanging on a pump, which was in operation, in resident #14's room. The tube feeding bag did not have a label with the resident's identifying information, or the date and time of administration of the tube feeding contents. During an observation on 5/15/19 at 4:10 p.m., staff member C prepared the bag for the tube feeding administration, using a new bag and tubing setup. Staff member C wrote the resident's name, date, and room number on label and applied to bag prior to filling. The staff member did not put the time on the label. During an interview on 5/15/19 at 4:56 p.m., staff member C stated the name and date should be written on the label applied to feeding bag. She could not recall what other information should be included on the label prior to the initiation of the tube feeding with the pump. A review of the facility's Lippincott Procedures titled, Enteral Tube Feeding, Gastric, showed: - Pour only a pre-measured 4-hour volume of enteral formula into the feeding bag and hang the bag on the IV pole. - Make sure the enteral formula container is labeled with the patient's identifiers; formula name, date and time of formula preparation, date and time the formula was hung; administration route; rate of administration' administration duration' initial of who prepared, hung, and checked the enteral formula against the order' expiration and date and time' dosing weight if appropriate' and notation Enteral use only. - Label the enteral administration set with the date and time that it was first hung.",2020-09-01
958,HOLY ROSARY EXTENDED CARE UNIT,275106,2600 WILSON ST,MILES CITY,MT,59301,2019-05-16,700,D,0,1,GJZ811,"Based on observation, interview, and record review, the facility failed to try alternative approaches prior to installing a side or bed rail, failed to assess for risk of entrapment, failed to review the risks and benefits with the resident, and failed to assess the need for the side rails for 1 (#37) of 23 sampled residents. Findings include: During an observation on 5/14/19 at 12:30 p.m., resident #37 was laying on his side in bed, and was unable to move to a front-lying position. He asked for help, and said he could not reach the side rail. A left side rail was on the bed. Resident #37 did not attempt to use it for assistance to reposition himself in the bed. A call light was wound through the side rail. During an interview on 5/15/19 at 8:48 a.m., staff member [NAME] stated she did not know how the facility determined which residents needed or wanted side rails, but she would find the answer. During an interview on 5/15/19 at 9:30 a.m., staff member [NAME] stated the process for determining who had side rails was an informal interdisciplinary decision, which the facility did not document. A policy and procedure for the safe use of side rails was requested, and not provided. The facility did not provide an assessment for the need or the safety of the side rail. No evidence of attempting any alternative approaches to the side rails was provided. No risk or benefits of the side rails were reviewed with resident #37. Review of the facility document provided showed The use of partial bed rails may assist an independent resident to enter and exit the bed independently, and would not be considered a physical restraint.",2020-09-01
959,HOLY ROSARY EXTENDED CARE UNIT,275106,2600 WILSON ST,MILES CITY,MT,59301,2019-05-16,759,E,0,1,GJZ811,"**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%. The medication error rate for the facility was 6%. The facility failed to administer medications per the physician's orders [REDACTED].#9); and failed to roll Humalog insulin prior to being drawn up for 1 (#7) of 24 sampled and supplemental residents. Findings include: 1. During an observation and interview on 5/13/19 at 6:01 p.m., staff member C administered one [MEDICATION NAME] 5 mg tablet, and two [MEDICATION NAME] 20 mg tablets to resident #9. Staff member C stated she was a little late giving resident #9 his medications. The resident was sitting at the dining room table eating dinner. Review of resident #9's MAR, dated (MONTH) 2019, showed, [MEDICATION NAME] was due at 4:00 p.m. The order showed, [MEDICATION NAME] 5 mg tablet give three times a day before meals. The MAR indicated [REDACTED]. Staff member C gave both of the medications while the resident was eating dinner. During an interview on 5/15/19 at 10:00 a.m., staff member C stated medications should be given as ordered. She stated she thought the facility had a policy which showed medications could be given one hour before and one hour after the ordered time. She stated it would be important to give medications which were ordered on an empty stomach as ordered so they would work effectively. During an interview on 5/15/19 at 3:15 p.m., staff member [NAME] stated staff were expected to give medications as ordered. She said medications which were ordered to be given before meals, should be given to the resident before they eat. She stated staff had annual Healthstream training for medication administration. A review of the facility's policy and procedure titled, Medication Administration, showed, 4. Administration of (facility) medications is done by Registered Nurses from bubble pack administration system. Administration times should match the times noted in the MAR. If these times do not meet the resident's needs, a request for time change may be completed by (facility) Director of Nursing. 2. During an observation on 5/14/19 at 1:35 p.m., staff member B drew up 0.6 ml of Humalog from a multi-dose vial. The staff member did not roll the Humalog vial prior to drawing up the insulin in the syringe. During an interview on 5/14/19 at 1:45 p.m., staff member B stated she had not rolled the Humalog vial prior to drawing it up in the syringe. She stated that was something she usually did, but failed to do it during this administration. During an interview on 5/15/19 at 3:15 p.m., staff member [NAME] stated insulin should be inspected before it was administered, and when necessary, rolled slightly to mix the medication. A review of the facility's Lippincott procedure titled, Subcutaneous Injection, showed, For insulin injections . Before drawing up an insulin suspension, gently roll and invert the bottle. Don't shake the bottle because shaking can cause foam or bubbles to develop in the syringe .",2020-09-01
960,HOLY ROSARY EXTENDED CARE UNIT,275106,2600 WILSON ST,MILES CITY,MT,59301,2019-05-16,880,D,0,1,GJZ811,"Based on observation, interview, and record review, the facility failed to ensure the safe storage of gastric enteral feeding tube supplies for 1 (#1); and nebulizer therapy supplies for 1 (#14) of 23 sampled residents, to ensure the prevention of the spread of infection. Findings include: 1. Feeding Tube Supplies During an observation on 5/14/19 at 2:30 p.m., resident #1's 60 ml syringe, dated 5/14/19, was placed inside a clear, 250 ml graduated measuring cup, dated 5/14/19. The set was stored face-up by the sink, under the towel dispenser. Staff member C washed her hands using the sink which the resident's clean tube feeding supplies had been placed by. During an observation on 5/15/19 at 3:15 p.m., resident #1's 60 ml syringe, dated 5/15/19, was placed inside a clear, 250 ml graduated measuring cup, dated 5/15/19. The set was stored face-up under the towel dispenser. Staff member C washed her hands in the sink, then picked up the resident's tube feeding supplies, and prepared them for the resident's enteral tube feeding. The supplies were stored in close proximity to a hand washing sink, and the items were uncovered, which could result in contamination of the clean supplies during hand washing. During an interview on 5/15/19 at 3:45 p.m., staff member C stated the tube feeding supplies were rinsed and stored on the resident's side of the sink. She stated all staff who assist both the residents in that room, were expected to wash their hands before providing care. She stated the staff would use the same sink on which the resident's feeding tube supplies were kept. She stated the storage of the resident's feeding tube supplies could become contaminated because of the proximity to the sink which they were stored. She stated it may be better to store the supplies in an area away from the sink. During an interview on 5/15/19 at 3:48 p.m., staff member [NAME] stated the resident's feeding tube supplies were stored on the side of the resident's sink. She stated the supplies should be stored out of the splash zone of the sink to prevent contamination of the resident's supplies. During an interview on 5/16/19 at 8:58 a.m., staff member H stated resident #1's feeding tube supplies should be stored away from any potential contamination. She stated they should not be stored next to the sink where staff wash their hands. A review of the facility's Lippincott Procedure titled, Enteral Tube Feeding, Gastric, showed, .Store clean equipment away from potential sources of contamination . 2. Nebulizer Supplies During an observation on 5/13/19 at 5:24 p.m., resident #14's oxygen face mask, oxygen tubing, and nebulizer canister setup were found plugged into the nebulizer. The supplies were from a past treatment and stored with the nebulizer on the bedside table. There was no resident identifying information or dates found on the nebulizer tubing setup. During an observation on 5/15/19 at 7:26 a.m., resident #14's oxygen face mask, oxygen tubing, and nebulizer canister setup were plugged into the nebulizer from a past treatment and stored with the nebulizer on the bedside table. There was no resident identifying information or dates found on nebulizer tubing setup. During an observation on 5/15/19 at 4:45 p.m., resident #14's oxygen face mask and nebulizer medication canister were stored upside down on a paper towel on the bedside table. During an interview on 5/15/19 at 4:45 p.m., staff member C stated the nebulizer setup was rinsed after each use and left to dry on a paper towel. She stated this practice was used each time a treatment was given, and the tubing and supplies for the nebulizer treatments were changed every 30 days. She stated the oxygen tubing was also changed every 30 days. During an interview on 5/15/19 at 5:00 p.m., staff member [NAME] stated oxygen and nebulizer treatment tubing was replaced every 30 days, and the facility did not have any special procedures or policies for the nebulizer equipment and tubing. During an interview on 5/16/19 at 8:58 a.m., staff member G stated the facility did not have a written policy for the nebulizer treatment supplies. The tubing and supplies were changed every 30 days similar to the regular oxygen tubing and rinsed out after each use, more often if respiratory complications were noted. A review of the facility's Lippincott Procedures titled, Nebulizer Therapy, showed, Rinse the nebulizer with sterile water and allow it to air-dry, or discard it after the treatment; and if a nebulizer device is for single-patient use, be sure to use it only for a single patient, label it with the proper patient identifiers and discard it at the end of the patient's stay to prevent cross-contamination.",2020-09-01
961,HOLY ROSARY EXTENDED CARE UNIT,275106,2600 WILSON ST,MILES CITY,MT,59301,2016-11-17,154,E,0,1,R3HS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to inform 6 (#s 1, 2, 4, 5, 8, and 9) of 11 sampled residents, or the responsible parties for those resident's with cognitive deficits, of the risks and benefits of the treatment for [REDACTED]. 1. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A review of an Admission MDS, with an ARD of 4/4/16, reflected the resident had a BIMS score of 11; moderately impaired. A review of a Quarterly MDS, with an ARD of 9/26/16, reflected the resident's cognition continued to be severely impaired. A review of the resident's MAR indicated [REDACTED]. She received [MEDICATION NAME] 1 mg on 11/10/16 at 11:03 a.m. and 7:07 p.m., and [MEDICATION NAME] 1 mg on 11/13/16 at 7:29 p.m. A review of the resident's medical record did not include documentation that the resident's POA received education regarding the risks and benefits of taking [MEDICATION NAME] or [MEDICATION NAME]. A review of the resident's Behavior Occurrences report showed the resident yelled, cursed at staff or other residents and had visual hallucinations 32 times over the past 106 days, and medications had been utilized to alter the behaviors. During an interview on 11/15/16 at 10:50 a.m., staff member C stated the facility did not have a process to provide education to the residents or their POA regarding the risks and benefits of treatment relating to [MEDICAL CONDITION] medications. On 11/15/16 at 4:36 p.m., a call was made to the resident's daughter. She was not available for an interview. 2. Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. A review of an Admission MDS, with an ARD of 4/4/16, reflected the resident was cognitively intact, had minimal hearing loss, and required limited assistance of 1 staff member with her activities of daily living. A review of the resident's MAR indicated [REDACTED]. A review of the resident's medical record did not include documentation that the resident had received education regarding the risks and benefits of taking [MEDICATION NAME] and [MEDICATION NAME]. During an interview on 11/15/16 at 3:10 p.m., staff member B stated the facility did not have a process to provide education to the residents or their POA regarding the risks and benefits of treatment. During an interview on 11/16/16 at 11:36 a.m., the resident stated she had not been educated regarding the risks and benefits of taking [MEDICATION NAME] and [MEDICATION NAME]. Review of the facility's Residential Living/Antipsychotic Medication use policy, read, Residents will receive antipsychotic medications only when necessary to treat specific conditions for which they are indicated and effective. Residents receiving antipsychotic medications, unless clinically contraindicated, will have gradual dose reduction attempted along with behavioral based interventions in an effort to discontinue antipsychotic medication use. 3. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #2's Quarterly assessment, with an assessment reference date of 8/29/16, reflected the resident was cognitively intact, had moderate hearing loss, and required extensive assistance of 1-2 staff with her activities of daily living. During an observation and interview on 11/15/16 at 8:15 a.m., resident #2 was eating her breakfast in her room. The resident was hard of hearing and had difficulty communicating. The resident reported her son could answer questions. Review of the resident's Medication Administration Record [REDACTED]. The order reflected [MEDICATION NAME] 0.5 mg three times per day as needed. The order reflected a start date of 2/10/16, and an end date of 4/12/16. The medical record did not include documentation that the resident received education regarding the risks and benefits of taking [MEDICATION NAME]. During an interview on 11/15/16 at 5:00 p.m., staff member C stated the facility did not have a process to provide education to residents regarding the risks and benefits of treatment. During an interview on 11/16/16 at 10:40 a.m., staff member G stated the facility pharmacy staff provided the medications. She stated the pharmacy did not have a role in providing education to the residents regarding the risks and benefits of treatment. During an interview on 11/16/16 at 2:00 p.m., staff member H stated he was responsible for the facility drug regimen review but not part of the resident education process. On 11/16/16 at 2:26 p.m. a call was made to the resident's son. He was not available for interview. 4. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. A review of nursing notes, dated 9/18/16, showed the physician was contacted due to resident #4 having difficulty sleeping at night. A review of a physician's orders [REDACTED].#4. A review of resident #4's (MONTH) (YEAR) MAR, showed the resident was receiving [MEDICATION NAME] 7.5 mg at bedtime. During an interview on 11/16/16 at 8:20 a.m., resident #4 said she was taking a pill to help her sleep. Resident #4 said it worked pretty good. 5. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. A review of resident #5's (MONTH) (YEAR) MAR, showed resident #5 was receiving [MEDICATION NAME] 5 mg at bedtime for anxiety disorder, and [MEDICATION NAME] 20 mg every day for depression. During an interview on 11/16/16 at 8:20 a.m., resident #5 said she took medicine for her sadness and for her feelings of anxiety. During an interview on 11/16/16 at 10:20 a.m., staff member C said the facility did not have a process to provide education to the residents or their POA regarding the risks and benefits of [MEDICATION NAME] and [MEDICATION NAME]. 6. Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. A review of resident #8's (MONTH) (YEAR) MAR, showed resident #8 was receiving [MEDICATION NAME] 0.5 mg every day, [MEDICATION NAME] 1 mg at bedtime, [MEDICATION NAME] 25 mg every day, [MEDICATION NAME] 50 mg at bedtime, and [MEDICATION NAME] 50 mg every day. Resident #8 was unable to be interviewed due to her dementia. During an interview on 11/16/16 at 10:20 a.m., staff member C said the facility did not have a process that showed the risks and benefits of [MEDICATION NAME], and [MEDICATION NAME] had been explained to resident #8's daughter who was also the resident's PO[NAME] During an interview on 11/16/16 at 10:30 a.m., resident #8's daughter said she knew her mom was taking [MEDICATION NAME], and [MEDICATION NAME], but the facility had not explained the risks and benefits of these medications to her.",2020-09-01
