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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2711 | 2711 | NORTHERN MONTANA CARE CENTER | 275112 | 24 13TH ST | HAVRE | MT | 59501 | 2015-03-26 | 441 | E | 0 | 1 | RGSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Lift Maintenance: During an observation on 03/24/15 at 7:29 a.m., staff member L, CNA, returned a sit to stand lift to the shower room on East Hall without cleansing the lift after resident care. The sit to stand lift had a medium sized brown stain on the right wheel base. During an observation on 03/24/15 at 1:08 p.m., staff member M, CNA, returned a sit to stand lift to the shower room on East Hall without cleansing the lift after resident care. The sit to stand lift had a medium sized brown stain on the right wheel base. During an observation on 03/24/15 at 2:06 p.m., staff member N, CNA, returned a sit to stand lift to the shower room on East Hall without cleansing the lift after resident care. The sit to stand lift had a medium sized brown stain on the right wheel base. During an observation on 03/24/15 at 2:30 p.m., staff member O, CNA, returned a sit to stand lift to the shower room on North Hall without cleansing the lift after resident care. During an observation on 03/25/15 at 10:23 a.m., staff member P, CNA, returned a sit to stand lift to the shower room on East Hall without washing the lift after resident care. The sit to stand lift had a medium sized brown stain on the right wheel base. During an interview on 03/25/15 at 1:03 p.m., staff member B, and staff member Q, Infection Control Nurses, stated the lifts should be washed with the purple top wipes after each resident contact. The slings that were used for the lifts were to be washed when visibly soiled. Review of the facility's policy on mechanical lifts indicated: III. Cleaning/Maintenance and Storage of Lifts: 2. Surface cleaning of lifts shall be conducted between each resident with attached sani-cloths. A complete cleaning will be performed nightly. Review of the facility's policy on CNA Night Shift Routines indicated: Wheelchair, Geri-Chairs, Walkers, Lifts and Commodes: Monday, Wednesday & Friday: Pod 1. Tuesday, Thursday and Saturday: Pod 2. Clean items with brush … | 2018-11-01 |
| 2887 | 2887 | PIONEER CARE AND REHABILITATION | 275124 | 200 N OREGON ST | DILLON | MT | 59725 | 2015-02-25 | 323 | D | 0 | 1 | 9YVE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Comprehensive Care Plan showed the resident had limited physical mobility relating to neurological deficits. The resident was also at risk for falls, had an unsteady gait, decreased muscle endurance and strength, perceptual and cognitive impairment, amputation, depression and severe anxiety. Interventions on the care plan included monitoring for evidence of complications related to immobility (e.g., contracture, redness, open areas, and venous stasis) and report as identified. The Interim Plan of Care, dated 11/27/14, showed under section 3, Mobility, resident #11 was a one person assist with a gait belt. During an observation on 2/24/15 at 11:45 a.m., resident #11 requested staff member K, CNA, to assist her to the toilet. At 11:51 a.m., staff member K washed her hands, put on clean gloves, and began to assist the resident to the toilet. Staff member K lifted the resident up and out of the wheelchair by pulling up on the resident's pants, which lifted the resident. The CNA used her own knee to push the resident back onto the toilet to a sitting position, after the resident's pants were removed. Several times the resident voiced difficulty holding herself up by using the grab bars next to the toilet. It was observed that the resident's grip on the bars was loose. A gait belt was not used during the transfer. At 11:53 a.m., staff member K used a gait belt to assist the resident from the toilet to the wheelchair. Based on observation and record review, the facility failed to ensure staff use a gait belt for transfer on 1 (#11) of 13 sampled residents. | 2018-08-01 |
| 5300 | 5300 | RIVERSIDE HEALTH CARE CENTER | 275126 | 1301 E BROADWAY | MISSOULA | MT | 59802 | 2011-11-09 | 514 | D | 0 | 1 | WOER11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/7/11 at 12:30 p.m., a review of the active medical chart was completed. The physician ordered, "[MEDICATION NAME] 1 mg tablet take one or two tablets every 4 hours if needed for agitation" on 7/13/10". It was printed with the order on the MAR to chart the amount of [MEDICATION NAME] given. It was documented on the MARs: -March, 2011 dosage was not documented 20 of 23 times the [MEDICATION NAME] was given; -July, 2011 dosage was not documented 2 of 2 times the [MEDICATION NAME] was given; and -October, 2011 dosage was not documented 5 of 8 times the [MEDICATION NAME] was given. The MARs lacked consistent documentation of whether [MEDICATION NAME] 1 mg or 2 mg was administered to resident #3. The back of the MARs for 3/11, 7,11 and 10/11 lacked documentation of the dosage. The physician ordered, "[MEDICATION NAME] 1 mg take one tablet four times daily if needed for anxiety," on 7/13/10. It was documented on the MARs: -March, 2011 [MEDICATION NAME] PRN was administered 21 times; -April, 2011 [MEDICATION NAME] PRN was administered 11 times; -July, 2011 [MEDICATION NAME] PRN was administered 2 times; -August, 2011 [MEDICATION NAME] PRN was administered 2 times; and -September 2011 [MEDICATION NAME] PRN was administered 2 times. There was no documentation provided regarding the rationale for administering the as needed [MEDICATION NAME]. The physician ordered, "Ambien 5 mg take one tablet or two tablets at bed time," on 5/28/10. It was printed with the order on the MAR to chart the amount [MEDICATION NAME]. It was documented on the MARs for 8/2011, 9/2011, 10/2011 and 11/2011 [MEDICATION NAME] administered nightly. The MARs lacked documentation of whether one tablet or two tablets were administered. On 11/8/11 at 10:00 a.m., the DON stated that nursing staff were to document if one or two tablets were administered for [MEDICATION NAME] resident #3. 2. Resident #2… | 2014-10-01 |
| 4945 | 4945 | LAUREL HEALTH & REHABILITATION CENTER | 275111 | 820 3RD AVE | LAUREL | MT | 59044 | 2012-04-12 | 514 | E | 0 | 1 | F7I011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. a. Resident #7 was admitted to the facility on [DATE]. Resident #7's MARs and TARs were reviewed for December 2011 through March 2012. The following medications and treatments did not have the required signatures of the licensed nurse who administered the medications or performed treatments: -12/24 and 12/30/11, [MEDICATION NAME] 2.5 mg/3 cc every six hours; -1/30/12, protein powder 1 scoop three times daily; -1/30, 2/27, Cal Dense Med Pass 60 cc three times daily; -1/30/12 at 6:00 p.m., acidophilus caps 240 mg twice a day; -1/1 - 1/6, 1/11/12, Pulse for [MEDICATION NAME] once a day; -1/11/12, [MEDICATION NAME] 125 mcg once a day; -1/2 and 1/11/12, [MEDICATION NAME] tablet once a day; -1/11/12, [MEDICATION NAME] 20 mg once a day; -1/11/12, multivitamin with minerals once a day; -1/28/12, [MEDICATION NAME] cream to bilateral lower extremities daily; -1/3, 1/4, 1/6, 1/14, 1/15, 2/1, 2/2, and 2/3, wound care to lower extremities; -1/3, 1/15, 2/2, 2/8, 2/20, and 3/30/12, wound care to right hip wound vac every three days; -1/14 and 1/28/12, check oxygen saturations every Saturday and as needed; and -1/29 - 1/31/12, left lower extremities apply [MEDICATION NAME] cream twice a day. b. Resident #7's meal monitor flow sheets were reviewed for December 2011 through March 2012. The following dates were missing documentation of the percentage of the meal eaten and drinks consumed: 1/8, 1/15, 1/20, 1/22, 1/23, 1/25, and 1/31/12. c. Resident #7's ADL Flow sheets were reviewed for December 2011 through March 2012. The following dates were missing documentation of the resident performance and staff help: 3/7 - 3/16, 3/18, 3/27, and 3/31/12. 2. a. Resident #8 was admitted to the facility on [DATE]. During the review of resident #8's medical record, the surveyor noted an admission physician order [REDACTED]. The Montana Provider Orders For Life-Sustaining Treatment (POLST) form signed by resident #8 on 4/3/12 code status was "Resuscitate (Full Code)." The … | 2015-06-01 |
| 5313 | 5313 | APPLE REHAB COONEY | 275080 | 2555 E BROADWAY | HELENA | MT | 59601 | 2011-09-29 | 441 | E | 0 | 1 | 1B8T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During observations on 9/26/11 at 3:40 p.m. to 5:25 p.m., staff member E picked up resident #20's roast beef sandwich with her gloved hand and held it in front of the resident's mouth, prompting her to take a bite. Staff member E then placed the sandwich back on resident #20's plate and went to resident #9. Staff member E picked up resident #9's spoon while using the same gloves, dipped from the resident's serving of fruit and prompted the resident to take a bite. The resident did not take a bite and staff replaced the spoon in resident #9's bowl of fruit and went to a tray of glasses. With the same gloved hand as she had used with residents #20 and #9, staff member E grasped the top of the glass of water. Staff took the glass of water to resident #10. 3. During observations on 9/27/11 between 10:25 a.m. to 10:30 a.m., clear tubing lay across the hall between rooms [ROOM NUMBERS]. A nasal cannula at the end of the tubing was on the floor. Staff member D picked up the tubing, winding it into a coil, and walked into resident #5's room. Staff member D unwound the coiled tubing and placed the nasal cannula around the head of resident #5 so that it fit into the resident's nostrils. During an interview with staff member D on 9/27/11 at 10:30 a.m., she indicated resident #10, who was laying in resident #5's roommate's bed, must have taken the nasal cannula off of resident #5 and carried it across the hall to room [ROOM NUMBER]. ?"Hands must be washed with antiseptic soap and water or alcohol-based handrub: 1. Before and after client contact and between clients. 2. After contact with a source of microorganisms. 3. After removing gloves. Before donning gloves. 4. After touching equipment or surfaces that may be contaminated." Smith, Sandra; Duell, Donna; Martin, Barbara; Clinical Nursing Skills, Basic to Advanced Skills; "Handwashing, Hand Antisepsis and Gloving CDC Recommendations." Sixth Edition; Pearson Education, Inc. copyright 2004. p. 383. Ba… | 2014-09-01 |
| 2995 | 2995 | LIVINGSTON HEALTH & REHABILITATION CENTER | 275047 | 510 S 14TH ST | LIVINGSTON | MT | 59047 | 2014-12-17 | 323 | D | 0 | 1 | GGEV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the facility's ADL care plan and Care Conference Summary for resident #12 reflected he was a total assist with two-plus persons physical assist, unable to make his needs known, incontinent of bowel and bladder, and required a mechanical lift for transfers. During an observation on 12/16/14 at 7:44 a.m., staff member H, CNA, repositioned resident #12 in his wheelchair by pulling the resident by the pants. During an observation on 12/16/14 at 9:01 a.m., staff members H and G, used a sit-to-stand lift to assist resident #12 into bed after breakfast. During the transfer, resident #12 was not able to bear weight and was transferred to the bed while dangling his arms in the sit-to-stand lift. During an observation on 12/16/14 at 5:11 p.m., staff members M and N, CNAs, transferred resident #12 from his bed to his wheelchair using the sit-to-stand lift. During an observation on 12/16/14 at 5:12 p.m., staff member N lifted resident #12 from under the residents arms to reposition him in the wheelchair. During an observation on 12/17/14 at 9:00 a.m., staff members H and G, used a hoyer sling for resident #8 on resident #12. Staff member H stated to staff member G, We need to use the hoyer on this one, (resident #12), he's not going to stand. During an observation on 12/17/14 at 9:07 a.m., staff members H and G crossed the leg straps for the hoyer transfer on resident #12. During an interview on 12/17/14 at 9:19 a.m., staff members L and K, physical therapist, stated resident #12 should use his own sling with the hoyer lift. Staff member K, stated the CNAs should have notified the nursing staff that resident #12 was no longer able to bear weight. Staff members L and K stated they would not have recommended the leg straps be crossed for resident #12, and PT would have provided an inservice on hoyer use specifically for resident #12. During an interview on 12/17/1… | 2018-05-01 |
| 2542 | 2542 | VALLEY VIEW ESTATES HEALTH & REHABILITATION | 275101 | 225 N 8TH ST | HAMILTON | MT | 59840 | 2015-10-22 | 441 | E | 0 | 1 | 01S411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #14 was readmitted to the facility with [DIAGNOSES REDACTED]. During an observation on 10/20/15 at 7:55 a.m., staff member W provided wound care to the resident's coccyx. The resident was lying in bed, on his left side. The staff member washed her hands, donned gloves and removed the foam dressing covering the coccyx. There was an open area to the resident's coccyx, the size of a fifty-cent coin, that had red beefy tissue to the wound bed. The wound margins were pink and thick. The upper right corner of the wound was a darker red. The staff member removed her gloves, did not wash or sanitize her hands, and donned clean gloves. The staff member used a 2x2 skin prep to wipe around the open wound bed, then applied a foam dressing. During an interview on 10/20/15 at 8:00 a.m., staff member W stated she did not wash or sanitize her hands prior to donning clean gloves because she did not touch the open area. 3. Resident #29 was readmitted to the facility with [DIAGNOSES REDACTED]. During an observation on 10/21/15 at 2:20 p.m., staff members O and II provided perineum care to the resident. Staff member O removed her gloves, did not wash or sanitize her hands, and provided oral care to the resident. The resident was resistant. During an interview on 10/21/15 at 2:30 p.m., staff member O stated she should have washed or sanitized her hands after removing her gloves. Based on observation, record review and interview, the facility failed to provide infection control measures during scabies treatment and environmental cleaning of the SCU on 7/28-7/29/15 and 10/16-10/17/15, which had the potential for causing additional scabies infections for the SCU residents and staff. On 10/16-10/17/15, the residents, after being treated and showered, with the exception of 1 (#16), were dressed in clothes taken directly out of their closets. The closet had not yet been sanitized, nor were their clothes freshly washed. Protective gowns were not worn by the … | 2019-02-01 |
| 5153 | 5153 | BENEFIS EXTENDED CARE CENTER | 275012 | 2621 15TH AVE S | GREAT FALLS | MT | 59405 | 2012-01-05 | 278 | D | 0 | 1 | TC7L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The surveyor observed resident #16 enter the facility on 1/4/12 at 7:20 a.m. independently in his wheelchair. Resident #16 had cigarettes and a lighter on his lap. The surveyor observed resident #16 return to the East Wing dining area and speak with staff member R. Resident #16 kept his cigarettes and lighter. During an interview on 1/4/12 at 8:00 a.m., staff member R stated that resident #16 kept his own cigarettes and lighters. She stated that resident #16 was supposed to sign in and out when he left the facility to smoke. She further stated that resident #16 did not always sign in and out like he had agreed upon. Staff member R stated she was not sure where he smoked outside. The surveyor observed resident #16 leave the facility without signing out or telling staff he was leaving, and went outside to smoke on 1/4/12 at 9:43 a.m. The surveyor was unable to locate a completed safe smoking assessment in the medical record during record review on 1/3/12. The admission MDS with an ARD of 4/29/11, section J1300, tobacco use, was coded 0 for No. The quarterly MDS with an ARD of 7/22/11, section J1300, tobacco use, was coded 1 for Yes. The MDS with an ARD of 10/17/11 section J1300, tobacco use, was coded 1 for Yes. The surveyor did find documentation on the plan of care that resident #16 had deformities of the hands, and that resident #16 needed to leave the campus to smoke due to the fact the facility was a non-smoking facility. During an interview on 1/4/12 at 11:15 a.m., with staff member I, she stated she created resident #16's smoking care plan that morning, along with his smoking assessment. Staff member I stated she did not actually perform the smoking assessment the morning of 1/4/12 but that she had seen resident #16 smoke before so she based the assessment on previous observations. The facility failed to ensure the accuracy of the MDS the staff member signe… | 2015-01-01 |
| 2279 | 2279 | POWDER RIVER MANOR | 275087 | 104 N TRAUTMAN | BROADUS | MT | 59317 | 2015-08-13 | 274 | D | 0 | 1 | NOZ311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During dining observations on 8/11/15 at 7:55 a.m., 8/12/15 at 7:45 a.m. and 11:45 a.m., and 8/13/15 at 7:30 a.m., staff was feeding resident #3. Review of his quarterly MDS, ARD 6/19/15, showed resident #3 needed only supervision and an assist of one staff while eating. Review of resident #3's care plan reflected it was updated on 7/30/15 to include: Hoyer lift transfer to bath chair and wash me. When my bed is in lowest position I will sometimes roll over and onto floor mat. I also have a mat beside bed to prevent injury if I should slide down from bed or fall by bed or roll OOB. I need to be hoyer lifted onto toilet or laid on bed to check and change attempt every 2 hours. Do not leave me alone on the toilet. Hoyer lift only- My strength and balance have declined after possible stroke and since I am so tall I am like dead weight trying to stand @ times. During an interview on 8/12/15 at 10:10 a.m., staff member D, MDS Coordinator, said that resident #3 was suspected to have had a stroke the last part of July. She also said, I have observed him the last couple of days, he is being fed completely. Staff member D also said that a significant change MDS should probably have been done since he is totally being fed and is now being transferred with a lift. Based on observation, interview and record review, the facility failed to complete a significant change MDS for 2 (#s 8 and 3) of 11 sampled residents. Findings include: 1. Resident #8 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Review of the quarterly MDS, with an ARD of 4/18/15, reflected resident #8 was cognitively intact, had minimal depression, no behaviors, required limited assistance with her activities of daily living, and had no weight loss or gain. Review of the annual MDS, with the ARD of 7/17/15, reflected resident #8 had extensive assist with her activities of daily living w… | 2019-06-01 |
| 2742 | 2742 | GLACIER CARE CENTER | 275104 | 707 3RD ST SE | CUT BANK | MT | 59427 | 2015-05-07 | 281 | E | 0 | 1 | GNJY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. During an observation and interview on 5/5/15 at 7:10 a.m., the resident was sitting on the side of the bed. The resident repositioned and with movement began to wince, and was holding the side of her body, and exhibited shortness of breath. The resident voiced not feeling well for the last few days, and was unable to sleep that night. The resident stated she was, miserable. The resident stated the nurse was aware of the concern and waiting for the doctor to return a call back with an order for [REDACTED]. The resident began to cough, and appeared to have trouble catching her breath. The resident stopped eating and removed herself from the dining room without finishing the meal. At 8:10 a.m., the resident was observed in the solarium. An oxygen concentrator was providing oxygen to the resident. On approach, the resident asked if the nurse had heard from the physician on the stronger pain medication. The nurse was notified of the resident's status and continued discomfort. During an interview on 5/5/15 at 8:15 a.m., staff member F, RN, stated the resident had not been feeling well for a couple of days. She stated she had given the resident Tylenol that morning and put [MEDICATION NAME] gel on the resident to assist with pain. The nurse was awaiting a physician's response for a stronger pain medication. She stated she would reassess the resident's pain at a later time. The nurse stated a specimen cup had been given to the resident a couple of days prior, but the resident had not returned the cup yet. Review of the resident's Interdisciplinary Progress Notes showed on 4/30/15 the nurse documented the resident believed she had another respiratory infection. The resident was complaining of a cough which At times was productive. A specimen cup was given to the resident for a sputum sample, and the provider was notified by facsimile. The progress notes failed to refl… | 2018-10-01 |
| 5184 | 5184 | FALLON MEDICAL COMPLEX N H | 275095 | 202 S 4TH ST W | BAKER | MT | 59313 | 2012-03-01 | 365 | D | 0 | 1 | JP7311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. A mechanical soft diet with thickened liquids PRN was prescribed by the physician on 10/18/11. During a meal observation on 2/29/12 at 12:15 p.m., the surveyor observed resident #6 with a glass of unthickened water and a glass of unthickened red liquid. Resident #6 received a meal of unaltered roast beef, potatoes, and spinach. A full pitcher of unthickened water was observed in resident #6's room on 2/29/12 at 2:40 p.m. During an interview on 12/29/12 at 2:45 p.m. with staff member D, a CNA, she stated resident #6 was ordered thickened liquids about 2 months ago, but pushed them away all the time. Staff member D stated she started with a spoonful of thickener until the liquid was about honey thick consistency. Staff member D stated the licensed nurse would inform the CNA staff during the shift reports if they were to thicken the liquids for resident #6. Staff member H was interviewed on 2/28/12 at 9:35 a.m. She stated the facility did not have therapeutic menus to follow. She said the RD was aware there were no menus to follow for therapeutic diets. During the kitchen tour on 2/28/12 at 9:25 a.m. with the DM, the preplanned menus were reviewed. Geriatric generalized diets reviewed on 5/11/2004 by an RD, were the only preplanned menus the facility had as guidance. The facility guidelines for dysphagia evaluations were reviewed. The guidelines indicated an evaluation and assessment of chewing and/or swallowing disorders were required to secure appropriate resident care and providing the correct " level of diet modification." The guidelines directed the facility to contact a speech therapist and/or the registered dietician if there was a concern regarding a resident's swallowing or chewing abilities. There was no documentation found for chewing or swallowing evaluations and/or assessments for either resident reviewed. Based on observation, record review and staff interview, … | 2015-01-01 |
| 2329 | 2329 | FRIENDSHIP VILLA | 275081 | 2300 WILSON | MILES CITY | MT | 59301 | 2015-08-13 | 176 | D | 0 | 1 | CILF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an observation on 8/13/15 at 8:00 a.m., staff member E, LPN, was providing medications to the residents seated in the dining room area. On 8/13/15 from 8:47 a.m. to 9:06 a.m., resident #8 was seated in the dining room area eating breakfast. A medication cup had been placed next to the resident's meal tray. The cup contained two oblong and one round tablet. No nurses were present in the dining area, two dietary aides were cleaning tables at the other end of the dining room. During an interview on 8/13/15 at 10:15 a.m., staff member E, stated resident #8 did not self-administer his own medications. The staff member also stated it was not customary to leave medications on the dining room table. A review of the resident's Self-Administration of Medications Assessment form dated 4/15/13 reflected the resident has short term memory loss. On the form, the signature line for the physician, nurse, care plan coordinator, and resident was blank. Based on record review and interview, the facility did not ensure self-medication administration assessments had been completed. Specifically, staff were not monitoring residents for taking their own medications for 2 (#s 8 & 12) of 13 sampled residents. Findings include: 1. Resident #12 was admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the resident's care plan, dated 7/27/15, reflected the resident may keep his inhaler at bedside and self administer as necessary. There was no other documentation in the care plan of self administering any other medications. Review of the resident's physician's orders [REDACTED].>-monitor self administration of medication; -[MEDICATION NAME] Diskus Aerosol Powder Breath Activated 100-50 mcg; -Aspirin tablet 81 mg; -[MEDICATION NAME] 1 drop in both eyes every morning and at bedtime for dry eyes, supervised self administration. There was no other evidence that the physician'… | 2019-05-01 |
