cms_MT
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| Link | rowid | facility_name | facility_id | address | city | state | zip ▼ | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4865 | 4865 | PIONEER MEDICAL CENTER LTC | 275139 | 301 W 7TH AVE | BIG TIMBER | MT | 59011 | 2012-12-20 | 281 | E | 0 | 1 | JQ4C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to meet professional standards of quality when monitoring vital signs and neuro checks following a fall for 3 (#s 1, 2, and 5 ) of 25 sampled residents. Findings include: 1. Resident #2 was admitted to the facility on [DATE]. According to the Interdisciplinary Progress Notes, on 11/25/12 at 11:30 a.m., the resident fell out of the wheelchair sustaining abrasions on the left forehead and bridge of nose. The provider was notified due to the resident being on anticoagulant therapy. physician's orders [REDACTED].? to fall. According to the Resident/Patient Fall Report, dated 11/25/12, and the Resident Issue Follow Up form, the resident's vital signs (blood pressure, temperature, pulse, respirations, and oxygen saturations at room air) were taken and recorded as the following: 11/25/12 11:15 a.m.: 134/82, 97.6?F, 86, 20, and 91%, 11/25/12 8:00 p.m.: 117/68, 97.6?F, 93, 18, and 93%, 11/26/12 8:00 p.m.: 149/74, 98.1?F, 93, 20, and 90%, and 11/27/12 8:00 p.m.: 130/70, 97.1?F, 86, 20, and 91%. No further documentation of vital signs and neuro checks could be found in the record. 2. Resident #1 was readmitted to the facility on [DATE]. According to the Resident/Patient Fall Report, on 11/9/12 at 9:15 p.m., the resident fell and sustained lacerations to the nose and above the eye. According to the Resident/Patient Fall Report, dated 11/9/12, the resident's vital signs were taken and recorded as the following: 11/9/12 9:15 p.m.: 140/56, 98.6?F, 91, 20, and 93%, 11/10/12 10:00 a.m.: 153/65, 97.5?F, 82, 20, and 96.1%, 11/10/12 8:00 p.m.: 155/64; 97.1?F, 84, 20, and 95%, 11/11/12 (no time documented): 154/62, 98.2?F, 75, 12, and 95%. According to the Neuro Flowsheet, neuro checks were obtained and recorded on 11/9/12 at 9:30 p.m. and 10:30 p.m., 11/10/12 at 12:30 a.m., 2:30 a.m., 4:30 a.m., 6:30 a.m., 8:30 a.m., 10:30 a.m., 12:30 p.m., 2:30 p.m., 4:30 p.m., and 6:30 p.m. No furt… | 2015-07-01 |
| 4866 | 4866 | PIONEER MEDICAL CENTER LTC | 275139 | 301 W 7TH AVE | BIG TIMBER | MT | 59011 | 2012-12-20 | 323 | D | 0 | 1 | JQ4C11 | Based on observation and staff interview, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible when transporting an oxygen cylinder from the storage area to the resident's room. Findings included: On 12/19/12 at 8:05 a.m., staff member L, a CNA, was observed carrying an oxygen cylinder over her left shoulder. The staff member was asked to show the surveyor where she obtained the oxygen cylinder. Staff member L showed the surveyor the storage area. In the storage area, a carrier was available for the staff member to transport the oxygen cylinder. | 2015-07-01 |
| 4867 | 4867 | PIONEER MEDICAL CENTER LTC | 275139 | 301 W 7TH AVE | BIG TIMBER | MT | 59011 | 2014-02-27 | 156 | C | 0 | 1 | EV5411 | Based on observation and staff interview, the facility failed to provide a posting of the names, addresses, and telephone numbers of all pertinent State client advocacy groups. In addition, the facility failed to post a statement that a resident may file a complaint with the State survey and certification agency. Findings include: On 2/24/14 at 4:40 p.m., during an observation of the facility, the bulletin board containing the most recent health survey was located. On this board was a copy of the resident rights, survey results, and the contact information for the Ombudsman. There was no further contact information for the State survey and certification agencies, the state licensure office, the protection and advocacy network nor the Medicaid fraud control unit. Likewise, there was no statement pertaining to the resident's right to file a complaint with the State survey and certification agency concerning resident abuse, neglect, misappropriation of resident property in the facility, and non-compliance with the advance directives requirement. At 4:45 p.m. on 2/24/14 the main lobby was observed as the survey results were posted in two locations. A posting of the pertinent state client advocacy groups was not found in this location. On 2/24/14 at 5:10 p.m. during an interview with staff members A and B, the DON and ADON respectively, no information has been taken down from the bulletin boards. They conveyed that if the information is not located in either of those two spots then it was not posted. | 2015-07-01 |
| 4868 | 4868 | PIONEER MEDICAL CENTER LTC | 275139 | 301 W 7TH AVE | BIG TIMBER | MT | 59011 | 2014-02-27 | 253 | C | 0 | 1 | EV5411 | 2. During the initial tour of the facility on 2/24/14 at 10:50 a.m. a number of residents' rooms were observed to have a significant amount of damage to the drywall. This included the bathroom of rooms 28 and 29, rooms 30 and 31 and the dining room. In the bathroom shared between rooms 28 and 29 were a set of scratches and gouges to the left of the sink from the level of the sink to the floor. The largest gouge measured three inches by 6 inches and contained a light brown stain. There were also gouges and scratches to the right of the toilet just above the vinyl molding. Room 30 had numerous areas of damage. There was drywall damage at the head of bed 30A from the vinyl molding on the floor to at least 12 inches and 8 inches wide. To the side of bed 30A was was an area of speckled scratches and gouges measuring 5 inches by 18 inches. Above the vinyl molding on the floor near the head of bed 30B were two areas of damaged drywall measuring 6 inches by 10 inches and 4 inches by 6 inches. There were also numerous quarter sized gouges located on the wall with the residents' closets. Room 31 had two quarter sized scratches at the side of bed 31A, and 2 sets of scratches and gouges to the head of bed 31A. Both sets measured 6 inches by 12 inches. The room also contained a scratch/gouge on the wall and measured 1/2 inch by 4 inches between the dresser and closet located behind the commode. This damage also contained a light brown stain running the length of the damage and another six inches above the scratch. On 2/24/14 at 4:30 p.m. during dining observations one chair at table 3 had a tear in the left arm rest measuring 2-3 inches long. The wall next to the white board contained 3 quarter sized gouges. The dish return to the kitchen contained extensive damage to both sides of the wall above the metal protected area. The damaged area measured 6 inches by at least 12 inches on both sides. On 2/25/14 at 10:34 a.m., the nurse's station was observed. The two pillars, one to the right of the door to enter the nurse's station … | 2015-07-01 |
| 4869 | 4869 | PIONEER MEDICAL CENTER LTC | 275139 | 301 W 7TH AVE | BIG TIMBER | MT | 59011 | 2014-02-27 | 323 | E | 0 | 1 | EV5411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record review, the facility failed to ensure that the resident environment remained as free from accident hazards as was possible for all residents, and ensure that one (#11) of 14 sampled and supplemental residents received adequate assistive devices during transfers to prevent accidents. Findings include: 1. On 2/25/14 at 1:11 p.m., an observation was made of the mechanical room door on the long term care unit (C wing) having been left unlocked. A sign indicating that the door was to remain locked at all times was on the front of the door. The surveyor entered the room and found large industrial mechanical units. On top of one of the units were sharp pieces of metal. The pieces of metal were four feet off the ground. Copper drainage pipes for one of the units was located near the ground and positioned toward a floor drain which was in the walking lane. The door was checked again on 2/25/14 at 2:35 p.m. and was unlocked. At 2:37 p.m. on 2/25/14, a corner guard on the entrance to C wing was broken and had a sharp pointed edge at ankle level. There were no pieces of the broken corner guard on the ground. This corner extends from the dining room to the residents' rooms. At 2:50 p.m. on 2/25/14 staff members D, maintenance, and E, facility manager, were interviewed regarding the content of the mechanical room on C wing. The room contains the HVAC system for the facility. When informed that the door had been unlocked, staff member D asked staff member E to ensure that the door was locked when we exited the room. On 2/25/14 at 3:05 p.m. the broken corner guard was shown to staff members A, B, and E. Staff member E was unaware of a work order for the broken guard. All stated they were unaware of the broken piece, and staff member A said she personally had not filled out an order to have it replaced, but wondered if it was new. All three staff members said they would follow up with staff member D, mainten… | 2015-07-01 |
| 4870 | 4870 | PIONEER MEDICAL CENTER LTC | 275139 | 301 W 7TH AVE | BIG TIMBER | MT | 59011 | 2014-02-27 | 441 | F | 0 | 1 | EV5411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record reviews, the facility failed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection for all residents. A resident's catheter bag was observed multiple times dragging on the floor; the separation door in the laundry room was propped open and the potential for cross contamination during laundry procedures was present; and the staff failed to follow proper hand washing procedures during care for 5 (#s 2, 10, 11, 13, and 14) of 14 sampled and supplemental residents. Findings include: 1. The surveyor observed resident #2's catheter bag dragging on the floor on 2/24/14 at 5 p.m., 2/25/14 at 11:15 a.m., 2/26/14 at 4:55 p.m. and 2/27/14 at 8:15 a.m. Staff member A, DON was interviewed on 2/27/14 at 8:17 a.m. and stated that if a catheter bag is dragging on the floor, it is a problem, and that it could "get snagged on something and tear." 2. On 2/25/14 at 10:34 a.m., the separation door between the soiled linen room and the washing room was found propped open. Staff member G, a laundry aide, showed the process of sorting, washing, drying and folding the linen and residents' clothes. The staff member put on a pair of purple gloves to show how the soiled laundry is separated. While putting on her gloves she stated that the gloves are for the soiled linen side only. While showing the soiled linen separation procedure the staff member touched a blanket that had been used for a resident's bed. She then opened the lid to the contaminated/potentially hazardous linen and showed the procedure for pre-cleaning these articles. She picked up the spray nozzle located in the soiled linen room that would be used after placing the laundry into the wash sink, and showed how the sprayer worked. The observation proceeded to the room that housed the washing machines. A clean lift harness was draped across one of the washing machines. Staff member… | 2015-07-01 |
| 4871 | 4871 | PIONEER MEDICAL CENTER LTC | 275139 | 301 W 7TH AVE | BIG TIMBER | MT | 59011 | 2014-02-27 | 514 | C | 0 | 1 | EV5411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to maintain complete and accurate documentation for 5 (#'s 1, 2, 3, 4, 5 ) of 14 sampled and supplemental residents. 1. Resident #2 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident #2 scored a 9 on his last BIMS with an ARD of 1/20/14. During a review of resident #2's clinical record, the surveyor found that the following medications had not been properly signed off on the MAR (medication administration record). - [MEDICATION NAME] 500 mg at bedtime was not signed off on the following date: 1/21/14 at 18:00. - [MEDICATION NAME] 10 mg twice daily was not signed off on the following dates: 1/16/14 at 18:00 and 1/21/14 at 18:00. - [MEDICATION NAME] 20 mg at bedtime was not signed off on the following date: 1/21/14 at 18:00. - [MEDICATION NAME] 200 mg at bedtime was not signed off on the following date: 1/21/14 at 18:00. - Senna Tab 8.6 mg twice daily was not signed off on the following date: 1/21/14 at 18:00. - [MEDICATION NAME] 0.4 mg at bedtime was not signed off on the following dates: 1/21/14 at 18:00 and 11/26/13 at 18:00. - [MEDICATION NAME] 20 mg twice daily was not signed off on the following date: 1/21/14 at 12:00 - [MEDICATION NAME] Creme 1% BID (twice daily) was not signed off on the following dates: 12/31/13 at p.m., 1/3/14 at p.m. and 1/9/14 at p.m. - [MEDICATION NAME] 10 mg daily was not signed off on the following date: 12/25/13 at 8:00. - Slow Fe 140 mg daily was not signed off on the following date: 12/25/13 at 8:00. - [MEDICATION NAME] 40 mg daily was not signed off on the following date: 12/25/13 at 8:00. - [MEDICATION NAME] 5 mg each morning was not signed off on the following date: 12/25/13 at 8:00. - [MEDICATION NAME] 10meq was not signed off on the following date: 12/25/13 at 8:00. - [MEDICATION NAME] 5 mg was not signed off on the following dates: 12/25/13 at 8:00 and 11/24/13 at 8:00. On 11/5/13 resident #2 w… | 2015-07-01 |
| 4872 | 4872 | PIONEER MEDICAL CENTER LTC | 275139 | 301 W 7TH AVE | BIG TIMBER | MT | 59011 | 2014-02-27 | 431 | B | 0 | 1 | EV5411 | Based on observations of the medication cart and the medication room, the facility failed to dispose of three outdated medications. Findings include: On 2/26/14 at 3:00 p.m., two tubes of Glucose oral glucose gel with expiration dates of 1/2014 and one bottle of chewable antacid tablets, 1/4 full, with an expiration date of 1/2013 were found in the medication room. | 2015-07-01 |
| 4873 | 4873 | PIONEER MEDICAL CENTER LTC | 275139 | 301 W 7TH AVE | BIG TIMBER | MT | 59011 | 2014-02-27 | 221 | D | 0 | 1 | EV5411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and record review the facility failed to ensure the right to be free from physical restraints for two (#'s 1, and 12) of 14 sampled and supplemental residents. Findings include: 1. Resident #12 was admitted on [DATE] with the [DIAGNOSES REDACTED]. On 2/24/14 at 4:45 p.m., resident #12 was sitting at the dining table in her wheel chair; she shuffled her feet and caused the wheelchair to move back and forth from the table. At 5:05 p.m., an unidentified aide brought the dinner meal to resident #12 and locked the wheels on the wheelchair. The resident proceeded to eat. On 2/25/14 at 8:00 a.m. the surveyor reviewed the medical records and found no order for locking the wheels of the wheelchair during meals for resident #12. The care plan interventions had not indicated the use of wheelchair locks at mealtime. At 11:00 a.m., resident #12 was eating lunch and her wheelchair was not locked. On 2/26/14 at 4:55 p.m., resident #12 was taken to the dining table in her wheelchair, and a CNA proceeded to lock both wheels of the wheelchair once in the dining room. 2. Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. On 2/26/14 at 9:45 a.m., after staff member M, RN, finished giving medications and tube feeding to resident #1, staff members K and J, CNAs, proceeded to help resident #1 get ready for the morning. When staff members K and J assisted the resident into his wheelchair, staff member J proceeded to place a harness over chest. The harness was attached to the wheelchair back. Staff member J, stated that the harness helps resident #1 to sit up straighter, and helps with his contractures. On 2/26/14 at 1:00 p.m., the medical record was reviewed. There was no physician order for [REDACTED].#1's flexion contractures. The MDSs dated 10/21/13 and 1/13/14 showed no restraints in use. On 2/27/14 at 9:55 a.m., an interview with staff member N, PT took place. He stated that the chest harnes… | 2015-07-01 |
| 4874 | 4874 | PIONEER MEDICAL CENTER LTC | 275139 | 301 W 7TH AVE | BIG TIMBER | MT | 59011 | 2014-02-27 | 279 | E | 0 | 1 | EV5411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview the facility failed to update and maintain complete and accurate care plans for 4 (#1, #2, #3, #6 ) of 14 sampled and supplement residents. 1. Resident #2 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident #2 scored a 9 on his last BIMS with an ARD of 1/20/14. During a review of the resident's clinical record, nutrition CAA (care area assessment) and his care plan, the surveyor observed that the monthly physician's orders [REDACTED]. The note for the nutrition CAA (care area assessment) dated 1/21/14, reads, "Triggered for high BMI (body mass index) and mechanical soft diet." "Res has hx (history) of choking on lg (large) pieces of meat. Staff cuts meat for resident to reduce potential for choking. Sources include: Nutrition assessment from 1/14; Dr orders 1/14; Res interview 1/14. Proceed to care plan 1/21/14. KP" While reviewing resident #2's care plan the surveyor noted that the nutrition section, dated 1/21/14, indicated that he is on a regular diet and that staff must cut all meats and food into bite sized pieces. The surveyor interviewed staff member C, dietician and dietary manager on 2/26/14 at 10:15 a.m. regarding the conflicting information contained on the physician's monthly orders, CAAs (care area assessment), and the care plan for resident #2. Staff member C told the surveyor that the mechanical soft diet should be on his care plan. She told the surveyor that she would get resident #2's care plan updated to reflect a mechanical soft diet. 2. Resident #3 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident #3 was not scored on her BIMs due to her cognitive impairment. Her most current ARD was 12/09/13. During a review of resident #3's clinical record the surveyor noted her diet on the physician's monthly orders, dated 2/1/14 through 2/28/14, was for "4 oz of Ensure tid with meals and a reg diet with mech… | 2015-07-01 |
| 4875 | 4875 | PIONEER MEDICAL CENTER LTC | 275139 | 301 W 7TH AVE | BIG TIMBER | MT | 59011 | 2014-12-31 | 241 | E | 0 | 1 | MXDM11 | Based on observation and interview, the facility failed to provide privacy of personal information for 8 (#s 1, 2, 7, 9, 10, 11, 12, 13) of 13 sampled and supplemental residents. Findings include: During observations on 12/29/14 at 4:05 p.m. and 12/30/14 at 1:15 p.m., laminated cards were taped to the wall inside the entry door of eight resident rooms (#s 1, 2, 7, 9, 10, 11, 12, 13). The cards listed personal information regarding each resident's care needs. This information included oxygen needs, number of staff and equipment necessary to transfer the resident, dietary requirements of the resident and delivery systems, such as PEG tubes, assistance necessary for ambulation and equipment used (walker, w/c), continence or incontinence status, continence or incontinence at night, use of chair and bed alarms, use of TED hose, hearing aids, toilet risers, dentures, and glasses. The information on the cards was visible to the public. During an interview on 12/29/14 at 2:28 p.m., staff member B, care coordinator, said the laminated cards on the wall were to give the CNAs information regarding the residents. She said the cards had not been updated since the last DON was at the facility. Staff member B said she felt there was too much information displayed on the cards and hoped to talk to the new DON about this when she (the new DON) "got up and running." Staff member B provided a "cheat sheet" the CNAs utilize on a daily basis that contain similar resident information. During an interview on 12/29/14 at 2:45 p.m., staff member C, CNA, said she used the information on the cards regarding resident care needs when she started working at the facility, but did not need the cards once she knew the residents. | 2015-07-01 |
| 4876 | 4876 | PIONEER MEDICAL CENTER LTC | 275139 | 301 W 7TH AVE | BIG TIMBER | MT | 59011 | 2014-12-31 | 154 | E | 0 | 1 | MXDM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide information to show the resident or their representative had been educated on the risks and benefits of [MEDICAL CONDITION] medications for 4 (#'s 1, 5, 7 and 8) of 8 sampled residents. Findings include: 1. Resident #5 was admitted to the facility on [DATE] with a [MEDICAL CONDITION] disorder. Review of resident #5's medical record showed a lack of documentation of education for resident #5 and her representative regarding the use, the risk, and the benefits of [MEDICATION NAME], an antianxiety medication. 2. Resident #8 was re-admitted to the facility on [DATE]. Review of resident #8's medical record lacked documentation of education for the resident or their representative of the risks and benefits of use of [MEDICAL CONDITION] drugs, specifically [MEDICATION NAME], an antidepressant. During an interview on 12/30/14 at 8:55 a.m., staff member A, CEO, stated there was no paper or form used to educate residents or their representative of the risks and benefits of [MEDICAL CONDITION] drugs. He also stated that he was not aware of any documentation done on admission that showed the facility educated the resident, family, or POA on the risk and benefits of the [MEDICAL CONDITION] medication. During an interview on 12/30/14 at 2:30 p.m., staff member D, social services, stated the IDT, the resident, and the family discussed [MEDICAL CONDITION] medications at the quarterly care plan meetings. She thought it was discussed when residents were placed on a new medication and upon admission, but did not think this was documented each time. She thought that it was probably being done by the admitting doctor in his office. 3. Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of resident #1's annual MDS, with an ARD of 12/9/14, showed that the resident's BIMS was a 9, indicating a moderate impairment of her cognition. The resident had a designated … | 2015-07-01 |
| 5202 | 5202 | PIONEER MEDICAL CENTER LTC | 275139 | 301 W 7TH AVE | BIG TIMBER | MT | 59011 | 2012-01-19 | 425 | D | 0 | 1 | Z12S11 | Based on observation, record review, and staff interview, the facility failed to provide medications for 1 (#2) of 4 residents sampled during the medication pass observation and failed to remove expired medications from the active inventory. Findings include: 1. During the medication pass observation conducted on 1/18/12 at 9:30 a.m., resident #2's MAR indicated [REDACTED]. The documentation on the reverse side of the MAR indicated [REDACTED]. The documentation lacked information regarding the missed dose of medication on 1/17/12. When interviewed during the medication pass observation, staff member N, an RN, stated the facility did not currently have the medication on hand and the medication was "on order". During an interview conducted on 1/18/12 at 4:45 p.m., staff member A, the DON, stated she was not aware the resident had missed three doses of medication. 2. During the medication room inspection conducted on 1/17/12 beginning at 1:30 p.m., the following expired medications were found: - 14 ampoules of injectable Vitamin K with a manufacturer's expiration date of 11/1/11; and - 6 vials of injectable Procrit with a manufacturer's expiration date of 10/11. The above expired medications were verified and given to staff member A for disposal on 1/18/12 at 4:30 p.m. | 2015-01-01 |