962,HOLY ROSARY EXTENDED CARE UNIT,275106,2600 WILSON ST,MILES CITY,MT,59301,2016-11-17,281,D,0,1,R3HS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of quality for 1 (#9) of 11 sampled residents. Specifically, staff continued to use a multi-dose vial of insulin past the expiration (opened) date. Findings include: Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation on [DATE] at 8:00 a.m., staff member D administered five units of Humalog insulin to the resident. The staff member used a multi-dose vial, of 3 milliliters, with a Do not use after [DATE] sticker label on the vial. The vial was almost empty. An unopened multi-dose vial of Humalog insulin was also observed with a Do not use after [DATE] sticker label which was in the Meadowlark hall medication cart. A review of the resident's MAR for ,[DATE] showed the resident received 5 units of Humalog insulin three times a day by different facility staff members. During an interview on [DATE] at 9:20 a.m., staff member D stated she should have double checked the expiration date on the insulin prior to administering. She stated she thought the insulin vial expired on [DATE], not [DATE]. During an interview on [DATE] at 11:05 a.m., staff member C stated facility staff should be writing the opened date on multi-dose vials of medications when opened by staff members. She stated that documenting the opened date on multi-dose vials of medications was a common nursing profession standard, and each staff member should have been reviewing the expiration date on the insulin prior to administering. During an interview on [DATE] at 2:00 p.m., staff member H stated the pharmacy department was responsible for labeling multi-dose vials of insulin with the Do not use after stickers. He stated the labeled sticker was to be dated no more than 28 days past the requested date. He stated facility staff members should be double checking the stickers to ensure it was not used after the opened date. Staff member H stated his biggest concern was contamination and issues with the stability of the preservative used in the insulin vials. A review of the facility's Multiple Dose vials policy, revised ,[DATE], read, In order to ensure the safety and effectiveness of medications, multiple dose vials of injectable drugs will only be used for 28 days after the vial is opened. 1. Multiple dose vials of injectable's (sic) (i.e., Insulin, Bact. (sic) Sodium Chloride, .) will be dated with a revised expiration date when opened (once the vial cap is removed or the vial is punctured). a. Multiple dose vials are to be discarded 28 days after first use. b. Multiple dose vials are to be discarded if sterility is questioned or compromised. c. Expiration date will be documented as 28 days from the date and time of opening. d. Example of dating to be documented: Multiple dose vial opened 03.01.2014, vial will be labeled with a revised expiration date of 3.28.14 by the provider. 2. Vials that have been opened for 28 days or have no dating will be destroyed.",2020-09-01
963,HOLY ROSARY EXTENDED CARE UNIT,275106,2600 WILSON ST,MILES CITY,MT,59301,2016-11-17,315,G,0,1,R3HS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to provide services that would minimize the spread of infection for 1 (#1) of 11 sampled residents. Specifically, staff lifted a Foley catheter bag and tubing containing urine above the level of the resident's bladder. Findings include: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A review of an Admission MDS, with an ARD of 4/4/16, reflected the resident required extensive assistance with activities of daily living, and she had an indwelling Foley catheter. A review of a Quarterly MDS, with an ARD of 9/26/16, reflected the resident required extensive assistance with activities of daily living. The resident's primary mode of transportation was a wheelchair, and she had an indwelling Foley catheter. A review of the nursing notes, dated from 8/1/16 through 11/10/16, reflected the resident had numerous episodes of yelling and crying out, she had visual hallucinations, complained of generalized pain, and had numerous episodes of excessive sleepiness. Notes reflected the resident's physician changed her dose of [MEDICATION NAME] and [MEDICATION NAME] multiple times. A review of nursing notes, dated 11/10/16, reflected the resident had an increase in yelling .threw cups at staff and spit out some morning medication out (sic). Resident has very angry tone to voice and is unable to be calmed by staff. Resident position changed for comfort but does little to calm resident. Lights dimmed but no change in resident's behavior. PRN [MEDICATION NAME] (sic) given and resident absent of visual hallucinations after lunch but is still yelling . A review of nursing notes, dated 11/11/16, reflected the resident continued to have an increase in behaviors, and the staff and family were unable to redirect or calm the resident. The resident was given PRN [MEDICATION NAME] and [MEDICATION NAME]. At 3:50 p.m., nurse's notes reflected a facsimile was sent to the resident's physician and the physician asked that a (urinalysis) be obtained. The nurse's notes read, (Urinalysis) obtained through port in cathater (sic) today at (3:15 p.m.) and sent to lab. awaiting (sic) results. Daughter (name) aware of new orders. A review of nursing notes, dated 11/11/16 at 7:02 p.m., read, (Urinalysis) results faxed to (physician's name). Shows trace blood, positive for [MEDICATION NAME], 1 plus leukocytes, amorphous crystals, and budding yeast. No response at this time. Will encourage fluids with resident. A review of nursing notes, dated 11/12/16 at 00:56 a.m., read, (Resident's name) was hollering and res (sic) was not soiled, but when asked if she hurt, she said yes. Asked where she hurt and she reported 'all over', then said she had to feed those kids cuz they're always hungry after school. Res med (sic) @ (00:20 a.m.) with [MEDICATION NAME] 1 PO for generalized pain. A review of a facsimile sent to the resident's physician, dated 11/14/16, reflected the resident's urine results. The physician wrote a telephone physician's orders [REDACTED]. This was the first time the resident was diagnosed with [REDACTED]. During an observation on 11/15/16 at 5:07 p.m., staff members [NAME] and F provided perineal care to resident #1. The resident was lying flat on her back in her bed. A Foley catheter bag and tubing containing yellow fluid was tossed onto the bed between the resident's feet by staff member F. At 5:11 p.m., staff member D entered the resident's room, picked up the catheter tubing and began wiping them down with a cleansing cloth. There was a yellow liquid inside the catheter tubing. Staff member D picked up the catheter bag above the level of the resident's bladder and wiped the bag with the cleansing cloth. The bag was lifted eight inches above the level of the resident's bladder. At 5:19 p.m., staff members [NAME] and F put a clean brief on the resident, put her pants back on and assisted the resident to her wheelchair. Staff member F folded the catheter bag in half and passed it through the right leg of the resident's pants while the resident was lying flat in bed. During an interview on 11/15/16 at 5:22 p.m., staff member F stated she always put the catheter bag on the bed during perineal care. The staff member stated there was no easy way to provide perineal care and dressing of residents with a Foley catheter bag. During an interview on 11/15/16 at 5:26 p.m., staff member D stated catheter bags were to remain below the level of the bladder at all times to prevent CAUTI. A review of the facility's Health stream power-point education slides for licensed nurses, page 3, read, Draining a Foley Catheter- Keep drainage bag below the level of the patients (sic) abdomen at all times. A review of the facility's Indwelling urinary catheter care and management policy, page 2 of 6, read, Keep the drainage bag below the level of the patient's (sic) bladder and hips to prevent black flow (sic) of urine into the bladder, with increases the risk of CAUTI.",2020-09-01
964,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2018-03-08,561,E,0,1,GWLR11,"Based on interview, record review, and observation, the facility failed to support resident choice by removing a dessert from the meal tray for 1 (#11), and providing alternative foods not chosen by the resident for 3 (#s 10, 13 and 15) of 19 sampled and supplemental residents. Findings include: 1. Review of resident #10's Quarterly MDS, with the ARD of 1/19/18, showed she had severe cognitive impairment, and rarely/never made decisions. During an observation on 3/6/18 at 8:09 a.m., resident #10 received hot cereal and pureed pears for breakfast. The menu for breakfast on 3/6/18 showed fresh fruit, egg, and cinnamon toast. During an observation on 3/6/18 at 11:47 a.m., resident #10 received pureed soup and ice cream. The menu for lunch on 3/6/18 showed turkey, bread dressing, and butternut squash. During an observation on 3/7/18 at 8:19 a.m., resident #10 received hot cereal and pureed fruit for breakfast. The breakfast menu showed fresh fruit, egg, sausage, and an English muffin. During an interview on 3/7/18 at 8:19 a.m., staff member J stated resident #10 sometimes received the entree on the menu. She was unable to explain how the decision was made to provide only soup, versus the pureed meal, as specified on the menu. 2. Review of resident #13's Admission MDS, with the ARD of 12/27/18, showed the resident was rarely/never understood. During an observation on 3/5/18 at 11:45 a.m., resident #13 was served a peanut butter sandwich for lunch. Resident #13 had adaptive silverware, but she did not pick them up during the meal. She drank a boxed juice supplement with a straw, and did not attempt to eat her sandwich. During an interview on 3/6/18 at 11:50 a.m., staff member F stated resident #13 could point to the menu to choose foods. Sandwiches were not on the menu. She stated resident #13 would not let anyone assist her with meals, and she would use her hands to eat. 3. Review of resident #15's Quarterly MDS, with the ARD of 12/29/18, showed the resident was rarely/never understood. During an observation on 3/5/18 at 11:44 a.m., resident #15 was served a peanut butter and jelly sandwich, and a cookie. During observations at lunch on 3/6/18, resident #15 received a sandwich only, instead of the meal specified on the menu. During an observation on 3/7/18 at 11:45 a.m., resident #15 received a sandwich and a cookie. During an interview on 3/8/18 at 12:10 p.m., resident #15 was unable to answer the question, Do you want something for lunch other than a sandwich? The facility was unable to provide documentation regarding the resident #s 10, 13, and 15's choices for meal substitutions that were not of equal nutritive value to the menu. 4. During an observation on 3/5/18 at 11:55 a.m., resident #11's cookies were placed in the middle of the table. During an interview on 3/5/18 at 11:56 a.m., staff member O stated resident #11 would eat her cookies first, so they removed them until she ate her meal. During an observation on 3/6/18 at 8:15 a.m., resident #11 had not received fruit with her breakfast. She was drinking a red liquid. During an interview on 3/6/18 at 4:30 p.m., staff member G stated resident #11 was receiving plain canned apples instead of the apple crisp. The menu showed residents on a low concentrated sweets diet should receive 1/4 cup of the apple crisp. During an interview on 3/7/18 at 1:00 p.m., staff member C stated resident #11 received Crystal Light for breakfast to lower her calories. The menu called for juice. During an observation on 3/8/18 at 12:10 p.m., resident #11 was eating her lunch meal in bed. Her dessert was on the other side of the room, on a shelf. Resident #11 stated that it was her dessert, and she would like it on her meal tray. During an interview on 3/8/18 at 12:30 p.m., staff member K stated she did remove resident #11's dessert because she would eat it before her meal, and her blood sugar would spike. During an interview on 3/8/18 at 12:40 p.m., staff member A stated the facility did remove resident #11's dessert during all meals because she would eat the dessert first. She stated the family agreed with this. Resident #11 was not allowed to choose to eat her dessert first.",2020-09-01
965,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2018-03-08,577,E,0,1,GWLR11,"Based on interviews and observations, the facility failed to communicate the location of the survey results for 9 (#s 4, 5, 6, 8, 9, 10, 13, 15, and 17) of 19 sampled and supplemental residents. Findings include: During the group meeting on 3/6/18 at 1:56 p.m., all residents in attendance, #s 4, 5, 6, 8, 9, 10, 13, 15, and 17, stated they did not know where the survey results were located. During an observation on 3/7/18 at 1:00 p.m., the survey results were in a binder on the wall, in a hanging shelf, above the nurses station countertop. The hanging shelf was approximately five feet from the ground. There were two 8 by 10 plastic holders sitting on the countertop directly in front of the survey book. The holders were inhibiting the ability to see the survey book behind them. During an observation on 3/7/18 at 1:07 p.m., resident #5 was in her wheelchair and unable to reach the survey results book from the wall.",2020-09-01
966,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2018-03-08,584,D,0,1,GWLR11,"Based on observation, interview, and record review, the facility failed to maintain a clean environment for 1 (#12) of 12 sampled residents. Findings include: During an observation and interview on 3/5/18 at 3:11 p.m., the large double window, next to resident #12's bed, was observed to be dirty on the outside of both panes. The view was obstructed by dirt and water stains. Resident #12 stated she liked to look outside, but was unable to do so because the window was too dirty. During an interview on 3/8/18 at 12:47 p.m., staff member A stated a couple of days ago she had identified that resident #12's window was dirty. She stated maintenance was responsible for cleaning windows on the outside. She said she was unsure what the plan was to clean the window, but she would check with the maintenance department. Staff member A said the windows were not cleaned more often because they only stayed clean about 20 minutes. Review of a document provided by the facility, titled, Window Cleaning Log for Long Term Care, showed the exterior of the windows was to be cleaned quarterly, or more often as needed, by the groundskeeper or a housekeeper. The document showed the last scheduled cleaning in (YEAR) was to be done on (MONTH) 2 (2017). The (YEAR) schedule was not provided. A verbal request of evidence showing completion of the most recent window cleaning was made to staff member A on 3/8/18 at 1:10 p.m. No evidence of completion of the window cleaning was provided.",2020-09-01
967,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2018-03-08,585,E,0,1,GWLR11,"Based on interviews and observation, the facility failed to ensure residents knew how to file a grievance for 8 (#s 5, 6, 8, 9, 10, 13, 15, and 17) of 19 sampled and supplemental residents. Findings include: During the group meeting on 3/6/18 at 1:56 p.m., eight residents in attendance (#s 5, 6, 8, 9, 10, 13, 15, and 17) stated they did not know how to file a grievance or where the forms were. During an observation on 3/7/18 at 1:00 p.m., one grievance form was located in the hanging shelf on the wall by the nursing station approximately one foot above the hand rail. During an observation on 3/7/18 at 1:07 p.m., resident #5 was in her wheelchair and unable to reach the grievance forms on the wall without trying to stand up.",2020-09-01
968,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2018-03-08,606,D,0,1,GWLR11,"Based on observation, interview, and record review, the facility failed to complete a background check on staff member S, who was an indirect care staff member, and the staff member engaged in a negative verbal interaction with 1 (#9) resident, of 12 sampled residents. Findings include: During an observation on 3/5/18 at 1:00 p.m., resident #9 called staff member S bonehead, and in response, staff member S stated No, you are! A review of staff member S's employee file showed a lack of evidence for a background, which was to be completed prior to the indirect care staff member being allowed to work at the facility, or with the residents. During an interview on 3/7/18 at 1:42 p.m., staff member R stated, I did not know that the facility didn't do a background check when staff member S was hired to volunteer here.",2020-09-01
969,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2018-03-08,609,D,0,1,GWLR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to report and investigate a bruise of unknown origin for 1 (#1) of 12 sampled residents. Findings include: 1. Resident #1 was admitted with [DIAGNOSES REDACTED]. During an observation on 3/5/18 at 4:21 p.m., resident #1 was observed to have a dark purplish bruise to her left chin area. Resident #1 only laughed when asked how she got the bruise. There was no documentation in the nursing progress notes regarding the investigation of the bruise or the reporting of the bruise to the State Survey Agency. During an interview on 3/7/18 at 9:09 a.m., staff member A stated she did not report the bruise, on resident #1's chin, to the State Survey Agency. She stated she was not informed about the bruise. Staff member A stated the licensed nurse is to investigate how the resident got the bruise or an injury, and if unable to find the cause of the bruise, the nurse was to report it to staff member A, for further investigating and reporting. She stated the nurse that was on duty was a new nurse. She stated she would need to provide the staff member with education on reporting bruises. During an interview with staff member I on 3/7/18 at 9:13 a.m., she stated she had reported the bruise to staff member [NAME] She stated she and staff member A had a conversation about the bruise. Staff member I stated if the resident was unable to tell her how he/she got a bruise she would assess the resident and try to figure out how they got a bruise. She stated she would then report it to staff member [NAME] As of 3/12/18 at 1:27 p.m., the bruise of unknown origin had not been reported to the State Survey Agency.",2020-09-01
970,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2018-03-08,610,D,0,1,GWLR11,"Based on record review, observation, and interview, the facility failed to provide evidence for the thorough investigation for a bruise of unknown origin for 1 (#1) of 12 sampled residents. Findings include: During an observation on 3/5/18 at 4:21 p.m., resident #1 was observed to have a dark purplish bruise to her left chin area. Resident #1 only laughed when asked how she got the bruise. A review of resident #1's medical record failed to show documentation in the nursing progress notes regarding an investigation of the bruise of unknown origin to the resident's chin, or a plan to prevent further injuries of unknown origin, for the protection of the resident. During an interview with staff member I on 3/7/18 at 9:13 a.m., she stated if the resident is unable to tell her how the bruise occurred, then she would assess the resident and try to figure out how they got a bruise.",2020-09-01