| 3707 | 3707 | MOUNTAIN VIEW HEALTHCARE COMMUNITY | 275039 | 205 N TRACY AVE | BOZEMAN | MT | 59715 | 2014-06-19 | 241 | D | 0 | 1 | VSZ511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #8 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident's annual MDS with the ARD of 5/27/14 indicated resident #8 needed extensive assistance with eating. During a breakfast observation on 6/17/14, resident #8 was wearing a clothing protector that was covered in coffee. She was observed to have spilt coffee from her mouth while she was drinking. An observation was made during this time, that Resident #8 had plastic spoons on the table while other residents in the dining room had regular utensils. In an interview on 6/17/14 at 8:45 a.m., a CNA, who was working in the dining room, stated she did not know why resident #8 used plastic spoons, but she could find out. She also reported that resident #8 used two clothing protectors to keep her clothes clean. During observations on 6/18/14 at breakfast and dinner, and on 6/19/14 at breakfast, resident #8's clothing protector was covered in coffee and she was eating with plastic spoons. In an interview on 6/19/14 at 12:50 p.m., Staff member D, unit manager/MDS nurse, reported resident #8 had been in the facility for a long time. Staff member D stated she did not know the reason the resident used plastic spoons. She was not aware of any interventions to prevent resident #8 from spilling coffee from her mouth or for alternatives to plastic spoons. When asked if she liked coffee, Resident #8, who was nonverbal, responded with a nod of her head. In an interview on 6/19/14 at 1:30 p.m., staff members E and G, CNA and Restorative Aid, reported they had not tried any interventions to prevent resident #8 from spilling her coffee and that she did use two clothing protectors. After resident #8's care conference on 6/19/14 at 1:00 p.m., staff member D stated resident #8's daughter reported her mother used the spoons because of teeth clenching and grinding. In an interview on 6/18/14 at 3:30 p.m., Staff member F, CNA, reported she knew resident #8 for 8 years and had not… | 2017-05-01 |
| 2959 | 2959 | MONTANA VETERANS HOME N H | 275100 | 400 VETERANS DR | COLUMBIA FALLS | MT | 59912 | 2014-08-28 | 225 | E | 0 | 1 | GLQ711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of the facility reported incidents from 8/15/13-8/12/14 revealed 16 of the 42 reports involved residents money that was missing. Fourteen of the reports lacked a 5-day follow-up showing a thorough investigation. Six of the reports were reported to the local authorities. There was no evidence that the facility had conducted an internal investigation to see if abuse had occurred and if the money was recovered. Further review of the reports revealed 12 incidents that lacked the results of thorough investigations, if abuse had occurred, and corrective action if needed. Specifically, two reports involved staff to resident allegations of abuse. Staff member C, Social Services Director, was interviewed on 8/28/14 at 9:05 a.m. She stated that in regards to one of the incidents involving an employee and resident, which was suspected abuse, a 5 day follow-up was not sent in to the SA. She also stated that she was unaware that the required 5 day follow-up report needed to address what corrective action would be taken to protect the residents. The Abuse-Resident policy, under Procedure IV. Investigation, read, .3. The investigator will be responsible to interview and obtain signed statements from all people involved in the incident. 4. The investigator will complete the attached Abuse Report & Investigation form and discuss his/her findings with the Superintendent and the Director of Nursing prior to a final determination that abuse did or did not occur. The investigator will copy all material obtained during the investigation including the Abuse Report & Investigation form and mail them to the Certification Bureau . Based on record review and staff interviews, the facility failed to thoroughly investigate two injuries of unknown origin for 2 (#'s 4 and 5) of 27 sampled residents and failed to report to the state agency within 5 days the results of all investigations and, if verified, appropriate corrective action that was taken. Findings inc… | 2018-07-01 |
| 4708 | 4708 | POWDER RIVER MANOR | 275087 | 104 N TRAUTMAN | BROADUS | MT | 59317 | 2012-07-19 | 323 | E | 0 | 1 | R8NT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #2 was admitted on [DATE] with the [DIAGNOSES REDACTED]. On 2/13/2012, resident #2 was assessed by her MD's PA-C for pain in her knee from gout. On 2/24/2012, her care plan was amended as follows Staff will reposition her or give her hot packs when she appears to be in pain (furrowed brow, loud sing/mumble, guarding, etc.) prior to giving PRN med. On 2/29/2012, the physical therapy notes stated Mo. (monthly) summary: Res (resident) continues to show signs of pain in B (both) knees. Mst (moist) ht (hot) pk (pack) being used when res is singing loudly. Res does quiet down & sleep p (after) ht pk is used. The record review for resident #2 resulted in an absence of doctor's/PT orders for the hot pack treatments and an absence of instructions for the restorative CNA for the safe use of the Hydrocollator. 4. The Hydrocollator hot pack unit was in the therapy room at the end of 100 hall. On 7/17/12 at 9:10 a.m. to 10:00 a.m. and 7/18/12 from 8:45 a.m. to 9:30 a.m., staff member G, the restorative CNA conducted an exercise class for 11 of 25 residents in the activity room. The activity room was approximately 140 feet from the therapy room and outside the direct line of vision. The therapy room was unattended and unlocked. Multiple times throughout the survey, the Hydrocollator unit was left unattended and unsecured in the therapy room. Resident #3 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. A significant change MDS assessment was completed with an ARD of 3/8/12. The resident was assessed with [REDACTED]. The resident was observed wandering throughout the day on all days of the survey. Based on clinical record review, observations, and staff interviews, the use of a Hydrocollator heat application presented an accident hazard for 3 (#s 2, 3, and 8) of 10 sampled residents. Findings included: 1. During the initial facility tour on 7/16/12 at 3:15 p.m., a Hydrocollator hot pack treatment unit was noted in the therapy service… | 2015-10-01 |
| 2748 | 2748 | GLACIER CARE CENTER | 275104 | 707 3RD ST SE | CUT BANK | MT | 59427 | 2015-05-07 | 514 | D | 0 | 1 | GNJY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #2 was re-admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the nursing progress notes reflected the resident had a fall on 11/25/14, 11/17/14, 10/22/14, 10/1/14, 8/6/14, and 8/4/14. There was no documentation in the nursing notes that the family was notified of the fall. The notification of the falls were documented on the incident reports, which were not part of the resident's permanent clinical record. Further review showed that the clinical record lacked evidence for the nursing assessment completed after the falls on 11/25/14, 11/17/14, 10/1/14, and 8/3/14. The nursing assessments were documented on the facility incident reports, which were not part of the resident's permanent clinical record. During an interview on 5/6/15 at 3:15 p.m., staff member B, DON, stated the nursing assessment and notification of family should be documented in the medical record. Staff member B stated it would be prudent to include that information in the medical record. During an interview on 5/7/15 at 9:08 a.m., staff member D, care manager, stated when a resident fell , the resident was assessed before moving the resident. The family was always notified and the incident was documented on a nursing progress note (SBAR). Staff member D stated the assessment and notification of family should be put in SBAR in the progress note. Based on record review, interview and observation, the facility failed to maintain a complete and accurate clinical record for a resident who had pain for one (#10); failed to document the completion of physician ordered skin treatments for one (#6); and failed to include the documentation for nursing fall assessments and notification of the family in the clinical record for one (#2) out of 10 sampled residents. Findings include: 1. Resident #10 was admitted to the facility on [DATE]. A review of the resident's clinical record lacked evidence that the facility requested physician ordered intervention… | 2018-10-01 |
| 4446 | 4446 | APPLE REHAB COONEY | 275080 | 2555 E BROADWAY | HELENA | MT | 59601 | 2013-10-31 | 241 | E | 0 | 1 | 28X211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During the initial tour on 10/7/13 at 8:03 a.m. in room [ROOM NUMBER], there was a sign posted on the inside of the door to resident # 4's room. The door was open to the hallway and the sign was visible. The sign had a large circle with a line at an angle over the large word STOP. Under the circle the sign had the following documented: Please check OC (oral care), Hair, Shave. When the surveyor and unit manager walked into Resident #4's room, there was another sign posted in the room. The resident's bed was against the wall and above the bed, there was a sign posted on the wall with the following information displayed: DX (diagnosis) [MEDICAL CONDITION], L side weakness, Hoyer Lift. Observation of the room on 10/22/13 revealed that the DX [MEDICAL CONDITION] had been peeled off the sign above the resident's bed. Observation of the room on 10/23/13 revealed both signs had been removed from the room and door. 4. Resident #7 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. According to the MDS assessment dated [DATE], resident #7 had a BIMS score of 9 showing she was moderately impaired in cognition. The resident's MDS showed the resident needed extensive 2+ person assistance with most activities of daily living, including bed mobility and transfers. On 10/21/13 at 12:20 p.m. the surveyor observed a sign in the resident's room posted on the wall by the door that stated Dx: Fall, confusion - ok to be up on own with walker. On 10/22/13, at the end of day the meeting with surveyors, staff member A, administrator and staff member B, DON, were informed of the signs found in residents' rooms. On 10/24/13 at 5:23 p.m. staff member V, LPN, was interviewed about the sign in resident #7's room. The LPN stated the signs, Had the transfer status and weight bearing status for staff who did not work often. On 10/29/2013 the sign for resident #7 was no … | 2016-03-01 |
| 4657 | 4657 | FRIENDSHIP VILLA HEALTHCARE COMMUNITY | 275081 | 2300 WILSON | MILES CITY | MT | 59301 | 2012-05-24 | 176 | E | 0 | 1 | 16V911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #6 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's record included a blank, undated Self-Administration of Medication Assessment Form, as well as a 5/11/12 Physician order [REDACTED]. Resident keeps in locked box in room. During an interview with staff member C, the assistant DON, on 5/23/12 at 3 p.m., staff member C indicated she had gone into the resident's room; the [MEDICATION NAME] box was in the resident's room, but the resident did not want to talk, so she could not get the resident's permission to find the lock box. Staff member C indicated that the self medication assessment was in the chart but not filled out and confirmed the physician's orders [REDACTED]. The nurses were not sure if he actually had the inhaler in his room. Without the resident's cooperation, there was no method in place for the nurses to know if and when the resident used the inhaler. There was no method in place to document when he used the inhaler. Based on observation, record review, and staff interview, the facility failed to ensure that 3 (#s 6, 18, and 19) of 15 sampled and 6 supplemental residents had been determined safe to self-administer medications by the interdisciplinary team. Findings include: 1. During the medication administration observation on 5/22/12 at 8:00 a.m., staff member E, a nurse, was observed administering medications. The staff member administered the medications for resident #19 into the medication cup. The nurse took the medications to resident #19, handed the resident the medication cup, then the nurse returned to the medication cart. The nurse began administering medications for the next resident, which was resident #18. The nurse administered resident #18's medications into the medication cup, handed the resident the medication, and returned to the medication cart. The nurse left the dining room. At 8:40 a.m., resident #18 was noted to take the medications. The nurse was obse… | 2015-11-01 |
| 4998 | 4998 | BUTTE CENTER | 275103 | 2400 CONTINENTAL DR | BUTTE | MT | 59701 | 2012-03-01 | 246 | E | 0 | 1 | R2W611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A PEG tube was in place on admission. The PEG tube was removed on 2/2/12. On 2/27/12 at 2:30 p.m., review of the medical record for resident #7 was completed. The nutrition assessment, Review of Food Preferences Interview, dated 11/29/11, indicated under food allergies [REDACTED]. The rest of the form was blank. On 2/24/12, staff member U, a speech-language pathologist noted that as of 1/16/12, "Pt has been on regular texture and patient continues to receive ground meat from the kitchen." On 2/28/12 at 3:00 p.m., a review of the Food preference policy stated: "The Nutrition Service Director/or Designees, visits residents within 24 hours of admission, and completes the Food Preferences Interview." On 02/29/12 at 8 a.m., resident #7 was sitting in the in the temporary C-wing dining room with 3 remaining residents. Two pieces of toast and one poached egg were on resident #7's plate. Resident #7 stated that the eggs were good, but he can't eat them, because it is difficult for him to cut them up. Resident #7 stated he'd like help cutting up his food. Staff member R, entered the dining room and when asked, assisted resident #7 by cutting up his food. Resident #7 then began eating his food. At 8:25 a.m., the dining room was empty of residents. Resident #7 left 1/2 of a piece of toast on his plate. Based on observations, record review, and staff interviews, the facility staff did not provide reasonable accommodations of individual needs for 3 (#s 7, 28, and 27) of 30 sampled residents. Findings include: 1. On 2/28/12 at 4:00 p.m., resident #27 was hollering "help, help, help", on the C hall. Resident #27's room was the last room on the C hall. The surveyor observed CNAs on the C hall. The surveyor asked staff member S, a CNA, to see what resident #27 wanted. Staff member S stated resident #27 "always hollers for help. She cannot use her call light because her hands were… | 2015-05-01 |
| 5446 | 5446 | BUTTE CENTER | 275103 | 2400 CONTINENTAL DR | BUTTE | MT | 59701 | 2011-04-28 | 281 | E | 1 | 1 | QJ0811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. At 10:45 a.m., on 4/26/11, staff member R, a CNA, wheeled resident #15 into the sunroom. There was an oxygen tank attached to the back of the wheelchair. The oxygen tank was turned off and the tubing was wrapped around the tank on the back of the chair. The surveyor observed the CNAs going in and out of the room for 15 minutes; at which time the surveyor approached staff member S, an LPN, and requested an O2 sat on the resident. The resident's O2 sat was taken and registered at 73%. Staff member S then turned on the oxygen tank and applied the nasal cannula for the resident to receive oxygen. Resident #15's medical record was reviewed. The physician order, dated 8/3/2010, documented, "O2 at 2 lpm per nasal cannula continuously - Every Shift Everyday." The physician's orders [REDACTED]. 5. At 2:00 p.m., on 4/26/11, resident #21 was observed sitting next to staff member S in the dining area. The resident had an oxygen tank on the back of her wheelchair and the nasal cannula was in place. The surveyor observed the oxygen tank was empty. The surveyor requested an O2 sat on the resident. The resident's O2 sat was 84%. Staff member C replaced the empty oxygen tank for a full tank. Resident #21's medical record was reviewed. The physician order, dated 4/9/2010, documented, "Oxygen by nc to keep O2 sat >90% - Every Shift Everyday." The physician's orders [REDACTED]. 6. At 2:20 p.m., on 4/26/11, resident #14 was observed lying in bed. An oxygen machine was next to the bed, turned off, with the tubing in a plastic bag. Resident #14 had not been observed with O2, at anytime during the survey week. Resident #14's medical record was reviewed. The physician order, dated 1/26/11, documented, "O2 at 2 lpm per nc continuously - Every Shift Everyday." The physician's orders [REDACTED]. Staff member C stated that she was aware the resident had not been on O2. She stated she thought resident #14's oxygen order had been discontinued. She later stated she had m… | 2014-08-01 |
| 5211 | 5211 | MISSOURI RIVER CENTER | 275026 | 1130 17TH AVE S | GREAT FALLS | MT | 59405 | 2011-08-18 | 425 | E | 0 | 1 | RPQL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During the 400 wing medication storage room inspection conducted on 8/16/11 at 10:45 a.m., the following opened and undated multi-dose vials were found: 1 bottle of lorazepam oral concentrate with manufacturer's instructions to "Discard opened bottle after 90 days.", and 1 vial of PPD with manufacturer's instructions "Once entered, vial should be discarded after 30 days." When interviewed, staff member R, an LPN, verified the vial, bottle, and outer packing for both items lacked an open date. ?According to Documentation and Reimbursement for Long-Term Care by Ella James, " The content of the order should be accurate and complete. It should reflect the medication and treatment needed, including the reason or [DIAGNOSES REDACTED]. " Documentation and Reimbursement for Long-Term Care. James, Ella. American Health Information Management Association, Chicago, Illinois, 2004. pg. 213. Based on observation, clinical record review and staff interview, the facility failed to ensure medication orders were complete and accurate and contained a reason or [DIAGNOSES REDACTED].? for 3 (#s 12, 22, and 29) of 29 residents. In addition, the facility failed to provide pharmaceutical services addressing the dating of opened multi-dose vials from the active stock. Findings include: 1. On 6/13/11, Celebrex (Celecoxib) 200 mg daily was ordered by staff member P for resident #29. The order as written was for twice a day. On 6/13/11 at noon, the nurse documented in the IDPN, " N.O. - Celebrex 200 mg daily. " The order was transcribed onto the MAR indicated [REDACTED]. On 6/18/11, the MAR indicated [REDACTED]. But, there was no order for the change and no documentation that the physician had been informed the Celebrex had not been given twice a day for five days. 2. On 3/3/11, the physician wrote an order for [REDACTED]." This was handwritten on the March, 2011 MAR indicated [REDACTED]." This transcription disregarded the instruction to try Benadryl for three nigh… | 2014-12-01 |
| 4282 | 4282 | CENTRAL MONTANA NURSING & REHABILITATION CENTER | 275064 | 408 WENDELL AVE | LEWISTOWN | MT | 59457 | 2013-01-04 | 431 | E | 0 | 1 | SFGE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 1/2/13 at 5:30 p.m., a medication cart located at the nurses' station was be unlocked and unattended. The surveyor was able to open the medication drawers. The surveyor located staff member F, the DON, in the treatment room and had her check the medication cart. The DON also found the cart to be unlocked and unattended. She then requested that staff member N, the LPN in charge of the cart, return to the cart and reminded her that she needed to keep the cart locked. Staff member N said, I was only going to be away from it for a few minutes. 5. On 1/3/13 at 8:17 a.m., the surveyor walked up to a medication cart located near the dining room. The cart was unlocked and unattended. This surveyor was able to open the medication storage compartments. A few minutes later, staff member O, the RN in charge of the cart, returned to the cart and locked it. This surveyor questioned staff member O on the policy regarding locking the medication cart. She said, I try to always keep it locked, but sometimes I forget. Based on observation, policy review, and staff interview, the facility failed to store drugs in a safe manner for 5 of 5 observations. Findings include: 1. On 1/3/13 at approximately 6:45 a.m., staff member P left 2 syringes pre-filled with insulin, which were labeled with the residents' names, on top of the medication cart unattended, while she went into a resident's room to check the placement of a Fentanyl patch. The syringes were left unattended for approximately 5 minutes. 2. On 1/2/13 at 5:20 p.m., staff member N was passing medications to residents in the dining room. The medication cart was parked in the hallway by the dining room and was observed by the surveyor to be unlocked. Medication drawers were opened by the surveyor. When staff member N returned to the cart, the surveyor asked if the carts with key pads locked automatically. Staff member N said no, you have to lock it, and then pushed in the knob to lock it, and stated that … | 2016-06-01 |
| 4578 | 4578 | MISSOURI RIVER CENTER | 275026 | 1130 17TH AVE S | GREAT FALLS | MT | 59405 | 2012-08-30 | 241 | E | 0 | 1 | M8XB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 8/28/12 at 8:07 a.m. and again on 8/29/2012 at 8:15 a.m., a surveyor observed staff members A, B and C sitting at the dining table with residents. Two of the 3 staff were helping to feed 10 residents. The 3 staff members discussed personal aspects of their day and family issues. The residents were not included in the conversations, nor was it observed that the residents were encouraged to contribute to the conversations. Based on observation, record review, and staff and family interview, the facility failed to maintain and enhance each resident's dignity and respect for 18 (# 15, 15 residents in the secure unit and 2 unidentified residents in the main dining room) of 31 sampled and supplemental residents. Findings include: 1. Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. An interview was conducted with resident #15's daughter at 4:00 p.m. on 8/28/12. She was concerned that staff failed to shave her mother regularly, as she currently had a few hairs on her chin exceeding one inch in length. She stated that if her mother knew about it that she would not approve of that. 3. On 8/28/12 at 8:35 a.m., in the main dining room, the surveyor observed two CNAs standing while helping to feed two residents. 2. On 8/28/12 at 8:30 a.m., during the medication pass on the secure unit, the surveyor observed 4 staff members assisting 4 to 5 residents with breakfast. The staff members were discussing a co-worker's wedding plans. One of the staff members turned her back to the resident she was assisting and talked with another co-worker about her wedding plans. The staff members were talking over the residents' heads and not trying to include them in the discussion. | 2015-12-01 |
| 3420 | 3420 | GLENDIVE MEDICAL CENTER N H | 275067 | 202 PROSPECT DR | GLENDIVE | MT | 59330 | 2014-02-27 | 323 | E | 0 | 1 | KGXL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident # 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS, section G, with an ARD of 1/28/14 indicated that resident # 5 required extensive assist of 1 staff member for transfers, dressing, and hygiene. On 2/25/14 at 10:55 a.m., the surveyor observed staff member I assist resident # 5 with her bath. Staff member I transferred resident # 5 with a sit-to-stand lift from the shower chair to her wheelchair. Staff member I positioned resident # 5 over her wheelchair. Staff member I did not apply the lift brake or the wheelchair breaks. Staff member I leaned over while operating the lift, and held one side of the wheelchair as she lowered the resident into it. ?According to Basic Skills for Nursing Assistants in Long-Term Care By Sorrentino and Gorek, the procedure for transferring a person using a mechanical lift the aide needs to, .18. Lock the lift wheels in position . Sorrentino, Sheila & Gorek, Bernie, (2005). Basic Skills for Nursing Assistants in Long-Term Care St. Louis: Elsevier Mosby. Based on observations, staff interview and record review, the facility failed to ensure that staff locked the brakes on lifts and wheel chairs while transferring 3 (#s 5, 7, and 15) of 16 sampled and supplemental residents.? Findings include: 1. Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS with an ARD of 2/4/14 was reviewed. Documentation in section G of the MDS indicated resident #15 required extensive assist of 1 staff member for transfers, dressing, and hygiene. On 2/25/14 at 1:35 p.m, surveyor observed staff members D and E transfer resident #15 from the wheel chair to the toilet using a mechanical lift. Staff members D and E secured resident #15's legs in the lift, locked the wheel chair brakes, lifted resident #15 off the wheel chair and then transferred her to the toilet. The brakes were not in the locked position on the lift while lifting resident #15 up from th… | 2017-09-01 |
