cms_MT
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| Link | rowid | facility_name | facility_id | address ▼ | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 444 | 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 … | 2020-09-01 |
| 445 | 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… | 2020-09-01 |
| 446 | 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… | 2020-09-01 |
| 447 | 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 a… | 2020-09-01 |
| 448 | 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 | 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 | 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 | 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 | 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 | 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 elo… | 2020-09-01 |
| 454 | 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 ass… | 2020-09-01 |
| 455 | 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 resto… | 2020-09-01 |
| 456 | 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. Ed… | 2020-09-01 |
| 457 | 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 sta… | 2020-09-01 |
| 458 | 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 ha… | 2020-09-01 |
| 459 | 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… | 2020-09-01 |
| 460 | 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 … | 2020-09-01 |
| 461 | 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 | 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… | 2020-09-01 |
| 463 | 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 | 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 res… | 2020-09-01 |
| 465 | 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. Staf… | 2020-09-01 |
| 466 | 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 pref… | 2020-09-01 |
| 467 | 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 sta… | 2020-09-01 |
| 468 | 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 | 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 | 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 | 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] a… | 2020-09-01 |
| 472 | 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 … | 2020-09-01 |
| 473 | 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 [MEDIC… | 2020-09-01 |
| 474 | 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 | 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 | 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… | 2020-09-01 |
| 1794 | 1794 | CEDAR WOOD VILLA | 275053 | 1 S OAKS | RED LODGE | MT | 59068 | 2016-05-12 | 225 | E | 0 | 1 | XO7K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a background check was completed on all employees prior to being hired and failed to ensure one employee received abuse training. Ten of fifteen files were identified as lacking required documents prior to being hired by the facility. Findings include: 1. Staff members F and O had ordered background checks that were not completed. The employees provided resident care during the survey. 2. Staff members E, L, U, V, W, CC, DD, and EE showed a date of hire prior to a background check being completed. 3. Staff member E's employee file lacked evidence of abuse training. During an interview on 5/11/16 at 3:45 p.m., staff member [NAME] stated she had not received abuse training from the facility. She could not identify the types of abuse, nor the facility policy and procedure on reporting alleged abuse. During an interview on 5/11/16 at 4:25 p.m., staff member D stated the facility performs a background check on all employees during orientation. She stated some employees get a background check prior to their hire date and some after their hire date. The turnaround time for a background check is anywhere from 3-8 days. During an interview on 5/12/16 at 8:40 a.m., staff member A, stated she was responsible for ensuring all direct-care staff received abuse training, including types of abuse and whom to report alleged abuse. A review of the facility's Abuse Prevention policy read, 1) SCREENING: All potential employees will be screened for a history of abuse, neglect, or mistreatment of [REDACTED]. The facility will also attempt to obtain information regarding past or current employment. Any negative findings for any of these sources will be evaluated as to the appropriateness of this person's employment with this facility so as to prevent any risk of abuse to our residents. | 2020-04-01 |
| 1795 | 1795 | CEDAR WOOD VILLA | 275053 | 1 S OAKS | RED LODGE | MT | 59068 | 2016-05-12 | 241 | D | 0 | 1 | XO7K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to refer to residents in a dignified and respectful manner for 2 (#s 5 and 15) of 16 sampled and supplemental residents. Findings include: 1. Resident #15 was recently admitted to the facility with [DIAGNOSES REDACTED]. During an observation on 5/10/16 at 9:18 a.m., staff member F prepared medications for the resident. The staff member was standing at the nurse's station. Several residents and staff members were at the nurse's station. The staff member stated it was time to wake the beast. During an interview on 5/10/16 at 9:19 a.m., staff member F stated she was not sure why she made the reference of waking the beast. 2. Resident # 5 was admitted to the facility with [DIAGNOSES REDACTED]. A review of an Annual MDS, with an ARD of 3/31/16, reflected the resident required extensive assistance with transfers and eating. The resident required total assistance with locomotion in her wheelchair, dressing and toileting. The resident was coded as non-verbal. During an observation on 5/11/16 at 7:53 a.m., staff member H placed an infant nursing pillow on the resident's lap while the resident was seated in a wheelchair. The staff member referred to the resident as the leaning Tower of Pisa. During an interview on 5/11/16 at 7:54 a.m., staff member H did not answer when she was asked why the resident was referred to as the leaning Tower of Pisa. A review of the facility's Quality of Life- Dignity policy, read, Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not 'labeling' or referring to the resident by his or her room number, diagnosis, or care needs. | 2020-04-01 |
| 1796 | 1796 | CEDAR WOOD VILLA | 275053 | 1 S OAKS | RED LODGE | MT | 59068 | 2016-05-12 | 243 | E | 0 | 1 | XO7K11 | Based on record review and interview, the facility failed to provide residents with privacy for meetings without interference from the life enrichment department. Specifically, the resident council had not been encouraged to obtain or hold an election for a resident president since 2010; the facility failed to ensure all staff attending the resident council meetings were at the group's invitation. This has the potential to affect all residents participating in the group council. Findings include: During the group interview on 5/10/16 at 10:00 a.m., the attending resident council members stated they were not aware they could elect a resident to preside over the monthly group meetings. The attending members of the group interview, stated they had a resident president but since she left there has never been another resident president. The attending residents stated the activities director performed the role of the resident president. The attending residents were not aware of their right to participate in the group meetings in private and having staff attend only by invitation from the group. During the group interview, several residents stated they were at times hesitant to express concerns regarding certain issues when the staff were present at the meeting. The group used the example of expressing concerns with the food at group meetings because the dietary manager had attended the entire meeting instead of attending only a portion of the meeting and leaving. During an interview on 5/10/16 at 12:13 p.m., staff member J stated the group council has opted not to have a resident president since 2010. Staff member J stated she opened the meetings with any follow up concerns from the last meeting minutes, then addressed any new business. Staff member J stated she did the duties of the resident president. Staff member J stated the group council had a resident president but has not had a new president since she left in 2010. Staff member J stated she replaced the former activities director whom attended the group council … | 2020-04-01 |