971,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2018-03-08,625,B,0,1,GWLR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide bed hold information, during a period of hospitalization , for 2 (#s 12 and 14) of 12 sampled residents. Findings include: 1. During an interview on 3/5/18 at 3:05 p.m., resident #12 stated she had recently been hospitalized for [REDACTED]. Review of resident #12's Discharge MDS, with an ARD of 2/2/18, showed the resident was discharged to the hospital on [DATE]. Review of resident #12's Entry Tracking Record showed she re-entered the facility, from the hospital, on 2/4/18. A written request was made for resident #12's bed hold notice related to the recent hospitalization . No bed hold notice was provided. 2. During an interview on 3/5/18 at 4:15 p.m., resident #14 stated she had a recent hospitalization . Review of resident #14's progress notes showed she was discharged to the hospital on [DATE], and readmitted to the LTC facility on 2/2/18. A written request was made for resident #14's bed hold related to the recent hospitalization . No bed hold notice was provided. During an interview on 3/7/18 at 10:30 a.m., staff member A stated the facility did not provide a bed hold notice at the time of transfer. She stated the admission packet, that each resident received on admission, contained generic information regarding bed holds. A written request was made for the facility's bed hold policy. Review of a document provided by the facility, titled, Bed Holds, showed, The Resident shall be give notice of the bed holding option at the time of hospitalization or therapeutic/social leave. (sic)",2020-09-01
972,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2018-03-08,656,D,0,1,GWLR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan which described the respiratory services required by the resident for 1 (#5) of 12 sampled residents. Findings include: During an observation on 3/6/18 at 7:54 a.m., resident #5 was lying in bed using oxygen at three liters per minute. Review of resident #5's (MONTH) (YEAR) physician's orders [REDACTED]. The (MONTH) (YEAR) physician's orders [REDACTED]. Review of resident #5's care plan, last edited 3/5/18, showed the need for the oxygen was not addressed on the care plan. During an interview on 3/7/18 at 3:03 p.m., staff member B stated resident #5 used oxygen at night, and she did not see the oxygen use on the care plan. She stated she had missed including the use of oxygen in resident #5's care plan. Prior to the end of the survey, staff member B presented an updated version of resident #5's care plan which included the need for oxygen at night.",2020-09-01
973,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2018-03-08,657,E,0,1,GWLR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to to update the resident's care plan relating to a fall, for 1 (#5); when a resident had an acute infection, for 2 (#s 2 and 7); and with a significant change in status for 1 (#7) of 12 sampled residents. Findings include: 1. a. During an observation and interview on 3/5/18 at 11:40 a.m., resident #7 was lying in bed with her eyes closed. Two family members of resident #7 were present at bedside. NF1 stated resident #7 was on comfort care, and could no longer eat or drink, and meals were no longer being provided. She stated resident #7 was no longer able to get out of bed, was minimally responsive, and required total assistance for her needs. She stated resident #7 had been her usual self the prior week. NF1 said resident #7 had been able to walk, eat, and participate in activities a week ago. She stated resident #7 had had a complete change. Throughout this interaction, resident #7 did not attempt to move or speak, but she did open her eyes and appeared to look at NF1. Review of resident #7's care plan, last edited 1/30/18, showed the following: -she was independent or needed supervision with bed mobility, transfers, and walking; -she needed minimal to moderate assistance with dressing, hygiene, and toileting; -she fed herself with set-up; -she ambulated independently with a four-wheeled walker; -staff should encourage her to use the call light; -she received a regular diet with thin liquids; -there was a goal for resident #7 to consume 1300 milliliters of fluids per day. During an interview on 3/7/18 at 2:59 p.m., staff members B and V stated they made the changes to the care plan when needed. Staff member B stated resident #7's care plan did not reflect her current status. She stated the care plan had not been updated since resident #7's change of condition, and a comfort measures care plan had not been added. b. Review of resident #7's (MONTH) (YEAR) MARs showed an order for [REDACTED]. Review of resident #7's provider communication form, dated 2/6/18, showed an order for [REDACTED]. Review of resident #7's laboratory results showed a urine culture, dated 2/6/18, which was positive for the presence of bacteria, and showed a [DIAGNOSES REDACTED]. Review of resident #7's care plan, last edited 1/30/18, did not show the presence of a UTI and the use of an antibiotic as an active or resolved concern. The care plan did not show interventions to initiate when a UTI was present or an antibiotic was in use. During an interview on 3/7/18 at 2:59 p.m., staff member B stated there was no resolved care plan for the problem of a UTI for residents #2 or #7. She stated the nurses documented their assessments and orders in the progress notes so nothing was updated on resident #2's care plan. Staff member B stated the facility does not update care plans to show acute infections, or add interventions related to the infection. 2. Review of resident #2's Quarterly MDS, with an ARD of 1/5/18, showed the resident had a UTI within the past 30 days. Review of resident #2's laboratory results showed a urinalysis, dated 12/2/17, which was positive for the presence of bacteria. Review of resident #2's physician's orders [REDACTED]. Review of resident #2's Monthly Summary/RICC report, dated 12/4/17, showed resident #2 had a UTI on 12/2/17, and was treated with antibiotics. Review of resident #2's care plan, last edited 9/5/17, showed a history of UTI's, and to observe for symptoms. Resident #2's care plan did not show the presence of a UTI, and the use of an antibiotic as an active or resolved concern. The care plan did not show interventions to initiate when a UTI was present or when an antibiotic was in use. 3. During an interview on 3/6/18 at 10:20 a.m., resident #5 stated she had fallen recently. She was unable to report when the falls had occurred, or what had happened, but she believed one fall was very recent. Review of resident #5's progress notes, dated 9/8/17-3/5/18 showed the resident had two falls during this period. A progress note, dated 11/2/17, showed resident #5 was observed, by the nurse, to be lying on the floor. A progress note, dated 3/1/18, documented as a late entry for 2/28/18, showed resident #5 lost her balance, went down onto her knees, and then fell to the right. During an interview on 3/7/18 at 2:50 p.m., staff member V stated resident care plans were not necessarily updated after a fall. She said the care plan would not likely be updated if the resident was known to have fallen before. Review of a document provided to the State Survey Agency, after the conclusion of the survey, showed the intervention for the fall that occurred 2/28/18, was to leave resident #5's bed sheets un-tucked. This intervention was not included on resident #5's care plan.",2020-09-01
974,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2018-03-08,689,E,0,1,GWLR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to identify root cause, investigate staff-associated falls, implement interventions, and monitor and modify interventions to prevent multiple falls for 3 (#s 5, 13 and 11) of 12 sampled residents. Resident #13 had a laceration to the head and a skin tear from falls, and resident #11 had scratches and bruises from a fall. Findings include: 1. Review of the Care Area Assessment for falls, noted 12/29/17, showed (Resident) triggered for fall due to receiving [MEDICAL CONDITION] medications, and for impaired balance. (Resident) had [MEDICAL CONDITION] (YEAR), with residual right sided weakness as well as communication deficit. She has not attempted to self transfer from bed or wheelchair since admission. Staff has been using a tab alarm when she is in wheelchair to alert them for unintended position changes which could result in a fall. Review of resident #13's progress note, dated 1/3/18, showed Resident slipped during AM care transfer, hitting head on bedside door pull resulting in 2 cm laceration left of midline of forehead. Resident assisted back to bed. Area cleansed and 2 steri strips applied. Review of resident #13's progress note, dated 1/17/18, showed Resident found laying head first on the floor with legs caught in the wheelchair legs. Wheelchair removed. Bleeding noted from skin tears to right hand and [MEDICAL CONDITION]. Taken to ED. Review of resident #13's Care Plan for falls, dated 1/22/18, showed the resident fell on [DATE], during a CNA transfer, and fell from her wheelchair on 1/17/18. Review of resident #13's progress note, dated 1/26/18, showed Resident found on her knees near her bed. Mat had been placed on floor this am, and was in place upon entering room. No injury noted. Review of resident #13's progress note, dated 2/24/18, showed Resident on her knees on floor pad leaning over bed. Tab alarm still intact. Further review of resident #13's care plan showed interventions which were: - Extensive assist to dependent for transfers. Use stand-up lift as needed. Let her know each step of process before proceeding. Go Slow. Right foot may turn medial when she is on the lift, and she has indicated right arm pain with sling use. - Tab alarm while seated in wheelchair to alert staff when leans to the right or forward. - Has not tried to self transfer but hangs her legs off of side of bed at night. - Wheelchair with back that leans back for more comfortable positioning and to decrease risk of falling forward. During an observation on 3/6/18 at 3:10 p.m., resident #13 was in her room, kneeling on her fall mat on the floor. During an interview on 3/7/18 at 8:45 a.m., staff member A stated the facility did not have fall investigations. She said the facility did an investigation, but it was not part of the medical record. Review of resident #13's progress notes, care plan, and Care Area Assessment, did not show the root causes of her four falls, particularly for a staff-related fall, and did not show interventions to prevent falls, contributing factors, or if monitoring of the resident for fall safety was adequate. During an interview on 3/8/18 at 10:34 a.m., staff member A stated falls were discussed and trended at the Quality Assurance meeting, but the facility did not show documented specifics for fall reduction. 2. Review of resident #11's Care Area Assessment, dated 3/30/17, showed the resident had been swung off balance in the stand-up lift, and was lowered to the floor. Her bed was exchanged with a new bed that would accommodate the use of the lift. Review of resident #11's nursing progress note, dated 3/6/18, showed While being prepared for shower in shower room, resident leaned forward while in shower chair as it was being rolled over shower drain and resident tipped forward onto left side on floor. Small scratch above left knee and small bruise left shoulder noted. During an interview on 3/8/18 at 9:30 a.m., staff member A stated the facility had no investigations to share for #11's falls. Review of resident #11's Care Area Assessment, showed No falls since 3/30/17. 3. During an interview on 3/6/18 at 10:20 a.m., resident #5 stated she had fallen recently. She was unable to report when the falls occurred, or what had happened, but she believed one fall was very recent. Review of resident #5's progress notes, dated 9/8/17-3/5/18, showed the resident had two falls during this period. A progress note, dated 11/2/17, showed resident #5 was observed, by the nurse, to be lying on the floor. The note did not show how resident #5 came to be on the floor, what she was doing prior to being on the floor, or if resident #5 sustained any injury. A progress note, dated 3/1/18, documented as a late entry for 2/28/18, showed resident #5 was pulling on her bed sheet, lost her balance, went down onto her knees and then fell to the right. The progress notes did not show a root cause analysis of why resident #5 had fallen, or if the staff had identified contributing factors, if monitoring was adequate, or what the interventions were to prevent future falls. A written request was made for the fall investigations for resident #5 from (MONTH) (YEAR) through (MONTH) (YEAR). No documentation was provided. No directions were provided for where this information would be found in the paper medical records or in the electronic medical records. Review of resident #5's fall care plan, last edited 3/5/18, showed she had four falls in (YEAR). The fall of 2/28/18, was not noted on the care plan. Resident #5's care plan included a list of interventions for fall prevention. None of the interventions were dated for when the intervention was implemented to show the plan was evaluated or modified based on effectiveness of the interventions. The care plan did not show if the interventions were related to a specific event. During an interview on 3/7/18 at 2:50 p.m., staff member V stated resident care plans were not necessarily updated after a fall. She said the care plan would not likely be updated if the resident was known to have fallen before. Staff member V stated new interventions were not always added after a fall. She stated she could not say if new, resident-specific interventions, were added after resident #5's falls. During an interview on 3/7/18 at 2:59 p.m., staff member B stated new interventions were discussed at the RICC meeting. During an interview on 3/8/18 at 2:10 p.m., at the conclusion of the survey, staff member A stated she had not understood that documentation was still needed regarding fall investigations. She was advised that the information could be faxed to the State Survey Agency. No documentation was received regarding fall investigations. The facility failed to show preventative efforts for falls. Review of a document, labeled Fall Investigations, provided to the State Survey Agency after the conclusion of the survey, showed a summary of the resident #5's falls on 11/2/17, and 2/28/18. The summaries failed to show the investigation of the root causes for the falls, in an attempt to prevent future falls for the resident.",2020-09-01
975,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2018-03-08,692,G,0,1,GWLR11,"Based on interview, record review, and observation, the facility failed to identify a significant weight loss, and failed to implement interventions to prevent further weight loss for 1 (#10) of 19 sampled and supplement residents. Findings include: Review of resident #10's weight record showed she weighed 180 pounds on 1/1/18, and 168 pounds on 2/5/18. The resident had a six percent significant weight loss in one month. Review of resident #10's monthly summary, dated 1/3/18, showed the resident had lost 6.4 pounds in six months, and 17.8 pounds in the last year. Supercereal was tried in (MONTH) (YEAR) due to weight loss, which (resident) refused to eat. Review of resident #10's medical record showed the weight loss for (MONTH) (YEAR) was documented in the record, but the loss was not identified as a concern to be addressed by other interdisciplinary team members. Review of resident #10's nutrition note, dated 3/5/18, showed Weight loss. Resident showing persistent weight loss. Although not significant in the past six months, she had lost 25 pounds over the past year. She has been sick over the past few months and has not been eating very well. Will see if she will accept supplements or milkshakes. During an interview on 3/8/18 at 1:10 p.m., staff member D stated she would need to review her notes to describe why she did not note resident #10's significant weight loss. During an observation on 3/6/18 at 8:09 a.m., resident #10 received hot cereal and pureed pears for breakfast. The menu for breakfast on 3/6/18 showed fresh fruit, egg, and cinnamon toast. During an observation on 3/6/18 at 11:47 a.m., resident #10 received pureed soup and ice cream. The menu for lunch on 3/6/18 showed turkey, bread dressing and butternut squash. During an observation on 3/7/18 at 8:19 a.m., resident #10 received hot cereal and pureed fruit for breakfast. The breakfast menu showed fresh fruit, egg, sausage, and an English muffin. During an interview on 3/7/18 at 8:19 a.m., staff member J stated resident #10 sometimes received the entree on the menu. She was unable to explain how the decision was made to provide only soup, or the pureed meal, as specified on the menu. During an interview on 3/7/18 at 12:48 p.m., staff member C stated he believed resident #10 only wanted soup, although it was not documented, and she was unable to make her choices known. Review of resident #10's Care Plan, dated 1/16/18, showed the resident was ordered a Regular, pureed diet, and to assess food like/dislikes. The Care Plan did not show the resident's meals should be limited to soup and cereal, or how those food limits were decided by staff. During an interview on 3/8/18 at 10:45 a.m., staff member A stated resident #10's weight loss may not have been identified because there was a period of time when the dietitian was not available.",2020-09-01
976,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2018-03-08,700,D,0,1,GWLR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to attempt alternatives before the use of side rails for 1 (#1) of 12 sampled residents. Findings include: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation on 3/5/18 at 4:08 p.m., resident #1 was in bed with the bilateral half side rails in the up position. During an observation on 3/6/18 at 9:37 a.m., staff member O provided morning care for resident #1. Staff member O had to request assistance from staff member L in order to turn resident #1 in bed. Resident #1 did not attempt to use the side rails while turning in bed. Review of resident #1's untitled document showed she used the side rails for left upper extremity assist with bed mobility. The document was updated 12/12/17, and showed no changes. The record lacked documentation that alternatives to side rails were attempted, and did not clearly show indication for use. During an interview on 3/6/18 at 8:46 a.m., staff member O stated that resident #1 did not use her side rails, and that she required two staff members for assist with turning and positioning.",2020-09-01