| 2539 | 2539 | VALLEY VIEW ESTATES HEALTH & REHABILITATION | 275101 | 225 N 8TH ST | HAMILTON | MT | 59840 | 2015-10-22 | 323 | E | 0 | 1 | 01S411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #10 was readmitted to the facility with [DIAGNOSES REDACTED]. A review of the resident's Admission MDS, with an ARD of 9/15/15, showed the resident had a BIMS of 13, cognitively intact. The resident required extensive assistance with transfers, dressing, and was a 2+ person physical assist. The resident had functional limitations in range of motion to both lower extremities. A review of physical therapy notes, dated 9/1/15, reflected the resident had an exacerbation of decrease in functional mobility, decrease in transfers, decrease in range of motion. In the Balance section of the evaluation, the notes reflected the resident was unable to stand and was totally dependent on staff for transfers. A review of occupational therapy notes, dated 9/2/15, reflected the resident was unable to stand and had not stood for more than 2 years. In the Balance section of the evaluation, the notes reflected the resident was unable to stand and was totally dependent on the staff for ADLs. During an observation on 10/19/15 at 2:25 p.m., staff member H attempted to transfer resident #10 from the wheelchair to the toilet using a Hoyer lift. The resident informed staff member H that she did not use a Hoyer lift and was unsure of which mechanical lift the staff used. The staff member returned to the resident's room with an EZ lift. During an observation on 10/19/15 at 2:31 p.m., staff member H, transferred the resident from the wheelchair to the toilet using a sit to stand EZ lift. The safety strap to the harness was not buckled. The resident's wheelchair brakes were not locked. The resident's lower extremities were swollen and her right foot was turned inward at the ankle. The resident was unable to stand or put any weight on her right foot. The resident hollered out in pain that the sling was hurting her armpits. The staff member continued with the transfer. The resident was transferred while dangling from the lift sling during the transfer. During an… | 2019-02-01 |
| 5309 | 5309 | APPLE REHAB COONEY | 275080 | 2555 E BROADWAY | HELENA | MT | 59601 | 2011-09-29 | 272 | B | 0 | 1 | 1B8T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #6 was admitted [DATE]. Her [DIAGNOSES REDACTED]. A Significant Change in Status MDS with an ARD of 7/01/11 did not contain CAAs for Nutritional Status (12) and Psychological Well-Being (7), although both were triggered. Based on record reviews, the facility failed to complete section V with location and date of information used and complete all triggered CAAs for 4 (#s 1, 6, 11 and 12) of 14 residents reviewed. Findings include: 1. Resident #1 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. An annual MDS with an ARD of 11/2/10 was not complete. ADL Function/Rehabilitation Potential (5), Urinary Incontinence and Indwelling Catcher (6), Falls (11), Nutritional Status (12), Pressure Ulcer (16) and [MEDICAL CONDITION] Drug Use (17) were among the triggered Care areas in Section V. The location and date of CAA information was not documented for care areas 5, 6, 11, 12, 16 and 17. CAAs were not available for care areas 5, 6, 11, 12, 16 and 17. 2. Resident #12 had an Annual MDS assessment with an ARD of 3/8/11 completed. Section V did not contain the dates of the information used to determine if issues needed to be addressed on the care plan for the following triggered CAAs: Cognitive Loss/Dementia (2), Visual Function (3), Behavioral Symptoms (9), Nutritional Status (12), and [MEDICAL CONDITION] Drug Use (17). The Nutritional Status CAA was triggered, but a CAA was not completed. 3. Resident #11 had a Significant Change in Status MDS assessment with an ARD of 10/10/10 completed. Section V did not contain the date of the information used to determine if issues needed to be addressed on the care plan for the following CAAs that were triggered: Falls (11) and Nutritional Status (12). The CAAs that were triggered were not all completed with the MDS. The CAAs for Cognitive Loss/Dementia (2), Visual Function (3), and Communication (4) were the only CAAs in the record. The CAAs for ADL Functional/Rehab Potential (5), Urinary… | 2014-09-01 |
| 4580 | 4580 | MISSOURI RIVER CENTER | 275026 | 1130 17TH AVE S | GREAT FALLS | MT | 59405 | 2012-08-30 | 281 | E | 0 | 1 | M8XB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #7 was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the diet orders dated 7/20/12 and the physician's orders [REDACTED].#7 was to get large portions on plastic plates, his food textures were to be pureed, and fluid consistency was to be honey thick. At 5:15 p.m. on 8/27/2012, a meal tray was brought to the resident's room. The juice glasses contained juice and were not mixed to a honey fluid consistency. 5. Resident #15 was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the Medical Nutrition Therapy assessment dated [DATE] stated that the resident had dysphagia and should receive house puree and honey liquids. During an interview at 6:00 p.m. on 8/27/2012, a family member discovered that a dietary person had given a non-pureed plate of food to her mother. The family member reminded the dietary staff that her mother had dysphagia and could choke on such a meal. At 4:00 p.m. on 8/28/12, an interview was conducted with the daughter of resident #15. She stated that on the weekend (8/25/12), she checked on her mother. Her mother was attending an activity. Her mother had received two cookies from an activities attendant and her mother was choking on them when she arrived. She also stated that her mother had received a plate of food for dinner on 8/27/12, which was not pureed, but was cut-up. Her mother was choking on the food again. She stated that her mother also received glasses of juice which were not honey thick in consistency. Based on observation, record review, resident and staff interviews, the facility failed to follow professional standards for physician orders? for 6 (#s 3, 4, 7, 15, 20, and 24) of 24 residents reviewed. Findings included: 1. Resident #3 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. a. On 8/30/12 at 7:15 a.m., the surveyor reviewed the narcotic count book for resident #3. The su… | 2015-12-01 |
| 5523 | 5523 | MONTANA MENTAL HEALTH NURSING HOME | 27A052 | 800 CASINO CREEK DR | LEWISTOWN | MT | 59457 | 2011-01-06 | 281 | E | 0 | 1 | 9QDJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident #10 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. The resident resided on the locked unit; she had a history of [REDACTED]. According to review of nurses' notes between 8/15/10 - 1/1/11, the resident experienced 11 falls or accidents (8/19/10, 8/22/10, 9/13/10, 9/17/10, 9/19/10, 9/24/10, 11/13/10, 11/17/10, 12/5/10, 12/29/10 and 12/31/10). The facility administrative staff members were asked for neuro signs checks for the resident during the time frame specified above on 1/4/11 at 4:00 p.m. and again at the exit conference on 1/6/11 at 11:15 a.m. Neuro signs checks were not provided for the following accidents documented in the nurses' notes: --8/19/10 at 5:45 p.m., the resident was found laying on the floor in a different resident's room next to the recliner with the chair flipped forward. --8/22/10 at 3:15 p.m., the resident was found on the floor in her room. There were no witnesses to the fall. --12/29/10 at 7:50 p.m., the resident was observed to walk into the door frame and hit the side of her face. See F323 for more information regarding the failure to provide supervision and assistive devices to prevent accidents. 4. The DON, staff member J, was interviewed on 1/4/11 at 4:45 p.m. and stated the facility conducted training on neurochecks in October 2010 because they were not being completed consistently. ? Urdan, L. D., Stacy, K.M., & Lough, M.E. (2006) . Thelan's critical care nursing: [DIAGNOSES REDACTED].). St. Louis, Missouri : Mosby Elsevier. pg 727. ?Manual of Nursing Practice 8th Edition. Lippincott, Williams & Wilkins, 2006. pp. 1142 - 1148. ?Burrell, Gerlach, Pless. Nursing Management of Adults With Crisis Problems. Chapter 75, pp. 2082-2083 Based on record review and staff interview, the facility staff failed to ensure that professional standards were followed concerning completion of neurological assessments after a fall with injury to the head or with unwitnessed falls for 3 (#s 6, 10 and 12) of … | 2014-06-01 |
| 5223 | 5223 | VILLAGE HEALTH CARE CENTER | 275043 | 2651 SOUTH AVE W | MISSOULA | MT | 59804 | 2011-11-22 | 441 | E | 0 | 1 | N1KG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. The surveyor observed staff members B and C on 11/22/11 at 8:05 a.m., provide peri care for resident #34. Both staff members washed their hands and put on gloves. Staff member B removed resident #34's soiled brief and cleansed her peri area. Staff member B opened the dresser drawer, closed the drawer, and walked over to the closet and obtained the [MEDICATION NAME]. Staff member B then removed her gloves and used hand sanitizer. Staff member C applied the [MEDICATION NAME] to resident #34's buttocks and placed a new brief. Staff member C, without removing her gloves, pulled resident #34's pants up. Staff member C then removed her gloves and washed her hands. 6. The surveyor observed staff members B and J provide care to resident #6 on 11/21/11 at 11:30 a.m. Staff members B and J were observed changing an incontinence brief, applying ointment, and using a lift to get resident #6 up in his wheelchair. Staff member B was observed applying ointment to resident #6's coccyx. Staff member B then removed her gloves and put on a new pair of gloves without sanitizing or washing her hands between the glove change. Based on observations, policy review, and staff interview, the facility failed to implement measures to minimize the risk for the development and transmission of disease and infection for 5 (#s 6, 31, 32, 33, and 34) of 34 sampled residents. Findings include: 1. On 11/21/11 at 7:50 a.m., the surveyor observed staff member R put on gloves, listen to resident #33's lung sounds, set up the machine for the breathing treatment, check the resident's pulse, and turn on the machine. The machine was unplugged from the wall, so staff member R plugged the machine in and turned on the machine. Staff member R took off her gloves, talked with resident #33 and adjusted the breathing treatment mask. Staff member R did not wash/sanitize her hands after removing her gloves. 2. On 11/21/11 at 10:40 a.m., the surveyor observed staff member P enter resident #31… | 2014-12-01 |
| 5067 | 5067 | MISSOURI RIVER MEDICAL CENTER N H | 275062 | 1501 SAINT CHARLES ST | FORT BENTON | MT | 59442 | 2011-12-08 | 281 | E | 0 | 1 | 7BNM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. On 5/12/08 resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. During record review, the surveyor noted the following orders on the computer generated physician's orders [REDACTED]. -"[MEDICATION NAME] 325 mg-50 mg-40 mg PO PRN; -[MEDICATION NAME] 650 mg-100 mg-80 mg PO PRN; -Milk of Magnesia 30 cc PO PRN; -APAP 650 mg PO PRN; -Tums 1000 mg PO PRN; -[MEDICATION NAME] 0.5 mg PO PRN; and -[MEDICATION NAME] Topical 0.1% TOP PRN."? The above physician orders [REDACTED]. 7. On 5/29/07 resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. During record review, the surveyor noted the following orders on the computer generated physician's orders [REDACTED]. -"Milk of Magnesia 30 cc PO PRN; -Tylenol 650 mg PO PRN; -[MEDICATION NAME] 30 cc PO PRN; -[MEDICATION NAME] 0.5 mg PO PRN; -[MEDICATION NAME] 0.25 mg PO PRN; and -Immodium A-D 2 mg PO PRN."? The above physician orders [REDACTED]. 8. On 8/25/11 resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. During record review, the surveyor noted the following orders on the computer generated physician's orders [REDACTED]. -"Milk of Magnesia 30 cc PO PRN; -[MEDICATION NAME] laxative 10 mg REC PRN; -APAP 650 mg PO PRN; -[MEDICATION NAME] 30 cc PO PRN; -[MEDICATION NAME] 500 mg-5 mg PO PRN; and -[MEDICATION NAME] 10 mg PO PRN."? The above physician orders [REDACTED]. 9. On 2/1/08 resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. During record review, the surveyor noted the following orders on the computer generated physician's orders [REDACTED]. -"APAP 2 tabs PO PRN; -[MEDICATION NAME] 1 GTT OPH PRN; -[MEDICATION NAME] 1/150 (0.4 mg) SL PRN; -[MEDICATION NAME] 2-3 GTTS OTIC PRN; -[MEDICATION NAME] 4 mg PO PRN; -[MEDICATION NAME] 12.5 REC PRN; -[MEDICATION NAME] 0.5 mg PO PRN; -[MEDICATION NAME] 0.5 mg INJECT PRN; -[MEDICATION NAME] 5/325 162.5 mg/2.5 mg PO PRN; and -[MEDICATION NAME]-[MEDICATION NAME] 15 mg-6.25 mg/5 ml PO PRN."? The above phys… | 2015-03-01 |
| 5530 | 5530 | MONTANA MENTAL HEALTH NURSING HOME | 27A052 | 800 CASINO CREEK DR | LEWISTOWN | MT | 59457 | 2011-01-06 | 514 | E | 0 | 1 | 9QDJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Resident #5 was admitted to the facility on [DATE]. The MARs for September 2010 through December 2010 were reviewed. Resident #5 received the medications which were not signed out by a licensed nurse as follows: September - Calcium 500 mg/Vit D 200 IU one tablet BID - 9/16 AM dose. - [MEDICATION NAME] 10 mg tablet po TID - 9/22 noon dose, 9/23 - PM dose. - [MEDICATION NAME] 0.5 mg po BID - 9/16 - AM dose, 9/23 - PM dose. October - [MEDICATION NAME] HCL 20 mg tablet po q 0530 - 10/3, 10/10, and 10/27. - [MEDICATION NAME] 200 mg tablet po q 0530 - 10/3, 10/10, and 10/27. - Senna 8.6 mg tablet 2 tablets q 0530 - 10/3, 10/10, 10/20 - 10/30. - [MEDICATION NAME] NA 125 mg cap 8 caps q 0530, may use liquid [MEDICATION NAME] (20 ml) - 10/3 and 10/28. - Calcium 500 mg/Vit D 200 IU one tablet BID - 10/3, 10/10, 10/11, 10/19 - 10/30 for the AM dose, 10/20 - 10/30 for the PM dose. - [MEDICATION NAME] 800 mg tablet BID - 10/3, 10/10, and 10/27 AM dose,10/30 PM dose. - [MEDICATION NAME] 10 mg tablet po TID - 10/3 and 10/27 AM dose. - [MEDICATION NAME] 2 mg BID -10/3 and 10/27 AM dose, 10/11 PM dose. - [MEDICATION NAME] 300 mg AM - 10/14 and 10/27. - [MEDICATION NAME] 1 mg po q 0530 -10/27. November - [MEDICATION NAME] HCL 20 mg tablet po q 0530 - 11/29. - Polyethylene [MEDICATION NAME] 3350 po (2 TBSP) q day -11/26 and 11/29. - [MEDICATION NAME] 200 mg tablet po q 0530 -11/26 and 11/29. - [MEDICATION NAME] NA 125 mg cap 8 caps q 0530. May use liquid [MEDICATION NAME] (20 ml) -11/26 and 11/29. - [MEDICATION NAME] 300 mg CA one capsule po q 0530 - 11/26 and 11/29. - [MEDICATION NAME] 1 mg tablet one tablet po q 0530 - 11/26 and 11/29. - [MEDICATION NAME] Sodium 150 mg/15 ml 100 mg = 10 ml po q AM - 11/26 and 11/29. - [MEDICATION NAME] 300 mg tablet po q noon - 11/8. - [MEDICATION NAME] 400 mg tablet po q 1700 - 11/5 and 11/8. - [MEDICATION NAME] NA 125 mg cap 4 caps q 1700. May use liquid [MEDICATION NAME] (10 ml) - 11/6 and 11/8. - [MEDICATION NAME] 800 … | 2014-06-01 |
| 4450 | 4450 | APPLE REHAB COONEY | 275080 | 2555 E BROADWAY | HELENA | MT | 59601 | 2013-10-31 | 279 | E | 0 | 1 | 28X211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. Resident #13 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of Resident #13's Care Plan dated 10/08/13 revealed the resident was at high risk for falls related to history of falls and fall risk score of 20 (initiated 4/2/13 with one revision on 10/08/13). The care plan goal was for the resident to be free of minor injury through the review date (Date initiated 4/2/13 with a target date of 12/30/13). Care plan interventions were: -Bed alarm and chair alarm. (Date initiated 10/8/13) -(Resident) needs a safe environment with: even floors free from spills and/or clutter: adequate (sic), a working and reachable call light, the bed in low position at night; air mattress with bolster, fall mat, bedside (sic) table by bed, and personal items within reach. (date initiated: 4/2/13; revision on: 4/30/13). -Follow facility fall protocol (date initiated: 4/2/13). -Keep call light is (sic) within reach and encourage (Resident) to use it for assistance as needed (date initiated: 4/2/13; revision on: 7/30/13). Resident #13 had falls on 7/2/13, 8/19/13, 9/19/13, 10/04/13, and 10/18/13. According to this care plan, the care plan was revised twice, once on 7/30/13 concerning keeping the call light within reach and on 10/8/13 with adding a chair alarm. A review of a Fall Committee Review dated 7/2/13 reflected, Review of meds, chart et care plan. Resident continues to get self out of bed despite need for assist. Reasonable related to the resident's condition et unavoidable - esp r/t weakness et periods of confusion. Notifications made to MD, DON, Admin et family. No changes to care plan at this time. A review of a Fall Committee Review dated 8/19/13 reflected: Fall Committee Review of event. Resident is impulsive and continues to attempt self transfers after multiple reminders. Fall precautions in place and no injuries noted. Appropriate notification made. A review of a Fall Committee Review dated 10/04/13 reflected: Fall … | 2016-03-01 |
| 4660 | 4660 | FRIENDSHIP VILLA HEALTHCARE COMMUNITY | 275081 | 2300 WILSON | MILES CITY | MT | 59301 | 2012-05-24 | 272 | B | 0 | 1 | 16V911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. Resident #6 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. An admission MDS with an ARD of 11/7/11 was reviewed. The completed MDS assessment triggered CAAs for Cognitive Loss/Dementia, Visual Function, Communication, ADL Functional/Rehabilitation Potential, Psychosocial Well-Being, Behavioral Symptoms, Nutritional Status, Dehydration, Dental Care, Pressure Ulcer and Urinary Incontinence and Indwelling Catheter. Under the Location and Date of CAA Information on Section V, the number of the CAA with a date was listed. When the CAA documents were reviewed, the facility used the reference forms in Appendix C. The information provided on these documents was minimal, with no reference of where the information was obtained. Under the Care Plan Considerations column on these forms, it was noted Taking to Care Plan except on the Cognitive Loss CAA which stated These problems will not be addressed in the plan of care; they appear to have resolved per situation. However, anger and associated behaviors will be addressed, Visual Function CAA, which stated Large print need will be addressed in the plan of care, Communication, which stated hearing problem will be addressed in the plan of care Activities of Daily Living, which stated ADLs are addressed in the plan of care, Psychosocial Well-Being, which stated Verbal outburst was not violent; just expressed anger towards staff for wrongs he perceives. His anger will be addressed in the plan of care; not the verbal because it seems to be a situational problem and has been resolved., Behavioral Symptoms which stated, The rejection of care will not be addressed in the plan of care. The refusal of the eye drops was a one time occurrence. The eye drops are not medically required (disease of the eye), and Dental Care, which stated This will not be taken to care plan. There was no further information about why any of the triggered areas would be taken or not taken to the care plan.… | 2015-11-01 |
| 4762 | 4762 | APPLE REHAB COONEY | 275080 | 2555 E BROADWAY | HELENA | MT | 59601 | 2012-08-02 | 353 | H | 1 | 0 | 4BGW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. The surveyor observed the call light for resident #15 was sounding on 8/1/12 from 7:50 a.m. until 8:22 a.m. During the observation time, on the 200 hall, the surveyor observed 2 unidentified CNAs and another unidentified staff member walk by the room and not answer the call light. During an interview with resident #15 on 8/1/12 at 10:15 a.m., she stated sometimes it takes more than 15 minutes for the staff to answer the call light. 9. The surveyor observed the call light for resident #16 was sounding on 8/2/12 from 8:15 a.m. until 8:35 a.m. The call light was answered by a staff member at 8:35 a.m., twenty minutes after the resident initially rang for assistance. During an interview with staff member K on 8/1/12 at 10:30 a.m., she stated there was another CNA to assist her on the rehab unit until 8:00 a.m. Staff member K stated that after 8:00 a.m. she was the only CNA working on the rehab unit with a census of 48.. 10. On 8/1/12 at 7:00 a.m., the surveyor was walking into the B hall. Resident #7 was in the middle of the hall. He had slid out of his wheelchair, his elbows on the armrests, his buttocks beyond the seat edge and his feet extended out in front as he tried to not fall onto the floor. He was calling out for help. A nurse was noted across the day room area, less than 30 feet away. The nurse did not pay attention to the resident's requests for help until the surveyors asked the nurse to assist the resident. At that time, she came over and assisted him back into his chair. No other staff was in the vicinity. Bathing: 11. Residents of the LTC, #s 4, 7, 8, and 13, did not receive baths for 10 to 15 days during the month of July 2012. The average daily resident census was 48 for July 2012. The average CNA staffing for day shift for July 2012 was 3. The average CNA staffing for evening shift for July 2012 was 3. The average CNA staffing for night shift for July 2012 was 2. During an interview on 7/31/12 at 11:00 a.m. with staff member … | 2015-08-01 |
| 247 | 247 | PARK PLACE TRANSITIONAL CARE AND REHABILITATION | 275030 | 1500 32ND ST S | GREAT FALLS | MT | 59405 | 2019-09-25 | 677 | D | 1 | 0 | I4CJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > 1. During an observation on 9/24/19 at 12:05 p.m., resident #2 reclined in a recliner, in his room. The resident did not respond. When spoken to, he yawned. The resident's teeth were noted to have a whitish, thick substance, caked on his upper teeth, along the gum line. During an interview on 9/24/19 at 10:10 a.m., and again at 2:30 p.m., NF1 stated staff were not assisting resident #2 with oral care. NF1 stated resident #2 was unable to do this for himself and needed help. NF1 stated the staff did not always brush resident #2's teeth. During an interview on 9/24/19 at 12:10 p.m., staff member H stated resident #2 required staff to perform all his cares as he was unable to do this for himself. The staff member stated CNAs were to brush resident #2's teeth. Staff member H stated brushing resident #2's teeth was difficult at times as he resisted. Review of resident #2's care plan, with an initiation date of 3/20/17, showed staff were to attempt to provide oral care in the AM (morning), and the HS (evening). The resident was more accepting of the oral care when sleepy. Review of the CNA Kardex report, with an admission date of [DATE], did not address the need for the CNAs to provide oral care. Review of resident #2's Interdisciplinary Team (IDT) Care Conference Summary, dated 2/11/19 and 4/22/19, showed NF1 had identified concerns that resident #2's teeth were not being brushed two times daily. There was no documentation showing the facility staff followed through with attempting to improve on brushing resident #2's teeth, twice a day. Review of resident #2's MDS, with an ARD of 6/26/19, showed resident #2 required extensive assist with all cares, including hygiene. Review of resident #2's nurse progress note, dated 7/8/19 at 1:47 a.m., showed a friend had visited resident #2, and complained to staff that the resident's teeth were not cleaned. There was no documentation that showed the facility staff had looked into the visitor's claim, update… | 2020-09-01 |
| 1425 | 1425 | HI-LINE RETIREMENT CENTER | 275131 | 801 S 3RD ST E | MALTA | MT | 59538 | 2018-07-12 | 661 | D | 1 | 1 | 6W1G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to complete a discharge summary, for 1 (#43) of 19 sampled residents. Findings include: During an interview on 7/12/18 at 10:12 a.m., staff member C stated resident #43 was hospitalized from assisted living. She had pneumonia and needed oxygen so she was put back in the nursing home and then when her condition improved she went back to the assisted living. Review of resident #43 closed record showed there was not a discharge plan completed when resident #43 was admitted into the assisted living facility. During an interview on 7/12/18 at 8:32 a.m., staff member D stated resident #43 was in assisted living then came to nursing home and now she is back in assisted living, and it didn't look like there was a discharge plan. During an interview on 7/12/18 at 8:35 a.m., staff member D stated it does not look like there was a discharge plan ever completed for resident #43. Review of resident #43's Admission MDS, with a date of 3/27/18, showed resident #43 was admitted to the facility on [DATE]. Resident #43 was admitted with a [DIAGNOSES REDACTED]. Review of resident #43's discharged /Return Not Anticipated MDS, with a date of 4/11/18 showed her discharge date was 4/11/18. | 2020-09-01 |
| 1427 | 1427 | HI-LINE RETIREMENT CENTER | 275131 | 801 S 3RD ST E | MALTA | MT | 59538 | 2018-07-12 | 758 | D | 1 | 1 | 6W1G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to have a physician review PRN [MEDICAL CONDITION] medications every 14 days, for 1 (#36) of 19 sampled residents. Findings include: During an interview on 7/11/18 at 2:10 p.m., staff member C stated the physician completed a [MEDICAL CONDITION] monthly review. Staff member C stated PRN [MEDICAL CONDITION] medications and anti-psychotic medications are reviewed by the physician every 14 days. Review of resident #36's Physician order [REDACTED]. Review of resident #36's Medication Administration History, for 6/1/18 - 6/30/18, showed [MEDICATION NAME] had an end date of 6/28/18, which was beyond the 14 day required timeline. During an interview on 7/12/18 at 8:51 a.m., staff member C stated there were no documented non-pharmacological interventions for resident #36, or for his behaviors. Staff member C stated she thought they monitored behaviors for the residents. She stated the behaviors were discussed in the QA meeting monthly. During an interview on 7/12/18 at 8:54 a.m., staff member C stated there was no consent form signed for resident #36 to receive [MEDICATION NAME]. During an interview on 7/12/18 at 9:27 a.m., staff member A stated the physicians reviewed the [MEDICAL CONDITION] medications every month, and not every 14 days. | 2020-09-01 |