| 5203 | 5203 | PIONEER MEDICAL CENTER LTC | 275139 | 301 W 7TH AVE | BIG TIMBER | MT | 59011 | 2012-01-19 | 431 | E | 0 | 1 | Z12S11 | Based on observation, temperature log review, and staff interview, the facility failed to store medications within the manufacturer's stated temperature range. Findings include: 1. During the inspection of the medication storage area conducted on 1/17/12 at 2:05 p.m., the contents of the pharmacy room refrigerator was observed. The refrigerator contained two vials of PPD with the manufacturer's temperature range indicated on the outer packaging. The indicated temperature range was "36?- 46?F". The package also indicated "Do not freeze." The temperature log dated January 2012 documented temperature readings for 17 days. Eight of the 17 days documented indicated the temperature was 34? F. Three of the 17 days documented indicated the temperature was 32?F. When asked to check the current temperature on 1/17/12 at 2:05 p.m., staff member N stated it was "32? (F)". 2. During the inspection of the medication storage area conducted on 1/17/12 at 2:05 p.m., the contents of the medication room refrigerator was observed. The refrigerator contained five vials of Humalog insulin with the manufacturer's temperature range indicated on the outer packaging. The indicated temperature range was "36?- 46?F". The package also indicated "Do not freeze." The temperature log dated January 2012 documented temperature readings for 17 days. Six of the 17 days documented indicated the temperature was 34? F. Three of the 17 days documented indicated the temperature was 32?F. 3. During the inspection of the medication storage area conducted on 1/17/12 at 4:30 with staff member A, a bottle of Pilocarpine eye drops was observed in the refrigerator. The manufacturer's storage temperature range on the outer packaging indicated "59? - 86?F". 4. During the inspection of the medication storage area conducted on 1/17/12 at 4:30 p.m. with staff member A, an unopened bottle of Latanoprost eye drops was observed on a wall shelf. The manufacturer's storage temperature range on the outer packaging indicated unopened bottles should be stored "under refrig… | 2015-01-01 |
| 5204 | 5204 | PIONEER MEDICAL CENTER LTC | 275139 | 301 W 7TH AVE | BIG TIMBER | MT | 59011 | 2012-01-19 | 490 | B | 0 | 1 | Z12S12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to remove expired supplies from the active inventory. Findings include: During the inspection of the medication storage areas conducted on [DATE] at 4:30 p.m., the following items were found: - 1 24 gauge IV catheter needle with a manufacturer's expiration date of ,[DATE]; - 1 16 gauge IV catheter needle with a manufacturer's expiration date of ,[DATE]; - 9 20 gauge IV catheter needles with a manufacturer's expiration date of ,[DATE]; - 1 intraosseous needle with a manufacturer's expiration date of ,[DATE]; and - 1 opened bottle of hemoccult test developer. When interviewed during the inspection, staff member N stated the above items were expired and should be removed from the active inventory. | 2015-01-01 |
| 5205 | 5205 | PIONEER MEDICAL CENTER LTC | 275139 | 301 W 7TH AVE | BIG TIMBER | MT | 59011 | 2012-01-19 | 278 | B | 0 | 1 | Z12S12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview, the facility failed to ensure the MDS assessments for 3 (#s 2, 6, and 7) of 10 sampled residents were accurately documented. Findings include: 1. Resident #6 was admitted on [DATE] with [DIAGNOSES REDACTED]. During the entrance tour on 1/17/12 at 10:00 a.m., resident #6 was noted to have a turning/positioning bar attached to the bed. During record review, the Quarterly MDS assessment with an ARD of 12/5/11 was reviewed. According to this assessment, Section P0100 Physical Restraints was coded A for bed rail used less than daily while in bed. Further review of the medical record failed to show a physician's order for the use of [REDACTED]. The care plan did not contain mention of the use of the bed rail. During an interview with staff members A, B, and E on 1/18/12 at 4:45 p.m., staff member B stated they had been cited in the past for not coding items that would be considered restraints. The staff members were encouraged to read the definition of restraints that is contained in the RAI manual in Section P. If an item does not meet the definition and has been assessed as not being a restraint, it should not be coded as a restraint. The turning/positioning bar for resident #6 did not meet the definition of a restraint, so should not have been coded as a restraint. 2. Resident #7 was admitted on [DATE] with [DIAGNOSES REDACTED]. During the entrance tour on 1/17/12 at 10:00 a.m., resident #7 was not noted to have restrictive devices of any type. During record review, the Annual MDS with an ARD of 5/15/11, the Quarterly MDS with ARDs of 8/8/11 and 10/31/11 were reviewed. The 5/15/11 and 8/8/11 MDS assessments coded P0100 D Other restraint used in bed daily. The 10/31/11 MDS coded P0100 D Other restraint used in bed less than daily. The Quarterly MDS with an ARD of 2/28/11 was reviewed, and noted no restraints were coded. During further record review, the care plan was noted to list the rest… | 2015-01-01 |
| 5206 | 5206 | PIONEER MEDICAL CENTER LTC | 275139 | 301 W 7TH AVE | BIG TIMBER | MT | 59011 | 2012-01-19 | 514 | B | 0 | 1 | Z12S12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the clinical records for 1 (#6) of 10 sampled residents was complete and accurately documented. Findings include: 1. Resident #6 was admitted on [DATE] with [DIAGNOSES REDACTED]. While comparing the Quarterly MDS assessments for ARD 9/11/11 and ARD 12/5/11, there were multiple changes noted that could have warranted a significant change. These changes were noted in: - D0300 was 17 (moderate severe depression ) on 9/11/11, and was 8 (mild depression) on 12/5/11, which was an improvement; - J0600A pain intensity was 7 of 10 on 9/11/11, and was 4 of 10 on 12/5/11, which was an improvement; - G0110C Walk in Room was coded 8/8 (didn't occur) on 9/11/11, and 0/0 (independent) on 12/5/11, which was an improvement; - G0110E and G0110F Locomotion on and off unit was coded 2/2 (limited assistance of 1 person) on 9/11/11, and was coded 8/8 (didn't occur) on 12/5/11, which was two declines; - M1040 Other Ulcers, Wounds and Skin Problems was coded Z (none of the above) on 9/11/11, but was coded D (open lesion other than foot) on 12/5/11, which was a decline; - M1200 Skin and Ulcer Treatments was coded A (pressure reducing device for chair) on 9/11/11, and was coded G (nonsurgical dressing other than feet) and H (ointments/medications other than feet), which was two declines; and - P0100 Physical Restraints was not coded on 9/11/11. but was coded as Bed rail used in bed less than daily on 12/5/11, which was a decline. 2. During an interview with staff member E on 4/18/12 at 4:45 p.m., staff member E stated they had discussed the changes for resident #6, but did not document that conversation anywhere in the medical record. Staff member E further stated they did not have a portion of their computer program installed until January, so did not have access to the significant change information. | 2015-01-01 |
| 5588 | 5588 | PIONEER MEDICAL CENTER LTC | 275139 | 301 W 7TH AVE | BIG TIMBER | MT | 59011 | 2011-03-17 | 363 | E | 79GP11 | Based on observation, review of the posted menus, and staff interview, the facility failed to follow menus for 6 (#s 5, 6, 7, 12, 13, and 14) of 6 residents receiving pureed or prn pureed diets. Findings included: On 3/15/11, the noon meal was posted as follows: Ham stromboli, potato soup, asparagus spears and a strawberry oatmeal bar. The alternate meal was a chicken artichoke bake and asparagus spears. At 11:10 a.m., the surveyor asked staff member H, a CNA who served residents in the feeding assistance area, what the pureed diet meat was. Staff member H replied that she was unsure. On 3/15/11 at approximately 11:15 a.m., the cook, staff member L, stated the pureed diet included sweet potatoes with gravy, mashed potatoes with gravy, roast beef and applesauce for dessert. Referring to residents who received pureed diets, the cook stated, "Most of the time they would receive what's on the menu," she said. "But today, I had leftover roast beef." She said that she used leftover sweet potatoes because asparagus did not puree well. "It gets kind of stringy," she said. At 5:07 p.m. on 3/15/11, the surveyor observed the dinner meal service. The posted menu for dinner was a grilled turkey and Swiss cheese sandwich, chips, stewed tomatoes and spiced peaches. The alternate was shrimp gumbo and cornbread. The surveyor asked staff member J, a CNA, what the pureed items were on a resident's plate in the assisted dining area. He replied potatoes and gravy, stewed tomatoes and tapioca pudding. He was unsure what the meat was. On 3/15/11 at approximately 5:15 p.m., staff member K, the cook serving the meal, stated the pureed meat was leftover stromboli sandwich from lunch. On 3/16/11 at 4:48 p.m., the surveyor observed the dinner meal service. The posted menu included beef stroganoff, mashed potatoes and gravy or noodles, peas and jello. The alternate was corn chowder and roast beef sandwich. Staff member K said the pureed meal was pork chops and mashed potatoes with gravy and squash. Staff member K said the pork chops and squa… | 2014-04-01 | ||
| 5589 | 5589 | PIONEER MEDICAL CENTER LTC | 275139 | 301 W 7TH AVE | BIG TIMBER | MT | 59011 | 2011-03-17 | 329 | D | 79GP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility increased an anxiolytic medication without adequately monitoring behaviors for one (#5) of 10 sampled residents. Findings include: Resident #5 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. On 9/7/10, resident #5's physician reduced her order for [MEDICATION NAME] from .5 mg p.o. TID and at hs to .5 mg po TID. On 11/9/10, in a nursing home visit report, the family nurse practicer (FNP) wrote "Patient had been decreased on her [MEDICATION NAME] dose from qid (four times a day) dosing to tid dosing and the staff reports that patient has had increased combativeness." The FNP's plan was "We are going to bump her [MEDICATION NAME] to .5 mg one p.o. tid and at bedtime for anxiety." The surveyor reviewed resident #5's Interdisciplinary Progress Notes dated 9/7/10 to 11/9/10. On 10/3/10, at 0200 (2 a.m.), the nurse wrote: "Resident did a lot of yelling tonight scream out 'get me to bed' pt was in bed - would tell her this..." Then at 0300 (3 a.m.), the nurse wrote "Resident is resting @ this time no more yelling @ this time." On 10/26/10, at 16:15 (4:15 p.m.), the nurse wrote: "After lunch today she was hollering and hollering - when checked it was noted that her face was red and slightly swollen - Indicated she had pain in her abdomen - medicated c Tylenol 650 mg crushed." During an exit meeting on 3/15/11 at 5:15 p.m., the surveyor asked how the facility monitored behaviors. Staff member A, the DON, said the nurses chart behaviors. Staff member G, the ADON, said behaviors are also monitored on progress note sheets by the CNAs. On 3/16/11 at 9 a.m., the ADON said the CNAs had not documented any behaviors for resident #5. The facility failed to monitor behaviors during the gradual dose reduction of the [MEDICATION NAME]. The dose was increased with two documented incidents of hollering between 9/7/10 and 11/9/10. In one of the documented incidents, the resident was hollering beca… | 2014-04-01 | ||
| 5590 | 5590 | PIONEER MEDICAL CENTER LTC | 275139 | 301 W 7TH AVE | BIG TIMBER | MT | 59011 | 2011-03-17 | 161 | B | 79GP11 | Based on administrative record review and staff interview, the facility failed to maintain a surety bond in an amount sufficient to ensure the security of the residents' personal funds. Findings include: On 3/14/11, the facility provided a surety bond that was executed on 10/6/05. A renewal was attached to the bond extending coverage from 10/10/08 through 10/10/09. No additional premium notices were provided that verified a surety bond was in effect after 10/10/09. For the past four months (November 2010 through February 2011), the resident trust account balance exceeded the surety bond value of $5000.00. On 3/15/11 at 4:30 p.m., the facility administrator was informed of the concern. As of the survey exit on 3/17/11 at 10:30 a.m., no additional information was provided. | 2014-04-01 | ||
| 5591 | 5591 | PIONEER MEDICAL CENTER LTC | 275139 | 301 W 7TH AVE | BIG TIMBER | MT | 59011 | 2011-03-17 | 333 | G | 79GP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review, one (#1) of 10 sampled residents sustained a significant medication error. Findings included: On 3/15/11 at 8:00 a.m., staff member M, an RN, was observed as she administered resident medications. Resident #1 was admitted to the facility on [DATE], following a [MEDICAL CONDITION] and subsequent [MEDICAL CONDITION] disorder. The resident was prescribed [MEDICATION NAME] ([MEDICATION NAME]) 250 mg twice a day for [MEDICAL CONDITION] control. The medication was dispensed as a liquid and administered through a gastrostomy tube. The medication concentration was 100 mg/5 ml (milliliters). At approximately 9:00 a.m., staff member M prepared the resident's medications. The medication, labeled as [MEDICATION NAME] on the bottle, was poured into a medication cup. The medication was pink and separated into sediment at the bottom of the medication bottle and thin liquid at the top. The surveyor asked the staff nurse if the medication needed to be shaken. The staff member stated the medication liquid was shaken before it was poured into the medication cup. The staff nurse then returned the liquid to the medication bottle and shook the medication again. The staff nurse poured the medication into a medication cup. The nurse then stated that the medication was incorrect. A nearly empty, second bottle, labelled [MEDICATION NAME], was in the medication cart. The nurse poured the medication from the second bottle and the fluid was thick and orange in color. The medication that was initially poured into a medication cup by the nurse, as stated above, was dispensed on 2/14/11 as [MEDICATION NAME] 100 mg/5 ml, 300 cc (cubic centimeters). Approximately 75 cc had been administered from the medication bottle (225 cc remained in the bottle). A second bottle of '[MEDICATION NAME]' was located in the medication storage room. The second bottle was labeled the same as the first bottle and also contained a p… | 2014-04-01 | ||
| 5592 | 5592 | PIONEER MEDICAL CENTER LTC | 275139 | 301 W 7TH AVE | BIG TIMBER | MT | 59011 | 2011-03-17 | 425 | G | 79GP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review, the facility failed to ensure accurate dispensing of medications for one (#1) of 10 sampled residents. Findings included: On 3/15/11 at 8:00 a.m., staff member M, an RN, was observed as she administered medications to a resident. Resident #1 was admitted to the facility on [DATE] following a traumatic brain injury with subsequent seizure disorder. The resident was prescribed carbamazepine (Tegretol) 250 mg twice a day for seizure control. The medication was dispensed as a liquid and administered through a gastrostomy tube. The medication concentration, per the pharmacy label, was 100 mg/5 ml (milliliters). At approximately 9:00 a.m., staff member M prepared the resident's medications. The medication labeled as carbamazepine, was poured into a medication cup. The medication was separated into sediment at the bottom of the medication bottle and thin liquid at the top. The surveyor asked the staff nurse if the medication needed to be shaken. The staff member stated the medication liquid was shaken before it was poured into the medication cup. The staff nurse then returned the liquid to the medication bottle and shook the bottle of medication again. The staff nurse poured the medication into a medication cup. The nurse then stated that the medication was incorrect. A nearly empty, second bottle, labeled Tegretol, was in the medication cart. The nurse poured medication from the second bottle and the fluid was thick and orange in color. Staff member N, the lead pharmacist with the contract pharmacy, was interviewed on 3/15/11 at 9:40 a.m. The pharmacist stated that she thought the carbamazepine was mislabeled. The pharmacist theorized that Carafate was dispensed instead of carbamazepine. The two medications were stored next to one another on the pharmacy shelf. The pharmacist stated as a result of the error, an official policy change had occurred effective immediately. The procedure … | 2014-04-01 | ||
| 5593 | 5593 | PIONEER MEDICAL CENTER LTC | 275139 | 301 W 7TH AVE | BIG TIMBER | MT | 59011 | 2011-03-17 | 441 | E | 79GP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of policies and procedures, and staff interview, the infection control program lacked measures to facilitate the investigation, control and prevention of infections. Findings included: Review of the infection surveillance system lacked standardized definitions and listings of the symptoms of infections. Laboratory cultures and physician orders [REDACTED]. The infection control activities did not include an antibiotic review to monitor the appropriate use of antibiotics in the resident population. On 3/16/11 at 10:00 a.m., following review of the infection control policies, records of incidents and reports, the infection preventionist was interviewed. The infection preventionist acknowledged the facility infection control program lacked the above elements. | 2014-04-01 | ||
| 5594 | 5594 | PIONEER MEDICAL CENTER LTC | 275139 | 301 W 7TH AVE | BIG TIMBER | MT | 59011 | 2011-03-17 | 157 | D | 79GP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to notify the physician of a sub-therapeutic laboratory value for 1 (#1) of 10 sampled residents. Findings included: Resident #1 was admitted to the facility on [DATE], following a [MEDICAL CONDITION] and subsequent [MEDICAL CONDITION] disorder. The resident was prescribed [MEDICATION NAME] ([MEDICATION NAME]) 200 mg twice a day for [MEDICAL CONDITION] control. On 3/8/11, the physician requested a [MEDICATION NAME] level. On 3/9/11 at 5:39 a.m., the results of the blood test were faxed to the facility. The resident's [MEDICATION NAME] level was 2.9 (therapeutic range was 8.0 - 12.0). The physician was not notified of the sub-therapeutic medication level. On 3/9/11 at 10:00 p.m., the resident had a [MEDICAL CONDITION]. On 3/10/11 at 2:26 p.m., the provider noted the results of the [MEDICATION NAME] lab test. The resident's [MEDICATION NAME] ([MEDICATION NAME]) dose was increased to 250 mg twice a day. On 3/15/11 at 9:30 a.m., staff member A stated it was the provider's responsibility to follow up on questionable laboratory values. | 2014-04-01 | ||
| 5595 | 5595 | PIONEER MEDICAL CENTER LTC | 275139 | 301 W 7TH AVE | BIG TIMBER | MT | 59011 | 2011-03-17 | 280 | D | 79GP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to revise the plan of care to include interventions to prevent skin breakdown for 1 (#5) of 10 sampled residents. Findings include: Resident #5 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. According to a Pressure Ulcer Risk assessment dated [DATE], resident #5 scored a 15 (high risk for skin breakdown). On resident #5's quarterly MDS, with an ARD of 2/7/11, she was coded a "4" (total dependence) for bed mobility, transfer and all other activities of daily living. Resident #5 had a care plan problem, dated 6/9/10, that stated "Potential for impaired skin integrity R/T (related to) decreased mobility and incontinence of urine and medications use." Interventions included "position changes every two hours during the day and night" and "keep my bed linen free of wrinkles and do not over pad the bed." The surveyor reviewed Skin Impairment Flow Sheets in resident #5's medical record. According to the form, resident #5 had developed "open [MEDICAL CONDITION]" on her left outer heel and right inner heel on 9/1/10. The surveyor observed resident #5 sleeping in bed on her left side at 2:35 p.m. on 3/15/11. Resident #5 had a pillow between her knees. She was wearing socks, but no heel protectors. On 3/15/11 at 5:00 p.m., staff member A, the DON, stated the wounds were from pressure. According to the flow sheets, the wounds were healed on 10/15/10. Staff member A stated they were using heel protectors on resident #5. On 3/16 /11 at 9:15 a.m., staff member A told the surveyor that she was mistaken and that the staff were floating resident #5's heels rather than using heel protectors. The surveyor observed resident #5 napping on her back in bed at 2:23 p.m. on 3/16/11. Resident #5 had a pillow placed under her upper calves. Her feet extended beyond the pillow and layed flat on the bed. In summary, the facility failed to revise the care plan after the resident had d… | 2014-04-01 | ||