977,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2018-03-08,758,D,0,1,GWLR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess psychoactive medication use quarterly, and to provide a rationale for the denial of a gradual dose reduction of psychoactive medication(s) for 1 (#12) of 12 sampled residents. Findings include: Review of resident #12's Psychopharmacologic Resident Interdisciplinary Care Committee Medication Review, dated 8/1/17, showed resident #12 was receiving [MEDICATION NAME] (an antianxiety medication) 15 mg three times a day, and the indication for use was anxiety. The committee recommended no GDR be attempted for the [MEDICATION NAME] due to behaviors and resident diagnoses. The behaviors and [DIAGNOSES REDACTED]. The bottom of the form showed an area for provider response and orders. The same section showed the provider must write a rationale for all responses, per regulation. In this section was written, No change, and was signed by the physician. No rationale was provided for the denial of the GDR. Review of resident #12's Psychopharmacologic Resident Interdisciplinary Care Committee Medication Review, dated 8/1/17, showed resident #12 was receiving [MEDICATION NAME] (an antidepressant) 30 mg every day, and the indication for use was anxiety. The committee recommended no GDR be attempted for the [MEDICATION NAME], and the reason checked for the recommendation was the resident was stable with no adverse side effects. Handwritten in this section was the direction to see the [MEDICATION NAME] worksheet. The bottom of the form showed an area for provider response and orders. The same section showed the provider must write a rationale for all responses, per regulation. In this section was written, No change, and was signed by the physician. No rationale was provided for the denial of the GDR. Review of resident #12's Psychopharmacologic Resident Interdisciplinary Care Committee Medication Review, dated 10/30/17, showed resident #12 was receiving [MEDICATION NAME] 15 mg three times a day, and the indication for use was anxiety. The committee recommended no GDR be attempted for the [MEDICATION NAME], and the reason checked for the recommendation was the resident was stable with no adverse side effects. The bottom of the form showed an area for provider response and orders. The same section showed the provider must write a rationale for all responses, per regulation. In this section was written, agree, and was signed by the physician. No rationale was provided for why the physician agreed. Review of resident #12's Psychopharmacologic Resident Interdisciplinary Care Committee Medication Review, dated 10/30/17, showed resident #12 was receiving [MEDICATION NAME] 30 mg every day, and the indication for use was anxiety. The committee recommended no GDR be attempted for the [MEDICATION NAME], and the reason checked for the recommendation was the resident was stable with no adverse side effects. The bottom of the form showed an area for provider response and orders. The same section showed the provider must write a rationale for all responses, per regulation. In this section was written, agree, and was signed by the physician. No rationale was provided by the physician for the lack of a GDR. Review of resident #12's Psychopharmacologic Resident Interdisciplinary Care Committee Medication Review, dated 10/30/17, showed resident #12 was receiving Trazadone (an antidepressant) 100 mg every day at bedtime, and the indication for use was [MEDICAL CONDITION]. The committee recommended no GDR be attempted for the Trazadone, and the reason checked for the recommendation was the resident was stable with no adverse side effects. The bottom of the form showed an area for provider response and orders. The same section showed the provider must write a rationale for all responses, per regulation. In this section was written, agree, and was signed by the physician. No rationale was provided. Review of resident #12's physician's orders [REDACTED]. Review of resident #12's provider communication, dated 1/31/18, showed: - The facility requested the provider review the current psychoactive medications for a possible gradual dose reduction. - The provider's response was written in the orders section and showed an order for [REDACTED]. During an interview on 3/6/18 at 1:00 p.m., staff member A stated the Psychopharmacologic Resident Interdisciplinary Care Committee Medication Review form was the tool used as the medication review, and the GDR recommendation. She stated the provider communication was not a medication review, and the form was sent specifically to obtain the rationale for the refusal on the (MONTH) (YEAR) reviews. Staff member A stated obtaining GDR rationale was a process the facility was still working on. A written request was provided, to the facility, for resident #12's GDR reviews/requests. No medication reviews/GDR recommendations were provided that were completed after 10/30/17.",2020-09-01
978,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2018-03-08,761,E,0,1,GWLR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to dispose of expired insulin for 1 (#14) of 12 sampled residents; and failed to dispose of expired stock medications which had the potential to affect all residents who received those medications. Findings include: 1. During an observation and interview on 3/6/18 at 9:20 a.m., resident #14's Humalog (insulin) Kwikpen showed an open date of 1/28/18. Staff member H stated the date indicated the insulin pen had been opened and first used on 1/28/18. She stated insulin bottles (vials) could only be kept for 28 days after opening, but she was uncertain for the pens. During an interview on 3/6/18 at 9:27 a.m., staff member H stated the rule applied to the insulin pens as it did for the insulin bottles, and she would throw it out and access the new insulin supply that was available in the refrigerator. Staff member H stated resident #14 had been receiving the insulin every day since it expired. Review of resident #14's physician's orders [REDACTED]. Review of resident #14's (MONTH) and (MONTH) (YEAR) MARs showed the order for [MEDICATION NAME] had not been updated to reflect the use of the Humalog insulin instead of the [MEDICATION NAME] insulin. The MARs showed insulin had been administered to resident #14 from one to four times every day for the nine days the insulin had been expired. During an interview on 3/8/18 at 8:53 a.m., staff member A stated the facility had received an order from resident #14's physician that the Humalog insulin could be substituted for [MEDICATION NAME] until the Humalog supply was all used. She then clarified, saying the order did not show the insulin was to be used beyond the expiration date. Staff member A stated the policy for multi-dose vials also applied to insulin pens. Review of a policy titled, Multi-Dose Vials, Care of, last revised 7/2017, showed, Insulin will be labeled appropriately and discarded 28 days from the date of opening. 2. During an inspection of the medication room storage cupboards, on 3/6/18 at 4:08 p.m., the following was observed: -Antacid liquid 12 oz. bottle, expired 2/18. -Children's Tylenol, expired 12/17. During an interview on 3/6/18 at 4:10 p.m., staff member H stated that assuring there are no expired medications in the cupboard was every nurse's responsibility. She said the night nurse used to monitor the cupboard for expired medications, but recently traveling nurses were working, and the task was not being done consistently.",2020-09-01
979,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2018-03-08,803,E,0,1,GWLR11,"Based on record review, interview, and observation, the facility failed to follow the prescribed menu, and had no written documentation for the changes to the menu. This had the potential to affect all residents' nutritional status, who live and eat at the facility. Findings include: Review of the lunch menu for 3/5/18 showed wheat dinner roll or bread with margarine, and a praline bar, should be served. During an observation on 3/5/18 at 11:40 a.m., the residents did not receive bread or margarine, and received a cookie instead of a praline bar. Review of the dinner menu for 3/5/18 showed a fruit plate, or a fruit pie, should be served for dessert for the dinner meal. During an observation in the kitchen at 4:35 p.m., the dessert was fruit cocktail, in a plastic cup. Review of the breakfast menu for 3/6/18 showed fresh fruit was to be served. During an observation on 3/6/18 at 8:05 a.m., the residents received canned peaches in a plastic cup. During observations of lunch and dinner on 3/6/18, no bread and margarine was served to the residents, even though both were on the menu. During an interview on 3/7/18 at 12:10 p.m., staff member F stated the residents did not want bread. This was not documented. Review of the breakfast menu for 3/7/18 showed fresh fruit and an English muffin should be served. During an observation on 3/7/18 at 8:10 a.m., the residents received canned pears in a plastic cup, and a blueberry muffin. During an interview on 3/7/18 at 8:15 a.m., staff member F stated the residents could not chew English muffins.",2020-09-01
980,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2018-03-08,806,E,0,1,GWLR11,"Based on observation and interview, the facility failed to offer a substitution for meals that was similar to the nutritive value of the meal, which affected 4 (#s 1, 4, 10, and 13) of 19 sampled and supplemental residents. Findings include: During lunch meal observations on 3/5/18, 3/6/18, and 3/7/18, the choice provided to residents who did not want the meal on the menu, was a soup and sandwich. Resident #4 was provided only soup for lunch. Resident #10 was provided pureed soup and dessert for lunch. Resident #1 was provided a sandwich and dessert. Resident #13 was provided sandwiches for lunch. During an interview on 3/7/18 at 11:18 a.m., staff member C stated the facility had always offered soup and a sandwich as the alternative to the meal. During an interview on 3/8/18 at 2:00 p.m., resident #4 stated that staff member F told residents This is not a restaurant, and they could not choose what they want to eat. He stated this occurred last Thursday.",2020-09-01
981,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2018-03-08,807,D,0,1,GWLR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and observation, the facility failed to provided nectar thick liquids, as ordered by the physician, for 1 (#13) of 12 sampled residents. Findings include: During an observation on 3/5/18, 3/6/18 and 3/7/18, resident #13 was drinking a boxed juice supplement with a straw, at breakfast and lunch. Review of resident #13's physician orders, dated 12/20/17, showed the resident was on a soft diet with nectar thick liquids. During an interview on 3/5/18 at 2:50 p.m., staff member H stated she did not know if resident #13 was on thickened liquids. During an observation and interview on 3/8/18 at 10:20 a.m., with staff member M and A, resident #13's water pitcher contained water, and a powder-like substance at the bottom of the pitcher. Staff member M stated he followed the directions on the can of powdered thickener, to produce nectar thick liquids. Staff member A did not know why the thickener had separated, but she thought it would thicken up as the resident tilted the cup to drink. The water did not thicken without shaking the water pitcher. A review of the information for the Boost supplement showed it was not a nectar thick liquid. Review of resident #13's nutrition note, dated 1/15/18, showed the resident required soft food with finger foods, and nectar thick liquids. A new swallow study was recommended, because the family believed the resident did not need thickened liquids, and the resident could use a straw. Review of resident #13's nutritional status Care Area Assessment, dated 12/29/17, showed the resident had a swallow study on 9/28/16, which showed she was a silent aspirator with thin liquids. During an interview on 3/7/18 at 2:16 p.m., staff member F stated They said the resident could be on thin liquids. She stated they were the nursing management. During an interview on 3/7/18, at 11:18 a.m., staff member C stated the facility had talked about the resident's thin liquids at a care conference, and he stated they should have gotten a physician's orders [REDACTED]. During an interview on 3/8/18, staff member A stated the facility had no evidence a new swallow evaluation had been completed for resident #13.",2020-09-01
982,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2018-03-08,810,D,0,1,GWLR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess the need for, and provide an assistive device, for eating for 1 (#2) of 12 sampled residents. Findings include: Review of resident #2's Quarterly MDS, with an ARD of 1/5/18, showed the following: -she had moderately impaired vision; -she was unable to complete the cognitive assessment; -she received supervision and set-up for eating; -she had a [DIAGNOSES REDACTED]. Review of resident #2's care plan, last edited 9/5/17, showed she had [MEDICATION NAME] degeneration, [MEDICAL CONDITION], and cognitive impairment. The care plan showed resident #2 fed herself with set-up by staff. The care plan showed goals that resident #2's needs would be met, and that she would maintain independence for her ADL's. During an observation and interview on 3/6/18 at 8:10 a.m., resident #2's breakfast tray was delivered by staff member K and placed on a tray table next to resident #2's bed. Resident #2 was assisted to sit up at the tray table. Staff member K stated resident #2 ate her meals in her room and rarely came out of her room. Staff member K removed the silverware from the wrapper and laid it on the tray. The meal included two fried eggs with soft-cooked yolks, a slice of toast which had been cut into two pieces, a glass of juice, and a cup of cut fruit in a plastic cup. The food was served on a small plate. Staff member K left the room. Resident #2 used her fingers to locate various items on her tray. She moved her silverware and napkin to the right, and moved the juice and fruit cup to the top of the tray. Staff member K returned with a cup of hot cocoa and set in on the tray, telling resident #2 what she had brought. Staff member K left the room. After locating the eggs with her fingers, resident #2 repeatedly poked at an egg with her fork. She was unable to cut it or pick it up with the fork. After several attempts to cut the egg with the fork, she laid the fork aside, and pulled the egg apart with her fingers. Yolk spilled onto the plate and resident #2's fingertips. She continued to tear off pieces of egg with her fingers, occasionally using her fork to stab a bite. Resident #2 periodically licked the yolk from her fingers as she ate. She denied needing assistance with her breakfast. During an interview on 3/7/18 at 10:30 a.m., staff member J stated resident #2 ate her meals in her room, and could feed herself. She said she did not stay with resident #2 while she ate, and did not think anyone else did either. Staff member J stated resident #2's meal was usually consumed, so she did not know resident #2 was having difficulty, or was using her fingers to cut her food. Staff members J and V stated it is not dignified for resident #2 to use her fingers to eat fried eggs, and that she should be assessed for her ability to self feed. During an interview on 3/8/18 at 8:35 a.m., staff member V stated she had completed an observation of resident #2 eating her breakfast. She stated breakfast was served on a small plate, and included a fried egg with a soft-cooked yolk, and pancakes. Staff member V said resident #2 did not use her fingers to eat the egg, but that she did have difficulty stabbing her food with the fork, and she needed a scoop plate. She stated the resident needed her food cut up. She stated the staff need to try to get resident #2 to come to the dining room for meals so she has more supervision. Review of resident #2's progress note, dated 3/9/18, as a late entry for 3/8/18, was provided to the survey agency after completion of the survey. The progress note showed staff member V observed resident #2 during breakfast and determined that adaptive utensils and plate would be beneficial to accommodate resident #2's self-feeding needs.",2020-09-01
983,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2018-03-08,880,E,0,1,GWLR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a sanitary environment by not performing hand hygiene when needed for 1 (#2), and by placing a medical device on a meal tray for 1 (#12); failed to develop a procedure for cleaning and disinfecting of a shared glucometer for 2 (#s 11 and 14) of 19 sampled and supplemental residents. Findings include: 1. During an observation and interview on 3/6/18 at 8:43 a.m., staff member K was assisting resident #2 in the bathroom. With gloved hands, staff member K pulled down resident #2's pants and wet pull-up brief, and assisted her to sit on the toilet. Staff member K removed resident #2's wet pull-up brief, placed it in the trash, removed her soiled gloves, and threw them in the trash. Staff member K stepped into resident #2's room, pushing the wheelchair from the bathroom doorway, so she could pass through. Staff member K moved resident #2's breakfast tray, folded and put away the tray table, gathered dirty cups and put them on the breakfast tray. Staff member K then washed her hands. Staff member K stated she should have washed hands after removing her gloves but was nervous due to being watched. Staff member K returned to the bathroom, donned gloves, and provided perineal care to resident #2. She then removed the soiled gloves and pulled up resident #2's pull-up brief and pants, assisted her into her wheelchair, pushed her out of the bathroom, and then washed her hands. Staff member K stated she did not have any way to clean her hands between removing the gloves and assisting resident #2 with her clothing. 2. During an observation and interview on 3/7/18 at 8:44 a.m., staff member I prepared to administer a bolus dose of [MEDICATION NAME] to resident #12. Staff member I stated resident #12 had a [MEDICATION NAME] pump implanted, under her skin, and a hand-held device, approximately 2 inches by 3 inches, which was used to trigger the pump to administer a [MEDICATION NAME] bolus. Staff member I laid the device on resident #12's breakfast tray, on top of the napkin and knife handle as she performed other tasks. Staff member I stated she should not have laid the device on the breakfast tray. She stated she should have laid it on the table, beside the tray. 3. a. During an observation and interview on 3/7/18 at 10:37 a.m., staff member J prepared to complete a blood glucose check for resident #14. She stated the glucometer was shared among all residents who required blood glucose checks. Staff member J cleaned the glucometer with a white disposable wipe she took from an unlabeled zippered baggie. She stated the wipe was from the red top canister, but she could not recall the product name. She said they usually had individually packaged wipes for cleaning the glucometer, but they had run out. Staff member J wiped the glucometer front and back for less than ten seconds, then dried it with a paper towel. She completed the blood glucose check and cleaned the glucometer with the same technique used prior to the procedure. b. During an observation on 3/7/18 at 10:42 a.m., staff member J prepared to complete a blood glucose check for resident #11. Staff member J removed a white disposable wipe from an unlabeled zippered baggie, and cleaned the glucometer for six seconds. She laid the glucometer on a paper towel (barrier) to dry. Staff member J completed the blood glucose check, and laid the used glucometer on a dresser, without a barrier. After washing her hands and donning gloves, she cleaned the glucometer for five seconds, dried it with a paper towel, and laid it in a tray with the blood glucose testing supplies. During an interview on 3/7/18 at 10:47 a.m., staff member J stated the red top canister was Sani-cloth Plus Disinfecting Wipes, as she held the canister and read from the label. The canister had a red cap. Staff member J stated she took a course many years ago, maybe ten, to be permitted to do blood glucose checks. She stated her competency had not been checked for months. Staff member J stated she was not taught to use a barrier under the glucometer, and that she did not always use one, but she tried to. She stated she did not know what the cleaning and disinfecting time for the glucometer was, or what the wipes manufacturer recommended. Staff member J reviewed the product label and stated the instructions said to leave the surface wet for three minutes. She stated she had not left the glucometer wet for three minutes, but will do so from now on. Review of a document titled, CNA Check-Off Sheet for Vital Signs and Blood Glucose, dated 8/6/15, showed, in an area labeled, Blood Glucose, The above named individual successfully demonstrated how to measure blood glucose using equipment normally used on residents. The instructions on the form showed the CNA should be able to verbalize handwashing, cleaning the equipment, and explaining the procedure to the resident. The form did not show if the CNA was required to demonstrate competency. The form did not specify the steps for accurate cleaning of the glucometer, or the need to use a barrier under the glucometer when laid on a surface. The form had the name of staff member J and was signed by staff member A with a pre-printed statement that the signatory is completely confident this CNA is able to accurately and consistently perform all the above tasks. Review of a policy titled, Glucometer Use, last revised 11/2017, showed the equipment needed and the procedural steps for completion of a blood glucose check. The cleaning and disinfecting of the glucometer was not addressed. Step 9 of the procedure showed the staff will demonstrate competency before obtaining blood sugar levels and will reviewed yearly thereafter.",2020-09-01