| 505 | 505 | COPPER RIDGE HEALTH AND REHABILITATION CENTER | 275060 | 3251 NETTIE ST | BUTTE | MT | 59701 | 2019-06-05 | 658 | D | 1 | 0 | IEQL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to obtain a lab level ordered by a physician for 1 (#2) of 5 sampled residents. During an interview on 6/5/19 at 1:59 p.m., staff member D stated when lab orders were received from a physician the nurses were to fill out a Lab Requisition sheet and the white copy was sent to the lab and the yellow carbon copy was put on a board. Staff member D stated that it was essential to make sure that the lab sheet was filled out as ordered by the physician. Staff member D stated that the results were checked with the carbon copy of the Lab Requistion sheet, noted, and faxed to the doctor. She then throws the carbon copy of the Lab Requisition sheet away. During an interview on 6/5/19 at 2:44 p.m., staff member F stated when receiving a lab order from a physician the nurse reviews the order and completes the lab order. The lab slip was then posted on a board for night shift, then written on a hard calendar, and was put in the computer under treatments. Staff member I stated when results come in they check to make sure the labs were drawn. If the labs were not drawn she would then make sure they were set up to be drawn, but that doesn't happen. During an interview on 6/5/19 at 2:10 p.m., staff member A stated the process of fulfilling labs ordered by a physician was done by the nurse as they fill out a slip and fax it to the lab. Staff member A reviewed resident #2's physician order, dated 5/29/19, and stated it did not look like the same hand writing. Staff member A stated she had talked to resident #2's physician, and the (Physician) had not ordered a dig level. During an interview on 6/5/19 at 2:15 p.m., staff member J reviewed the physician order [REDACTED].#2's chart. Staff member J stated the hand writing on the order was hers and she had ordered a routine [MEDICATION NAME] level lab on 5/29/19. No [MEDICATION NAME] level was drawn for resident #2 on 5/31/19. Review of resident #2's Medicati… | 2020-09-01 |
| 1037 | 1037 | LAUREL HEALTH & REHABILITATION CENTER | 275111 | 820 3RD AVE | LAUREL | MT | 59044 | 2017-08-31 | 312 | E | 1 | 1 | HYNB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to provide consistent personal hygiene for 35 of 64 residents for the month of (MONTH) (YEAR). Findings include: 1. A review of Shower/Bath Sheets (records) for (MONTH) (YEAR) showed: - A review of records showed one resident was admitted on [DATE]. The resident was offered a bath on 8/23/17. The resident refused a bath at that time. The bath aid noted the bath aide would try on Saturday. The (MONTH) (YEAR) bath record did not show the resident had been offered a bath at any time after 8/23/17. - A review of the (MONTH) (YEAR) bath sheet showed a resident had received a bath on 8/16/17. The record showed three other opportunities when the resident should have received a bath. The record showed shower aides were pulled to the floor on 8/2/17 and 8/9/17. The bath record does not show why the resident did not receive a bath on 8/23/17. Due to shower aides being pulled to the floor, staff missed three opportunities to bathe the resident. - A review of the (MONTH) (YEAR) bath sheet showed four opportunities when the resident should have received a bath. The record showed shower aides were pulled to the floor 8/2/17, 8/9/17, and 8/16/17. The resident received one bath for the month of (MONTH) on 8/23/17. Due to the shower aides being pulled to the floor, three opportunities to bathe the resident were missed. - A review of the (MONTH) (YEAR) bath sheet showed four opportunities when the resident should have received a bath. The record showed the shower aide was pulled to the floor 8/2/17, 8/16/17, and 8/23/17. The resident received one bath for the month of (MONTH) on 8/9/17. Due to the shower aides being pulled to the floor, three opportunities to bathe the resident were missed. - A review of the (MONTH) (YEAR) bath sheet showed four opportunities when the resident should have received a bath. The record showed the shower aide was pulled to the floor 8/2/17 and 8/16/17. The resident receive… | 2020-09-01 |
| 890 | 890 | CONTINENTAL CARE AND REHABILITATION | 275103 | 2400 CONTINENTAL DR | BUTTE | MT | 59701 | 2019-04-10 | 760 | D | 1 | 0 | OT4G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, a nurse failed to follow the correct medication administration process, and administered another resident's pain medication to a fell ow resident who had an allergy to the specific kind pain medication given, and this resulted in a negative outcome and the resident experienced nausea and vomiting. This was considered a significant medication error, for 1 (#1) of nine sampled residents. Findings include: During an interview on 4/10/19 at 7:48 a.m., NF1 said resident #1 received the wrong medications about three and a half weeks ago. NF1 said the facility had contacted him about the medication error. NF1 said resident #1 received Tylenol #3 which contained [MEDICATION NAME]. NF1 said resident #1 experienced vomiting three times because she had an allergy to [MEDICATION NAME]. NF1 said the resident's allergy to this medication was well documented. During an interview on 4/10/19 at 11:47 a.m., resident #1 said she did remember getting sick several weeks prior when she was given someone else's pills. The resident said she had never been given the wrong medications before. Resident #1 said she thought a nurse had given her a pill to help her when she was throwing up. During an interview on 4/10/19 at 2:46 p.m., staff member F said she had recently received training on the five rights of the medication pass, per nursing professional standards. During an interview on 4/10/19 at 2:48 p.m., staff member G said an in-service had been conducted by staff member B, who went over the five rights of medication administration. During an interview on 4/10/19 at 2:54 p.m., staff member C said she was aware staff member B had conducted in-service training's with the floor nurses in relation to a medication error that had happened for resident #1. Staff member C said she knew about this because it had been discussed in the morning management meetings, and an incident report had been completed on the medication error. During… | 2020-09-01 |
| 1430 | 1430 | HI-LINE RETIREMENT CENTER | 275131 | 801 S 3RD ST E | MALTA | MT | 59538 | 2018-07-12 | 835 | E | 1 | 1 | 6W1G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, facility administration failed to address multiple concerns in a timely manner, to include the completion of the facility assessment, in an attempt to determine resources needed, or identify corrective actions for facility concerns, relating to the day to day operations of the facility for resident care and services. This failure had the potential to affect all residents at the facility. Findings include: Heating/Cooling - Facility Temperatures During an interview on 7/10/18 at 8:02 a.m., staff member L stated the main air conditioning system had not worked for approximately four years. He stated there had been problems with the facility heating and cooling for several years. He stated the boiler quit functioning in (MONTH) (2018). Staff member L stated when the boiler quit working the facility placed electric heaters in all of the resident rooms to heat the building. He stated the facility was currently installing three new boilers that they purchased approximately one month ago. During an interview on 7/9/18 at 5:05 p.m., staff member A stated the air conditioner was still not working and did not know why. Staff member A stated it may take a long time to figure out what the trouble was and he would call a local person to see if they could do something. Staff member A stated the maintenance department would add freon to the air conditioning unit in the morning. The current temperature outside on 7/9/18 was approximately 96 degrees Fahrenheit. Antibiotics During an interview on 7/12/18 at 9:12 a.m., staff member N stated that the facility did not have an antibiotic stewardship program in place. Staff member N said she pulled antibiotic reports and the pharmacist gave her a list of residents placed on antibiotics. Staff member N stated the norm is that residents are placed on antibiotics while waiting for the culture and sensitivity results to come back. Staff member N said there were no antibiotic proto… | 2020-09-01 |
| 353 | 353 | BIG SKY CARE CENTER | 275044 | 2475 WINNE AVE | HELENA | MT | 59601 | 2019-06-07 | 580 | D | 1 | 0 | 5WFT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, facility staff failed to notify the physician of a change in condition, the increased need for PRN nebulizer treatments after smoking cigarettes, for 1 (#1) of 8 residents. Findings include: During an interview on 6/6/19 at 9:25 a.m., staff member B stated resident #1 had a PRN order for nicotine [MEDICATION NAME]. The staff member stated resident #1 had not requested any [MEDICATION NAME] because the resident went outside to smoke every 30 minutes to 1 hour. Staff member B stated resident #1 would frequently request a nebulizer treatment when he returned to the facility after smoking. Staff member B stated the increase in smoking and nebulizer treatments began several months ago, and the physician had not been informed. Review of resident #1's (MONTH) 2019 MAR indicated [REDACTED]. The start date was 11/28/18. Staff documented PRN nebulization treatments were administered on 5/8/19, 5/13/19, 5/15/19, 5/16/19, 5/18/19, 5/19/19, 5/20/19, 5/22/19, 5/26/19, and 5/27/19. Review of resident #1's (MONTH) 2019 MAR indicated [REDACTED]. Staff documented PRN nebulization treatments were administered on 6/3/19 and 6/4/19. Review of resident #1's Nurse's Notes showed the following: - 5/12/19 at 11:58 p.m., .he had to wait 5 minutes for a breathing treatment and then went out to smoke as soon as he finished it. Upsetting rsdts around him because he comes out and stands out in the hall and dry heaves very loudly . - 5/13/19 at 10:52 p.m., .Rsdt came in from smoking and requesting a nebulizer treatment ASAP. - 5/15/19 at 11:31 p.m., Earlier in the evening rsdt came in from smoking and up to me and asked for a breathing treatment. He spoke like he needed it right away. Rsdt did breathing treatment and went back out to smoke. A few hours later he was seen in his room using his inhaler and right after he went out to smoke. - 5/17/19 at 1:49 a.m., res c/o SOB .res was given 2000 meds and neb tx . - 5/21/19 at 1:26 a.m., … | 2020-09-01 |
| 1646 | 1646 | AWE KUALAWAACHE CARE CENTER | 275153 | 10131 S HERITAGE RD | CROW AGENCY | MT | 59022 | 2018-03-01 | 835 | K | 1 | 0 | PHIL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility administrator and administrative staff failed to ensure residents were provided an environment free from abuse and harm, when a new staff member was hired, and the staff member had a criminal history of abuse (assault), and an allegation of sexual abuse was reported by 1 (#1) and the alleged employee caused ongoing psychosocial fear for 3 (#s 1, 2, and 3) of 9 sampled residents. Refer to F606 and F607 for details related to abuse. Findings include: During an interview on 3/1/18 at 12:25 p.m., staff member C stated she knew staff member A had been convicted of assault, but it had been an isolated incidence. Staff member C stated staff member A's allegations of inappropriate behavior had been brought to her attention, but staff member C stated resident #1 was known to have behaviors, such as refusing medications and attending appointments. Staff member C stated staff member A no longer provided transportation for resident #1, but staff member A was still providing transportation to other residents of the facility. During an interview on 3/1/18 at 2:20 p.m., staff member [NAME] stated she recalled the day when resident #1 reported that he had been inappropriately touched (in the genital area) by staff member [NAME] Staff member [NAME] stated all facility staff should have been reporting allegations of abuse to protect the residents. Staff member [NAME] stated she knew staff member A was on probation, had a history of [REDACTED]. Staff member [NAME] had knowledge that staff member A was related to the administrator. During an interview on 2/28/18 at 6:25 p.m., staff member F stated NF3 had informed her staff member A had inappropriate behavior with resident #1 during a transportation trip out of town. Staff member F stated the facility still had staff member A employed as a driver for other vulnerable residents, even after the administrator had been informed of the sexually inappropriate behavi… | 2020-09-01 |
| 361 | 361 | BIG SKY CARE CENTER | 275044 | 2475 WINNE AVE | HELENA | MT | 59601 | 2019-09-11 | 689 | D | 1 | 0 | YENF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed on admission to document the events surrounding the possession of a knife, or knives, that belonged to 1 (#1) resident, and confiscate the item(s) for ongoing resident(s) safety, which caused fear for 1 (#12) resident, of 14 sampled residents. Findings include: 1. a. During an interview on 9/11/19 at 8:14 a.m., resident #12 stated he was fearful of another resident who had a knife in his possession. Resident #12 was sure the other resident still had a knife. Review of resident #12's care plan, with a revision date of 7/3/19, showed the resident was at risk for abuse because he was unable, at times, to communicate his needs and staff were to monitor any signs of abuse or neglect. b. During an interview on 9/10/19 at 8:45 a.m., resident #1 stated he had brought his knife into the facility when he was admitted to the facility. He said he had always carried a knife around prior to entering the facility. He stated he had the knife with him in the facility but staff had recently, just recently taken his knife away and they locked it up. During an interview on 9/11/19 at 8:30 a.m., staff member N said the facility was told resident #1 had a knife. Staff member N said resident #1's room was searched by herself and staff member B. They failed to find any knives in the resident's room. Staff member N said staff member B was notified on 8/10/19 that resident #1 had a knife, in a sheath, attached to his belt. The staff member said resident #1's room was searched on 8/10/19 and knives were found and confiscated. Staff member B said the knives were put in the facility safe. Review of resident #1's records showed the resident was admitted to the facility on [DATE]. There was no personal inventory lists for resident #1 located, which should have identified whether the resident had a knife or knives when he entered the facility, or if the facility staff were aware of the resident having knives. Revie… | 2020-09-01 |
| 1890 | 1890 | DEER LODGE | 275134 | 1100 TEXAS AVE | DEER LODGE | MT | 59722 | 2017-02-02 | 315 | D | 1 | 0 | VV8Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to accurately assess the need for antibiotics for urinary tract infections that could potentially put a resident at risk for antibiotic resistance, related to being on antibiotics with out symptoms of an infection for 1 (#18) of 38 sampled residents. Findings include: Review of resident #18's MAR, dated 10/28/16, showed an order for [REDACTED]. Review of resident #18's MAR, dated 11/15/16, showed [MEDICATION NAME] Capsule, for UTI, until 11/25/16. Review of resident #18's MAR, dated 12/10/16, showed Bactrim DA, for UTI, for 10 days. Review of resident #18's temperature log showed no elevated temperature for those 3 months. Review of resident #18's Progress Notes, correlated to the antibiotic start dates, showed no burning pain on urination, no flank pain, no change in character of urine, and no change in mental status. During an interview on 2/1/17 at 2:10 p.m., staff member C stated the resident's urine was cultured. She stated she knew the residents should meet 3 of the criteria (burning on urination, flank pain, change in character of urine, and change in mental status) before treatment, and Maybe everybody needs more education regarding current standards of practice for antibiotic stewardship. | 2020-02-01 |
| 1357 | 1357 | IMMANUEL SKILLED CARE CENTER | 275129 | 185 CRESTLINE AVE | KALISPELL | MT | 59901 | 2018-05-17 | 697 | G | 1 | 1 | FK8Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to address and identify a resident's pain needs timely after a fall which caused several fractures, for 1 (#142) of 41 sampled and supplemental residents. Findings include: Review of resident #142's SBAR Communication Form, dated 3/19/18 at 3:15 p.m., showed Resident became weak while being stood (sic) from toilet and was 'purposefully' lowered to the floor in front of (sic) toilet so a sling could be placed under her for transfers. She had BLE weakness and could not stand even c (sic) gait belt, CNA assist & walker in her hands. Review of resident #142's Falls Management-Post Fall Assessment Tool showed for 7. Were you in pain? and resident #142's response was, Yes. Review of resident #142's nursing progress notes showed the following: -3/20/18 at 12:28 p.m., showed, Pain: c/o pain in legs today, given PRN Tylenol. -3/20/18 at 3:09 p.m., showed, Yesterday 3/19 around 15:15 (3:15 p.m.) at change of shift from day to evening, the CNA was toileting resident and was standing up the resident in front of toilet, using gait belt and walker and resident became weak in BLEs and was unable to stand even with the assist of CN[NAME] Resident was puposely (sic) lowered to the floor in order to reposition her so a sling could be placed under her and a lift used to transfer the resident with 2 staff. Resident has a purposeful 'change of plain (sic) /change of position.' No injury noted. -3/21/18 no documentation on nursing progress notes to show pain was addressed after the fall. The MAR for (MONTH) (YEAR) showed the resident received Tylenol 500 mg on 3/21/18. -3/22/18 at 8:36 p.m., showed, During pericare it was noted that her right lower shin has a deep pink/maroon coloring and lumps along bone. Pedal pulses are palpable on both feet but right foot is cool to touch. Pain was not addressed for the identified injury. -3/23/18 at 10:07 a.m., showed, Resident has deformity/discoloration to right lo… | 2020-09-01 |
| 218 | 218 | AVANTARA OF BILLINGS | 275029 | 2115 CENTRAL AVE | BILLINGS | MT | 59102 | 2017-11-21 | 309 | G | 1 | 1 | S6P111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to adequately control a resident's pain, which interfered with the residents daily activities and made it hard for him to sleep, and provide adequate pain intervention to maintain the resident's highest practicable well-being, 1 (#1) of 23 sampled residents. Findings include: 1. Resident #1 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The resident was discharged from the facility on 8/21/17. Review of resident #1's Admission MDS, with an ARD of 4/24/17, section C, showed the resident had a BIMS of 15; cognitively intact. Review of this MDS, section J, showed the resident had frequent episodes of pain, which measured 7 of 10 on the pain scale. The pain interfered with resident #1's day-to-day activities. Review of resident #1's Quarterly MDS, with an ARD of 7/17/17, showed the resident was in pain almost constantly. The pain measured 9 of 10 on the pain scale. The pain interfered with day-to-day activities and made it hard for the resident to sleep at night. Review of resident #1's (MONTH) (YEAR) recapitulation Physician Orders, showed the following had been ordered for pain management: - [MEDICATION NAME], 15 mg extended release, three tablets every 12 hours. - [MEDICATION NAME], 2 mg tablet, one tablet if pain was 5 of 10 on the pain scale, and two tablets when the pain was 6 of 10 on the pain scale, every 4 hours as needed for pain. Review of resident #1 MARs (Medication Administration Record) showed the following for the resident's inadequate pain management program, and lack of documentation showing the physician was notified of the resident's ongoing pain even after medication was provided: - (MONTH) (YEAR); Orders reflected [MEDICATION NAME] 2 mgs, and 4 mgs, as needed every four hours (for pain). a. On 4/18/17 at 6:01 a.m., staff documented in resident #1's EMR that his pain level was an 8 of 10 on the pain scale. The resident was administered [MED… | 2020-09-01 |
| 1877 | 1877 | HOT SPRINGS HEALTH & REHABILITATION CENTER | 275069 | 600 1ST AVE N | HOT SPRINGS | MT | 59845 | 2017-03-16 | 226 | E | 1 | 0 | 7RPF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to adequately investigate and address an allegation of neglect and mistreatment by staff for 1 (#10), and failed to investigate an allegation of a missing [MEDICATION NAME] for 1 (#1), of 10 sampled residents. The facility failed to promote a culture of safety in reporting for staff. Findings include: 1. Resident #1 was admitted to the facility on [DATE] with a chronic pai[DIAGNOSES REDACTED] and used a [MEDICATION NAME] to manage pain. During an interview on 3/15/17 at 6:45 p.m., staff member C said the [MEDICATION NAME] and part of the [MEDICATION NAME] that covered the patch disappeared (2/23/17). She said she, Mounted the remaining portion of the [MEDICATION NAME] on a new [MEDICATION NAME] wrapper. She said the [MEDICATION NAME] had been cut out of the area directly under the [MEDICATION NAME], and the [MEDICATION NAME] itself was missing. Staff member C said she gave the remaining [MEDICATION NAME] and wrapper to staff member D, who worked the morning shift of 2/24/16. Staff member D then gave the wrapper with the [MEDICATION NAME] to staff member B. Staff member C said staff member H had found the cut out piece of the [MEDICATION NAME] about three days later (2/26/17), and she was told the patch had been rolled up and taped to resident #1's right shoulder. Staff member C said she did not write an incident report, or a nursing note regarding the missing patch, and had not heard a thing about the missing patch since. During an interview on 3/20/17 at 3:45 p.m., staff member D said staff member C had given her the [MEDICATION NAME] wrapper on the morning of 2/24/17, when she arrived at work. She said the outer portion of the [MEDICATION NAME] was attached to the paper wrapper, and the actual [MEDICATION NAME] was missing. Staff member D said the missing portion was horseshoe shaped, and looked like the patch had been cut out of the center of the [MEDICATION NAME]. Staff member D … | 2020-03-01 |
| 217 | 217 | AVANTARA OF BILLINGS | 275029 | 2115 CENTRAL AVE | BILLINGS | MT | 59102 | 2017-11-21 | 281 | E | 1 | 1 | S6P111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to administer insulin as prescribed by the attending physician for 1 (#5); and failed to accurately document the administration of narcotic medications in the EMR and Controlled Substance Treatment Book for 1 (#1) of 23 sampled residents. Findings include: 1. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #5's medication administration record, dated (MONTH) (YEAR), showed several doses of [MEDICATION NAME]had not been administered according to the attending physician's orders [REDACTED].>Review of resident #5's administration of [MEDICATION NAME] 100 unit/ml subcutaneous before meals, with a start date of 8/4/17, reflected several doses had not been given by the nurse per the sliding scale order according to resident #5's blood glucose level. Review of resident #5's medication administration record for (MONTH) (YEAR) showed: -11/1/17 for the p.m. dose, resident #5 was administered 9 units of insulin for a blood glucose recording of 305 by staff member S. The resident should have received 10 units. -11/3/17 for the a.m. dose, resident #5 received 3 units for a blood glucose recording of 204 by staff member T. The resident should have received 6 units. -11/9/17 for the noon dose, resident #5 received 6 units for a blood glucose recording of 290 by staff member T. The resident should have received 10 units. -11/11/17 for the p.m. dose, resident #5 received 6 units for a blood glucose recording of 258 by staff member S. The resident should have received 8 units. -11/19/17 for the noon dose, resident #5 received 5 units for a blood glucose recording of 284 by staff member T. The resident should have received 10 units. During an interview on 11/21/17 at 10:15 a.m., staff member S stated resident #5 was to receive insulin only if she ate her full meal. Staff member S stated the blood glucose amount and insulin were entered manually into the electronic… | 2020-09-01 |