| 1797 | 1797 | CEDAR WOOD VILLA | 275053 | 1 S OAKS | RED LODGE | MT | 59068 | 2016-05-12 | 246 | E | 0 | 1 | XO7K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to answer activated call lights within a timely manner for 5 (#s 6, 12, 13, 14 and 16) of 16 sampled and supplemental residents. Specifically, staff walked passed activated call lights and failed to inquire residents' needs. Findings include: 1. Resident #12 was admitted to the facility with [DIAGNOSES REDACTED]. A review of an Annual MDS, with an ARD of 2/20/16, reflected the resident required extensive assistance with bed mobility, transfers, bathing, and hygiene. The resident preferred to stay in her room, seated in a recliner watching TV. During an observation on 5/10/16 from 10:37 a.m. to 10:40 a.m., a call light was activated by resident #12. There was an audible alarm with a visual light corresponding to the resident's room on a wall at the nurse's station. Staff members F, O and Q were seated at the nurse's station talking amongst themselves. Staff members B, K and N spoke briefly at the nurse's station then walked towards the opposite hall. At 10:40 a.m., staff member N returned to the South hall and acknowledged the resident's call light. During an observation on 5/10/16 from 8:00 p.m. to 8:10 p.m., resident #12 activated her call light. There was an audible alarm at the nurse's station. Staff members J, B, and P were seated at the nurse's station. The call light was acknowledged at 8:12 p.m. by staff member P. During an observation on 5/11/16 from 9:05 a.m. to 9:18 a.m., the call light for resident #12's room was activated. There was an audible alarm with a visual light corresponding to the resident's room on a wall at the nurse's station. Staff members F and H were at the nurse's station looking at their computers. 2. Resident #13 was admitted to the facility with [DIAGNOSES REDACTED]. A review of an Annual MDS, with an ARD of 2/19/16, reflected the resident required total assistance with mobility, transfers, bathing, and hygiene. During an observation on 5/10/… | 2020-04-01 |
| 1798 | 1798 | CEDAR WOOD VILLA | 275053 | 1 S OAKS | RED LODGE | MT | 59068 | 2016-05-12 | 248 | E | 0 | 1 | XO7K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide meaningful activities according to residents personal interests for 2 (#s 3 and 8) of 11 sampled residents. Findings include: 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #3 was completely confined to his bed. A review of resident #3's Initial MDS with an ARD of 4/11/16, showed the resident had a BIMS of 15. A review section F0500, showed the resident's activity preference for news was very important, and the activity preference for reading materials, music, animals and group activities was somewhat important to the resident. A review of resident #3's Initial Activities Assessment, dated 3/31/16, showed the Activity Pursuit Patterns/Daily and Activity Preferences for the resident were a current interest in music, reading, walking, wheeling outdoors, watching TV, talking or conversing and watching movies. During observations on 5/9/15, 5/10/16 and 5/12/16, resident #3 was not offered to join the facility's activities. Resident #3 remained in his room in bed with the door closed. During an interview on 5/10/16 at 12:51 p.m., resident #3 stated he wished he had the use of a computer. Resident #3 stated he used to read the Billings Gazette every morning when he was home, and since he has been at the facility has not been able to use either a computer or read the newspaper. Resident #3 stated he also enjoyed talking with people and gossiping. Resident #3 stated he has a phone that his step-daughter brought him and that is very important to him to be able to use the phone when he wanted. A review of resident #3's Activities Log for 5/2016 showed he received the following activities: -Dog therapy x 4 days. -Mother's Day Tea on 5/8/16. -Phone calls x 5 days -TV in room x 8 days. Resident #3 did not receive any one to one activities, news, music or movies provided to him in his room, since he is confined to the bed. During an… | 2020-04-01 |
| 1799 | 1799 | CEDAR WOOD VILLA | 275053 | 1 S OAKS | RED LODGE | MT | 59068 | 2016-05-12 | 252 | E | 0 | 1 | XO7K11 | Based on observation and interview, the facility failed to provide an environment free of odors which had the potential to affect most residents. Findings include: 1. During an observation on 5/9/16 at 9:17 a.m., a strong smell of urine was apparent in the South Hall, before the nursing station. During an observation on 5/10/16 at 7:15 a.m., and 5/11/16 at 7:10 a.m., there was a urine odor when entering the south hall by the nurses station. During an interview on 5/11/16 at 9:40 a.m., resident #7's family member stated that there had been a problematic urine odor at this facility. During an interview on 5/11/16 at 5:00 p.m., staff member B stated there was a cloth chair that had been soiled by a resident that was removed from the room and could possibly be the reason for the urine odor. | 2020-04-01 |
| 1800 | 1800 | CEDAR WOOD VILLA | 275053 | 1 S OAKS | RED LODGE | MT | 59068 | 2016-05-12 | 279 | D | 0 | 1 | XO7K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a comprehensive care plan for 1 (#6) of 11 sampled residents. Specifically, the facility failed to address behaviors which impacted consumption of food and fluid with significant weight change. Findings include: 1. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During observations on 5/9/16 at 3:45 p.m., 5/10/16 at 7:17 a.m., 5/11/16 at 8:30 a.m., and 5/12/16 at 7:20 a.m., and 8:55 a.m., the resident stayed in her room in bed, or in her recliner. Personal items had been taken from her closets and laid on the bed, on a dresser, or were folded in a bag. A cross stitched picture sat upright in a chair across from the resident's recliner. Staff member AA said the resident packed and unpacked her personal items as she believed she was leaving. During an observation of cares on 5/10/16 at 10:50 a.m., staff member AA said the resident ate in her room. Resident #6 told staff member AA when providing care, that she wanted a shower but not in the one around the corner. During an interview on 5/10/16 at 8:30 a.m., staff member F said the resident refused her breakfast. The resident had her own schedule, self isolated, and refused meals at times because she believed the food was poisoned. During an interview on 5/10/16 at 11:05 a.m., staff member O said the resident usually drank the supplement offered with meals and with her medications, even if she refused to eat. During an interview on 5/9/16 at 3:45 p.m., resident #6 stated she was born on (MONTH) 31st and stated, I am a witch. The resident said this several times when visiting with her. Review of resident #6's admission MDS, with an ARD date of 12/10/15, reflected in section C, behavior was coded as constant for inattention and disorganized thinking. In section D, mood and behaviors were coded as occurring 2-6 days and at times half or more of the days. In section E, hallucinations and de… | 2020-04-01 |