| 765 | 765 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2018-01-11 | 550 | D | 0 | 1 | U25Y11 | Based on observation and interview, the facility failed to treat 1 (#1) of 14 sampled residents with dignity and respect, for a resident who had wanted to make a choice regarding a meal preference. Findings include: During an observation and interview on 1/8/18 at 6:00 p.m., resident #1 refused to eat the chicken salad sandwich she had ordered for the evening meal. Resident #1 said the chicken salad looked like runny baby food. Staff member A was observed speaking to resident #1. Resident #1 received a hamburger on a bun at 6:25 p.m. Resident #1 said the hamburger looked much more appetizing than the chicken salad sandwich she had received earlier. During an interview on 1/9/18 at 1:30 p.m., resident #15 spoke about an incident from 1/8/18, when resident #1 refused to eat her chicken salad sandwich. Resident #15 said resident #1 was approached by staff member A, who asked resident #1 if she had a problem with the chicken salad sandwich. Resident #15 said staff member A told resident #1 it was what she had ordered for dinner. Resident #15 said resident #1 told staff member A she could not eat the chicken salad sandwich because it looked terrible. Resident #1 told staff member A she wanted a hamburger. Resident #15 said staff member A was reluctant to give resident #1 something different to eat. Resident #15 said resident #1 started to cry because staff member A was insisting resident #1 eat what she had ordered. Resident #1 nodded in affirmation of what resident #15 had said. Resident #1 did not want to speak of the conflict she had with staff member A regarding the evening meal on 1/8/18. | 2020-09-01 |
| 766 | 766 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2018-01-11 | 580 | D | 0 | 1 | U25Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to notify the resident and his guardian, and consult with the physician, for a severe weight gain in one month, for 1 (#30) of 14 sampled residents. Findings include: Review of resident #30's physician visit note, dated 12/07/17, showed the resident had a decrease in his weight, and his extremities showed a trace of [MEDICAL CONDITION], but they actually look quite good. Review of resident #30's Weights and Vitals Summary showed he weighed 169.5 pounds on 12/5/17, and on 1/8/18, he weighed 190.5 pounds, a weight gain of 21 pounds in 1 month During an observation on 1/11/18 at 10:21 a.m., resident #30 had [MEDICAL CONDITION], on his lower legs and ankles. During an interview on 1/10/18 at 10:55 a.m., staff member H stated the resident's legs were swollen, and had 2+ or more [MEDICAL CONDITION]. She stated when he elevated his legs, the [MEDICAL CONDITION] improved. She looked through the Physician notification book, and stated the physician had not been notified of the [MEDICAL CONDITION] or severe weight gain of 21.5 pounds in one month. Review of resident #30's EHR lacked evidence the resident and his guardian were aware of the resident's change in status. Review of resident #30's nutrition note, dated 1/09/18, showed triggering for significant gain. Weight had declined to 169.5-176 pounds while he was sick. Now back to 190.5 pounds which is what he was weighing prior to becoming sick. He has had variable weight trends in the past with possibly some of this related to [MEDICAL CONDITION] ([MEDICATION NAME] on board), overall stable. Monitoring weights, and follow-up with additional interventions PRN. | 2020-09-01 |
| 767 | 767 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2018-01-11 | 610 | D | 0 | 1 | U25Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide evidence of a thorough investigation for an allegation of abuse for 1 (#22) of 14 sampled residents, and failed to protect residents from further potential abuse by allowing an alleged abusive employee to continue to work. Findings include: Review of a facility incident report, dated 7/12/17, showed a CNA was reported and witnessed to be physically and verbally abusive to a resident #22. Review of the facility investigation showed the allegation included the CNA yelling at the resident, stating he made her life more difficult, and forcibly placing his foot on the foot plate of the mechanical lift during a transfer. Resident #22 was reportedly saying please please. Review of the facility incident report, dated 7/17/17, showed Through our investigation and interview of cognitive residents and staff members, we have unsubstantiated the abuse allegation toward this resident. Review of the facility Notice of Discipline for the CNA, dated 7/13/17, showed the employee was suspended from 7/13/17 through 7/17/17. It was not documented that the CNA was removed from resident care on 7/12/17. Review of the facility Notice of Discipline for the CNA, dated 8/3/17, showed the employee was provided a Final Warning for rude or discourteous conduct towards a resident, and unacceptable treatment of [REDACTED]. The employee gave a two-week resignation notice, and was allowed to work until 8/15/17, when another allegation of abuse was reported. Review of resident #22's EHR showed he was discharged from the facility on 7/25/17. During an interview on 1/10/18 at 11:00 a.m., staff member A stated the facility did not have documentation to show how the abuse was not substantiated, and had no evidence of education provided to the CN[NAME] When asked why the CNA was given a final warning on 8/3/17, if the abuse was unsubstantiated, she stated corporate employees had conducted the investigation, and st… | 2020-09-01 |
| 768 | 768 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2018-01-11 | 641 | E | 0 | 1 | U25Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and observation, the facility failed to accurately reflect the communication and cognitive status for 2 (#s 29 and 30); and the use of anticoagulant medication for 3 (#s 3, 17, and 40) of 22 sampled and supplemental residents. Findings include: 1. Review of resident #30's Significant Change MDS, with the ARD of 12/4/17, showed the resident was always understood and always understands. The Brief Interview for Mental Status showed the resident was rarely/never understood, and was not completed with the resident. The Mood interview was not completed with the resident because it was coded as rarely/never understood. During an observation and interview on 1/9/18 at 9:40 a.m. resident #30 could answer simple questions, and use one word gestures. During an interview on 1/11/18 at 11:10 a.m., staff member [NAME] stated she had miscoded the communication section for resident #30. 2. Review of resident #29's Quarterly MDS, with the ARD of 12/01/17, showed the resident was sometimes understood, and sometimes understands. The cognition and mood sections were coded as rarely/never understands, and the interviews were not attempted for resident #29. During an interview on 1/11/18 at 11:08 a.m., staff member J stated she did not know she should attempt the interview for cognition and mood, and code 99 if the resident was unable to complete the interview. 3. During an interview on 1/9/18 at 1:30 p.m., resident #40 stated she was not receiving [MEDICATION NAME], but she was getting some type of blood thinner. Review of resident #40's (MONTH) (YEAR) MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Review of resident #40's Admission MDS, with an ARD of 12/26/17, showed, in Section N0410E, the resident had received an anticoagulant 7 of 7 days during the look-back period. During an interview on 1/9/18 at 2:48 p.m., staff member C stated she coded resident #40's Admission MDS to show the use of an anticoagulant due to the… | 2020-09-01 |
| 769 | 769 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2018-01-11 | 656 | E | 0 | 1 | U25Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to develop a comprehensive care plan to describe an effective method of communication, and for a risk of choking, for 1 (#30); failed to address [MEDICAL CONDITION], visual loss, mood, and shortness of breath, for 1 (#40); failed to appropriately address dementia care and needs, for 1 (#14) of 14 sampled residents. Findings include: 1.a. During an interview on 1/8/18 at 1:45 p.m., staff member J stated the facility could communicate fairly well with resident #30, because he had lived at the facility for several years. The resident had a [DIAGNOSES REDACTED]. She stated the resident should be able to be interviewed, and would answer simple questions. She stated if he got frustrated, he would place his hand on his face. During an interview on 1/11/18 at 10:40 a.m., staff member [NAME] stated she had miscoded the communication section on the MDS. The miscoding resulted in the problem for communication not being triggered for development on the care plan. During an interview and observation on 1/9/18 at 9:41 a.m., resident #30 could use gestures and verbalize one word to communicate. He showed, using single words and gestures, that he had some stomach pain, was happy, and had no teeth. Review of resident #30's Care Plan, initiated on 2/11/14, did not include a concern with the resident's ability to communicate. b. Review of resident #30's progress note, dated 11/23/17, showed the resident coughed at breakfast while eating bacon and eggs. He was encouraged by the staff to eat lunch, and started to cough again. He started to vomit. He became more agitated. At 2:12 p.m., his lips turned blue, and he was sent to the ER, for respitory distress from choking. Review of resident #30's History and Physical Report from the hospital, dated 11/24/17, showed the resident had an [MEDICAL CONDITION] food impaction, which resulted in pneumonia. Review of resident #30's progress note, dated 1… | 2020-09-01 |
| 770 | 770 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2018-01-11 | 758 | D | 0 | 1 | U25Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure 1 (#14) of 14 sampled residents was free from an antipsychotic medication that was prescribed based on the resident's behaviors. Findings include: Review of resident #14's admission orders [REDACTED]. Review of resident #14's Psychopharmacological Drug Assessment form, dated 7/28/17, showed resident #14 was receiving [MEDICATION NAME], 2.5 mg, twice a day. The document showed resident #14's behaviors, mood, and psychiatric symptoms had improved. Review of resident #14's Antipsychotic Use For Residents With Dementia form, dated 10/27/17, showed the resident had no behaviors. Section 2e. related to prior life patterns and preferences and showed resident #14 had lived at home with her daughter, and the daughter had reported resident #14 had occasional wandering behaviors. This document noted resident #14 had not had any behaviors since admission to the facility. Review of resident #14's nursing progress notes from 4/19/17 to 1/07/18, did not show resident #14 had any behaviors since her admission to the facility. Review of resident #14's electronic health record did not show any behavior monitoring for resident #14. Review of resident #14's pharmacy consultation report, dated 8/3/17, showed the facility requested a dose reduction for resident #14's [MEDICATION NAME]. The [MEDICATION NAME] was decreased from 2.5 mg, twice a day, to 2.5 mg, once a day. The physician agreed with the request, and the [MEDICATION NAME] was decreased to 2.5 mg per day. Review of resident #14's pharmacy consultation report, dated 10/3/17, showed the facility requested the [MEDICATION NAME] be discontinued. The physician declined the recommendation. Review of resident #14's pharmacy consultation report, dated 12/04/17, showed the facility requested the [MEDICATION NAME] be discontinued. The physician accepted the recommendation. The [MEDICATION NAME] was discontinued on 12/5/17. Review of resident #14's… | 2020-09-01 |
| 771 | 771 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2018-01-11 | 759 | E | 0 | 1 | U25Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5%, which affected 3 (#s 6, 8, and 20) residents, out of 22 sampled and supplemental residents, and the facility medication error rate was 12.9%. Findings include: 1. During an observation, interview, and record review, on 1/9/18 at 7:56 a.m., staff member F prepared medication for administration to resident #6. She poured a thick, orange-colored liquid into a plastic graduated medication cup. The graduated markings were in 2.5 ml increments. Review of the label on the bottle, and the order in the EHR, showed the medication was [MEDICATION NAME] (an anti-convulsant), and the dose to be administered was 3.5 ml. Staff member F stated she determined the correct dose by pouring the liquid [MEDICATION NAME] to a point in between the 2.5 ml marking and the 5.0 ml marking. She asked, how else could I do it? After hesitating briefly, staff member F asked, with a syringe? She then obtained a 1.0 ml syringe, withdrew 1 ml of the liquid [MEDICATION NAME] from the medication cup, and put it into a plastic drinking cup. After withdrawing 3 mls, there were a few drops of the medication left in the cup. Staff member F stated she did not have enough of the medication and poured more of the medication into the cup and withdrew the last 0.5 ml needed. The next medication prepared was a pinkish liquid. Review of the label on the bottle showed the medication was Felbamate (an anti-convulsant). Staff member F pointed out the dosage sticker which showed the dose was 1600 mg/ 13.3 ml. The label showed the suspension was 600 mg/ 5 ml. Staff member F stated she would use a graduated medication cup and a 1.0 ml syringe to measure the dosage. She filled the medication cup to 12.5 ml and stated she would add another 0.5 ml. She then stated she would add another 1.3 ml. She then stated she would add another 1.2 ml. Staff member F then calculated the do… | 2020-09-01 |
| 772 | 772 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2018-01-11 | 760 | D | 0 | 1 | U25Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a medication, after not completing an ordered lab test designed to monitor the appropriate therapeutic dose of the medication, for 1 (#33) of 14 sampled residents. Findings include: Resident #33 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. During an interview on 1/8/18 at 5:02 p.m., resident #33 stated he did not believe he was receiving all his scheduled medications. Review of resident #33's (MONTH) (YEAR) MAR and TAR showed an order to monitor for adverse side effects related to the use of anticoagulant medication, but did not show the use of an anticoagulant medication. Review of resident #33's Nursing progress note, dated 12/20/17, showed an order had been received for a dose change of [MEDICATION NAME] (an anticoagulant medication), and for a PT/INR (a lab test to monitor therapeutic blood levels) to be drawn in ten days. Review of resident #33's physician orders, in the EHR, showed the [MEDICATION NAME] dose change, dated 12/20/17, but not the order for the lab test. Review of resident #33's lab results, in the EHR, did not show a PT/INR for 12/30/17, or any date following the order of 12/20/17. A written request was made, on 1/9/18, for the PT/INR results for 12/30/17. Review of resident #33's PT/INR lab report, dated 12/18/17, showed hand written orders that the physician requested the [MEDICATION NAME] dose be changed, and to recheck the PT/INR in ten days. The order was noted by two nurses. During an interview and record review on 1/9/18 at 3:06 p.m., staff member G looked at the orders in the EHR and said she did not see an order for [REDACTED]. She stated, It sure looks like we dropped the ball. She stated the facility routinely writes [MEDICATION NAME] orders with a stop date the day prior to the lab draw date, and after the lab results are received, the physician gives new orders based on the current values. Staff member G stated there was … | 2020-09-01 |
| 773 | 773 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2018-01-11 | 770 | D | 0 | 1 | U25Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a physician-ordered lab test for 1 (#33) of 14 sampled residents. Findings include: Review of resident #33's (MONTH) (YEAR) MAR and TAR showed an order to monitor for adverse side effects related to the use of anticoagulant medication, but did not show the use of an anticoagulant medication. Review of resident #33's progress note, dated 12/20/17, showed an order had been received for a dose change of [MEDICATION NAME] (an anticoagulant medication), and for a PT/INR (a lab test to monitor therapeutic blood levels) to be drawn in ten days. Review of resident #33's physician orders [REDACTED]. Review of resident #33's lab results in the EHR did not show a PT/INR for 12/30/17 or any date following the order of 12/20/17. A written request was made on 1/9/18, for the PT/INR results for 12/30/17. Review of resident #33's PT/INR lab report, dated 12/18/17, showed hand written orders to change the [MEDICATION NAME] dose, and to recheck the PT/INR in ten days. During an interview and record review 1/9/18 at 3:06 p.m., staff member G looked at the orders in the EHR and said she did not see an order in the EHR for the blood draw for PT/INR. She stated, It sure looks like we dropped the ball. During an interview on 1/9/18 at 5:15 p.m., staff member M stated no PT/INR had been drawn for resident #33 on 12/30/17, and as a result, resident #33 had not received any [MEDICATION NAME] since 12/29/17. During an interview on 1/9/18 at 5:24 p.m., staff member G stated a lab order should be put on the lab calendar, and that it was done for resident #33's PT/INR due on 12/30/17. Staff member G stated labs were not usually scheduled for Saturday, and a nurse would not likely look for it. She said it should have been passed on in the (nurse to nurse) shift report. Staff member G stated all the processes failed. See F760 for further details. | 2020-09-01 |
| 774 | 774 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2018-01-11 | 804 | E | 0 | 1 | U25Y11 | Based on observation and interview the facility failed to provide hot, attractive, and palatable food for 3 (#s 1, 3, 14) of 14 sampled residents. Findings include: 1. During an interview on 1/08/18 at 1:26 p.m., resident #3 said the food could be hotter. Resident #3 said he eats a lot of hot dogs and hamburgers, the alternate food choice, because he doesn't like what is being served as the main entree. Resident #3 said the main entree is frequently chicken or turkey, and he does not like poultry. Resident #3 said facility staff had never asked about his food likes and dislikes. 2. During an interview on 1/8/18 at 5:10 p.m., resident #1 said she had a breakfast tray in her room every morning. Resident #1 said her breakfast was always cold. During an observation and interview on 1/8/18 at 6:00 p.m., resident #1 refused to eat the chicken salad sandwich she had ordered for the evening meal. Resident #1 said the chicken salad looked like runny baby food. Resident #1 said everything else she had ordered for the evening meal was fine. 3. During an interview and observation on 1/08/18 at 6:16 p.m., resident #14 refused to eat the chicken salad sandwich, stating it did not look good. During an observation on 1/08/18 at 5:55 p.m., the alternate dinner item was a chicken salad sandwich, with the chicken salad being blended into a puree. During an interview on 1/08/18 at 6:07 p.m., staff member D stated the chicken salad did get a little too squishy with the machine she used to prepare the salad. 4. During an observation on 1/11/18 at 8:35 a.m., resident #141's breakfast tray, which included pureed pancake, egg, and sausage, had temperatures ranging from 90 to 97 degrees when the meal was provided to the resident. During an observation on 1/11/18 at 8:45 a.m., resident #21's breakfast tray showed the temperature of the food was 90 degrees, and the margarine was not melting on the pancake. The resident stated the eggs were too cold to eat. Review of the resident council minutes, for 11/7/17, showed the residents stated brea… | 2020-09-01 |
| 775 | 775 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2018-01-11 | 842 | D | 0 | 1 | U25Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain a complete and accurate medical record for 1 (#14) of 14 sampled residents. Findings include. Resident #14 was admitted to the facility on [DATE] from a psychiatric unit. Resident #14 had been admitted to the psychiatric unit from home, and was at the psychiatric unit for three days. Review of resident #14's electronic health record failed to show the facility had any information regarding resident #14's admission to, and discharge from, the psychiatric unit. Resident #14's admission History and Physical, and the Discharge Summary from the psychiatric unit, was requested from the facility on 1/9/18. During an interview on 1/10/18 at 4:25 p.m., staff member B said the facility had no information from the psychiatric unit for resident #14. Staff member B was unable to answer any questions regarding resident #14's stay at the psychiatric unit. Staff member B did not know why resident #14 had been admitted to a psychiatric unit, she did not know any of the findings from resident #14's stay, and she did not know what behaviors, if any, resident #14 had exhibited during her stay at the psychiatric unit. Staff member B said the facility forgot to request the information from the psychiatric unit. Staff member B said she hadn't thought it was necessary because resident #14's physician was local to the facility, and he would have notified the facility of anything important. | 2020-09-01 |
| 776 | 776 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2018-01-11 | 849 | D | 0 | 1 | U25Y11 | Based on record review and interview, the facility failed to provide designated facility staff to communicate with Hospice Services, and failed to collaborate with a hospice representative in the care planning process, for 1 (#141) of 14 sampled residents. Findings include: Review of resident #141's Care Plan, dated 12/22/17, showed Please refer to my hospice plan of care located in this care plan for more details of my care. Review of the Care Plan showed no further Hospice Care Plan details. During an interview on 1/11/18 at 11:50 a.m., staff member C stated resident #141's Hospice Care Plan should be at the nurses' station in a binder. She also stated there was not a facility designated employee to communicate and coordinate with Hospice Services. Resident #141's Hospice Care Plan was not located in the binder at the nurses' station, per staff member C's interview. | 2020-09-01 |