| 506 | 506 | COPPER RIDGE HEALTH AND REHABILITATION CENTER | 275060 | 3251 NETTIE ST | BUTTE | MT | 59701 | 2019-06-05 | 684 | G | 1 | 0 | IEQL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to assess and monitor 1 (#1) of 5 sampled residents when there was a change in condition. Resident #1 experienced increased weakness, nausea, vomiting, and diarrhea, however there was not documentation in the medical record showing the resident was assessed and monitored for worsening of condition in the 14 hours prior to the resident being sent to the hospital. Findings include: During an interview on [DATE] at 10:37 a.m., NF1 stated resident #1 had been experiencing increased nausea and diarrhea in the week prior to being sent to the ER. NF1 stated resident #1 would just lay in bed with the blinds closed. NF1 stated she inquired on [DATE] regarding a [MEDICATION NAME] level but did not get a response from the staff. NF1 stated resident #1's nausea had gotten worse and by [DATE] the resident had required transport to the hospital for weakness, nausea, vomiting, and diarrhea. NF1 stated by the time the resident got to the ER her diarrhea was horrible. NF1 stated resident #1 had expired on [DATE], at the hospital from [MEDICATION NAME] toxicity. During an interview on [DATE] at 3:28 p.m., staff member G stated the signs and symptoms for [MEDICATION NAME] toxicity were blood pressure changes, disorientation, and confusion. Staff member G stated she would contact the physician by fax or phone, depending on the acuity. Staff member G stated she would wait 30 minutes for the physician to respond and then attempt to contact again. Staff member G stated if it was in the evening she would wait 20 minutes. Staff member G stated if the physician still did not respond, she would call the DON and the administrator. Staff member G stated she would monitor vital signs, alertness, neurological status, cardiac status, lungs and abdominal condition when a resident had a change in condition. During an interview on [DATE] at 3:35 p.m., staff member H stated the signs and symptoms of [MEDICATION NAME] t… | 2020-09-01 |
| 573 | 573 | COMMUNITY NURSING HOME OF ANACONDA | 275065 | 615 MAIN ST | ANACONDA | MT | 59711 | 2019-04-11 | 689 | G | 1 | 0 | RT4011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to assess the resident's safety with transfers, for a resident that experienced [MEDICAL CONDITION] episodes during the transfers, resulting in repeated falls, to include one fall with a [MEDICAL CONDITION], for 1 (#1) and failed to identify the root causes and implement fall prevention interventions for 8 falls for 1 (#2); and failed to adequately assess and treat pain for 17 days after a fall for 1 (#3) of 3 sampled residents. Findings include: 1. Review of resident #1's Progress Note, dated 1/16/19, showed the CNA reported the resident's eyes rolled in the back of his head, and the resident had passed out while being toileted. His vitals were taken, but the physician was not notified. Review of resident #1's Physician Visit Note, dated 1/17/19, showed the facility staff reported he was no longer able to stand on his lower extremities. No transfer assessment was completed for the safety of the sit to stand lift. Review of resident #1's Progress Note, dated 1/23/19, showed the resident had passed out while getting ready to be toileted. Vitals were taken, but the physician was not notified. Review of resident #1's Progress Note, dated 2/5/19, showed it was reported by the CNA that the resident had slumped backwards onto the toilet and was staring off into space, during the transfer. Vitals were taken. No further follow-up assessments were completed for the incident. Review of resident #1's Progress Note, dated 2/18/19, showed the resident was taken into the bathroom on the sit to stand lift, and as he was lowered onto the toilet, and he passed out. The fall intervention implemented was to continue to monitor. Review of resident #1's Progress Note, dated 2/22/19, showed it was reported by the CNA that the resident was being assisted to the bathroom, and became unresponsive for a short time. No assessment was completed for the reason for the unresponsive episode, and the physician was … | 2020-09-01 |
| 696 | 696 | APPLE REHAB COONEY | 275080 | 2555 E BROADWAY | HELENA | MT | 59601 | 2017-07-14 | 314 | E | 1 | 0 | JO6P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to assess, monitor, and document skin breakdowns for 3 (#s 1, 6, and 7) of 7 sampled residents. The facility failed to ensure that a new protocol was established with new management arrangements ensuring the current clinical standards of practice in skin management and treatment in order to accurately monitor the healing process and prevent further skin issues; all staff, including the contracted temporary staff, were educated with the newly established skin management and treatment protocol; and finally the facility failed to ensure all skin issues were identified, assessed and documented in the medical records of the residents in a timely manner by the appropriate staff.Findings include: 1. Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Review of the 3/24/17 initial Nursing Assessment, under the title Bowel Function/Habits, showed the resident was wearing briefs, had redness and excoriation to her sacrum/coccyx, and she had open areas on her left buttock. The answers to the Skin Questions on the assessment showed the resident was status [REDACTED]. Review of the Interdisciplinary Progress notes, dated 3/24/17, also showed the resident had red and excoriated sacrum and coccyx. The note also showed the left buttock had open areas and was tender. The resident also had black areas to the left foot's 1st, 2nd, 3rd and 5th toes. Neither nursing assessment document was complete as to the stage, size, and appearance of the open areas on the left buttock including undermining, depth, drainage, and status of wounds' tissue. Review of the telephone orders showed the physician ordered skin prep to the buttocks and coccyx for excoriation, and Alevyn dressing to the left buttock on 4/5/17 reflecting the resident still had open areas. The medical record lacked a nursing assessment of the skin condition on 4/5/17. Review of … | 2020-09-01 |
| 2289 | 2289 | VALLEY VIEW HOME | 275091 | 1225 PERRY LN | GLASGOW | MT | 59230 | 2016-06-23 | 514 | D | 1 | 0 | 01NY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to complete adequate documentation on the day a resident discharged from the facility; specifically, the discharge assessment, status at the time of discharge, how medications were managed for the discharge, by what means the resident left the facility or if he was accompanied at the time of discharge, for 1 (#2) of two sampled residents. Findings include: Resident #2 was admitted to the facility on [DATE]. A review of the facility discharge list showed the resident discharged the facility on 5/29/16. A review of a communication sent from the facility to the physician showed the resident was planning to discharge the facility on 6/1/16. The resident would be going to an assisted living facility out of town. The physician responded with, Make the order as above. an order for [REDACTED]. A review of the resident's nursing notes lacked evidence for any documentation on 5/28/16 or 5/29/16. The last documented nursing entry was dated 5/27/16. During an interview on 6/21/16 at 6:15 p.m., staff member B stated the nurse working that day was not available, but she recalled some details from the transfer. On 6/22/16, documentation was received that showed a late entry was completed for the day of the resident's discharge. The documentation pertained to the resident's status at the time of the discharge, and how medications were provided by the nurse on duty at the time. A review of the resident's Discharge Planning form, which was blank, had been provided on 6/21/16 by staff member B. A review of a Discharge Planning form, which was received on 6/22/16 showed the form was completed on 6/22/16, when the resident had discharged the prior month. During an interview on 6/21/16 at 3:30 p.m., staff member B stated a past employee was responsible for the completion of the discharge paperwork, but it had not been done. A review of the Discharging the Resident policy showed documentation should includ… | 2019-06-01 |
| 2680 | 2680 | PONDEROSA PINES HEALTH CARE | 275096 | 1341 ROSEBUD LN | BILLINGS | MT | 59101 | 2017-05-25 | 202 | D | 1 | 1 | PRVT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to conduct the appropriate assessments, to identify changes, interventions, or risk factors, for a resident, in an attempt to update the resident's care plan to allow the resident to stay at the facility, and failed to have the physician involved in resident care prior to a resident's transfer to a psychiatric treatment center for 1 (#1) of 10 sampled residents. Findings include: Resident #1 had [DIAGNOSES REDACTED]. During a record review, resident #1's care plan, dated 12/08/16, showed Concerns: Behavior issues due to diagnosis, Resident Goals: Behaviors manageable, and Approach Plan: 1) Can be hyper, demanding, and loud. If her behavior escalates, take to her room and reason with her in private. 2) Involve social services is needed. 3) Medications as ordered. and 4) Hoarder, ADON and social services will intervene. The resident's record did not show any documentation of the facility staff using resident #1's Approach Plan, or how effective those interventions were. Resident #1's medical record did not contain any documentation regarding behavior monitoring. Resident #1's care plan did not show any updates as the resident's verbal and physical behaviors continued to increase as evidenced by nursing notes, and social service notes reviewed from 3/8/17 to 4/19/17. During a review of Resident #1's nursing notes dated 3/29/17, the ADON was notified of resident #1's continued manic type behaviors and of the need to contact resident #1's psychiatrist. A nursing note, dated 4/18/17, said resident #1 had been observed to be in a very manic state over the last several weeks as evidenced by resident #1's obsession over a bionic knee replacements, accusing persons of stealing her stuff, calling 911 to have them dust for prints, and calling her physician to express various health concerns without telling the facility nurse first. This nursing note also showed an appointment would be made with … | 2018-11-01 |
| 1542 | 1542 | ASPEN MEADOWS HEALTH AND REHABILITATION CENTER | 275140 | 3155 AVE C | BILLINGS | MT | 59102 | 2020-01-02 | 655 | D | 1 | 0 | LFEX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to develop and implement a baseline care plan for 1 (#1) of 6 sampled residents. Findings include: During an interview on 12/26/19 at 9:06 a.m., NF2 stated she had to strongly advocate for resident #1 in regard to her medications and her care. NF2 stated resident #1 was not sleeping well because she was not getting her [MEDICATION NAME] as at home. NF2 stated resident #1's surgeon was disappointed in her progress. NF2 stated she believed it was because resident #1 was tired, and wasn't receiving the best care. During an interview on 12/26/19 at 9:15 a.m., resident #1 stated she was very unhappy with the care that she had received while at the facility. Resident #1 stated therapy was helpful, but she felt no one else did much to help her recover. Resident #1 stated she received one shower during her 12 day stay and had difficulty getting assistance to go to the bathroom or getting clean sheets on her bed. During an interview on 12/26/19 at 12:10 p.m., staff member [NAME] stated she was responsible for initiating a baseline care plan once the admission assessment had been completed. Staff member [NAME] stated the baseline care plan was probably just missed, because they had been quite busy during the month of (MONTH) 2019. A review of resident #1's baseline care plan, dated 8/16/19, showed a problem related to the use of antidepressant medications and possible side effects, with appropriate goals and interventions. The care plan showed a problem related to impaired cognitive function with no goals or interventions; and a problem related to the establishment of a baseline care plan with the intervention of, Bathing 1 Specify Type. The care plan failed to show any problems, goals, or interventions related to resident #1's recent surgical procedure, rehabilitation needs, pain management, or discharge planning. | 2020-09-01 |
| 1474 | 1474 | WHITEFISH CARE AND REHABILITATION | 275132 | 1305 E 7TH ST | WHITEFISH | MT | 59937 | 2019-11-06 | 655 | D | 1 | 0 | REK811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to develop and implement baseline care plans for 2 (#s 1 and 10) of 11 sampled residents Findings include. 1. Resident #1 was admitted to the facility on [DATE]. A baseline care plan for the resident was requested for review of facility identified care concerns for the resident. The facility was not able to provide a baseline care plan for the resident. 2. Resident #10 was admitted to the facility on [DATE]. A baseline care plan for the resident was requested for review of facility identified care concerns for the resident. The facility was not able to provide a baseline care plan for the resident. During an interview on 11/6/19 at 10:35 a.m., staff member A said the facility did not have baseline care plans for resident #1 or resident #10. The staff member did not know why baseline care plans had not been done for these two residents. | 2020-09-01 |
| 2695 | 2695 | PONDEROSA PINES HEALTH CARE | 275096 | 1341 ROSEBUD LN | BILLINGS | MT | 59101 | 2017-05-25 | 354 | E | 1 | 0 | PRVT12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure a RN was on staff for at least 8 consecutive hours, seven days a week which resulted in a care deficit related to medication administration for 2 (#s 3 and 6) of 9 sampled residents. This deficient practice had the potential to affect all residents receiving care from the facility. Findings include: Review of the facility's Daily Staffing Information, dated 8/14/17, showed: RN/DON/Admin: out sick. Day shift 0600-1830: no RN available. Evening Shift 1800-0630: no RN available. During an interview on 8/14/17 at 11:44 a.m., staff member B stated the only RN scheduled for the day shift was out sick, and the facility did not have a RN scheduled for the night shift. The staff member stated the facility's DON and Administrator was an RN and she was the available RN for the days when an additional RN was not on the schedule. Review of the facility's nursing schedule for the month of June, (YEAR), showed a failure to have RN coverage on the following dates: 6/2/17, 6/3/17, 6/5/17, 6/6/17, 6/11/17, 6/17/17, 6/18/17, 6/19/17, 6/24/17, 6/25/17. Review of staff member A's time card showed the staff member was out of the facility, and an RN was not on staff at the facility on the following dates: 6/2/17, 6/3/17, 6/5/17, 6/6/17, 6/11/17, 6/17/17, 6/18/17, 6/19/17, 6/24/17, 6/25/17. Review of the facility's nursing schedule for the month of July, (YEAR), showed a failure to staff a RN coverage on the following dates: 7/9/17, 7/22/17, 7/23/17, and 7/25/17. Review of staff member A's time card showed the staff member was out of the facility, and an RN was not on staff at the facility on the following dates: 7/9/17, 7/22/17, 7/23/17, 7/25/17. Review of the facility's nursing schedule for the month of August, (YEAR), showed a failure to staff an RN on the following dates: 8/5/17, 8/6/17, 8/12/17, 8/13/17, and 8/14/17. Review of staff member A's time card showed the staff member was out of the … | 2018-11-01 |
| 1426 | 1426 | HI-LINE RETIREMENT CENTER | 275131 | 801 S 3RD ST E | MALTA | MT | 59538 | 2018-07-12 | 755 | F | 1 | 1 | 6W1G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure a missing narcotic medication patch was reported to the facility management and investigated for the disposition and reconciliation of the medication, which was a [MEDICATION NAME], for 1 (#37) of 19 sampled residents. Findings include: Review of resident #37's medical record reflected a nurse's note, dated 6/30/18 at 4:01 p.m., that the resident's [MEDICATION NAME] was missing, and the nurse placed a new one on the resident. There was no documentation to show the missing [MEDICATION NAME] was reported or that an investigation was completed for the reconciliation of the missing narcotic patch. During an interview on 7/11/18 at 4:15 p.m., staff member N stated all narcotic counts are tracked on the computer. She stated staff conducted a count of all the narcotics at the end of their shift with the oncoming shift nurse. She stated both staff signatures were electronically signed when reconciling narcotics at the end of the shift. During an interview on 7/12/18 at 7:33 a.m., staff member M stated if a [MEDICATION NAME] was missing off of the resident the staff member would search for it, and if it was not found an incident report would be completed, and the incident would be reported to the nurse. She stated a [MEDICATION NAME] was placed over the [MEDICATION NAME] when it was administered to help prevent the patch from rolling off of the resident. She stated when it was time to change the patch another staff person observed the patch being disposed of in the Sharps container. She stated the disposal was documented in the electronic health record, but the person who witnessed the disposal was not able to electronically sign that he/she witnessed the disposal. She stated there was no other non-electronic documentation that would show signatures by both the staff person disposing of the [MEDICATION NAME] and the witness. She stated she and another staff person have discussed the… | 2020-09-01 |
| 89 | 89 | ST JOHN'S LUTHERAN HOME | 275024 | 3940 RIMROCK RD | BILLINGS | MT | 59102 | 2019-08-22 | 625 | D | 1 | 1 | P5VQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure a resident or a resident's representative received written information regarding the Bed Hold Policy prior to a transfer, for 3 (#s 22, 100, and 135) of 29 sampled residents. Findings include: 1. During an interview on 8/20/19 at 9:55 a.m., staff member F stated that resident #100 was transferred to the hospital for a [MEDICAL CONDITION] in (MONTH) of 2019. Review of resident #100's medical record failed to show any documentation of the provision of bed hold policy information prior to her transfer to the hospital on [DATE]. During an interview on 8/22/19 at 9:55 a.m., staff member B stated the only bed hold information given to the resident and/or resident's representative was upon admission by the Admission Director. Staff member B stated the facility had not provided any bed hold information upon the transfer to the hospital. During an interview on 8/22/19 at 10:10 a.m., staff member D stated she had not provided any written information to the resident or resident's representative prior to transfer to the hospital. During an interview on 8/22/19 at 10:25 a.m., staff member F stated she had not done any written notifications to the resident or resident's representative regarding the bed hold policy. Staff member F stated she did the communication notice that informed the facility of the change for a resident upon transfer. Staff member F stated the written notices were completed by medical records, and the admissions director. 2. During an interview on 8/21/19 at 3:14 p.m., staff member B stated the facility did not notify the resident or resident's representative of a the bed hold policy upon transfer, but resident #22 was notified at admission. Review of resident #22's Iview Notification, dated 7/24/19, showed, Nurse left voicemail for (name) to return call-called and spoke with (name) and given ok to send to ED (emergency department). (sic) A request on 8/21/19 at 11:0… | 2020-09-01 |
| 1504 | 1504 | BLACKFEET CARE CENTER | 275133 | 728 S GOVERNMENT SQ | BROWNING | MT | 59417 | 2019-10-31 | 600 | G | 1 | 0 | DC1U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure a resident received timely treatment for [REDACTED].#74) of 22 sampled residents. Findings include: During an interview on 10/30/19 at 2:30 p.m., staff member D stated she received a report of bruising to resident #74 on 9/22/19. Staff member D stated bruises were to be reported to the DON or Social Services upon observing them. Staff member D stated nursing did not report the bruising like they should have. During an interview on 10/30/19 at 3:00 p.m., staff member B stated if a CNA finds a bruise, they are to fill out a pink slip and give it to the nurse. Staff member B stated the nurses are to report to the DON, who then would follow up. Staff member B stated the bruise would be assessed and documented in the medical record. Staff member B stated she had received a report about a bruise on resident #74's shoulder on 9/19/19. Staff member B stated it was first reported as a small bruise on the resident's arm and worsened from there. Review of resident #74's nursing progress notes, from 9/19/19 through 9/22/19, showed the following: -9/19/19 at 6:45 p.m., CNA stated that she had found a small bruise to her Right shoulder. bruise small and approx quarter in size on the upper arm. (sic) -9/20/19 at 3:28 a.m., Resident has a bruise on right shoulder. -9/21/19 at 5:03 a.m., 0800 during showing resident a large bruise on right frontal axilla, reported by the CN[NAME] (sic) -9/21/19 at 6:17 p.m., (Resident name) has a huge bruise from the top of inner right arm to approximately the anticubital area. Unknown cause. Pink slip filled out and turned into the DON. (sic) -9/22/19 at 2:31 a.m., Bruising of RUE, beginning at the top of bicep to above inner elbow. Noted 15cm x 6cm. At top of bicep is a hard raised swelling-measures 7cm x 5cm. measured in an X formation as swelling is not round but oblong in shape. Assessment and configuration of bruising and area of swelling-It appears s… | 2020-09-01 |
| 906 | 906 | CONTINENTAL CARE AND REHABILITATION | 275103 | 2400 CONTINENTAL DR | BUTTE | MT | 59701 | 2018-08-23 | 684 | G | 1 | 1 | 4NKL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure a resident received treatment and care to avoid obstipation resulting in the resident being sent to the emergency department to be evaluated for fecal impaction, and the resident admitted to the hospital, for 1 (#61) of 25 sampled residents. Findings include: During an interview on 8/22/18 at 3:16 p.m., staff member M stated the facility did not have a policy and procedure for a bowel protocol. She stated she received a report every morning from the Dash Board on the EHR, and she gave it to the nurses if a resident did not have a BM within 72 hours. She stated staff were to start with MOM and then a suppository. She stated if the suppository did not work within two hours, then the nurse called the doctor and would give a Fleets enema or other prescribed orders. Staff member M stated the admission physician's orders [REDACTED]. Resident #61 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #61's medical record showed she had a discharge to the hospital on [DATE], and was readmitted to the facility on [DATE]. Review of resident #61's emergency room medical records, dated 8/12/18, showed she presents by ambulance from a local nursing home with complaint of 'not feeling well' and not having a bowel movement for 9 days. The patient is very confused and when I asked how long her abdomen has been hurting she said 'forever.' She also thought it was 1988. According to nursing home she has had vomiting a couple times in the past 24 hours. She states she has been passing gas. The emergency room Exam notes showed resident #61 had, liquid stool at the anus and on digital exam there is hard impacted stool in the rectal vault. Documented under the heading Final Impression was, 1. Fecal impaction 2. Acute kidney injury. Resident #61 was admitted to the hospital from the Emergency Department. Review of resident #61's hospital Discharge Summary, dated 8/15/18, under … | 2020-09-01 |
| 65 | 65 | VALLE VISTA MANOR | 275021 | 402 SUMMIT AVE | LEWISTOWN | MT | 59457 | 2017-10-12 | 201 | D | 1 | 1 | BU9C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure a resident was assisted with an appropriate discharge plan, when the resident wanted to immediately leave the facility, to ensure the resident's ongoing needs were met, but the facility had determined that long term care was necessary, for 1 (#1) of 10 sampled residents. Findings include: During an interview on [DATE] at 6:00 p.m., staff member C stated that resident #1 was discharged from the facility on [DATE]. Staff member C stated that resident #1 was discharged because the facility could not meet his needs per staff member B. Staff member C stated that resident #1 did not have an initial discharge plan, as he was considered to be a long term resident, and could not return to live in the community. Staff member C stated that after the resident left the facility, and had been taken to the hospital, the hospital had not notified the facility directly when resident #1 was discharged from the hospital. Review of the resident's Discharge Return Anticipated MDS, with an ARD date of [DATE], showed in Section Q, under Discharge Plan, A was coded as a 1 which is for a yes meaning active discharge planning was already occurring for the resident to return to the community. The MDS contradicted what staff member C had stated relating to long term care placement. Review of resident #1's Resident Incident Report, dated [DATE] at 9:18 p.m., showed resident #1 became increasingly verbally angry with facility staff, and he stated he wanted to leave in his vehicle. When resident #1 would not calm down, staff member P phoned staff member B and was informed of the situation. Staff member B advised staff member P to contact law enforcement, due to the resident's behavior. Resident #1 was escorted from the facility by law enforcement, although a discharge plan had not been initiated for the resident, prior to the resident leaving the facility. Further review of the incident report for reside… | 2020-09-01 |
| 2114 | 2114 | VILLAGE HEALTH & REHABILITATION | 275043 | 2651 SOUTH AVE W | MISSOULA | MT | 59804 | 2016-09-29 | 327 | D | 1 | 0 | N7JV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure adequate fluid intake, to maintain proper hydration for 2 (#s 1 and 7) of 14 sampled residents. Findings include: 1. Resident #1 was admitted to the facility on [DATE] and discharged to the hospital on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Nutritional Assessment, dated 8/3/16, showed the resident required 1093-1311 kcals and cc fluid, and 44-52 gm (grams) protein qd (daily). The facility failed to identify a UTI in the past 30 days, and less than 1200 cc fluid intake daily as risk factors for dehydration for resident #1. Review of resident #1's fluid intake record, from 8/1/16 through 8/15/16, showed the following: -8/1/16=120 cc -8/2/16=240 cc -8/4/16=360 cc -8/5/16=480 cc -8/6/16=240 cc -8/7/16=0 cc -8/8/16=240 cc -8/9/16=0 cc with a notation sleeping -8/10/16=240 cc -8/11/16=360 cc -8/12/16=0 cc -8/13/16=0 cc -8/15/16=0 cc with a notation refused Resident #1's fluid intake record lacked documentation for 8/3/16 and 8/14/16. The facility documentation failed to show the resident's daily fluid intake was adequate to prevent dehydration. Review of the resident's MAR, for 8/2016, showed the resident received 8 oz of Ensure three times daily. The facility documentation failed to show the amount of supplement the resident consumed. Resident #1 was transferred to the hospital on [DATE]. Review of the resident's emergency room visit notes showed the following: -altered mental status -respiratory rate of 38 -heart rate of 159 with new onset [MEDICAL CONDITION], related [MEDICAL CONDITION] -air oxygen saturation 84% -urinalysis was consistent with urinary tract infection -high sodium (sign of dehydration) of 160 Review of the resident's hospital inpatient Nutrition consult, dated 8/16/16, showed inadequate oral intake, low BMI, severe weight loss, a stage II pressure ulcer on the resident's coccyx. Review of the weights, by the hospital dietician, showed the r… | 2019-09-01 |
| 812 | 812 | VALLEY VIEW HOME | 275091 | 1225 PERRY LN | GLASGOW | MT | 59230 | 2018-08-09 | 660 | D | 1 | 1 | PQ0P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure discharge plans were identified and updated regularly throughout a resident's stay, ensuring the family was aware of the identified needs and services when or if there was a discharge from the facility, for 1 (#205) of 28 sampled and supplemental residents. Findings include: During an interview on 8/8/18 at 1:13 p.m., NF1 stated the resident's family was not aware the facility was going to send resident #205 out of town to a behavioral unit, until the facility was ready to send the resident. During an interview on 8/9/18 at 8:30 a.m., staff member A stated resident #205's discharge plan, on admit, was that the resident was going to be a long term stay at the facility. During an interview on 8/9/18 at 8:01 a.m., staff member A stated the facility staff had contacted the family 11/8/17, after resident #205 had hit a staff member. The behavior unit out of town was discussed. The family said they would think about transferring the resident. Review of resident #205's nursing progress note, dated 8/18/17 at 11:04 a.m., showed the resident was admitted to the facility. Review of resident #205's physician progress notes [REDACTED].#205 after the resident was admitted to the facility. The facility staff were reporting the resident had increased bad behaviors. Review of resident #205's progress notes, dated 9/6/17 at 10:46 a.m., showed social services spoke to resident #205's wife, stating the possibility of a stay at an out of town hospital's behavioral unit to try and stabilize the resident's behavior. Review of resident #205's progress notes, dated 9/6/17 at 1:27 p.m., showed social services staff had contacted the out of town hospital's BHU, stating the facility would first monitor the resident for effects of the added [MEDICATION NAME] (a medication) before a behavioral unit stay. There was no documentation that the resident's wife or the POA was notified. There was no update on… | 2020-09-01 |
| 1709 | 1709 | MONTANA MENTAL HEALTH NURSING HOME | 27A052 | 800 CASINO CREEK DR | LEWISTOWN | MT | 59457 | 2017-06-23 | 281 | D | 1 | 0 | 9PC311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure medications were secured, and a non-licensed staff member administered medications to a resident and the resident had negative affects from the medication, for 1 (#2) of 8 sampled residents. Findings include: During an interview on 6/22/17 at 9:45 a.m., staff member B said that a CNA took a medication cup off the medication cart and gave the medications to a resident (#2). Review of resident #2's Interdisciplinary Progress Notes, dated 5/19/17 at 10:00 p.m., showed that resident #2 was given two medications; [MEDICATION NAME] (anticonvulsant) and [MEDICATION NAME] (antipsychotic). Review of resident #2's physician orders, signed on 5/23/17, showed that resident #2 did not have [MEDICATION NAME] and [MEDICATION NAME] ordered by the physician. Review of the investigation notes, dated 5/25/17, showed that the employee who provided the medications to resident #2 had worked outside the employee's scope of practice, and on 5/19/17, the employee administered medication from the medication cart without approval or oversight from the RN. The medication administered to the resident was the wrong medication. The employee was not hired at the facility to administer medications to the residents, but was employed as a CN[NAME] Review of staff member N's statement showed she took a medication cup off the medication cart on 5/19/17 and gave the medications from the cup to resident #2. It was determined by the RN that the medications staff member N administered were not ordered for the resident, and were identified to be [MEDICATION NAME] and [MEDICATION NAME]. A review of the facility records, and resident #2's medical record, showed the resident had an adverse effect from the medications given by staff member N. The resident was monitored from 5/19/17 through 5/20/17. Resident #2's Interdisciplinary Progress note dated 5/20/17 at 5:30 p.m., showed that resident #2 was extremely lethargic,… | 2020-09-01 |
| 1071 | 1071 | ROCKY MOUNTAIN CARE CENTER | 275114 | 30 S RODNEY ST | HELENA | MT | 59601 | 2018-04-23 | 550 | E | 1 | 0 | FF0J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure resident preferences were met for bathing to include disrupting a resident's preferred routine for 1 (#8); for maintaining clean skin for a resident who had a skin rash, for 1 (#11); and for meeting a resident's personal preferences for hygiene, for 1 (#10) of 11 sampled residents. Findings include: 1. Review of resident #8's Admission MDS, with an ARD of 3/6/18, showed the resident had a BIMs of 15, and set up assistance with bathing. During an interview on 4/19/18 at 8:40 a.m. resident #8 stated she had a choice of when she took a shower. The resident said when she was at home, she took showers daily. At the facility, she received about two showers a week. She stated she would like more showers and that the shower before breakfast, around 5:30, 6:00 a.m. The resident stated she left her compression stockings off until her shower, related to the difficulty of putting on and taking off. She did not want to wait until later on in the day for a shower, and have her stockings on until then. The resident also stated she was very hot, in the facility. The resident believed the high heat in the facility could cause her to have [MEDICAL CONDITION] and or a stroke. The resident said showers would help her deal with the heat. Review of resident #8's bathing sheet, dated 2/19/18-4/19/18, showed the resident did not have a shower between; - 3/2/18 and 3/7/18, six days without a shower, - 3/19/18 and 3/21/18, three days without a shower, - 3/26/18 and 3/31/18, six days without a shower, - 4/9/18 and 4/13/18, five days without a shower, - 4/16/18 and 4/23/18, eight days without a shower. Review of resident #8's care plan, with a review date of 4/17/18, did not show the resident's preference for daily showers, just that she needed limited assistance with the shower. 2. Review of resident #11's Annual MDS, with an ARD of 3/22/18, showed the resident had a BIMs of 14; cognitively intact. T… | 2020-09-01 |
| 542 | 542 | CENTRAL MONTANA NURSING & REHABILITATION CENTER | 275064 | 410 WENDELL AVE | LEWISTOWN | MT | 59457 | 2019-09-05 | 602 | E | 1 | 0 | 45BK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure residents were free from misappropriation of property, and exploitation for 5 (#s 4, 6, 7, 8, and 9) of 9 sampled residents. Findings include: During an interview on [DATE] at 11:05 a.m., staff member C stated APS notified the Executive Director (ED), on [DATE], of a possible exploitation situation between NF4 and resident #8. Staff member C stated resident #8 was in charge of his own affairs until his death on [DATE]. NF4 was an employee and a family friend of resident #8. APS had been notified by resident #8's bank that NF4 had been writing checks on resident #8's account, after his death. Staff member C stated the facility placed NF4 on suspension, and initiated an investigation to determine if any other residents had been affected. Staff member C stated she was responsible for managing the balances and keeping copies of the receipts. Staff member C stated she started working at the facility in (MONTH) of (YEAR), and was not sure how the process was handled prior to her arrival. During an interview on [DATE] at 12:50 p.m., staff member A stated she was notified by APS on [DATE] of possible misappropriation of resident #8's funds by NF4. Staff member A stated the Medicaid Fraud Unit was also involved in the investigation. During an interview on [DATE] at 9:07 a.m., staff member C stated four residents used a trust account for personal spending. She said the Social Services Designee (SSD) usually did the shopping for the residents. Staff member C stated the SSD was given cash, and brought back the receipts and the purchases. Any staff member available was asked to co-sign the receipt to confirm the purchases had been made. Staff member C stated she kept the receipts and maintained the bookkeeping records. Staff member C said the shopping began in (MONTH) of (YEAR), around Christmastime. Staff member C stated she wondered about the items because of the number of shoes and j… | 2020-09-01 |
| 684 | 684 | APPLE REHAB COONEY | 275080 | 2555 E BROADWAY | HELENA | MT | 59601 | 2019-05-22 | 760 | G | 1 | 0 | T2P611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for 2 (#s 1 and 2) of 4 sampled residents. Resident #1 was given the wrong medication and required transport to the hospital. Resident #2 was given an overdose of medication and sustained a fall following the incident. Findings include: 1. During an interview on 5/22/19 at 12:45 p.m., staff member B stated resident #1 received the wrong medications. Staff member B stated staff member [NAME] had drawn up medications for resident #1, however the resident had refused the medications at that time. Staff member [NAME] then began to draw up medications, [MEDICATION NAME] 40 mg and [MEDICATION NAME] 75 mg, for another resident when resident #1 called and stated she was ready for her medications. Staff member B stated staff member [NAME] grabbed the wrong medication cup and gave resident #1 medications belonging to another resident. Staff member B stated resident #1 was transferred from the facility to the hospital for evaluation following the incident. Staff member B stated she observed staff member [NAME] administering medications to other residents and there were no further incidents that night. Staff member B stated there was a staff meeting on 4/25/19 in which she discussed with nursing staff how to file a medication error report. Staff member B stated there was a staff meeting last Wednesday (5/15/19) in which she went over the rights of medication administration. There was no evidence of follow up on staff member E's competency with medication administration. Review of resident #1's nurse's note, dated 5/6/19 at 8:00 p.m., showed resident #1 received another resident's HS meds around 7:15 p.m. The resident had just left the facility via ambulance for monitoring at the ER. At 9:20 p.m., the facility received word from the hospital that resident #1 would be admitted for observation. The resident did not return to the facil… | 2020-09-01 |
| 508 | 508 | COPPER RIDGE HEALTH AND REHABILITATION CENTER | 275060 | 3251 NETTIE ST | BUTTE | MT | 59701 | 2018-07-31 | 678 | D | 1 | 0 | GLJS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure staff provided CPR to a resident who was a full code for 1 (#1) of 7 sampled residents. Findings include: Resident #1 was admitted to the facility after a fall at home resulting in a [MEDICAL CONDITION] and a left hip arthroplasty. Review of resident #1's admission records showed he was admitted to the facility to be evaluated and treated with physical and occupational therapy. The admission orders [REDACTED]. The orders were signed by NF1. Review of resident #1's POLST showed the form was not completed. At the bottom of the form was written, Does not want to address at this time and was signed by resident #2's wife and staff member D. The form was not dated. Review of resident #1's nurse's note, dated [DATE] without a time noted, showed, up took meds, meal on wing went to P/T, Ret to Rm. Hoyer into bed went to remove sling Pt became limp color pale. called to room last breath no pulse no B/P expired wife Dr. notified Wife visited him. Review of resident #1's Record of Death showed the date of death as [DATE] at 9:05 a.m. During an interview on [DATE] at 1:45 p.m., staff member D stated resident #1's wife wanted him to be a full code. She stated in the past his wife stated to resident #1 that he didn't want a code but reminded him of how well he came out of the hospital. Staff member D stated the POLST was addressed during the care plan meeting on [DATE] and resident #1 was sleeping throughout the meeting. She stated resident #1's wife kept waking him and would try to talk to him. Staff member D stated resident #1's wife did not want to make the decision for him. She stated resident #1 wanted to go to bed and did not want to address completing the POLST. Staff member D stated if a resident coded, and was a full code, CPR would be administered. Review of resident #1's Care Conference form, dated [DATE], showed resident #1, his wife, and a staff member from nursing, therapy, … | 2020-09-01 |
| 1021 | 1021 | LAUREL HEALTH & REHABILITATION CENTER | 275111 | 820 3RD AVE | LAUREL | MT | 59044 | 2018-03-28 | 580 | D | 1 | 0 | NY5D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure the physician and resident representative was notified of a change of condition for 1 (#11) of 15 sampled residents. Resident #11 sustained an injury of unknown origin. Findings Include: Review of resident #11's Multi-Disciplinary Progress Notes showed the resident fell on [DATE]. The entries dated 1/24/18, 1/25/18, 1/28/18, 1/29/18, 1/30/18 and 1/31/18 showed no new skin trauma, bruising or injuries were documented by the nursing staff. Then the next entry was dated 2/5/18 and showed the resident had a skin tear on her left lower leg measuring approximately 5.2 cm x 0.2 cm x 0.1 cm. The entry showed the resident could not state how she sustained the injury. The medical record lacked the physician's and the DPOA's notification of the significant skin tear. Review of the provider's book showed an entry, dated 2/18/18, requesting the physician to check a wound on the resident's left lower extremity. The physician's extender initialed the entry in the provider's book on 2/19/18. During an interview on 3/27/18 at 8:45 a.m., Staff member B stated staff member M failed to notify appropriate entities, including the physician, the DPOA and the administrative staff; and staff member M failed to report the injury in the 24-hour alert charting. Staff member B stated staff member M, who found the skin tear on 2/5/18 no longer was employed by the facility. She stated she agreed the event was not handled properly. During an interview on 3/27/18 at 3:03 p.m., NF1 stated the facility called and she was notified that the resident fell at some point, but she was not told about any skin tears on the resident's leg. NF1 stated one day she was visiting her mother, she saw the resident's leg, and asked the staff what happened. The facility failed to show evidence they had notified resident #11's attending physician and the emergency representative of the leg injury initially when it was discover… | 2020-09-01 |
| 1541 | 1541 | ASPEN MEADOWS HEALTH AND REHABILITATION CENTER | 275140 | 3155 AVE C | BILLINGS | MT | 59102 | 2020-01-02 | 585 | D | 1 | 0 | LFEX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure the prompt resolution of a resident grievance, and to maintain evidence demonstrating the result of a resident grievance for 1 (#2) of 6 sampled residents; and the facility failed to notify residents individually, or through postings throughout the facility, of the necessary contact information for the grievance official. This deficient practice resulted in stress and frustration for the resident. Findings include: 1. During an interview on 12/24/19 at 8:50 a.m., resident #2 stated she had been admitted approximately six weeks earlier, after suffering a [MEDICAL CONDITION] at home. Resident #2 stated she was blind, and had been hoping to get into an assisted living facility. Resident #2 stated she had been having a problem with a CNA since first arriving at the facility. Resident #2 stated due to her [MEDICAL CONDITION], she was sensitive to the tone of voice of staff who spoke to her. She stated she had several conversations with the administrator about how a CNA had been gruff and very rude to her. Resident #2 considered these conversations to be complaints, and resident #2 stated she went so far as to request the CNA not care for her. Resident #2 stated the only thing the administrator ever did was to tell the staff member to, Be nicer. Resident #2 stated nothing ever changed. The attitude and treatment by the CNA did not change. Resident #2 stated this had caused her stress and frustration, and she did not know who to trust. During an interview on 12/26/19 at 1:53 p.m., staff member G stated the current Social Service Director was the Grievance Official, but he had been handling some of the complaints due to changes in the Social Services position over the past eight months or so. Staff member G stated he had not been documenting all of the resident concerns in the grievance log. Staff member G stated he asked the resident if they wanted to file a grievance. If the resi… | 2020-09-01 |
| 216 | 216 | AVANTARA OF BILLINGS | 275029 | 2115 CENTRAL AVE | BILLINGS | MT | 59102 | 2017-11-21 | 280 | E | 1 | 1 | S6P111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure the resident was provided the opportunity to have a care plan meeting and participate in their own treatment, for 3 (#s 4, 5, 15); the facility failed to review and revise the care plan to accurately reflect a resident's changing care needs for impaired skin integrity for 1 (#2) of 23 sampled residents. Findings include: 1. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #4 has been a resident at the facility for over one year. During an interview on 11/19/17 at 3:55 p.m., resident #4 stated she had been to one care plan conference meeting since her admission. Resident #4 stated she had not participated in a care conference meeting for several months. During an interview on 11/20/17 at 2:55 p.m., resident #4 stated she had asked staff several times for ice to be placed in her water. Resident #4 stated staff was supposed to pass fresh water every shift, but many times they did not have time. Resident #4 stated she had a catheter and was prone to urinary tract infections and must have a lot of water. Resident #4 stated she had a difficult time drinking water if it was room temperature. Resident #4 stated she had told staff several times she did not want to continue to take her medication, Senna, as it caused her to have diarrhea. Resident #4 stated the nurses continued to give it to her, and she had refused to take it. The resident did not understand why the nurses did not call her physician and notify him that she did not want the medication scheduled daily. Resident #4 did not have an opportunity to report her concerns at her care plan meeting, or request that a change be made to her care plan, to address the need for ice water. She was unable to discuss the change of treatment to address the prescribed Senna. Review of resident #4's medical record did not include documentation, through notes or signatures of participation, that the resident had… | 2020-09-01 |
| 1022 | 1022 | LAUREL HEALTH & REHABILITATION CENTER | 275111 | 820 3RD AVE | LAUREL | MT | 59044 | 2018-03-28 | 609 | D | 1 | 0 | NY5D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure timely investigation, documentation, and reporting of bodily injuries of unknown origin for a resident who had dementia, for 1 (#11) of 15 sampled residents. Although, the resident was at high risk for falls and injury, the facility failed to investigate and report a significant size skin tear injury to rule out potential physical and mental abuse or anguish to the resident. The resident's wound worsened before becoming better again. (Refer to F684) Findings include: Review of the resident #11's medical record showed a physician's orders [REDACTED]. Review of the Annual MDS with an ARD of 1/26/18 showed the resident had a BIMS score of 05 (severely impaired) for section C0500. During an interview on 3/28/18 at 7:20 a.m., resident #11 was getting ready to put her make up. She asked where her foundation was located. She was in the bathroom, with the box of make up in a drawer. She was assisted by the surveyor finding her compact case for the foundation. She rinsed the sponge in the running water and dipped wet sponge in the compact and tried to apply watered down foundation on her face. Review of resident #11's Multi-disciplinary Progress Notes showed a nursing entry on 2/5/18, illustrating a skin tear measuring approximately 5.2 cm x 0.2 cm x 0.1 cm on the left lower leg of the resident. The entry showed the resident could not state how she sustained the injury. Review of the Multi-Disciplinary Progress Notes entry dated 2/16/18 showed the wound on the resident's left lower leg was categorized more of a DTI or diabetic ulcer. The wound measured 5.8 cm x 2.7 cm. The entire left lower leg was quite red around the wound and appeared to have areas with bruising, and dark discoloration. The administrative staff were notified on 2/16/18. During an interview on 3/27/18 at 8:45 a.m., a record request was provided to staff member B, which included the facility investigations and repo… | 2020-09-01 |
| 1498 | 1498 | BLACKFEET CARE CENTER | 275133 | 728 S GOVERNMENT SQ | BROWNING | MT | 59417 | 2019-07-31 | 726 | G | 1 | 0 | OTSO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to evaluate and monitor a resident after multiple choking and aspirating events during meals for 1(#1) of 3 sampled residents. This deficiency has the potential to affect all residents. Findings include: During an interview on 7/31/19 at 2:41 p.m., staff member F stated the procedure for choking and/or aspiration is the [MEDICATION NAME] maneuver, monitor lungs and breathing for change of condition [MEDICATION NAME] 24 hours, and to keep the resident up and out of bed. Staff member F stated if needed send the resident to the hospital or have the doctor asses the resident or if resident was to aspirate, she would call the emergency room and ask them what to do. During an interview on 7/31/19 at 2:42 p.m., staff member B stated if a resident choked or aspirated, the procedure would be to call the doctor or send to the emergency room if needed, notify the family member, get a doctor order for a swallow evaluation, and then schedule the swallow evaluation as soon as possible. Staff member B stated the staff is to monitor the resident and the consistency of the food or drink that cause the event to happen and revise the diet as needed such as upgrading or downgrading the diet texture. Staff member B stated that following an event of choking or aspirating it should be documented in an incident assessment called the sbar communication note. Staff member B stated there were no sbars for resident #1. During an interview on 7/31/19 at 3:36 p.m., staff member C stated she had not experienced anyone choking or aspirating in the facility but if it did happen, she would check to make sure there was not anything in the resident's mouth then you would do the [MEDICATION NAME] maneuver. During an interview on 7/31/19 at 4:55 p.m., staff member D stated if a resident was choking or aspirating, she would perform the [MEDICATION NAME] maneuver and lean the resident forward and rub their back. Staff memb… | 2020-09-01 |