984,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2018-03-08,883,E,0,1,GWLR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to determine if residents had received both the Pneumococcal [MEDICATION NAME] Vaccine, and the Prevnar 13 Vaccine, for 9 (#s 1, 2, 5, 9, 11, 12, 13, 15, and 19) of 12 sampled residents; and failed to provide vaccine information sheets when administering vaccines to residents, which had the potential to affect any resident who received vaccinations in the facility. Findings include: 1. a. Review of the facility-wide immunization log for (YEAR)-2018 showed a single column for coding the resident's influenza vaccination status and the date received, if applicable. The form showed a single column for coding the resident's pneumo vaccination status and the date received, if applicable. The form did not distinguish the type of pneumo vaccine, or offer a space to document the vaccine status for a second type of pneumococcal vaccine. b. Review of the individual immunization record for resident #2 showed the following: -a section on the form with the word Pneumoccocal (sic) with a line (line 1) for documenting the date the vaccine was received and other relevant information. -In the same section, under the word pneumococcal, were the letters PCU, with a line (line 2) for documenting the date the vaccine was received and other relevant information. -On line 1 was the date 1994. -On line 2 was the date 11/29/05. -The documentation did not differentiate if the vaccine was the Pneumococcal [MEDICATION NAME] Vaccine (PPSV23) or the Pneumococcal Conjugate Vaccine (PCV13, also known as Prevnar 13). During an interview and record review on 3/6/18 at 10:40 a.m., staff member H stated she believed the date 11/29/05, indicated a second dose of the pneumococcal vaccine. She stated she did not know what the letters PCU meant on the form. c. Review of the individual immunization forms for residents 1, 5, 9, 11, 12, 13, 15, and 19 showed the following: -Resident #1's immunization form showed a Pneumococcal vaccine was received on 10/7/10. -Resident #5's immunization form showed a Pneumococcal vaccine was received on 12/11/00. -Resident #9's immunization form did not show a Pneumococcal vaccine was received. The facility-wide immunization log showed resident #9 received a Pneumococcal vaccine in 2001. -Resident #11's immunization form showed a Pneumococcal vaccine was received in 10/2007. -Resident #12's immunization form showed a Pneumococcal vaccine was refused. -Resident #13's immunization form referred the reader to the Main Street Medical Sheet. The sheet showed a [MEDICATION NAME] given x 2 with the most recent date being 10/28/08. -Resident #15's immunization form showed a Pneumococcal vaccine was received on 11/29/05. The date 8/12/15 was written on the same line, under a column labeled initials. -Resident #19's immunization form showed a Pneumococcal vaccine was received on 2/14/17. -The documentation on the forms did not differentiate if the vaccine given or refused was the Pneumococcal [MEDICATION NAME] Vaccine (PPSV23) or the Pneumococcal Conjugate Vaccine (PCV13, also known as Prevnar 13). d. During an interview and record review on 3/7/18 at 2:11 p.m , staff member B reviewed the form and stated she did not see where the Prevnar vaccine was specifically addressed, but if the facility determined it had been given, that information would be documented in the Pneumococcal section. She stated that upon admission of a new resident, a facility nurse attempted to determine if the new resident had received a pneumococcal vaccine. Staff member B stated the facility only tried to determine if the resident had received either of the Pneumococcal or Prevnar vaccines, and did not differentiate between the two vaccines. She said the facility did not offer an additional vaccine if the resident had received only one or the other. e. Review of a policy titled, Influenza & Pneumonia Vaccination Administration, Physician Clinical Pathway, last revised 11/2017, showed the purpose of the document was to authorize standing orders to vaccinate, as appropriate, patients/residents within the facility with influenza and pneumococcal vaccinations. The form does not differentiate the two types of pneumococcal vaccines or show that both vaccines should be offered with specific sequencing and timing. 2. During an interview and record review on 3/7/18 at 11:04 a.m., staff member N stated she gave most of the influenza vaccinations administered in the facility. She stated an information sheet would only be given if a resident was receiving an influenza vaccination for the first time. She clarified by stating she did not remember ever giving out an information sheet. Staff member N stated she did not usually give the pneumococcal vaccines, but did not recall ever seeing an information sheet for those vaccines either. Review of a policy titled, Influenza & Pneumonia Vaccination Administration, Physician Clinical Pathway, last revised 11/2017, showed under Procedure: item 4., Appropriate Center for Disease Control (CDC) information sheets to be given to the patient for educational purposes.",2020-09-01
985,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2018-03-08,943,D,0,1,GWLR11,"Based on observation, record review, and interview, the facility failed to ensure an indirect care staff member, staff member S, had been trained on the facility policies and procedures for abuse, and the staff member was observed in a negative verbal exchange with 1 (#9) resident of 12 sampled residents. Findings include: Review of staff member S's employee file, who was an indirect care staff member, showed no evidence for training on abuse or the facility policies for abuse. During an observation on 3/5/18 at 1:00 p.m., staff member S was assisting the residents during a bowling activity. Resident #9 called staff member S bonehead, and in response, staff member S stated No, you are! Staff member R (who provided oversight) was not present during this time. During an interview on 3/6/18 at 2:00 p.m., staff member R stated that he did not know of an orientation or abuse and neglect training for the indirect care staff members. Staff member R stated that he had no documentation of training for staff member S. Staff member R stated that volunteer S came from a partnership organization, and he may have had training there. Staff member R stated that he taught the abuse and neglect training to staff yearly and was always monitoring staff member S. During an interview on 3/7/18 at 10:00 a.m., staff member A stated indirect care staff do not complete the same training as facility direct care staff. Staff member A stated that she did not know if staff member S completed any orientation. Training records were requested for staff member S, which was not provided.",2020-09-01
986,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2019-04-04,584,D,0,1,3IN211,"Based on interview and record review, the facility failed to update a resident on follow up and action taken on a concern regarding missing items the resident had reported, which had not yet been found, for 1 (#24) of 13 sampled residents, which caused resident #24 to feel upset and saddened. Findings include: During an interview on 4/2/19 at 11:36 a.m., resident #24 stated she was missing a plain red V-neck top with long sleeves, and dark blue textured pants. Resident #24 stated she had reported the missing items to the staff. The resident stated she did not think her missing items had been found. During an interview on 4/2/19 at 12:36 p.m., staff member B stated she was unable to locate any documentation or incident report for resident #24's missing items. During an interview on 4/2/19 at 4:25 p.m., staff member H stated she was familiar with the facility's incident reporting policy. Staff member H stated You fill out a report and look for the missing items. Staff member H stated, I don't know about the timeline regarding reporting in the policy or how they handle the replacement or reimbursement process for missing items. Staff member H stated the missing items were reported about three weeks ago. Staff member H stated, We searched room to room, in drawers, other resident rooms, and nothing has turned up. Staff member H stated she did speak to the daughter of resident #24 regarding the missing items. During an interview on 4/3/19 at 9:47 a.m., staff member A stated, The initial report for the missing items should be completed as soon as the items are reported missing. We do ask the family to let us know when they bring items in, so we can tag them. We will keep looking for the missing item for twenty-four hours, then I think it is about five days when the investigation is closed. Staff member A stated the information gathered from investigations is sent to risk management for review and discussion on how and if the items are to be replaced. Review of the Resident Council Meeting Minutes, dated 3/13/19, showed under the subheading of laundry, (resident # 24) has a brand-new pair of warm felt pants her daughter made for her black and blue with green on them. She is very upset. (Resident # 24) said when they were going through her closet they were finding clothes that weren't hers (sic). A review of the facility's policy titled, Occurrence Reporting, under the heading procedure, showed: . 4. Occurrence reports will be documented as completely as possible on the yellow form approved by the risk manager and routed to risk management in the yellow interoffice envelopes provided for this purpose within 24 hours of the event or first knowledge of the event . 6. A form will be provided for review and follow up which the manager can complete and attach the report to. Once notified, managers will be allowed 10 days to perform review and follow-up activities, unless an extension is approved by the Risk Manager .",2020-09-01
987,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2019-04-04,658,D,0,1,3IN211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to identify and treat a [DIAGNOSES REDACTED].#13) of 13 sampled residents. Findings include: Review of resident #13's Vital Signs record, dated 3/21/19, showed she had a temperature of 101 degrees and her oxygen saturation level was at 90 percent on room air. Review of resident #13's Nursing Progress Note, dated 3/22/19, showed she had complaints of congestion, and not feeling well. Her oxygen saturation level was 92 percent on room air and her temperature was 101 degrees. Review of resident #13's Nursing Progress Note, dated 3/23/19, showed she had episodes of nausea, vomiting and diarrhea the night before, with a low grade temperature. Review of resident #13's Nursing Progress Note, dated 3/24/19, showed she continued to complain of nausea and diarrhea. Review of resident #13's Nursing Progress Note, dated later in the day on 3/24/19, showed she was not eating, and had some diarrhea and nausea. Review of resident #13's Nursing Progress Note, dated 3/25/19, showed she was tired and her breathing was labored and wheezy. Review of resident #13's Nursing Progress Note, dated 3/26/19, showed she was unable to stand to get off the toilet, was very weak and thirsty, with bilateral wheezes and crackles in her lungs. Her oxygen saturation level was 78 percent. She was sent to the emergency room , diagnosed with [REDACTED]. During an interview on 4/4/19 at 9:36 a.m., staff member J stated an assessment should have been completed immediately after the temperature and complaints of not feeling well. During an interview of 4/4/19 at 9:44 a.m., staff member C stated the facility should have been concerned for resident #13's health on 3/21/19, with the onset of the temperature.",2020-09-01
988,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2019-04-04,679,D,0,1,3IN211,"Based on observation, interview, and record review, the facility failed to provide individualized activities, and one to one activities on a consistent basis for a resident who did not like noise or groups for 1 (#25); and failed to provide one to one activites weekly, as indicated on the care plan for 1(#4) of 13 sampled residents. Findings include: 1. During observations on 4/2/19 and 4/3/19, at 7:00 a m., and 4:20 p.m., resident #25 was up at 7:00 a.m., in the dining room, and continued to sit in the dining room, sitting or sleeping until 4:20 p.m. During an interview on 4/3/19 at 10:46 a.m., staff member N stated that it was difficult to get resident #25 engaged in group activities, because the resident did not like noise. Review of resident #25's Activity Report showed the resident received 1:1 activities two times in four months. During an interview on 4/4/19 at 10:10 a.m., staff member N stated he did not know why only two 1:1 visits were provided for resident #25. He said he does not do the 1:1 visits. He also wondered why the 1:1 visits were not on her care plan, since she did not like groups. During an interview on 4/2/19 at 9:50 a.m., staff member K stated resident #25 was mostly nonverbal and did not make her needs known. She stated the staff had her sit outside of the dining room, so there is less stimulation, as the resident can become agitated and resistive to care with too much noise or too many people. Review of resident #25's Care Plan showed Resident to attend activities of her choice. Interventions included: 1. Post activities calendar in room monthly. 2. Provide reading materials to resident. 3. Provide TV for resident to watch for entertainment Review of resident #25's Quarterly MDS, with the ARD of 2/1/19, showed the resident had severely impaired cognition. 2. Review of resident #4's Activities Report showed she received two one to one visits in four months. Review of resident #4's Care plan showed weekly 1:1 visits. During an interview on 4/4/19 at 10:10 a.m., staff member N stated he could have miscoded resident #4's 1:1 visits on another resident's Activity Report. Review of resident #4's Quarterly MDS, with the ARD of 2/15/19, showed the resident had severely impaired cognition.",2020-09-01