| 777 | 777 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2019-03-21 | 695 | D | 0 | 1 | TRHL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to consistently monitor portable oxygen tank levels; failed to replace the empty portable tank with a full tank; and failed to have the necessary regulator available to deliver the prescribed amount of oxygen per minute for 1 (#20) of 17 sampled residents, which caused the resident to report feeling short of breath. Findings include: During an observation and interview, on 3/19/19 at 12:42 p.m., the oxygen tank on the back of resident #20's chair was empty. Resident #20 had the nasal cannula on. Resident #20 stated he had [MEDICAL CONDITION]. He stated he was supposed to be on three liters of oxygen. The regulator on the portable tank showed it was on two liters per minute. During an observation and interview on 3/19/19 at 2:50 p.m., resident #20's oxygen tank was observed to be empty. Staff member J looked at the portable oxygen tank on the back of the resident #20's wheel chair and stated, Oh your tank is empty. Staff member J stated, We check the tanks when we bring them back from meals. Staff member J stated the resident brought himself back from meals, And to be honest, I got busy and didn't think to check it. Staff member J asked resident #20 if he was having any trouble breathing, and the resident stated sometimes he gets short of breath. During an observation and interview on 3/21/19 at 9:57 a.m., K stated We have to check (resident name) oxygen constantly. Staff member K stated he thought the resident was to be on three liters of oxygen per minute. Staff member K and the surveyor looked at the regulator, which showed the dial was on two liters per minute. Staff member K asked staff member I how many liters of oxygen the resident was supposed to be on, and staff member I stated three and a half liters. Staff member K then went to turn the regulator up, but stated the regulator did not have a three and a half setting. Staff member K stated he was going to check to … | 2020-09-01 |
| 778 | 778 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2019-03-21 | 759 | D | 0 | 1 | TRHL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to ensure the medication error rate was less than 5 percent, which affected 2 (#s 19 and 27) of 17 sampled residents. The facility medication error rate was 6 percent. Findings include: During an observation on 3/19/19 at 8:49 a.m., staff member H was observed giving insulin to resident #19 in her room. The nurse administered the dose in the resident's abdomen, at her request. Staff member H did not prime the insulin pen prior to administering the dose. Review of resident #19's medical record showed #19 had a [DIAGNOSES REDACTED].#19's MDS Annual Assessment, dated 10/3/18, and MDS Quarterly Assessment, dated 1/3/19, showed a [DIAGNOSES REDACTED].#19 had received Insulin for all seven days of the assessment period. During an observation and interview on 03/20/19 at 4:21 p.m., staff member H administered insulin to resident #27. Staff member H did not prime the insulin pen prior to administering the dose. Staff member H stated No, I did not prime the pen. I have not been instructed to do this. Review of resident #27's Care Plan, dated 1/24/19, showed a [DIAGNOSES REDACTED]. Review of the facility Policy, Number NS0667, Insulin and Non-Insulin Pen Delivery Systems, under Procedure number eight, showed .In order to assure each dose of insulin is administered completely and safely, air must be expelled from the cartidge by giving an airshot BEFORE EACH INJECTION | 2020-09-01 |
| 779 | 779 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2019-03-21 | 804 | E | 0 | 1 | TRHL11 | Based on observation, interview, and record review, the facility failed to prepare food that was palatable and attractive, and the residents reported the food was at times flavorless, awful, horrible, dry, did not look good or taste good, and was hard to chew. The failure affected 5 (#s 10, 12, 24, 25, and 32) sampled and supplemental residents. Findings Include: During an observation on 3/18/19 at 3:34 p.m., staff member G took corned beef out of the oven. The corn beef was on a baking sheet and appeared dark brown and dry. During an interview on 3/18/19 at 4:20 p.m., resident #24 stated the food at the facility was often times dry and flavorless. He stated the kitchen staff do not listen when they are given feedback on how the meals taste. During an interview on 3/18/19 at 5:33 p.m., resident #32 stated the appearance and the taste of the food was not good, saying, It doesn't look good. The resident stated, You know, you eat with your eyes first. Resident #32 stated They don't ask for feedback, and they don't push the alternative. During an observation and interview on 3/18/19 at 6:05 p.m., resident #12 left the dining room and was observed making a peanut butter and jelly sandwich in her room. Resident #12 stated the food was awful because it was often dry and had no flavor. She stated she had food in her room for the days when the meals were bad at the facility. Resident #12 stated today the corned beef was very over cooked, hard to chew, and dry. During an observation at 3/19/19 at 12:30 p.m., roasted pork loin was served with cauliflower for lunch. The roasted pork loin appeared dry and gray, and the cauliflower was mushy. During an interview on 3/19/19 at 1:27 p.m., NF1 stated the food at the facility had been horrible. He stated the food is always dry and hard to chew. He stated the resident (#25) is missing some teeth and it is hard for him to eat the meat the facility prepared. NF1 stated the pork was dry and had no flavor and the cauliflower was so mushy and over cooked he could not eat it. Resident #2… | 2020-09-01 |
| 780 | 780 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2019-03-21 | 880 | D | 0 | 1 | TRHL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to minimize the risk of infection by ensuring oxygen tubing is kept off the floor, and failed to replace the contaminated tubing that had been on the floor with clean tubing, for 1 (#20) of 17 sampled residents, which caused contaminated oxygen tubing to be placed in resident #20's nares. Findings include: During an observation on 3/19/19 at 12:42 p.m., resident #20's nasal cannula, connected to the concentrator, was laying on the floor. The concentrator was very dirty and had a brownish colored substance that had been spilled down the side and had dried. Staff member J was in the room with the resident, and was tending to his empty portable oxygen tank, and did not take note of the oxygen tubing laying on the floor, or address the tubing on the floor. During an observation on 3/21/19 at 8:41 a.m., resident #20's nasal cannula tubing for the portable tank was laying on floor. During an observation on 3/21/19 at 10:01 a.m., no labeling or date was observed on resident #20's oxygen tubing on the concentrator or portable tank. During an interview on 3/21/19 at 9:57 a.m., staff member K stated Every Sunday the tubing is changed. If the tubing is found on the floor we switch it out and date it. Review of resident #20's Care Plan, dated 10/22/18, showed I have SOB at times due to my [DIAGNOSES REDACTED]. Nursing will change my oxygen tubing every seven days as per facility policy. | 2020-09-01 |
| 781 | 781 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2016-10-20 | 253 | C | 0 | 1 | 4EQE11 | Based on observation and interview, the facility failed to repair areas of the main tub and shower room, which was utilized by the residents, and maintain the cleanliness of the building which was also used by the residents who resided at the facility. Findings include: During on observation on 10/17/16 at 3:30 p.m., baseboards, which appeared to be wood-like, had missing areas or chunks broken out at the corners on Shady Lane and Sunnyside hallways. During an observation on 10/19/16 at 9:05 a.m., the tub room, on the Mountaintop hallway, was observed to have broken floor tiles around the tub chair lift, and an area where a toilet had been removed. On the right wall of the tub room, where the floor and wall met, the caulking was missing, and dirt was on the floor. A rubber mat was covering a floor drain, and the rubber mat had hard water build-up. During an interview on 10/19/16 at 9:15 a.m., staff member H said the broken floor tiles in the bathing room should be replaced. During an interview on 10/20/16 at 7:30 a.m., Staff member J said the broken floor tiles could not really be fixed without ripping out big sections of the tiles. Staff member J said the whole tub room needs to be remodeled. Staff member J said the wood-look baseboards that were missing chunks were of a foam/wood composition, and were on the schedule to be replaced in the future. | 2020-09-01 |
| 782 | 782 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2016-10-20 | 275 | D | 0 | 1 | 4EQE11 | Based on record review and interview, the facility failed to complete the MDS assessment accurately, or within the required 14 day timeline for 1 (#7); and failed to complete an Annual MDS assessment for 1 (#8) of 11 sampled residents. Findings include: 1. During a review of resident #7's most current Annual MDS, with an ARD of 7/9/16, section G400, Range of Motion, showed No Assessment for the resident's range of motion. During a review of resident #7's most current Annual MDS, with an ARD of 7/9/16, section J1800, Falls Since Adm/Reentry or Prior Assessment showed No Assessment for the resident's falls. During a review of resident #7's nursing notes, the resident had a fall on 6/24/16 were she hit the back of her head, and the nurse identified a bump. Nursing notes showed neurological checks were completed, and the resident's family was notified. During a review of resident #7's most current Annual MDS, with an ARD of 7/9/16, showed section Z0500 B was not dated until 8/2/16. 2. A review of resident #8's clinical records showed Annual assessments had been completed by nursing, the dietary manager, and the activities director. A review of resident #8's MDSs showed the most current MDS to be a Quarterly, with an ARD of 6/16/16. Resident #8 had an Admission MDS, with an ARD of 9/21/15. Resident #8 did not have an Annual MDS in progress or available for review, showing the assessment had not been completed as required. During an interview on 10/18/16 at 5:45 p.m., staff member A said the last director of nursing completed all the MDS assessments and signed off on them. Staff member A said the employee left in (MONTH) of (YEAR). Staff member A said the facility had not had a consistent MDS coordinator since that time. Staff member A said the facility had hired an MDS coordinator two weeks ago, and she was receiving MDS training. | 2020-09-01 |
| 783 | 783 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2016-10-20 | 276 | D | 0 | 1 | 4EQE11 | Based on record review and interview, the facility failed to complete the Quarterly MDS assessment accurately for 1 (#7); and failed to sign off the assessment was completed timely within the 14 day required timeline, for 1 (#9) of 11 sampled residents. Findings include: 1. A review of resident #7's most current Quarterly MDS, with an ARD of 10/7/16, section G400, Range of Motion, was blank. A review of resident #7's most current Quarterly MDS, with an ARD of 10/7/16, section H300, Bladder Continence was blank, and section H400, Bowel Continence was blank. During a review of resident #7's care plan, the care plan showed the resident had bowel and bladder incontinence. A review of resident #7's most current Quarterly MDS, with an ARD of 10/7/16, section J100, Pain Management was blank. During a review of resident #7's Medication Administration Record, [REDACTED]. The Medication Administration Record [REDACTED]. A review of resident #7's most current Quarterly MDS, with an ARD of 10/7/16, showed section Z0500 B was not dated. 2. Review of resident #9's Quarterly MDS showed an assessment reference date of 7/15/16, and a Z0500B date of 8/9/16. During an interview on 10/19/16 at 11:20 a.m., staff member A stated the staff member who was formerly completing the MDSs was also the DON, and was no longer employed at the facility. Staff member A stated she was aware the MDS assessments were not in compliance. | 2020-09-01 |
| 784 | 784 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2016-10-20 | 280 | E | 0 | 1 | 4EQE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to update the resident care plan for falls with injury for 1 (#4); for severe weight loss for 1 (#5); and for respiratory status and oxygen use for 1 (#2) of 11 sampled residents. Findings include: 1. Resident #4 was admitted to the facility with anxiety disorder and dementia. Review of resident #4's Significant Change MDS, with an ARD of 1/25/16, and a Quarterly MDS, with and ARD of 7/19/16, showed a BIMS score was not documented. The assessment indicated in section C0100 that the resident was not recommended for a BIMS interview. Review of resident #4's Fall Risk Assessment, dated 11/24/16, showed the resident scored a 17. The score indicated a risk of falling. Review of resident #4's progress notes showed the resident fell on [DATE], 12/28/15, 1/14/16, and 6/29/16. The care plan lacked evidence for fall prevention protocols, and approaches to prevent falls. Refer to F323 for detailed fall and lack of care plan information. During an interview on 10/19/16, at 11:20 a.m., staff member A stated the former DON left employment, and the care plans got lost in the pieces. She said the plan was to revamp the care plans. 2. A review of resident #2's admission physician's orders [REDACTED]. The order was to be adjusted per facility protocol, and was e-signed by the resident's physician. A review of resident #2's medication administration records, dated (MONTH) of (YEAR), showed that oxygen had been ordered for resident #2 on 08/26/16. Three liters per minute were to be given at rest and five liters per minute were to be given with activity. It was documented with signatures that the resident had received it once per shift (three times a day) since 10/1/16. There were no recordings of oxygen saturation levels on the MARS for resident #2. During observations on 10/18/16 at 8:20 a.m. and at 12:32 p.m., resident #2 was observed in the dining room wearing her oxygen cannula in her no… | 2020-09-01 |
| 785 | 785 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2016-10-20 | 281 | D | 0 | 1 | 4EQE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to verify and/or request a change or clarification in the unusual dosage of a physician prescribed medication. This resulted in a medication error with potential harm for 1 (#14) of 15 sampled and supplemental residents, when the resident was given the medication from the facility's stock medications in a dose other than what was prescribed for the resident. Findings include: During a medication pass observation on 10/18/16 at 7:45 a.m., [MEDICATION NAME] 325 mg, one tablet, was poured from a stock medication container by staff member K, and administered to resident #14. A review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The record showed the medication had been ordered to start on 10/14/16. Twice daily doses had been signed off by the nurses as given for the last five days. During an observation and interview on 10/18/16 at 6:10 p.m., staff member K reviewed resident #14's physician's orders [REDACTED]. Staff K then verified the 325 mg dosage of the stock medication bottle of [MEDICATION NAME] on her medication cart, as used for resident #14. She stated she had probably given the wrong dose of [MEDICATION NAME] to resident #14 at 7:45 a.m. She also said that she had never heard of [MEDICATION NAME] coming in a 140 mg dose, and stated that she would check the dosage with the resident's physician. During an interview on 10/19/16 at 9:35 a.m., staff member C stated she had noted the difference in the dose of [MEDICATION NAME] ordered for resident #14 and the dose of the stock medication she had available on her medication cart to give to the resident. She said she had sent a fax requesting a dosage change from the physician because the dosage of 140 mg ordered was unavailable to the facility. The physician had not yet responded to the fax. A review of resident #14's Medication Administration Record [REDACTED]. It was not determined if this dosage ha… | 2020-09-01 |
| 786 | 786 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2016-10-20 | 323 | G | 0 | 1 | 4EQE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement interventions, and provide assistance for a resident who: had severe cognitive deficits, was unable to comprehend fall prevention efforts, and had repeated falls for self-transferring; failed to show the resident's care plan was reviewed to ensure the fall interventions were successful, or that the plan was modified for falls; and failed to complete neurological assessments after falls. This included a fall with a hip fracture, which required surgery, for 1 (#4) of 11 sampled residents. Findings include: Resident #4 was admitted to the facility with anxiety disorder and dementia. Review of resident #4's Fall Risk Assessment, dated 11/24/16, showed the resident scored a 17. This score indicated a risk of falling. Review of resident #4's progress notes showed the resident fell on [DATE], 12/28/15, 1/14/16, and 6/29/16. Fall details included: - Fall #1: The progress note, dated 11/28/15, showed resident #4 was found on the floor under the table in the small parlor. The fall was unwitnessed by staff. The note showed there was no injury. When the resident was found, one wheelchair break was locked and the other was not. The note showed it was uncertain if the resident had unlocked one of the brakes. Review of the resident's progress notes for 11/29/15-12/2/15, failed to show the facility completed neurological assessments for the resident after an unwitnessed fall. Neurological assessment records were requested on 10/19/16, for this fall, but were not received prior to the end of the survey. Review of the facility falls log for the resident showed the care plan was reviewed and updated. Review of the resident's care plan did not show any updates or modifications had been made for the 11/28/15 fall, or to address the root cause of the fall. - Fall #2: The resident's progress note, dated 12/28/15, showed resident #4 was found in the hallway on the floor, lying on her left side. S… | 2020-09-01 |
| 787 | 787 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2016-10-20 | 325 | G | 0 | 1 | 4EQE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement new nutritional interventions in order to prevent severe weight loss for 1 (#5) of 11 sampled residents. Specifically the resident had 20.2% severe weight loss in six months (4/19/16 to 10/20/16). The facility failed to utilize their policies to address the resident's severe weight loss. Findings include: During an observation on 10/18/16 at 8:20 a.m., resident #5 was seated for breakfast in the dining room. She was observed feeling around for her silverware with her hand. She put an unopened container of jelly in her hot tea, and then rested her fingers in her hot tea. At 8:35 a.m., staff member A sat down next to the resident and commented on her ring. The resident woke up, took her hand out of the hot tea, took the jelly packet out of her tea, and placed it back with the other unopened jelly. She had not eaten any of her food, and the staff did not assist the resident. At 8:40 a.m., staff member L offered to cut the resident's food and then brought the resident a full bowl of cereal and stated, I want to see you eat. The resident placed her fingers on top of her food, and did not attempt to take any bites. Staff had not assisted her at this point with eating her food. At 8:45 a.m., staff member [NAME] asked the resident how she was doing. The resident pushed the new bowl of cereal away, but alternative were not offered, or assistance with the meal. At 8:55 a.m., the resident was finished with her meal, and had not received assistance, but had only eaten 5% of her breakfast. She was not offered a supplement at this meal. During an interview on 10/18/16 at 8:20 a.m., staff member [NAME] stated resident #5 was offered Boost Breeze BID at lunch and evening meals not at her breakfast meals. Record review of the P[NAME] Response History (resident intake record) showed resident #5 had refused the supplement at breakfast on 10/17/16 and 10/18/16, although she had … | 2020-09-01 |
| 788 | 788 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2016-10-20 | 332 | D | 0 | 1 | 4EQE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to administer the physician prescribed dosage of medication for 2 residents (#s 14 & 15) of 15 sampled and supplemental residents. The two medication errors made, out of a total 38 opportunities, were not significant but resulted in an unacceptable facility medication administration error rate of 5.2%. Findings include: 1. During a medication pass observation on 10/18/16 at 7:45 a.m., [MEDICATION NAME] 325 mg, one tab was poured from a stock medication container by staff member K and administered to resident #14. A review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. During an observation and interview on 10/18/16 at 6:10 p.m., staff member K reviewed resident #14's physician's orders [REDACTED]. Staff member K then verified the 325 mg dosage of the stock medication bottle of [MEDICATION NAME] on her medication cart as used for resident #14. She said she had probably given the wrong dose of [MEDICATION NAME] to resident #14 at 7:45 a.m. 2. During an observation of a medication pass on 10/18/16 at 8:17 a.m., staff member K brought [MEDICATION NAME] suspension nasal spray to resident #15 in her room and set it down in front of the patient. The resident picked it up, and without receiving instructions, gave herself one spray in each nostril. Staff member K gave resident #15 additional oral medications and then left the room. Review of the resident's medication review report, signed on 10/11/16 by resident #15's physician, showed [MEDICATION NAME] was ordered on [DATE] as [MEDICATION NAME] Suspension ([MEDICATION NAME] Propionate), 2 sprays in both nostrils one time a day for allergies [REDACTED].>During an observation and interview on 10/18/16 at 6:10 p.m., staff member K reviewed resident #15's physician's orders [REDACTED]. | 2020-09-01 |