| 1801 | 1801 | CEDAR WOOD VILLA | 275053 | 1 S OAKS | RED LODGE | MT | 59068 | 2016-05-12 | 312 | D | 0 | 1 | XO7K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were provided with assistance with personal hygiene care for 1 (#3) of 11 sampled residents. Specifically, the facility failed to provide assistance with brushing resident #3's teeth every day and did not provide showers as scheduled. Findings include: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of resident #3's Initial MDS with an ARD of 4/11/16, showed a BIMS of 15. A review of resident #3's Initial MDS with an ARD of 4/11/16, section F0400, showed the preference for bathing was very important. Section G0110 showed resident #3 was a total assist with one person physical assist for personal hygiene, total assist with two person physical assist with bathing. A review of resident #3's Care Plan showed the resident needed total assistance with dressing, grooming, and bathing. Resident #3's Care Plan showed the resident wanted to be well dressed and neatly groomed. The interventions showed the resident needed assistance with mouth care, and total assistance with two staff members for tub, shower, or bed bath. [NAME] During an observation on 5/9/16 at 3:36 p.m., resident #3 had several teeth missing in the front of his mouth, with two dental implants in place of the bottom incisors. The remaining teeth had a moderate amount of soft white plaque build up around the teeth by the gums. Resident #3's breath was malodorous. During an interview on 5/9/16 at 3:36 p.m., resident #3 stated the staff did not brush his teeth. During an observation on 5/10/16 at 7:24 a.m., staff member G assisted resident with his morning meal. Staff member G did not offer to assist resident with personal hygiene after his meal. During an interview on 5/10/16 at 9:32 a.m., resident #3 stated staff did not offer assistance with brushing his teeth. Resident #3 stated he did not have his teeth brushed. During an observation on 5/11/16 at 7:15 a.m… | 2020-04-01 |
| 1802 | 1802 | CEDAR WOOD VILLA | 275053 | 1 S OAKS | RED LODGE | MT | 59068 | 2016-05-12 | 323 | D | 0 | 1 | XO7K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a gait belt was used during the transfer of 1 (#5) from a shower chair to the bed, and failed to reduce choking hazards for 1 (#2) of 11 sampled residents. Findings include: 1. Resident # 5 was admitted to the facility with [DIAGNOSES REDACTED]. A review of an Annual MDS, with an ARD of 3/31/16, reflected the resident required extensive assistance with transfers and eating. The resident required total assistance with locomotion in her wheelchair, dressing and toileting. The resident was coded as non-verbal. During an observation on 5/9/16 at 2:52 p.m., staff members X and Y transferred the resident from a shower chair to her bed. The staff members stood on either side of the resident and lifted her from under her armpits, and under each leg. The resident was draped with a towel and no gait bet was used during the transfer. During an interview on 5/9/16 at 3:10 p.m., staff member Y stated the resident should have been transferred using a gait belt. During an interview on 5/10/16 at 10:32 a.m., staff member C stated staff were required to use a gait belt during all transfers. The staff member stated, Although two people can lift and transfer (resident #5), the staff must use a gait belt. A review of the facility's Transfer Belt policy read, A transfer belt must be used with EVERY assisted transfer, unless care plan indicates otherwise. This means unless the resident is INDEPENDENT, a transfer belt must be used. 2. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. A review of an Annual MDS, with an ARD of 3/24/16, reflected the resident required extensive assistance with bed mobility, transfers, dressing and toileting. The resident was on a mechanical soft diet. During an observation on 5/11/16 at 9:37 a.m., staff member K partially opened and offered the resident an individual Kit-Kat candy bar. The staff member held the candy bar, and the residen… | 2020-04-01 |
| 1803 | 1803 | CEDAR WOOD VILLA | 275053 | 1 S OAKS | RED LODGE | MT | 59068 | 2016-05-12 | 371 | F | 0 | 1 | XO7K11 | Based on observation and interview, the facility failed to ensure food was served and stored under sanitary conditions. The facility failed to ensure kitchen staff demonstrated proper hand hygiene during meal preparation, and when putting away clean dishes after handling dirty dishes. This deficiency had the potential to affect all of the residents who receive meals from the facility's kitchen. Findings include: 1. During an observation on 5/10/16 at 7:45 a.m., staff member V was wearing gloves while pre-rinsing the dirty dishes. Staff member V picked up the dirty plates, rinsed them, and put the plate in the rack to be washed in the dishwasher. While wearing the same pair of gloves used to pre-wash the dirty dishes, staff member V put away the clean dishes. Staff member V did not change her gloves or wash her hands between washing the dirty dishes and putting away the clean dishes. Staff member V transitioned between the dirty dishes and the clean dishes five separate times without changing her gloves or washing her hands. During an interview on 5/10/16 at 2:20 p.m., staff member V stated she should have washed her hands and changed her gloves between washing the dirty dishes and putting away the clean dishes. 2. During an observation on 5/10/16 at 8:20 a.m., staff member W was wearing a pair of gloves. Staff member W handled raw frozen bacon. She put the bacon on wax paper and placed it inside the microwave to cook. While wearing the same gloves she was wearing to handle the raw bacon, staff member W opened and poured liquid eggs into a pan she then removed the pan off the stove and threw those eggs in the garbage. Staff member N then touched several different saute pans and grabbed another pan. Using the same gloved hands she used to handle the raw bacon, she re-opened the liquid eggs and poured another batch into a new pan. Staff member W then took out two pieces of bread and put them in the toaster. She then proceeded to finish cooking the eggs. When the toast was finished staff member W removed the toast fr… | 2020-04-01 |
| 1804 | 1804 | CEDAR WOOD VILLA | 275053 | 1 S OAKS | RED LODGE | MT | 59068 | 2016-05-12 | 441 | E | 0 | 1 | XO7K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide services that would minimize the spread of infection for 2 (#s 3 and 5) of 11 sampled residents. Specifically, staff failed to sanitize scissors prior to an aseptic procedure, failed to wash or sanitize hands prior to donning clean gloves, and donned two gloves when performing a dressing change. Findings include: 1. Resident # 5 was admitted to the facility with [DIAGNOSES REDACTED]. A review of an Annual MDS, with an ARD of 3/31/16, reflected the resident required extensive assistance with transfers and eating. The resident required total assistance with locomotion in her wheelchair, dressing and toileting. The resident was coded as non-verbal. A review of weekly skin assessments, last dated 4/12/16, showed the resident had an unstageable 1.2 cm x 0.4 cm wound to her right buttock. The wound base had 100% [MEDICATION NAME] cells. There was no discharge or drainage. During an observation on 5/10/16 at 8:30 p.m., resident #5 had a wound to her coccyx above her gluteal crease. There was a thick white skin flap approximately 2 cm x 1 cm in length. There was an open, bright red, approximately 0.5 x 0.2 cm area along the medial side of the wound. The wound did not have any visible discharge or drainage. Staff member P replaced the foam dressing that had come loose. During an observation on 5/11/16 at 7:35 a.m., staff member H removed the resident's soiled brief with bare hands. The staff member donned sterile gloves without washing or sanitizing her hands. The staff member removed a pair of scissors from a left pocket of her scrub top. During an observation on 5/11/16 at 7:40 a.m., staff member H sprayed the scissors with wound cleanser. The staff member double-gloved her right hand. She proceeded to cleanse the resident's coccyx with wound cleanser then cut a piece of Puracol wound dressing to fit the coccyx wound. The wound was covered with a foam dressing that con… | 2020-04-01 |