989,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2019-04-04,689,D,0,1,3IN211,"**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 for a total of 11 falls, and failed to implement new interventions after each fall, for 2 (#s 4 and 25); and the facility failed to provide adequate supervision and assistance for a resident who was a high risk of aspiration while eating, and the resident was left unsupervised, he had an emesis during a meal, was returned to his room and left unmonitored, and he was not assessed for the risk of aspiration by the nursing staff, who did not identify or implement any other safety interventions related to the event, for 1 (#19) of 13 sampled residents. Findings include: 1. During observations at breakfast on 4/2/19 at 8:07 a.m., residents' #25 and 4 had fall alarms on their wheelchairs, and attached to their shirts. Review of resident #25's Incident Report: Falls, showed she had eight falls from 12/1/18 through 2/28/19. Review of resident #25's Incident Report, dated 12/01/18, showed the resident fell out of the bed. No root cause analysis or interventions were provided by the facility. Review of resident #25's Incident Report, dated 12/14/18, showed an unwitnessed fall on the bathroom floor. The resident sustained [REDACTED]. Review of resident #25's Root Cause Analysis, dated 12/14/18, showed it was a busy time of night, and no root cause was identified, and no interventions were implemented. Review of resident #25's Incident Report, dated 1/19/19, showed the resident was reaching for a blanket and fell out of her wheelchair. The Root Cause Analysis Report, dated 1/19/19, showed Maintain safe environment, moving resident as needed. No root cause was identified and no interventions were implemented Review of resident #25's Incident Report, dated 1/22/19, showed the resident fell in the doorway of room [ROOM NUMBER]. The resident was agitated, had not slept the previous night, and was not able to redirect. No Root Cause Analysis Report was provided by the facility. No interventions were implemented. Review of resident #25's Incident Report, dated 1/28/19, showed the resident had an unwitnessed fall outside of the Resident Care Coordinator's office. No Root Cause Analysis Report was provided by the facility. No interventions were implemented. Review of resident #25's Incident Report, dated 1/29/19, showed the resident was being transferred to a shower chair and stiffened up and was lowered to the floor. The Root Cause Analysis Report showed the resident was difficult in most transfers whether with the CNA or the lift. The intervention was to assess mobility on transfers if uncooperative - use lift or get assistance. Review of resident #25's Incident Report, dated 2/3/19, showed the resident was found in a door way, with feet in the room, and the rest of her body was in the hallway. No Root Cause Analysis Report was provided by the facility. No interventions were implemented. Review of resident #25's Incident Report, dated 2/28/19, showed the resident was in the shower room, and became stiff and uncooperative. CNA assisted the resident to the floor gently. The Root Cause Analysis Report, dated 2/28/19, showed no root cause, and possibly have second CNA in room with transfer. Second occurrence of this nature, (MONTH) need to reassess for safety - possible bed baths as alternative. No assessment for safe transfers for resident #25 was provided by the facility. During an interview on 4/3/19 at 9:50 a.m., staff member K stated the facility had been working on a safer way to transfer resident #25 in the shower room. Review of resident #25's Care Plan, edited on 2/12/19, showed the following interventions: 1. Supervise and assist as needed when attempting to ambulate. 2. Psychoactive medications to be reviewed after admission and quarterly to determine recommendations for a gradual dose reduction. 3. Assess for environmental hazards every shift. The Care Plan did not identify the eight falls or fall interventions. During an interview on 4/4/19 at 8:50 a.m., staff member C stated the procedure for falls in the facility was to fill out the incident report right away. She was not aware of the procedure for identifying the root cause or interventions. 2. Review of resident #4's Incident Report: Falls, dated 11/10/18, showed she was in the bathroom, then found on the floor.Spoke with CNA not to leave the resident unattended in bathroom. Review of resident #4's Incident Report: Falls, dated 12/1/18, showed the resident had a witnessed fall in the dayroom, sustaining a skin tear. No Root Cause Analysis Report was provided regarding the two falls. Review of resident #4's Incident Report: Falls, dated 12/18/18, showed the CNA responded to the fall alarm sounding, and found the resident on the floor in the dayroom. She had complaints of hip and shoulder pain. Her Power of Attorney did not want her sent the the emergency room . There were no staff in the dayroom at the time of the fall. Review of resident #4's Care Plan showed the falls and the root cause were not identified. Interventions included: 1. Monitor frequently when awake. 2. Activate tab alarm when seated in wheelchair or recliner, and while in bed. 3. Provide frequent reminders to use call light. 4. Ensure tab alarm is working and change batteries as needed. Resident #4's Care Plan did not show adequate fall prevention interventions. Review of the facility Fall Policy and Procedure did not include the root cause analysis or implementing fall prevention interventions. 3. During an observation on 4/2/19 at 8:23 a.m., resident #19 vomited at the breakfast table. This surveyor heard staff member H state to CNA staff present in the dining room Someone should have been sitting with (the resident) while he was eating. During an observation and interview on 4/2/19 at 8:28 a.m., resident #19 was taken to his room immediately after the vomiting episode and was left unattended by facility staff. Resident #19 was observed to have serveral episodes of coughing while in his room. Staff member G entered the room with another breakfast tray for the resident. Staff member H had not been observed in the room to assess for safety for the resident to begin eating again. Staff member G stated, He really should be a 1:1 when feeding because he eats too quickly on his own. Staff member G had to keep telling resident #19 to take a breath while she was assisting the resident with his meal. Resident #19 had several episodes of coughing while being assisted with his second breakfast meal. Staff member G stated she was going to leave the resident up for 30 minutes before laying him down after eating. During an observation on 4/3/19 at 11:48 a.m., resident #19 was in his room alone, head down, with a long string of drool hanging from his lips. His lunch tray was sitting beside him within reach, waiting for a staff member to come in and assist him. A moist cough was noted from resident #19. During an interview on 4/3/19 at 2:57 p.m., staff member C stated she would expect close monitoring of a resident who was a high risk for aspiration that had just vomited. Staff member C stated, Everybody needs to be aware of the aspiration risk, the resident should not to be laid down, and I would assess lung sounds for sure, to make sure there is no indications of aspiration. Staff member C stated, I would want vitals and an assessment, alert charting for five days, and I would want the nurse monitoring the vital signs. During an interview on 4/3/19 at 3:23 p.m., staff member H stated, I would not have done an assessment because here is the thing with (the resident), it has been ongoing. I felt his stomach which was a little firm, so I did give him a suppository, and night shift reported (the resident) was having bowel movements throughout the night, and so far, today he hasn't had any vomiting. Staff member C stated, Yeah, he (resident #19) is an aspiration risk. Staff member C stated, I did not listen to his lungs yesterday after his emesis, and the CNA did not get a set of vitals after he threw up, but It probably would have been a good idea to get a set of vitals. Staff member C stated, I believe the resident shovels his food in too fast or takes too much fluid at one time, and she thought that may have been the cause of resident #19's emesis. Staff member C stated, You know, I didn't really even think that it could be something else. Review of resident #19's Care Plan, dated 1/22/19, showed Risk for impaired nutrition/hydration related to: DX: Dysphagia, [MEDICAL CONDITION], upper denture poor fit-not wearing, lower teeth in poor condition, left-sided weakness. Interventions showed . pureed diet with nectar thick liquids . supervision at meals and snacks . Review of resident #19's physician's orders [REDACTED].",2020-09-01
990,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2019-04-04,759,E,0,1,3IN211,"**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%. The medication error rate for the facility was 8.33%. The facilty failed to administer medications per the physician's orders [REDACTED].#9); failed to ensure administered medications left on the bedside table were received, and failed to clean a communal glucometer in accordance with the manufacturers guidelines, and touched medications with unwashed and ungloved hands for 1 (#15) of 15 sampled and supplemental residents. Findings include: 1. During an observation on 4/3/19 at 8:15 a.m., the directions on the bubble pack of [MEDICATION NAME] 0.025 mg showed for resident #9 take one tablet by mouth every morning before breakfast. The medication was observed to be given as resident #9 had already begun to eat breakfast. During an interview on 4/3/19 at 8:07 a.m., staff member H stated, [MEDICATION NAME] should be given before breakfast. I have tried to change the times several times, but it keeps getting changed back. It could be night shift changing the times, I am not sure. We do have the ability to change the times on the MARS right now, but the new pharmacy will be generating the MARS. During an observation on 4/4/19 at 8:16 a.m., staff member J touched multiple medications for resident #9, with unwashed and ungloved hands, before she administered them in applesauce. During an observation on 4/4/19 at 8:22 a.m., staff member J touched the potassium tablet for resident #9 to remove it from the bubble pack. During an observation and interview on 4/4/19 at 8:16 a.m., Staff member J had all medications for resident #9 signed out in the MARS before administration. The staff member did not verify each medication matched the MAR. Staff member J pulled all the medications out to be observed and documented. The medications staff member J had provided for Resident #9 were compared to the MAR. The bottles of Loratidine 10 mg and Aspirin 81 mg were missing. The two medications were scheduled at 8:00 a.m. along with the other medications that had been provided for review. Staff member J stated Oh I must have missed those, those are stock medications. Staff member J pulled the medications out of the medication cart and placed them in a cup and administered them to resident #9. 2. During an observation on 4/4/19 at 7:51 a.m., Staff member J administered morning medications to resident #15. Resident #15 requested PRN medications, which staff member J went and retrieved, and left the medications on the table for resident #15 to take but did not stay at the resident's bedside to witness if the resident took the medications. During an observation on 4/4/19 at 7:51 a.m., staff member J wiped the glucometer down she had just used for resident #15 and tossed it back into the blood glucose kit which contained blood glucose supplies such as cotton balls, test strips, and alcohol wipes. Staff member J looked at the sanitation wipe instructions, and stated the surface being cleansed should stay wet for 1 minute. Staff member J grabbed the glucometer back out of the bucket and set it on the wipe but did not wipe down the glucometer or cover the glucometer completely with the sanitizing wipe. A review of the facility's policy, titled Medication Administration, under the heading Policy, showed: The focus of medication administration is to ensure the process is performed correctly, safely, and without errors while maintaining the security of the medications. Medication pass process will focus on the established standard of practice that includes the Seven Rights of Medication Administration: Right Resident, Right Drug, Right dose, Right Route, Right Time, Right Documentation, Right Evaluation of Efficacy of the Medication .",2020-09-01
991,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2019-04-04,808,E,0,1,3IN211,"Based on observation, interview, and record review, the facility failed to provide the therapeutic diet as ordered by the physician for 5 (#s 25, 15, 5, 20 and 21) of 15 sampled and supplemental residents. Findings include: Review of the Other Orders by Type Dietary form, showed: 1. Resident #25 was to receive a General diet. 2. Resident #15 was to receive a Consistent Carbohydrate diet. 3. Resident #5 was to receive a General diet. 4. Resident #20 was to receive a General diet. 5. Resident #21 was to receive a Full diet. Review of the Cooks Notes (the facility did not use tray or meal tickets) showed residents #25, 5 and 20 were on a Regular diet; Resident #15 was receiving a No Concentrated Sweet diet; Resident #21 was receiving a Regular Finger Foods- cut up diet. During an observation on 4/2/19 at 8:16 a.m., resident #21 received a regular textured breakfast, and not Full liquids. During an interview on 4/3/19 at 11:06 a.m., staff member D stated the Full diet would include liquids only. He stated the registered dietitian said the consistent carbohydrate diet could be substituted for the No Concentrated Sweet diet, and the General diet would be the same as the Regular diet. He stated he would have the diet orders changed to match what the facility served.",2020-09-01
992,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2019-04-04,880,E,0,1,3IN211,"Based on observation, interview, and record review, the facility failed to ensure the staff performed hand hygiene before and after resident cares for 4 (#s 1, 11, 19, and 20), failed to ensure staff changed gloves when going from a dirty to clean enviornment for 2 (#s 11 and 20), failed to properly handle soiled linens for 1 (#20), and failed to properly don PPE for droplet precautions for 1 (#1) of 13 sampled residents. Findings include: During an observation on 4/1/19 at 11:05 a.m., the facility had the main door locked and sign posted showing there was confirmed cases of Influenza at the facility. During an observation on 4/1/19 at 4:07 p.m., staff member G and staff member M did not perform hand hygiene before peri-care with resident #11. Staff member M reached into the wipe container twice during the cleansing of resident #11, when there was BM involved. Staff member M applied the clean brief with her dirty gloves. During an observation on 4/1/19 at 4:18 p.m., staff member G threw soiled linens and a pillow on the floor at the foot of resident #20's bed. Staff member M was standing watching staff member G make an occupied bed, and staff member M stated to staff member G, You're not supposed to put the clean sheet over the dirty sheet, it is cross contamination. Staff member G stated, It's not touching the clean sheet. The clean sheet was observed touching the dirty sheet during the bed change. Resident #20 was soiled with BM when staff rolled him over to finish changing the bed. Staff member G grabbed the wipes and a clean brief for resident #20. Staff member G and M were observed reaching into the wipe container with soiled gloves. Staff member G did stop to change her gloves, as her gloves were very soiled with BM. Staff member G continued to cleanse resident #20's buttocks of BM. Staff member G tossed the dirty brief in the direction of the trash bin, but missed, causing the soiled brief to land on the floor. Resident #20 had excoriation on his upper bilateral buttocks, and staff member G used dirty gloves to apply moisture barrier cream to his bottom, then rolled resident #20 onto his back, and applied moisture barrier cream to the front of the peri-area and applied clean brief. Staff member G unfolded the clean top sheet, which drug on the floor, and placed it over resident #20. Staff member G was observed to throw a dirty pillow case on the floor. Staff member G finished making the bed, took off her gloves, and moved resident #20's side table so he could reach his items. Staff member G then grabbed a cookie the resident had sitting on the side table with unwashed hands and handed it to the resident. During an interview on 4/1/19 at 4:35 p.m., staff member G stated Yeah, sometimes things land on the floor. If you know a way to do what I just did and not throw laundry on the floor, please let me know. During an interview on 4/1/19 at 4:46 p.m., staff member M stated, No linens are not supposed to go on the floor, they should go into a bag. Staff member M stated, Yeah, we probably shouldn't reach into the clean wipes with dirty gloves on. Staff member M stated, You should wash your hands after using the bathroom, before feeding, and after cares. During an observation on 4/2/19 at 8:28 a.m., staff member G began assisting resident #19 with his breakfast meal in his room. Staff member G did not wash her hands or don gloves before she began to assist the resident with his meal. Staff member G did not wash her hands before leaving resident #19's room after providing meal assistance. During an observation on 4/2/19 at 3:16 p.m., staff member H grabbed the handrail on the wall for balance as she applied the protective booties with clean gloves. Staff member H's gloves touched her shoes in several spots while applying the protective booties. Staff member H did not change her gloves or wash her hands before she entered the isolation room. Staff member H took resident #1's medications into the isolation room and administered them to the resident. During an observation on 4/4/19 at 9:14 a.m., staff member O touched the bottom of her right shoe with her gloves when applying protective booties. Staff member O did not change the gloves or wash her hands before entering the isolation room for resident #1. During an observation on 4/4/19 at 9:27 a.m., staff member G applied the protective booties with her gloves on. Staff member G's gloves touched the bottom of both of her shoes. Staff member G did not change her gloves or wash her hands before entering resident #1's room. Staff member G entered the isolation room, went over to the bed, and with the comtaminited gloves touched the right side of resident #1's face and head. Staff member G then wet a washcloth and began to wash the resident's face. Staff member G started by washing resident #1's matted eyes, and then used the same wash cloth to wipe around the resident's mouth. A review of the facility's policy, titled, Basics, Infection prevention, under the heading Hand Hygiene, showed: Hand Hygiene is the most important effective means in preventing nosocomial transmission of organisms, because nosocomial/hospital acquired infections (HAIs) are most frequently spread by contact and the most common form of contact is hand contact . E. Handling of all linen. Personnel will process linen in a manner that provides safe handling of soiled (contaminated) linen and maintains cleanliness of clean linen. 1. a. Soiled linen will be considered potentially infectious. Avoid unnecessary shaking of soiled linen . e. Soiled linen is not to be placed on the floor, patient's chair, or other patient surfaces. Place soiled linen directly into designated plastic soiled linen bag .",2020-09-01