| 789 | 789 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2016-10-20 | 371 | E | 0 | 1 | 4EQE11 | Based on observation, interview, and record review, the facility failed to label, for proper storage, one food item brought into the facility for resident use, and failed to discard 3 items that were stored beyond their manufacturer's expiration dates. This had the potential for harm to residents or staff members who would have consumed the items. Findings include: During an observation survey of the facility's medication storage room, on 10/17/16 at 3:25 p.m., a plastic container of what appeared to be chicken and noodles was found in the medication room refrigerator, undated, and without the name of the person for whom it was being stored. At the same time a yogurt was found with a manufacturer's expiration date of 7/23/18, and 2 protein shakes were found to have manufacturer's expiration dates of 8/29/16. All four items were removed from the refrigerator and disposed of at the time of the survey by staff member I. Staff member I stated none of the items should have been in the refrigerator. During an interview on 10/19/16 at 11:45 a.m., staff member [NAME] stated there was no policy for the labeling of food held in the food refrigerator in the medication storage room. She said the kitchen food labeling policy applied to foods in the medication room refrigerator. A review of the facility's policy entitled USE BY DATE/Discard Date, Food Labeling Guide as revised 5/6/15, showed the manufacturer's expiration date, when available, is the use by for unopened items. Cooked leftovers have a use by date of 3 days after the original cooking date. | 2020-09-01 |
| 790 | 790 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2016-10-20 | 425 | E | 0 | 1 | 4EQE12 | Based on observations, interview, and record reviews, a facility staff member failed to dispose of an over-the-counter medication in a safe manner for 1 (#1); failed to ensure a medication was available to a resident (#9); and, failed to maintain direct control of medications given to resident's by walking away from the resident's prior to medications being consumed, once they had been given to the resident's, for 2 (#s 8 and 9) of 9 sampled residents. Findings include: During an observation on 12/27/16 at 12:25 p.m., staff member C had passed medications to resident #8 in the dining room. Staff member C had placed the resident's medications in front of him and walked back to her medication cart to continue her medication pass. The staff member had not observed the resident consume the medications, prior to leaving the resident. During an observation on 12/27/16 at 12:27 p.m., staff member C was observed disposing of an over-the-counter medication (acetaminophen), which belonged to resident #1. The medication had dropped on the floor, and the nurse put the pill in the garbage. During an observation on 12/27/16 at 12:35 p.m., staff member C had passed medications to resident #9 in the dining room. Staff member C had placed the resident's medications in front of him and walked back to her medication cart to continue her medication pass. The staff member had not observed the resident consume the medications prior to leaving the resident. During the observation on 12/27/16 at 12:35 p.m., staff member C had passed medications to resident #9. The resident's Medication Administration Record [REDACTED]. The medication was out of stock and unavailable, and the resident had not received her dose of carafate. During an interview on 12/27/16 at 1:00 p.m., staff member C stated the following: - The residents' in the facility had not had orders to self-administer their medications. She also stated she had not watched the resident's take their medications, but she was supposed to. - Resident #9 had the medication, carafate, 1 g… | 2020-09-01 |
| 791 | 791 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2016-10-20 | 441 | F | 0 | 1 | 4EQE11 | Based on observation, interview and record review, the facility failed to: Maintain a cleanable surface for a bathing tub located on the Mountaintop hallway, which had the potential to affect all resident's how used the tub and area; and failed ensure oxygen tubing, oxygen cannula, and nebulizer changes were completed in a manner to prevent bacterial contamination and spread of potential infection, and document the change of the equipment, for 4 (#s 2, 10, 12, and 13) of 15 sampled and supplemental residents. Findings include: 1. During an observation on 10/19/16 at 9:05 a.m., the fiberglass tub in the Mountaintop tub room was observed to have five areas on the inside edges of the tub where the protective coating had been broken or chipped away, creating uncleanable surfaces. The rubber surround on the outside of the tub was missing or broken in three areas, creating uncleanable surfaces. The area of the tub surround, above the key lock, had a crack approximately one inch long, creating an uncleanable surface. The floor to the tub room was observed to have multiple missing or broken floor tiles which created an uncleanable surface. A touch control panel at the front of the tub had a plastic film covering it, the film was bubbled and ridged, creating an uncleanable surface. During an interview on 10/19/16 at 9:15 a.m., staff member H said 41 of the 43 residents in the facility used the tub weekly. Staff member H said the broken floor tiles in the bathing room should be replaced. Staff member H said she knew about the chips in the tub's surface, the missing rubber pieces of the tub surround, and the crack above the key lock. Staff member H said she used chemicals to clean the inside of the tub, including the tub jets, but she did not clean the outside of the tub. Staff member H said the staff had been trying to get the tub replaced for at least the last eight months. During an interview on 10/20/16 at 7:30 a.m., staff member J said the control panel on the tub could not be replaced. Staff member J said the tub was … | 2020-09-01 |
| 792 | 792 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2016-10-20 | 456 | F | 0 | 1 | 4EQE11 | Based on observation and interview, the facility failed to maintain essential equipment in the correct working order for 41 of 43 residents. Findings include: During an observation on 10/19/16 at 9:00 a.m., of the tub room on the Mountaintop hallway, an object appeared to be stuck in a hole at the front of the tub. The object appeared to be a turkey baster. A touch control panel at the front of the tub, were the turkey baster was located, had a plastic film covering it which was bubbled and discolored. During an interview on 10/19/16 at 9:15 a.m., staff member H identified the object as an actual turkey baster and stated it was a replacement for the on/off switch that controlled the water flow into the tub. Staff member H said a lot of the residents in the facility liked to use the tub to soak in because it helped with their aches and pains. Staff member H said 41 of the 43 residents in the facility used the tub to bathe, as it was the only tub in the facility. During an interview on 10/20/16 at 7:30 a.m., staff member J said the control panel, and the on/off switch on the tub could not be replaced. Staff member J said the tub was too old, and replacement parts could no longer be ordered. | 2020-09-01 |
| 2225 | 2225 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2016-07-27 | 224 | J | 1 | 0 | 946011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure 1 (#1) of 6 sampled residents were free from staff mistreatment and neglect. This practice resulted in the resident being left on a bed pan for 12-15 hours, resulting in a pressure sore injury to a resident. IMMEDIATE JEOPARDY On 7/27/16 at 2:40 p.m., the facility administrator and director of clinical operations were notified that an immediate jeopardy situation existed in the areas of F224 Staff treatment of [REDACTED]. PLAN TO REMOVE THE IMMEDIATE JEOPARDY The facility submitted an acceptable plan to remove the immediacy on 7/27/16 at 5:40 p.m. After the plan to remove the immediacy was accepted, the scope and severity of this deficiency was reduced to a G. A summary of the facility's plan to remove the immediacy was as follows: 1. Abuse and Neglect Training to be provided for all staff, to be taught by the Director of Clinical Services, starting 7/27/16 at 5:40 p.m. and ending on 8/10/16. 2. A review of all incidents of suspected abuse or neglect will be reviewed, and reported immediately by the Director of Clinical Services or the Director of Operations to the State Agency. This review will continue until the facility demonstrates knowledge and understanding of abuse and neglect, reporting and conducting a thorough investigation. 3. The administrator and DON will receive immediate education from the regional Director of Clinical Services on reporting and investigating alleged abuse and/or neglect. 4. The regional Director of Clinical Services will review all incident reports for the past 6 months and provide an in-service by 7/28/16. 5. Contact information for the Regional Director of Clinical Services and the Director of Operations will be posted at the nurse's station for staff access. Staff will receive an in-service on locating this information. Findings include: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A review of an annual MDS, with an … | 2019-07-01 |
| 2226 | 2226 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2016-07-27 | 225 | J | 1 | 0 | 946011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to thoroughly investigate suspected neglect for 1 (#1) of 6 sampled residents. Specifically, the facility failed to investigate a pressure ulcer caused when a resident was left on the bed pan for 12-15 hours. IMMEDIATE JEOPARDY On 7/27/16 at 2:40 p.m., the facility administrator and director of clinical operations were notified that an immediate jeopardy situation existed in the areas of F224 Staff treatment of [REDACTED]. PLAN TO REMOVE THE IMMEDIATE JEOPARDY The facility submitted an acceptable plan to remove the immediacy on 7/27/16 at 5:40 p.m. After the plan to remove the immediacy was accepted, the scope and severity of this deficiency was reduced to a G. A summary of the facility's plan to remove the immediacy was as follows: 1. Abuse and Neglect Training to be provided for all staff, to be taught by the Director of Clinical Services, starting 7/27/16 at 5:40 p.m. and ending on 8/10/16. 2. A review of all incidents of suspected abuse or neglect will be reviewed, and reported immediately by the Director of Clinical Services or the Director of Operations to the State Agency. This review will continue until the facility demonstrates knowledge and understanding of abuse and neglect, reporting and conducting a thorough investigation. 3. The administrator and DON will receive immediate education from the regional Director of Clinical Services on reporting and investigating alleged abuse and/or neglect. 4. The regional Director of Clinical Services will review all incident reports for the past 6 months and provide an in-service by 7/28/16. 5. Contact information for the Regional Director of Clinical Services and the Director of Operations will be posted at the nurse's station for staff access. Staff will receive an in-service on locating this information. Findings include: A review of nurse's note, dated 4/25/16 at 2:05 a.m., showed resident #1 had been given a suppository to promote… | 2019-07-01 |
| 2227 | 2227 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2016-07-27 | 314 | G | 1 | 0 | 946011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to provide the services necessary to prevent the development of an avoidable pressure ulcer for 1 (#1) of 6 sampled residents: Findings include: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. She was receiving Hospice services at the time of her injury. A nurses note dated 4/25/16 at 2:05 a.m., showed resident #1 was given a suppository to promote BM. During an interview on 7/26/16 at 3:03 p.m., staff member N said she had put resident #1 on the bed pan at 4:30 a.m. or 5:30 a.m. (4/25/16), and was told by the nurse to leave her there until she poops. Staff member N said she passed this information on to the oncoming CNA, staff member AA, at the shift change at 6:00 a.m. Staff member N said she did not work the following two days. When she returned to work, she was pulled into the office and told what had happened (resident #1 had been left on the bed pan). She said they told her the bed pan was not found until 4:00 p.m. Staff member N emphasized the bed pan would have been found by the day shift if resident #1 had been being turned and positioned at least every two hours, as that was the expectation of service required of the staff. During an interview on 7/26/16 at 3:30 p.m., staff member AA said she had no knowledge of resident #1 being left on a bedpan or the subsequent injury to resident #1's bottom. A review of the resident's skin integrity care plan, initiated 4/27/16, read, Staff will keep (her) positioned off of her back, will use a side to side method. Nursing will monitor positioning in bed. Moisture barrier will be applied, or oils provided by sister (name). During an interview on 7/27/16 at 11:00 a.m., staff member H said she worked late that day to help out (4/25/16), and had taken over care of resident #1 after staff member AA had left for the day, at 2:00 p.m. Staff member H said she provided care for resident #1 at 4:00 p.m., to turn and position … | 2019-07-01 |
| 2228 | 2228 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2016-07-27 | 490 | G | 1 | 0 | 946011 | > Based on interview and record review, the facility failed to maintain substantial compliance in investigating and reporting incidents of alleged abuse of residents. This practice has the potential to affect all residents. Findings include: A complaint investigation was conducted 3/16/16 at the facility, and F225 was cited for failure to report and investigate a bruise of unknown origin for one resident. Another complaint investigation was initiated on 7/26/16 at 7:40 a.m. A review of the staffing schedule showed staff member N had worked the 10:00 p.m. to 6:00 a.m. shift on the night of 4/24/16. A review of the staffing schedule showed staff member AA was the oncoming CNA who worked with resident #1 from 6:00 a.m. until 2:00 p.m. During an interview on 7/26/16 at 3:30 p.m., staff member AA said she had no knowledge of resident #1 being left on a bedpan or the subsequent injury to resident #1's bottom. A review of the staffing schedule showed staff member H was schedule to work the 6:00 a.m. to 6:00 p.m. shift on 4/25/16. A review of the Incident Log for the month of April, failed to showed the incident had been recorded. During an interview on 7/27/16 at 9:10 a.m., staff member A said, The only thing we really did was have an IDT meeting. They had met as an IDT and included hospice when the injury to resident #1's bottom had occurred. She said, I guess I didn't see the incident as neglect. Staff member A said she did not know where the investigation report was at this time. She said the incident had not been reported to the state. Review of the staffing schedule showed staff member AA returned to the facility that night, after having worked the 6:00 a.m. to 2:00 p.m. on 4/25/16, and worked the 10:00 p.m. to 6:00 a.m. shift. She returned to the facility later that week and worked 4/28/16, 4/29/16, 4/30/16, and 5/1/16. She was assigned to the same hall and residents she had been assigned to on the date of the incident, 4/25/16. This individual continue working at the facility until the day prior to the start of t… | 2019-07-01 |
| 2229 | 2229 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2016-07-27 | 520 | G | 1 | 0 | 946011 | > Based on record review and interview, the facility failed to develop and implement all necessary elements of the abuse prevention program. The abuse/neglect prevention and reporting system was identified as a deficiency during a (MONTH) of (YEAR) complaint survey. Subsequently, the facility failed by not identifying and investigating an allegation of neglect, by not protecting the resident during an investigation, and by not reporting the alleged neglect to the State Agency, for 1 (#1) of 6 sampled residents. Findings include: A complaint investigation was conducted 3/16/16 at the facility, and F225 was cited for failure to report and investigate a bruise of unknown origin for one resident. A review of the facility's Monthly Mandatory (staff) meetings, dated 4/13/16, read, Incident reports- get from the nurse from the nurses' station- fill out within 10 minutes- have the nurse assess. A review of the facility's Quality Assurance meeting notes provided by the facility, dated 7/19/16, failed to document an ongoing plan to address the F225 citation. During an interview on 7/27/16 at 9:10 a.m., staff member A said, The only thing we really did was have an IDT meeting. They had met as an IDT and included hospice when the injury to resident #1's bottom had occurred. She said, I guess I didn't see the incident as neglect. Staff member A said she did not know where the investigation report was at this time. She said the incident had not been reported to the state. See F224, F225, and F314 for details of the facilities failure to investigate and take appropriate action after alleged neglect. | 2019-07-01 |
| 2381 | 2381 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2015-11-19 | 157 | D | 0 | 1 | UVSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the physician in a timely manner of pressure ulcers which developed to the left and right heel for one (#8) of 12 sampled residents. Findings include: Resident #8 was admitted to the facility on [DATE]. Record review of the resident's clinical record lacked evidence to show the physician was notified in a timely manner of two new pressure ulcers, which were shown to be first identified on the resident's heels on 11/16/15. The clinical record lacked evidence to show the pressure ulcers to the heels were initially identified on 11/2/15, which is when the ulcers were identified during a bathing session (refer to F314 - Pressure Ulcers). During an interview on 11/19/15 at 5:15 p.m., staff member R, physician, stated he was informed the pressure ulcers to the resident's heels were identified on 11/16/15. He stated he assessed the resident's heels on Tuesday the 17th. The left heel was a stage one pressure ulcer. The right heel was a stage two pressure ulcer. A treatment was in place for the heels. A review of the facility Pressure Ulcer Policy, under Reporting, showed the nurse was to report information in accordance to the policy and professional standards of practice. During an interview on 11/19/15 at 10:45 a.m., staff member B, director of nursing, stated the nurse on duty at the time the heel wounds were identified should have completed a skin and wound progress note, to include the notification of the physician, when the wounds were first identified. | 2019-04-01 |
| 2382 | 2382 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2015-11-19 | 241 | D | 0 | 1 | UVSZ11 | Based on observation and record review, the facility failed to treat residents with dignity and respect for 2 (#s 13 and 15) of 16 sampled and supplemental residents. Findings include: 1. During an observation on 11/17/15 at 7:23 p.m., 6 residents were sitting in the dining room with food and drinks still on the tables in front of them. There were no staff in the dining room at that time. The staff returned to the dining room at 7:30 p.m. and proceeded to wheel resident #15 from the dining room. Resident #15 indicated she was still hungry. Staff member T stood over resident #15, put food on a fork and placed it in the resident's mouth. Resident #13, who was at the same table, was trying to get food on her fork. Staff member T stood over resident #13, placed food on a fork and placed the fork in the resident's hand. Staff member T continued to stand over both residents until she wheeled resident #15 from the dining room at 7:40. The last resident was wheeled from the dining room at 7:50 p.m. During an interview on 11/18/15 at 7:35 p.m., staff member S said staff should be seated when assisting residents with eating. | 2019-04-01 |
| 2383 | 2383 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2015-11-19 | 253 | C | 0 | 1 | UVSZ11 | Based on observation and interview, the facility failed to maintain a clean environment in the main dining room. This has the potential to affect all residents who use the dining room. Findings include: During observations on 11/16/15, 11/17/15, 11/18/15, and 11/19/15, the lighting fixtures in the main dining room contained dead insects. There were two sets of lighting fixtures that ran the entire length of the dining room. The lighting fixtures were hanging directly over the dining tables that were used by the residents. During an interview on 11/18/15 at 12:22 p.m., staff member AA said she had talked to staff member BB and staff member BB said the maintenance department cleaned the lights in the dining room. During an interview on 11/18/15 at 12:35 p.m., staff member AA said she thought housekeeping cleaned all the light fixtures. During an interview on 11/19/15 at 10:55 a.m., staff member BB said his department cleaned the lighting fixtures in the dining room twice a year, but the lights had not gotten cleaned out this fall. Staff member BB said the lighting fixtures in the dining room were difficult to clean out because they had to be taken apart. | 2019-04-01 |
| 2384 | 2384 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2015-11-19 | 278 | D | 0 | 1 | UVSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to accurately code the MDS for 1(# 11) of 12 sampled residents. Findings include: A review of resident #11's Quarterly MDS, dated [DATE], reflected at H0100, A. Indwelling Catheter. During an observation on 11/19/15 at 9:20 a.m., Resident #11 did not have a catheter. During an interview on 11/19/15 at 9:20 a.m., staff member U stated Resident #11 had never had a catheter. During an interview on 11/19/15 at 6:10 p.m., staff member B stated the information marked in the Quarterly MDS dated [DATE], for an indwelling catheter, was a mistake. | 2019-04-01 |