| 2591 | 2591 | CEDAR WOOD VILLA | 275053 | 1 S OAKS | RED LODGE | MT | 59068 | 2015-02-26 | 278 | D | 0 | 1 | W7YF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview the facility failed to accurately reflect the cognition and BIMS status for 1 (#2) of 11 sampled residents. Findings include: 1. Resident #2 was readmitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD of 1/13/15, section B0700 and B0800, showed the resident was coded as understood and understands. Section C 0100 of the same quarterly MDS showed the resident was coded as rarely/never understood and section C1000 showed the resident was severely cognitively impaired in making daily decisions. Review of the resident's significant change MDS with an ARD of 10/15/13, showed the resident had a BIMS score of 14, meaning cognitively intact. Review of the resident's annual MDS with an ARD of 10/14/14, showed the resident had a BIMS score of 12, meaning moderately impaired cognition. Review of the resident's quarterly MDS with an ARD of 1/13/15, the BIMS score was left blank. During an interview on 12/24/14 at 2:20 p.m., staff member C, MDS Coordinator, stated that staff member H, SS director was new at doing sections C, D, and E of the MDS and had only been doing these MDS sections since January. Staff member C stated that she will need to do some more education with staff member H. | 2018-12-01 |
| 2592 | 2592 | CEDAR WOOD VILLA | 275053 | 1 S OAKS | RED LODGE | MT | 59068 | 2015-02-26 | 332 | D | 0 | 1 | W7YF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to ensure that 2 (#'s 15 and 16) of 16 sampled and supplemental residents were free of a medication error rate of five percent or greater. The medication error rate was 7.5% based on 3 errors out of 40 opportunities. Findings include: 1. Resident #15 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. During an observation on 2/24/15 at 7:35 a.m., staff member F, RN, gave resident #15 three vitamin D3, 2,000 unit tablets by mouth, during the morning medication pass. Review of the medication review report signed by the physician and the MAR, dated 2/1/15 to 2/28/15, reflected an order for [REDACTED]. During an interview on 2/25/15 at 1:00 p.m., staff member B, DON was informed of the medication error and verified the order for two instead of three. 2. Resident #16 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. During an observation on 2/24/15 at 7:53 a.m., staff member F, RN, gave resident #16 one folic acid 400 mcg tablet by mouth and one [MEDICATION NAME] ER 50 mg tablet by mouth during the morning medication pass. During record review on 2/25/15 at 9:30 a.m., review of the admission orders [REDACTED]. During an interview on 2/25/15 at 12:50 p.m., staff member B, DON, stated the nurse at the hospital wrote the admission orders [REDACTED] During an interview on 2/25/15 at 1:35 p.m., staff member B, DON, stated staff member G, RN, should have noticed the admission order was written for the wrong [MEDICATION NAME] and clarified the order with the MD but she (resident #16) was actually receiving the correct medication and has always gotten the [MEDICATION NAME] ER since she has been here. Staff member B stated that when the resident returned from the hospital with the admission orders [REDACTED]. During an interview on 2/25/15 at 3:30 p.m., staff member G, RN, stated the nurse at the hospital wrote the admission orders [REDACTED]. T… | 2018-12-01 |
| 2593 | 2593 | CEDAR WOOD VILLA | 275053 | 1 S OAKS | RED LODGE | MT | 59068 | 2015-02-26 | 371 | E | 0 | 1 | W7YF11 | Based on observation and interview, the facility failed to store food items in the manner as recommended by the manufacturer. This would affect all resident receiving nutritional supplements from the kitchen. Findings include: During an observation on 2/23/15 at 3:00 p.m., 23 cartons of vanilla, 24 cartons of strawberry and 30 cartons of chocolate nutritional supplements had been placed on large rectangular trays in the walk in cooler. All of the nutritional supplements had been thawed. None of the cartons were observed to be dated. The manufacturer's instructions, on each carton, had the following instructions: To remain frozen until ready for use. The instructions also directed the shakes were to be used within 14 days of being thawed. All the cartons contained a date line for the thaw date to be written on each carton. The facility failed to date any of the nutritional supplements cartons. During an observation on 2/23/15 at 3:00 p.m., 25 cartons of nutritional supplemental orange juice had been placed on a large rectangular tray in the walk in cooler. All of the nutritional supplements had been thawed. None of the cartons were observed to be dated. The manufacturer's instructions, on each carton, had the following instructions: To remain frozen until ready for use. The instructions directed the shakes were to be used within 14 days of being thawed. All the cartons contained a date line for the thaw date to be written. The facility failed to date any of the cartons. During an interview on 2/23/15 at 3:15 p.m., staff member D, dietary manager, stated that she was not aware that each nutritional supplement carton had to be dated. She further stated each type of supplement was on its own tray and a sticky note was attached to each tray and contained the thaw date. | 2018-12-01 |
| 3459 | 3459 | CEDAR WOOD HEALTHCARE COMMUNITY | 275053 | 1 S OAKS | RED LODGE | MT | 59068 | 2014-01-30 | 246 | E | 0 | 1 | 4U6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and resident/staff interview, the facility failed to provide reasonable accommodations of individual needs and preferences by ensuring the call system was available to 3 (#s 4, 6, 18) of 18 sampled and supplemental residents and to residents who used the bathroom in the main hallway near the activity room. Findings include: 1. Resident #6 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. During an observation on 1/27/14 at 3:21 p.m., resident # 6 was lying on her back in the bed with the head of the bed raised 30%. Her neck was secured in a neck pillow on top of her bed pillow. The resident's over the bed table was in place over her body in front of her. The resident was alert and was able to move both hands and answer questions. Her call light was on the floor at the wall behind her bed, beneath the call light junction. The resident's over the bed light was missing the chain that turned the light off and on. The chain was broken off up near the light itself. The resident verified she was not able to reach the chain for the light or her call light. During a second observation on 1/28/14 at 4:00 p.m., resident #6's call light remained on the floor away from the resident's bed and irretrievable for the resident. The call light for the other resident in the room was also on the floor beside resident #6's call light. 2. Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #18 experienced a fall in her room on the morning of 1/29/14 and was sent to the emergency room for evaluation. On 1/29/14 at 2:00 p.m., during an observation of the environment, the call system in the bathroom of resident #18's room, S-14, showed the call light did not have an attached string that would allow the resident to be at the toilet and call for assistance. This was pointed out to staff member B, the DON, and she indicated this problem would be fixed. 3. Resident #4 was admitted to the … | 2017-08-01 |