993,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2016-11-03,166,E,0,1,WOF111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow through with a grievance from the resident council regarding the lack of showers and baths, and the timeliness of the showers and baths provided. The facility also failed to keep the resident council group apprised of the progress, and resolution of the grievance. This had the potential to affect all residents who attended the resident council, and specifically 3 (#s 3, 4, and 7) of 10 sampled residents. Findings include: Review of the resident council meeting minutes, dated (MONTH) 8, (YEAR), showed resident concerns of the shower aide being pulled to the floor to work when needed, rather than completing the baths or showers scheduled. Review of the resident council meeting minutes, dated (MONTH) 6, (YEAR), showed resident concerns with not receiving their showers on scheduled days. Review of the resident council meeting minutes, dated (MONTH) 10, (YEAR), again showed resident concerns regarding the lack of showers on scheduled days. During a group meeting on 11/1/16 at 9:00 a.m., the residents stated not receiving showers had been a problem during the middle of summer. The group stated the concern was brought up in previous group meetings but had not been addressed and fixed. 1. Review of resident #3's Quarterly MDS, with an ARD of 9/2/16, showed the resident required an extensive assist with personal hygiene and bathing. Review of resident #3's care plan, with a goal date of 1/21/17, showed the resident needed assist with ADLs. Approaches included a shower weekly, and/or as needed or requested. Review of resident #3's electronic bath records showed the resident did not receive a bath from 8/11/16-8/25/16, thirteen days in between baths. 2. Review of resident #4's Quarterly MDS, with an ARD of 10/21/16, showed the resident required an extensive assist with baths. Review of resident #4's care plan, with a goal date of 2/17/17, showed the resident was very conscious of her appearance. She needed moderate to maximum assist with ADLs. Approaches included a shower weekly and as needed or requested. Review of resident #4's bath report showed the resident did not receive a bath from 10/20-11/1/16, eleven days between baths. 3. Review of resident #7's Admission MDS, with an ARD of 9/20/16, showed the resident required set up assistance and encouragement with personal hygiene and bathing. Review of resident #7's care plan, with a goal date of 1/20/17, showed the resident needed assistance with ADLs, related to general weakness. Approaches included a shower twice weekly and prn. Review of resident #7's bath report showed the resident did not receive a bath twice a week in the week of 9/18, the week of 10/2, the week of 10/11, and the week of 10/23/16. During an interview on 11/3/16 at 7:25 a.m., staff member A stated in mid (MONTH) there was not enough staff to have a bath aide so the CNAs began giving their own showers/baths to their assigned residents. Afternoons seemed to be hit or miss with showers as afternoon shift had a shorter period of time to do the bathing in related to dinner and then bed. During CNA shortage, the staff member stated the facility tried to get one shower aide per week to catch up. Residents were being notified a day ahead of time for their bath time. The facility was running short an afternoon CNA as the staff member stated there should be three CNAs, on the afternoon shift. Review of the actual worked CNA schedule for the months of (MONTH) and (MONTH) (YEAR), showed the afternoon shift, from 6/5/16 until 8/3/16, had either one or two CNAs. The accustomed number of CNAs on afternoon shift had been 3 CNAs. During an interview on 11/1/16 at 1:50 p.m., resident #11 stated she was hopeful for two showers a week. She stated the past month was better with shower frequencies, however the concern continued. She stated staffing changes and losses was the main reason for the bathing issues. She said at one time she had not received a shower for 14 days. During an interview on 11/2/16 at 9:15 a.m., resident #12 stated some residents did not receive baths or showers for up to 10 days or more. The resident stated during the staffing concern, the facility could, but did not use [MEDICATION NAME] (contracted staff) especially for the nocturnal (night) shifts to provide baths and showers. He said if [MEDICATION NAME] were used, this could help with worker fatigue. The resident stated his assumption was that night shift only had one CNA and one nurse. The nurse did not answer the call lights in general, so the CNA could offer showers to some of the residents. During an interview on 11/2/16 at 10:15 a.m., staff member A stated the facility did not have any formal grievances that were received, investigated, and resolved, since she became the long term care manager in (MONTH) of (YEAR). During the interview, she showed a 3-ring binder containing the resident council meeting minutes. The action items were not specific with goal dates, and lacked to show that the council was apprised with the progress of resolutions. She also showed the blank forms located in the 3-ring binder, titled Resident Rights Grievance Report Form, for the formal grievance process. She stated these forms were not publicly or readily available to the residents and/or to family members any where in the facility, but this would be an easy fix. She said she actually talked with individual residents about their issues, but she needed to improve upon documenting these interviews as well as her action items. During an interview on 11/3/16 at 10:00 a.m., staff member K stated she had not remembered any grievance forms being filled out formally by any residents or their family members. She stated, since (MONTH) of (YEAR), she had not attended the monthly interdisciplinary team meetings (RICCs), but she generally visited 2 to 3 residents weekly and informally, without documenting about these meetings. She stated residents' concerns were mostly addressed during the resident council meetings. She stated she was in transition in employment, and the facility was currently in the process of hiring a new medical social worker. Review of the Grievance policy and procedure showed the residents would be advised and encouraged to submit a complaint to the medical social worker and/or the nursing administration, either in writing or through the resident council. The medical social worker and/or nursing administration would document in each resident's record all instances of grievances being received. A record would be kept of all grievances filed and actions taken. The policy showed that upon report of a verbal complaint, a staff member would notify the medical social worker either by phone or an email message, and would begin to document the report/complaint on proper form and route to the medical social worker.",2020-09-01
994,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2016-11-03,225,E,0,1,WOF111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to report allegations of verbal abuse involving several staff members, and show evidence of a thorough investigation for the events. This failure had the potential to affect all resident's involved in the allegations; and the facility failed to report and show a thorough investigation for a bruise of unknown origin for 1 (#5); and failed to report and show a thorough investigation for a bruise and a skin tear of unknown origin, for 1 (#9). This failure had the potential to affect all residents who had injuries of unknown origin. The facility also failed to show in all of the above events, how the facility identified and implemented interventions for the prevention of abuse or unknown injuries in the future for those resident's affected. Findings include: 1. During an interview on 11/3/16 at 7:25 a.m., staff member A stated there were alleged observations of three staff members verbally abusing residents in the recent past. Staff member A stated she reported the events up the chain of command, but did not provide information on the resident's affected, or time frames for the events. Review of a written document, dated 10/5/16 at 9:30 a.m., showed staff member A had interviewed four staff members, identifying one as having multiple, verbally aggressive behavior towards residents. Staff member A stated she spoke to the staff members in question. Staff member A stated she was not aware of the need to report allegations of abuse if there had been an investigation completed by the facility, and staff were reprimanded or trained. Review of the facility policy, with a revision date of 7/31/07, and titled Long Term Care, Abuse, Neglect and Exploitation of Elderly and Disabled, showed the facility was to report immediately an alleged abuse incident to the State Agency. Review of the Abuse Reporting/Investigation policy, with a revision date of 7/07, showed the facility was to complete an investigation within five days and send a report to the State Agency. Review of the facility's reports to the State Agency (SA) did not show the allegations, dated 10/5/16, had been reported to the S[NAME] 2. Resident #5 was admitted to the facility with the [DIAGNOSES REDACTED]. Review of the Quarterly MDS, with an ARD of 10/7/16, showed the resident generally communicated her needs except during episodes of confusion. Resident #5 required maximum assist with bathing from one care giver. A review of facility skin documentation showed skin checks were usually completed on bath days. Review of the nursing progress notes, dated 7/30/16, showed a black bruise, measuring 2 centimeters by 1 centimeter, it was found on resident #5's left forearm. The nursing staff entries following this entry, lacked additional investigative information about the black bruise, which was an injury of unknown origin. 3. Resident #9 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the Annual MDS, with an ARD of 5/6/16 and the Care Area Assessments dated 5/12/16, showed resident #9 usually understood the speaker, and answered questions appropriately except during episodes of confusion. Additionally, resident #9 was totally dependent on one care giver for bathing. Review of facility skin documentation showed skin checks were completed on days residents received a bath. a) Review of the nursing progress notes, dated 4/30/16, showed a blue bruise measuring 2 centimeter by 1.5 centimeters was found on resident #9's left buttock near her coccyx. The center of the bruise had a superficial opening that measured 1 centimeter in diameter. The nursing staff entries following this entry lacked additional investigative information about this injury of unknown origin. b) Review of the nursing progress notes, dated 11/1/16, showed a skin tear, measuring 2 centimeters in length, was found on resident #9's right forearm. There was bruising around the skin tear. [MEDICATION NAME] was applied to the injured area. The nursing staff entries following this entry, lacked additional investigative information about this injury of unknown origin. During an interview on 11/3/16 at 10:30 a.m., staff member A stated these injuries were not reported to her for investigation and reporting to the S[NAME] She said she started the investigations and the reporting process for the injuries of residents #5 and #9. She stated the staff were to report all injuries of unknown origin to her for an investigation to be completed. Review of the facility's Administrative policy, titled Long Term Care Neglect and Exploitation of Elderly and Disabled, showed all injuries of unknown origin, and alleged violations of abuse shall be reported to the administration of the facility and other officials in accordance with the State law (including the State Survey and Certification). The policy also showed all alleged violations would be investigated thoroughly. The SA did not receive reports or investigations from the facility for any of the aforementioned injuries for residents #5 and #9, prior to the survey date of 11/3/16. The facility failed to provide evidence that the injuries and events were thoroughly investigated, including any follow up action or potential interventions to prevent injuries in the future.",2020-09-01
995,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2016-11-03,281,D,0,1,WOF111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to follow physician orders [REDACTED].#1 and #4) of 10 sampled residents. 1. Review of resident #4's nurses notes, and provider communication note, dated 10/16/16, showed the resident had fallen on 10/15/16 and 10/16/16. The resident had tried to get out of her wheel chair without assistance. Review of resident #4's physician orders, dated 10/16/16, showed the resident was to have a lap buddy worn while in a wheel chair, as an assistive device to aid in the safety of the resident. During observations on 11/1/16 at 8:22 a.m., resident #4 was in the dining room. The lap buddy was not on the resident's wheel chair. During an interview on 11/2/16 at 12:40 p.m., staff member I stated being unaware of resident #4 having a lap buddy on her wheel chair. Staff member I stated seeing the lap buddy in the resident's room. During an interview on 11/2/16 at 1:20 p.m., staff member B stated resident #4 did not keep the lap buddy on the wheel chair. The lap buddy lasted like a day. 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the resident's Discharge Summary, dated 8/18/16, showed the resident was admitted to the hospital for a fracture of her left humerus which was sustained in a fall at the facility. A review of the resident's physician's orders [REDACTED]. In reviewing the physician's orders [REDACTED]. During observations on 10/31/16 at 2:15 p.m. and 5:15 p.m., 11/1/16 at 7:15 a.m., 11/2/16 at 8:25 a.m., and 11/3/16 at 8:30 a.m., showed the resident had no sling on her left arm. A review of the resident's care plan edited 10/26/16 showed a sling to the left arm had not been added to her plan of care. References Nurses are obligated to follow the orders of a licensed physician or other designated health care provider unless the orders would result in client harm. DeLaune, S. & Ladner, P. (1998). Fundamentals of Nursing, Standards and Practice Albany, N.Y., page 237.",2020-09-01
996,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2016-11-03,312,E,0,1,WOF111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, the facility failed to provide necessary assistance for the provision of incontinent care for 1 (#2) and for oral care and denture use for 1 (#6) out of 10 sampled residents; and failed to ensure resident's received, and the facility documented, scheduled baths or showers. The lack of bathing or showing services was brought forth as a concern during the resident group meeting. Findings include: Review of the resident council meeting minutes for June, (MONTH) and (MONTH) (YEAR), showed concerns regarding the lack of provision of baths or showers. During a group meeting on 11/1/16 at 9:00 a.m., the residents voiced concerns with not receiving showers, and this had been a problem during the middle of summer. The group stated the concern was brought up in previous group meetings but had not been addressed and fixed. Record reviews of bathing and showing documentation for resident's #s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11, showed periods when the provision of bathing or showering services were not documented from (MONTH) (YEAR), until the date of the survey. Refer to F166 for further information. 1. Resident #2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the Quarterly MDS, with an ARD of 9/23/16, showed the resident required extensive assistance from one care giver with toileting and personal hygiene. The care plan, last edited on 10/28/16, showed the resident required extensive assistance to maintain personal hygiene. During an observation on 10/31/16 at 4:30 p.m., staff member G assisted the resident with ambulation into the bathroom near the activity/living room and closed the door. The resident's pants were soaked with urine. The resident was assisted back to a recliner in the activity room after toileting assistance, in the same urine soaked pants. During an interview following this observation, staff member G stated she had not noticed the resident's pants were wet. She assisted the resident from the public area to her room to change the resident's soiled clothing. During an interview following dressing assistance, staff member G wanted to show the garment to the surveyor. Staff member G opened the soiled linen bag in the soiled linen room and stated the pants were not wet. But upon review of the garment, both the CNA and the surveyor saw that pants were soiled. Staff member G apologized and left the area. During this same observation, staff member D was in the area, and was assisting other residents with toileting. She was observed looking at resident #2 right after the resident left the bathroom with staff member [NAME] Staff member D looked at the direction of the resident's pants where they appeared darker in color. Staff member D did not notify staff member G of her observation. When she was asked if she noted the resident's wet pants, staff member C stated she thought maybe there were wet, but she thought maybe it was the lighting in the area causing a shadow on the garment. She stated she could have double checked and notified staff member [NAME] 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #6 was observed during provision of care on 11/1/16 at 8:10 a.m. in her room. Staff member F assisted the resident during this time. The resident required set up from the care giver during provision of care. However, the resident was not cued to cleanse her mouth before she attempted to put her dentures in her mouth. Staff member F had to assist the resident, and placed her bottom dentures in the resident's mouth. Staff member F did not instruct the resident to swab her gums and rinse her mouth before this procedure. During an interview on 11/1/16 at 9:30 a.m., staff member F stated she was rushed and forgot to cue the resident for oral care prior to dentures.",2020-09-01