| 1323 | 1323 | IMMANUEL SKILLED CARE CENTER | 275129 | 185 CRESTLINE AVE | KALISPELL | MT | 59901 | 2019-02-05 | 578 | D | 1 | 1 | JYZK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to follow a court appointed guardianship when obtaining consent for a change in a resident's POLST for 1 (#68) of 27 sampled residents. Findings include: During an interview on [DATE] at 10:28 a.m., a confidential interviewee stated resident #68 was provided a guardianship by a court of law. She stated this guardianship was appointed for a permanent full guardianship due to his disability, which prevented the resident from making informed decisions and giving consent regarding his healthcare. The confidential interviewee stated the resident had a court appointed POLST which she provided to the facility upon the resident's admission on [DATE]. She stated she received a phone call from the facility that the resident needed some consent forms signed. She stated when she arrived at the facility she was told to talk with the nurse on the resident's unit. When she asked the nurse, she was told that the resident had already signed a couple consents for pneumonia and flu vaccines, [MEDICAL CONDITION] medications, and his POLST. When the confidential interviewee explained to the nurse that the resident was not capable to give an informed consent, she said the nurse shrugged her shoulders and told her she could just sign over the resident's signature. The confidential interviewee stated she was alarmed by the staff's lack of concern with the legal documents. She stated the nurse did not want to fill out new documents for her to sign, so she signed next to the resident's signature on all the consents except for the POLST. She stated when she reviewed the POLST, which the nurse had the resident sign, the POLST had been down-graded from a full code to limited interventions. The confidential interviewee stated this was a concern because a POLST can only be changed by a Judge. She stated in order to change the standing of a POLST for an individual who has a court appointment guardianship, a physici… | 2020-09-01 |
| 2247 | 2247 | INVIGORATE POST ACUTE OF WHITEFISH | 275132 | 1305 E 7TH ST | WHITEFISH | MT | 59937 | 2016-07-07 | 281 | D | 1 | 0 | 998S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to follow physician prescription orders by not giving scheduled pain medication and monitor a resident's pain every shift for 1 (#1) of 5 sampled residents. Findings include: Resident #1 was admitted to the facility on [DATE]. The current [DIAGNOSES REDACTED]. The resident passed away on 4/29/16, while on hospice care. Review of resident #1's Medication Administration Record [REDACTED]. All three orders were scheduled medications starting 4/19/16. The resident was ordered [MEDICATION NAME] sulfate solution, 20 MG/ML, give 30 mg by mouth every four hours for the [DIAGNOSES REDACTED]. Between 4/19/16 and the afternoon of 4/26/16 the order of [MEDICATION NAME] was not given six times, the [MEDICATION NAME] was not given eight times, and the [MEDICATION NAME] was not given two times. Specifically, on 4/25/16, resident #1 was only given 3 of 6 doses of [MEDICATION NAME], missing 3 consecutive doses and only 1 of 3 doses of [MEDICATION NAME] were given. On 4/25/16-4/26/16 the [MEDICATION NAME] dose was missed 5 consecutive times it was to be given. The Medication Administration Record [REDACTED]. In a confidential interview on 7/7/16 at 8:30 a.m., the interviewee stated the medications were changed from PRN to scheduled on 4/19/16 because of resident #1's increased pain, agitation, and anxiety. The PRN medications were not enough. The medications were in a form which could be slipped into the cheek or under the tongue, so doses would not be missed. The interviewee also stated there was never any explanation from the nurses caring for resident #1, as to why the medications were held. The Medication Administration Record [REDACTED]. During the month of (MONTH) (YEAR), there was no documentation for pain monitoring 27 out of 58 times, with no documentation why the monitoring was missed. Nurses are obligated to follow the orders of a licensed physician or other designated health care provider … | 2019-07-01 |
| 1265 | 1265 | THE LIVING CENTRE | 275125 | 57 MAIN ST | STEVENSVILLE | MT | 59870 | 2019-10-03 | 658 | D | 1 | 0 | 9LZG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to follow professional standards of practice, with the potential to cause medication errors, by not documenting the administration of PRN, narcotic medications in the electronic medication administration records, for 3 (#s 9, 10, and 17) of 15 sampled residents. The deficient practice had the potential to negatively affect all residents in the facility that received PRN, narcotic medications. Findings include: During an interview on 10/1/19 at 3:10 p.m., NF2 stated PRN, narcotic medications were not always being documented in the MAR indicated [REDACTED]. My fear was it put the residents at risk for an overdose. This was reported to staff member A and B for over a year, and nothing was done about it. During an interview on 10/2/19 at 2:15 p.m., staff member I stated PRN, narcotic medications are documented in three places. Staff member I stated, You sign it out in the computer in point click care, sign it out of the resident's log sheet, and the narcotic tracking sheet. Staff member I stated she was trained on administering PRN, narcotic medications during orientation training. During an interview on 10/2/19 at 2:35 p.m., staff member J stated the process for signing out PRN, narcotic medication was to first sign out the medication in Point Click Care (EHR system) in the computer, after you checked when the last dose was given. Staff member J stated, You then sign it out on the resident's narcotic sheet, then on the general sign out sheet. Staff member J stated she was trained on the PRN narcotic medication administration procedure in orientation. During an interview 10/3/19 at 8:09 a.m., staff member B stated PRN, narcotic medications are signed out in the MAR, on the computer, the individual sign out sheet for each resident's PRN medication, and finally the PRN tracking forms. Staff member B stated, We created the PRN, tracking form because some nurses were having a hard time signi… | 2020-09-01 |
| 1432 | 1432 | HI-LINE RETIREMENT CENTER | 275131 | 801 S 3RD ST E | MALTA | MT | 59538 | 2018-07-12 | 881 | E | 1 | 1 | 6W1G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to have an antibiotic stewardship program for the facility for the tracking, trending, and monitoring of antibiotics, to ensure the antibiotics, which affected 1 (#33) of 19 sampled residents. Findings include: Resident #33 was admitted with [DIAGNOSES REDACTED]. During an interview on 7/12/18 at 9:12 a.m., staff member N stated that the facility did not have an antibiotic stewardship program in place. Staff member N said she pulled antibiotic reports and the pharmacist gave her a list of residents placed on antibiotics. Staff member N stated the norm is that residents are placed on antibiotics while waiting for the culture and sensitivity results to come back. Staff member N said there were no antibiotic protocols in place. Review of resident #33's progress note, dated and timed 5/1/18 at 1:23 p.m., showed the resident's catheter was changed as it was leaking. His urine was turbid, with obvious sediment. A urine sample was obtained. The resident's MD was notified. Review of resident #33's progress note dated and timed 5/1/18 at 7:24 p.m., showed the resident had a temperature of 100.5 F. The provider on call was called, updated, and an antibiotic was ordered. The culture and sensitivity report was not completed. Review of resident #33's hospital admission note dated 5/3/18, showed the resident was admitted to the hospital with [REDACTED]. | 2020-09-01 |
| 117 | 117 | HERITAGE PLACE | 275025 | 171 HERITAGE WAY | KALISPELL | MT | 59901 | 2017-11-22 | 166 | D | 1 | 0 | D7BM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to identify a Grievance Officer; failed to promptly follow-up on a grievance, document the date the original grievance was filed, notify the resident in writing of the decision, and document the date the written decision was issued for 1 (#2) of 11 sampled and supplemental residents. Findings include: 1. Resident #2 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The resident was discharged to another facility on 11/3/17. During an interview on 11/21/17 at 9:36 a.m., resident #2's family member stated the day the resident was discharged on [DATE], he did not have his dentures in his mouth. She stated she asked the facility staff where his dentures were and she was told one of the CNAs took his dentures out the night before around 2:00 a.m. She stated she and the facility staff both looked in the room, the dining room, and other areas where the resident's dentures might have been placed. She was told by the facility staff they will file a concern regarding the missing dentures and had planned to follow up with her about the outcome. The family member stated she did not hear back for over a week from the facility. She stated she called several times during that week and left messages to have staff member A and/or staff member C call her back regarding the missing dentures. She stated she called for a third time a week later to follow up with the Staff member A, whether facility had found resident #2's dentures. She stated when she called, she was told by the person whom answered the phone, they believed they had found the dentures and she could come and pick them up. When she arrived at the facility, she was told staff member A wanted to discuss something with her first. She stated when she entered the staff member A's office, he held up a broken partial and told her they thought they had found resident #2's dentures. She explained to staff member A, the item they … | 2020-09-01 |
| 325 | 325 | BIG SKY CARE CENTER | 275044 | 2475 WINNE AVE | HELENA | MT | 59601 | 2019-02-21 | 600 | D | 1 | 1 | ZR9X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to identify and implement interventions for a resident who was unable to communicate her needs, and there was documented behaviors of excessive crying, and the failure resulted in the resident being placed in her room by staff and secluded, with the door shut; even though the resident would frequently continue to cry, and further interventions were not provided, for 1 (#19) of 18 sampled residents. Findings include: During an interview on 2/19/19 at 2:48 p.m., resident #11 stated (resident #19) was taken to her room and left there when she cried. Resident #11 stated, I saw staff member S take (resident #19) into her room and close the door. You could hear her screaming. During an interview on 2/20/19 at 7:11 a.m., staff member U stated resident #19 did not like to be alone, so staff would place her where there were other people. During an interview on 2/20/19 at 8:22 a.m., staff member EE stated resident #19 had crying episodes out of the blue. Staff member EE stated sometimes you can console her and sometimes you can't. Staff member EE stated, We try to talk to her, if she continues to cry, we put her in her room and put on a movie. Staff member EE stated that she leaves the resident for maybe five minutes. Staff member EE stated she has heard in report that other staff have seen resident #19 left in her room for longer periods, in the evening. Staff member EE stated there was no medication to give the resident to help the behavior. Staff member EE stated, We monitor her behavior. Staff member EE stated resident #19 was prescribed [MEDICATION NAME] (an antidepressant), which she was given in the morning, for depression. During an interview on 2/20/19 at 9:30 a.m., NF2 stated the staffing was horrible. When discussing resident #19 NF2 stated, They take her to her room and leave her there when she is crying. During an interview on 2/20/19 at 4:30 p.m., staff member L stated When she c… | 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 |
| 1678 | 1678 | AWE KUALAWAACHE CARE CENTER | 275153 | 10131 S HERITAGE RD | CROW AGENCY | MT | 59022 | 2019-11-14 | 607 | E | 1 | 0 | WKSC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to implement and operationalize policies and procedures for the identification of abuse and neglect, and the reporting and investigation of allegations of abuse and neglect. This deficient practice had the potential to affect any of the 26 vulnerable residents residing in the facility. Findings include: During an interview on 11/14/19 at 10:25 a.m., staff member D stated she had been made responsible for investigating all verbal incidents since (MONTH) of (YEAR). Staff member D stated the DON and the Administrator were responsible for handling any incidents which involved physical or sexual contact. Staff member D stated she received these reports in the form of concerns or complaints. Staff member D stated she investigated and followed up on these complaints, logged them, and placed the completed form in the Grievance Log. Staff member D stated there was no additional investigative documentation related to these incidents other than what was in the Grievance Log. Staff member D stated the forms were given to the administrator for review. Staff member D stated she did not know anything about reporting any of these incidents as abuse. Review of the Grievance Log, maintained by staff member D, showed seven incidents reported by staff, between 2/9/19 and 10/2/19, which involved either staff mistreatment of [REDACTED]. None of these incidents were reported to the State Survey Agency. During an interview on 11/14/19 at 11:50 a.m., staff member B stated she was responsible for investigating any abuse allegations received. Staff member B had not received any reports of alleged abuse since starting in early (MONTH) of 2019. When asked, staff member B was unaware of the verbal incidents contained in the Grievance Log maintained by staff member D. Staff member B stated if a staff member reported mistreatment by another staff member, it should have been treated as alleged abuse; and therefore, … | 2020-09-01 |
| 879 | 879 | VALLEY VIEW ESTATES HEALTH & REHABILITATION | 275101 | 225 N 8TH ST | HAMILTON | MT | 59840 | 2017-11-08 | 202 | D | 1 | 1 | 2DHO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to include documentation, in the resident's medical record from a physician to show why a transfer or discharge was necessary for 1 (#2) of 10 sampled residents. Findings include: Review of resident #2's electronic health record showed a physician's orders [REDACTED]. if resident becomes agitated/aggressive send to ER R/T being a danger to self/ others (sic). Review of resident #2's clinical notes and events reported by the facility, to the SA, dated 3/2/17-9/12/17, showed resident #2 had 11 physical altercations with other residents prior to 9/11/17, and none of these events had resulted in the resident being transferred or discharged , except when resident #2 required medical treatment for [REDACTED]. Review of resident #2's (MONTH) (YEAR) and Sept (YEAR) clinical notes and care plan, dated 3/2/17-present, showed no evidence of new non-pharmacological interventions to manage the adverse behaviors that lead to discharge and showed no plan to discharge resident #2 to a behavioral treatment facility or other care setting. The most recent update to resident #2's care plan for behavioral interventions was on 7/17/17. The care plan showed staff were to remind the resident not to touch or attempt to hurt other residents. The care plan showed the resident would require multiple reminders due to dementia. The facility failed to recognize resident #2 was severely cognitively impaired as evidenced by initiating the intervention of cognitive reminders. Review of resident #2's physician's notes did not show documentation of why the transfer was necessary and or why the resident could not return to the facility. | 2020-09-01 |
| 1711 | 1711 | MONTANA MENTAL HEALTH NURSING HOME | 27A052 | 800 CASINO CREEK DR | LEWISTOWN | MT | 59457 | 2018-07-19 | 552 | D | 1 | 0 | OUYP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to inform and include the resident's guardian in the decision making process, for the conduction of a diagnostic pregnancy test performed without a physician's orders [REDACTED].#1) of 7 sampled residents. Findings include: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. During an interview on 7/18/18 at 1:30 p.m., resident #1 spoke in broken sentences and was not interviewable. Review of a facility reportable event, submitted on 6/29/18, to the Certification Bureau, showed resident #1 had reported to a CNA she was pregnant by (staff member's name) and if he didn't pay more attention to her she would call the police. The report showed the incident date as 6/26/18. Review of resident #1's medical record did not include documentation that the alleged sexual abuse had been documented on the nurse's notes, or placed on the Abuse paperwork by nursing staff on 6/26/18, when it was first reported to staff member [NAME] by staff member B, and C. A nurse's note entry by staff member K, dated 6/28/18, showed .(resident's name) believes that she is pregnant and having sexual relations with a staff member. D/T allegations OTC pregnancy test performed with not pregnant result. (resident's name) has a pituitary tumor which can cause external abd growth. (resident's name) is also menopausal. Dulc tabs po ii given for c/o constipation and tender abd with lg BM resulting. (resident) is to be in line of site when up, 2 staff, one must be female, with all cares, no off unit pass, care plan updated. Has not put head in sink to get hair wet today. The medical record failed to include documentation that showed resident #1's guardian had been informed about the pregnancy test so he/she could consent to the treatment decision and discuss the need for the test, and risks and benefits thereof. Review of a physician's orders [REDACTED]. During an interview on 7/19/18 at 1:05 p.m., staff mem… | 2020-09-01 |
| 1044 | 1044 | LAUREL HEALTH & REHABILITATION CENTER | 275111 | 820 3RD AVE | LAUREL | MT | 59044 | 2019-10-10 | 842 | D | 1 | 0 | TUEN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to maintain a complete and accurate medical record for 1 (#1) of 4 sampled residents. Findings include: During an interview on 10/10/19 at 12:00 p.m., staff member C stated she did not know why a weekly skin check on a treatment record would be blank. Staff member C stated she generally, over-charted, when something was refused or missed. She stated she initialed the box, and then circled her initials. Staff member C stated she would then write a note describing the circumstances of the refusal or the missed treatment or medication. Staff member C stated that not all of the nurses documented the same way. During an interview on 10/10/19 at 2:35 p.m., staff member [NAME] stated she did not think there was a consistent method for documenting missed or refused medications or treatments. But, she did feel something should be documented, either on the treatment record or in the nursing notes. Review of resident #1's Wound TAR, dated (MONTH) 2019, showed: - wound treatment of [REDACTED]. - wound treatment of [REDACTED]. - wound treatment of [REDACTED]. - wound treatment to right calf cluster every day shift - showed blank dates without nursing notes providing an explanation for the blank dates: 5/23/19, 5/24/19, and 5/26/19 - wound treatment to scrotum every day shift - showed blank dates without nursing notes providing an explanation for the blank dates: 5/23/19, 5/24/19, and 5/26/19 - wound treatment to right hip and right knee M and F - showed blank dates without nursing notes providing an explanation for the blank dates: 5/20/19 and 5/24/19 Review of the facility Aseptic Dressing Technique Competency, dated (MONTH) 2014, showed, .sign TAR, document on skin grid if appropriate. | 2020-09-01 |
| 2631 | 2631 | INVIGORATE POST ACUTE OF WHITEFISH | 275132 | 1305 E 7TH ST | WHITEFISH | MT | 59937 | 2015-12-02 | 514 | E | 1 | 0 | YSI311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to maintain an accurate and complete clinical record for a resident who had falls for one (#1) out of 7 sampled residents. Findings include: 1. Resident #1 admitted to the facility on [DATE]. A review of the resident's Interdisciplinary Progress notes and SBAR Communication forms showed the resident had multiple falls (refer to F323 for detail). The clinical record lacked adequate information for the following items relating to the falls: - date of event - location of event - environmental risk factors identified - the resident's report of the event - if witnesses were present for the fall - the resident assessment, to include: vitals, range of motion, skin check - what actions were taken by the nurse to address the fall - fall interventions identified for future fall prevention - if the care plan was reviewed or modified A review of the SBAR Communication form showed the document included three pages. The form did not include an area for the date of the event. The form prompted the nurse to documented specific areas relating to a fall. Further review of the clinical record showed the SBAR forms utilized for the resident's falls did not include all three pages of the form. Two of the resident's falls were also documented in the nursing notes, but lacked the necessary information relating to the falls. During an interview, on 12/2/15 at 9:30 a.m., staff member B stated the nurse had two options to document fall events for a resident. These included documenting in a resident's progress notes, or documenting on the SBAR Communication form. During the interview, the two forms of documentation were reviewed, and it was found that documentation lacked evidence relating to the information listed above for the resident's falls. Staff member B stated the nurse was also required to document the falls in the facility electronic event system (not considered part of the medical record). Upon revi… | 2018-12-01 |
| 2249 | 2249 | INVIGORATE POST ACUTE OF WHITEFISH | 275132 | 1305 E 7TH ST | WHITEFISH | MT | 59937 | 2016-07-07 | 514 | D | 1 | 0 | 998S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to maintain nursing records to be accurate and complete for 1 (#1) of 5 sampled residents. Findings include: Resident #1 was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. The resident passed away on 4/29/16, while on hospice care. Review of resident #1's MAR for (MONTH) (YEAR) reflected an incomplete record in several areas. The pain monitoring section showed it was blank for 15 of 58 blocks. There were an additional 10 of 58 blocks with just the nurses' initials. The nurse was supposed to put an answer to the question if the resident was free of pain or hurting, not just initial the box, this is an inaccurate record. The section for the order to check the placement of the resident #1's [MEDICATION NAME] was found to have 8 boxes left blank as well. Review of three different scheduled medications for pain, agitation, and anxiety reflected on a total of of 16 occasions where a medication was not given, the nurses' initials were circled. There was no explanation as to why a medication was not given. On the back of the MAR, there is a list of codes to be used for occasions when a medication is held or refused. In an interview on 7/7/16 at 10:37 a.m., staff member B stated when a medication is not given, it is circled, and the nurse should use a code for an explanation. | 2019-07-01 |
| 63 | 63 | VALLE VISTA MANOR | 275021 | 402 SUMMIT AVE | LEWISTOWN | MT | 59457 | 2020-01-28 | 684 | G | 1 | 0 | 65C211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to monitor a resident for change of condition and follow through to obtain physician consultation, which resulted in a delay in treatment and ultimately a hospitalization , for 1 (#1) of 5 sampled residents. Findings include: During an interview on 1/28/20 at 12:24 p.m., NF1 stated he had noticed a difference in resident #1's cognition and status the two days prior to the hospitalization . NF1 stated he was in to see resident #1 on Saturday, 1/4/20, around one or two in the afternoon. NF1 stated he noticed a puddle on the floor around resident #1's foot and thought it was urine. He notified the nurse, and the nurse took resident #1's sock off, and NF1 immediately noted resident #1's foot was swollen like a balloon, and the fluid matter on the floor was not urine but was coming from resident #1's foot. NF1 stated he asked the nurse if he should take resident #1 to the hospital. The nurse stated no we have a wound nurse consult scheduled for Monday (six days later). NF1 stated it should have been obvious resident #1's foot was infected. NF1 stated he had not been notified of the swelling on resident #1's foot prior to seeing it in person. NF1 stated he received a phone call around 4:30 a.m., on Sunday 1/5/20, notifying him resident #1 was being sent to the emergency room . NF1 stated resident #1 was septic (infection) by the time he was admitted to the hospital, and the resident had [MEDICAL CONDITION]. During an interview on 1/28/20 at 1:27 p.m., staff member B stated she was not present in the facility when resident #1 had been sent out to the hospital. During the weekend it was the Registered Nurse that was in charge of overseeing cares. Staff member B stated the facility had been aware of the redness and swelling of resident #1's foot on 1/3/20. On 1/4/20 it was assessed, but resident #1 did not have a temperature until 1/5/20. Staff member B stated it would be alarming if a reside… | 2020-09-01 |
| 64 | 64 | VALLE VISTA MANOR | 275021 | 402 SUMMIT AVE | LEWISTOWN | MT | 59457 | 2020-01-28 | 686 | D | 1 | 0 | 65C211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to monitor an identified reddened skin area, and implement interventions for prevention of further deterioration, for the skin area, and the area worsened to an avoidable Stage II Pressure Ulcer; and the facility failed to identify the risk of the pressure ulcer development and revise interventions for a resident with a reoccurring pressure ulcer, for 2 (#s 1 and 2) of 5 sampled residents. Findings include: 1. During an interview on 1/28/20 at 12:24 p.m., NFI stated resident #1 had a red spot on admission that was not open. NF1 stated resident #1 was not repositioned, and the pressure ulcer worsened at the facility to the point resident #1 was uncomfortable when sitting. NF1 stated he was not sure if resident #1 moved nearly enough. NF1 stated he was aware of an order from the doctor for the pressure ulcer but was not sure if it had been adhered to. During an interview on 1/28/20 at 1:27 p.m., staff member B stated she was not in the facility for resident #1's admission, and she was not sure how resident #1 acquired the avoidable Stage II pressure ulcer. Staff member B stated the facility has not had many pressure ulcers and had recently implemented a system of caring for pressure ulcers. Staff member B stated the system included that a nurse would complete a skin assessment weekly, on a bath day, for a resident. Staff member B stated the implementation of the system was evaluated and is an ongoing process. Staff member B stated the resident had a head to toe evaluation in his progress note, after the abundant number of falls the resident had, during his stay at the facility. Staff member B stated resident #1 had Braden Scale skin assessments completed on the 19th, and the 26th of December, 2019, as well as on January 2nd, of 2020. During an interview on 1/28/20 at 2:46 p.m., staff member A stated resident #1 had a pressure skin injury he acquired during his stay at the facility. A r… | 2020-09-01 |
| 114 | 114 | HERITAGE PLACE | 275025 | 171 HERITAGE WAY | KALISPELL | MT | 59901 | 2018-09-18 | 580 | D | 1 | 0 | VB9B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to notify family members of a resident's transfer to the emergency department and subsequent hospital admission for 1 (#1) of 8 sampled residents. This failure caused undue anxiety for NF1. Findings include: During an interview on 9/17/18 at 4:35 p.m., NF1 said the facility had not called the family when resident #1 was transferred from the facility on 6/9/18. NF1 said the family received notification from a Hospitalist on 6/10/18 at 11:00 a.m. the resident #1 was in ICU. NF1 said the Hospitalist told the family they needed to come to the hospital quickly because resident #1's health was declining rapidly. NF1 said she and her husband, the resident's brother, got the hospital within an hour of the phone call. NF1 said resident #1 was in a coma like state when they got to her room in the ICU. NF1 said the resident did wake up but was not able to communicate with NF1 or the resident's brother. NF1 said resident #1 passed away on 6/12/18. NF1 said if the hospital had not called her, they would not have known resident #1 was not at the facility until NF1 had shown up for the scheduled hematologist appointment on 6/11/18. NF1 said she did not understand why the facility had not contacted them of resident #1's transfer to the emergency department, or the resident's admission to the hospital. NF1 said the facility had called her on 6/8/18 to tell her resident #1 had an appointment on 6/11/18 with a hematologist. NF1 said she or her husband, resident #1's brother, went to every doctor appointment with the resident. NF1 said they both had attended the initial care plan meeting for resident #1. NF1 said resident #1 had been admitted to the facility on [DATE]. NF1 said because of the delay in notification on resident #1's admission to the hospital, her other brother, who lived in Virginia, was unable to get to the hospital prior to the resident's death. NF1 said the whole situation increased he… | 2020-09-01 |
| 1712 | 1712 | MONTANA MENTAL HEALTH NURSING HOME | 27A052 | 800 CASINO CREEK DR | LEWISTOWN | MT | 59457 | 2018-07-19 | 609 | D | 1 | 0 | OUYP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to notify the administrator of an alleged violation of sexual abuse immediately; and failed to report to the Certification Bureau within 24 hours of the alleged sexual abuse, and report to the local authorities within 2 hours for a potential crime, for 1 (#1) of 7 sampled residents. Findings include: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. During an interview on 7/18/18 at 1:30 p.m., resident #1 spoke in broken sentences and was not interviewable. Review of the facility self reported event, submitted on 6/29/18, to the Certification Bureau showed resident #1 had reported to a CNA she was pregnant by (staff member's name) and if he didn't pay more attention to her she would call the police. The report showed the incident date as 6/26/18. There was no documentation in resident #1's medical record that showed the administrator was notified immediately, or that the potential crime was identified and reported to the authorities within the 2-hour required timeline. The report of alleged sexual abuse was not reported to the administrator until the following day, after the facility stand down IDT(interdisciplinary team) meeting. Initial report of concern made on 6/25/18 from staff member C to unit RN, Staff Member L: A request was made by the surveyor, to the administrator and DON, for a contact number for staff member C on 7/19/18. A call was made to staff member C and a message was left with a request for a return call to conduct an investigation interview. Staff member C is a temporary employee for a traveling staffing service. Staff member C returned the call and was interviewed by telephone on 7/26/18 at 4:30 p.m. Staff member C stated she was working on the unit that resident #1 was on on 6/25/18. Staff member C stated resident #1 kept looking for (staff member's name) and was saying repeatedly she was having his baby. Staff member C stated she reported the … | 2020-09-01 |
| 507 | 507 | COPPER RIDGE HEALTH AND REHABILITATION CENTER | 275060 | 3251 NETTIE ST | BUTTE | MT | 59701 | 2018-07-31 | 580 | G | 1 | 0 | GLJS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to notify the physician of a change in physical condition after a resident's fall with injury, for 1 (#2) of 7 sampled residents, and the resident was found to have a significant injury. Findings include: Family Interview During a family interview on [DATE] at 9:32 a.m., NF3 stated she received a call from the facility that her mother had a fall. She stated her sister came in to see their mom in the morning around 7:45 a.m. and she came a little later. NF3 stated her mother had bruising to the right side of her face, from the top of her head to her cheek and between her eye socket and her ear. NF3 stated she noticed a cut on the top right side of her head above her forehead and to her right shoulder and arm. NF3 stated she told staff member B she wanted her mom to go to the hospital. NF3 stated her mom's eyes were rolling back in her head and she couldn't stand. NF3 stated she and her sister took resident #2 to the hospital. She stated the hospital did a CT scan and found her mom had bleeding in the back of her brain. NF3 stated resident #2 lingered for a week and died at the hospital. NF3 stated the situation could have been different if her mother would have gotten treatment sooner to stop the bleeding by being administered vitamin K right away. NF3 stated, They took away her chance to live by delaying treatment. Resident Fall Detail Review of the facility Occurrence Report for the resident's fall showed resident #2 had a fall in her room on [DATE] at 11:30 p.m. The report showed staff found her laying on her back on the floor with her FWW in her hands. The report showed resident #2 had been confused and had been yelling out and had been given a [MEDICATION NAME] 5 mg at 9:00 a.m. The report showed items that were on the bedside table had been knocked off onto the floor. The follow-up report for the Occurrence Report showed changes to the resident status as facial bruising. Review … | 2020-09-01 |
| 88 | 88 | ST JOHN'S LUTHERAN HOME | 275024 | 3940 RIMROCK RD | BILLINGS | MT | 59102 | 2019-08-22 | 623 | D | 1 | 1 | P5VQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to notify the resident or resident's representative, in writing, of the reason for a transfer for 4 (#s 22, 100, 135, and 238) of 38 sampled and supplemental residents. Findings include: 1. During an interview on 8/21/19 at 8:55 a.m., staff member F stated that resident #100 had sustained a fall with a [MEDICAL CONDITION] which required hospitalization in (MONTH) of 2019. During an interview on 8/22/19 at 10:10 a.m., staff member D stated when a resident has been transferred, she has not given the resident or resident's representative any written documentation related to the reason for the residents's transfer. During an interview on 8/22/19 at 10:15 a.m., staff member C stated when a resident has been transferred, she has not given the resident or the resident's representative any documentation related to the reason for the resident's transfer. During an interview on 8/22/19 at 10:25 a.m., staff member F stated she has done the communication notice, which informs the facility of the change for a resident. She stated the written notices to the resident, or the resident's representative, were done by the staff in Medical Records and Admissions. During an interview on 8/22/19 at 10:30 a.m., staff member [NAME] stated she had not done any written notification to the resident, or the resident's representative, when a resident had been transferred. Review of resident #100's medical record showed she was hospitalized from [DATE] through 6/3/19 for a [MEDICAL CONDITION]. The medical record failed to show a written transfer notification was provided in writing, identifying the reason for the transfer, and given to resident #100 or her representative. The transfer notification documentation was requested for resident #100 on 8/21/19 at 3:10 p.m. No documentation was received prior to the end of the survey. 2. During an interview on 8/21/19 at 3:14 p.m., staff member B stated the facility does… | 2020-09-01 |
| 2626 | 2626 | INVIGORATE POST ACUTE OF WHITEFISH | 275132 | 1305 E 7TH ST | WHITEFISH | MT | 59937 | 2015-12-02 | 157 | D | 1 | 0 | YSI311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to notify the responsible party when a resident was moved to an alternate room for one (#2) and failed to notify the responsible party of a family conference for one (#4) of 7 sampled residents. Findings include: 1. Resident #2 was admitted to the facility on [DATE]. On 6/16/15 a Room Transfer Change Form showed Happy with the bathroom setup w/left hand setup .If he has to move he is happy with 314. The form also included areas for patient notified and responsible party notified. The area for responsible party notification was not completed. On 6/22/15 in an Interdisciplinary Progress Note, staff documented. Res (resident) moved to private room on rehab hall. On 7/1/15 a grievance form was completed. The grievance was from the resident's POA and stated, Son was upset; not notified of father's room change. Review of resident #2's care plan showed Resident has stated it is important to have family involved in care discussions. During an interview on 12/1/15 at 9:45 a.m., staff member B stated, family should be notified of room changes. 2. Resident #4 was admitted to the facility on [DATE]. On 9/1/15 a Post Admission Patient/Health Care Decision Maker/Family Conference was completed. Under l, the form showed the daughter was not notified of meeting. On 9/1/15 the care plan showed Provide resident/healthcare decision maker with sufficient information to make an informed decision. During an interview on 12/1/15 at 10:30 a.m., resident #4's POA stated she was out of town when resident #4 was admitted and was not notified of the meeting held on 9/1/15. During an interview on 12/1/15 at 12:30 p.m., staff member C stated the initial assessment is started within 72 hours of admission and this is when the facility can visit with the family regarding resident expectations and discharge. Staff member C further stated that the meetings were set up through the admission department. | 2018-12-01 |
| 1707 | 1707 | MONTANA MENTAL HEALTH NURSING HOME | 27A052 | 800 CASINO CREEK DR | LEWISTOWN | MT | 59457 | 2017-06-23 | 226 | K | 1 | 0 | 9PC311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to operationalize necessary components of abuse, some of which were documented in the facility abuse policy, relating to: The identification of staff to resident abuse, ensuring resident safety during, and after, an allegation of abuse is received from a resident; thorough and timely investigations of abuse; and timely reporting, investigation, and completion of abuse allegations. This failure had the potential to affect all residents who came in contact with the alleged staff members, and specifically included 5 (#s 1, 4, 5, 6, and 7) of 8 sampled residents. Findings include: IMMEDIATE JEOPARDY On 6/22/17 at 1:45 p.m., an Immediate Jeopardy was announced in the area of Resident Behavior & Facility Practices; Abuse, for F225 Not Employ Abusers, Reporting/Investigate, and F226 Abuse Policies and Procedures. These were found to be at the Severity and Scope of K. PLAN TO REMOVE IMMEDIACY The facility submitted an acceptable plan to remove the immediacy on 6/22/17 at 6:00 p.m. After the plan was accepted, the Severity and Scope was reduced to an H for F225 and F226. Refer to F000 for the Plan to Remove the Immediacy. A review of facility allegations showed: 1. Resident #1 reported an allegation of staff abuse to the facility on [DATE], on the Resident Rights Grievance Report Form. Review of the facility's abuse reports showed this incident was not reported to the State Agency. 2. Resident #4 was physically restrained by staff members, on 4/25/17. This incident was documented, in resident #4's medical record, on a facility form Interdisciplinary Progress Notes. The facility did not investigate this incident as an alleged physical restraint of a resident by staff members. Review of the facility's abuse reports failed to show this incident had been identified and reported as an alleged physical restraint of a resident by staff members. The event was not investigated. Protective measures wer… | 2020-09-01 |
| 878 | 878 | VALLEY VIEW ESTATES HEALTH & REHABILITATION | 275101 | 225 N 8TH ST | HAMILTON | MT | 59840 | 2017-11-08 | 201 | D | 1 | 1 | 2DHO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to permit 1 (#2) of 10 sampled residents to remain in the facility. The facility failed to demonstrate that the transfer/discharge was necessary. Findings include: Resident #2 was admitted to the facility on [DATE], and the resident resided on the special care unit. Review of resident #2's Significant Change in Status MDS, with an ARD of 6/1/17, showed resident #2 had a BIMS score of 3, severely impaired. Review of resident #2's Quarterly MDS, with an ARD of 8/22/17, showed resident #2 had a BIMS score of 3, severely impaired. Review of resident #2's clinical notes, dated 9/11/17, showed the resident was sent to the ER after being seen by staff, sitting in his wheelchair, hitting a female resident who was on the floor in his room. The clinical notes showed staff member B told resident #2's daughter that he would not be permitted to return to the facility. During an interview on 11/6/17 at 1:10 p.m., NF2 stated she was aware of resident #2's behavior, regarding physical altercations, in the facility. She stated no one from the facility had told her the behavior of resident #2 could potentially lead to the resident being transferred or discharged from the facility. NF2 stated she was reassured on several occasions, after being notified of an altercation, the facility would manage resident #2's behavior. She stated other residents wandering into resident #2's room was what caused the resident to become upset and act out. She stated the facility put up a Velcro stop sign on resident #2's door, but she was not aware of other efforts to keep residents out of resident #2's room or his personal space. Review of resident #2's clinical notes dated 3/2/17-9/12/17, showed resident #2 had 11 physical altercations with other residents prior to 9/11/17. Review of events reported, by the facility, to the SA, during the same time period, showed the same altercations. The event reports showed resident… | 2020-09-01 |
| 198 | 198 | HILLSIDE HEALTH & REHABILITATION | 275027 | 4720 23RD AVENUE | MISSOULA | MT | 59803 | 2018-10-30 | 689 | G | 1 | 0 | 1PNL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to prevent an accident when a resident was smoking with oxygen on and caused a fire, and the resident was unsupervised by staff, for 1 (#1) of 3 sampled residents. The resident sustained [REDACTED]. Findings include: During an interview on 10/29/18 at 12:50 p.m., resident #3 stated she was an independent smoker and came outside often to smoke. She stated the smoking rules had changed since (resident name) caught herself on fire. Resident #3 stated since then We have to leave our oxygen with a staff member before we can go outside to smoke. She stated before the lady caught herself on fire we just had to hang our oxygen by the door to the smoking area and go out. Resident #3 stated, We could only have two cigarettes at a time and we have to take our oxygen up to the front desk and trade it for our two cigarettes and lighter. Review of resident #1's Smoking Risk Evaluation showed, on 6/28/18 at 7:00 p.m., staff member A signed off on resident #1 as Must be supervised and Smoking materials must be secured by staff. On 6/28/18 at 8:35 p.m., staff member A signed off a new Smoking Risk Evaluation as, Independent and, Smoking materials must be secured by staff. Review of resident #1's progress notes, dated 8/27/18 showed, At approx. 1330 I was called to go out to the smoking area as res was in distress, as I entered the dining room res was sitting in her w/c hunched over in pain holding her face, I could see her oxygen cannula was burnt and melted off, as I get close to res I see black area covering below her nose and cheeks, right and left, she said she was smoking, forgot to take off her oxygen, cold compress being applied for comfort but res crying in pain, another O2 mask and tube provided .mask being held lightly in front of her nose, it appears that small amt of plastic attached to her cheeks as well, normal saline used to try to cleanse area causing some peeling off 1350 ambulance h… | 2020-09-01 |
| 1460 | 1460 | WHITEFISH CARE AND REHABILITATION | 275132 | 1305 E 7TH ST | WHITEFISH | MT | 59937 | 2019-06-27 | 600 | G | 1 | 1 | BDNZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to prevent neglect for 2 (#s 43 and 52) of 37 sampled residents, resulting in hip dislocation for resident #52 and incontinence for resident #43. Findings include: 1. During an interview on 6/26/19 at 10:17 a.m., resident #52 explained he was admitted to the facility following surgery on his left hip. Resident #52 confirmed he was hospitalized in (MONTH) of 2019 for a hip dislocation and infection. Resident #52 denied experiencing current issues with pain. Review of the Facility Reported Incident regarding resident #52, dated 2/8/19 at 5:15 p.m., showed, Around 330 pm (sic) facility received a call from ER nurse at (hospital). Resident (#52) was transferred to (hospital) earlier with infection to the left hip. Report received that resident did have infection in left hip and hip was dislocated. Upon transfer to (hospital), nurse stated that resident (#52) reported that the woman involved in his care is rough with him especially when he soils himself. Review of the facility's findings of the above incident, submitted on 2/13/19, indicates, .Upon interviewing resident (#52) he stated that CNA (NF1) had been rough with him while providing care. He stated that he was having pain in his hip and was needing to be helped into his wheelchair. He stated that CNA was rough when turning him and preparing him to be transferred. When asked if he believed CNA did it on purpose, he stated she has done this before, she is a big strong girl and he believes she just lost patience with him. Resident (#52) stated he had a good relationship with the CNA, and confirmed that this occurred with another CNA present. That CNA was interviewed and confirmed that CNA (NF1) was present on the night of Wednesday 2/6/19. CNA confirmed that (NF1) and she were getting him up and while doing so she noticed (NF1) being rough and when resident expressed discomfort during care CNA swore out of frustration. Other residents… | 2020-09-01 |
| 1522 | 1522 | IVY AT DEER LODGE | 275134 | 1100 TEXAS AVE | DEER LODGE | MT | 59722 | 2019-10-17 | 600 | G | 1 | 1 | 0R6Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to protect 1 (#2) of 21 sampled residents from verbal abuse by a CN[NAME] Findings include: Review of the facility's incident report, dated 9/26/19, showed resident #2 had reported to CNAs that NF1 had abused him by having the gait belt too tight and swearing at him. Event occurred 9/24/19 sometime after dinner, not reported until this morning (9/25/19). (NF1) suspended pending investigation. Review of the facility's five-day investigation notes showed resident #2 was interviewed again and he stuck to his statement that (NF1) had swore at him. Roommate confirmed staff cursed at (resident #2). NF1 admitted she swore at him in her statement. No injuries. Verbal abuse substantiated . During an interview on 10/17/19 at 7:55 a.m. with staff members A and B, staff member B stated resident #2 had reported NF1 had cursed at him during the previous evening. Staff member A stated he started an investigation immediately, and the allegation was confirmed by both resident #2's roommate and NF1. Staff member A stated he notified the facility's regional nurse, district manager, and their Human Resources Department. Staff member B stated the facility provided in-service training's on abuse with all staff the day of the investigation. Staff member B said the facility attached the seven different types of abuse to staff's identification cards as an additional intervention. Staff member A stated in addition to the in-service abuse training which occurred 9/30/19 for all staff, the facility also required staff to complete an abuse training annually. During an interview on 10/17/19 at 9:26 a.m., resident #2 stated, (NF1) was mean. Resident #2 stated he had not had any conflicts with staff since. Review of resident #2's medical record showed an active [DIAGNOSES REDACTED]. Review of the facility's in-service abuse training sign-in was dated 9/30/19 and signed by all staff attendees. Review of NF1's file s… | 2020-09-01 |
| 796 | 796 | VALLEY VIEW HOME | 275091 | 1225 PERRY LN | GLASGOW | MT | 59230 | 2020-01-09 | 600 | G | 1 | 1 | ZMML11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to protect 1 (#70) of 19 sampled residents from several incidents of physical and verbal abuse from family members, which resulted in emotional and mental anguish for the resident. Findings include: During an interview on 1/8/20 at 9:31 a.m., staff member B stated resident #70 was no longer residing in the facility, but when he was a resident, staff had some concerns with his family being aggressive, but (it was) nothing serious. Staff member B explained that when staff had concerns about the way resident #70's family was interacting with him, staff would require the family to meet in the common area so staff could observe them. During an interview on 1/8/20 at 10:48 a.m., staff member E recalled interactions she had observed between resident #70 and his family. Staff member E stated resident #70's father would raise his voice and sometimes a hand at resident #70. Staff member E explained when staff observed this aggressive behavior, they would ask resident #70's father to leave the facility, and he would comply. Staff member E added staff required resident #70's family to have supervised meetings. Staff member E stated resident #70 had started yelling out and screaming a lot, but only a month or so after he had been admitted to the facility. Staff member E explained resident #70's yelling would irritate his family, who would then tell him to shut up. During an interview on 1/8/20 at 11:02 a.m., staff member A stated staff had to constantly monitor resident #70 because he would act out and yell for no apparent reason. Staff member A stated staff could not figure out what resident #70 needed. Staff member A continued to explain staff had witnessed resident #70's parents hitting, yelling, and threatening him, and forcing food into his mouth. Staff member A stated he witnessed resident #70's parents grab his hands and shake him, or grab resident #70's side while holding up a fist and te… | 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 );