| 3460 | 3460 | CEDAR WOOD HEALTHCARE COMMUNITY | 275053 | 1 S OAKS | RED LODGE | MT | 59068 | 2014-01-30 | 278 | D | 0 | 1 | 4U6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review and observations, the facility failed to complete a timely and accurate quarterly MDS assessment for 1 (#8) out of 12 sampled residents. Findings include: Resident #8 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The quarterly MDS for resident #8 with an ARD of 12/03/13 was not completed until 12/27/13. The RAI requirements specify completion of the MDS within no more than 14 days after the ARD (12/16/13). Under section B of the MDS for hearing, speech and vision, resident #8 was coded as being usually understood. According to the 12/3/13 MDS, the resident was unable to be interviewed for mood and cognition because of his inability to communicate. During resident observation on 1/27/14, 1/28/14, 1/29/14 and 1/30/14, resident #8 was able to say one word, yeah, at times. Resident #8 was unable to speak any other words during multiple interview attempts throughout the survey. According to observations, unsuccessful attempts to interview the resident, and the MDS which showed the resident could not be interviewed for mood and cognition, the coding showing he was usually understood was inaccurate. Under section H of the MDS for bladder and bowel, the facility inaccurately coded resident #8 as having a bladder and bowel training program. According to the RAI manual?, toileting programs refer to a specific approach that is organized, planned, documented, monitored, and evaluated and in accordance with current standards of practice. A toileting program does not refer to random assistance with toileting or hygiene. The care plan did not identify an individualized toileting program. Resident #8's approach to a toileting program consisted of to be toileted in the morning, before meals, at night if awake, and before activities. Under section K of the MDS for swallowing/nutritional status, the facility failed to code loss of liquids/solids from mouth when eating or drinking. Resident #8 was o… | 2017-08-01 |
| 3461 | 3461 | CEDAR WOOD HEALTHCARE COMMUNITY | 275053 | 1 S OAKS | RED LODGE | MT | 59068 | 2014-01-30 | 279 | D | 0 | 1 | 4U6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review and observation, the facility failed to review and revise the comprehensive plans of care for 2 (#s 4 and 8) of 12 sampled residents. Findings include: 1. Resident #8 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. According to the 9/13/13 annual MDS, the resident required extensive assistance of of two or more people for dressing, bed mobility, toilet use and transfers. The resident was coded as not walking or being able to turn around while walking under section F0300, balance during transitions and walking. The resident was coded as being unsteady and not able to balance without staff assistance when moving from a seated to standing position. During observation of care on 1/29/13 at 11:35 a.m., two staff used a sit to stand lift to position the resident in an upright manner in order to provide peri-care. The care plan for self care deficit: assistance required with bathing, hygiene, dressing, grooming and transfers, did not address the use of a sit to stand lift or how many staff were required to assist the resident. The care plan did not provide direction regarding how resident #8 should be transferred or that the lift should be used when peri-care was provided. During a staff interview with staff member B, the DON, on 1/29/13, she acknowledged resident #8's transfer status was not documented on the care plan and stated, I know why you had me look, because it isn't there. 2. Resident #4 was admitted to the facility 7/26/12 with [DIAGNOSES REDACTED]. Review of the clinical record for resident #4 showed evidence of a fax communication with the physician dated 10/6/13 and was signed by the physician on 10/7/13. It read, Resident refuses to wear O2 at HS. Could we change his NOC order to PRN during times of lethargy or decreased O2 sats? The return order from the physician was written as, O2 at 2L/min (two liters per minute) if O2 sat is less than 88% as needed. After the communica… | 2017-08-01 |
| 3462 | 3462 | CEDAR WOOD HEALTHCARE COMMUNITY | 275053 | 1 S OAKS | RED LODGE | MT | 59068 | 2014-01-30 | 309 | D | 0 | 1 | 4U6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to provide services that met professional nursing standards of quality for 1 (#2) of 12 sampled residents who was an insulin dependent diabetic. Specifically, -There were two policies/protocols that had conflicting information regarding [DIAGNOSES REDACTED]; -Nurses were not aware of what measures to take to be in accordance with the facility policy or protocol for [DIAGNOSES REDACTED]; -Nurses did not contact the physicians with incidents of [DIAGNOSES REDACTED]; -Nurses did not consistently take appropriate action for incidents of [DIAGNOSES REDACTED]. -The facility policy failed to address low blood sugars that warranted immediate notification to the physician. Findings include: 1. Background information - [DIAGNOSES REDACTED] [DIAGNOSES REDACTED] (low blood sugar) with a blood sugar below 70 can present with symptoms of sweating, nervousness, shaking, nausea, hunger, dizziness, headache, blurred vision, fast heartbeat, and feeling anxious. Diabetics with a blood sugar below 40 may appear confused, irritable, exhibit slurred speech, unsteadiness, muscle twitching, and have personality changes. If a diabetic's blood sugar decreases to below 20 a [MEDICAL CONDITION], loss of consciousness, stroke, and even death can occur?. 2. Resident #2 was admitted to the facility on [DATE]; current [DIAGNOSES REDACTED]. The care plan identified the resident's chronic health conditions that required monitoring including insulin dependent diabetes mellitus. The goal was for the health conditions to remain stable evidenced by no hospitalization s. The care plan also identified the resident's refusal of treatments and medications and potential for negative outcomes such as hypo and [MEDICAL CONDITION]. The physician ordered fasting blood sugar checks twice daily at 7:00 a.m. and 5:00 p.m. If the resident's blood sugars were over 400, the physician was to be called. There were no orders regarding… | 2017-08-01 |
| 3463 | 3463 | CEDAR WOOD HEALTHCARE COMMUNITY | 275053 | 1 S OAKS | RED LODGE | MT | 59068 | 2014-01-30 | 312 | D | 0 | 1 | 4U6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to provide the necessary services to maintain good grooming and personal hygiene for 2 (#s 3 and 8) of 12 sampled residents. These residents required staff assistance for ADLs. Findings include: 1. Resident #8 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The quarterly MDS with an ARD of 12/03/13 did not identify any rejection of care in section E0800/Behavior. The MDS indicated the resident required extensive assistance of one staff member for dressing and personal hygiene. The resident's care plan included the problem of Self care deficit. Assistance required with bathing, hygiene, dressing, grooming, and transfers. The goal was for the resident to be odor free, dressed and out of bed daily over the next 90 days. (Resident #8) will assist with ADLs to the highest degree possible. Interventions included coaxing and reminding the resident of potential risk when care was refused and providing the assistance of one staff member for all ADLs. A physician note dated 8/19/13 read General appearance: chronically ill appearing and poor dentition, food and liquids staining his clothing. Observations showed the resident lacked adequate grooming and hygiene each day of the survey: 1/27/14 -At 8:45 a.m. resident #8 had dried food on his face and was wearing a shirt that was wet and soiled with food and fluid. -At 9:05 a.m. resident #8's face and shirt were in the same condition as 8:45 a.m. Resident #8 continued to sit in the hallway with dried food on his chin, and wearing the soiled shirt. -At approximately 2:00 p.m., an unidentified nurse was observed to wash the resident's face with a wet cloth while he was in the hallway. His face had not been cleaned prior to this time following breakfast that morning. 1/28/14 -At 8:30 a.m. the resident was observed to have food on his chin, and was wearing a soiled shirt. -At 2:45 p.m. resident's shirt was changed… | 2017-08-01 |