997,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2016-11-03,323,E,0,1,WOF111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure safe transfers for 3 (#s 1, 2, and 5) of 10 sampled residents. Staff failed to use mechanical lifts in a safe manner with the assistance of the appropriate number of staff to conduct the lift. Findings include: 1. Resident #5 was admitted to the facility with the [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, with an ARD of 10/7/16, showed the resident required extensive assistance from two care givers during transfers. The care plan, last edited on 10/26/16, showed the resident required use of the standing lift with the assistance of 1-2 care givers. The care plan showed the resident had left sided paralysis and weakness. The resident was unable to use the prosthesis due to cognitive decline and dementia. During an observation on 10/31/16 at 4:45 p.m., the resident was transferred from her wheelchair into the bathroom, onto the toilet, in the hallway near the activity room. Staff member D used the sit-to-stand lift to transfer the resident who had a left below the knee amputation. The resident's right leg was placed on the lift, the resident could not reach and hold onto the lift's handle bar on the left side. The resident right lower leg (at the shin level) was not strapped onto the lift. The resident only received assistance from one care giver during the transfer. During an observation on 11/2/16 at 1:40 p.m., staff members B and C were assisting resident #5 from her wheelchair to a recliner in the activity/day room. The staff were using a sit-to-stand lift. The staff placed the padded sling around the resident's back, under the arms and hooked the sling up to the lift. The staff raised the resident out of the wheel chair. Staff did not strap the resident's lower right leg to the lift at the shin/calf level. The resident was observed with her left arm dangling down her side, and wobbling to the left side as she was turned around and was lowered into the recliner. The resident could not grab the left handle bar with her left hand. During an observation on 11/2/16 at 9:30 a.m., staff member B used a stand up lift to transfer resident #5 from her wheelchair to the toilet. Resident #5's right foot was not placed on the lift's platform, and her leg was not strapped to the lift at the shin/calf level, and her right knee was not placed against the lift support bar. While the CNA was lifting the lift up, resident #5 started moving forward out of wheelchair, and was barely able to hang on to the lift with her right hand. The resident began to fall to her right knee, when staff member B hollered for another staff. Staff member I came to help assist the resident back into the wheelchair. Staff member B stated this has never happened before. The resident's right foot had slipped off the lift's platform, and the resident almost fell during the transfer. During an interview on 11/2/16 at 11:00 a.m., staff member C stated resident #5 could not hold onto the lift with her left hand due to paralysis, therefore, she required transfer assistance from two care givers with the use of the standing lift. Staff member C stated two CNAs needed to assist the resident during transfers because the resident leaned towards her weak side (left). He stated there was potential for the resident to bang her left arm and/or elbow into the doors and/or door jams. When he was told about the previous transfer observation, he stated that was concerning because resident #5 never stepped off the lift when he transferred her in the past. He stated resident #5 might perhaps be safer if a shin strap was used. He stated he did not know the whereabouts of the shin strap for the standing lift. Staff member C stated he did not use the shin strap with resident #5. He stated only one of the three standing lifts had the shin strap. Review of the resident's EHR showed a lack of documentation regarding a referral to physical therapy for an evaluation related to safe transfers. 2. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, with an ARD of 9/23/16, showed the resident required extensive assistance with walking in her room, and limited assistance with walking in the corridor from one care giver. The resident required extensive assistance with transfers from one care giver. The care plan, last edited on 10/28/16, showed the resident was increasingly unsteady with ambulation and transfers. The resident had variable unsteadiness. During an observation on 10/31/16 at 4:40 p.m., staff member G assisted resident #2 with ambulation from the activity/day room to the bathroom in the hallway. The resident was restless, sad, unstable on her feet, and kept losing her balance to her left side. Staff member G's arm was around the resident's waistline. Staff member G pulled the resident towards her whenever the resident shifted towards the left side. Staff member G did not use a gait belt during this transfer. Following toileting, staff member G assisted resident #2 with ambulation back the activity/day room and assisted her into a recliner. During this time, staff member G did not use a gait belt. When the resident lost her balance, staff member G pulled the resident towards her. During an interview on 10/31/16 at 5:05 p.m., staff member G was told about the observation above. She stated she should have used a gait belt while transferring resident #2. Staff member G entered a room, grabbed a gait belt which was hanging behind the room door, and put it around her waist. Review of the resident's EHR showed a lack of evidence relating to a referral for physical therapy relating to an evaluation of safe transfers and ambulation. The care plan lacked information related to gait belt use. 3. Resident #1 was admitted to the facility with the [DIAGNOSES REDACTED]. Review of the Significant Change MDS, with an ARD of 8/26/16, showed the resident required extensive assistance from two care givers during transfers. A review of the resident's care plan, last edited 10/26/16, showed the staff was to use the butt (leg) sling during transfers. During an observation and interview on 11/1/16 at 7:15 a.m., resident #1 was transferred from the recliner to the wheelchair by staff member F in the activity room. Staff member F used a sit-to-stand lift to transfer the resident. During this time, the resident was not weight bearing. She hung from the upper/underarm sling. Staff member F did not use a leg sling to support the lower body weight of the resident. The resident could not reach and hold onto the right handle bar of the lift during the transfer. The resident was transferred down the hall into her room in her wheelchair. Once in the room, staff member F transferred the resident from her wheelchair to the toilet. The resident could not reach the right handle bar of the lift and hung from lift during the transfer. Staff member F stated they (facility) had the leg slings, but they did not use them. She stated the leg slings would get in the way while the residents were toileted. She stated resident #1 had declined within the last year. The resident was mobile a year ago, but she was no longer mobile. Staff member F stated the resident fell and hurt her right shoulder in the recent past, and that's why during transfers she could no longer reach for the lift and assist herself up. During an interview on 11/2/16 at 11:10 a.m., staff member C stated resident #1 required two care givers' assistance with the use of the standing lift during transfers. Staff member C stated if the leg strap or sling was not used, one person would be behind the resident supporting the resident's lower body if needed. Review of the resident's EHR showed a lack evidence relating to a referral for physical therapy relating to an evaluation of safe transfers with the mechanical lift. During an interview on 11/3/16 at 9:30 a.m. staff member A stated since she started as a unit manager in (MONTH) of (YEAR), she had not provided any inservice training to the staff on infection control or mechanical lifts.",2020-09-01
998,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2016-11-03,441,E,0,1,WOF111,"Based on observation, interview and record review, the facility staff failed to ensure dust from a work area was contained in the dining room while 15 resident's were eating their meal, which had the potential to affect all resident's eating at the time in the area; failed to perform hand hygiene before donning gloves, after removing contaminated gloves, and between clean and dirty tasks to minimize the potential spread of infection for 2 (#s 1 and 6) of 10 sampled residents; and failed to ensure a catheter bag was covered, monitored, and placed in an appropriate location to maintain infection control measures for 1 (#7) of 10 sampled residents, which had the potential to affect all those resident's using a catheter and bag. Findings include: 1. During a meal observation in the dining room on 10/31/16 at 5:29 p.m., two maintenance employees climbed down a ladder from a ceiling access into the dining room. Particles of dust were observed falling from the opening in the ceiling as the workers ascended from the ladder placed at the opening. The men were dusty and carried two plastic oversized bags, holding trash from the ceiling. The ladder was between two dining tables where residents sat, eating their meals. The last man picked up the ladder, swung the ladder legs up and over a resident at the table, and both men walked through the dining area, exiting to the day room to an outside exit. During an interview on 11/1/16 at 5:00 p.m., staff member A agreed the staff members in the ceiling should not have exited the ceiling during the evening meal on 10/31/16. 2. During an observation on 11/1/16 at 8:27 a.m., resident #7 was observed sitting at a bed side table, in his room, eating breakfast. The resident was wearing a catheter. The tubing went through the pant leg and out the end of the left pant leg. The catheter bag was hanging to the left side of the wheel chair, about the height of resident's bladder. During an interview on 11/1/16 at 8:27 a.m., resident #7 stated he had to place the bag there, otherwise, he ran the bag and the tubing over with his wheel chair. The resident then tossed the catheter bag onto the floor in front of his wheel chair. There was no covering on the bag, and the tubing dragged on the floor. He stated the covering had been sent to laundry, and there was nothing to cover the catheter bag. During an interview on 11/1/16 at 9:01 a.m., staff member B stated resident #7 placed his catheter bag on the wheel chair, above his bladder. The staff member stated the catheter bag should hang on the back of the wheel chair, off the floor, and in a covering. If the covering was soiled, staff would use a pillow case. During an interview on 11/1/16 at 3:58 p.m., staff member L stated the staff should have been aware of the positioning of the catheter and positioned the catheter properly. 3. During an observation on 11/1/16 at 7:17 a.m., staff member F provided personal care to resident #1 in her room. Staff member F provided perineal care to the resident in the bathroom. Immediately after this, staff member F did not remove her gloves and perform hand hygiene. She handled the resident's clothing, the lift, and flushed the toilet. Without performing hand hygiene, staff member F further handled the lift, the slings, opened the door and wheeled the lift into the hallway. She came back in and started to run the water in the sink. She left the room again and came back with a can of deodorant. She assisted the resident with dressing while the resident sat in her wheelchair. She handled the Tabs alarm and the wheelchair. Staff member F then washed her hands. After removing the resident's garments (while the resident sat on the toilet), staff member F placed the garments first on the floor in the bathroom, then picked them up and placed them on the floor next to the trash container in the room. She did not bag the garments before transferring them from the room, into the hallway, or when she carried them into the soiled linen room. She did not wash her hands before leaving the room with the un-bagged soiled garments. 4. During an observation on 11/1/16 starting at 8:10 a.m., staff member F prepared the resident for the morning meal, and assisted the resident with breakfast set up in the dining room without proper glove changing between dirty to clean tasks or hand hygiene. Staff member F entered resident #6's room and did not wash her hands. She woke the resident up, and assisted her with ambulation into the bathroom. Staff member F donned gloves, removed the urine soaked brief from the resident, and left the bathroom without removing the gloves and performing hand hygiene. She made the resident's bed with the same gloves. Staff member F wiped her sweat off her forehead with both of her forearms several times. She also handled the closet doors. She washed her hands and regloved. She provided perineal care to the resident who had a bowel movement during the observation. Staff member F used three wipes to cleanse the resident while handling the wipe package 3 times with her soiled gloves. She handled the resident's clean brief, garments, the walker, and flushed the toilet with soiled gloves. She took her gloves off, and did not perform hand hygiene. Staff member F assisted the resident with set up at the sink only. When needed, staff member placed a glove on without hand hygiene and helped the resident place her bottom denture. She took the gloves off, and did not perform hand hygiene. She left the room with the resident, and did not perform hand hygiene before leaving the room. Staff member F handled the door knob, the resident's walker, assisted the resident with ambulation to the dining room, set up her breakfast by removing it from the refrigerator in the activity/day room, heating it in the microwave, handling the resident's silverware and assisting with putting jelly on her toast. At this time, staff member F washed her hands in the activity day room sink at 9:00 a.m. During an interview on 11/1/16 at 9:25 a.m., staff member F was asked about linen handling and hand hygiene. She stated she was not taught to wash her hands right after perineal care before handling the garments. She stated they were allowed to use alcohol based hand sanitizer up to five times before hand washing, but she did not carry it and dispensers were not in the room. She said she would have to leave the bathroom to wash her hands in the sink after perineal care, and this was not very efficient with residents who needed immediate assistance. During an interview on 11/3/16 at 9:30 a.m. staff member A was asked about inservice training related to use of lifts and infection control. She stated since she started as a unit manager in (MONTH) of (YEAR), she had not provided any inservice training to the staff.",2020-09-01
999,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2016-11-03,456,F,0,1,WOF111,"Based on observation, interview, and record review, it was identified that the facility stored foods in a freezer, which was not working properly, and the facility failed to correct the issue timely. This had the potential to affect all food stored in the freezer, and all residents who consumed the food from the freezer. Findings include: During an observation on 10/31/16 at 10:37 a.m., while touring the kitchen with staff member J, the walk in freezer door was observed to have a build up of ice on the outside of the door. The left bottom edge of the door, had a one inch thick ice layer lining the bottom of the door. When the door was opened, ice was observed to have built up around the door frame. The electric thermometer, outside of the door, read minus 10 degrees. Staff member J could not find a thermometer inside the freezer to show the freezer was maintaining the proper temperatures due to the ice build up. During an interview on 10/31/16 at 10:37 a.m., staff member J stated the build up of ice had been ongoing. He stated staff checked every morning for the temperature of the walk in freezer. The walk in freezer temperature was not scheduled to be checked at nights. During an interview on 11/2/16 at 1:07 p.m., staff member J stated there had been previous problems with the freezer door, and he had documentation with dates of when the freezer door had been worked on. Upon review, these included: - 6/29/16; Maintenance replaced the freezer door seal with a new seal. - 7/29/16; The walk in freezer was again de-iced, cleaned, and treated with dry silicone. Review of the July, August, September, and (MONTH) (YEAR) monitoring sheets for the freezer, showed 22 days out of 122 opportunities were blank, with no temperature documented on the log.",2020-09-01
1000,CLARK FORK VALLEY NURSING HOME,275107,10 KRUGER RD,PLAINS,MT,59859,2019-12-20,600,G,1,0,WY2611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, facility staff neglected to stay with a resident who required a one-person assist with eating and drinking; neglected to adjust the temperature of a coffee machine to prevent burns; and neglected to implement interventions after 1 (#1) of 4 sampled residents sustained 1st and 2nd [MEDICAL CONDITION] her legs. The facility had system failures identified related to the provision of goods and services to promote the residents' well-being. Findings include: 1. During an interview on 12/19/19 at 1:30 p.m., staff member F stated, recalling the incident on 12/4/19, she had placed resident #1's coffee on the table in front of her and walked away for a few minutes. Staff member F stated when she returned to resident #1, she saw that the coffee had spilled in resident #1's lap. Staff member F explained staff immediately took resident #1 to her room and changed her, and noticed she had sustained a burn. Review of a Nurse's Note, dated 12/7/19, showed: the resident had a burned area, measuring 7 inches by 2.5 inches that was beefy red, wet, with tissue layers that were rolled back at edges, small areas of purulent exudate in wound bed, and it appeared to be a second degree burn. Two smaller burns, approximately 1.5 inches to mid left thigh, and a 2 inch area to the lateral left thigh was red with skin intact, and identified to be a first degree burn from the coffee spill. Review of a provider's note, dated 12/7/19, showed: (Approximately) 1% (of body surface area) right inner thigh with second degree burn .Wound cleaned with sterile saline and gently debrided significant amount of ruptured blister .Some eschar still in middle of burn .Macerated especially around the edges. Review of resident #1's MDS, with an ARD of 10/25/19, under Activities of Daily Living, showed she required supervision with one-person physical assistance during eating and drinking. 2. During an observation on 12/18/19 at 4:52 p.m., a cup was filled with coffee directly from the machine in the dining room. An infrared thermometer showed the temperature was 154 degrees Fahrenheit. During an interview on 12/19/19 at 12:26 p.m., staff member [NAME] stated he checked the coffee temperatures three times daily. Staff member [NAME] stated he knew 170 degrees Fahrenheit was too hot, and if the machine reached that temperature, he would ask the manufacturer to come in and adjust the machine. Staff member [NAME] stated he did not call the manufacturer on 12/4/19, the day resident #1 was burned by the coffee, because the coffee was at an acceptable temperature. During an interview on 12/19/19 at 2:40 p.m., staff member A stated staff member [NAME] checked the coffee temperature within an hour after resident #1 had spilled it, and it had read between 160.8 and 161 degrees Fahrenheit. Staff member A stated staff member [NAME] had told her that was in the normal temperature range. Review of a temperature log for (MONTH) of 2019 showed coffee temperatures ranged from 158 to 170 degrees Fahrenheit. Staff neglected to adjust and monitor the coffee machine to ensure safe temperatures for their residents. 3. During an interview on 12/19/19 at 2:40 p.m., staff member A stated she met with the CNAs following the incident with resident #1, and recommended they add an ice cube or two in resident #1's coffee. Staff member A stated she was not sure if an ice cube would reduce the temperature of resident #1's coffee sufficiently, and she would have to stick a thermometer in it to be sure. Staff member A stated if residents were at risk (of injuring themselves), the facility would protect them, although staff neglected to update resident #1's care plan following the incident. Staff member A stated no other safety precautions were put in place for resident #1 or other residents who drink coffee (e.g. lids, separate containers to cool the coffee outside of the machine, etc.) Review of resident #1's care plan, dated 12/10/19, showed resident #1 required assistance during meals for set-up only. No supervision or one-person assist recommendations were noted, as per resident #1's MDS. There was no intervention within resident #1's care plan that showed staff should add ice to her coffee, or take any other preventive measures to lower the temperature of the coffee. The combined concerns, showed an overall system failure for the resident's event, but also individual failures related to identifying and addressing neglect, protecting the resident(s), implementing safety interventions, and ensuring equipment, such as the coffee pot, was safe for resident use.",2020-09-01