| 2385 | 2385 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2015-11-19 | 280 | E | 0 | 1 | UVSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to update resident care plans for two (#s 5 and 7) to reflect the care the residents were currently receiving. Findings include: 1. Review of resident #7's medical record showed the physical therapist wrote an order to restorative nursing on 2/10/15 and another one on 11/6/15 directing the restorative care resident #7 was supposed to receive. A review of resident #7's care plan did not show the facility had addressed the resident's restorative needs and/or the physical therapist's orders for treatment. The focus area, on the current care plan, titled Hygiene/ADLs and created on 2/27/2014, did not show the resident was to receive restorative nursing to maintain or prevent resident #7's loss of function in her ADLs. The focus area, on the current care plan, titled Mobility/Fall Prevention and created on 8/25/2015, did not show the resident was to receive restorative nursing to maintain or prevent resident #7's loss of mobility in her ADLs. During an interview on 11/17/15 at 3:00 p.m., staff member B said the nurse receiving an order regarding resident care or treatment is supposed to update the care plan. 2. Resident # 5 was admitted to the facility on [DATE]. A review of Resident #5's Medication Review Report showed an order date of 10/15/15 for PT and OT. An order dated 10/16/15 showed ST to be ordered. Review of the Care Plan lacked evidence the resident received PT, OT, and/or ST. During an interview on 11/18/15 at 4:00 p.m., staff member B stated there was a weekly Medicare meeting and the therapists attended. Therapists would give what went on with the resident. The therapists are not to do any work on the facility computer programs per their boss' say so. The facility had to be responsible for updated information on the care plans. | 2019-04-01 |
| 2386 | 2386 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2015-11-19 | 281 | D | 0 | 1 | UVSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to failed follow physician orders for one (#2) of 12 sampled residents. Findings include: 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an observation on 11/17/15 at 7:25 a.m., the resident was sitting in a recliner, slouched forward and was being provided oxygen through a nasal cannula. The oxygen concentrator was observed to be set at 3.5 liters. The resident was observed on 11/18/15 at 7:30 a.m., sitting in the recliner again. She had her oxygen on again and the concentrator was set to 3 liters. A review of the resident's admission orders [REDACTED]. A review of the resident's (MONTH) (YEAR) physician's orders [REDACTED]. A review of the resident's Progress Notes for 10/7/15 showed the nurse increased the resident's oxygen from two to three liters because the resident was short of breath, so a request was made regarding the current physician's orders [REDACTED]. During an interview on 11/19/15 at 10:45 a.m., staff member B, stated the nurse reported the resident would change the oxygen concentrator on her own. She stated the nurse had checked the concentrator earlier in the day, and changed it to the required setting. A current oxygen order was requested from staff member B. No further documentation was received. Nurses are obligated to follow the orders of a licensed physician or other designated health care provider unless the orders would result in client harm. DeLaune, S. & Ladner, P. (1998). Fundamentals of Nursing, Standards and Practice (p.237). Albany, N.Y. | 2019-04-01 |
| 2387 | 2387 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2015-11-19 | 309 | E | 0 | 1 | UVSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to adequately identify and address residents who did not have bowel movements for extended periods of time for two (#s 1 and 3); failed to adequately show the identification, assessment, treatment or documentation on the status and monitoring of skin injuries for one (# 8); failed to monitor the resident's oxygen use to ensure the physician's orders [REDACTED].#2) out of 12 sampled residents. Findings include: 1. Resident #1 was admitted to the facility on [DATE]. A review of the resident's Quarterly MDS, with an ARD of 9/25/15, showed the resident was a two plus person, physical assistance for toileting. A review of the resident's bowel movement documentation showed a bowel movement occurred on 10/20/15, 10/28/15 and 11/5/15. During an interview on 11/16/15 at 4:35 p.m., staff member C stated she would check the resident's clinical record to ensure the resident had a bowel movement documented at least every three days. If not, the nurse would give the resident a stool softener and notify the physician. A review of the resident's (MONTH) (YEAR) Physician order [REDACTED]. 2. Resident #3 was admitted to the facility on [DATE]. A review of the resident's Quarterly MDS, with an ARD of 8/25/15, showed the resident was coded as a two plus person, physical assistance for toileting. A record review of the resident's bowel documentation showed the resident had a large bowel movement on 11/8/15, which was documented at 21:59 p.m. The documentation failed to show any further bowel movements up to 11/16/15. A review of the resident's (MONTH) (YEAR) physician orders [REDACTED]. During an interview on 11/16/15 at 4:45 p.m., staff member D, stated she would review the electronic medical record system each day to ensure a resident had a bowel movement regularly. During the interview, the nurse reviewed the resident's electronic record information and a warning was displayed which showed,… | 2019-04-01 |
| 2388 | 2388 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2015-11-19 | 310 | E | 0 | 1 | UVSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide restorative services for three (#s 3, 7, and 10) of 12 sampled residents. Findings include: 1. Resident #3 was admitted to the facility on [DATE]. A review of the resident's (MONTH) (YEAR) Physician order [REDACTED]. The order was dated 7/7/15. A review of the facility Restorative binder showed the resident had a restorative program referral completed on 7/21/15 to Work on standing up from a seated position, ambulate in halls with CNA and hand held assistance with a gait belt. The goal was to make ambulation and transfers easier. The frequency of the program provided was to be three to six times each week. A review of the resident's Restorative Charting Records showed the resident received restorative services for: - Sit to stand exercises and ambulation in the halls with a gait belt; service was provided six times in (MONTH) (YEAR). - Sit to stand exercises and ambulation in the halls with a gait belt; service was provided five times in (MONTH) (YEAR). - Sit to stand exercises and ambulation in the halls with a gait belt; service was provided two times in (MONTH) (YEAR). - Sit to stand exercises and ambulation in the halls with a gait belt; service was provided one time in (MONTH) (YEAR). A review of the resident's Minimum Data Set assessment, dated 8/25/15, showed the resident declined in activities of daily living for bed mobility, transfers, walking in corridor, dressing, and toilet use. The resident was coded as going from limited assistance to needing extensive assistance. During an interview on 11/18/15 at 8:00 p.m., a family member stated a decline had occurred in the resident's ability to ambulate over the last eight months. The family member was not aware that the resident was on a restorative program. During an interview on 11/17/15 at 9:30 a.m., staff member F stated the resident had a decline in the ability to use the bathroom and when ambulating. S… | 2019-04-01 |
| 2389 | 2389 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2015-11-19 | 314 | D | 0 | 1 | UVSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide adequate services for the prevention of pressure ulcers for a resident; specifically for pressure ulcer identification, pressure ulcer assessment, physician and responsible party notification of the new ulcers, treatment of [REDACTED].#8) out of 12 sampled residents. Findings include: 1. Resident #8 was admitted to the facility on [DATE]. During an observation on 11/17/15 at 12:30 p.m., the resident was sitting in a reclining wheelchair at the dining table. The resident had slipper socks on his feet, and the right foot/heel was sitting on the floor. The CNA pulled the resident's chair back to reposition the chair and his right heel was drug on the floor. As the chair was repositioned, the resident grimaced in pain. During an observation on 11/18/15 at 7:10 p.m., the resident was observed sitting in a reclining wheelchair. The resident was restless and yelled out repeatedly. The resident had slipper socks on both feet. His right foot/heel was on the floor to the side of the right foot pedal. He was slouched down in the wheelchair, and his buttocks were sitting on the end of the wheelchair seat. The resident was leaning to the right side of the chair. The wheelchair did not have any pressure relieving devices. A review of the resident's Skin Care Plan showed the skin was intact with no open areas. One of the interventions included a pressure relieving pad in the chair. During an observation on 11/18/15 at 7:15 p.m., staff member L removed the resident's slipper sock from the right foot. The resident had a pressure ulcer on the heel which was approximately 1 inch wide by 1 inch long in size. The ulcer went from the back of the heel to the bottom of the heel. The pressure ulcer was dark in color, and appeared to be similar to a blood blister. The skin on top of the blister appeared opaque in color. The resident grimaced in pain as the foot was moved. The resident's… | 2019-04-01 |
| 2390 | 2390 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2015-11-19 | 323 | E | 0 | 1 | UVSZ11 | Based on observation, record review, and interview, the facility failed to provide staff supervision during mealtime for residents who needed assistance with eating for 4 (#s 1, 3, 8, and 13); or who were on a mechanically altered diet for one (# 13) out of 16 sampled and supplemental residents. Findings include: During an observation of the dining room on 11/17/15 at 7:20 p.m., the following occurred: Seven residents were sitting in the dining room unattended. Staff were observed in the kitchen, and out of the line of sight of the residents. During an interview at 7:23 p.m., staff member T entered the dining room. She stated the residents were all assisted feeders. She stated the CNAs were taking the residents to their rooms. The food on the tables in front of the residents was pointed out. The CNA stated the residents needed help eating. Staff member T then walked to a resident and touched her shoulders and looked at the cup on the table, then went to another table. Staff member T attempted to give resident #1 a bite of food as she stood over the resident, but the resident did not take the food. Staff member T then went to another resident (#8) and attempted to give him a bite of food, which the resident did not accept. At 7:30 p.m., staff member T exited the dining room, leaving the residents unattended again. At 7:33 p.m., staff member T returned and immediately exited the dining room with resident #3, leaving the dining room unattended. At 7:37 p.m., resident #13 was observed to have a full sliced roast beef sandwich on a hoagie bun on the plate in front of her. The sandwich was uneaten. The resident also had a lettuce salad with tomatoes, which was also uneaten. A review of the facility form which showed all the resident's physician ordered diets showed resident #13 was to receive a mechanically altered diet. During an interview on 11/17/15 at 7:40 p.m., staff member I stated the resident had received the wrong diet. At 7:50 p.m., resident #13 remained at the dining table with the uneaten sandwich, and staf… | 2019-04-01 |
| 2391 | 2391 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2015-11-19 | 365 | D | 0 | 1 | UVSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide the physician ordered diet to meet the resident's individual needs for one (# 13) of 16 sampled and supplemental residents. Findings include: 1. Resident #13 was admitted to the facility on [DATE]. During an observation on 11/17/15 at 7:37 p.m., the resident was observed to have a sliced roast beef sandwich on a hoagie bun, and a green salad with dressing placed in front of her for the dinner meal. The resident's meal was untouched. A review of the resident's (MONTH) (YEAR) Physician order [REDACTED]. During an interview on 11/17/15 at 7:40 p.m., staff member I stated the resident was served the wrong diet. Staff member I stated he was responsible for checking the diet prior to serving the meal, and referenced a posting in the kitchen which had resident diets available for use. During an observation on 11/18/15 at 8:35 a.m., the resident was observed and her plate had two whole link sausages. The breakfast was untouched. During an interview on 11/18/15 at 8:40 a.m., staff member K stated she served the resident the meal, but did not know what the resident's diet consisted of. During an interview on 11/18/15 at 8:45 a.m., staff member I stated the resident's sausage links should have been ground to in order to meet the mechanical soft requirement. | 2019-04-01 |
| 2392 | 2392 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2015-11-19 | 367 | D | 0 | 1 | UVSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide mechanically altered food that was in a form the resident was able to eat for two (#s 1 and 3) out of 12 sampled residents. Findings include: 1. Resident #1 was admitted to the facility on [DATE]. Review of the resident's (MONTH) (YEAR) Physician order [REDACTED]. The order was dated 12/7/14. During an observation on 11/18/15 at 1:10 p.m., the resident was served turkey divine casserole. Review of the resident's Care Plan showed the following: I am on a regular diet, regular textures and want finger-food choices so I can eat most of my meal not using any utensils. During an interview on 11/18/15 at 12:45 p.m., staff member E stated the turkey divine casserole should have been sliced turkey, and the casserole was not listed on the therapeutic menu as a finger food. 2. Resident #3 was admitted to the facility on [DATE]. During an observation on 11/8/15 at 12:40 p.m., the resident had a meal in front of her which was not eaten. The meal included turkey divine casserole. A review of the resident's Care Plan, initiated on 3/15/14, and revised on 8/27/15, showed the resident was to receive finger foods as tolerated. During an interview on 11/18/15 at 1:10 p.m., staff member E stated the resident was given the wrong meal item. She stated the turkey casserole should have been sliced turkey, so she could have eaten it independently. | 2019-04-01 |
| 2393 | 2393 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2015-11-19 | 368 | E | 0 | 1 | UVSZ11 | Based on observation, interview, and record review, the facility failed to ask all residents if they wanted an HS snack. Findings include: During confidential interviews on 11/17/15 at 9:00 a.m., several residents said a snack cart is put in front of the nursing station after dinner. These residents said they go to the snack cart and pick out what they want. One resident said the facility encourages them to ambulate to the snack cart to get what they want. During an observation on 11/17/15 from 7:30 p.m. to 9:00 p.m., several residents approached the snack cart and took snacks. No staff members were observed to offer snacks to residents sitting in the day room or in their rooms. During an observation on 11/18/15 from 7:00 p.m. to 8:00 p.m., the snack cart was sitting in front of the nursing station. Several resident went to the snack cart and helped themselves to items on the cart. One CNA asked a resident who sitting by the nursing station, if he wanted a snack. During an interview on 11/18/15 at 7:35 p.m., staff member S said residents that are able to come to the snack cart are encouraged to do so. Other residents, we give snacks to or when they ask, we give them one. She said, We don't necessarily offer every resident a snack at bedtime. | 2019-04-01 |
| 2394 | 2394 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2015-11-19 | 369 | D | 0 | 1 | UVSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to serve resident food on divider plates which were identified on the care plan as an intervention to maintain resident independence for 2 (#s 3 and 8) out of 12 sampled residents. Findings include: 1. Resident #3 was admitted to the facility on [DATE]. During an observation on 11/18/15 at 12:40 p.m., the resident's meal was served on a regular plate. A review of a kitchen posting, which was utilized by the cook to ensure accurate meals were served to the residents, showed the meal for resident #3 was to be served on a divided plate. A review of the resident's Nutritional Care Plan included an intervention dated 3/15/14, which showed a divided plate was to be used when the resident was served meals to maintain independence. During an interview on 11/18/15 at 12:35 p.m., staff member G, stated she did not know the resident's meal was supposed to be served on a divided plate. 2. Resident #8 was admitted to the facility on [DATE]. During an observation on 11/18/15 at 12:25 p.m., the resident was sitting at the dining room table. He was not attempting to eat on his own. The resident's plate had turkey divine casserole, cooked broccoli, pasta salad and roll. The plate was a regular plate. The meal was untouched. A record review of the kitchen's diet information sheet showed the resident was to receive meals on a divided plate. During an interview on 11/18/15 at 12:30 p.m., staff member H stated she did not know the meal was supposed to be served on a divided plate. A review of the resident's Nutritional Care Plan showed the resident preferred to eat without assistance most of the time. The care plan showed he was on a regular diet with finger foods. The care plan was revised on 9/4/15. The interventions lacked evidence for the divided plate. | 2019-04-01 |
| 2395 | 2395 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2015-11-19 | 441 | D | 0 | 1 | UVSZ11 | Based on observation and interview, the facility failed to maintain sanitary conditions for 1 (#16) of 16 sampled and supplemental residents. Findings include: During an observation on 11/17/15 at 9:00 a.m., resident #16 was in the large parlor. Her catheter tubing was on the floor, underneath her wheel chair. During an observation on 11/17/15 at 7:50 p.m., resident #16 was leaving the dining room assisted by a CNA. The CNA wheeled the resident to her room. Her catheter tubing was dragging on the floor underneath her wheel chair. During an observation on 11/18/15 at 8:35 a.m., resident #16 was eating breakfast in the dining room. Her catheter tubing was on the floor underneath her wheel chair. During an interview on 11/18/15 at 8:51 a.m., staff member X said catheter tubing should not drag on the floor. Staff member X said the tubing should be clipped up. During an interview on 11/18/15 at 9:00 a.m., staff member W said catheter tubing should not drag on the floor. | 2019-04-01 |
| 2396 | 2396 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2015-11-19 | 490 | C | 0 | 1 | UVSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to administer the facility in a manner as to maintain or improve the resident's physical, emotional and psychosocial well being for 4 (#s 1, 2, 3, and 13) of 16 sampled and supplemental residents. Findings include: 1. The facility failed to meet professional standards of nursing by failing to follow physician orders [REDACTED].#s 1, 3, and 2) of 12 sampled residents. Refer to F281. 2. The facility failed to prevent, intervene, or provide treatment of [REDACTED].#8) of 12 sampled residents. Refer to F314. 3. The facility failed to prevent potential hazardous outcomes for 4 (#s 1, 3, 8, and 13) of 16 sampled and supplemental resident by not providing supervision in the dining room to residents who required assistance with eating. Refer to F323. | 2019-04-01 |
| 2397 | 2397 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2015-11-19 | 497 | D | 0 | 1 | UVSZ11 | Based on record review and interview, the facility failed to have a complete and accurate employee file for one (Z) of seven CNA employee files. Findings include: Staff member Z was hired on 3/9/14. Review of Staff member Z's employee file showed there lacked a yearly evaluation completed for the CNA. During an interview on 11/19/15 at 6:30 p.m., staff member B stated they would send missing information by fax. As of 11/24/15, a copy of the requested evaluation had not been received by the State Agency from the facility. | 2019-04-01 |
| 2398 | 2398 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2015-11-19 | 514 | D | 0 | 1 | UVSZ11 | Based on record review and interview, the facility failed to maintain a complete and accurate record for 1 (#8) of 12 sampled residents. 1. Resident #8 was receiving hospice services at the facility. The facility's medical records did not contain copies of any of the hospice treatment notes for this resident. During an interview on 11/18/15 at 4:30 p.m., staff member B said the facility used to have binders for each hospice resident at the nursing station containing all the hospice charting and information. Staff member B said she doesn't know what happened and why the facility isn't doing them any more. | 2019-04-01 |
| 2399 | 2399 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2015-11-19 | 520 | C | 0 | 1 | UVSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure an effective quality assurance process was in place for: Professional Standards - Obtaining physician orders - Transcribing physician orders - Communication of physician orders [REDACTED].>- Following physician orders [REDACTED]. Pressure Sores: - Identification of pressure sores - Assessment, including risk factors for pressure sores - Implementation of interventions for pressure sores - treatment of [REDACTED].>- Notification of physician and other parties in regards to pressure sores - Updating the current plan of care to include interventions and/or the treatment of [REDACTED].> pressure sores - Monitoring of pressure sores by the interdisciplinary care team - To ensure nutritional interventions were adequate - To ensure nutritional needs were met - To ensure treatments and interventions were used and/or effective This deficient practice has the potential to affect all 46 residents. Dining Room Supervision: - The lack of supervision of residents in the dining room during meal times to prevent potential hazardous outcomes. This deficient practice has the potential to affect all 46 residents. 1. RESIDENT ASSESSMENT A. F281 SERVICES MEET PROFESSIONAL STANDARDS The facility failed to meet professional standards of nursing by failing to follow physician orders [REDACTED].#s 1, 2, and 3) of 12 sampled residents. Refer to F281. 2. QUALITY OF CARE A. F314 PRESSURE SORES The facility failed to prevent, intervene, or provide treatment of [REDACTED].# 8) of 12 sampled residents. Refer to F314. B. F323 ACCIDENTS, HAZARDS, & SUPERVISION The facility failed to prevent potential hazardous outcomes for 3 (#s 1, 3, and 13) of 16 sampled and supplemental resident by not providing supervision in the dining room to residents who required assistance with eating. Refer to F323. | 2019-04-01 |
| 2451 | 2451 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2016-03-16 | 225 | D | 1 | 0 | EY9L11 | > Based on observation, record review and interview, the facility failed to report and thoroughly investigate a bruise of unknown origin for 1 (#12) of 13 sampled residents. Findings include: Review of resident #12's Progress Note, dated 2/29/16, showed a bruise had been discovered at the top of the resident's left breast. Review of the Progress Note, dated 3/2/16, showed bruise upper area left breast fading. Question if she might have dropped something she was holding on area. During an interview on 3/16/16 at 10:00 a.m., staff member B stated she did not know about the bruise. It had not been reported to her. Review of the Bathing Checklist and Skin Assessment, dated 3/1/16, showed bruise on breast. A different hand writing, without date or signature, showed we went back together and verified the cup from nebulizer matched the area. During an observation on 3/16/16 at 9:45 a.m., the bruise was yellow/black and the size of a walnut. During an interview on 3/16/16 at 9:50 a.m., staff member J stated it was in an unusual spot. During an interview on 3/16/16 at 12:10 p.m., staff member D stated she was the staff member who discovered the bruise, and she thought maybe the resident had hit herself, as she could be fidgety. During an interview on 3/16/16 at 9:45 a.m., the resident was not able to speak appropriate words when asked about the cause of her bruise. | 2019-03-01 |
| 2452 | 2452 | BEARTOOTH MANOR | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2016-03-16 | 353 | F | 1 | 0 | EY9L11 | > Based on record review and interview, the facility failed to have sufficient CNA staffing to promote each residents' highest well-being for restorative therapy for 2 ( #s 6 and 13) out of a sample of 13 residents, and for residents not being turned every two hours and not recieving their showers. This practice has the potential to affect all residents. During an interview on 3/15/16 at 3:10 p.m., staff member E stated it was difficult to meet the needs of the residents on evening shift, because they do not have enough staff. Each CNA on evenings takes care of 12 to 15 residents. We get the basics done, but nothing extra. There is some frustration and tiredness. During an interview on 3/16/16 at 9:50 a.m., staff member K stated she was on light duty and had a 10 pound lifting restriction. She stated on 3/8/16 only one CNA was on duty for all residents on halls A and D. One CNA was in the Special Care Unit. The 2 other scheduled CNAs had called in sick. Staff member K stated she worked the floor with one other CNA, staff member H. We did the best we could. Did everyone get turned every 2 hours? Absolutely not. During an interview on 3/16/16 at 11:55 a.m., staff member H stated the facility had been working short. It is difficult to get residents to meals and feed them. We lay some down because we don't have the time to assist them. Night shift really struggles to provide good incontinent care. There is one aide, and one in the unit. She stated she had filed a grievance in (MONTH) about having only one staff on the floor. Review of the Resident Council Minutes, dated 3/16/16, reflected the nursing staff work as best they can with the shortage of CNAs and nurses. During an interview on 3/16/16 at 1:15 p.m., staff member A stated the facility knew staffing was currently a challenge. Two CNAs were on medical leave, and the facility had 18 sick call ins for March, related to illnesses. She also stated the managers would come in and help on the short days. Review of the Weight Sheets, which tracked showers given, showe… | 2019-03-01 |
| 3145 | 3145 | BEARTOOTH HEALTHCARE COMMUNITY | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2014-12-04 | 225 | D | 0 | 1 | WVZO11 | Based on interview and record review, the facility failed to report injuries of unknown origin to the State Agency and investigate for 1 (#1) of 10 sampled residents. Findings include: Review of a nursing progress note for resident #1 dated 8/10/14 reflected a late entry for 8/8/14. The progress note showed that nursing staff found a 2.4 centimeters dark blue bruise above and to the left of resident #1's coccyx. No documentation was provided to show that facility staff had reported the bruise of unknown origin or had investigated the bruising. Review of the State Agency abuse reports showed the facility had not reported resident #1's bruise of unknown origin. During an interview on 12/2/14 at 4:30 p.m., staff member A, the director of nursing, stated she had not reported the bruise of unknown origin on resident #1's coccyx area. She did not realize she needed to report the bruise. | 2018-02-01 |
| 3146 | 3146 | BEARTOOTH HEALTHCARE COMMUNITY | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2014-12-04 | 253 | E | 0 | 1 | WVZO11 | Based on observation and interview, the facility failed to provide a well maintained environment on the SCU unit of the facility. Findings include: During an observation on 12/2/14 at 8:00 a.m., room #204 was noted to have chipped paint, and dark rub marks on 2 of 4 walls. The rub marks were approximately 2 feet by 6 inches. During an observation on 12/2/14 at 8:30 a.m., the dining area in the SCU was noted to have chipped paint on 2 of 4 walls. One chip was approximately 1 inch by 1/2 inch and the other was approximately 2 inches by 1/2 inch. During an observation on 12/2/14 at 8:45 a.m., the hallway was noted to have a dark mark on the right wall approximately 2 feet in length and 1/2 inch wide. There were gouged/chipped paint on the door frames of the rooms on the SCU. The gouged/chipped areas of paint ranged from 1 inch to 2 inches in diameter. During an observation on 12/3/14 at 10:10 a.m., room #209 was noted to have a scrape mark across the width of the closet door, approximately 2 feet long. The heat register's front panel drooped on the right side and a piece behind the front panel was bent inward from the side. There was a gouge on 1 of 4 walls that was approximately 1/2 inch wide and 1 foot long. During an observation on 12/3/14 at 10:20 a.m., room #203 was noted to have plaster on one wall, with no paint covering the area. Another wall had gray a streaked area approximately 2 feet by 1 foot. The closet door had a 1 foot worn area across the width of the closet door. The door frame was gouged in several places. During an observation on 12/3/14 at 10:40 a.m., the SCU living room was noted to have a dark mark 2 feet long and 1 inch wide on one wall. Another wall was not painted where a sink had once been. The door frame had chipped paint. During an observation on 12/3/14 at 11:00 a.m., room #211 had chipped paint on the door frame. The closet doors had scratch marks. During an observation on 12/3/14 at 11:00 a.m., room #210 had chipped paint and chipped wood around the door frame. The bathroom door had s… | 2018-02-01 |
| 3147 | 3147 | BEARTOOTH HEALTHCARE COMMUNITY | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2014-12-04 | 278 | E | 0 | 1 | WVZO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an assessment that accurately reflected the resident's status for 6 (#s 1, 2, 3, 4, 5, and 15) of 15 sampled and supplemental residents. Findings include: 1. Resident #1 was re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of resident #1's quarterly MDS, with the ARD of 9/9/14, showed the resident had an external catheter and did not show the resident's urinary continence status. Review of a nursing progress note, dated 9/1/14, reflected the resident had a Foley catheter. Review of physician orders [REDACTED]. Review of the care plan with a review completion date of 7/1/14 reflected the resident had a Foley catheter requiring staff assistance. 2. Resident #2 was admitted to the facility on [DATE]. Review of the nursing progress notes showed the resident had falls on 6/20, 6/21, and 7/27/14. Resident #2's annual MDS with the ARD of 8/22/14, did not reflect the resident's falls. 3. Resident #3 was admitted to the facility on [DATE]. Review of the quarterly MDS, with the ARD of 8/22/14, showed the resident moved in bed, transferred out of bed, ate, and was toileted only two days out of the 7 day look back period. During an interview on 12/2/14 at 7:35 a.m., staff member E, CNA, stated resident #3 got up each day for meals. During an interview on 12/3/14 at 1:15 p.m., staff member C, MDS coordinator, stated resident #3 got up each day, and the coding was not correct because the coordinator was new and had not had enough training for the MDS. 4. Resident #4 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the quarterly MDS, with the ARD of 10/13/14, showed the resident was usually understood with unclear speech, and the resident usually understands. The resident interviews for cognition, mood, and pain were not completed because the resident was coded as rarely/never understood for those sections of the MDS. Du… | 2018-02-01 |
| 3148 | 3148 | BEARTOOTH HEALTHCARE COMMUNITY | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2014-12-04 | 280 | E | 0 | 1 | WVZO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to revise, follow and update the care plan to reflect the residents' current status for 4 (#s 1, 2, 3 and 4) of 10 sampled residents. Findings include: 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #2's last care plan review completed on 5/29/14, reflected a goal, initiated on 3/21/14, to maintain her current weight of 102.7 pounds. The interventions were for staff to monitor the resident's weight and report any loss/gain of 5% in 30 days, 7.5% in 90 days or 10% in 180 days to nursing and the dietician. Review of resident #2's Weights and Vitals Summary showed the resident weighed 102.7 pounds on 5/21/14 and dropped to 96.5 pounds by 6/18/14. On 8/13/14, resident #2's weight was 88.3 pounds, a severe weight loss. Review of resident #2's Nutrition at Risk IDT Committee note dated 6/19/14, showed staff documented the resident had been sick, not feeling well, and her weight had dropped 6 pounds, over the last 30 days. The committee documented the resident's appetite was 0-75% overall, often only 25%. Per the note, the dietician was notified and a fax was sent to the physician, asking if a supplement would be appropriate. Review of a progress note dated 7/23/14, reflected the registered dietician identified that the resident's weight was 89.7 pounds, a significant loss over 180 days. He advised a trial house supplement once daily. Review of a Nutrition at Risk IDT note dated 8/19/14, showed the dietary manager documented for the Committee that the resident had been slowly losing weight and was down to 88.3 pounds. She was triggering for a loss of 15.1% over 90 days. Per the note, the physician was faxed, asking for a supplement with each meal due to her poor intake and the registered dietician was notified. A review of the Medication Review Report, dated 11/1-11/30/14, reflected resident #2 was to receive Boost with meals. … | 2018-02-01 |
| 3149 | 3149 | BEARTOOTH HEALTHCARE COMMUNITY | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2014-12-04 | 281 | E | 0 | 1 | WVZO11 | Based on observation and interview, the facility staff failed to follow professional standards of nursing practice for 4 (#s 11, 12, 13, and 14) of 15 sampled and supplemental residents. The nurse did not wait for the identified residents in the dining room to take all their medications before she left. Findings include: During an observation on 12/2/14, staff member C, RN, passed medications in the dining room. At 7:50 a.m., staff member C gave resident #11 her medications in a souffle cup, poured her water in a glass, and walked to the other end of the dining room. The staff member did not wait for resident #11 to take her medications. At 7:54 a.m., staff member C placed a souffle cup with resident #12's medications on the table next to the resident. She then walked off to the other side of the dining room before the resident was finished taking the medications. At 8:00 a.m., staff member C placed a souffle cup with resident #13's medications on the table next to the resident. The staff member did not wait until resident #13 took the medications before leaving the resident's side; walked over and closed the dining room curtain, and then left the dining room. At 8:07 a.m., staff member C placed a souffle cup with resident #14's medications on the table next to the resident. She walked out of the dining room before resident #14 was able to take the medications. During an interview on 12/2/14 at 1:40 p.m., staff member A, DON, stated there were no residents in the facility who could self-administer their medications. She stated the nurse needed to wait for the residents to take their medications before leaving their side. ADMINISTERING MEDICATIONS Critical Decision Point h. Stay until client has completely swallowed each medication. Ask client to open mouth if uncertain whether medication has been swallowed. Perry. Potter, Clinical Nursing Skills & Techniques, 5th Edition, Mosby, 2002, p. 460 | 2018-02-01 |
| 3150 | 3150 | BEARTOOTH HEALTHCARE COMMUNITY | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2014-12-04 | 323 | D | 0 | 1 | WVZO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide safe transfers for 2 (#s 3 and 4) of 10 sampled residents. Findings include: 1. Resident #3 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. During an observation on 12/2/14 at 8:10 a.m., staff members E and I, CNAs, transferred resident #3 to a chair with their hands under his armpits. Resident #3 had a BKA, and was unable to bear weight on the unaffected leg. The resident cried out during the transfer. The chair was placed four feet away from the bed. The staff of two carried him under his arms to the chair. During an observation on 12/3/14 at 8:25 a.m. staff member E, CNA, and K, social worker, transferred resident #3 by placing their hands under his armpits and moved him to the chair, four feet away. He cried out in pain. Staff member E stated the resident had a lot of pain in his leg. The care plan reflected the transfer should be a fireman lift transfer per the resident's request. No description of a fireman's lift was provided by the facility. During an interview on 12/2/14 at 1:00 p.m., staff member J, PT, stated resident #3 did not like any other transfer. The facility was unable to provide documentation they had tried other transfers related to the resident's inability to bear weight, pain, and safety. 2. During an observation on 12/3/14 at 1:35 p.m., staff members I and L, CNAs, transferred resident #4 by placing their hands under the arms. The wheelchair was not locked and a gait belt was not used. During an interview on 12/3/14 at 2:40 p.m., staff member B, administrator, stated the facility did not have a policy for transfers, but thought the staff followed standards of practice. Mosby's Textbook for Nursing Assistants, 7th Edition. 2008 Chapter 12: Preventing Falls, Promoting Safety and Comfort Transfer/Gait belts are routinely used in nursing centers. If a person needs help, a belt is required. | 2018-02-01 |
| 3151 | 3151 | BEARTOOTH HEALTHCARE COMMUNITY | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2014-12-04 | 325 | D | 0 | 1 | WVZO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to recognize, evaluate, follow up, and implement interventions in response to a severe weight loss for 2 (#2 and 4) of 10 sampled residents. Findings include: 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #2's Weights and Vitals Summary showed the resident weighed 102.7 pounds on 5/21/14 and dropped to 96.5 pounds on 6/18/14. On 8/13/14, resident #2's weight was 88.3 pounds, a severe weight loss of 14.4 pounds in 85 days. A review of the facility's Nutrition Department Policy/Procedure, updated in 2010, reflected that when the facility identified a significant weight loss .refer to registered dietician for review at next visit . implement the meal boost (enrichment) program . if weight loss continues . attain order and serve a two calorie per milliliter supplement product .BID .then upgrade to TID .advise registered dietician of .worsened conditions . Review of resident #2's Nutrition at Risk IDT Committee notes dated 6/19/14, reflected the resident had been sick, not feeling well, and her weight had dropped 6 pounds, over the last 30 days. The committee documented the resident's appetite was 0-75% overall, most often being 25%. Per the note, the dietician was notified and a fax was sent to the physician to ask if a supplement would be appropriate. Review of an email, dated 6/19/14, sent by the past dietary manager to the RD (registered dietician), reflected the RD was notified of the resident's weight loss and nursing staff were to ask for a supplement order. The dietician replied, that the interventions/plans looked suitable. No documentation was located to show the facility staff had implemented the meal boost plan, or obtained a supplement product BID in June 2014. The supplement was not implemented until 8/20/14. Review of a follow-up assessment by the RD on 6/20/14 showed resident #2 had a recent upper respiratory infection, s… | 2018-02-01 |
| 3152 | 3152 | BEARTOOTH HEALTHCARE COMMUNITY | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2014-12-04 | 365 | D | 0 | 1 | WVZO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide altered texture meals for 1 (#4) of 10 sampled residents. Findings include: Resident #4 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #4 weighed 125.7 pounds on 9/20/14 and weighed 112.7 pounds on 11/26/14, a severe weight loss from September through November. During a breakfast observation on 12/2/14 at 8:30 a.m., resident #4 was sitting at the table with his head down. Staff member E, CNA, was assisting the resident with his meal, which included scrambled eggs and an English muffin. During an interview on 12/2/14 at 8:30 a.m., staff member E stated she would not even try to give the resident the muffin, he would not be able to eat it because, He has no upper teeth. Review of the dietary communication book reflected on 11/28/14 a trial of a pureed texture had been requested for resident #4 by nursing. The diet texture had not been implemented on 12/2/14 for breakfast. During an interview on 12/2/14 at 8:50 a.m., staff member A, DON, stated the facility did not have anything formal for a trial of altered textures, but the doctors wanted them to go ahead and try the different texture for 7 days, and then get an order for [REDACTED]. During an interview on 12/2/14 at 9:40 a.m., staff member G, activity director/interim dietary manager, stated the facility used a communication book for nursing and dietary. Review of the diet card for resident #4 did not show a pureed texture trial for the resident. During an interview on 12/2/14 at 9:10 a.m., staff member H, cook, stated the card would not be updated until the MD order was received. Resident #4 did not receive a pureed diet for breakfast on 12/2/14. He received the regular scrambled eggs and an English muffin. During an interview on 12/2/14 at 9:40 a.m., staff member G stated we have no documentation to show we tried the pureed food. During an interview on 12/2/14 at 1:05 p.m., staf… | 2018-02-01 |
| 4037 | 4037 | BEARTOOTH HEALTHCARE COMMUNITY | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2013-11-07 | 157 | D | 0 | 1 | IF2L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to notify the resident's physician regarding significant weight loss for 1 (#15) out of 17 sampled and supplemental residents. Findings include: Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/5/13 at 9:30 a.m., the surveyor reviewed the medical record for resident #15; the following weights were recorded in the medical record: -5/31/13 - 107.0 lbs -6/4/13 - 108.0 lbs -7/1/13 - 104.0 lbs -8/11/13 - 101.5 lbs -8/25/13 - 97.4 lbs -9/8/13 - 97.6 lbs -9/29/13 - 95.0 lbs -10/6/13 - 95.3 lbs -10/27/13- 93.2 lbs The resident experienced a 13.8 lb or 12.8% significant weight loss (greater than 10% in six months is significant) in approximately five months since admission. The medical record included evidence of an assessment completed by staff member D, registered dietician, on 6/11/13 and 10/18/13 addressing the weight loss with recommendations. Review of the care plan indicated weight loss as a concern with an initial date of 6/3/13. The care plan included updates related to the weight loss concern on 8/20/13 during a quarterly review, and on 11/6/13. Resident #15 was assisted with eating for all meals and receives supplements and finger food. On 11/5/13 at approximately 9:45 a.m., the surveyor interviewed staff member C, the food service supervisor, regarding the resident's weight loss and notification of resident #15's physician. Staff member C reported he maintained a weight at risk list and had a weekly weight meeting with the nursing staff. On 11/5/13 at 9:45 a.m., the surveyor asked staff member B, DON, if the physician had been notified. The medical record did not include evidence that the physician had been notified. Staff member B stated, we did not notify the physician and we should have. It was a miscommunication between dietary and nursing. The facility policy and procedure titled, significant weight loss, under the heading, after calorie… | 2016-11-01 |
| 4038 | 4038 | BEARTOOTH HEALTHCARE COMMUNITY | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2013-11-07 | 241 | D | 0 | 1 | IF2L11 | Based on observation and staff interview, the facility failed to maintain the dignity of 1(#2) of 17 sampled and supplemental residents. Findings include: On 11/5/13 at 3:50 p.m., the surveyor heard staff member K, CNA, asking resident #2 if she needed to, go potty. This conversation occurred in the main hallway by the nursing station with numerous staff and residents in the vicinity. The surveyor then observed staff member K, CNA, push resident #2's wheelchair over to the bathroom doorway, open the door, and push the resident's wheelchair into the bathroom. The bathroom door was left open. Staff member K, CNA, wheeled the resident to the toilet and left her sitting in her wheelchair while telling her I'll be back in a few minutes to put you on the potty, (resident name) #2. The bathroom door remained open into the hallway during the course of the conversation until staff member K, CNA, closed it when exiting the bathroom. Numerous staff, residents, and other unidentified individuals passed this open door during the conversation. On 11/5/13 at 7:50 p.m. the surveyor heard staff member K, CNA, asking resident #2 if she needed to go potty. This conversation occurred in the main parlor of the facility. The surveyor observed four other residents sitting within hearing distance in the main parlor at that time. On 11/5/13 at 8:55 p.m., the surveyor interviewed staff member K and asked her to explain what dignity meant in regards to interacting with residents. Staff member K, CNA, responded We're not supposed to call the residents honey or dear. We're supposed to knock on their doors before we go into their rooms and we are supposed to make sure the privacy curtain is closed when doing cares. | 2016-11-01 |
| 4039 | 4039 | BEARTOOTH HEALTHCARE COMMUNITY | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2013-11-07 | 253 | D | 0 | 1 | IF2L11 | Based on observation and staff interview, the facility failed to provide necessary maintenance services to maintain an orderly and sanitary interior. Specifically, shower room D was in a state of disrepair. Findings include: 1. On 11/4/13 at 4:40 p.m., the surveyor observed broken or missing tiles on the walls in shower room D as follows: -the lower left wall of the shower stall; -along the lower, inner aspect of the door frame of the entrance door into the room from the hallway; and -tiles were laying on the floor just under the exposed wall (tiles were missing) to the left when entering the room. 2. There were multiple dented areas and exposed, rusted metal on the electric wall heater that was located next to the toilet in shower room D. 3. The surveyor interviewed staff member J, a CNA, and asked how long the tiled areas had been in a stated of disrepair. Staff member J stated, It's been like that since I started working here in May. 4. The surveyor interviewed staff members J, K, and L (all CNAs) regarding which residents used shower room D. Staff members J, K, and L reported that all residents who required the assistance of two staff for toileting were toileted in shower room D because the bathrooms in the residents' rooms were too small for more than one staff to assist. Staff members J, K, and L indicated that residents were also given showers in shower room D. 5. The surveyor observed staff toileting resident #4 in shower room D on 11/4/13 at 4:40 p.m. | 2016-11-01 |
| 4040 | 4040 | BEARTOOTH HEALTHCARE COMMUNITY | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2013-11-07 | 281 | D | 0 | 1 | IF2L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure professional standards of nursing practice were adhered to for 2 (#s 1 and 3) of 11 sampled residents. physician's orders [REDACTED]. 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During the review of resident #1's medical record on 11/6/13 at 11:00 a.m. the following physician's orders [REDACTED]. [MEDICATION NAME] 20 mg po (orally) 1 tab (tablet) q (every) p.m. (in addition to [MEDICATION NAME] HCT 20/25 1 tab q a.m.). [MEDICATION NAME] is a medication used to treat hypertension or high blood pressue. There was no indication on the MAR indicated [REDACTED]. The [MEDICATION NAME] HCT 20/25 morning dose was omitted for August - October 2013. The physician's orders [REDACTED]. On 11/7/13, at approximately 1:15 p.m. during an interview with staff member B, the director of nursing, she said it appeared to be a medication error and that she would look in to it. Cross refer to F333 for information regarding this significant medication error for resident #1. 2. Resident #3 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. a. Elbow protectors Resident #3 had a physician's orders [REDACTED]. The surveyor observed Resident #3 sitting in her recliner in her room, and was not wearing her elbow protectors on the following dates and times: -11/4/13 at 3:30 p.m.; -11/5/13 at 9:10 a.m., -12:25 a.m. and 7:15 p.m., and -11/6/13 at 9:10 a.m. On 11/6/13 at 9:40 a.m., during an interview with staff members E and F, LPNs, they both reported that they were unaware of an order for [REDACTED].#3 wouldn't keep the elbow protectors on anyway and that she would fax the doctor to discontinue the order. During an interview with staff member B, DON on 11/6/13 at 12 p.m., she agreed the elbow protectors were not being worn as ordered by the doctor, and they would ask the doctor to discontinue the order. The medical record did not inclu… | 2016-11-01 |
| 4041 | 4041 | BEARTOOTH HEALTHCARE COMMUNITY | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2013-11-07 | 333 | D | 1 | 1 | IF2L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure 2 (#s1 and 3) of 11 sampled residents were free of significant medication errors. Specifically, nursing staff made significant medication errors in the administration of blood pressure medications to residents #1 and #3. Findings include: 1. Resident #3 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident #3 had the following physician's orders [REDACTED]. Note: Monitor VS (vital signs) BID (twice a day). Hold [MEDICATION NAME] unless BP over 150/90. Review of the resident's medical record showed that the BP was within the parameters ordered by the physician, for giving the medication on the following occasions: -8/22/13 BP 156/82 @4:00 p.m. -8/25/13 BP 143/92 @ 5:00 a.m. -8/28/13 BP 166/94 @ 5:00 a.m. -9/5/13 BP 153/100 @ 4:00 p.m. -9/7/13 BP 160/72 @ 4:00 p.m. -9/8/13 BP165/90 @ 5:00 a.m. -9/10/13 BP 155/74 @ 5:00 a.m. -9/10/13 BP 162/79 @ 4:00 p.m. -9/11/13 BP 155/86 @ 5 a.m. -9/15/13 BP 154/68 @ 4 p.m. -9/17/13 BP 145/99 @ 4 p.m. -9/18/13 BP 155/96@ 5 a.m. -9/20/13 BP 153/75 @ 4 p.m. -9/24/13 BP 170/92 @5 a.m. -10/1/13 BP 155/76 @5 a.m. -10/4/13 BP 180/78 @5 a.m. -10/6/13 BP 159/93 @5 a.m. -10/15/13 BP 158/72 @ 4 p.m. -10/21/13 BP 154/66 @ 5 a.m. -10/21/13 BP 162/64 @ 4 p.m. -10/25/13 BP158/78 @ 4 p.m. -11/6/13 BP 141/97 @ 5 a.m. -11/6/13 BP 152/80 @ 4 p.m. During the time frame from 8/15/13 - 11/6/13, [MEDICATION NAME] 20 mg orally was given to resident #3 on the following dates and times: -8/20/13 BP 152/72 @ 5 a.m. - [MEDICATION NAME] 20 mg po given -8/20/13 BP 155/82 @8:00 p.m. -[MEDICATION NAME] 20 mg po given -10/22/13 BP156/76 @ 5 a.m. - [MEDICATION NAME] 20 mg po given On 11/5/13 at 10:50 a.m., during an interview with staff member B, the DON, she stated that ordering [MEDICATION NAME] PRN doesn't make any sense and the electronic system won't bring up a PRN automatically and it sets the nurses up. I'm sure some have been… | 2016-11-01 |
| 4042 | 4042 | BEARTOOTH HEALTHCARE COMMUNITY | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2013-11-07 | 368 | E | 0 | 1 | IF2L11 | Based on observation and staff interview the facility failed to offer bedtime snacks to residents residing throughout the facility. Findings include: On 11/4/13 at 4:00 p.m. the surveyor interviewed the dietary manager regarding the kitchen's procedure for providing bedtime snacks. The dietary manager reported, We have snack carts that are taken to the nursing stations between 7:00 p.m. and 7:30 p.m. usually after the kitchen is cleaned. The surveyor asked the dietary manager what the bedtime snacks included. The dietary manager stated, The carts have cheese sticks, yogurt, pudding cups, granola bars, fresh fruit, rice crispie treats, sugar free cookies, fresh fruit, and sandwich halves. The surveyor asked what the procedure was for making sure residents were offered bedtime snacks. The dietary manager stated, It isn't the kitchen staff's responsibility. That is the CNA's job. We just make sure the snacks are at the nursing stations. On 11/5/13 at 7:10 p.m. the surveyor observed a resident on the SCU asking staff member M, a CNA, for a snack. Staff member M went to the unit desk area and got a snack and distributed it to the resident requesting it. The surveyor interviewed staff member M about bedtime snacks. Staff member M stated, I do bedtime snacks between 8:00 p.m. and 8:30 p.m. If a resident is asleep, I don't wake them up. The surveyor then asked on average how many residents on the SCU get snacks. Staff member M stated, Usually 3 to 4 residents are up and about and get offered a snack. On 11/5/13 at 8:00 p.m. the surveyor observed that a resident came to the snack cart at the main nursing station and got a snack for himself. On 11/5/13 at 8:15 p.m. the surveyor observed staff member M, a CNA, offering snacks to 6 out of 9 residents still awake in the SCU. On 11/5/13 at 8:55 p.m. the surveyor observed that one resident helped himself to a snack on the snack cart at the main nursing station. The surveyor did not observe bedtime snacks being offered to the residents, in the main part of the facility, by the d… | 2016-11-01 |
| 4043 | 4043 | BEARTOOTH HEALTHCARE COMMUNITY | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2013-11-07 | 371 | F | 0 | 1 | IF2L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to maintain sanitary conditions for food preparation and distribution in the kitchen, having the potential to affect all residents. Findings include On 11/4/13 at 1:15 p.m., in the dry storage area, the surveyor observed an opened box of devil's food chocolate cake mix on a shelf that was not sealed with the contents being exposed to air and contamination. The surveyor observed a box of baking soda that was not sealed and the contents were exposed to air and contamination. On 11/4/13 at 1:20 p.m., in the walk-in freezer, the surveyor observed ice and frost build up on the [MEDICATION NAME] piping leading to the freezer fans and motor unit. The surveyor observed an open box of frozen bread dough sticks sitting underneath this [MEDICATION NAME] pipe. There was a frozen ice puddle that had formed on top of this open box. On 11/4/13 at 1:25 p.m., in the main kitchen area, the surveyor observed accumulated grease and dust buildup on the handles of the baffles inside the grill hood. There was grease and dust buildup on the inside edges of the grill hood. The surveyor observed a grease and dust buildup on the back edges of the grill, and accumulated food crumbs under the stove burners. The surveyor observed grease and dust build-up on the side of the kitchen counter between the sink and the steam table. On 11/5/13 at 4:00 p.m. the surveyor interviewed staff member C, the dietary manager, regarding the hood above the stove. Staff member C told the surveyor, The facility has a cleaning service that cleans the hood once every 6 months. The surveyor showed staff member C, dietary manager, the ice and frost build-up on the [MEDICATION NAME] pipe leading to the fans and motor in the walk in freezer. The surveyor pointed out the frozen water/ice on top of the bread dough box to staff member C. Staff member C, dietary manager, stated, This box of frozen bread dough will be thrown away. Staff memb… | 2016-11-01 |
| 4044 | 4044 | BEARTOOTH HEALTHCARE COMMUNITY | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2013-11-07 | 441 | D | 0 | 1 | IF2L11 | Based on observation, record review, and staff interview, the facility failed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection for 3 (#s 4, 16 and 17) of 17 sampled and supplemental residents. Findings include: 1. During observation of the medication pass on 11/05/13 at 7:40 p.m., staff member H, an RN, entered resident #16's room to administer a suppository. Staff member H put on gloves without first sanitizing her hands, pulled back the bedding and pulled down the resident's incontinent brief that was wet with urine. Wearing the same gloves, staff member H opened closet and dresser doors and got a clean brief. Staff member H then stated I can't find any wipes, so I'll use whatever I can. Staff member H went to the sink and wet a dry wipe. Staff member H reurned to the resident and inserted a suppository into the resident's rectum, removed the wet brief, cleansed the resident's perineal area and put the wet brief in the trash can. Staff member H put a clean brief on the resident, elevated the resident's feet with a pillow, and covered the resident with a blanket. Staff member H removed the gloves and washed her hands. Staff member H did not sanitize or wash her hands before putting on gloves. She did not remove her gloves or sanitize her hands after touching the soiled brief and opening the closet. She also touched a clean brief, the bed covers and a pillow before removing the soiled gloves and washing her hands. 2. During observation of medication pass on 11/05/13 at 7:50 p.m., staff member H, RN, entered resident #17's room to administer medications. Resident #17's oxygen concentrator was running, and the O2 tubing with the nasal cannula was on the floor. Staff member H put on gloves, searched the room for wipes, could not find any, wet a dry wipe with water in the bathroom sink, used it to wipe BM from the resident's buttocks, and applied prescribed topical ointment to the resident's buttocks, touching the ointment tube. Staff me… | 2016-11-01 |
| 4618 | 4618 | BEARTOOTH HEALTHCARE COMMUNITY | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2012-11-16 | 272 | E | 0 | 1 | 0GTP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the summary information regarding additional assessments performed on the CAAs triggered by the MDS were completed with signatures, dates, and locations for the additional assessments for 8 (#s 1, 2, 3, 4, 5, 6, 8, and 10) of 12 sampled residents. Findings include: 1. Resident #1 was admitted on [DATE]. The Annual MDS assessment with an ARD of 7/22/12 showed missing signatures for the following triggered CAAs: ADL Functional Status/Rehabilitation Potential, Urinary Incontinence and Indwelling Catheter, Falls, Dental Care, Pressure Ulcer, [MEDICAL CONDITION] Medication Use, and Pain. The CAAs for Psychosocial Well-Being, Activities, and Dental Care did not contain dates and locations of where the additional information used to complete the CAAs was obtained. 2. Resident #2 was admitted on [DATE] and readmitted on [DATE]. The Annual MDS assessment with an ARD of 8/17/12 showed missing signatures and dates for the CAA, ADL Functional Status/Rehabilitation Potential. The following CAAs were missing signatures: Urinary Incontinence and Indwelling Catheter, Falls, Pressure Ulcer, and [MEDICAL CONDITION] Medication Use. 3. Resident #3 was admitted on [DATE]. The Annual MDS assessment with an ARD of 3/21/12 showed missing signatures and dates for the following triggered CAAs: Psychosocial Well-Being and Activities. The CAAs for Cognitive Loss, Visual Function, ADL Functional Status/Rehabilitation Potential, Urinary Incontinence and Indwelling Catheter, Falls, Nutritional Status, and Pain did not contain dates and locations of where the additional information used to complete the CAAs was obtained. The CAAs for Psychosocial Well-Being, Activities did not contain any additional information. 4. Resident #4 was admitted on [DATE]. The Initial MDS assessment with an ARD of 10/31/12 showed missing signatures for the triggered CAA, Nutritional Status. 5. Resident #5 was admitted on [D… | 2015-12-01 |
| 4619 | 4619 | BEARTOOTH HEALTHCARE COMMUNITY | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2012-11-16 | 278 | B | 0 | 1 | 0GTP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure MDS assessments accurately reflected the resident's status for 10 (#s 1, 2, 3, 4, 5, 6, 7, 8, 10, and 11) of 12 sampled residents. Findings include: 1. Resident #1 was admitted on [DATE]. The resident had an allergy to the influenza vaccine, which was documented in the physician orders. Review of the care plan showed the resident had an allergy to the pneumococcal vaccine. Review of the Beartooth Manor - Resident Immunization Record showed the resident refused the influenza vaccine in 2011, and the pneumococcal vaccine in 2012. Also included in the resident's chart were Pneumococcal & Influenza Vaccination Standing Orders that stated the resident is allergic to the flu vaccine. Under the Pneumococcal Vaccine Orders, it was noted a booster dose was given in January 2009. Review of the MDS assessments with ARDs of 7/22/12 and 10/16/12 showed the resident was coded at Section O0300A/B - Is resident's pneumococcal vaccination up to date as 0/3 (no/not offered). The correct coding should have been 1 for yes, since the resident received a booster in 2009. 2. Resident #2 was admitted on [DATE] and readmitted on [DATE]. Review of the MDS assessments with ARDs of 5/27/12 and 8/17/12 showed the resident was coded at Section O0300A/B - Is resident's pneumococcal vaccination up to date as 0/3 (no/not offered).? Review of the Beartooth Manor - Resident Immunization Record showed the resident was given the pneumococcal vaccine on 11/9/12. 3. Resident #3 was admitted on [DATE]. Review of the MDS assessments with ARDs of 3/21/12, 6/11/12, and 9/2/12 showed the resident was coded at Section O0300A/B - Is resident's pneumococcal vaccination up to date as 0/3 (no/not offered). Review of the Beartooth Manor - Resident Immunization Record showed a notation under Pneumococcal Vaccine, 2012 Refused per (family member) she had already. 4. Resident #4 was admitted on [DATE]. Review of the MDS a… | 2015-12-01 |
| 4620 | 4620 | BEARTOOTH HEALTHCARE COMMUNITY | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2012-11-16 | 371 | F | 0 | 1 | 0GTP11 | Based on observation and staff interview, the facility failed to ensure food was prepared under sanitary conditions. Findings include: 1. On 11/14/12 at 8:05 a.m., staff member F was observed during the breakfast service putting peanut butter on resident #2's toast while holding the toast in her bare hands. 2. On 11/14/12 at 10:28 a.m., during the tour of the dry storage room, plastic wrap was noted stored on the floor. 3. On 11/15/12 at 7:45 a.m., staff member G was observed in the back corner of the main dining room. Staff member G had an apron on, and had her hair pulled back into a pony tail while she was frying eggs. The staff member was not wearing a hair covering. Staff member G was noted cracking open the eggs with bare hands. Staff member G was not observed to wash or sanitize her hands between tasks. The fried eggs were placed onto individual plates and taken by staff member G to the residents. While the eggs were frying, staff member G was observed leaning across the first pan of eggs to reach the pan of eggs that was on the far side of the table. On 11/16/12 at 8:15 a.m., staff member G discussed the process they use when frying eggs. Staff member G stated she had used hair spray on her hair and had it pulled back into a pony tail, which she thought was correct. When she is cracking the pasteurized eggs, she does not wear gloves. When she has cracked enough eggs to cover both of the griddles, she wipes her fingers on a paper towel. The small paper plates are used so the fried eggs can be transported to the resident, and the egg tipped onto the resident's plate, so they don't actually touch the egg. | 2015-12-01 |
| 4621 | 4621 | BEARTOOTH HEALTHCARE COMMUNITY | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2012-11-16 | 441 | E | 0 | 1 | 0GTP11 | Based on observations, review of the infection control log, and staff interviews, the infection control program lacked measures to facilitate staff practices that complied with techniques? that minimized the risk of cross contamination for 4 (#s 1, 2, 4, and 14) of 15 sampled and supplemental residents. Findings include: 1. On 11/15/12 at 6:36 p.m., staff member B, the DON, stated she does not track the organisms from the cultures or the antibiotics used to treat the infections. The staff member stated a night shift nurse used to track the cultures and if the antibiotic was the appropriate treatment. Staff member B stated, in the past few months, she had revamped the infection control program. During the review of the Infection Control Program, the following forms were noted in the book: -Infection Control Report; -Map of facility; and -a document labeled as Infection Control. The Infection Control Report form contained the following areas: -type of infection; -infection acquired nosocomial; -infection community acquired; -total resident days infection rate; and -action taken. The map was of the facility with room numbers, type of infection listed with color code, and the rooms with infections. The Infection Control document contained the following areas: -month; -year; and -skin issues. The surveyor noted that during the months of January to July 2012, the book contained a map and Infection Control Report. During the months of January to July 2012, infection control program did not contain the following items: -residents name with room number; -date when signs and symptoms started; -type of antibiotic ordered; -the date the antibiotic was ordered; -the number of days the antibiotic was ordered for; -if the infection was cultured; and -the results of the culture. For the months of August and September 2012, the Infection Control document did not contain the following items: -the resident's complete name with room number; -date signs and symptoms started; -type of antibiotic ordered; -the date the antibiotic was o… | 2015-12-01 |
| 5176 | 5176 | BEARTOOTH HEALTHCARE COMMUNITY | 275090 | 350 W PIKE AVE | COLUMBUS | MT | 59019 | 2011-11-21 | 520 | F | 0 | 1 | 5XDT11 | Based on staff interview, the facility failed to ensure the quality assessment and assurance committee consisted of a physician designated by the facility. Findings include: During the quality assurance review with staff members A, B, and C on 11/21/11 at 7:20 a.m., the staff members stated they do not have a physician that attends their quality assurance meetings. The department managers meet monthly, but they "cannot get (physician's name) to attend." Staff member A stated they have "tried everything" to get the physician to attend, but the physician will not attend the meetings. | 2015-01-01 |
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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 );