| 3464 | 3464 | CEDAR WOOD HEALTHCARE COMMUNITY | 275053 | 1 S OAKS | RED LODGE | MT | 59068 | 2014-01-30 | 323 | D | 0 | 1 | 4U6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, the facility failed to ensure residents were transferred safely using a gait belt and by locking the wheels of the lift and wheelchairs for 1 (#17) of 18 sampled and supplemental residents. Findings include: 1. Resident #17 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the 9/17/13 annual MDS, the resident required extensive assistance of two or more staff members for transfers, locomotion on and off the unit, dressing and toilet use. The resident was severely impaired in cognition according to the BIMs score of 0. On 1/29/14 at 7:40 a.m., morning cares were observed for resident #17. Staff members O and C, both CNAs, provided care. During the transfer of the resident from her bed to her wheel chair using a hoyer lift, staff failed to lock the brakes on the lift prior to lifting the resident. The resident was lifted, then moved and positioned over her wheelchair. The staff proceeded to lower the resident into the wheel chair without locking the brakes on the hoyer lift or the wheel chair. The transfer was not completed in a safe manner. ? ? Staff member O was interviewed and asked about the training she received related to use of brakes on mechanical lifts and wheelchairs. She said, I was taught to use the brakes. Review of the facility's policy Lifting Safety Precautions was provided by staff member B, the DON. It directed staff to follow safety precautions that had been established for all personnel when lifting or handling heavy objects. Under Procedure Guidelines, it directed staff, when lifting or moving residents, to make sure that equipment was secure (i.e., wheelchair, beds, stretcher, etc.). Gait belt use was required when transferring residents who required assistance. If there were mechanical devices available to assist in moving residents more safely, they were to be used. REFERENCES ? Transferring the person using a mechanical lift Procedu… | 2017-08-01 |
| 3465 | 3465 | CEDAR WOOD HEALTHCARE COMMUNITY | 275053 | 1 S OAKS | RED LODGE | MT | 59068 | 2014-01-30 | 328 | D | 0 | 1 | 4U6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview the facility failed to provide the necessary respiratory care and services for 1 (#4) of 12 sampled residents. Findings include: Resident #4 was admitted to the facility 7/26/12 with [DIAGNOSES REDACTED]. a. Oxygen orders The resident was prescribed oxygen; however, had a history of [REDACTED]. A fax communication with the physician dated 10/6/13 and was signed by the physician on 10/7/13. It was written as, Resident refuses to wear O2 at HS. Could we change his NOC order to PRN during times of lethargy or decreased O2 sats? The return order from the physician read, O2 at 2L/min (two liters per minute) if O2 sat is less than 88% as needed. A review of the physician order [REDACTED]. b. Care plan A review of the current care plan for oxygen use, with a goal date of 1/29/14, read, (resident #4) will maintain on oxygen saturation greater than 90% over the next 90 days. c. Observations On 1/27/14 at 5:30 p.m., resident #4 was observed in the dining room waiting for a meal. He was not utilizing oxygen at that time. On 1/28/14 at 7:45 a.m., resident #4 was observed walking to the dining room by himself, utilizing a walker. He was not utilizing oxygen at the time. On 1/28/14 at 10:15 a.m., resident #4 was observed sitting in a chair in his room and was not utilizing oxygen at the time. During the observation it was noted there was an oxygen concentrator located in his room. The concentrator had an oxygen bubbler humidifier, tubing, and a nasal cannula attached to the concentrator. The date written on the oxygen bubbler humidifier was 9/13, September of 2013. d. Staff interviews On 1/28/14 at 10:30 a.m., staff member K, a CNA, was interviewed regarding the outdated bubbler on the oxygen concentrator. He acknowledged the bubbler was out dated and said, He only wears it sometimes. On 1/28/14 at 10:45 a.m., staff member L, an LPN, was interviewed regarding resident #4's oxygen use. She said, He us… | 2017-08-01 |
| 3466 | 3466 | CEDAR WOOD HEALTHCARE COMMUNITY | 275053 | 1 S OAKS | RED LODGE | MT | 59068 | 2014-01-30 | 441 | E | 0 | 1 | 4U6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, the facility failed to ensure staff followed appropriate infection control and hand washing practices when providing care to 3 (#s 8, 13, and 17) of 18 sampled and supplemental residents. Findings include: 1. During an observation on 1/28/14 at 11:04 a.m., staff member C, a CNA, did all of the following without washing her hands: Staff member C assisted resident #13 into the tub after undressing her. The CNA shut the door of the tub and began to fill the tub with water. When the tub was 1/3 full, the CNA washed the resident's back, underarms, arms and hands with liquid soap and a wash cloth. Upon finishing, the CNA handed the wash cloth to the resident and asked her to wash her private areas. Resident #13 washed her breast and her peri-area. When the resident was finished, the CNA asked the resident if she wanted to wash her face now? Resident #13 washed her face with the same cloth she had used to wash her peri-area. Without washing her hands, the CNA went over to a clip board and began writing on the clip board. When the aide was finished writing, the aide got the resident's 02 tubing off of her chair and put the tubing over her ears and into her nares. The CNA brushed the resident's hair, picked up the dirty laundry and put it in the hamper, opened the door, and assisted the resident out to the hallway and to her room. When asked about hand washing, the CNA stated, (while washing her hands she was to) count to 20 or sing Twinkle Twinkle Little Star through every single time I deal with a resident. The CNA did not wash her hands or use an alcohol-based hand rub from the beginning of the bath procedure to the end of the bath procedure. 2. Resident #17 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/29/14 at 7:40 a.m., morning cares were observed for resident #17, with staff members O and C, both CNAs providing cares. During the cares and working as a team, the… | 2017-08-01 |
| 4271 | 4271 | CEDAR WOOD HEALTHCARE COMMUNITY | 275053 | 1 S OAKS | RED LODGE | MT | 59068 | 2012-12-06 | 272 | D | 0 | 1 | SH3211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility staff failed to assess weight loss for 1 (#6) of 2 sampled residents. Findings include: Resident #6 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. An annual MDS assessment was completed with an ARD of 2/28/12. The resident's weight was 178# (K0200 B). A quarterly MDS assessment was completed with an ARD of 11/11/12. The resident's weight was 159# (K0200 B). The RD completed a Nutritional Assessment/Risk Review Form on 11/13/12. The weight section of the assessment, included the resident's weight, body mass index, weight change of 5% or 10%, and if the resident had [MEDICAL CONDITION] or if the resident had undergone diuresis. All assessment areas were blank. The Nutritional Approaches were also blank. The options included therapeutic diet, supplements, snack/nourishment, and other diet orders. The Care Plan Conference Summary dated 11/28/12, was reviewed. The summary document included a new [DIAGNOSES REDACTED]. The dietary section included a weight of 153.6#, regular mechanical soft diet, scrambled eggs and toast for dinner, and initiation of a supplement if acceptable by the resident. The plan of care dated 3/5/12, did not have any new interventions to address the 25# (14%) weight loss the resident sustained [REDACTED]. On 12/4/12 at 4:30 p.m., staff member B, the DON, stated the resident suffered [MEDICAL CONDITION], was hospitalized during the weight loss time frame and received diuretics. However, the clinical record did not include a comprehensive assessment of factors that may impact weight or an analysis of relevant information to draw conclusions as to why the resident was unable to maintain his weight. | 2016-06-01 |
| 4272 | 4272 | CEDAR WOOD HEALTHCARE COMMUNITY | 275053 | 1 S OAKS | RED LODGE | MT | 59068 | 2012-12-06 | 332 | E | 0 | 1 | SH3211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review and staff interview, the facility medication error rate exceeded 5 percent. Findings include: The following medication errors were observed during medication administration: 1. On 10/25/12, an attending physician prescribed atorvastatin calcium 10 mg one tablet at bedtime, every day for resident #5. The medication delivery was scheduled on the Medication Administration Record [REDACTED] On 12/3/12, staff member G, an RN, administered the medication at 4:15 p.m. When questioned regarding the timing discrepancy, the RN stated the medication was always given at 4:00 p.m. and she would telephone the physician to modify the order. 2. Resident #1 was a diabetic. On 9/28/12, the attending physician prescribed morning insulin based on the amount of carbohydrates the resident planned to consume during the meal. For the breakfast meal, the physician ordered one unit of insulin for every 6 grams of carbohydrates. On 12/4/12 at 7:30 a.m., staff member E, an RN, asked a kitchen staff member what the resident would receive for breakfast. Based on the information from the dietary aide, staff member E calculated the planned carbohydrate intake as follows, English muffin 15 grams, fruit 15 grams, hot cereal 15 grams, Boost dietary supplement 20 grams, and milk 15 grams. Staff member E calculated 13 units of Regular insulin for 80 grams of carbohydrates (1 unit for every 6 grams of carbohydrates). The Regular insulin was administered at 7:40 a.m. At 8:10 a.m. the resident's meal tray was reviewed. The resident did not receive hot cereal for breakfast. Therefore the insulin dose should have been 10 units instead of 13 units. 3. On 12/4/12 at 7:55 a.m., staff member E administered [MEDICATION NAME] 20 mg to resident #9. The resident was already eating his breakfast.? On 12/4/12 at 4:30 p.m., staff member B, the DON, stated she did not believe the facility policy for administration of proton pump inhibitors (PPI) diff… | 2016-06-01 |
| 4273 | 4273 | CEDAR WOOD HEALTHCARE COMMUNITY | 275053 | 1 S OAKS | RED LODGE | MT | 59068 | 2012-12-06 | 333 | D | 0 | 1 | SH3211 | Based on observation, clinical record review and staff interview, the facility staff failed to prevent a significant medication error for 1 (#1) of 15 observed residents. Findings include: Resident #1 was a diabetic. On 9/28/12, the attending physician prescribed morning insulin based on the amount of carbohydrates the resident planned to consume during the meal. The physician ordered one unit of insulin for every 6 grams of carbohydrates for the breakfast meal. On 12/4/12 at 7:30 a.m., staff member E, an RN, asked a kitchen staff member what the resident would receive for breakfast. Based on the information from the dietary aide, staff member E calculated the planned carbohydrate intake as follows, English muffin 15 grams, fruit 15 grams, hot cereal 15 grams, Boost dietary supplement 20 grams, and milk 15 grams. Staff member E calculated 13 units of Regular insulin for 80 grams of carbohydrates (1 unit for every 6 grams of carbohydrates). The Regular insulin was administered at 7:40 a.m. At 8:10 a.m. the resident's meal tray was reviewed. The resident did not receive hot cereal for breakfast. Therefore, the insulin dose should have been 10 units instead of 13 units. The resident worked daily in a sheltered workshop. On 12/4/12, a staff member from the sheltered workshop stated the resident's blood glucose value was 175 mg prior to the lunch meal. On 12/5/12 at 1:05 p.m., staff member B, the DON, stated the kitchen staff consistently omitted a carbohydrate serving from the resident's meal tray. | 2016-06-01 |
| 4274 | 4274 | CEDAR WOOD HEALTHCARE COMMUNITY | 275053 | 1 S OAKS | RED LODGE | MT | 59068 | 2012-12-06 | 367 | D | 0 | 1 | SH3211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview and record review, the facility staff failed to provide a therapeutic diet for 1 (#3) of 10 sampled residents. Findings include: Resident #3 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. On 12/4/12, the resident's breakfast included shredded wheat cereal, scrambled eggs, one slice of bacon, 1/2 of an English muffin, Boost dietary supplement, and coffee. On 12/4/12 at 11:15 a.m., staff member C, the dietary manager stated the resident received a controlled carbohydrate diet. The meal tray card was reviewed. Based on the meal tray card, the kitchen staff was directed to provide a controlled carbohydrate diet. On 11/12/12, the attending physician prescribed a stict (sic) diabetic diet. Staff member N, an RN, wrote a Diet Order & Communication for an 1800 calorie ADA, diet on 11/12/12. During a telephone interview on 12/5/12 at 8:10 a.m., the attending physician verified he intended for the resident to receive an 1800 calorie ADA diet. | 2016-06-01 |
| 4275 | 4275 | CEDAR WOOD HEALTHCARE COMMUNITY | 275053 | 1 S OAKS | RED LODGE | MT | 59068 | 2012-12-06 | 371 | F | 0 | 1 | SH3211 | Based on observation, staff interview and record review, the facility failed to ensure that the chlorine sanitizer for the dish machine was within 50 to 100 parts per million and that the facility was monitoring the cooked temperature for breakfast and the hot holding temperatures for all meals. Findings include: 1. During the observation of 12/3/12 at 1:35 p.m., staff member I, kitchen staff, tested the rinse water in the dish machine. The reading on the test strip was 10 ppm. Staff member I had run a tray of water carafes through the dish machine. Then staff member I put the water carafes away. The Dietary Manager intervened and pushed a button for sanitizer at the top of the dish machine. The Dietary Manager commented that they did not push the button after changing the bucket of sanitizer over the weekend. The Dietary Manager retested and indicated the test strip looked to be testing at 10 ppm. The Dietary Manager indicated she thought it needed a new hose. The Dietary Manager and the maintenance staff, staff member M, agreed they should not be using the Ecolab test strips. Review on 12/3/12 of the December 2012 Dish Machine Sanitizer & Temperature Recording Form indicated that on 12/2/12 the sanitizer concentration was recorded as being 40 ppm at breakfast and 50 ppm for supper. There was not a recording of the sanitizer concentration for lunch. On 12/3/12 at breakfast, the dish machine sanitizer was recorded at 50 ppm and lunch at 10 ppm. The instructions at the bottom of this form indicated Record temps. & sanitizer before washing session. If temp. is less than 120 degrees F or more than 155 degrees F or if chlorine (hypocloritee) (sic) sanitizer is less than 50 ppm or more than 150 ppm. Implement the following. 1.) consider the dishes unsafe for use, unless advised otherwise (get directions on how to handle the dishes) 2.) Contact Dietary Manager, if not available then 3.) Contact Maintenance, if not available then 4.) Contact dish machine repair service. During an interview on 12/3/12 at 2:15 p.m., with … | 2016-06-01 |
| 4276 | 4276 | CEDAR WOOD HEALTHCARE COMMUNITY | 275053 | 1 S OAKS | RED LODGE | MT | 59068 | 2012-12-06 | 441 | F | 0 | 1 | SH3211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on program policy review, staff interview, and observations, the infection control program lacked elements that facilitated analysis of infection incidents, and staff failed to provide care in a manner consistent with accepted infection control standards of practice for 4 (#s 2, 7,11, and 12) of 10 sampled residents and 2 supplemental residents. 1. Infection Control Program On December 5, 2012, the infection control program policies, infection logs, investigations and committee reports were reviewed. - The infection control log and infection reports lacked evidence that standardized infection definitions were used as part of the surveillance system. - The infection control program did not include an antibiotic review to monitor the appropriate use of antibiotics in the resident population. - Infection control records lacked analysis of infection control surveillance data including incidence or prevalence of infections and staff practices or other processes that may be modified to enhance infection prevention and minimize the potential for transmission of infections. - The infection preventionist, the DON, had not received training in infection control. 2. Care concerns a. On 12/6/12 at 6:50 a.m., resident #7 was observed as two CNAs, staff members K and O, provided assistance with activities of daily living. The staff assisted the resident with perianal cleansing after she had a bowel movement using a bedside commode. Staff member O was gloved and cleaned the resident's peri anal area. After cleaning the resident's peri anal area, staff member O continued with the following tasks without sanitizing her hands and changing gloves,? transferred the resident to the bedside using a sit to stand transfer device, removed the transfer sling, repositioned the resident to a supine position in bed, removed the resident's slippers, placed a pillow under the resident's lower legs, folded two bed blankets, and repositioned the privacy curtain. ? At t… | 2016-06-01 |
| 5545 | 5545 | CEDAR WOOD HEALTHCARE COMMUNITY | 275053 | 1 S OAKS | RED LODGE | MT | 59068 | 2011-06-09 | 323 | B | E2V311 | Based on observation and staff interview, the facility failed to ensure cognitively impaired residents had not left the building from the exit door at the end of the south hall when the alarm sounded. The door exited to a city street which was observed to be moderately busy with traffic. Findings include: 1. On 6/7/11 at 8:10 a.m., an elderly man was observed going out the south hallway door. The door alarm sounded. No staff members responded to the alarm sounding to determine if the person was a resident, staff, or visitor. At approximately 8:12 a.m., a male CNA turned off the alarm at the nurses' station but did not investigate to determine if a resident had left the building. 2. On 6/7/11 at 3:17 p.m. the south door alarm was noted to be sounding. The nurse working on the south hallway shut off the alarm. The nurse did not check to determine why the alarm was going off, or if a resident had exited through the south door. She shut off the alarm at the nurses's station and went back to work at the counter. At approximately 3:18 p.m., the south door alarm sounded again, and the nurse turned off the alarm without investigating to determine if a resident had left the building. 3. On 6/8/11 at 2:17 p.m., a visitor exited the building through the south hall door. The alarm sounded. At 2:20 p.m., a CNA exited a resident's room on the north hall, walked to the alarm system board, behind the nurses' station and turned the alarm off. She was not aware of who had exited and she did not investigate to see who had left the facility. | 2014-04-01 | ||
| 964 | 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… | 2020-09-01 |
| 965 | 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 | 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 | 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 | 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 | 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 | 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 | 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 | 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 | 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 showe… | 2020-09-01 |
| 974 | 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 … | 2020-09-01 |
| 975 | 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 e… | 2020-09-01 |
| 976 | 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 | 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,… | 2020-09-01 |
| 978 | 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. Dur… | 2020-09-01 |
| 979 | 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 | 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 | 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 … | 2020-09-01 |
| 982 | 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, an… | 2020-09-01 |
| 983 | 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… | 2020-09-01 |
| 984 | 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 v… | 2020-09-01 |
| 985 | 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 | 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 … | 2020-09-01 |
| 987 | 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 | 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 cou… | 2020-09-01 |
| 989 | 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 … | 2020-09-01 |
| 990 | 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 an… | 2020-09-01 |
| 991 | 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 | 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 glov… | 2020-09-01 |
| 993 | 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 ap… | 2020-09-01 |
| 994 | 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 investi… | 2020-09-01 |
| 995 | 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 Pr… | 2020-09-01 |
| 996 | 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… | 2020-09-01 |
| 997 | 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… | 2020-09-01 |
| 998 | 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 … | 2020-09-01 |
| 999 | 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 | 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… | 2020-09-01 |
| 1001 | 1001 | CLARK FORK VALLEY NURSING HOME | 275107 | 10 KRUGER RD | PLAINS | MT | 59859 | 2019-12-20 | 609 | D | 1 | 0 | WY2611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to identify and report a neglect incident to the State Survey Agency for 1 (#1) of 4 sampled residents. Findings include: During an interview on 12/20/19 at 2:55 p.m., staff member A stated she did not think resident #1 spilling coffee and sustaining 1st and 2nd [MEDICAL CONDITION] have been considered possible abuse or neglect. Staff member A stated, It was an accident, which was why she did not report it to the State Survey Agency. Review of the facility's reported incidents for the past three months showed the facility did not send an initial incident report to the State Survey Agency for resident #'s coffee spill with significant injury. Additionally, the facility did not report the results of their investigation to the State Survey Agency. | 2020-09-01 |
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CREATE TABLE [cms_MT] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );