rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
1,BENEFIS SENIOR SERVICES,275012,2621 15TH AVE S,GREAT FALLS,MT,59405,2017-03-09,226,E,0,1,KTFZ11,"Based on observation, record review, and interview, the facility failed to protect residents during the investigation process for allegations of abuse for 6 (#s 8, 14, 26, 27, 28 and 32) of 36 sampled and supplemental residents. Findings include: Review of an incident report, dated 10/6/16, showed resident #8 sustained a 7 cms. reddish/brown bruise to her right wrist during an allegation of rough cares. The Plan to Prevent Further Abuse section did not show preventative steps taken by the facility to protect other residents from harm. The staff member identified in the allegation continued to work the floor with the residents through completion of her shift. Review of the facility's Abuse Policy and Procedure (prior to 3/9/17) did not show protective action was to be taken when a resident reported an allegation of abuse by a staff member. The policy and procedure failed to identify definitive steps for staff members involved in allegations of abuse. During an interview on 3/8/17 at 2:30 p.m., staff member S stated a procedure was followed when an allegation of abuse was voiced by a resident: -The social worker or nurse would be asked to talk to the resident. -Then the nurse manager would follow up and talk with the resident. -The nurse manager put in a 24-hour report to the state. -The nurse manager would interview all the staff members involved. -If needed, involved staff would be put on administrative leave. -The nurse manager would notify the Director of Nursing of the incident. -Education on abuse and resident rights would be repeated for all staff. Staff member S stated the CNA involved in resident #8's incident, self-reported to another staff member that the resident had complained of rough cares. During an observation on 3/9/17 at 8:06 a.m., staff member T brought an over-the-bed table into the dining room to be used by a resident, however the table did not fit under the resident's wheel chair. Staff member T pushed the table toward the dining room entrance. A female resident seated at a table close to the entrance stated, You can't leave that there (the over-the-bed table). There are two people with wheel chairs. Staff member T stated I know, and walked away. Staff member T's voice was rough, and her demeanor was abrupt. The female resident stated No you don't. Staff member T returned with a smaller table and stated See, I told you I knew, and I'm moving it now. Staff member T took the other table out of the dining room. Staff member T's demeanor was, abrupt and her voice sounded rough. During an interview on 3/9/17 at 9:30 a.m., staff member T stated Some residents say we are being rough with care, but it is because we are rushed. 2. Review of an incident report, dated 2/1/17, showed resident #14 was treated very very rough by staff member G, while assisting her with upper body dressing. Staff member C investigated the rough handling allegation between 2/1/17 and 2/6/17. On the reporting form, staff member C indicated staff member G was assigned to another cottage, during which time, interviews could be conducted with other residents. During an interview on 3/8/17 at 9:15 a.m., staff member C stated, usually alleged staff members were assigned to a different area until the investigation was final. However, about two weeks ago it was decided, during the managers huddle meetings, to put the alleged staff members on administrative leave with pay, until the investigations were finalized. This decision was made due to a recent increase in the number of allegations against the staff. Staff member C stated as a result of this investigation, two more residents came forward complaining about the same CNA rushing cares with them. She stated these allegations warranted further investigations about the CN[NAME] Staff member C provided the facility's abuse prevention protocol and stated the facility was in the process of updating the policy. 3. A record review of an incident report sent to the state agency, by the facility, dated 9/6/16, showed details of alleged staff rudeness and rough care during resident cares provided for resident #26 by staff member Y. The report showed that staff member Y was reassigned . pending further family interview and investigation of the complaint. A record review of an incident report sent to the state agency, by the facility, dated 1/17/17, showed details of alleged staff rudeness and rushed care, during personal cares for resident #28, by staff member T. The report showed that after the alleged abuse had been reported, staff member T was told by a nurse she needed to switch to another resident, and she was not supposed to work with the alleged abused resident. The report showed that staff member T said she did go into resident #28's room later that day because the call light was going and no one else was around. A record review of another incident report sent to the state agency, by the facility, dated 1/22/17, showed details for another report of rough cares by staff member T involving resident #32. The report showed that staff member T was placed on administrative leave until completion of this incident's investigation. A record review of an incident report sent to the state agency, by the facility, dated 2/9/17, showed details of alleged staff rudeness and disrespect during resident cares, provided to resident #27, by staff member Z. The accompanying investigation report, dated 2/14/17, showed that it was determined there was reason for concern with the care provided by staff member Z. The report said that staff member Z would be placed in discipline. The report showed, she will be moved to another Cottage until the current resident with concerns is discharged . The report did not indicate that staff member Z had discontinued providing resident cares after the allegation of abuse had been reported, or during the investigation of the allegation. During a meeting with the facility DON, and members of the abuse prevention committee, on 3/8/17 at 1:00 p.m., the committee members were asked what criteria was used to determine if a staff member, as an alleged abuser, was placed on administrative leave, or allowed to continue to perform cares for residents during the abuse incident investigation. Staff member B responded by saying that the committee members had recently concluded they needed to consider a change in the policy of how the facility conducted investigations of allegations of staff to resident abuse incidents. This was prompted by several allegations of staff to resident abuse events reported in the first two months of this year, and included one incident that was determined as substantiated following investigation. A new abuse education program had also recently been put together, and was to be conducted for all employees throughout all the LTC facilities within the next couple of weeks. It was discussed, during this meeting, that allowing an alleged abuser to continue to perform cares for any residents during abuse incident investigations had the potential of placing residents at risk for abuse. It was also discussed that the accused employee is due protection from those who might take the opportunity to allege further abuse. During an interview on 3/9/17 at 8:30 a.m., staff member A provided a copy of the facility's new abuse policy, and stated the changes in the policy had been signed into effect that morning, less than an hour earlier. A comparison review of the old and new facility abuse policies showed that changes had been made regarding removal from duty of staff members who were being investigated for an allegation of abuse. Under part II of Allegations of Abuse, Neglect, and/or Misappropriation of Funds, letter e of the old policy, was the statement The Resource Nurse, with support and guidance from the Unit Manager and/or their designee may remove from duty any employee being investigated for an allegation of abuse during the investigation process. The new policy states, The Resource Nurse . removes from duty any employee being investigated . The new policy goes on to show the employee suspected of abuse is to be placed on administrative leave pending completion of the investigation. If abuse is substantiated the administrative leave will be unpaid leave. It also stipulates that the employee's privacy is to be protected during the abuse investigation. It outlines the investigation process to be followed indicating who will review the alleged occurrence with the employee, who will inform the employee of the investigation results, and when the employee will be able to return to work.",2020-09-01
2,BENEFIS SENIOR SERVICES,275012,2621 15TH AVE S,GREAT FALLS,MT,59405,2017-03-09,246,E,0,1,KTFZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to furnish a table which accommodated the ability for 2 (#s 19 and 36) of 36 sampled and supplemental residents to feed themselves. The facility, at Westview, failed to accommodate wheel chair bound residents in 37 of 37 bathrooms, giving them the ability to see themselves in their bathroom mirrors. The facility failed to ensure 1 (#7) of 24 residents was accommodated with a bathroom doorway wide enough for entry. Findings include: 1. Review of resident #19's Quarterly MDS, with an ARD of 1/27/17, showed the resident was cognitively impaired and required assist with meals. During an observation on 3/6/17 at 4:35 p.m., resident #19 was observed in the Lodge dining room. The resident was seated in a smaller than usual Broda chair. The resident had poor head control and was bent forward, resting her hand on her chest. The resident's chair was pushed up to a table, farthest from the Lodge kitchenette. The table was level with resident #19's nose. The resident was drinking hot chocolate out of a plastic, lidded glass, with a straw. The resident had to reach up to the table to place her glass on the table top. The glass wobbled, tipped. The resident was unable to see up on the tabletop. During an interview on 3/6/17 at 4:35 p.m., resident #19 stated, Might would help if the table was lower, to eat by herself. During an observation on 3/7/17 at 4:43 p.m., resident #19 sat at the table farthest from the Lodge kitchenette. The resident was in a small broad chair. The table was at nose level. A plate with a half of a peanut butter/jelly sandwich was on the table in front of the resident. The resident tried to reach the sandwich. The resident was unable to grasp the sandwich. The resident was able to grab the plate, and pull the plate with the half sandwich to her lap. Staff member V placed the plate back on the table and cut a small piece out of the middle of the sandwich and encouraged resident #19 to eat the bite. Staff member V left the side of resident #19. -At 5:01 p.m., resident #19 was reaching for an almost empty glass, secured with a lid and straw. The glass fell sideways on the table, dripping white liquid content from the glass onto resident #19's lap. -The resident tried lifting the glass to drink, again. After sipping the drink with a straw, the resident lowered her head towards her chest, hitting the edge of the table with her forehead. During an observation on 3/8/17 at 4:05 p.m., resident #19 was seated in a small broad chair, against the table, farthest from the Lodge dining room kitchenette. The resident's nose was level with the table top. During an observation on 3/9/17 at 9:30 a.m., resident #19 was seated in the Lodge dining room. The table had been lowered to shoulder level. During an interview on 3/8/17 at 1:44 p.m., staff member V stated the resident, as long as she could remember, was to have a lowered table for meals. Review of the interdisciplinary notes, dated 1/1/17, showed the resident had a bruise on her right eye due to bumping her head on the table in the dining room. Staff were educated to not push the resident too close to the table at meals, and the table was raised a bit to prevent the resident from bumping her head on the table. Record review showed a lack of documentation involving the table height, during meal times, for resident #19. 2. Resident #36 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation on 3/8/17 at 5:40 p.m., resident #36 was in the dining room waiting to eat dinner. Resident #36 was sitting at a round table with both her feet extended in front of her. Resident #36 was placed at the table with her left side closest to her plate. Resident #36 was reaching across her body, with a fork in her right hand. She would spear food with her fork, and bring her right hand back to the middle of her body to place the food in her mouth. Resident #36 was observed to eat 20 percent of her meal. During an interview on 3/8/17 at 5:40 p.m., resident #36 said it would be easier for her to eat if her food was placed in front of her. When resident #36 was asked if a bedside table, that could be placed in front of her, would be better, resident #36's comment was, Well sure! Then I wouldn't have to reach across myself to eat. Resident #36 then said, But they'll never think of that here. During an interview on 3/8/17 at 5:50 p.m., staff member HH said resident #36's feet were very sensitive, and needed to stay elevated. Staff member HH said she did not know if the facility had ever addressed using a bedside table for resident #36 during meals. Staff member HH said they would try a bedside table, at breakfast, for resident #36. During an observation and interview on 3/9/17 at 8:45 a.m., resident #36 had a bedside table placed in front of her. Her food was on the table, and resident #36 was eating breakfast. Resident #36 said it was easier to eat her food with it sitting in front of her. Resident #36 had eaten 85 percent of her breakfast. 3. During an interview on 3/9/17 at 8:00 a.m., resident #7's family member voiced several concerns for the resident: -The family member said if resident #7's wheelchair could fit through the bathroom door, resident #7 would be able to brush her own teeth, and wash her own face, which would allow resident #7 to be more independent. The family member said the mirror above the sink was to high, and resident #7 would not be able to see herself in it, if she could fit her wheelchair into the bathroom. -The family member said resident #7 had the ability to transfer herself from one surface to another. The family member said if resident #7 would toilet herself if her wheelchair could fit through the doorway of the bathroom. The family member said resident #7 could use a walker at times, and could get into the bathroom in that manner, but with trying to steady the walker, and grab the assist rails around the toilet, resident #7 was not, at times, able to get her pants down prior to her bladder releasing. The family member said the facility wanted resident #7 to use a bedside commode instead of the toilet. The family member said resident #7 was not comfortable with doing that, but at times she would. During a review of resident #7's Annual MDS, with an ARD of 8/6/16, showed the resident to be an extensive assist of 1 person for personal hygiene. This Annual MDS also showed the resident had no range of motion limitations. During an interview on 3/9/17 at 11:00 a.m., staff member T said there were several residents who could wash their faces, and brush their hair if they could get their wheelchairs into their bathrooms. Staff member T said resident #7 could do that for sure, if her bathroom door was wider so she could get in her bathroom. 4. Observations made from 3/6/16 to 3/9/17, throughout the Westview facility, showed all the mirrors in the resident bathrooms were at the same height above the bathroom sinks. Residents in manually operated wheelchairs were unable to view themselves in the bathroom mirrors.",2020-09-01
3,BENEFIS SENIOR SERVICES,275012,2621 15TH AVE S,GREAT FALLS,MT,59405,2017-03-09,280,D,0,1,KTFZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to follow the established plan of care for swallowing precautions and assisting with protective boots for 2 (#s 15 and 19) of 24 sampled residents. Findings include: 1. Resident #15 was readmitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. During an observation on 3/6/17 at 12:33 p.m., resident #15 was on the other side of the dining room, eating at a table independently. The resident coughed periodically. Shortly after this observation, the resident was wheeled into his room. Review of the resident's meal tray card, found in a basket in the Goodnow kitchen, showed the resident was on a quality of life diet, required finely chopped meat approximately 1/8 to 1/4 inch size bites, required one small bite with swallow, and was to be encouraged to eat at a slow rate with dining room supervision. The resident required decreased distractions during the meals. During an observation on 3/7/17 at 12:35 p.m., staff member N rushed to resident #15 who was coughing and making gurgling sounds with a reddened face. Staff member N wheeled the resident into his room and held a spit cup under his mouth while he coughed. Staff member N stated he did not cough up anything. She brought him back to the dining room. She sat with him and offered him fruit chunks which were cut up approximately 2/3 of an inch in size. The resident drank his soda and coughed more. Staff member N only asked the resident to slow doww, no other instructions were provided to the resident. The resident was not told to alternate food bites with beverage sips or to swallow between each bite of food. When asked if the resident required supervision with meals, staff member N stated He eats alone. She stated she had some extra time right now to sit with the resident. She stated the staff were to remind him to slow down. The resident had small bites of roast beef with gravy and tater tots (not 1/8th or 1/4th quarter of an inch in size bites). During an observation on 3/7/17 at 5:20 p.m., resident #15 was eating his evening meal unattended while nursing staff served other residents. He was taking large bites quickly and repeating this prior to swallowing his food. He began coughing with his face becoming reddened. At 5:25 p.m. resident continued to take quick bites while coughing. At 5:26 p.m., staff member [NAME] approached the resident and spoke with him. Resident #15 stopped eating and took a drink after the CNA redirected him. Staff member [NAME] sat with the resident and provided cues to the resident. With the CNA's supervision, the resident took less frequent bites. This continued until 5:37 p.m. and there was no further coughing. The CNA wheeled the resident away leaving the table. Review of the resident's most recent speech/swallow therapy discharge summary, dated 7/28/16, showed the following: a) Swallow Strategies/Positions: 1. Quality of life diet (regular textures of whatever the resident wanted). 2. All foods to be chopped to 1/2 inch bite sized pieces. 3. Extra gravy and sauces on foods. 4. Slow rate eating with one small bite followed by a sip of fluid. 5. Decreased distractions. 6. Dining room supervision at all times. b) Supervision for oral intake: Close supervision These instructions by the speech therapist were not observed during the aforementioned dining room observations. Review of the most recent care plan, dated 1/24/17, showed the following: 1. Small portions with seconds to avoid loading the oral cavity. 2. Encourage resident to sit at the kitchen counter for the close staff supervision. 3. Reflux precautions. 4. Staff was to remind him to eat at a slow pace with one bite of food followed by subsequent swallow. 5. Although chopped foods to 1/2 inch bite size worked in the past, the son requested food to be cut down to 1/8th or 1/4th of an inch size bites. 6. The resident had numerous choking incidents due to [MEDICAL CONDITION] structural deficits, large hiatal hernia, anxiety, paranoia and dementia. The resident refused pureed foods and thickened fluids. 7. The resident choked and the [MEDICATION NAME] maneuver was attempted on the following dates: 2/26/17, 1/16/17, 12/27/16, 10/10/16, 7/17/16, and on 7/13/16. The resident's care plan did not indicate that the resident was refusing staff's supervision during the meals with alternate methods for close supervision. During an observation of the meal service and an interview on 3/7/17 at 5:10 p.m., staff member D stated resident #15 did not like supervision or anyone sitting with him during meals. She stated he would throw his tray or food and/or quit eating. She stated he became paranoid when people watched him eat. When asked if the staff sat down and ate with him, while monitoring him and giving him instructions on his swallow precautions, she stated she did not not know. The resident was sitting alone at the table. During an interview on 3/8/17 at 8:30 a.m., staff member R stated she was very familiar with resident #15. The resident had psychological issues and quit eating if someone sat with him. She stated the resident refused pureed textures. She stated he truly needed to eat in a quiet place. She was asked if these statements were part of the resident's medical records and if so to provide it to the surveyor. As of the end of the survey on 3/9/17, no additional documentation was provided. During an interview on 3/8/17 at 3:45 p.m., staff member C stated the resident used to dislike it if staff supervised or helped him with his meals. She stated she understood that they were not really following the resident's care plan. She stated he was changing, and he did not have behaviors as before during meals. The resident declined an interview on 3/8/17 at 1:39 p.m. 2. Review of resident #19's Quarterly MDS, with an ARD of 1/27/17, showed the resident was cognitively impaired and required extensive assistance with ADLs. Review of physician orders, dated 5/29/13, showed resident #19 was to wear bilateral protective sleeves and Rooke boots (foam boots around the leg and foot) to be worn all the time. During an observation on 3/7/17 at 5:08 p.m., resident #19 was seated in a broda chair, in the Lodge dining room. The resident was wearing Rooke boots. During an interview on 3/7/17 at 5:20 p.m., staff member V stated resident #19 was to wear Rooke boots all the time, even in bed. During an observation on 3/8/17 at 4:05 p.m., resident #19 was seated in the Lodge dining room, awaiting the meal. The resident was sitting in the broda chair, wearing Rooke boots. Review of resident #19's Care Plan, with a start date of 2/1/17, showed the facility staff had not identified the need, goal, and procedure for the wearing of the bilateral protective sleeves and Rooke boots.",2020-09-01
4,BENEFIS SENIOR SERVICES,275012,2621 15TH AVE S,GREAT FALLS,MT,59405,2017-03-09,312,E,0,1,KTFZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assist with bathing or showering for periods longer than seven days for 3 (#s 2, 3, and 20) of 24 sampled residents, and 1 (#19) of 24 sampled residents did not receive assistance with combing or brushing hair after lying down. Additionally, shower and bathing services in the Goodnow cottage lacked consistency and weekly frequency for at least 3 (#s 12, 30, 31) of 16 residents in this cottage. This deficient practice had the potential to affect all residents in the Goodnow cottage. Findings include: SHOWERS/BATHS 1. Review of resident #2's Significant Change MDS, with an ARD of 12/6/16, showed the resident's BIMS was 14, moderately intact, but she required extensive assistance with showering or bathing. Review of resident #2's Care Plan, with a start date of 1/3/17, did not address shower/bathing needs. During an interview on 3/9/17 at 9:32 a.m., resident #2 stated if she refused a shower, she would not receive another chance for a shower until the following week. The resident had to wait until the next week to receive a shower on her assigned shower day. Review of the electronic bathing reports for 12/16 - 3/8/16, showed resident #2 did not have a shower between the following dates: - 12/8/16 and 12/23/16, a span of 15 days, - 1/6/17 and 1/16/17, a span of 10 days. - 2/20/17 and 3/3/17, a span of 11 days. During an interview on 3/8/17 at 8:55 a.m., staff member V stated resident #2 went through periods of heavy sleeping and would refuse to take a shower. Staff should be offering a shower during the week. 2. Review of resident #20's Quarterly MDS, with an ARD of 2/28/17, showed the resident's BIMS at 9, moderately intact, and the resident required extensive assistance with showering or bathing. Review of resident #20's electronic bath reports, from 12/1/16 through 3/6/17, showed the resident did not have a shower between the following dates: - 12/17/16 and 1/1/16, a span of 13 days, - 1/24/17 and 2/20/17, a span of 27 days, - 2/20/17 and 3/5/17, a span of 13 days. Review of resident #20's Care Plan, with a start date of 1/3/17, did not address the resident's ADL needs including showering or bathing. During an interview on 3/8/17 at 8:55 a.m., staff member V stated resident #20 refused a shower. All the staff member could do was encourage the resident to have a shower, throughout the week. During an interview on 3/8/17 at 8:20 a.m., staff member U stated resident #20 refused showers often. The staff member stated, if she (the staff member) was available, she could usually get resident #20 to take a shower or bath for her. 3. During an interview on 3/9/17 at 9:32 a.m., resident #3 stated if she missed her shower, she was not offered another time to take one that week. She tried to take her showers on her shower day and not refuse or be unavailable. Review of resident #3's electronic bath reports, from 12/1/16 through 3/6/17, showed the resident did not have a shower between 2/9/17 and 2/23/17, a span of 14 days. Review of resident #3's Care Plan, with a start date of 2/21/17, showed the resident was to be as independent as possible with ADLs. Staff was to set up and provide assistance as needed. During an interview on 3/8/17 at 9:53 a.m., staff member V stated documentation for showers was to be documented on the Care Tracker. No other documentation was made available which showed the facility was showering or bathing the identified residents in a timely manner. HAIR CARE 4. During an observation on 3/7/17 at 5:08 p.m., resident #19 was seated at the table in the Lodge dining room. The resident's hair was flattened in the back, and on the sides of her head it was sticking up or laying in all directions. During an interview on 3/8/17 at 1:44 p.m., staff member V stated the CNAs were to comb resident #19's hair after getting her up from bed after napping. The staff member stated resident #19 had just got up from a nap. The staff member took her hand and caressed resident #19's hair down. During an observation on 3/8/17 at 4:05 p.m., resident #19 was seated in the Lodge dining room, awaiting the meal. The resident's hair did not appear to have been combed or brushed. The resident's hair was smashed to the right side of her head. Review of resident #19's Quarterly MDS, with an ARD of 1/27/17, showed the resident was cognitively impaired and required extensive assist with hygiene. Review of resident #19's Care Plan, with a start date of 2/1/17, showed staff were to encourage or assist her to eat, and she sometimes likes her plate in her lap so she can reach the food . The care plan showed the resident had a [DIAGNOSES REDACTED]. 5. Review of the Care Tracker Bath Type Detail Report for Goodnow cottage, for (MONTH) and (MONTH) of (YEAR), showed between 2/1/17 and 3/8/17, there were 16 resident showers or baths tracked in the Goodnow cottage with the following findings: Resident # 12 received one bed bath on 2/8/17. No other bathing activity was documented for the months of (MONTH) or (MONTH) of (YEAR). During an interview and observation, on 3/6/17 at 5:50 p.m., resident #12 stated she did not think she smelled bad, but the resident's hair was observed to be unclean. Resident #30 received a shower on 2/2/17, 2/23/17, and 3/2/17. The Care Tracker Bathing Type Report showed that during (MONTH) (YEAR), the resident experienced a 21 day span between showers. During an interview on 3/9/17 at 11:55 a.m., resident #30 stated she received showers on Thursdays, but she missed one recently. When she was asked about her preferred bathing frequency, she stated I prefer showers on Thursdays, every Thursday. During an interview on 3/9/17 at 12:00 p.m., resident #31 stated she preferred baths once a week, every week. She stated she was getting baths once a week. Review of the Care Tracker Bath Type Detail Report showed she was given a shower on 2/9/17 and a bath on 3/2/17, a span of 21 days between bathing events. During an interview on 3/9/17 at 10:20 a.m., staff member AA stated she was not currently aware of any residents who routinely refused baths. During an interview on 3/9/17 at 11:40 a.m., staff member H stated they had bath assignments which were by room numbers and shifts. She stated they usually gave two baths per shift. If the resident refused a bath, then the staff asked the resident two more times, and then reported to the nurse the refused bath if not given. She said they entered the occurrence of the baths in the Care Tracker electronic record. Some staff forgot to enter the baths were given. Staff member H stated they also had resident roster sheets that they carried with them when on shift. During the shift change the staff would exchange care issues and missed baths to the staff on the following shift. During an interview on 3/9/17 at 11:51 a.m., staff member C stated had no system in place for the validation of baths being given by the nursing staff to show residents were receiving their weekly or requested showers or baths. She stated the baths were missed during the evening shifts, and she would revisit the issue with the evening staff.",2020-09-01
5,BENEFIS SENIOR SERVICES,275012,2621 15TH AVE S,GREAT FALLS,MT,59405,2017-03-09,371,E,0,1,KTFZ11,"Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions; failed to date foods when the foods were removed from their original containers; failed to ensure nursing staff wore aprons and contained their hair during food preparation and service in the kitchen (Goodnow); and failed to clean food contact or non-contact surfaces in the cottage kitchens. This deficient practice had the potential to affect all residents that received service from the kitchens in the cottages. The facility also failed to ensure food safety by allowing a freezer cooling unit to defrost and drip onto cases of food stored in the Westview kitchen walk-in freezer. This had the potential to affect all residents receiving food from the Westview kitchen. Findings include: 1. During an observation on 3/7/17 at 12:10 p.m., staff member F was washing dishes in the kitchen of the Goodnow cottage and staff member BB was setting food trays with silverware, tray cards and napkins. Neither of the staff members were wearing aprons. Both of the CNA's scrub tops (uniforms) were contacting the kitchen counters. At 12:15 p.m., staff member BB started to scoop soup into cups. She was not wearing a hair net or an apron. During this same observation, staff member F stated they pretty much did everything, in addition to their nursing tasks (bathing and toileting of residents), and dish washing, food preparation, kitchen inventory, food orders, and stocking the refrigerators. She stated homemakers also helped with dinner service and dish washing as needed. She stated they wore hair nets when they entered the culinary side of the kitchen only, when they were beyond the yellow line. At 12:55 p.m., staff member BB was wearing an apron and a hair net and was in the kitchen. Staff member C stated it was because staff member BB went behind the yellow line. Staff member BB stated she was preparing a grilled cheese sandwich for a resident. 2. During an observation on 3/7/17 at 5:10 p.m., staff members [NAME] and I were in the kitchen in Goodnow cottage setting up for the evening meals. Neither of the staff members had donned aprons and hair nets when completing the tasks. They both leaned on the kitchen counters, and their uniforms came in contact with the kitchen counters. 3. Tour of the Ario cottage kitchen During an observation on 3/8/17 at 10:41 a.m., the following concerns were identified and documented: - The lower cupboard doors, located under the food warmer, were covered with dried food debris and stains on them. - The gasket to the small freezer, located on the culinary side, had an unknown fuzzy substance and food debris on it. - The lower gasket of the left door of the reach-in cooler, located on the culinary side, was stained and filled with sticky food substance. - Six ice cream containers, in the front side kitchen refrigerator freezer compartment,were opened and mostly consumed. They were not marked with the container open dates. Labels were stuck on these containers, but they were not filled out by the staff. - Five of the six Ziploc bags full of frozen raw cookies were not marked with dates of use or expiration, although perishable. During an interview on 3/8/17 at 11:10 a.m., staff member CC stated the staff were only responsible to clean the front side of the cottage kitchens. The culinary sides were cleaned by the kitchen staff. Staff member CC also stated when they opened the ice cream containers, they had to labeled it with the open date. She stated she was just going to mark the ice cream with open dates. She was told that at least 3 containers were almost empty, and she could not accurately guess the open dates. This was the task of the person who opened the container. She said they did not have cleaning schedules. She stated they cleaned the kitchen during downtimes or on the weekends. During an interview on 3/8/17 at 11:12 a.m., staff member Q stated the opened ice cream containers, found in the refrigerator that day, needed to be disposed of since they were not dated when the containers were opened. She said the containers were labeled, and the labels were left blank because CNAs and/or homemakers did not mark the items when they opened the container for consumption. 4. Tour of the TCC Cottage Kitchen During an observation of the TCC Cottage Kitchen on 3/8/17 at 11:16 a.m., the following concerns were documented: - The gaskets to the refrigerator and the freezer compartment of the refrigerator, located in the front kitchen, were showed an accumulation of food debris. - A Ziploc bag of the frozen cookies, located in the front kitchen refrigerator, was not dated. The frozen cookies were portioned into a Ziploc bag after being removed from their original packaging. The freshness of the cookies could not be determined. - On the culinary side of the kitchen, beyond the yellow line, two lower cabinet shelves, located under the food warmer, were damaged, the surface coating/laminate was missing and exposing the particle board, creating uncleanable porous surfaces. At the same time, the shelves were covered in large, dried, brown colored stains. - The plate warmer housing the china was left uncovered. This was allowed during meal service but between meals the plates must be covered to prevent potential dust or other contaminants landing on the china. - The culinary side of the reach-in cooler's gaskets, for both of the doors, were filled with food debris and dried stains. - The tip of the whipped cream tube was uncovered and exposed to air. - The ice scoop was left uncovered. 5. Tour of the Goodnow Cottage Kitchen During an observation on 3/8/17 at 11:26 a.m., the following concerns were documented: - The trash can, located in the culinary side of the kitchen, was covered with dried stains and food splatter. - The ice scoop was not covered. - The gasket to the small freezer, located on the culinary side, had a unknown fuzzy substance and was filled with food debris. - The gasket to the freezer compartment of the refrigerator, located in the front kitchen, was filled with food debris. The gasket was torn at the top of the right door of the same refrigerator. - The range oven needed to be cleaned. The interior side of the oven door, and the bottom surface, was covered in black and brown color stains and burnt debris. During an interview on 3/9/17 at 9:00 a.m., staff member GG stated he would visit these identified dietary issues in a timely manner. 6. During an observation on 3/7/17 at 10:20 a.m., the cooling unit of the walk in freezer was found to have ice build-up on it. The ice had thawed and refrozen. During that process, water had dripped onto a case of pastry dough, a case of brussel sprouts, a case of chopped spinach, and then refrozen. During an interview on 3/7/17 at 10:45 a.m., staff member FF said a new food service company had taken over four days ago, and the freezer door had been left open a lot due to boxes of frozen food being moved in and out of the freezer. Staff member FF said a lot of rearranging had been going on in the freezer, and the freezer door would be left open when that was occurring. Staff member FF said kitchen staff were supposed to shut the freezer fan off when the freezer door was left open for an extended period of time, to reduce the defrost cycle, which would in turn reduce the ice build up on the cooling unit.",2020-09-01
6,BENEFIS SENIOR SERVICES,275012,2621 15TH AVE S,GREAT FALLS,MT,59405,2017-03-09,411,D,0,1,KTFZ11,"Based on record review, and interview, the facility failed to provide dental care for a resident who had a fractured tooth, for 1 (#5), and for a resident who had been referred for dental services, and who had mouth pain and discomfort, for 1 (#17) of 24 sampled residents. Findings include: 1. During a record review, the dental hygienist progress note for resident #5, dated 8/5/16, showed resident #5 had a missing crown with a fractured tooth. The hygienist documented that resident #5 needed to see a dentist. During an interview on 3/8/17 at 2:40 p.m., staff member S said staff member HH was the person who would schedule appointments with the dentist. During an interview on 3/8/17 at 3:30 p.m., staff member HH said she scheduled appointments with the dentist for residents, identified by the dental hygienist, who needed dental work done. Staff member HH said resident #5 saw the dental hygienist in (MONTH) of (YEAR), but she had not been scheduled to see a dentist. Staff member HH said the facility was having problems finding a dentist that would take residents with a medicaid pay source. Staff member S provided a copy of a document stating resident #5 was scheduled to see a dentist on 3/14/17, although this had not occurred prior to the survey. 2. During a record review of resident #17's Admission MDS, with an ARD of 2/28/17, section L, titled Oral/Dental Status, showed resident #17 had no natural teeth, and he had mouth or facial pain, discomfort or difficulty with chewing. The facility's dietician had noted the resident was to have chopped meat. During an observation on 3/8/17 at 12:30 p.m., resident #17 was eating spaghetti with meatballs. The meatballs had been cut into bite sized pieces. Resident #17 also had applesauce, and a piece of cake. The other residents seated at the table had spaghetti with meatballs, a garlic breadstick, and a piece of cake. During an interview on 3/8/17 at 12:30 p.m., resident #17's family member said the resident was eating applesauce instead of the garlic breadstick because He doesn't have any teeth so he can't eat it. The family member was referring to the garlic breadstick. During an interview on 3/9/17 at 10:00 a.m., resident #17's family member said the dietitian had modified resident #17's diet so he could eat better. The family member said resident #17's meat had to be chopped so he could eat it. The family member also said resident #17 might have an abscess in his mouth because he was having so much mouth pain. The family member said resident #17's dentures were broken. The family member said resident #17 had not seen a dentist since admission to long term care. The family member said facility staff notified her, on 3/8/17, that an appointment had been scheduled for resident #17 to see a denturist on 3/14/17. During an interview on 3/8/17 at 3:30 p.m., staff member HH said a denturist appointment had been scheduled for resident #17. Staff member S provided a copy of a document showing resident #17 was scheduled to see a dentist on 3/14/17.",2020-09-01
7,BENEFIS SENIOR SERVICES,275012,2621 15TH AVE S,GREAT FALLS,MT,59405,2017-03-09,441,D,0,1,KTFZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure nebulizers were cleansed after each treatment and cleaned daily with soapy water for 1 (#14) of 24 sampled residents. This practice had the potential to promote the growth of bacteria and spread of infection to a resident receiving nebulizer treatments, and specifically for those receiving multiple treatments in a day. Findings include: Resident #14 was admitted to the facility on [DATE] with heart attack, [DIAGNOSES REDACTED], anxiety, depression, sacral pressure sore, chronic obstructive pulmonary disease, renal insufficiency, diabetes, and hypertension. a) Unbagged and uncovered nebulizer mask During an interview on 3/6/17 at 4:00 p.m., resident #14's nebulizer mask was placed on the bed side table. During an interview on 3/7/17 at 2:00 p.m., resident #14's nebulizer mask was placed on the bed side table next to the bed. During an interview on 3/7/17 at 3:02 p.m., resident #14's nebulizer mask was placed on the bed side table next to the bed. During this time, the resident was interviewed about bagging the nebulizer mask after treatments to prevent contamination. She stated no one told her to bag the mask, and no one bagged it for her. b) Rinsing of the nebulizer mask, pipe, and cup, after each treatment During an interview on 3/6/17 at 4:00 p.m., resident #14 stated she was independent with the administration of the nebulizer treatment as she also administered it at home. She stated the nurse set it up the treatments for her and left, and the resident turned it off at the end of the treatments. She stated no, they don't when asked if nursing came back within the 10 - 15 minutes of the treatment as it finalized and rinsed the device after each use. During an interview on 3/7/17 at 2:15 p.m., staff member C stated the residents use either the pipe or the mask, depending on their abilities. After the treatment, the resident turned off the machine and laid the mask or the pipe on the bed or the table. Staff member C stated she was not aware of any process for the cleaning of the mask, pipe, or the cup, but the tubing was changed regularly and labeled with the date when changed. During an interview on 3/8/17 at 8:55 a.m., staff member N stated she did not rinse the nebulizer attachments, but mainly assessed the resident's status, lungs, and the effectiveness of the treatment. Review of the Benefis Health System Treatment/Guideline, titled Respiratory Therapy Benefis Senior Services, showed Nebulizers are rinsed after each use and air dried in the room. They are washed with soapy water, rinsed and air dried on the evening shift after the last treatment of [REDACTED].",2020-09-01
8,BENEFIS SENIOR SERVICES,275012,2621 15TH AVE S,GREAT FALLS,MT,59405,2017-03-09,456,E,0,1,KTFZ11,"Based on observation, record review, and interview, the facility failed to ensure a system was in place for the identification, cleaning, and/or replacement of soiled oxygen concentrator filters for 3 of 4 sampled concentrators; and failed to follow the manufacturer's recommendations for the concentrators and filters used by the residents. This failure had the potential to affect any resident utilizing the concentrator equipment, and filters. Findings include: During observations of the facility on 3/7/17 at 2:35 p.m., oxygen concentrators were inspected in the residents' rooms. The exterior filters of the concentrators in resident rooms 501, 509, and 612 were found to have a heavy accumulations of dust build up. The dust also covered the panel under the filters. Review of the Perfecto2 Preventative Maintenance manufacturer's recommendations showed Remove the filter and clean at least once a week depending on environmental conditions. The recommendations further showed the explanation of the procedure for how to wash the filters and cautioned that the filters may need frequent cleaning. Additionally, the recommendations showed the concentrators were to be cleaned and disinfected between residents and explained what parts of the concentrator required disposal and replacement to prepare the machine for another resident's use. During an interview on 3/7/17 at 10:15 a.m., staff member C stated the concentrators received annual preventative maintenance, but she was not sure about the cleaning of the filters. She stated the concentrators were wiped down between residents, and once cleaned, placed in the storage room. The cleaning of the concentrator equipment was a shared task between the homemakers and the CNAs. On 3/7/17 at 2:14 p.m., staff member C also stated, upon further investigation, she found out that the concentrators received annual PMs (preventative maintenance) and the filters were replaced then. She stated as far as she knew, there was no system in place by nursing staff of monitoring the cleanliness of the concentrators' filters. During an interview on 3/7/17 at 2:53 p.m., staff member K stated there was no nursing policy on filter cleaning and/or replacement. He stated the housekeepers vacuumed them, and the concentrators received annual PMs. During an interview on 3/7/17 at 2:55 p.m., staff member I stated they wiped the concentrators, but the filters were not cleaned. She stated and they are filthy dirty. She stated she brought this issue to the facility's attention two years ago when she worked at Eastview, but she was told not to touch the filters. During an interview on 3/9/17 at 10:00 a.m., staff member P stated she did not perform routine cleaning of the filters of the oxygen concentrators. She also stated she did not clean the units between the resident use. She stated if the unit beeps she reported this to the nurse.",2020-09-01
9,BENEFIS SENIOR SERVICES,275012,2621 15TH AVE S,GREAT FALLS,MT,59405,2018-05-17,554,D,0,1,FGZ511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to ensure 1 (#45) of 37 sampled and supplemental residents had been assessed, and had physician orders, for the self-administration of medications prior to staff leaving medications at the bedside. Findings include: Resident #45 was admitted to the Memory Care Unit (MCU) with [DIAGNOSES REDACTED]. A review of resident #45's (MONTH) (YEAR) Medication Administration Record [REDACTED] 1. D-[MEDICATION NAME] 500 mg - take 2 capsules in or with 8-10 ounces of liquid by mouth three times daily. During an observation and interview on 5/17/18 at 12:13 p.m., staff member B entered resident #45's room with two medication capsules in a medication cup. The staff member exited resident #45's room, and asked another staff member to assist the resident from the toilet back to her room. The two capsules were left on an over-the-bed table, next to a plate of salad. At 12:33 p.m., staff member B stated she wasn't sure if resident #45 had a self-administration of medications assessment in the medical record. Staff member B stated she should not have left the capsules on the table without witnessing the resident take the capsules with 8-10 ounces of liquids as prescribed. Staff member B stated she had been orienting with another staff member, earlier in the week, but that staff member was on vacation. Staff member B stated she was the only staff member in the MCU passing medications that day, and she was still learning which resident was which. During an interview on 5/17/18 at 1:00 p.m., staff member C stated no residents on the MCU had a self-administration of medications assessment on file. Staff member C stated it was not safe to let the residents of the MCU self-administer medications without staff witnessing the administration. During an interview on 5/17/18 at 1:02 p.m., resident #45 stated she was not sure if she had taken the capsules that had been left on her table. The resident was lying in bed, clutching a stuffed teddy bear. Review of resident #45's medical record, including physician orders [REDACTED]. Review of the facility's policy, Bedside Storage of Medications and Self Administration of Medications, read, Bedside medication storage is permitted and care planned for residents who are able to self-administer medications upon the written order of the prescriber and when it is deemed appropriate in the judgement of the facility's interdisciplinary resident assessment team.",2020-09-01
10,BENEFIS SENIOR SERVICES,275012,2621 15TH AVE S,GREAT FALLS,MT,59405,2018-05-17,610,G,0,1,FGZ511,"Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse, for 1 (#76) and prevent further abuse resulting in feelings of not being treated like a human, and fear of physical abuse, for 1 (#451) of 37 sampled and supplemental residents. Findings include: 1. During an interview on 5/15/18 at 2:40 p.m., resident #76 stated (staff member M) had been bird dogging me from the beginning of my stay here. A few weeks ago, (staff member M) said to me 'You keep that mask on or there will be trouble. I'll put you in your room, and you won't come out.' Resident #76 stated he did not need to wear the protective mask, and staff member M did not believe him. During an interview on 5/15/18 at 3:00 p.m., staff member N said she had been the nurse on duty that day, and she thought it was just a misunderstanding between the staff member and the resident. She said she told staff member M he needed to speak nicer to the residents. She thought the event had occurred on the 24th of (MONTH) (YEAR). During an interview on 5/16/18 at 1:36 p.m., NFI stated he was making rounds on 4/27/18, and he was visiting with resident #76. They sat in the lobby, and saw staff member M. Resident #76 and his wife became upset, and said staff member M was not supposed to be working in the cottage, because of their complaint against him. NF1 took the concern to the facility social worker, who stated he knew nothing about resident #76's concern. He discussed it with staff member L, who then did move staff member M to another area. Review of a communication note from staff member L, dated 4/29/18, showed she did talk to staff member M about the incident with resident #76. Staff member M stated the resident did become upset with him, because of the mask not being worn. Staff member M stated he was under the impression that the situation had been taken care of already. Staff member L wrote I assured staff member M he was not in trouble. Review of a written communication from staff member O, undated, showed, The way staff member M talks to residents is unacceptable. Review of staff member E's communication of the situation showed, The patient could not remember the details (of the interaction with staff member M) when interviewed. I will speak to NF1 on Monday to determine the original issue as presented to (NF1). In the meantime, the staff member has been reassigned a different patient load. The follow-up note, dated 4/30/18, showed Per NF1, staff member M was insistent the resident wear a mask for his own safety. The resident refused and the CNA said that he wouldn't be able to leave his room without a mask. An RN became involved and allowed the resident to leave the room. During an interview on 5/17/18 at 10:20 a.m., staff member D stated she had been involved in the incident, but had thought it had just been a misunderstanding, and not verbal or mental abuse. 2. Review of a State Survey Agency Report provided from the facility, dated 5/13/18, showed resident #451 reported staff member M had been verbally abusive, arrogant, and not treating (resident) like a human being. Resident #451 expressed to a nurse that he felt like staff member M was verbally abusive towards him and that after he told staff member M off, and it could have gotten physical. He also stated he would be afraid if he saw staff member M at his door. During an interview on 5/17/18 at 9:40 a.m., resident #451 said, If you are asking me if staff member M acted like this before, the answer is yes. During an interview on 5/17/18 at 10:35 a.m., staff member P stated she absolutely believed resident #451's allegation. Review of a written communication, dated 5/13/18, by staff member Q, showed resident #451 felt embarrassed, and was made to feel a burden when staff member M would take care of him. The resident stated, He should not be taking care of people or have this kind of job. Staff member Q wrote Later, staff member M tried to explain why the resident did not want him in his room, but he mostly just shrugged it off. I told him you have to put yourself in their place and think about how difficult it is to be in their position and to have someone have to physically take care of your toileting needs. The event with resident #451 occurred after the event with resident #76, showing the event with resident #76 was not addressed sufficiently to ensure resident protection in the future relating to staff member M.",2020-09-01
11,BENEFIS SENIOR SERVICES,275012,2621 15TH AVE S,GREAT FALLS,MT,59405,2018-05-17,656,D,0,1,FGZ511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a care concern on the comprehensive care plan for the use of a [MEDICAL CONDITION] to assist the resident with the maintenance, addition of water, set up, and placing it on him, and the resident did not receive the ordered services for six months, for 1 (#40) out of 28 sampled residents. Findings include: Resident #40 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #40's Annual MDS, with an ARD of 9/14/17, section G-Functional Status showed the resident required extensive assistance of two persons with bed mobility, transfers and dressing, and required extensive assistance of one person with hygiene and eating. Section O - Special Treatments, showed resident #40 required a respiratory treatment of [REDACTED]. During an observation and interview, on 5/14/18 at 1:20 p.m., resident #40 stated he used a [MEDICAL CONDITION] every night, and the staff did not help him. He stated he needed help to clean it, put water in it, set it up, and have staff place it on him. Resident #40 was limited in his ability to use his hands due to his [DIAGNOSES REDACTED]. The [MEDICAL CONDITION] was on his night stand next to his bed. During an observation and interview, on 5/15/18 at 3:10 p.m., resident #40 stated the last time he used the [MEDICAL CONDITION] was more than six months ago. Review of resident #40's Care Plan, with a start date of 3/15/18, failed to include a care area concern for resident #40's use of [MEDICAL CONDITION] for the [DIAGNOSES REDACTED]. During an interview on 5/17/18 at 2:31 p.m., staff member F stated the [MEDICAL CONDITION] was not on the resident's Care Plan or the TAR. Staff member F stated she obtained an order for [REDACTED].",2020-09-01
12,BENEFIS SENIOR SERVICES,275012,2621 15TH AVE S,GREAT FALLS,MT,59405,2018-05-17,658,D,0,1,FGZ511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to meet professional standards of quality, by administering the wrong medication to the wrong resident, and failed to follow the 5 rights when administering medications to 2 (#s 19 and 35) of 37 sampled and supplemental residents. Findings include: During an observation and interview on 5/17/18 at 11:41 a.m., staff member B crushed a Tylenol 500 mg tablet at the medication cart for resident #19. Staff member B was observed looking at the MAR for resident #35. Resident #35's MAR indicated [REDACTED]. Staff member B stated resident #19 did not resemble the picture on the MAR indicated [REDACTED]. Staff member B stated, I know, (resident #19) used to look different as the staff member pointed to resident #35's picture. Staff member B walked away from the medication cart, and walked towards resident #19 with the crushed medication mixed in a tablespoon of ice cream. During an observation 5/17/18 at 11:43 a.m., staff member B administered the crushed Tylenol to resident #19. The resident stated she did not like the Tylenol with ice cream, and the resident made a grimacing face, and stated, It's not good. Staff member B stated, its ok, and continued spoon feeding resident #19 the crushed Tylenol. A review of resident #19's Annual MDS, with an ARD of 2/19/18, showed the resident had a BIMS of 9; moderate impairment. Her weight was 82 pounds. A review of resident #19's (MONTH) (YEAR) Medication Administration Record [REDACTED] a. [MEDICATION NAME] 650 mg suppository rectally every 4 hours if needed for fever or mild pain. b. [MEDICATION NAME] 325 mg take 2 tablets by mouth every 4 hours if needed for fever or mild pain. A review of resident #35's Annual MDS, with an ARD of 12/11/17, lacked a BIMS assessment. Her weight was 147 pounds. A review of resident #35's (MONTH) (YEAR) MAR indicated [REDACTED]. During an interview on 5/17/18 at 11:52 a.m., staff member K stated resident #19 was seated in the dining room, and pointed to the table where resident #19 sat. Staff member K stated resident #35 was still in her room, on the other side of the MCU, and not in the dining room. During an interview on 5/17/18 at 12:13 p.m., staff member B stated she had given resident #19 medications prescribed for resident #35. Staff member B stated she had been oriented to the MCU by another staff member that was currently on vacation. Staff member B stated she was not familiar with all of the residents on the MCU, and had thought resident #19 was resident #35. Staff member B stated she was the only staff member in the MCU passing medications that day, and she was still learning which resident was which. Staff member B stated she should have ensured the 5 medication rights prior to administering medications to resident #19; the right patient, the right drug, the right dose, the right route, and the right time. Review of the facility's document titled, Skills- Medication Administration: Oral, read, 3. Verify the correct patient (sic) using two identifiers. References: http://www.ihi.org/resources/Pages/ImprovementStories/FiveRightsofMedicationAdministration.aspx One of the recommendations to reduce medication errors and harm is to use the 'five rights': the right patient, the right drug, the right dose, the right route, and the right time.",2020-09-01
13,BENEFIS SENIOR SERVICES,275012,2621 15TH AVE S,GREAT FALLS,MT,59405,2018-05-17,689,D,0,1,FGZ511,"Based on observation, interview, and record review, the facility failed to provide adequate supervision to keep a resident safe from six elopements and two falls (one with minor injuries), for 1 (#131) of 28 sampled residents. Findings include: Record Review of resident #131's Interdisciplinary Notes and Care Plan showed resident #131 eloped three times: a. 5/21/17 at 11:08 p.m., resident #131 left the doors from Eastview. Staff asked resident #131 to come back and stay on the unit. Resident #131 attempted to leave again out the unit doors by the nurse's station. Staff stopped him again. Resident #131 had clothing hidden under his coat. A review of the Care Plan showed, the intervention established was: resident #131 is monitored frequently by the staff. His room is checked frequently to see if he is in and if not to be sure of his where about's. In this case our monitoring and diligences prevented him from leaving the unit with clothing hidden under his coat. b. 6/4/17 at 2:00 p.m., resident #131 walked alone to the north tower information desk. The north tower staff called to alert the staff. Resident #131 was assisted back to the unit via wheelchair. Resident #131 was seen by the nurse in the dining room around 1:40 p.m. A review of the Care Plan showed, the intervention monitor frequently was established before this elopement. The new intervention method established was We have been told by the Clinical Engineering that the Wanderguard system is coming and then they will install it. We are not sure of the date. Until the system is installed, staff are doing half hourly checks in resident #131 when he is awake (sic). c. (no time or date) Resident #131 was found in the lobby during nightly rounds. During the walk back to his room resident #131 stated that he was going to leave tomorrow. He was escorted back to his room and the Eastview staff were notified.[NAME]remains on hourly checks, he had been checked and noted to be in his room several times before we were notified he was at the security station. A review of the Care Plan showed the intervention method was doing half an hour checks on resident #131 when he is awake. The new intervention method put in place on the Care Plan was This is a repeated elopement for resident #131 and as per his usual pattern walks to the north/south security desk. The manager will follow-up with Security regarding the auto door lock in the north egress after 9 pm daily. Administratively, we are evaluating the cost of the Wanderguard System to purchase with contingency funds (sic). d. 7/3/17 at 9:20 p.m., resident #131 was reported to be walking by her husband's window. When the floor nurse went to go get resident #131 he could not be seen. Upon searching for him, another family member recognized him and had walked with him back to the Eastview front entrance. Resident #131 was reported to have been around the corner heading toward another medical facility building. A review of the Care Plan showed the previous intervention method was follow-up with security regarding auto door lock on the north egress after 9 p.m. daily. The new intervention method was A one to one is being assigned to resident #131 until the Wanderguard system can be installed. e. 7/29/17 at 9:55 p.m., CNAs discovered that resident #131 was gone from his room after they told him they would be back to assist him to get changed for bed. They immediately went searching for him and found him half way down the hall leading to the hospital. A review of the Care Plan showed the pervious intervention method established was A one to one is being assigned to resident #131 until the Wanderguard system can be installed. This intervention was not care planned and there was not a new intervention put in place for the event to protect the resident from eloping. f. 9/1/17 at 2:00 p.m., resident #131 was found outside the facility, by the bus driver, laying on his back on the ground near the parking area of Eastview. He was witnessed by the truck driver to fall on the grassy area near the parking lot. He was assessed and was found not to have obvious injuries from the fall. He was returned to Eastview by staff. A review of the Care Plan showed the intervention method established on 9/3/17 was A one to on is being assigned to resident #131 until the Wanderguard system can be installed. There was no new intervention method established for future protection from elopements. g. 9/26/17 at 6:50 p.m., resident #131 was found in the long hallway of the facility, near the trash compactor area. A housekeeping employee who knew resident #131 found him, called Eastview staff, and stayed with resident #131 until staff came and got him. Resident #131 stated I was just taking a stroll. A review of the Care Plan showed the pervious intervention method established was A one to on is being assigned to resident #131 until the Wanderguard system can be installed. The new intervention method established was Resident #131 is very frequently monitored - including one on one as frequently as possible. h. 10/30/17 at 6:00 p.m., a CNA went into resident #131's room for a routine check and he was not there. The CNA notified the floor nurse and a search was initiated. A CNA coming on shift notified the staff he was on his way back with a security guard. The security guard found him in the south tower of the hospital and escorted him back. A review of the Care Plan showed the previous intervention method established was Resident #131 is very frequently monitored - including one on one as frequently as possible. The new intervention method established was We will cont. the very frequent monitored - including 1:1 frequently as possible (sic). The interventions had shown to be ineffective to protect the resident from elopement. i. 3/30/18 at 7:00 p.m., another resident's family notified the facility that the resident was in the orthopedics parking lot with the fire department. The resident was warmed with blankets for 25 minutes and given a warm shower due to the cold temperature outside. Resident #131's left fingers had minor scrapes, and the resident complained of right hip pain. A review of the Care Plan showed the previous intervention method established was, We will cont. the very frequent monitored - including 1:1 frequently as possible (sic). The new intervention method established was We will cont. the very frequent monitored - including 1:1 frequently as possible, until the Wanderguard can be installed (sic). Record Review of resident #131's Care Plan showed one-on-one as an intervention method and one-on-one intervention frequently as possible. During an interview on 5/17/18 at 9:15 a.m., staff member F stated that resident #131 was supposed to have a one-on-one 24/7 (24 hours a day/7 days a week), unless he was in bed sleeping. During an interview on 5/15/18 at 9:00 a.m., staff member F stated, usually someone checks on resident #131 every hour and then when he has had an elopement they check on him every 15 minutes, and then every half an hour during the night. There is usually someone with him during the day at all times, but he is alone during the night. During an interview on 5/16/18 at 2:03 p.m., staff member U stated resident #131 was supposed to have one-on-one supervision, however it is hard for that to happen every day. Staff member U stated that when the resident eloped he was unpredictable. Staff member U stated in (MONTH) (2018) when he left the building in the cold we were just more relaxed that day. Staff member U recalled resident #131 saying I saw you weren't watching so I left (sic). During an interview on 5/16/18 at 2:20 p.m., staff member S stated that she was on shift when resident #131 eloped out of the building in (MONTH) of (YEAR). Staff member S stated she was washing dishes when she got a call that resident #131 could not be located. Staff member S stated the resident was found outside and brought back in. Staff member S stated that the CNA staff watching resident #131 had to leave to check on another resident. When they went back to check on resident #131 he was gone. During an interview on 5/16/18 at 2:30 p.m., staff member R stated resident #131 was very fast when he wants to leave. He is supposed to be a one-on-one and we cannot, and do not, provide that all the time because we do not have enough staf. Staff member R stated, she was there the night he eloped out of the building in March. Staff member R stated, she was not watching resident #131 when he left the building because there was an incident with another resident she had to help with. Staff member R stated there were only three CNAs and one nurse on that night. During an observation on 5/17/18 at 7:56 a.m., resident #131 had his door shut to his room, and no one-to-one was being provided. During an interview on 5/17/18 at 8:05 a.m., staff member C stated that she thought resident #131 was in his room. She said she would check to make sure, then stated Yep, he's still here. Staff member C stated that staff do not usually check on him when he was sleeping. During an interview on 5/17/18 at 8:30 a.m., staff member D stated staff did not see resident #131 leave the building in (MONTH) of (YEAR) because there was an incident with another resident. We did one-on-ones for a while after his elopement in (MONTH) (2018) for about a day and a half until he was back to normal. Staff member D stated currently staff were just checking in on him or getting visuals of him. We usually try to check in on him every hour and then get a visual of him every half hour.",2020-09-01
14,BENEFIS SENIOR SERVICES,275012,2621 15TH AVE S,GREAT FALLS,MT,59405,2018-05-17,695,D,0,1,FGZ511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident was assisted with respiratory care needs for the use of and cleaning of a [MEDICAL CONDITION], and the resident did not receive the [MEDICAL CONDITION] treatments and services for six months, for 1 (#40) of 28 sampled residents. Findings include: Resident #40 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation and interview on 5/14/18 at 1:20 p.m., resident #40 stated he used a [MEDICAL CONDITION] machine every night, and the staff did not help him. He stated he needed help to clean it, put water in it, set it up, and place it on him. Resident #40 was limited in his ability to use his hands due to his [DIAGNOSES REDACTED]. The [MEDICAL CONDITION] machine was on his night stand next to his bed. There were two one-gallon containers of distilled water under the night stand. Review resident #40's physician order, dated 9/25/17, showed [MEDICAL CONDITION]- use while sleeping, all sleeping. During an observation and interview on 5/15/18 at 3:10 p.m., resident #40 stated the last time he used the [MEDICAL CONDITION] machine was more than six months ago. The [MEDICAL CONDITION] machine was observed on his nightstand and was dry, with no water or condensation noted in the water tank, tubing or mask. The mask was laying on top of the [MEDICAL CONDITION] machine. The distilled water containers were observed to be in the same position under the night stand, with the same amount of water in them as observed on 5/14/18. During an observation and interview on 5/16/18 at 8:30 a.m., resident #40's [MEDICAL CONDITION] machine was next to his bed on the night stand. Resident #40 stated staff did not offer to help him with it last night. The [MEDICAL CONDITION] machine was observed to be dry with no water. The distilled water containers were observed to be in the same position, with the same amount of water in them, as observed on 5/15/18. Review of resident #40's MAR and TAR failed to show the [MEDICAL CONDITION] order. During an interview on 5/17/18 at 2:31 p.m., staff member F stated the order for the [MEDICAL CONDITION] was not on the resident's Care Plan or the TAR. Staff member F stated she obtained an order for [REDACTED].",2020-09-01
15,BENEFIS SENIOR SERVICES,275012,2621 15TH AVE S,GREAT FALLS,MT,59405,2018-05-17,755,E,0,1,FGZ511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to maintain a system that recorded, reconciled, and monitored the accountability and accuracy of dispensing [MEDICATION NAME], a narcotic medication, and failed to maintain accurate Medication Administration Record [REDACTED]. Findings include: During an observation and interview on 5/16/18 at 8:32 a.m., staff member C opened a locked cabinet in the medication room of the East View campus. Staff member C stated the Narcotic Lock Box, also known as an E-Kit, was kept inside the cabinet. The E-Kit was on the top shelf of the cabinet, and had a red plastic padlock seal. The numbers on the lock ended in 573. Staff member C stated the plastic padlock seal numbers should have ended in 525. Staff member C reviewed the E-Kit log, and stated the correct number for the new lock had not been recorded when the E-Kit was last inventoried. At 8:41 a.m., Staff members C and F discovered six doses of [MEDICATION NAME] were missing from the E-Kit. A review of the facility's E-Kit Record, dated 8/24/17 to 5/16/18, showed the last date staff had accessed the E-Kit was on 3/28/18, for an Inventory Check. During an interview on 5/16/18 at 8:52 a.m., staff member C stated staff should have verified the accuracy of the E-Kit by documenting the date, time, tag number when sealed (padlock seal), name of the item removed/added, along with two nursing signatures to ensure accuracy. Staff member C stated staff should have sent a facsimile to the pharmacist showing what had been removed/added. Staff member C stated the Narcotic Lock Box Record had a listing of information required when accessing the locked box. Staff member C stated she was not sure what happened to the [MEDICATION NAME], was not sure if the missing tablets had been administered to a resident, and to which resident the [MEDICATION NAME] had been administered to. During an interview on 5/16/18 at 12:21 p.m., staff member F stated she had contacted the nurses working within the past month on the East view campus. Staff member F stated she spoke with the nurse that did not document the [MEDICATION NAME] doses removed from the E-Kit. Staff member F stated she also called the pharmacy to inquire which resident on the East View campus had been started on [MEDICATION NAME] around that same time frame. Staff member F stated the [MEDICATION NAME] had been dispensed to resident #75. Review of resident #75's (MONTH) (YEAR) MAR indicated [REDACTED] 1. [MEDICATION NAME] 50 mg one tablet by mouth every 4 hours as needed, may couple with [MEDICATION NAME] 325 mg. Dated 4/13. Resident #75's MAR indicated [REDACTED]. A review of resident #75's Physician's Telephone Orders, dated 4/13/18, showed orders to Start [MEDICATION NAME] 50 mg- one by mouth every 4 hours for pain. (MONTH) couple with [MEDICATION NAME] 350 mg- one for additional [MEDICATION NAME] effect. #60 and 5 refills. A review of the resident #75's Narcotic Record in the Controlled Substance Record binder, dated 4/16/18 at 12:45 a.m., showed resident #75 was administered [MEDICATION NAME], one tablet by mouth, for pain. The remaining tablets were documented as 59. On 5/11/18 at 3:50 a.m., resident #75 was administered [MEDICATION NAME], one tablet by mouth, for pain. The remaining tablets were documented as 58. On 5/11/18 at 7:50 a.m., resident #75 was administered [MEDICATION NAME], one tablet by mouth, for pain. The remaining tablets were documented as 57. Review of resident #75's medical record, including the (MONTH) (YEAR) MAR, E-Kit, and Controlled Substance Record lacked evidence showing [MEDICATION NAME] had been removed from the E-Kit and had been dispensed to resident #75. During an interview on 5/16/18 at 12:27 p.m., staff member F stated nursing staff had not, but should have, started a new sheet in the Controlled Substance Record binder. Staff member F stated nursing staff were required to start a new page in the Controlled Substance Record when dispensing new narcotic medications to any resident. During an interview on 5/17/18 at 10:00 a.m., staff member D stated she had not been informed of staff failing to document missed doses of [MEDICATION NAME] signed out to resident #75. Staff member D stated she had been told there were discrepancies with the [MEDICATION NAME] in the E-Kit. Staff member D stated staff should have documented the [MEDICATION NAME] in the E-Kit record, in resident #75 MAR, and on the Controlled Substance Record. Staff member D stated she would ensure a thorough investigation would be conducted since [MEDICATION NAME] is a narcotic medication. Review of an Investigation of missing [MEDICATION NAME], dated 5/16/18, read, (staff name) started the investigation- called the pharmacy to see which resident had been started on [MEDICATION NAME] in the last month- there were 2 residents, one had his card the other did not- (staff name) reports writing the verbal order for the [MEDICATION NAME] late in the afternoon- (name) called nurses about taking [MEDICATION NAME] out of the E-kit on or around the date of the resident (without the card) starting [MEDICATION NAME]- discovered a nurse had taken them for the resident- they were not signed out- several nurses did not sign out the PRN medication on the MAR- there is no proof of using the [MEDICATION NAME] on the resident except for nurses stating that they administered the [MEDICATION NAME] to the resident. A review of the facility's policy, Medication Storage and Handling, read, Medication storage is designed to assist in maintaining medication integrity, promote the availability of medications when needed, minimize the risk of medication diversion, and reduce potential dispensing error .C. All drugs removed from a medication storage area are removed just prior to administration and only for one patient (sic) at a time.",2020-09-01
16,BENEFIS SENIOR SERVICES,275012,2621 15TH AVE S,GREAT FALLS,MT,59405,2018-05-17,761,E,0,1,FGZ511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, several facility staff failed to ensure opened multi-dose vials of insulin, being administered to residents, were dated when opened, and not being used past the open-expiration date of 28 days, for 5 (#s 16, 36, 45, 56, and 77) of 37 sampled and supplemental residents; and failed to identify multi-dose vials were missing opened dates. Findings include: During an observation and interview on 5/16/18 at 9:10 a.m., review of the East View campus medication cart, showed opened, undated, multi-dose vials of insulin for residents #16, #36, #56, and #77 that were available for use. Staff member J stated staff were required to write an open date on multi-dose vials of insulin when opened. Staff member J stated if multi-dose vials of insulin have been opened, and were not dated, the vials should be discarded. Staff member J stated all staff members providing medications were responsible for checking the opened and the expiration dates for all medications administered by the staff. 1. a. Resident #16 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #16's (MONTH) (YEAR) MAR indicated [REDACTED]. b. Resident #36 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #36's (MONTH) (YEAR) MAR indicated [REDACTED]. c. Resident #56 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #56's (MONTH) (YEAR) MAR indicated [REDACTED] - Humalog 100 units/ml- 10 ml vial with sliding scale instructions; and inject 2 units subcutaneous (SQ) 15 minutes prior to each meal. Hold if he is not going to eat a meal or if premeal (sic) capillary blood glucose (CBS) - [MEDICATION NAME] 100 units/ml- 10 ml vial; inject 10 units (SQ) every day at 8:00 a.m. d. Resident #77 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #77's (MONTH) (YEAR) MAR indicated [REDACTED] - [MEDICATION NAME] 100 units/ml- 10 ml vial; inject 8 units SQ every evening. - [MEDICATION NAME] 100 units/ml- 10 ml vial with sliding scale instructions. During an observation and interview on 5/16/18 at 9:30 a.m., review of Memory Care Unit medication cart showed an opened, undated, multi-dose vial of insulin for resident #45. Staff member T stated staff were required to write open dates on multi-dose vials of insulin when opened. Staff member T stated she had not noticed the multi-dose vial of insulin was missing the opened date. 2. Resident #45 was admitted to the Memory Care Unit with [DIAGNOSES REDACTED]. Review of resident #45's (MONTH) (YEAR) MAR indicated [REDACTED]. During an interview on 5/16/18 at 3:05 p.m., staff member D stated staff were required to write an open dates on multi-dose vials of insulin when opened. She stated vials of insulin were to be discarded after 30 days of being opened. Staff member D stated multi-dose vials of insulin were only stable until the 30 days, therefore staff were required to date each vial when opened. Review of the facility's policy, Expiration Dating of Medications, read, .B. Multi-Dose Vials . 2. Any multi-dose vial not marked with date and initials after opening, is discarded. References: https://www.cdc.gov/injectionsafety/providers/provider_faqs_multivials.html If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.",2020-09-01
17,BENEFIS SENIOR SERVICES,275012,2621 15TH AVE S,GREAT FALLS,MT,59405,2018-05-17,812,E,0,1,FGZ511,"Based on observation, interview, and record review, the facility failed to properly store dishes and equipment and failed to label and date foods in the main kitchen for the cottages. The findings had the potential to affect anyone who consumed food from the kitchen or food stored in the kitchen storage areas. Findings include: During an observation on 5/14/18 at 11:07 a.m. the following storage issues were observed in the cottage's main kitchen: a. The slicer was stored on a bottom rack under a table, next to the sink, uncovered, and next to Multi-quat sanitizer solution. During an interview on 5/14/18 at 11:22 a.m., staff member A stated the food slicer is usually stored on the shelf by the sink next to the multi-quat sanitizer solution, with a garbage bag covering it. b. Dishes were found spread out on a top shelf with no perforations to allow for the dishes to sanitarily dry; the dishes were uncovered, with water droplet stains on the dishes. c. Bowls and plates were found on the top shelf stored face up, and they were to be used as clean dishes in the future. d. Bowls were stored upright on a wire rack by the preparation table in a clear container that was uncovered and was dusty. This dishes had been cleaned prior, and were to be used as clean dishes in the future. e. Scoops and spoons were stored near the preparation table on a wire rack in clear containers, uncovered. There was a brown mixture splattered in the clear container that the scoops were touching. The clear containers were dirty with dust and food crumbs. During an interview on 5/16/18 at 10:56 a.m. staff member A stated that the clear containers holding the dishes, including the scoops, are cleaned weekly. Staff member A stated it looks like the one with the brown splatter needed to be cleaned. f. Plastic forks and knives were stored in the dry food storage room uncovered in a box, open to dust and debris. g. In the dry storage room there was a scoop left inside the closed kidney bean container with the handle of the scoop touching the kidney beans. 2. During an observation on 5/14/18 at 11:17 a.m., in the cottage's main kitchen the following issues were observed a. Three bags of frozen pumpkin pie filling in the small freezer did not have a use by date. b. There was not an open date or label on a mixture that looked like powdered sugar. During an interview on 5/16/18 at 10:59 a.m., staff member A stated, the mixture appears to be powdered sugar. c. Vanilla pudding powdered mixture had no open date. During an observation on 5/14/18 at 11:45 a.m., there were two plastic containers of broken ready to drink prune juice cups in the dry storage room on the second shelf from the bottom. The prune juice containers appeared to have been smashed, cracking the plastic on the sides causing the containers to leak. Staff member A threw the prune juice packages away. During an interview on 5/17/18 at 10:38 a.m. staff member A stated they don't have scheduled cleanings for everything in the kitchen. Staff A stated that he goes through the kitchen to make sure that things have been cleaned and that if there are things that have not been cleaned he tries to figure out who is responsible for cleaning the item. Staff member A stated, They know as a team what needs to be done. Record Review of the Benefis Hospitals Policy/Procedure titled Sanitation, Food Safety, and Infection Control stated, Label all opened food items (exception bread) with: a. name of food b. date opened c. use by date d. staff initials Record Review of Benefis Hospitals Policy/Procedure titled Sanitation, Food Safety, and Infection Control stated, maintain non-food-contact surfaces free of dirt and debris. Record Review of Benefis Hospitals Policy/Procedure titled Sanitation, Food Safety, and Infection Control stated, provide ample space to facilitate self draining of equipment so that it can air-dry properly. Record Review of Benefis Hospitals Policy/Procedure titled Sanitation, Food Safety, and Infection Control stated, keep sanitary equipment covered when it is not being used.",2020-09-01
18,BENEFIS SENIOR SERVICES,275012,2621 15TH AVE S,GREAT FALLS,MT,59405,2019-07-11,554,E,0,1,01HJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to follow the self-administration of medication assessment, and maintain self-administration practices, for 3 (#s 47, 65, and 530) of 45 sampled and supplemental residents. Findings include: [NAME] During an observation and interview on 7/9/19 at 8:31 a.m., resident #47 was resting in his bed, with the head of the bed raised to 30 degrees. The lights in his room were off, and a plastic medicine cup filled with different medications was on his bedside table, which was placed parallel to resident #47's bed and within the resident's reach. No staff were observed in resident #47's room. Resident #47 stated, (Staff) must have left the cup of medications here .They usually do not let (medications) just sit like that. Resident #47 did not know when staff had brought the medication cup into his room and was unsure which medications he took in the mornings. Resident #47 did not know the name of the nurse in charge of his care that day. During an observation and interview on 7/9/19 at 8:38 a.m., staff member U entered resident #47's room to answer a call light. After assisting resident #47 with the urinal, she looked at the cup of medications, picked it up, and walked out of the room with the cup in hand. Staff member U stated if staff find medication cups with medications in the residents' rooms, they are to give them to the nurse. Staff member U then gave resident #47's medication cup to staff member B, who stated, Oh, I thought he took those. Review of resident #47's Self Administration of Medications form, dated 5/2/19, showed resident #47 requested he self-administer medications; however, upon assessment, it was determined resident #47 could neither safely self-administer medications, nor could he leave medications at the bedside. B. During an observation on 7/9/19 at 12:12 p.m., staff member H placed a medication cup with two unidentified tablets on the dining room table next to resident #65's water cup prior to lunch. Staff member H did not say anything to resident #65 about the medication and proceeded to walk away from the dining room table, and other residents were at the table. During an interview on 7/9/19 at 12:15 p.m., staff member H stated the medications were just Tums, and added that resident #65 self-administered Tums after lunch. During an observation on 7/10/19 at 9:54 a.m., staff member T administered medications to resident #65. After administering resident #65's oral medication, staff member T poured two Tums tablets into a plastic medication cup and left it on the dining room table. Staff member T stated resident #65 preferred to take Tums after she was done eating breakfast. Staff member T stated self-administration of Tums after meals should be in resident #65's care plan. Review of resident #65's current care plan did not reveal information about self-administration of medications. Review of resident #65's Admission Assessment, dated 4/20/18, showed resident #65 responded, No, to the following questions: Does rdt/pt want to self administer their own medications? And, Does the rdt/pt want medications to be left at bedside/at their table? (sic) Review of an Interdisciplinary Team note, dated 7/10/19 at 11:08 a.m., and signed by staff member T showed, Okay for (resident #65) to take scheduled morning Tums after meals and at the bedside after meals VORB per (provider). The note did not show approval for self-administration of medications. C. During an observation and interview on 7/10/19 at 8:35 a.m., staff member T pre-poured resident #530's medication and walked into the resident's room. Staff member T placed the medicine cup next to the resident's bedside on the table and walked out of the room to fill a cup of water. She then went back to the room and observed resident #530 take his medications from the medication cup which she had left previously. Staff member T stated leaving medications unattended at the bedside would be allowed if it were written in the resident's care plan. Staff member T was unsure if self-administration of medications was written in resident #530's care plan. She added she would always stay at the bedside of any resident to ensure they had taken all of their medications; otherwise, someone could come in and take the medications if staff were to leave medications unattended. Review of resident #530's Admission Assessment, dated 7/2/19, showed resident #530 answered No to the question, Does the rdt/pt want to self administer their own medications? (sic) Review of an Interdisciplinary Team Note, dated 7/10/19 at 10:39 a.m., and signed by staff member G, showed resident #530, .asked to self administer [MEDICATION NAME] eye drops. Order received from (provider) to self administer and leave at bedside. The note did not mention self-administration had been requested or approved for other medications. Review of the facility's Health System Policy/Procedure titled, Bedside Storage of Medications and Self Administration of Medications, with a revision date of (MONTH) (YEAR), showed, Nursing .obtains a written order for the bedside storage of medication and places the order in the resident's medical record .Uses self administration assessment form to evaluate resident.",2020-09-01
19,BENEFIS SENIOR SERVICES,275012,2621 15TH AVE S,GREAT FALLS,MT,59405,2019-07-11,657,D,0,1,01HJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess and update a resident's care plan for monitoring risks and interventions following a choking accident for 1 (#89) of 42 sampled residents. Findings include: During an observation on 7/8/19 at 4:50 p.m., resident #89 was eating alone in the back corner of the dining room. With a bedside table in front of him, a drink, and two bowls of pureed food. No staff were assisting or directly supervising to provide encouragement, or redirect the resident on alternating bites and sips, and to monitor for choking. During an observation and interview on 7/10/19 at 2:40 p.m., staff member L showed resident #89's diet card with 1:1 for dining. She stated the staff assisting meals may have missed the 1:1 for dining because the yellow post-it was covering the information. During an observation on 7/11/19 at 9:10 a.m., resident #89 was sitting alone eating breakfast in the back corner at the bedside table with three bowls of pureed food, and a drink for breakfast. No staff were assisting or providing 1:1 supervision to encourage alternating bites or sips, or to monitor for choking. Record review of resident #89's nursing note and an alert, dated 7/4/19, which showed resident #89 had a choking incident in which he turned blue and had to be given the [MEDICATION NAME] Maneuver. Record review of resident #89's Nutritional Status care plan, with a start date of 7/8/19, showed, Monitor for chewing and/or swallowing difficulties, . encourage small bites and sips alternated, .staff to assist if needed to eat. The 1:1 for dining was not on resident #89's care plan. Record review of resident #89's diet order card showed 1:1 for dining. Record review of resident #89's speech therapy notes, dated 7/8/19, showed precautions of 1:1 supervision. The skilled instruction category showed, ST discussed pt's recent choking episode with staff. Staff indicated pt. consumed a large bite of pureed solids. ST provided pt. with skilled education regarding safe swallowing strategies including small bites/sips. (sic) Record review of an Alert, dated 7/10/19 at 3:14 p.m., for resident #89 showed, Due to recent aspiration/choking events, ST recommends (#89) receive 1:1 supervision in dining room during meals. Record reveiw of the facility policy titled, Initial Nursing Assessment and Development of Interdisciplinary Resident Care Plans showed, The interdisciplinary care team, physicians, licensed nursing staff, Social Services, Activities, Physical Therapy, Occupational Therapy, Speech Pathology, Pharmac, and licensed nutrtion staff are responsible for entering additions or changes to the care plan as the condition of the resident changes.Changes in conditions are reported to the provider and resident/family member/PO[NAME]",2020-09-01
20,BENEFIS SENIOR SERVICES,275012,2621 15TH AVE S,GREAT FALLS,MT,59405,2019-07-11,686,G,0,1,01HJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent and evaluate the cause of an avoidable, Unstageable pressure ulcer to the left heel, that led to the development of an additional Unstageable pressure ulcer to the right heel, and a reoccurring one to the left buttock, for a resident that was at high risk for pressure ulcers for 1(#1) of 42 sampled residents. Findings include: During an observation and interview on 7/8/19 at 1:54 p.m., resident #1 was sitting in her recliner with her heels resting on the bar to her side table. No interventions were noted to be place at the time for the prevention of pressure ulcers. Resident #1 stated her pressure wounds were from spending too much time in bed. During an interview on 7/10/19 at 2:29 p.m., staff member G stated the interventions for resident #1's pressure ulcers was heel lift boots, off loading heels, and a pillow to float heels. Staff member G stated resident #1 received [MEDICATION NAME] cream on her buttocks every shift and with toileting. Resident #1's heels were painted with [MEDICATION NAME] twice daily. During an observation on 7/11/19 at 10:07 a.m., resident #1 was sitting in her recliner, with both her heels resting on the floor, without a protective boot. Resident #1 was not sitting on a pressure relieving cushion in her recliner. During an observation and interview on 7/11/19 at 10:09 a.m., staff members G and I performed wound care with resident #1. Staff members treated resident #1's sacral wound, which staff member I stated was an Unstageable pressure ulcer, measuring 2.7 cm x 3.2 cm. Staff member I stated resident #1 tends to sit in her recliner often and should be using a pressure relieving seat cushion at all times. Staff member I then noted resident #1's seat cushion was in resident #1's wheelchair, not in her recliner. Staff members G and I were unable to explain how the pressure area had developed. Next, staff members G and I observed the wound on resident #1's left heel. Staff member I stated that the wound was a resolving blister, but since the bed of the wound could not be observed, it was diagnosed as an Unstageable pressure ulcer. Staff member G stated the measurements of the wound were 2.3 cm x 1.9 cm. The wound was a dark red/light brown color, with slight bogginess in the middle. Staff members I and G stated that resident #1 should always wear heel lift boots to help relieve pressure, except when ambulating. Staff members G and I then stated resident #1 also had a pressure ulcer on her right heel. Upon observing resident #1's right heel, staff members G and I stated this was also an Unstageable pressure ulcer with measurements of 1.9 cm x 1.8 cm. Staff members I and G were unable to verbalize the factors that led to the development of the pressure ulcer on resident #1's bilateral heels. After treating resident #1's right heel with [MEDICATION NAME], staff members G and I assisted resident #1 back to her recliner, lifted her heels on the foot rest of the recliner, applied foam boots to both heels, and positioned a pillow under resident #1's feet. During an interview on 7/11/19 at 8:57 a.m., staff member F stated resident #1 had a pressure sore on her left heel and did not recall how she got it. Staff member F stated resident #1 wanted pillows under her legs, and she had booties. Staff member F stated the other day resident #1 did not want her heels to touch the bed. Staff F did not mention using a care plan to know interventions are used for resident #1's pressure ulcers. During an interview on 7/11/19 at 8:58 a.m., staff member H stated she did not know how resident #1 had developed a pressure sore on her left heel, but the first time it was noted was on 7/4/19. During an interview on 7/11/19 at 9:26 a.m., staff member G stated the treatment order for resident #1 included: treating a left heel pressure ulcer with [MEDICATION NAME] and keeping the heel in a boot; and monitoring the sacral wound, which, according to staff member G, healed open to air (without a dressing). During an interview on 7/11/19 at 10:42 a.m., staff member G searched through resident #1's care plan, and stated she could not find interventions explaining the recommendations for pressure relieving devices (i.e. boots and seat cushion). During an interview on 7/11/19 at 10:50 a.m., staff member K stated there was no root cause analysis for resident #1's left heel pressure ulcer as noted on 7/4/19. Staff member K stated resident #1 should have an air mattress with a pump. Staff member K stated resident #1 had heel lift boots, and her seat cushion should have been under her at all times, even in her recliner. Review of resident #1's Braden Scale for Predicting Pressure Sore Risk, dated 6/10/19, showed, If the residents total is 18 or less, consider him/her at risk for a pressure ulcer development. Resident #1 scored a 15. Review of resident #1's admission note, dated 6/28/19, showed the presence of pressure ulcers to both buttocks but had no mention of pressure ulcers on her bilateral heels. Review of resident #1's Weekly Bath Day Assessment showed the following: -7/2/19 Skin interventions being utilized were, wound rounds, wound treatment, fluids, Foley catheter, education, wheelchair cushion, and protein encouraged. -7/9/19 Skin assessment in the comments showed, blackened area to L outer heel. -7/9/19 Skin interventions being utilized were, wound rounds, wound treatments, Foley catheter, [MEDICATION NAME], Rooke boots/float heels, turned/repositioned per policy, wheelchair cushion, and pressure reducing mattress. Review of resident #1's care plan showed the following: -6/28/19, At risk for breakdown. Turn and position as per policy guidelines or as directed. Monitor skin integrity weekly and when assisting with adl's. (sic) Notify charge nurse of changes. -7/1/19, Admit skin assessment 6/28/19 Left buttock: L: 1.4cm, W: 2cm, D: 0.1cm, Right buttock: L: 0.5cm, W: 0.4cm, D: 0.1cm. No mention of alteration of skin to either the right or left heel were noted in the skin assessment. -7/6/19, Left heel wound, identified on 7/4/19. The care plan had no mention of interventions that should be in place to prevent the worsening or development of new pressure ulcers. Review of resident #1's Interdisciplinary Notes showed the following: -6/10/19 resident #1 was admitted to the facility noted no pressure ulcer to left and right heel. -6/28/19 resident #1 was readmitted back to the facility with wounds to her buttocks. No mention of heel wounds were noted. -7/4/19 resident #1 was seen for wound rounds for buttock. Wounds to buttocks were open to air and deemed healed. (Resident #1) is noted to have foam heel protectors in place and when questioned she reports mild discomfort of her left heel. There appears to be a pressure sore, a dry blister that is unstageable and measures 3x4cm. Will paint with [MEDICATION NAME] BID and monitor. -7/9/19 resident #1 was noted to have a small blackened area to her right heel. Review of resident #1's Treatment Record showed, blister left heel paint with [MEDICATION NAME] BID heel lift boots in bed, initiated on 7/4/19. Family brought in heel lift boots on while in bed. Review of resident #1's wound care order dated 7/4/19, showed blister to left heel- paint with [MEDICATION NAME] BID- monitor. Heel lift boots in bed. Remind (resident #1) to have her family bring in a pair of heel lift boots. Review of resident #1's (Facility) Wound Alert dated 7/11/19 showed the following: -Right buttocks reddened area blanchable less than 2 seconds, cool and soothe with off loading using cushion on all surfaces. Left buttocks unstageable wound-dry scabbed area measures 2.7 cmx3.2 cmx0.1 cm with previous chronic scar tissue. -Right heel pressure sore unstageable dried eschar peri wound is blanchable within 2 seconds. measures 1.9 cm x 1.8 cm. Painted with [MEDICATION NAME]. -Left heel pressure unstageable dried dark area appears to be resolving, center of wound firm, 2.3 cm x 1.9 cm. Paint with [MEDICATION NAME] off load with heel foams at this time, family requested to bring in heel lift boots, not in room at this time.",2020-09-01
21,BENEFIS SENIOR SERVICES,275012,2621 15TH AVE S,GREAT FALLS,MT,59405,2019-07-11,689,G,0,1,01HJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary supervision and assistance needed for a resident who had swallow deficits and a choking episode, which required staff to provide the [MEDICATION NAME] Maneuver, for 1 (#89) of 42 sampled residents, and failed to implement interventions for ongoing risks related to choking. Findings include: During an observation on 7/8/19 at 4:50 p.m., in the resident dining room, resident #89 was left unattended in the back of the dining room, behind the serving table, in his wheelchair. Resident #89 was positioned behind a bedside table. Resident #89, with his tongue thrusting out, was coughing on his thickened water. No staff came to check on the resident. He then set his drink down on the bedside table to use his clothing protector to wipe his face and wheeled out of the dining room. A staff member wheeled resident #89 back into the dining room entrance and resident #89 proceeded to go to a different table and took his soiled clothing protector off and set it on another resident's place setting and drinks. Resident #89 returned to his bedside table where two bowls of pureed food and his drink were waiting. Resident #89 fed himself with an adaptive spoon, and due to his frequent tongue thrusting, he had to place the spoon far back in his mouth in order to empty the spoon. Resident #89 resorted to picking up the bowl and placing it against his lips to scoop the food with the adaptive spoon without taking a break, or switching to a drink in between bites of food. No staff were directly supervising or encouraging resident #89 to slow down or alternate food with liquids. Record review of resident #89's nursing note and alert, dated 7/4/19, showed, Res was in dining room sand resident chokking, he was unable to clear his airway and started turning blue. Res was lifted out of WC and [MEDICATION NAME] was started. After three deep thrusts I was able to dislodge te object res swallowed it so I was unable to see what it was. Res had been seen at res table by the pole, appeared he was taking food. He is currently resting in his room. (sic) During an observation and interview on 7/10/19 at 2:40 p.m., staff member L showed resident #89's diet card. The 1:1 for dining intervention was written on the bottom right corner of the diet card. This notation was covered by a yellow post-it note labeled puree. Staff member L stated that the staff members serving meals may not have seen the intervention, because of where the post-it was placed on the diet card. Staff member L stated the discipline that implemented the intervention was responsible for updating the diet cards. During an interview on 7/10/19 at 11:38 a.m., staff member N stated, Staff, as a whole, periodically keeps an eye on (resident #89). During an interview on 7/10/19 at 2:30 p.m., staff member O stated, an incident would create an alert in the Kardex of the electronic medical record. She stated therapy, dietary, nursing, and all management would receive an alert in the case of a choking incident. During an interview on 7/11/19 at 8:33 a.m., staff member M stated she was not present for the choking incident that occurred on 7/4/19, but heard resident #89 had taken another resident's bread and choked on it. Staff member M stated all staff are to keep a close eye on resident #89 as he wanders. Staff member M had noticed that resident #89 would push the adaptive spoon so far back into his mouth, he would gag on it, when eating too fast. Resident #89 coughed a lot but usually forcefully coughed enough to clear his throat on his own. Staff member M stated the protocol for notification after performing the [MEDICATION NAME] Maneuver was to notify management, doctor, resident representative, dietician, and therapy. Staff member M stated the expectation of the nurse is to implement interventions necessary to keep the resident safe, while waiting for a call back from the provider. Staff member M stated management, therapy, and the oncoming shifts would see an alert in the electronic medical record notifying staff of the incident. During an observation on 7/11/19 at 9:06 a.m., resident #89 was left unattended in the back of the dining room, behind the serving table, in his wheelchair. Resident #89 was positioned behind a bedside table. Resident #89 had three bowls of pureed food and a drink. Resident #89 was using an adaptive spoon and had difficulty removing the food from his spoon. Resident #89 spilled food onto his clothing protector, scooped the food off, and ate it. Resident #89 then placed the spoon far back into his throat and gagged. Resident #89 tipped his head back and continued to cough, moan, and made a wet, gurgling sound with his tongue thrust out. Staff member O came over and adjusted the resident's clothing protector and told him he was okay. Staff member O walked away; no one was directly supervising resident #89. Record review of resident #89 Speech Therapy note on 7/8/19, showed a recommendation of 1:1 supervision for consuming food/liquids. High Choking/Aspiration Risk. No documentation was found for notification of the physician, resident representative, or assessment of resident #89's wellbeing related to the choking.",2020-09-01
22,BENEFIS SENIOR SERVICES,275012,2621 15TH AVE S,GREAT FALLS,MT,59405,2019-07-11,692,D,0,1,01HJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the dietary department failed to offer a carbohydrate controlled therapeutic diet ordered by a physician at meal times for 2 (#s 91 and 328) of 42 sampled residents. Findings include: 1. During an observation on 7/8/19 at 5:26 p.m., resident #91 received a full portion, filled to the brim of the bowl, of turkey and dumplings with peas and carrots. Resident #91 also received a salad, and a Diet Coke for dinner. During an interview on 7/8/19 at 5:28 p.m., staff member W stated a resident on a carbohydrate controlled diet should have been served no dessert, less potatoes, diet soda, and given less food or a half portion. During an interview on 7/9/19 at 1:54 p.m., staff member Y stated that all specialized diets should have been captured on the therapeutic spreadsheets that showed which food should be provided for the meal per the menu, as well as portion sizes. The sheets should have been used as a reference during meals. Carbohydrate controlled diets should have been provided unless the resident refuses. Staff member Y stated resident #91 should have received the baked turkey breast for dinner and not the turkey and dumplings. During an observation on 7/9/19 at 8:15 a.m., resident #91 received an omelet and muffin. Review of the Specialized Diet Spreadsheet for 7/9/19 showed a resident on a carbohydrate controlled diet should have received a Denver omelet, fresh fruit, yogurt, and cold cereal. Review of the Week 5 Monday Specialized Diet Spreadsheet, for 7/8/19, showed the carbohydrate controlled diet choices were pork chop smothered, creamy mushroom rice, and chocolate pudding, or baked turkey breast, peas, carrots, and onions. No baked turkey breast was observed during the meal. Review of resident #91's diet card showed, carb controlled diet was marked. The rest of the card was blank. Review of resident #91's diet order showed carbohydrate controlled diet. Review of resident #91's blood sugars showed 37 blood sugars over 200 and three blood sugars not marked as high with a reference range of 68-110 from 6/10/19 to 7/3/19. 2. During an observation on 7/9/19 at 12:12 p.m., staff member W was serving lunch with the specialized diet spreadsheet book not visible and it was on the counter in the pantry. Resident #328 was served carrot salad, mashed potatoes and gravy, a hot turkey sandwich smothered in gravy, and a cookie for dessert. During an interview on 7/9/19 at 2:24 p.m., staff member X stated that the chef and CNA are responsible for making sure the residents receive the right diets by following the diet cards. Staff member X stated the expectation is that the chef is to follow the spreadsheets for diets. Staff member X stated that the meal cards that the CNA follows are pretty clear and capture what should and should not be served. Staff member X stated that she was not sure how specialized diets are monitored or how they prevent the wrong diets from being served. During an interview on 7/10/19 at 9:57 a.m., staff member AA and staff member Z stated that diet spreadsheets are given to the cooks for the day and should be utilized while serving. Staff member AA stated that a medical diet is a physician order [REDACTED]. During an interview on 7/10/19 at 10:35 a.m., staff member J stated specialized diet cards are orange (colored), for carb control. Staff member J stated responsibiity for going around and taking food orders for the day to see which of the two options on the menu the resident would prefer. Staff member J stated he had never seen nor been trained on the specialized diet spreadsheet menu. Staff member J stated, It would be helpful to know what is in the diet. During an interview on 7/10/19 at 10:39 a.m., staff member BB stated he had not been trained on specialized diets. Staff member BB was responsible for serving meals and providing diet cards to the chef. Review of the Week 5 Tuesday Specialized Diet Spreadsheet showed for lunch a resident on a carbohydrate control diet should have received a hot turkey sandwich, poultry gravy, carrot salad, and fruit. Review of resident #328's diet card showed was marked carb control under diet the sectional, and the rest of the card was blank. Review of resident #328's diet order showed the resident was on a carbohydrate controlled diet.",2020-09-01
23,BENEFIS SENIOR SERVICES,275012,2621 15TH AVE S,GREAT FALLS,MT,59405,2019-07-11,697,G,0,1,01HJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess and provide pain management interventions during treatment of [REDACTED].#104) of 42 sampled residents, who described his pain as excruciating. Findings include: During an interview on 7/10/19 at 10:34 a.m., resident #104 stated he first noticed the pressure ulcer on his right heel prior to his arrival at the facility. Resident #104 explained the wound itself looked as if it were 90% healed, but .the bad part is the pain. Resident #104 described the pain on his right heel as excruciating, especially when staff performed dressing changes. Resident #104 stated he was unsure if he took pain medications prior to dressing changes on his right heel. During an interview on 7/10/19 at 10:51 a.m., staff member T stated resident #104, is fine, and has not needed or requested pain medications prior to dressing changes on his right heel. During an interview on 7/10/19 at 11:24 a.m., after staff member T was alerted to resident #104's pain, staff member T stated she would perform a dressing change on resident #104's right heel wound in about ten minutes. Staff member T stated, We ended up giving him a pain medication, so we are going to wait for that to kick-in. This was after the surveyor approached the topic of the resident's pain with the staff member. During an observation on 7/10/19 at 11:36 a.m., staff member T performed a dressing change on resident #104's right heel. While staff member T removed the compression stockings, resident #104 groaned in pain, and said Ow! multiple times. Staff member T did not perform a pain assessment, alter treatment, or implement pain relieving measures for resident #104 during the dressing change. During an interview on 7/10/19 at 2:37 p.m., staff member T stated she was not sure of the source of resident #104's pain. Staff member T stated resident #104 takes [MEDICATION NAME] as needed, but only requests it at night, and is not taking any scheduled pain medications. Staff member T stated the dressing change she performed earlier in the morning on 7/10/19 was the first time resident #104 had requested pain medication prior to a dressing change. During an observation on 7/11/19 at 9:02 a.m., staff member G performed wound care on resident #104's right heel. While staff member G removed resident #104's compression wraps and bandage, resident #104 grimaced and tensed his right leg. Staff member G described the wound as a Stage II pressure ulcer, with dimensions of 1.9 cm x 1.2 cm (length x width); she continued to describe the peri-wound as dark pink and beefy red. The wound itself, she said, had slightl red drainage; and yellow, dry, and flaky skin was noted to the top part of the wound, which staff member G peeled off. Resident #104 continued to grimace and tense his right leg throughout wound care. Staff member G did not perform a pain assessment, alter treatment, or implement pain relieving measures for resident #104 during wound care. During an interview on 7/11/19 at 9:18 a.m., staff member G stated she was not sure if resident #104 took pain medications prior to wound care on his right heel. Staff member G said she had not performed a pain assessment with resident #104. Staff member G consulted resident #104's MAR indicated [REDACTED]. Staff member G stated resident #104 takes [MEDICATION NAME], 50 mg tablets, one tablet by mouth once daily, as needed for pain; and [MEDICATION NAME] 1% gel, apply 2-4 grams to affected areas of joint pain up to four times daily. Review of resident #104's care plan, dated 6/11/19, showed under the category, Pain, resident #104 will achieve a consistent level of comfort while maintaining as much function as possible. Interventions under this goal include: -administer pain medications on scheduled and/or as needed basis; -if finding that adequate pain control is not occurring and remains greater than a 5/10 after 30 minutes after pain medication administration, document and notify primary care provider; and, -pre-medicate for pain as needed to optimize participation in therapies, activities and meals. Review of a Training Competency document, dated 2/1/19-2/28/19, showed staff member T met the standard for assessing and reassessing pain; and utilizing appropriate pain management techniques. Review of resident #104's pain assessment notes, between 6/28/19 and 7/11/19, showed five out of 27 pain assessments were completed. Out of those five, one assessment, dated 7/8/19, did not note the location of the resident's pain; one assessment, dated 7/4/19, showed resident #104 was experiencing a burning and restless pain in his right foot; assessments dated 6/26/19, 6/27/19, and 6/30/19 showed resident #104 was experiencing pain in both knees only.",2020-09-01
24,BENEFIS SENIOR SERVICES,275012,2621 15TH AVE S,GREAT FALLS,MT,59405,2019-07-11,760,D,0,1,01HJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to administer [MEDICATION NAME] for pain at the dose prescribed, causing unrelieved pain for 1 (#7) of 42 sampled residents. Findings include: During an observation and interview on 7/8/19 at 3:20 p.m., resident #7 was folding resident covers for meals. The resident stated her arms and hands would become sore from the folding after awhile. Review of resident #7's physician's orders [REDACTED]. The order also showed the resident was able to have 1/2 tab three times daily as needed for breakthrough pain. During an observation and interview on 7/10/19 at 1:28 p.m., staff member A stated the nurses administering, per the Controlled Substance Medication Administration Record [REDACTED]. The count sheet showed that from 6/2/19 through 7/10/19, resident #7 did not receive the correct dosage of [MEDICATION NAME] on 6/12/19 at hs, 6/19/19 at hs, 6/24/19 at hs, 7/1/19 at hs, and 7/9/19 at hs. The resident did not receive any of her [MEDICATION NAME] doses on the evenings of 6/27/19 and 7/5/19. During an interview on 7/11/19 at 8:12 a.m., resident #7 stated she only took pain pills as prescribed, but that did not mean she did not have pain. The resident stated she had learned how to control her pain by putting it in the back of my mind. During an observation and interview on 7/11/19 at 10:10 a.m., staff member B showed how the [MEDICATION NAME] was packaged. One half pill of a 5 mg pill was in each blister pack. The staff member explained resident #7 received one blister pack for mornings and two blister packs for evenings.",2020-09-01
25,BENEFIS SENIOR SERVICES,275012,2621 15TH AVE S,GREAT FALLS,MT,59405,2019-07-11,761,F,0,1,01HJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Schedule III-V controlled substances were separately locked, and not under the same access system used to obtain non-controlled substances; the facility failed to remove expired medication and supplies from medication supply rooms; and the facility failed to maintain staff education on checking expiration dates. Findings include: [NAME] During an observation and interview on 7/11/19 at 10:10 a.m., the medication refrigerator contained a ziplock bag of individually filled syringes containing [MEDICATION NAME] liquid for a resident and two medication cards containing dronabinol capsules for a resident. These medications are Schedule III controlled substances. The [MEDICATION NAME] and dronabinol were stored in the main area of the refrigerator and not locked separately from non-controlled medications. A locked box within the refrigerator contained a ziplock bag of individually filled syringes containing [MEDICATION NAME] liquid for stock use. Staff member L stated the stock items were locked as part of an e-kit. Staff member L stated she was not aware of the requirement for Scheduled controlled substances to be separately locked from non-controlled substances. B. During an observation and interview on 7/9/19 at 1:58 p.m., a bottle of aspirin 325 mg, which was located in the storage medication cart, had an expiration date of (MONTH) 2019. Staff member B stated, in reference to the facility's process for checking expired medications, the pharmacy goes through medication carts two to three times every month, and the night shift nurses are also pretty good at going through the carts to check for expired medications. During an observation of a medication storage room on 7/10/19 at 9:26 a.m., the following expired supplies were noted: -One Kangaroo E-pump Enplus spike set (exp. 1/14/19); -One E-pump safety screw spike set (exp. (MONTH) 2019); -One Prevantics Antiseptic non-sterile solution (exp. (MONTH) 2019); -One Creamy Vanilla Smoothie Readi-Cat 2, Rx only (exp. (MONTH) (YEAR)). During an interview on 7/10/19 at 9:33 a.m., staff member T stated the above supplies were not used regularly. Staff member T stated she was unsure if the facility had a specific policy on checking expiration dates. She added that the night shift usually had more time, so they probably checked medications and supplies that did not come directly from the pharmacy. During an interview on 7/10/19 at 10:14 a.m., staff member K stated staff checked for expiration dates as frequently as possible and pharmacy checked at least once every month. Staff member K added nurses were supposed to check the expiration date prior to administering medications. During an interview on 7/10/19 at 1:50 p.m., staff member V stated he checks expiration dates at least every other day, and on the first day of the week that (his) shift starts. He added that he checks expiration dates on insulin every day. Record review of the facility's Medication Administration Standards powerpoint document, provided to nurses during orientation, showed (in flow chart format): Select med(s) from patient Pyxis profile/MAR and verify on MAR: administration, due by, med name, dose, rte, time and check when last time given .Does med removed from Pyxis match MAR and is it expired? If the nurse answers Yes to the medication expiration question, the flow chart continues, Set aside med for Pharmacy. (sic)",2020-09-01
26,BENEFIS SENIOR SERVICES,275012,2621 15TH AVE S,GREAT FALLS,MT,59405,2019-07-11,812,F,1,1,01HJ11,"> Based on observation, interview, and record review, the facility failed to clean, maintain cleanliness, store food/equipment, or follow food services safety practices for the prevention of contamination of food or equipment uitlized, which had the potential to affect all residents recieving food in the facility. Findings include: During an observation on 7/8/19 at 1:18 p.m., Goodnow kitchenette had dried brown and yellow matter stuck to the range oven burners, whitish matter on the bottom of the fridge, and visible crumbs in the bottom of the warmer which had not been cleaned. During an observation of the Grandview main kitchen on 7/8/19 at 1:22 p.m., the convection oven had crumbs and black char on the bottom. The oven ranges had burnt food, dried leaves, and crumbs on the range oven tops. The ovens had splatters down the back of them, for the areas not previously cleaned. During an observation on 7/8/19 at 1:44 p.m., the Transitional Care Unit kitchenette stove top was visibly dirty with food splatters and burnt crumbs, with grease splattered on the back of range oven. Crumbs were found on the cookie sheets in the warmer, which was holding the clean plates, but the sheets had not been cleaned or removed from the day prior. During an observation on 7/9/19 at 7:47 a.m., the Transitional Care Unit kitchenette continued to have had dried food and yellow matter stuck to two of the four burners on the oven range top. Grease was splattered up the back of the stove. There were still crumbs on the cookie sheet, which was holding the clean plates in the warmer. During an observation on 7/10/19 at 9:26 a.m., the Transitional Care unit kitchenette had dried, cooked, and burnt food matter on the top of the stove, and crumbs on the cookie sheet, which the clean plates were sitting on in the warmer. During an interview and observation on 7/10/19 at 9:57 a.m., with staff member AA, while touring the Grandview main kitchen, there was a steam pipe from the steamer shooting steam out into the aisle-way of the kitchen. During the tour and interview, staff AA stated: - There was a ticket (request to repair) in with maintenance to fix the pipe. - Staff member AA stated the convection oven was the only piece of equipment which had not been cleaned, and it needed a new fan, as the convection oven was still visibly dirty with crumbs and char in it, and the doors were covered in a greasy film. - Staff member AA stated they were revamping the cleaning schedule, and the stove tops get cleaned weekly, and as they get dirty. - Staff member AA stated each cottage chef was now responsible for 15 different items on the revamped cleaning schedule. - The cleaning schedule had previously not been assigned to a specific staff member. Staff member AA stated they were rolling out the revamped cleaning list and would be checking the cleaning on Wednesdays and Saturdays, to ensure it was getting completed. During an interview on 7/10/19 at 12:00 p.m., staff member CC stated the warmers were cleaned weekly unless there were spills, and the stove tops were cleaned monthly. During an observation on 7/10/19 at 4:02 p.m., the Transitional Care unit kitchenette's oven range top was still covered in food matter. The flat grill was also visibly dirty with crumbs and grease, and splatters on the back of the oven were continued to be present. During an observation on 7/11/19 at 10:01 a.m., the steam pipe, from the steamer, in the Grandview kitchen, was shooting steam straight up into the air continuing to create a hazard. During an observation on 7/11/19 at 10:48 a.m., the Transitional Care unit kitchenette oven range top continued to have food particles present on the stove top which had not been cleaned after use. Review of the cleaning sheets from 4/1/19 through 6/23/19 showed the following: - did not specify which cottage stove tops had been cleaned - ranges and ovens were to be cleaned weekly on Fridays and Sundays - warmers, both large and small, were to cleaned daily by the Goodnow cook - the current cleaning sheets, requested on 7/9/19 at 11:50 a.m., were not provided by the facility. Review of the cleaning sheets for the ranges and oven, dated 4/1/19 through 6/23/19, showed the ovens had been cleaned on 5/4/19 and 6/13/19. Review of the cleaning sheets for the large and small warmer, dated 6/1/19 through 6/23/19, showed they were cleaned only 7 of the 23 days in the month. Review of maintenance ticket, dated 1/12/18, showed, The sanitizer in the kitchen was not working. The maintenance ticket was requested to confirm the request to repair the steamer and pipe was completed, but the ticket did not address the pipe from the steamer. During an observation and interview on 7/8/19 at 2:01 p.m., with staff member Q, in the main kitchen, the dry storage top shelf had a clear bin of cantaloupes that were rotting. The cantaloupes had soft, dark spots and white, fuzzy mold growing on them. The pipes in the back corner were covered in thick, fuzzy gray/brown dust. The freezer had pallets of food in the back of the center aisle, which were blocking the back right shelves and walkway. Staff member Q stated the pallets were there because they got a shipment in that morning. In front of the pallets was a metal cart with an uncovered, cooked roast. Other metal pans were stored above and below the uncovered roast. Staff member Q stated the roast was cooling, and that was why it was uncovered and in the freezer. Two trays of orange-colored liquid Jell-o with fruit chunks, were on the bottom of the prep refrigerator. There were no dates or labels on the trays which contained the Jell-o. The bottom shelf of the prep table was stained and had brown food crumbs on it. There were open bags of various seasonings in an unsealed bin, stored next to a variety of clean pans and mixing bowls. There were dried streaks of batter on the underside of the mixer arm. The mixer was not in use. A nearly empty, large plastic mayonaise jug, was observed without a date label. In the small refrigerator, in the kitchen, cooked chicken breast, in an unsealed ziplock bag, was observed. Staff member Q stated it was his expectation that staff would label and date food when opened, and clean up as they go. During an observation and interview on 7/9/19 at 8:30 a.m., in the main kitchen, there were dried streaks of batter on the underside of the mixer arm. The mixer was not in use. The bottom shelf of the prep table was stained and had brown food crumbs on it. There were open bags of various seasonings in an unsealed bin, stored next to a variety of clean pans and mixing bowls. A cook dropped an open box of pre-packaged dry ingredients on the floor. He picked the box up off the floor and placed the box on a prep table containing open containers of food. The freezer had an opened, unsealed, and unlabeled bag of french fries on the middle shelf. The top shelf of the refrigerator contained an unsealed box of sunflower seeds. The roast was now on a metal rack in the refrigerator, uncovered in the center. To the right of the roast was a metal rack with cut up red potatoes in water, uncovered and unlabeled in a metal pan. On the shelf below the potatoes, there was a metal pan containing uncovered, seasoned raw chicken. The dry storage room pipes had thick fuzzy gray/brown dust on them which had not been cleaned. During an observation on 7/10/19 at 11:19 a.m., in the kitchenette on the 4th floor, the flooring had well worn and peeling black, purple, and red tape in areas around the doorway. There was dark grime stuck along the edges of the tape. There was a bottle of Louisiana hot sauce with no lid and no date label, half empty, sitting out on the counter. The cappuccino machine tray was pulled out, and there were spills of light brown liquid along the counter. One ziplocked bag of frozen prunes in the freezer was not labeled or dated. A cabinet, which had a sign labeled (#89) cups, contained one clear cup inside, which was soiled with a light brown dried substance on the side of it from the top to the bottom. During an interview on 7/10/19 at 11:45 a.m., staff member N stated all senior services staff must do a training and get a food-handlers permit. They (staff) all take turns to work in the kitchenette on the 4th floor, but don't go in the main kitchen. Staff are taught things for the kitchens, such as how to clean, temp, store foods, and understand resident diets. Record review of facility policy titled, Sanitation, Food Safety, and Infection Control showed: - Do not place or store deliveries directly on the floor. - Keep all foods covered while refrigerated. - Keep all food held in freezers frozen solid. - Label all opened food items (exception bread) with: a.name of food, unless clearly identified on the original packaging b.date opened c.use by date d.staff initials -Maintain good housekeeping, general cleanliness, and sanitation of the entire location. -Verify that a clean as you go mentality is adopted by all associates. - Maintain food-contact surfaces clean to sight and touch. -Keep food contact surfaces free of encrusted grease deposits and soil accumulations. -Maintain non-food contact surfaces free of dirt and debris.",2020-09-01
27,BENEFIS SENIOR SERVICES,275012,2621 15TH AVE S,GREAT FALLS,MT,59405,2019-07-11,880,E,0,1,01HJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to label and ensure the safe storage of oxygen and nebulizer therapy supplies for 1 (#29); and a staff member failed to wear a mask during caring for residents while experiencing cold/flu type symptoms, and had a stated history of pneumonia, for 42 sampled residents, in an attempt to prevent the spread of infection. Findings include: 1. During an observation on 7/8/19 at 3:00 p.m., resident #29's used nebulizer canister setup was attached to, and setting on the top of, the nebulizer machine located on the resident's bedside nightstand. The canister contained droplets of liquid. The resident stated she had last used the nebulizer the previous afternoon (7/7/19), and that the nurses always set it up for her to use. A 7-2 label was written on the side of the nebulizer mouthpiece, canister ring lid, and oxygen tubing. An unopened package of ipatroprium [MEDICATION NAME] sulfate vials was laying on the bedside nightstand beside the nebulizer machine. During an interview on 7/11/19 at 10:05 a.m., staff member Q stated CNAs and nursing staff learn about nebulizer use during onboarding activities as a skills check off (competency), and nebulizer use was also presented last year during facility skills days. She stated that facility staff followed facility policies related to nebulizer use. During an observation on 7/11/19 at 10:09 a.m., resident #29's nebulizer canister and tubing set was attached to and setting on the top of the nebulizer machine located on the resident's bedside nightstand. The canister was dry and contained no liquid or droplets. An unopened package of ipatroprium [MEDICATION NAME] sulfate vials was laying on the bedside nightstand beside the nebulizer machine. During an observation and interview on 7/11/19 at 10:19 a.m., staff member R stated resident #29 had declined the nebulizer treatment earlier that morning and staff member R was preparing the nebulizer treatment for [REDACTED]. Staff member R stated that nursing staff prepare the medication in the nebulizer canister setup and then resident #29 self-administers the nebulizer treatment and calls the nurse when she is done. Staff member R stated after the resident is done with the treatment, the nursing staff separate the canister pieces and rinse the pieces with saline. Staff member R stated the saline is kept in the cabinet in resident #29's bathroom, however staff member R was not able to locate a bottle of saline in the bathroom cabinet at the time of the interview. During an interview on 7/11/19 at 10:23 a.m., resident #29 stated the nurses neither clean the nebulizer canister setup nor do they set it out to dry in between uses; they just come in and add the medicine. Resident #29 stated once a week on Tuesdays the nurses change the tubing on the nebulizer, and on Thursdays they change the tubing on the concentrator. During an observation on 7/11/19 at 10:25 a.m., a blue plastic bag containing oxygen tubing and nasal cannula was hanging on the front of the oxygen concentrator, located in resident #29's bathroom. No date labeling was observed on the oxygen tubing and cannula. A review of the facility's policy titled BSS-Respiratory Therapy, showed Equipment is cleaned in the following manner: Nebulizers - To be rinsed and allowed to air dry after each use. 2. During an observation and interview on 7/8/19 at 1:52 p.m., staff member A was observed wearing a mask, which covered her nose and mouth. The staff member was coughing. Staff member A stated she did not want to get pneumonia again. She said she thought her coughing was from the air, and she was wearing the mask, to keep the air off and trying not to get the condition worse. During an observation on 7/8/19 at 5:11 p.m., staff member A was assisting residents with their meals, in the Memory Care dining room. The staff member was wearing a mask. At times she would turn and cough. During an observation on 7/9/19 at 8:54 a.m., staff member A was in the Memory Care kitchenette/dining room area. Staff member A was wearing a mask, covering her nose and mouth. Staff member A was coughing repeatedly. Staff member A was trying to assist residents with their meal. Staff member A was observed stepping away from the resident as she was coughing so hard. After trying again, staff member A walked back into the office, behind the nurse's station. During an observation and interview on 7/10/19 at 9:00 a.m., staff member A was in the Memory Care dining area\kitchenette area, and hall, assisting with residents with their breakfast, seating, and transfers. Staff member A was not wearing a mask. Staff member A's cough sounded deeper in her chest than the day prior. She had a difficult time controlling the cough, while assisting residents. Staff member A stated she did not need a mask, her cough had gone to her chest. Staff member A was observed assisting residents, in between coughing periods, until 10:30 a.m. Staff member A was coughing into her arm and was not observed sanitizing her hands between coughing periods. During an interview on 7/10/19 at 5:00 p.m., staff member DD stated staff member A should have been wearing a mask, per facility policy, relating to the cough and being around the residents.",2020-09-01
28,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2018-03-21,550,E,1,0,U1E811,"> Based on interview and record review, the facility failed to ensure resident preferences were met for bathing for 5 (#s 5, 6, 8, 9, and 10) of 11 sampled residents. Findings include: 1. During an interview on 3/19/18 at 3:30 p.m., resident #5 said he was currently receiving two showers a week. Resident #5 said he wanted two showers a week, and he and NF1 had addressed that he had not consistently recieved two showers a week with the facility, repeatedly. Resident #5 said (MONTH) (YEAR) had been bad, and (MONTH) and (MONTH) of this year (2018) had been bad too (related to the provision of showers). Review of resident #5's Quarterly MDS, with an ARD of 12/5/17, showed the resident needed total assistance of two staff for bathing. During an interview on 3/20/18 at 3:35 p.m., NF1 said she and resident #5 had discussed his bathing preferences with the facility several times. NF1 said she thought residents were not getting bathed, based on their preferences, due to the facility not having shower aides available. Review of resident #5's Bath Aide Skin Assessment records, showed the resident had a bath on 9/11/17 and another one on 9/20/17. The resident went eight days without a bath. Review of resident #5's care plan failed to show the resident's bathing preferences, which was for a shower twice a week, had been identified by the interdisciplinary team. 2. During an interview on 3/21/18 at 7:45 a.m., resident #6 said she had gone nine days between showers. Resident #6 said she liked to have at least 2 showers per week due to her bowel incontinence. Resident #6 said she did not like to smell of body odor, feces or to have greasy hair, and she showered every day when she lived at home. Resident #6 said she would still like to have a shower every day but knew that was not possible. She had made the facility aware of her preference for two showers per week. Review of resident #6's Annual MDS, with an ARD of 1/2/18, showed the resident had not received a shower or bath in the seven day look back period. Review of resident #6's Quarterly MDS, with an ARD 10/3/17, showed the resident was total assistance of one staff for bathing. Review of resident #6's Bath Aide Skin Assessment records, for (MONTH) and (MONTH) (YEAR), showed the resident had a bath on 9/5/17 and another one on 9/17/17. The resident went 11 days without a bath. The resident had a bath on 9/29/17 and another on on 10/8/17. The resident went eight days without a bath. Review of resident #6's care plan failed to show the resident's bathing preferences of twice a week had been identified by the interdisciplinary team. 3. During an interview on 3/19/18 at 1:15 p.m., resident #8 said he had been getting a shower once a week lately. Resident #8 said, Awhile back we were having problems getting a shower once a week because there was no shower aide. Resident #8 said he would like to have shower more frequently than once a week, but is happy if he receives one a week. Review of resident #8's Quarterly MDS, with an ARD of 9/26/17, showed the resident had not received a shower or bath in the seven day look back period. Review of resident #8's Quarterly MDS, with an ARD of 12/26/17, showed resident #8 was a partial physical assistance of one staff for showers. Review of resident #8's Bath Aide Skin Assessment records, for (MONTH) and (MONTH) (YEAR), showed the resident had a bath on 9/6/17 and another one on 9/19/17. The resident went 12 days without a bath. Review of resident #8's care plan failed to show the resident's bathing preferences. 4. During an interview on 3/19/18 at 2:25 p.m., resident #9 said she generally gets a bath twice a week. Resident #9 said in (MONTH) of (YEAR) it was touch and go for awhile. Resident #9 said her baths were not twice a week in (MONTH) and (MONTH) of (YEAR). Resident #9 said she thought the bath aide had quit. Resident #9 said she preferred to have a bath every other day but was happy when she got two a week. Review of resident #9's Quarterly MDS, with an ARD of 2/13/18, showed the resident was total assistance of two staff for bathing. Review of resident #9's Bath Aide Skin Assessment records, for (MONTH) and (MONTH) (YEAR), showed the resident had a bath on 9/11/17 and another bath on 9/21/17. The resident went nine days without a bath. Review of resident #9's care plan failed to show her bathing preferences had been addressed by the interdisciplinary team. 5. During an interview on 3/19/18 at 2:40 p.m., resident #10 said she usually got a bath twice a week. Resident #10 said (MONTH) and (MONTH) of (YEAR) said she did not get baths twice a week. Resident #10 said she did not think the facility had a bath aide then. Resident #10 said she thought the facility had some problems in (MONTH) and (MONTH) of last year (2017) too. Resident #10 said she preferred to have a bath two times a week. Review of resident #10's Quarterly MDS, with an ARD of 1/2/18, showed resident #10 was total assistance of one staff for bathing. Review of resident #10's Bath Aide Skin Assessment records, for (MONTH) and (MONTH) (YEAR), showed the resident had a bath on 9/11/17 and another bath on 9/19/17. The resident received a shower on the eighth day. These bath records showed resident #10 had a bath on 9/22/17 and another bath on 10/3/17. The resident received a bath on the eleventh day. Review of resident #10's care plan failed to show her bathing preferences had been addressed by the interdisciplinary team. A review of the facility's policy, Shower and Hygiene, showed, 1. Administer resident shower once weekly and/or as often as necessary. 2. If reasonably practicable, try to accommodate resident's preference in the shower schedule. The facility's policy does not address the need to care plan the resident's shower preferences to create a more personal and individualized care plan for the residents.",2020-09-01
29,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2018-03-21,565,E,1,0,U1E811,"> Based on interview and record review, the facility failed to provide evidence to show the facility take action to acknowledge and resolve, or attempt to resolve, all concerns brought forth by the resident council. This had the potential to affect all residents who attended the resident council or who had interest in the council's activities, and specifically 2 (#s 6 and 8), of 11 sampled residents. Findings include: During an interview on 3/21/18 at 8:30 a.m., resident #6 said shower/bathing concerns had been brought up repeatedly in resident council meetings. Resident #6 said she went around the facility before resident council meetings and talked to the residents. Resident #6 said the quality of the food and residents not getting showers were the biggest concerns. Resident #6 said the facility was aware of these concerns, but the facility had never responded to resident council concerns in writing. She said everything was verbally addressed. During an interview on 3/20/18 at 2:28 p.m., staff members A and I said they attended the resident council meetings. Staff member I said she was responsible for taking the minutes of the meeting and for the follow through on the concerns voiced in resident council. Staff member I said she was behind in her documentation in the software program. Staff member A said the facility had been treating resident council concerns as grievances since (MONTH) (YEAR). Staff member A said the grievance forms include, Action Item, Follow-up completed by, and Date of resolution. These grievance forms were not included with the resident council meeting minutes. Review of resident council meeting minutes showed; -10/2/17: A resident said her podiatrist was concerned residents were not getting their feet scrubbed properly during showers and the frequency of showers. No response from the facility. -11/6/17: A resident voiced concerns about showers. Another resident suggested a shower schedule be put in place. No response from the facility. -2/5/18: A resident had concerns about showers. No response from the facility.",2020-09-01
30,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2018-03-21,657,E,1,0,U1E811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, observation and record review, the facility failed to update the care plan to accurately reflect the current status for 3 (#s 1, 5, and 6) of 11 sampled residents. Findings include: 1. During an interview and observation on 3/19/18 at 1:20 p.m., resident #1 stated she took care of herself, and did not need any assistance from the staff. The resident sat up in bed without assistance and sat at the edge of the bed to speak. During an observation on 3/20/18 at 11:05 p.m., resident #1 was walking without assistance or a device, to the nurses station. She stated she was going out to lunch that day. She was dressed up, had makeup on, and stated she had dyed her hair purple that morning. Review of resident #1's Care Plan, dated 7/28/17, showed the resident required guided maneuvering of extremities, verbal cueing and sufficient time to perform and/or assist during dressing and other ADL's as needed; transfer with walker and supervision; encourage resident to participate in ADL tasks as able. Review of resident #1's Care Plan, dated 7/28/17, showed she was at high nutritional risk. Review of resisdent #1's Weight sheet showed a severe weight loss of 13 percent from (MONTH) (YEAR) to her present weight of 95.6 pounds and was not identified on the care plan. Review of resident #1's discharge summary from the hospital, dated 1/2/18, showed the resident was diagnosed with [REDACTED]. The risk for dehydration with interventions and monitoring, was not addressed on the care plan. During an interview on 3/19/18 at at 1:30 p.m., resident #1 stated she smoked, and kept the cigarettes and lighter in her room, because the supplies kept disappearing. Review of resident #1's Care Plan showed she needed to check out smoking materials, and the supplies could not be kept in her room. During an interview on 3/20/18 at 1:20 p.m., staff member B stated she was not sure which staff member was to update resident care plans. Staff member B stated at times she updated the care plans, and at other times, the MDS Coordinator or the floor nurse updated the plans. 2. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #5's Quarterly MDS, with an ARD of 12/5/17, showed the resident needed total assistance of two staff for bathing. During an interview on 3/19/18 at 3:30 p.m., resident #5 said he wanted, and was getting, two showers a week. Resident #5 said NF1 and himself had addressed concerns with the provision of showers with the facility, repeatedly (refer to F550). The resident voiced concerns with not having showers provided, per his preference. Review of resident #5's care plan failed to show the resident's bathing preferences of twice a week had been identified by the interdisciplinary team. 3. During an interview on 3/21/18 at 7:45 a.m., resident #6 said she liked to have at least two showers per week due to her bowel incontinence issue. Resident #6 said she did not like to smell of body odor, feces or to have greasy hair. Resident #6 said she had made the facility aware of her preferences. Review of resident #6's Quarterly MDS, with an ARD 10/3/17, showed the resident needed total assistance of 1 staff for bathing. Review of resident #6's care plan failed to show the resident's bathing preferences of twice a week had been identified by the interdisciplinary team. A review of the facility's policy, Comprehensive Care Plans, Protocol, showed, 5. The care plan is reviewed with the first Comprehensive MDS Assessment is and revised to reflect personalization and resident specific preferences.",2020-09-01
31,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2018-03-21,686,G,1,0,U1E811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and observation, the facility failed to prevent the development of one unstageable pressure ulcer on the spine; and failed to have the supplies necessary for the physician-prescribed treatment order for a Stage IV pressure ulcer on the coccyx, for 1 (#2) of 11 sampled residents. Findings include: 1. Review of resident #2's At Risk report, dated 2/20/18, showed During rounds licensed nurse called writer to room of resident. Resident was lying on left lateral side. There were two red and blanchable skin spots on her posterior spine. There was one 1 X 1 unstageable on mid- [MEDICATION NAME]. The root cause was resident is very kyphotic and tends to lean against the back of the wheelchair, creating pressure points on back. Referral to therapy. Review of resident #2's physician order, dated 2/21/18, showed Skin prep wipes every morning and at bedtime for skin breakdown. And Resident to return to bed after each meal due to skin breakdown along spine, limited to one hour up maximum. Review of resident #2's Progress Note, dated 2/22/18, showed apply [MEDICATION NAME] dressings to spinal area and change every two days. During an observation on 3/20/18 at 1:20 p.m., resident #2 was up in her chair, after the 12 o'clock meal. There was no cushion to the back of her chair. At 2:30 p.m., resident #1 was still up in her chair. During an interview on 3/20/18, staff member [NAME] stated resident #2 did not like to return to her bed. Review of resident #2's Physician order, dated 3/9/18, showed PT to evaluate for back cushion in wheelchair 17 days after the pressure area and root cause were discovered. Review of resident #2's therapy evaluation for a back cushion for pressure relief, showed it did not occur until 3/20/18, during the survey investigation, and one month after the pressure ulcer was identified. Review of resident #2' Care Plan, dated 11/15/17, showed no identification of the spine pressure ulcer, or evidence of pressure relief for the spine. During an interview on 3/21/18 at 8:10 a.m., staff member D stated the facility had been watching the pressure area very closely, and she believed the resident had, at one point, a cushion for the back of the wheelchair. Weekly skin documentation for resident #2 was requested on 3/20/18. No skin checks were provided for the unstageable pressure area on the spine. 2. Review of resident #2's Progress Note, dated 3/9/18, showed the [DEVICE] was discontinued, for the Stage IV coccyx pressure ulcer. The treatment was changed to cleanse wound with normal saline, apply Iodosorb to alginate and pack in wound, cover with foam dressing. During an interview on 3/20/18 at 1:20 p.m., staff member C stated the facility was out of Iodosorb, and could not complete resident #2's dressing change. She stated staff member G was out of the facility looking for the treatment. During an interview on 3/20/18 at 1:30 p.m., staff member G stated the facility did not carry the Iodosorb, and the Hospice nurse would bring the supplies to the facility, and do the dressing change. Review of resident #2's Physician order [REDACTED]. During an interview on 3/21/18 at 8:40 a.m., staff member C stated Hospice did not have the Iodosorb dressing, so the order was changed. The facility was unable to determine if the prescribed Iodosorb treatment was provided from 3/9/18 to 3/20/18. During an interview on 3/20/18 at 10:40 a.m., staff member [NAME] stated the nursing department had difficulties getting the medications and supplies they needed from central supply. It does not flow well and it is not safe for the residents. During an observation on 3/21/18 at 9:10 a.m., of a dressing change to resident #2's pressure ulcer, the dressing from the day before was not dated, and there was no packing removed during the dressing change, as ordered by the physician.",2020-09-01
32,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2018-03-21,689,G,1,0,U1E811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, observation, and record review, the facility failed to reduce multiple falls, one with a pelvis fracture, for 1 (#3); failed to monitor and modify interventions and failed to identify meaningful root causes for falls, for 2 (#s 3 and 11); and failed to ensure Hoyer lifts, used for transfers, were completed with sufficient staffing, for 1 (#5) of 11 sampled residents. Findings include: 1. Review of the facility Fall Report showed resident #11 fell 12 times from 10/25/17 through 3/16/18. On 12/14/17, she fell and fractured her pelvis. a. Review of resident #11's Follow-Up Report for the fall on 10/25/17, showed she fell out of her wheelchair. Her socks were slippery, and she landed on her bottom. The root cause was her non-skid socks were worn out and slippery. The recommendation for the prevention of future falls was for newer socks with a non-skid bottoms. During an observation on 3/20/18 at 10:00 a.m., resident #11 had regular socks on, and not non-skid socks. b. Review of resident #11's Follow-Up Report for the fall on 10/27/17, showed she slipped and fell on her buttocks, as she transferred herself from the wheelchair to the bed. The root cause was Pt. transferring herself said she slipped and fell . The recommendation was to lock wheelchair brakes and keep next to the bed. Automatic wheelchair brake to be installed by maintenance. Review of a second fall on 10/27/17, showed the wheelchair was not locked, and it rolled away and she fell on the floor. The facility failed to implement the locked brakes on the wheelchair. She was not wearing slipper socks. Review of the Maintenance Log, dated 10/30/17, showed Please put back up brakes on wheelchair. c. Review of resident #11's Follow-Up report for the fall on 10/28/17, showed she fell out of her wheelchair. The intervention for future fall prevention was, Dycem placed beneath and on top of her wheelchair cushion. During an observation on 3/20/18 at 10:01 a.m., resident #11's wheelchair did not have dycem on the cushion. It did have a towel. d. Review of resident #11's Follow-Up report for the fall on 10/30/17, showed she was seen slipping to the floor and was holding on to arms of wheelchair. A transfer pole was installed in her room. During an observation on 3/20/18 at 10:05 a.m., resident #11's room do not have a transfer pole. Staff member D stated the therapy department removed it, because it was not safe for the resident. The transfer pole installation and removal were not documented on the Care Plan, or in the Nursing Progress Notes. e. Review of resident #11's Follow-Up report for the fall on 11/18/17, showed she was found sitting on the floor on her bottom. Resident's cushion had slid out of the chair with her and was still under her bottom when she was sitting on the floor. PT to evaluate wheelchair cushion for proper fit and stability. The dycem intervention to prevent slipping was not mentioned in the report. No evidence was provided for the PT evaluation for the cushion. f. Review of resident #11's Follow-Up report for the fall on 12/4/17, showed she was found on the floor, laying on her back. She stated the chair flew out from under me. The investigation did not include whether the wheelchair antilock breaks were in use. The root cause was Resident fell during self-transfer. g. Review of resident #11's Follow-Up report for the fall on 12/14/17, showed the resident stated she was transferring herself to the bathroom. The wheelchair was found in a corner of the room, away from the resident. The report did not specify why the wheelchair was in a corner. The root cause was toileting need. The resident complained of right hip pain, but no injury could be noted. The resident requested to go to the emergency room . Nurse asked the resident if she was certain she felt she needed to go and pointed out that no injury at this time could be found. Resident #11 was sent to the emergency room , and returned to the facility with a [DIAGNOSES REDACTED]. h. Review of resident #11's Fall Detail report for the fall on 1/21/18, showed the resident was found on her knees, next to the bed. She was on a fall mat. The root cause was toileting needs and restlessness. No new interventions were implemented. The need to anticipate resident #11's toileting needs was not addressed in the investigation. i. Review of resident #11's Fall Detail report for the fall on 2/4/18, showed her bed was in the low position, and she rolled out of bed. She hit her head and had a right eye hematoma. No root cause was identified, or new interventions implemented. Supervision was not addressed as an intervention, or lack of, for a root cause for resident #11's 12 falls. j. Review of resident #11's Fall Detail report for the fall on 2/27/18, showed she was barefoot, and found lying on the floor in her room. She stated she was taking herself to the bathroom. No root cause we identified; signs were placed in her room to remind her to call for assistance. During an observation on 3/20/18 at 10:06 a.m., resident #11's bed was not in the low position, and there was not a fall mat in the room. Resident #11 stated she moved the bed up and down, as she needed. During an interview on 3/21/18 at 8:40 a.m., staff member A stated the facility did discuss falls in their quality assurance meeting, and noted the fall rates were higher than the facility wanted. She stated the root causes on the fall reports were not meaningful. 2. Review of resident #3's Observed Fall report, dated 3/15/18, showed CNA called this nurse to resident's room, resident was on the floor sitting in front of her wheelchair with her legs on the EZ lift; sling was off and she was still hanging on to the right handle. CNA hooked her up to the sling for the EZ stand; everything was going OK, then the left sling slipped off and down to the floor. (The resident) landed on her bottom and tweaked her back and head, had a pain level of seven. The action taken was CNA was reinforced to use a 2 person transfer. The report did not include a signature or any other interventions. During an interview on 3/20/18 at 3:30 p.m., resident #3 stated she was hysterical and cried after the fall. My butt slugged the floor hard, and it hurt my sores that were just healing. During an interview on 3/21/18 at 8:50 a.m., staff member F stated she had been the staff member transferring resident #3 the day she fell . She stated she was frazzled that day, and so she did not check the placement of the sling. She stated she still transferred resident #3 by herself, and the resident was OK with that. She stated even with two people transferring the resident the day of the fall, she would still have fallen, but would not have hit the ground so hard. 3. During an interview on 3/19/18 at 3:30 p.m., resident #5 said staff transferred him using a Hoyer lift. Resident #5 said when using the Hoyer lift, only one CNA had been in the room operating the lift. Resident #5 said he did not feel safe when that happened. Review of resident #5's Quarterly MDS, with an ARD of 12/5/17, showed the resident was a total assist of two staff for transfers. During an interview on 3/20/18 at 2:28 p.m., staff member A said the Hoyer lift is to be used by two staff members when transferring a resident. Staff member A said a representative of the lift manufacturer was in the facility two months ago and did training for all the staff on the proper techniques used for the sit to stand and the Hoyer lifts. Staff member A said she did have a CNA come to her recently and tell her she had been using the Hoyer lift by herself to transfer residents. Staff member A said she asked the CNA why she had done that. The CNA said because there was no one to help her. Staff member A said she told the CNA the Hoyer lift required two staff members during a resident transfer, and if she couldn't find another CNA or nurse to help her, she needed to get the DON or anyone from the front office to assist her with the Hoyer lift transfers.",2020-09-01
33,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2019-04-18,644,D,0,1,D2B811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to refer a resident with a newly evident or possible serious mental disorder or related condition for a Level II review, for 1 (#35) of 30 sampled residents. Findings include: Review of resident #35's provider progress note, dated 12/12/18, showed a [DIAGNOSES REDACTED]. Doing okay, will monitor . The provider progress note, dated 1/7/19, showed information that resident #35 was open to mental health care. Review of resident #35's provider order, dated 1/21/19, showed [MEDICATION NAME] 2.5 mg, was started, and it was to be given daily to the resident. The [MEDICATION NAME] was stopped on 2/27/19, due to the resident's development of tremors. Review of resident #35's provider order, dated 3/1/19, showed Quetiapine was started. Review of resident #35's MAR indicated [REDACTED]. During an interview on 4/18/19 at 8:14 a.m., staff member O stated he answered the questions on the MDS and would notify Social Services of a [DIAGNOSES REDACTED]. If it did happen, he would notify Social Services. A copy of resident #35's Level of Care Determination that included the newly evident [DIAGNOSES REDACTED]. No documention was provided prior to the conclusion of the survey.",2020-09-01
34,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2019-04-18,657,D,0,1,D2B811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to update the comprehensive care plan for a resident with a severe weight loss, for 1 (#17) of 30 sampled residents. Findings include: During an observation on 4/16/19 at 6:23 p.m., resident #17 received pureed soup and ice cream for dinner, and the resident was not served the entire pureed meal, per the facility menu plan. Review of resident #17's Nutrition Care Plan, dated 4/11/18, showed she had the potential for alteration in nutrition. The care plan was not updated with a severe weight loss, and the plan did not specify the resident's dinner meal should be limited. Review of the nutrition goal showed, I will not lose greater than five percent (weight) and I will eat greater than 75%. All interventions, except for one, were dated 4/11/18. A new intervention, dated 11/15/18, was for a mechanical soft diet texture. A review of resident #17's physician orders [REDACTED]. The resident's weight loss had been occurring over the past year. During an interview on 4/17/19 at 8:20 a.m., staff member T stated she would update the resident's care plan with any new interventions.",2020-09-01
35,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2019-04-18,686,D,0,1,D2B811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed nursing staff failed to thoroughly assess a pressure ulcer, and failed to obtain physician orders [REDACTED].#11) of 30 sampled residents. Findings include: During an observation on 4/16/19 at 11:15 a.m., resident #11 had an unstageable wound to the left heel. Review of resident #11's Admission/Readmission paperwork, dated 3/26/19, showed a pressure area to the left heel, which was unstageable, and the resident had been readmitted to the facility after a four day hospital stay. The wound measurements were not documented in the resident's paperwork. Review of resident #11's physician orders, dated 3/26/19, did not include wound treatment orders for the pressure area. During an interview on 4/17/19 at 12:40 p.m., staff member D stated she had been notified of resident #11's wound on 4/1/19, and removed the resident's Una Boots, which she believed contributed to the cause of the pressure injury to the resident's left heel. Review of resident #11's Wound Assessment Details Report, dated 4/1/19, showed the pressure area was 2.20 by 2.40 with 85 percent necrotic tissue. Review of resident #11's current treatment plan was [MEDICATION NAME] and 4x4 and wrap with gauze. The removal of the Una Boots was not documented on the plan. Review of resident #11's skin Care Plan showed it was not updated with the pressure injury until 4/15/19, over two weeks after the resident returned to the facility, although the treatment for [REDACTED]. It included off loading the resident's heel when in bed. During an interview on 4/17/19 at 1:00 p.m., staff member A stated it was typical for residents at the hospital to return to the facility without wound orders, but it was identified the facility failed to obtain the treatment order for the wound timely, to prevent worsening of the wound.",2020-09-01
36,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2019-04-18,689,D,0,1,D2B811,"Based on observation, interview, and record review, the facility failed to provide food to a resident in the form ordered by the physician for safe swallowing for 1 (#17) of 30 sampled residents. Findings include: During an interview on 4/17/19 at 8:40 a.m., staff member T stated the CNA's should know when a resident is on a pureed diet, and provide pureed snack options. During an observation on 4/16/19 at 2:35 p.m., resident #17 was eating whole cookies, while sitting in her recliner. During an observation on 4/18/19 at 10:36 a.m., resident #17 had a package of cookies in her hand. Review of resident #17's diet prescription, dated 4/1/19, showed she was on a pureed diet. During an interview on 4/18/19 at 10:16 a.m., staff member I stated she knew the resident was on a pureed diet, and resident #17 should not have been provided cookies, because she could choke on them.",2020-09-01
37,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2019-04-18,692,G,0,1,D2B811,"Based on observation, interview, and record review, the facility failed to provide a resident adequate assistance for eating; failed to assess the effectiveness of the weight loss and nutritional interventions and implement new interventions; and failed to provide a breakfast and lunch tray to a resident. The accumulation of the failures increased the risk of the resident's continued severe weight loss of 15 percent in six months, for 1 (#17) of 30 sampled residents. Findings include: During an observation on 4/16/19 at 9:09 a.m., resident #17 was sleeping in her reclining chair. No breakfast tray had been delivered to the resident. During an observation on 4/16/19 at 10:43 a.m., resident #17 had not appeared to have moved from her position, observed earlier that morning. During an observation on 4/16/19 at 12:20 p.m., resident #17 continued to appear to be in the same position from the morning observations. No lunch tray had been delivered to the resident. The resident responded to her name, smiled, and nodded 'yes' when asked if she was hungry. She was attempting to eat sugar free cookies. During an observation on 4/16/19 at 12:39 p.m., resident #17 was sleeping. An unwrapped Rice Krispee bar was on her bedside table. Review of resident #17's physician order, dated 4/1/19, showed she was on a pureed diet. During an observation on 4/16/19 at 1:43 p.m., staff member F entered resident #17's room and provided toileting care. No food or fluids were offered to the resident. During an observation and interview, on 4/16/19 at 6:23 p.m., resident #17 received a dinner tray consisting of pureed soup and ice cream. Staff member H stated the resident did not eat very much, but liked ice cream. During an interview on 4/17/19 at 8:40 a.m., staff member G stated she did not know why resident #17 did not get the pureed meal, as specified on the therapeutic breakdown sheet. She stated the resident room trays on resident #17's hall were delivered one at a time, by the CNAs, because the facility did not have a food delivery cart. She stated the facility did not serve the room trays until the CNA came to the kitchen to pick them up. During an interview on 4/17/19 at 8:30 a.m., staff member T stated the resident had been refusing meals for the past six months. Staff is offering her snacks and sandwiches. She needs more help now with eating. Staff member T stated the CNAs were responsible for making sure every resident eating in their room received a meal tray. Review of resident #17's Quarterly MDS, with the ARD of 6/20/18, showed a weight of 160 pounds. Review of resident #17's weight record, dated 11/4/18, showed the resident weighed 137 pounds. On 4/2/19, the resident weighed 120.2 pounds. Review of resident #17's Physician Order, dated 2/15/19, showed, Glucerna, one BID. During an observation and interview on 4/18/19 at 9:45 a.m., the nutritional supplement closet did not contain Glucerna. Staff member G stated she did not know any residents were to receive Glucerna. Review of resident #17's Physician Order, dated 3/26/19, showed the resident was too tired to chew her food, and her food texture was downgraded to a mechanical soft texture. No other interventions were implemented for resident #17's 40 pound weight loss. Review of resident #17's Care Plan, dated 11/15/18, showed one new intervention for the mechanical soft texture. All other interventions were dated 4/11/18. Review of resident #17's Notification to the Physician for weight loss, dated 4/10/19, showed a 15 percent weight loss in 90 days, and intakes variable but less than 50 percent. Supplements in use, sometimes accepted. No new interventions were recommended by the facility or physician. Review of resident #17's most current Dietary Evaluation, dated 2/4/19, showed Resident unwilling to accept food supplement or to eat more than 3 meals a day. Staff are providing cues and encouragement for nutrition and hydration. Recommend Glucerna or house equivalent supplementation with meals tid. No supplement was observed with the dinner meal served 4/16/19 at 6:23 p.m.",2020-09-01
38,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2019-04-18,755,E,0,1,D2B811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure expired bottles of stock medications were removed from the medication carts and not readily available for resident use; and failed to ensure culture test swabs were not being used past their expiration date. This practice had the potential to affect all residents being administered stock medications or using supplies from the facility. Findings include: Expired Stock Bottles of Medications 1. During an observation and interview on [DATE] at 9:58 a.m., of the Rim View medication cart, with staff member C, a large bottle of Vitamin E, 1,000 unit capsules, was found in the stock supply. The expiration date printed on the bottle by the manufacturer read, ,[DATE]. Staff member C stated no residents were currently taking Vitamin E, but the medication should have been checked for an expiration date and removed from the cart. Staff member C stated medications in the medication carts were available for resident use. 2. During an observation and interview on [DATE] at 10:16 a.m., of the Mountain View medication cart, with staff member N, a large bottle of Magnesium, 400 milligram (mg) tablets, was found in the stock supply. The expiration date printed on the bottle by the manufacturer read, ,[DATE]. Staff member N stated she, Thought the unit manager checked for outdates. Staff member N stated she did not check for the expiration dates on stock medications she was dispensing because that was done by someone else. Expired Culture Swabs 3. During an observation and interview on [DATE] at 1:06 p.m., of the supply storage room on the 300 hall, with staff member S, two red-top and seven blue-top BBL Culture Swabs were found expired. The red-top swabs had an expiration date of [DATE], and the blue-top swabs had an expiration date of ,[DATE]. Staff member S stated all expired supplies should have been discarded and not available for resident use. A review of the facility's policy, Storage and Expiration of Medications, Biologicals, Syringes and Needles, read, .4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines .are stored separate from other medications until destroyed or returned to the pharmacy or supplier. 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened.",2020-09-01
39,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2019-04-18,761,E,0,1,D2B811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to ensure opened multi-dose vials of insulin, being administered to residents, were dated when opened, and not being used past the open-expiration date of 28 days, for 3 (#s 17, 33, and 46) of 31 sampled and supplemental residents; and failed to ensure the storage of medications, including narcotics, found in the Emergency Kit (E-Kit) were properly secured on the 300 hall. Findings include: Insulin Pens without Open Dates 1. During an observation and interview on [DATE] at 10:14 a.m., of the Mountain View medication cart, with staff member N, three insulin pens for residents #17, #33, and #46, were found without an open date. Staff member N stated she did not administer insulin and therefore had no knowledge by whom, or when, the pens had been opened. During an interview on [DATE] at 10:50 a.m., staff member L stated she had opened and had administered insulin pens to residents #17, #33, and #46, earlier that morning. Staff member L stated she had forgotten to date each insulin pen, after opening, and had dispensed the unit dosages to the residents. Staff member L stated she should have ensured all insulin pens had been dated when opened. Staff member L proceeded to date each pen, [DATE], with a black marker. Staff member L stated the facility policy and procedure was to date when opened, multi-dose, insulin pens immediately after being opened and administered to the residents. a. Resident #17 was admitted to the facility with [DIAGNOSES REDACTED]. A review of resident #17's (MONTH) 2019 Medication Administration Record [REDACTED]. The start date was [DATE] at 6:00 a.m. b. Resident #33 was admitted to the facility with [DIAGNOSES REDACTED]. A review of resident #33's (MONTH) 2019 MAR indicated [REDACTED]. The start date was [DATE] at 8:00 a.m. c. Resident #46 was admitted to the facility with [DIAGNOSES REDACTED]. A review of resident #46's (MONTH) 2019 MAR indicated [REDACTED]. The start date was [DATE] at 6:00 p.m. A review of the facility's policy, Storage and Expiration of Medications, Biologicals, Syringes and Needles, read, .4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines .are stored separate from other medications until destroyed or returned to the pharmacy or supplier. 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened .12. Controlled Substances Storage: 12.1 Facility should ensure that Schedule II - V controlled substances are only accessible to licensed nursing, Pharmacy, and medical personnel designated by Facility .Facility should ensure that Scheduled II - V controlled substances are immediately placed into a secured storage area (i.e., a safe, self-locked cabinet, or locked room, in all cases in accordance with Applicable Law. 12.3 Facility should ensure that all controlled substances are stored in a manner that maintains their integrity and security. Unsecured E-Kit medications 2. During an observation and interview on [DATE] at 1:06 p.m., of the medication storage room on the 300 hall, with staff member S, there was an unsecured E-Kit with medications, including narcotics. Staff member S stated the E-Kit had not been locked for the last six months. Staff member S stated the management staff, and the unit manager, were aware of the unsecured E-Kit. During an interview on [DATE] at 1:15 p.m., staff member U stated the E-Kit had never been kept locked, and two nurses had keys to the medication room, where the kit was kept. During an interview on [DATE] at 1:28 p.m., staff member A stated she had not been aware of the unsecured E-Kit on the 300 hall. During an interview on [DATE] at 9:31 a.m., staff member R stated he was aware of the cabinet not locking. He stated he had the information in his monthly reports for the past few months. Staff member R said ideally the narcotics should be double locked per the regulations.",2020-09-01
40,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2019-04-18,883,E,0,1,D2B811,"Based on interview and record review, the facility failed to determine whether residents had or had not received both PCV-13 and PSV-23 immunizations for 3 (#s 17, 21, and 28); failed to offer/provide PCV-13 for 2 (#s 17 and 28); and failed to provide PSV-23 for 1 (#21) of 30 sampled residents. Findings include: 1. Review of the immunization record for resident #17 showed PSV-23 was administered on 1/11/18. No documentation of refusal or administration of PCV-13 was found. 2. Review of the immunization record for resident #21 showed PCV-13 was administered on 1/10/18. Administration of PSV-23 was documented on 4/17/19, after the start of the survey. 3. Review of the immunization record for resident #28 showed PSV-23 was administered on 1/12/18. No documentation of refusal or administration of PCV-13 was found. During an interview on 4/18/19 at 7:59 a.m., staff member P stated the previous corporate owner did a house-wide pnuemonia vaccination in (MONTH) of (YEAR). Staff member P stated there needed to be a year between administration of the PCV-13 and the PSV-23. As PCV-13 was to be given first, the residents (#17 and #28) that recieved PSV-23 must have already received PCV-13. Staff member P stated, I guess I need to look into this to see if they (residents #17 and #28) actually received PCV-13. When asked, staff member P stated we (staff members A, P, and Q) talked this week about an audit to check the pneumonia vaccine status of all residents.",2020-09-01
41,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2018-06-14,554,D,0,1,JJY911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents, who had medications in their room, stored them safely, and had physician orders [REDACTED].#s 3 and 61) of 19 sampled residents; and failed to assess 1 (#3) of 19 sampled residents for self-administration of medications. Findings include: 1. During an interview on 6/12/18 at 3:06 p.m., resident #3 stated she had been sick, with a bad cold, during the winter. She stated she was doing okay, as she had medications like cough drops, and a rub, that she could take by herself. She did not know where the medication was at the time, as she had moved from one room to another. Review of resident #3's Annual MDS, with an ARD of 12/12/17, showed the resident had a score of 14, very little to no cognition problems. Review of resident #3's Order Review Report, dated 4/1/18 - 4/30/18, showed the resident only had a medicated chest rub ointment, as needed for congestion, may have at bedside. The order date was 2/25/18. During an interview on 6/13/18 at 2:18 p.m., staff member B stated resident #3 did have a physician order [REDACTED].#3 to self-administer any medications. The staff member was unable to find the medications in resident #3's room. The staff member said the nursing staff were getting a discontinuation order of the medication. Review of resident #3's Care Plan, with a revision date of 5/31/18, did not show the resident was able to self-medicate any medication. Review of a Nurse/Provider Communication Form, dated 6/13/18, showed nursing staff had requested an order to discontinue the at the bedside order for resident #3's [MEDICATION NAME] cream, as the resident had not been using it for the past 30 days. There was no document showing the facility had put in a request to discontinue the chest rub or that the nursing staff were aware that resident #3 had cough drops. 2. During an observation and interview on 6/11/18 at 4:48 p.m., an opened bottle of Tums antacids, an opened container of [MEDICATION NAME] topical powder, and a squeeze bottle of Equate nasal spray were on a shelf, above resident #61's bedside stand. During the interview, resident #61 stated he had a physician's orders [REDACTED]. Review of resident #61's Annual MDS, with an ARD of 7/4/17, showed the resident was capable of making reasonable decisions. Review of resident #61's Physicians' Recapitulation orders, dated 4/1/18 - 4/30/18, showed resident #61 had orders for: - Calcium antacid tablet chewable 500 mg, give one tablet by mouth every two hours as needed for heartburn, 15 times maximum, may keep at bedside, - Ayr saline nasal no drip gel, 1 unit in each nostril every eight hours as needed for dry nares. The order did not include self-administration of the medication and, - [MEDICATION NAME] 100,000 U/G powder, apply to affected area topically three times a day for rash. The order did not include self-administration of the medication. During an interview on 6/14/18, at 9:07 a.m., staff member J stated resident #61 was administering nasal spray and antacids by himself. The staff member stated resident #61 did not have an order to self-administer the nasal spray or powder. Review of resident #61's Self-Administration of Medication Evaluation, showed he had been assessed to have Tums, one by mouth as needed on 8/10/17. The evaluation did not include the [MEDICATION NAME] powder, or the nasal spray. The form showed the self-administration of the medication would be on the care plan. Review of resident #61's Care Plan, with a review completion date of 6/8/18, did not show that resident #61 was able to safely self-administer the Tums, the [MEDICATION NAME] powder, or the nasal spray. The care plan did not include a plan to address safety for other residents, related to the medications not being secured in a locked place, but in resident #61's room, on a shelf, viewable from the doorway. Review of a revision of resident #61's Care Plan, dated 6/13/18, showed an addition that the resident's ability to have only Tums by his bedside, and a self-administration review would be completed every three months, in conjunction with the MDS calendar. The care plan did not include the self-administration of the [MEDICATION NAME] or the nasal spray.",2020-09-01
42,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2018-06-14,584,D,0,1,JJY911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to assist moving a resident into her room for 1 (#3) of 19 sampled residents, leaving the resident's room with boxes in the middle of the floor. Findings include: During an observation and interview on 6/11/18 at 2:55 p.m., two large boxes were sitting between resident #3's bed and her bedside table. Resident #3 stated she had been in the hospital. Prior to the hospital visit, the resident's roommate had bed bugs, and the resident had to move to another room. The infected room was sprayed for the bugs and her belongings were treated. The resident stated the social service person had moved her boxes down to her room but no one would help her put her belongings away. The resident stated the CNAs told her the task was not their job and they had too much to do. During an interview on 6/14/18 at 8:45 a.m., staff member S stated she had moved resident #3 back to her room. She had folded the resident's clothes and placed them in the dresser. The staff member stated she had not been back to resident #3's room and was unaware the resident still had unpacked boxes on the floor, in her room. The staff member stated she was unaware no staff had assisted resident #3 to finish unpacking. The staff member stated she had so much work, she could not follow up with resident #3's move. The staff member stated she had hoped the CNAs would have helped the resident with the remaining items. Review of resident #3's progress notes, dated 5/31/18, showed the resident was told she could move back to room [ROOM NUMBER]. The document showed staff could help with the move.",2020-09-01
43,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2018-06-14,657,D,0,1,JJY911,"Based on observation, interview, and record review, the facility failed to ensure the care plan was updated to reflect the resident's current care needs and address fractured fingers on the resident's right hand, for 1 (#65) 19 sampled residents. Findings include: During an interview on 6/11/18 at 3:30 p.m. resident #65 stated she had fallen about a week or so ago while in the facility. She stated she broke two fingers on her right hand. During an observation on 6/11/18 at 3:30 p.m., resident #65 had an ace wrap around her right forearm, wrist, and fingers. Review of resident #65's care plan showed no information regarding the fractures fingers on the care plan. The care plan was dated 6/2/18.",2020-09-01
44,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2018-06-14,658,D,0,1,JJY911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow professional standards of practice for counting narcotics at shift change to ensure the proper count for narcotics for 1 (#52); and failed to administer a medication as prescribed by a physician's orders [REDACTED]. Findings include: 1. During an observation on 6/13/18 at 1:45 p.m. staff member G was preparing medications for resident #52. A review of the resident's MAR indicated [REDACTED]. Staff member G took one pill out leaving seven pills. Staff member G opened the narcotic book to sign out the [MEDICATION NAME]. The book showed there were seven pills left and when staff member G took one out, there would then be six pills left. The last dose of [MEDICATION NAME] signed out was on 6/12/18 at 10:30 p.m. by staff member R. Staff member G looked at the pill she had taken out and stated the color of the pill was different than the color of the [MEDICATION NAME]. The [MEDICATION NAME] was dark purple in color and the pill taken out was light pink in color. [NAME] tape was observed taped on the back of the blister pack. Staff member G requested staff member C to come to the unit. Staff member G informed staff member C of the findings. During an interview on 6/13/18 at 1:45 p.m., staff member G stated she had counted the narcotics at shift change with staff member R. She stated staff member R looked at the book and she looked at the narcotic blister pack. She stated they would call out the page number for the medication while one nurse would look at the blister pack and the other nurse would look at the narcotic book during the count. During an interview on 6/13/18 at 2:25 p.m. staff member Q stated the nurses normally call the page number out, one nurse looks at the blister pack, and one nurse looks at the narcotic book. She stated neither of the nurses look at both the blister pack and the narcotic book when counting the narcotics. During an interview on 6/14/18 at 10:00 a.m., staff member C stated both staff members G and R had been suspended pending an investigation. 2. During an observation of medication administration on 6/12/18 at 7:50 a.m., staff member AA administered resident #43 one calcium antacid chewable tablet of 500 mgs orally. A review of resident #43's Order Review Report, showed the resident was ordered to receive calcium [MEDICATION NAME] 600 mg tab, 1 tab PO one time per day. During an interview on 6/13/18 at 8:45 a.m., staff member U was shown resident #43's physician's orders [REDACTED].#43's corresponding medication bottle from the facility's medication cart. She provided the same stock bottle of calcium antacid tablets, 500 mgs per tab, that had been used to administer resident #43's calcium [MEDICATION NAME] on the morning of 6/12/18. Staff member U was shown resident #43's physician order [REDACTED]. During an interview on 6/13/18 at 3:00 p.m., staff member A said the new corporation took over the administration of the facility on (MONTH) 1st of this year. He said prior to (MONTH) the facility owned pharmacy allowed resident families to bring into the facility over the counter medications purchased from outside retail stores to be given to the resident by the nurses if the resident's physician had ordered the medication. Staff member A said this was no longer allowed by the present pharmacy. He said he thought this explained the reason for the discrepancy in the dose and type of calcium that resident #43 had been receiving as compared to what the resident's physician had ordered.",2020-09-01
45,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2018-06-14,677,D,1,1,JJY911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, facility staff failed to answer call lights and respond to, or follow up on, resident care needs in a timely manner, for 3 (#s 3, 13, and 27), which caused #3 and #37 incontinent episodes, of 31 sampled and supplemental residents. Findings include: During an interview with the resident group on 6/12/18 at 1:56 p.m., residents stated the call light response time was terrible. They stated sometimes it would take up to one hour before someone would answer the call light. They stated, many times someone did not answer the call bell in time, and this would cause some resident's to be incontinent of bowel or bladder. The residents stated when that happened to them, it made them feel less than human or unclean. The resident group, consisting of 10 out of 10 residents, were unanimous in their feelings that the facility did not have enough staff to help all the residents with their care needs. During an interview on 6/11/18 at 2:55 p.m., resident #3 stated that when she used the toilet, she was often left in the bathroom for 45 minutes. The resident stated she was continent but had accidents (incontinent) if staff did not come for a lengthy amount of time. During an interview on 6/12/18 at 8:46 a.m., resident #27 stated that if staff did not assist in time, she had to go in her pants (incontinence). She stated she used the toilet and had no accidents if staff assisted timely. The resident stated she waited quite a while for staff to answer her call light. During an observation on 6/11/18, at 3:20 p.m., a call light went off in room [ROOM NUMBER]. room [ROOM NUMBER]'s call light was answered by staff at 3:47 p.m., after a span of 27 minutes. During an observation on 6/12/18 at 3:22 p.m., a call light was going off. Staff member M was overheard telling resident #13 that only two CNAs were on the hall. The staff member stated she was too busy to help answer call lights. During an interview on 6/12/18 at 3:30 p.m., staff members W and X stated they were traveling staff and staff W had no official training before working on the hall. They both said they were just trying to meet the needs of the residents, through their previous working experience. Staff member X stated she had worked one day on the hall, with a veteran CNA, and there had been more staff working on the entire hall, more than just two CNAs. Staff member M stated she had never worked on this floor. The three staff members stated they were unfamiliar with the residents and did not know their preferences. During an interview on 6/13/18 at 10:00 a.m., staff member Y stated traveling staff reviewed policies and she tried to have an experienced staff with them to assist on their first time in the facility. The staff member stated she was aware the staff on the floor were swamped and she tried to help when she could. The staff member stated the facility was hiring new staff and they should be on the floor soon.",2020-09-01
46,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2018-06-14,684,D,0,1,JJY911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility nursing staff failed to provide bowel regimen care for 1 (#66) of 19 sampled residents which resulted in significant discomfort for the resident. Findings include: During an interview on 6/12/18 at 9:05 a.m., resident #66 stated she had constipation problems, no regular bowel movements, and discomfort because of the constipation. Review of resident #66's Significant Change MDS, with an ARD of 5/21/18, showed the resident was cognitively intact. The MDS showed the resident was dependent on staff for toileting and required a two person assist. Review of resident #66's Care Plan, with a review completion date of 6/8/18, showed no documentation that the facility staff had identified a concern with the resident's constipation concerns. Review of the BM Report, for bowel movements, dated 3/22/18 through 6/13/18, showed resident #66 had no documentation of bowel movements from: - 3/22/18 until 3/31/18, nine days without a bowel movement documented, - 4/1/18 until 4/11/18, ten days without a bowel movement documented, - 4/12/18 until 4/20/18, eight days without a bowel movement documented, - 4/22/18 until 4/27/18, five days without a bowel movement documented, and - 4/28/18 until 5/8/18, ten days without a bowel movement documented. Review of resident #66's physician orders, dated 3/1/18 - 3/31/18, showed the resident had an order, with a start date of 3/6/18, for [MEDICATION NAME] solution, 10 grams, one time a day, every other day for constipation. Another order, with a start date of 3/6/18, showed the resident had a decrease in the amount given of [MEDICATION NAME] 10 g/15 ml syrup, give 30 ml every six hours as needed, to giving [MEDICATION NAME] 30 ml every 48 hours as needed. Review of physician orders, dated 4/1/18 - 4/30/18, showed resident #66 had an order for [REDACTED].>- Polyethylene [MEDICATION NAME], 17 grams powder, give by mouth one time a day for constipation. The order date was 1/22/18 and the start date was 2/26/18, over a month from the order date. There was no documentation showing the physician had been made aware of the medication not being given for over a month. - An order, dated 4/23/18 for Tucks pads, to apply to hemorrhoids three times daily as needed; and, - The order for [MEDICATION NAME] 10 g/15 ml syrup, give 30 ml every 48 hours as needed, was changed on 4/23/18 to every day as needed. A review of the facility's Bowel Management Policy, with a revision date of 2/20/17, showed if there was a change in the resident's pattern of bowel movement, the facility would notify the physician and then follow up to ensure the physician's orders [REDACTED]. During an interview on 6/14/18 at 10:15 a.m., staff member B stated that reviewing the bowel documentation for resident #66, showed the resident was improving since the new company took over the facility in (MONTH) (2018). Review of the BM Reports showed from 3/22/18 until 5/8/18, resident #66's bowel regime had no consistency. There were many days between bowel movements. The physician's orders [REDACTED]. There was no documentation showing the physician was aware of resident #66 having pain related to constipation. The care plan showed no documentation that the facility staff were aware resident #66 was having constipation.",2020-09-01
47,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2018-06-14,692,D,0,1,JJY911,"Based on observation and interview, the facility staff failed to provide water to residents in their rooms for hydration, for 2 (#s 39 and 61) of 19 sampled residents. Findings include: During an observation and interview on 6/13/18 at 2:29 p.m., resident #61 did not have water in his room. He stated staff did not pass water to the residents' rooms and said the staff told him they were too short staffed to pass the water. During an observation and interview on 6/11/18 at 2:14 p.m., resident #39 requested a drink of cold water. No water was available in the large water glass on the bedside table, next to her bed. During an interview on 6/12/18 at 4:00 p.m., staff member H stated all shifts should be passing water to residents' rooms. During the resident group interview on 6/12/18 at 1:56 p.m., the residents stated they did not feel there was enough staff. They stated many times they would not get water passed during the day, because the staff were too busy to complete the task.",2020-09-01
48,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2018-06-14,695,D,0,1,JJY911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have a policy to ensure regular cleaning of [MEDICAL CONDITION] equipment to prevent respiratory infection for 1 (#9) of 31 sampled and supplemental residents. Findings include: During an observation on 6/13/18 at 3:35 p.m., resident #9 was in her room. She had an oxygen concentrator and a [MEDICAL CONDITION] machine connected with tubing to a [MEDICAL CONDITION] mask at her bedside. None of the respiratory equipment was labeled for dates when it had been placed into use. During an interview on 6/13/18 at 3:35 p.m., resident #9 said she used her [MEDICAL CONDITION] machine every night for sleeping. She said she used it with humidification and pointed to a gallon jug of distilled water on her bedside table with approximately one cup of liquid left. The opened jug was not labeled with an open date. She said she would need more distilled water for the upcoming night. She said in the past she had to argue with staff to get distilled water because staff had told her it was okay to use water from the room sink, and she said she knew that was not safe. She said she had to ask staff to clean her [MEDICAL CONDITION] mask otherwise it would not get done. She said she liked to have it cleaned at least once a week. She did not remember what the manufacturer's instructions were as to how often her [MEDICAL CONDITION] equipment should be cleaned or when the last time her [MEDICAL CONDITION] machine had been checked. She said she did not know when the last time the connecting tubing to her [MEDICAL CONDITION] machine had been changed. A written request was made on 6/13/18 at 5:30 p.m. for the facility to provide a copy of the [MEDICAL CONDITION] policy. As of 6/14/18 at 10:00 a.m., a policy had not been provided. The facility did provide reference materials sent by the facility's respiratory equipment contract company that showed the [MEDICAL CONDITION] equipment manufacturer's instructions should be followed for the cleaning of each individual resident's type of [MEDICAL CONDITION] mask. During an interview on 6/14/18 at 10:00 a.m., staff member B said she was not aware that the facility had a [MEDICAL CONDITION] policy. She asked staff member Z if the facility corporation had a [MEDICAL CONDITION] policy that would apply to the facility. Staff member Z said as far as she knew the facility did not have a [MEDICAL CONDITION] policy that covered the procedures for cleaning and maintenance of resident [MEDICAL CONDITION] equipment.",2020-09-01
49,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2018-06-14,698,D,0,1,JJY911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain and document vital signs when the resident returned to the facility after having [MEDICAL TREATMENT], failed to send medication to the [MEDICAL TREATMENT] clinic to be given as prescribed during [MEDICAL TREATMENT], and failed to plan individualized interventions for [MEDICAL TREATMENT] care for 1 (#s 48) of 3 sampled and supplemental residents on [MEDICAL TREATMENT]. Findings include: 1. During an interview on 6/13/18 at 8:50 a.m., staff member U said to prepare resident #48 for her scheduled [MEDICAL TREATMENT] treatment, she planned to get her FSBS and to administer her with sliding scale insulin if needed. She said she normally did not take the resident's vital signs and weight before sending the resident to the [MEDICAL TREATMENT] clinic. She said after residents returned from [MEDICAL TREATMENT], she usually checked their arteriovenous shunt sites for bleeding, and depending on how the resident looked, she might take the resident's vital signs. When shown a copy of the facility's [MEDICAL TREATMENT] Communication Record, staff member U said she had not previously seen the form and had never used it. A review of resident #48's TARS for (MONTH) and (MONTH) of (YEAR), did not show documentation of the resident's vital signs upon returning to the facility after [MEDICAL TREATMENT] treatments. A review of resident #48's Care Plan showed, Resident is at risk for End Stage [MEDICAL CONDITION] r/t Chronic Kidney Failure AEB weekly [MEDICAL TREATMENT]. Date Initiated 4/25/18. The interventions showed, Resident will be compliant with [MEDICAL TREATMENT] Appointments. The care plan did not mention the need for nursing assessments to include measurements of the resident's vital signs upon return to the facility, following [MEDICAL TREATMENT] treatment. 2. A review of resident #48's MARS for (MONTH) and (MONTH) (YEAR), showed the resident was ordered on [DATE] to receive [MEDICATION NAME] HCL 10 mg tablet, one tablet by mouth as needed for [MEDICAL CONDITION]. The order showed, Take at the beginning of [MEDICAL TREATMENT] and may repeat dose 1 hour before the end of treatment if needed. The MARS did not reflect resident #48 had received [MEDICATION NAME] during (MONTH) or June. A review of resident #48's [MEDICAL TREATMENT] Communication Records for (MONTH) and (MONTH) (YEAR), showed resident #48 received [MEDICATION NAME] on 5/4/18 and 5/14/18 as administered by the staff at the [MEDICAL TREATMENT] clinic. [MEDICATION NAME] had been sent by the facility with the resident went to the [MEDICAL TREATMENT] clinic on 5/4/18. The notes did not reflect the [MEDICATION NAME] had been sent with the resident on 5/14/18. During an interview on 6/13/18 at 8:57 a.m., staff member U said she had not sent [MEDICATION NAME] to the [MEDICAL TREATMENT] clinic for resident #48's use in the past. She said she did not know if the [MEDICAL TREATMENT] clinic had a stock of [MEDICATION NAME] to give to the resident if needed. During an interview on 6/13/18 at 9:00 a.m., NF1, at the ([MEDICAL TREATMENT] clinic) said, the clinic's renal doctor had ordered the [MEDICATION NAME] for resident #48 to be given as needed for [MEDICAL CONDITION] during [MEDICAL TREATMENT] treatment. She said the [MEDICAL TREATMENT] center did not keep stock medications. She said the facility had been called in the past and had sent [MEDICATION NAME] with the facility's driver to the [MEDICAL TREATMENT] clinic so resident #48 could be treated for [REDACTED]. When the [MEDICATION NAME] had been administered, the [MEDICAL TREATMENT] clinic had documented it on the resident's [MEDICAL TREATMENT] Communication Order. The resident had been scheduled for [MEDICAL TREATMENT] at the [MEDICAL TREATMENT] clinic twice a week for the months of (MONTH) and (MONTH) in (YEAR). Resident #48's prescription for [MEDICATION NAME] was to have been given at the beginning of each [MEDICAL TREATMENT] treatment and then it could have been repeated if needed. It had been given twice during the month of (MONTH) and had not been given in (MONTH) of (YEAR). 3. A review of resident #48's Order Review Report, dated (MONTH) 3, (YEAR), showed the resident was ordered to be monitored for thrill and bruit of her [MEDICAL TREATMENT] shunt/fistula daily, monitored for s/s of shunt/fistula for infection every shift, and not to have blood draws or her blood pressure taken on the arm with her shunt/fistula. The resident was also ordered a renal diet without potatoes, tomatoes, oranges and bananas. In an interview on 6/13/18 at 8:57 a.m., staff member U said resident #48 took all of her medications except for her insulin after she returned to the facility from her [MEDICAL TREATMENT] treatment. A review of resident #48's Care Plan showed only one intervention: Resident is at risk for End Stage [MEDICAL CONDITION] r/t Chronic Kidney Failure AEB weekly [MEDICAL TREATMENT]. Date Initiated 4/25/18. The care plan did not show specific information regarding the resident and her needs related to [MEDICAL TREATMENT]. It did not show how often, when, or where the resident was scheduled to receive [MEDICAL TREATMENT] treatments. It did not show how the resident was to be transferred to and from the facility for [MEDICAL TREATMENT] care. It did not show the residents need for the assessments of vital signs before and after [MEDICAL TREATMENT], shunt/fistula assessments for bruit, thrill or s/s of infection, weight measurements for potential fluid imbalance, or lab follow-ups for abnormal electrolyte concerns. The care plan failed to reflect the resident's medications were to be held until after her return from [MEDICAL TREATMENT] on the days she was scheduled to receive [MEDICAL TREATMENT]. The care plan did not show that the [MEDICAL TREATMENT] clinic had been notified of the resident's end of life wishes in case of emergency at the [MEDICAL TREATMENT] clinic. The care plan did not show the resident had been educated about her renal diet and to avoid potatoes, tomatoes, oranges and bananas. `",2020-09-01
50,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2018-06-14,755,E,1,1,JJY911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to maintain an accurate Narcotic Log Record, which reflected the medications administration count of controlled medications for 3 (#s 7, 52, and 234) of 31 sampled and supplemental residents; the facility failed to maintain an accurate Controlled Substance Record which reflected the physician ordered medications for 1 (#59) of 31 sampled and supplemental residents; and failed to timely administer a controlled substance that had previously been signed out as administered for 1 resident (#50) of 19 sampled residents. Findings include: 1. Inaccurate Controlled Substance Record: a. During an observation on 6/13/18 at 1:58 p.m., staff member M reviewed the medications in the narcotic lock box of the Rehab One Medication Cart. A comparison of the Narcotic Log Book, page 30, with the medication card numbered 30, showed a discrepancy. The Narcotic Log Book showed resident #7's Sildenafil 20 mg tablets, had a count of 5 remaining. The medication card, numbered 30, for resident #7's Sildenafil 20 mg tablets, showed a count of 4 tablets remaining. Review of resident #7's EMAR showed one, Sildenafil 20 mg tablet, was administered to the resident on 6/13/18 at 11:00 a.m. During an interview on 6/13/18 at 2:17 p.m., staff member M stated she had prepared resident #7's Sildenafil tablet at 11:00 a.m., that day, not realizing the resident had left the facility. She stated she had already signed the medication as given on the EMAR at 11:00 a.m. She said she did not give the medication to the resident until around 2:00 p.m., when the resident returned to the facility. She stated the facility's expectation was not to sign out medication before they were given to the resident. She stated she must have forgot to sign the Sildenafil out of the Narcotic Log Book after she removed the pill from the blister pack in the narcotic lock box. She stated all controlled medications should be signed out in the Narcotic Log Book immediately after removing them from the lock box for administration. b. During an observation on 6/13/18 at 2:26 p.m., staff member N reviewed the medications in the narcotic lock box of the Rehab Two Medication Cart. A comparison of the Narcotic Log Book, page 28, with the medication card numbered 28, showed a discrepancy. The Narcotic Log Book showed resident #234's [MEDICATION NAME] HCL 2 mg tablets, had a count of 15 tablets remaining. The medication card numbered 28, for resident #234's [MEDICATION NAME] HCL 2 mg tablets, showed a count of 16 tablets remaining. Review of resident #234's EMAR showed the resident was administered [MEDICATION NAME] 2 mg on 6/13/18 at 11:01 a.m. During an interview on 6/13/18 at 2:26 p.m., staff member N stated she must have forgot to sign the medication out in the Narcotic Log Book earlier that day. She stated it was the expectation to sign out the medication in the Narcotic Log Book immediately after dispensing the medication from the lock box. During an interview on 6/13/18 at 3:12 p.m., resident #234 stated she felt her pain was well managed by the staff, and had no concerns with not being able to get her pain under control. She stated once pain medication was given as ordered, it worked quickly. During an interview on 6/13/18 at 3:00 p.m., staff member B stated it was the expectation all controlled medications were accounted for in the Narcotic Log Book. She stated the Narcotic Log Book should accurately reflect what was remaining in the medication card for each resident. She stated any discrepancies should be reported to the nurse manager. She stated it was not an acceptable method to administer a controlled medication and sign it out at a later time. The staff member stated it was also not acceptable to prepare a medication, sign it out in the EMAR as administered, and give the medication at a later time than the time it was signed out as administered. During an interview on 6/14/18 at 9:16 a.m., staff member O stated he performed a 10% audit of the controlled medications once a month. He stated an audit was also conducted by the nursing quality review when the new administration became effective in (MONTH) (2018). He said they conducted a thorough audit of all the Narcotic log books and narcotics in the facility. He said a review of both audits, had no incidents of concerns with discrepancies between the two. c. During an observation on 6/13/18 at 1:45 p.m., staff member G was preparing medications for resident #52. Staff member G looked at the medication record, looked at the narcotic book for resident #52, and obtained a blister pack of medication for resident #52 out of the narcotic drawer. Staff member G popped the medication out of the blister pack and showed the card to the surveyor. Staff member G started to sign out the narcotic medication in the narcotic book. It was observed that the narcotic count was incorrect. The medication taken out of the blister pack was different than the medication in the blister pack and there was white tape placed on the back of the medication blister pack where staff member G had removed the medication. The medication staff member G removed was light pink in color and the medication in the blister pack was dark purple in color. During an interview on 6/13/18 at 1:45 p.m., staff member G stated she counted the narcotics with staff member R when she came on shift. She stated the narcotic count was right. She said she did not look at the book when she counted that morning. Staff member G stated she had only looked at the blister pack and staff member R looked at the narcotic book. Staff member G called for staff member C to inform her of the findings. During an interview on 6/13/18 at 2:25 p.m. staff member Q stated during the narcotic count, they normally call the page number out and one nurse looked at the narcotic book while the other nurse looked at the blister pack. She stated neither nurse looked at both the blister pack and the book. During an interview on 6/14/18 at 10:00 a.m., staff member C stated staff members G and R were both suspended pending an investigation. A review of the facility's policy and procedure titled, Controlled Medications Count, showed: It is the policy of the facility to maintain an accurate count of Scheduled II and controlled medications. 1. After removing the controlled medication from the blister pack or the individual packet, the nurse will sign off the accompanying controlled medication sheet indicating the medication is taken. 2. After administration of the controlled medication, the nurse will sign off the EMAR. 3. If the controlled medication needs to be wasted, another nurse should witness the wasting of the controlled medication. 2. Inaccurately Transcribed Order: During an observation on 6/13/18 at 1:58 p.m., staff member M reviewed the medications in the narcotic lock box of the Rehab One Medication cart. A comparison of the Narcotic Log Book, pages 57 and 59, with the medication cards numbered 57 and 59, showed a discrepancy. The medication cards showed resident #59 was to receive [MEDICATION NAME] 50 mg tablet, give half of a tablet (25 mg), by mouth every six hours, PRN pain. A review of the Narcotic Log Book pages 57 and 59, showed the order was written, [MEDICATION NAME] 25 mg tablet, give half of a tablet for a total of 12.5 mg, every six hours, PRN pain. Review of resident #59's Physician Orders, dated (MONTH) (YEAR), showed an order for [REDACTED]. During an interview on 6/13/18 at 1:58 p.m., staff member M stated she was not sure who had transcribed the order from the card into the Narcotic Log Book. She stated she had not noticed the discrepancy between the two, even after completing the narcotic count with the outgoing nurse. She stated it was the facility policy that a second nurse check the orders and the transcription of the medication card into the Narcotic Log Book for accuracy. She stated there was a time when the facility did not have enough staff and there was not always a second nurse to check the accuracy of the nurse transcription into the narcotic logs. During an interview on 6/13/18 at 4:33 p.m., staff member B stated it was the expectation the Narcotic Log Book accurately reflect the medication as on the medication card and the physician order. She stated it was the expectation the nurses double check the new order after it was transcribed into the Narcotic Log Book. 3. Narcotic Medications Recorded as Given but not Administered: During an observation on 6/13/18 at 2:00 p.m., a medication count was conducted of the narcotics on the medication cart and refrigerator on the Mountain View Hall, with staff member T. The count showed the number of [MEDICATION NAME] 0.5 mg tabs contained in the narcotic card, held in the cart, for resident #50 was 29. At the same time, the corresponding narcotic record for the [MEDICATION NAME] showed 28 tabs should still be contained in the card. The card was counted a second time by staff member T, and he verified the count was over by one, which was an [MEDICATION NAME] 0.5 mg tablet. Staff member U had signed out the last dose of [MEDICATION NAME], which was given at 10:10 a.m. that morning. During an interview on 6/13/18 at 2:00 p.m., staff member U reviewed the narcotic card and narcotic record counts. She said she had participated in the narcotic count at shift change in the morning and that it had been correct. She said she must not have poured an [MEDICATION NAME] 0.5 mg tab into the medication cup she had prepared for resident #50 at 10:10 a.m. She poured an [MEDICATION NAME] 0.5 mg tab into a disposable medication cup and crossed out the 10:10 a.m. time on the narcotic record, wrote above it 2:00 p.m., and proceeded to go to resident #50's room and gave resident #50 the [MEDICATION NAME] tablet. Staff member U stated she would provide a copy of the medication error report to the survey team when she completed it. The report was not received by the end of the survey.",2020-09-01
51,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2018-06-14,759,E,1,1,JJY911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% in which three medications were omitted from the medication administration for 1 (#227), and failed to administer a medication in the dose and type prescribed, for 1 (#43), of 31 sampled and supplemental residents. The facility's medication error rate was 7%. Findings include: 1. During an observation on 6/12/18 at 7:40 a.m., staff member L prepared and administered the following medications for resident #227: - [MEDICATION NAME] 5 mg, one tablet, - Carvedilol 3.125 mg, one tablet, - [MEDICATION NAME] 20 mg, one tablet, - acidophilus, one tablet, - [MEDICATION NAME] Inhaler 250/50 mcg, one puff, - aspirin 81 mg, one tablet, - calcium 500 mg with Vitamin D, one tablet, - [MEDICATION NAME] and [MEDICATION NAME], two capsules, - magnesium 64 mg, one tablet, - Senna Plus, one tablet, - Thera-M, one tablet, - [MEDICATION NAME] 80 mg, one tablet, - cranberry 465 mg, one tablet. Review of resident #227's EMAR for (MONTH) (YEAR), and the Physician order [REDACTED]. - one losartan 50 mg tablet for hypertension, - one [MEDICATION NAME] 25 mg tablet for [MEDICAL CONDITION], and - one [MEDICATION NAME] 5 mg tablet for history of urinary [MEDICATION NAME]. During an interview on 6/13/18 at 11:34 a.m., staff member L stated she was not aware she had omitted the three medications from her medication pass for resident #227. She stated she reviewed the medications on the EMAR and then retrieved the medication card. She would then pop the medication out of the card, and return the card to the drawer. She stated the EMAR could be confusing, because there were medications which were ordered at different times so the EMAR would not turn yellow even if the medication was due at the same time as the other medication. She stated the medications were entered into the EMAR by the nurse manager, and sometimes different nurse managers order the medications differently. The staff member stated she felt there was not always consistency with the way the medications were entered into the EMAR. She stated the only time she would intentionally omit medications from a resident's medication regimen, would be if there was a physician order, or the resident was outside of a safe parameter for administration; for example, if a pulse was too low, or a blood pressure was too low. During an interview on 6/13/18 at 11:45 a.m., staff member C stated it was the expectation of staff to use the rights of medication administration, follow any new physician orders, and administer medications as outlined in the EMAR for every resident. A review of the facility's policy and procedure, titled Medication Pass, showed, It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures . 2. During an observation of medication administration on 6/12/18 at 7:50 a.m., staff member AA administered resident #43 one calcium antacid chewable tablet of 500 mg orally. A review of resident #43's Order Review Report, showed the resident was ordered to receive calcium [MEDICATION NAME] 600 mg tablet, one tablet PO one time per day. During an interview on 6/13/18 at 8:45 a.m. staff member U was shown resident #43's physician's orders [REDACTED].#43's corresponding medication bottle from the facility's medication cart. She provided the same stock bottle of calcium antacid tablets, 500 mg per tab, that had been used to administer resident #43's calcium [MEDICATION NAME] on the morning of 6/12/18. Staff member U was shown resident #43's physician's orders [REDACTED]. She said the nurses giving medications should have clarified the order with the facility pharmacist and if what the physician had ordered was not available, the physician should have been called to order what equivalent medication was available.",2020-09-01
52,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2016-12-15,221,D,0,1,PSRD11,"Based on observation, record review, and interview, the facility failed to allow a resident the ability to move around freely while at meal service for one (#13) of 19 sampled residents. Findings include: During an observation in the Mountain View dining room, on 12/15/16 at 7:50 a.m., resident #13 was sitting at a table, with a meal in front of her. Resident #13 was in a wheel chair. The resident tried to leave the table. The resident could not leave. The resident's wheel chair just turned in a semi circle. The right brake was set. The resident's table mate asked if resident #13 could unlock the wheel chair brakes. Resident #13 looked down at the brakes and said no. The resident waited until a CNA released the brake and assisted her out of the dining room. Review of resident #13's Annual MDS, with an ARD of 9/13/16, showed the resident's BIMS at a 2, severe impairment. During an interview on 12/15/16 at 8:54 a.m., staff member A stated resident #13's wheel chair was not generally locked at the dining room table. The staff member was unaware the resident's wheel chair brakes were locked or who had locked the brakes. The staff member stated residents were not to have their wheel chair brakes locked by staff.",2020-09-01
53,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2016-12-15,225,D,0,1,PSRD11,"Based on record review, observation, and interview, the facility failed to ensure an accusation of verbal abuse by one (#20) of 22 sampled and supplemental residents, was reported within the required timeline (within 24 hours) to the state agency. Findings include: During an observation in the Mountain View dining room on 12/12/16 at 12:19 p.m., resident #20 stated a staff member had yelled at resident #21, stating I'll get to it when I get to it before you die. Staff member C approached resident #20, asking what was wrong. Resident #20 told the staff member again what had happened. The staff member asked which staff member it was but the resident was unsure. During an interview, directly after resident #20 reported the allegation, staff member C stated the incident sounded strange, and she/he would look into the allegation to appease resident #20. The staff member stated resident #20 was not always correct in his reporting as he had dementia. During an interview on 12/15/16 at 8:04 a.m., staff member B stated if a confused resident described an alleged verbal abuse, she would report to the head nurse, the DON, or the administrator if needed. Review of resident #20's Quarterly MDS, with an ARD of 11/1/16, showed the resident had a BIMS of 5, severe cognitive impairment. During an interview on 12/14/16 at 8:49 a.m., staff member D stated she was not aware of resident #20's accusation of any staff verbal abuse. The staff member stated there was no information in the resident's medical records of the allegation of abuse. At 10:15 a.m. staff member D stated she would investigate. At 11:02 a.m., staff member D agreed the incident should have been reported by staff member C. Staff member D reported that staff member C said she didn't see the accusation as abuse. Staff member D stated she provided education to staff member C on reporting abuse. Review of the state agency event reports showed the facility had not reported the accusation of verbal abuse until 12/14/16, after being made aware of the allegation.",2020-09-01
54,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2016-12-15,241,D,0,1,PSRD11,"Based on interviews, observations, and record review, the facility failed to provide a resident with a bath, and make a resident's bed as requested, for one (#7) of 19 sampled residents. Findings include: 1. During an interview on 12/13/16 at 8:35 a.m., resident #7 stated that she had only received a bath one time per week. She stated that she had asked for a bath more frequently but had not been allowed, and had not able to pick the time she wanted a bath. The resident stated she wanted a bath at least two times per week but had not been able to get one when she had asked the staff. Resident #7 stated she had felt stinky. The resident stated she had not refused any of her baths. During an observation on 12/13/16 at 8:35 a.m., resident #7 was sitting in her wheelchair in her room. The resident had a strong body odor present during an interview with a surveyor. During an interview on 12/13/16 at 9:00 a.m., staff member [NAME] stated resident #7 had refused her bath sometimes when she had already been dressed for the day. She stated staff utilized the Bath Aide Skin Assessments for the residents. A review of the facility's Bath Aide Skin Assessments showed that resident #7 had received only one bath in (MONTH) (YEAR), three baths in (MONTH) (YEAR), five baths in November, and three baths up until 12/13, in December. 2. A review of the facility's Resident Council Complaint Forms, showed residents had complained of beds being unmade on 4/4/16 and 11/7/16. During an interview on 12/13/16 at 8:35 a.m., resident #7 stated her bed had finally been made, that day. The resident also stated that she would like her bed to be made every day, but it had not been made every day. During an interview on 12/13/16 at 9:15 a.m., staff member F stated resident rooms should be cleaned daily, which would include making the bed. During an observation on 12/14/16 at 2:55 p.m., resident #7 had been sitting in her wheelchair, in her room. The bed had not been made, and the pillows were at the foot of the bed. Review of the facility's Daily General Cleaning Policy showed that the resident rooms were to be cleaned daily.",2020-09-01
55,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2016-12-15,253,E,0,1,PSRD11,"Based on observation, interview, and record review, the facility failed to consistently clean entry ways, floors, dining room tables, and window screens. The facility failed to consistently clean an electric wheel chair for one (#4); failed to thoroughly clean the resident room for one (#6); and failed to consistently clean a toilet for one (#7) of 19 sampled residents. Findings include: 1. During an observation on 12/13/16 at 11:10 a.m., resident #4 was in the Mountain View dining room. The resident was seated in an electric wheel chair. There was a right arm support connected to the wheel chair. Dried food, skin particles and a white colored stain, appearing to be the skin particles mixed with moisture from the resident's arm, were observed on the arm support, and beneath on the chair and right wheel. During an observation on 12/14/16 at 9:43 a.m., resident #4's wheel chair was against the outside wall of room 108. Dried food, skin particles, and the discolored white stain continued to be on the wheel chair arm support, on the chair, and the right wheel. During an observation on 12/14/16 at 2:21 p.m., resident #4 was assisted to bed. The resident's wheel chair was against the window in the room. Dried food and skin particles were on the wheel chair arm support, along with the discolored white stain. Skin particles and dried food were observed under the arm support, side of the chair, and wheel. During an observation on 12/14/16 at 4:25 p.m., resident #4 was in the Mountain View dining room. Skin particles and the white stain remained on the arm support of the wheelchair. Dried skin particles and dried food remained under the arm support, down the wheel chair wheel. Review of the Mountain View wheel chair washing schedule showed resident #4's wheel chair was to be washed on Tuesdays by night shift staff. During an interview on 12/13/16 at 3:30 p.m., staff member V stated that cleaning wheel chairs was up to the night shift. She stated she had observed some wheelchairs which looked like they had not been cleaned. 2. During an observation on 12/12/16 at 4:40 p.m., a resident #6's room had a dirty bed side table with circular stains from a glass that had been dried onto the table. The floor of the resident room had food stains and foot prints throughout the room. During an interview on 12/13/16 at 8:35 a.m., resident #7 stated she had been having diarrhea and her toilet was dirty with dried stool. The resident stated she had asked several times for her toilet to be cleaned but no one had cleaned the toilet for one week. During an observation of resident #7's bathroom on 12/13/16 at 3:25 p.m., the resident's toilet was soiled with dried feces around the entire inside of the toilet bowl. During an observation and interview on 12/14/16 at 2:55 p.m., resident #7 stated, and pointed out that her toilet had finally been cleaned that afternoon. During an interview on 12/13/16 at 9:15 a.m., staff member F stated that the following areas were to be cleaned daily: -garbage's -bathroom sinks -bed side tables The staff member also stated they would clean the toilets and floors twice a week. 3. During an observation on 12/12/16 at 3:21 p.m., the dining room tables in Copper East were soiled. Two of the tables had a red ketchup like substance on it. Another table had a Kleenex box, and when the box was moved it stuck to the table and some of the cardboard packaging was left stuck to the table. During an interview on 12/12/16 at 4:24 p.m., staff member W stated cleaning the dining room tables was a job typically completed by the housekeeper, but Mondays and Tuesdays were the housekeeper's day off. She stated the head housekeeper or another person was assigned to keep the Copper East wing clean. She also said the CNAs could help out and clean the tables after the CNAs finished situating the residents after meals. During observations on 12/13/16 at 8:00 a.m., at 9:00 a.m., and 10:30 a.m. an entry way in the Copper East dining room had dry, muddy foot prints continuing into the dining room. Water had begun to pool up on the floor, and was tracked into the resident dining room. Cobwebs were observed in the family dining room, and the windows of the resident dining room. During an observation on 12/13/16 at 3:30 p.m., three dining room tables, in the Copper East dining room, were not wiped down after the noon meal. The tables had a sticky substance all over the top of them, and on the sides of the table which looked like dried food. During an observation on 12/14/16 at 2:00 p.m., the Crest East dining room tables were soiled with food, wrappers, sugar, dirty tissues, empty saltine cracker wrappers, and unopened packages of saltines. Also, observed on the various tables in the dining room, were plastic lids with salad dressings on them, a spilled milky white liquid, salt and/or sugar which had spilled, and crumpled napkins. During an interview on 12/14/16 at 2:15 p.m., staff member X stated she realized the tables were soiled. She stated the CNAs had already assisted the residents after their meals and the tables should have been cleaned. She agreed the dining room was messy, and stated she didn't want the guests of the facility seeing the dining room in that condition. She stated she was going to grab the CNAs and have them tidy up the dining area. During an observation on 12/14/16 at 2:50 p.m., the Copper East dining room tables were stained with cup rings that were dry and sticky. During an observation on 12/12/16 at 3:26 p.m., The dining room tables, located in the dining room on Rimview, were sticky to the touch from dried food debris. The dining room tables had a light brown rubber edging around the outside. The rubber edging on the tables had food particles and a black grime rubbed into the rubber edging. The surface of the tables were also sticky from dried food debris. The dining room tables had food debris and left over sauce on the tables. During an observation on 12/13/16 at 2:52 p.m., the tables in the dining room, on Rimview, had food and debris buildup around the edges of the table. Two dining room tables had a brown sauce smear on the surface of the tables. There were three residents sitting in the dining room. During an interview on 12/13/16 at 2:55 p.m., staff member S stated the tables were wiped down after each meal service by the CNAs. A disinfecting wipe would be used to remove any food debris and dried on sauces after the meal. Staff member S stated house keeping did not provide a deep cleaning or degreasing of the dining room tables. During an interview on 12/13/16 at 6:37 p.m., staff member D stated the tables were designed with the sticky rubber edging to prevent dining ware from sliding off the table. Staff member D stated the facility had attempted to clean the tables with the rubber edging and had not been successful. During an interview on 12/14/16 at 8:50 a.m., staff member D stated the dining room tables on Rimview were cleaned. The black, brown grease build up on the rubber edging of the tables, had improved. However, on other tables in the dining area, there was still dried on food debris around the edges and on the sides of the tables. This observation was made with the staff member D present. During an observation on 12/14/16 at 8:55 a.m., dining room tables on Rimview showed the black, brown grease build up was removed. On the other dining room table edges there was food debris and sauce build up on the outside of the table edge. During an observation on 12/14/16 at 3:26 p.m., the dining room tables in the Rimview dining room had food and dried dark brown sauce stain on three tables. There were three residents sitting in the dining room. During an observation on 12/14/16 at 3:39 p.m., a CNA brought a resident down to the Rimview dining room. The CNA seated the resident across from another resident. The table the resident's were sitting at had a dried dark brown thick stain on the table. The CNA retrieved a disinfecting wipe and cleaned the table after the resident was seated. The resident had to wait for the table to dry prior to being served his beverages. During the same observation, two tables still had a dried dark brown stain on the table. Residents were sitting at the dirty tables. During an observation on 12/15/16 at 4:37 p.m., a resident was seated at a dining room table in the Rimview dining hall. The table the resident was seated at had a dried, thick, brown stain on the surface of the table. The stain had been on the table since the lunch service. The table was not cleaned after the lunch meal service, or before the resident was seated at the dining table for dinner service. During an interview on 12/15/16 at 4:40 p.m., staff member D stated it was the expectation of staff to clean the dining room tables after each meal service and when visibly soiled. A review of the facility's user manual, titled, Urethane Edge Tables, showed, Edgemold's urethane edge tables feature. The urethane flows around the table, and shrinks as it cools resulting in a tightly sealed, durable edge with no seam between the edge and laminate top. An edgemold original table seamless edge totally eliminates a place for dirt, microbial growth or moisture to accumulate. Our proprietary formula includes an antimicrobial agent that helps keep the edges sanitary. Review of the facility's Daily General Cleaning Policy showed that the following areas were to be cleaned daily: -Common areas -Restrooms -Resident rooms -Dining areas -Hallways -Windows -Bathroom toilet and sink -Sweeping floor -Dusting -Fixtures -Spot cleaning.",2020-09-01
56,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2016-12-15,279,E,0,1,PSRD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and observations, the facility failed to follow the care plan for a lactose free diet and offering an alternative meal if less than 50% of the original meal was consumed, for one (#1); failed to follow the care plan for straight cathing a resident three times a day, and for a specialized diet for one (#7); and failed to document restorative services on the care plan, and follow a restorative services plan, for a resident with contractures, for one (#10) out of 19 sampled residents. Findings include: 1. Care Plan for Catheter: Review of Resident #7's Physician order [REDACTED]. Review of Resident #7's Care Plan Report, with an effective date of 9/13/16 to present, showed that the resident's intervention was to straight cath, per MD orders, for [DIAGNOSES REDACTED]. Review of Resident #7's Treatment records and Clinical Notes for (MONTH) and (MONTH) (YEAR), showed inconsistencies in the resident being straight cathed three times daily as care planned. During an interview on 12/13/16 at 9:00 a.m., resident #7 stated she should be getting straight cathed three times daily. The resident also stated the staff had not been straight cathing her three times a day. During an interview on 12/13/16 at 3:25 p.m., resident #7 stated she had not been straight cathed yet today. The resident stated the nurse had not came back to cath her. During an interview on 12/13/16 at 3:30 p.m., staff member J stated resident #7 had straight cathed herself at home prior to being admitted to the facility. She also stated the resident had been scheduled to be straight cathed at 5 a.m., 2 p.m., and 10 p.m. Staff member J stated resident #7 had episodes of urinary tract infections. She also stated sometimes the resident had refused to be cathed. 2. Care Plan for Lactose Free Diet: Review of Resident #7's Physician order [REDACTED].>Review of Resident #7's Care Plan Report, with an effective date of 9/13/16 to present, showed the resident was lactose intolerant, the intervention was a lactose free diet. Review of Resident #7's Treatment Record, dated (MONTH) (YEAR), showed the resident was started on a continuous lactose free diet on 10/26/16. Review of Resident #7's Lunch Dining Card, dated 12/13/16, showed the resident was lactose intolerant. Review of the facility's Lactose-Free Diet guideline, showed all lactose products must be eliminated, which would have included foods that would have been prepared with milk. The guideline also showed food groups that would contain lactose such as: -Milk -Cheese -Ice cream -Cream soup, canned, and dehydrated soup mixes containing milk products Review of the facility's tuna and noodles recipe, from the Food for 50 book, showed the recipe contained cheese, canned cream of mushroom or celery soup, and milk. During an observation on 12/13/16 at 11:30 a.m., resident #7 was served tuna casserole, pickled beets with a lettuce garnish, and ice cream for dessert. The resident ate greater than 50 percent of her tuna casserole and 100 percent of her ice cream. The tuna casserole and ice cream contained lactose. During an interview on 12/13/16 at 12:10 p.m., staff member G stated that at the current time, they did not have any residents on a lactose free diet. During an interview on 12/13/16 at 12:25 p.m., staff member H stated the tuna casserole, served to resident #7, contained cream of mushroom soup, milk, and cheese. During an interview on 12/13/16 at 2:45 p.m., staff member I stated resident #7 had always been on a lactose free diet. He had also stated the Registered Dietitian would be the one who would update the interventions on a resident's care plan. During an interview on 12/13/16 at 3:00 p.m., staff member J stated resident #7 had a [DIAGNOSES REDACTED]. She also stated the resident was lactose intolerant and noted the resident had been served ice cream with her lunch. During an interview on 12/13/16 at 3:25 p.m., resident #7 stated she had diarrhea if she ate lactose. The resident stated she had been feeling queasy after lunch. 3. Review of the physician recapitulation orders, dated (MONTH) (YEAR), showed resident #1 had an order, dated 6/30/16, for a mechanical soft diet. The diet was documented in the order that the resident should be receiving mechanical soft, but also staff should send a pureed diet plate, and offer the puree if she refused to eat mechanical soft textures. Review of the Residents Care Plan, with an effective date of 3/31/16-current, showed the resident had the following nutritional interventions: - Provide max to total assist with eating. - Allow adequate time to eat; provide assistance, cueing, and encouragement as indicated. Feed the resident. - Offer alternates if - Provide diet as ordered: Mechanical Soft. Provide pureed foods as alternative. Review of the resident's diet card for 12/13/16, showed the following orders: - may need assistance - dysphagia level 3 (advanced) and dysphagia level 1 (pureed) During an observation on 12/13/16 at 7:28 a.m., resident #1 was sitting in the Mountain View dining room, waiting for her breakfast. She was served scrambled eggs and hot cereal. Staff left her sitting at the table, waiting for assistance, for a period of time after she appeared to be finished eating. No continued prompting or cuing was offered to her. The facility failed to allow adequate time for the resident to eat, and encourage her as the care plan showed. The resident ate less than 10% of her eggs or cereal at the meal. The staff members failed to offer her pureed eggs as an alternate as the doctor had ordered, and for what the care plan showed. During an observation on 12/13/16 at 11:46 a.m., resident #1 was sitting in the Mountain View dining room waiting for her lunch. Staff served her pureed carrots and mashed potatoes with gravy. The facility failed to offer her the mechanical soft diet prior to serving her the pureed carrots. During an interview on 12/13/16 at 12:00 p.m., staff member Z stated the resident had been receiving pureed meals, and recognized the resident was only given one option for breakfast. The staff member explained the resident's diet card showed the resident was to receive a pureed diet. The facility failed to follow the care plan by not offering her a mechanical soft diet menu item, prior to giving her a pureed meal. During an observation and interview on 12/14/16 at 9:00 a.m., a family member stated resident #1 ate well, and that the resident would not eat pureed food. The family member stated the resident ate the mechanical soft diet well. The family member also stated they had requested mashed potatoes and ice cream to be offered at meal. The resident would always eat those two foods items, because they were some of her favorites. The family member stated the diets had been a problem at the facility because there was a staff change over and sometimes she just doesn't get the assistance she needs. During the interview, the resident was observed eating a cookie that was broken into small pieces. The resident didn't appear to be having any struggles with eating the cookie, she just needed a bit more time to eat her snack. She was able to eat well with cueing and adequate time. 4. During an observation and interview on 12/13/16 at 8:30 a.m., in the dining room, resident #10's daughter assisted her with eating breakfast. The daughter stated she had a concern with her mother's hand, which was contracted. The daughter wanted a rolled up wash cloth in the hand which would keep the resident's fingers from curling inward. During an observation on 12/13/16 at 12:20 p.m. in the dining room, Resident #10 sat at the table with her right hand in her lap. Her fingers were curled into her palm. Review of resident #10's Physician order [REDACTED]. During an interview on 12/14/16 at 10:30 a.m., with staff members AA, BB, and R, staff member AA stated the PT department tried to work closely with resident #10 to meet her needs. Staff member BB stated she assessed Resident #10 quarterly for any changes the resident needed. Staff member R stated she did ask the resident to participate in restorative, but the resident usually refused. Review of the restorative care sheet showed the resident was to receive a TENS unit 2-3 times a week to her shoulder. There was no information on the care sheet for the splinting or bracing of the resident's hand. Review of resident #10's Care Plan showed a lack of restorative service, used as an intervention for the treatment of [REDACTED].#10's hand. During an interview on 12/15/16 at 9:00 a.m., staff member CC stated she missed putting restorative services on the resident's care plan. She thought resident #10 was no longer receiving restorative.",2020-09-01
57,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2016-12-15,312,D,0,1,PSRD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide oral care to one (#3) of 19 sampled residents. Findings include: During an observation on 12/13/16 at 7:25 a.m., resident #3 entered the dining room. During visiting, the resident's mouth and teeth, which had a white colored mucous covering them, was observed. The resident's tongue was whitish in color. The resident reached into his mouth with his fingers and grabbed at the whitish mucus on his tongue and teeth, trying to get it out of his mouth. During an interview on 12/13/16 at 7:30 a.m., resident #3 stated his teeth had not been brushed, but they needed to be brushed. During an interview on 12/15/16 at 8:54 a.m., staff member A stated resident #3 needed assistance with set up and stand by assistance for brushing his teeth. Review of resident #3's Annual MDS, with an ARD of 7/19/16, showed the resident needed extensive assistance with personal hygiene. Review of resident #3's care plan, with a goal date of 1/17/16, showed the resident required assist of one with ADLs, including oral care related to forgetfulness, Alzheimer's, [DIAGNOSES REDACTED], and [MEDICAL CONDITION].",2020-09-01
58,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2016-12-15,329,E,0,1,PSRD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to complete gradual dose reductions for residents on either antipsychotic or hypnotic medications for 3 (#s 1, 12, and 15) of 19 sampled residents. The findings include 1. Resident #1 had a psychiatric [DIAGNOSES REDACTED]. Review of resident #1's Medication Administration Record, dated (MONTH) (YEAR), showed resident #1 was receiving [MEDICATION NAME] 7.5 mg Tablet Oral, each day, starting 11/12/15. The orders showed to take the medication before dinner, at 1600, for [MEDICAL CONDITION]. She also had on order for 7.5 mg of [MEDICATION NAME], as needed every eight hours, starting 9/25/16, for acute agitation. Review of resident #1's medical record showed a lack of evidence for a gradual dose reduction for the [MEDICATION NAME] scheduled dose of 7.5 mg. During an interview on 12/13/16 at 3:03, staff member D stated resident #1's family did not allow the GDR's to be completed. She stated the resident's family member wanted the resident on the [MEDICATION NAME]. During an interview on 12/14/16 at 09:00 a.m., resident #1's family member stated they were unaware of what a GDR was, or why the facility should complete a GDR on medications. The family member stated they did not participate in the care plan meetings, so they were unaware if the facility had discussed a reduction of the scheduled dose of [MEDICATION NAME]. The family member stated that during the next appointment resident #1 had with the psychiatrist, they would ask about having the dose reviewed for the [MEDICATION NAME]. During an interview on 12/13/16 at 05:00 p.m., NFS 2 stated [MEDICATION NAME] was not ideal for the geriatric population. He stated he wrote to the psychiatrist asking for a GDR to be completed on the scheduled dose of [MEDICATION NAME], but he did not receive a response from the psychiatrist. He stated he also asked for a more definitive [DIAGNOSES REDACTED]. He also stated that he sent a letter to the psychiatrist in regards to resident #1's weight loss, asking for a review of the medications, and the psychiatrist failed to respond to that communication as well. 2. Resident #15 had a [DIAGNOSES REDACTED]. Review of resident #15's Quarterly MDS, section N0410, section D, dated 10/17/16, showed the resident had received a hypnotic medication 6 out of the 7 day look back period. Review of resident #15's MAR, dated (MONTH) (YEAR), showed [MEDICATION NAME] 5 mg, as needed, for [MEDICAL CONDITION], to be given at night. The order date was 4/26/16. The MAR showed the [MEDICATION NAME] had been given 12/1, 12/2, 12/3, 12/4, 12/5, 12/6, 12/7, 12/9, 12/10, 12/12, 12/13, and 12/14/16. Review of resident #15's medical record showed a lack of evidence for a gradual dose reduction for the [MEDICATION NAME] 5 mg, ordered 4/26/16. Review of resident #15's Chronological Record of Medication Regimen Review, reviewed by the pharmacist on 5/28/16, 6/25/16, 7/24/16, 8/27/16, 9/25/16, 10/29/16, and 11/27/16, showed a lack of evidence relating to a reduction or information on a reduction, for the [MEDICATION NAME]. During an interview on 12/14/16 at 2:15 p.m., staff member Y was unable to locate a GDR in the resident's medical records. Staff member Y stated a GDR probably was not completed for the [MEDICATION NAME] because the resident would never be taken off that particular medication due to her difficulty sleeping. During an interview on 12/14/16 at 4:30 p.m., staff member D stated the order was hand written for the medication, written in April, but there was no other paperwork in the resident's record for a GDR for the medication. Staff member D stated she consulted with NFS 2, and he was unable to find any paperwork related to a GDR or any other medication review for the [MEDICATION NAME]. 3. Resident #12 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the resident's Quarterly MDS, with an ARD of 11/15/16, showed the resident was cognitively intact, with a BIMS of 14. A review of resident #12's Physician Recapitulation Order, dated 12/12/16, showed the resident was on [MEDICATION NAME] 5 mg tablet, at the hour of sleep, for anxiety disorder, unspecified, which started on 6/28/16. A second order for [MEDICATION NAME] showed, [MEDICATION NAME] 5 mg tablet, as needed, every eight hours, for PRN anxiety, which started on 11/11/16. A review of resident #12's MAR, dated (MONTH) (YEAR), showed: [MEDICATION NAME] 5 mg tablet, at hour of sleep, starting on 6/28/16. The medication was given for anxiety disorder, unspecified, which was discontinued on 12/5/16. The order was changed to [MEDICATION NAME] 5 mg tablet, twice daily. The new order did not give a rationale for use. A second order on the resident's MAR for (MONTH) (YEAR), for [MEDICATION NAME], showed: [MEDICATION NAME] 5 mg tablet, as needed, every eight hours, starting 11/11/15, and discontinued on 12/5/16. There was no documented rationale for use of PRN anxiety medication. A review of resident #12's MAR, from (MONTH) (YEAR) to (MONTH) (YEAR), showed, [MEDICATION NAME] 5 mg tablet, at hour of sleep, starting 6/28/16, for anxiety disorder, unspecified. A second order on the resident's MAR's for (MONTH) through (MONTH) (YEAR), showed an order for [REDACTED]. A review of resident #12's physician progress notes [REDACTED]. Continue [MEDICATION NAME] 20 mg three times a day and 40 mg at bedtime. Continue [MEDICATION NAME] therapy. Medications listed on the Outpatient Encounter Prescriptions, as of 7/26/16, showed: [MEDICATION NAME] 5 mg tablet, take one tablet by mouth every eight hours as needed for Muscle Spasms. The indication noted in the progress note was not consistent for the use indicated in the resident's MAR and Physician Recapitulation Orders. A review of resident #12's physician progress notes [REDACTED]. A review of resident #12's physician progress notes [REDACTED]. [MEDICATION NAME] started last month. Change [MEDICATION NAME] to 5 mg BID and start [MEDICATION NAME] 0.5 mg by mouth every 6 hours as needed for anxiety. A review of resident #12's Monthly Drug Regimen Review, showed on 11/17/15, [MEDICATION NAME] 5 mg at bedtime as needed for anxiety. The Monthly Drug Regimen Review failed to show any further monthly reviews for [MEDICATION NAME]. A review of the facility's Gradual Dose Reduction Log, failed to show a gradual dose reduction was completed for resident #12 for the use of [MEDICATION NAME], dating back to 11/11/15. During an interview on 12/14/16 at 4:00 p.m., resident #12 stated she had felt the need for an increase in her [MEDICATION NAME] due to her anxiety, and due to her increased feelings of anxiety from the progression of her [MEDICAL CONDITION]. Resident #12 could not recall using the medication for muscle [DIAGNOSES REDACTED], but did mention she did take a medication for that as well. During an interview on 12/15/16 at 8:30 a.m., staff member D stated the gradual dose reductions needed to be completed at regular intervals as provided by the CMS regulation. Staff member D stated she was aware the gradual dose reductions had not been completed for resident #12's [MEDICATION NAME] dosing. During an interview on 12/15/16 at 9:33 a.m., NF1 stated she did get notifications from the pharmacist regarding the resident's gradual dose reductions. NF1 stated she recalled increasing resident #12's [MEDICATION NAME] due to muscle spasms, but did not recall completing any gradual dose reductions for resident #12. During an interview on 12/20/16 at 10:00 a.m., NF2 stated he had not completed a gradual dose reduction on resident #12, due to the medication being used for muscle spasms. NF2 stated he completed the monthly medication reviews for the residents, and when the quarterly reviews were due for [MEDICAL CONDITION] and hypnotic medications he would complete the gradual dose reductions, and notified the providers. NF2 stated he remembered the regulations showed if the resident was on a medication, which was exempt from needing a gradual dose reduction, he did not need to complete a GDR. A review of the [MEDICAL CONDITION] Medication policy showed: - 1. The facility will make every effort to comply with state and federal regulation related to the use of psychopharmacological medications in the long term care facility to include regular review for continued need, appropriate dosage, side effects, risk and or benefits . - 5. Efforts to reduce dosage or discontinuation of psychopharmacological medications will be ongoing, as appropriate, for clinical situations. A request was made on 12/15/16 at 7:40 a.m., for the gradual dose reduction policy. The facility stated there was no such policy, and they followed the federal guidelines on the completion of gradual dose reductions.",2020-09-01
59,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2016-12-15,333,D,0,1,PSRD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff primed the prefilled insulin pen prior to the medication administration for 2 (#s 12 and 22) of 22 sampled and supplemental residents. Findings include: Resident #12 was admitted to the facility with a [DIAGNOSES REDACTED]. Resident #22 was admitted to the facility with a [DIAGNOSES REDACTED]. During an observation on 12/12/16 at 4:30 p.m., staff member L put the needle on resident #12's [MEDICATION NAME] pen. The staff member twisted the dial back on the [MEDICATION NAME] pen to show 2 units of insulin. He then administered the insulin to the resident in the subcutaneous tissue in the left upper tricep. Staff member L did not prime the [MEDICATION NAME] pen with the 2 units of insulin prior to the insulin administration. During an observation on 12/12/16 at 5:01 p.m., staff member L, after placing the needle, twisted the dial back on the [MEDICATION NAME] pen to show 3 units of insulin. The staff member administered the insulin to the resident in the subcutaneous tissue of the right upper tricep. Staff member L did not prime the [MEDICATION NAME] pen with 2 units of insulin prior of the medication administration. During an interview on 12/12/16 at 5:03 p.m., staff member L stated he was not aware of the need to prime the insulin pen prior to the administration of medication. The staff member stated he had never primed the insulin pens before and had not been trained otherwise. During an interview on 12/12/16 at 5:15 p.m., staff member D stated it was the expectation of the staff to prime the insulin pen with 2 units of insulin prior administration. The staff member stated the last education provided to staff on the priming the insulin pens was at the last annual training. A review of the facility's Insulin Pen Instructions, dated 2/10/16, showed, Please use the following instructions prior to administering insulin from a prefilled pen: 2. You must give an airshot before each injection. Turn the dose selector to 2 units. Hold the pen with needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards and press the push-button all the way in. The dose selector returns back to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure. A review of the patient information pamphlet, provided by [MEDICATION NAME], showed: Giving the airshot before each injection. Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: E. Turn the dose selector to select 2 units. F. Hold your [MEDICATION NAME] with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. [NAME] Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times.",2020-09-01
60,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2016-12-15,367,E,0,1,PSRD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to follow the therapeutic diet that was ordered by a physician for 2 (#s 1 and 7), and failed to follow the physician ordered diet when providing snacks for one (#8) out of 19 sampled residents. Findings include: 1. Review of resident #1's diet order sheets, dated 5/6/16 and 6/30/16, showed the resident was to get both mechanical soft and pureed options at meal times. A physician's orders [REDACTED]. During an observation on 12/13/16 at 7:28 a.m., resident #1 was sitting in the Mountain View dining room waiting for her breakfast. She was served scrambled eggs and hot cereal. Staff left her sitting at the feeding assist table for a period of time after she appeared to be done eating. The resident consumed less than 10% of her meal. The staff members failed to offer her pureed eggs as a substitute, as the doctor's order showed. During an observation on 12/13/16 at 11:46 a.m., resident #1 was sitting in the Mountain View dining room, waiting for her lunch. Staff served her pureed carrots and mashed potatoes with gravy. The facility failed to offer her the mechanical soft diet prior to serving her the pureed carrots. During an interview on 12/13/16 at 12:00 p.m., staff member Z was asked why resident #1 received a pureed diet without getting mechanical soft textured food first. The staff member stated the resident had been receiving pureed meals. When the staff member was asked about the breakfast meal, and was reminded that the resident was only given mechanical soft food, the staff member recognized the resident was only given one option for breakfast. The staff member explained the resident's diet card showed the resident was to receive a pureed diet. Review of the resident's diet card for 12/13/16, showed the following orders: - may need assistance - dysphagia level 3 (advanced) and dysphagia level 1 (pureed) The diet card failed to specify instructions for which diet to be given to the resident, and when a diet was to be given. The card also included documentation that the resident may need assistance, but failed to show when she needed assistance. During an interview on 12/13/16 at 2:46 p.m., staff member I stated the pureed diet was really the only logical option for the resident, based on her age. Staff member I failed to explain why he thought two diets were ordered, and focused on why a pureed diet was the better option for the resident. During an observation and interview on 12/14/16 at 9:00 a.m., a family member stated resident #1 was a good eater, and that the resident would not eat pureed food. The family member stated the resident ate the mechanical soft diet well. The family member also stated they had requested ice cream be offered at meal times, along with mashed potatoes, because the resident would always eat those two foods. They were some of her favorites. The family member stated the diets were a problem with the facility because there was a staff change over and sometimes the resident just doesn't get the assistance she needs. During the interview, the resident was observed eating a cookie, broken into small pieces. The resident didn't appear to be having any struggles with eating the cookie. The resident was observed to need time to eat her snack, but was able with cuing from her family member. 2. Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the resident's Quarterly MDS, with an ARD of 9/21/16, showed the resident was cognitively intact, with an BIMS of 15. A review of residents #8's Physician Order, dated 9/21/16, showed, ST swallow eval (sic)completed. Patient appropriate for mechanical soft diet with chopped meat and nectar thick liquids. Pills to be given whole in pureed (pudding, applesauce). Patient swallow improves when completing chin tuck strategy. A review of resident #8's Physician Recapitulation sheet, dated (MONTH) (YEAR), showed, Thickened Liquids, nectar consistency, diet, mechanical soft diet with chopped meat. During an observation on 12/12/16 at 11:11 a.m., On resident #8's bed were four bags of Lays potato chips. Two of the bags were empty and placed inside an empty gray wash basin. The two remaining bags were full laying at the foot of the resident's bed. During an interview on 12/13/16 at 11:24 a.m., staff member G stated residents on altered therapeutic diets should receive snacks which are approved for the altered diet. The staff member stated potato chips were not an approved snack for a resident on a mechanical soft diet. A review of the facility's Dysphagia Diet, NDD Level 2, showed, The dysphagia diet is a transition from the pureed diet and requires the ability to chew and tolerate mixed textures. Foods are soft and moist. At times pureed versions of the menu items must be served to ensure integrity of the Dysphagia Diet. The Dysphagia Diet in the IMPAC Menu, showed, Food Groups: Desserts, avoid: Dry, course cakes and cookies. Potatoes and Starches: avoid: Potato skins and chips. During an observation on 12/13/16 at 11:30 a.m., resident #8 was in his bed. He had one empty bag of potato chips by him in his bed, and one unopened bag of potato chips on his bedside table. During an interview on 12/13/16 at 11:30 a.m., staff member N stated resident #8's favorite snack was potato chips and licorice. The staff member stated she knew resident #8 was on nectar thick liquids, but was not aware of him being on an altered diet. Staff member N stated the CNA kiosk (electronic system for documentation) showed the diets ordered for the residents, and it would also be posted on the white board at the Rimview nurses' station. During an interview on 12/13/16 at 11:35 a.m., staff member O stated she was aware resident #12 was on nectar thick liquids, but was not aware of him being on an altered diet. The staff member stated she was not aware the resident could not receive certain foods off the snack cart. Staff member O stated the refrigerator had a list of snacks approved for residents on altered diets, and for the type of altered diet, but the list did not show who was on altered diets. Staff member O stated she could look it up in the CNAs kiosk, or it might be on the white board in the report room. The staff member stated the last training she attended on altered diets was at last months, monthly training. During an observation on 12/13/16 at 11:49 a.m., staff member P gave resident #8 his medications. The staff member offered the medications to the resident whole, with thickened juice to swallow the medications. The resident started to cough. Staff member P offered another sip of thickened juice, and the resident stopped coughing. The resident's medication's were not administered with a pureed food item, such as applesauce or pudding, as the provider ordered. During an interview on 12/13/16 at 11:50 a.m., staff member P stated he was aware resident #8 was on thickened liquids, but did not know to administer his medications with a pureed food to swallow them. The staff member stated the MAR did not indicate the need to give resident #8 his medications with pudding or applesauce. Staff member P stated the resident had always taken his medications without pudding or applesauce. He stated the resident would cough at times after taking his medications. Staff member P stated he was not aware resident #8 was on an altered diet. He stated the resident would eat the snacks of his choice, and he could be very demanding for the type of snack he wanted. During an interview on 12/13/16 at 11:59 a.m., staff member M stated he was not aware of a specific diet change for resident #8. Staff member M stated he knew resident #8 was on nectar thick liquids, but was not aware of an altered diet, and snack options. Staff member M reviewed resident #8's record and found the diet order for mechanical soft diet with chopped meats and thickened liquids, and pills with puree. Staff member M stated the medications should have been ordered in the MAR. Staff member M stated it was the responsibility of the charge nurse to review all new orders and put the orders in the electronic medical record. Staff member M stated it did not appear the order for resident #8 was put in the record accurately. The staff member stated, by not providing the correct diet to a resident with dysphagia, it could have a negative result of choking, aspiration and/or pneumonia. He said if a resident had a specific snack preference, which conflicted with his diet order, the care plan would reflect that preference. During an interview on 12/13/16 at 12:10 p.m., staff member R stated she was aware resident #8 was on nectar thick liquids, but did not realize he was on an altered diet. The staff member stated she would know if the resident was on an altered diet, and what were the approved snack choices for the resident, by reviewing the white board at the nursing station. She could also look at the snack list on the refridgerator. Staff member R stated the snack cart did not have a list of approved snack alternatives for residents with altered diets. She stated it would be nice if the cart had a list of the residents receiving altered diets, and what would be an appropriate snack for them. An observation on 12/13/16 at 12:19 p.m., showed the snack cart located on Rimview had a blue cooler filled with ice, and on the second shelf a tray filled with snack options. The options on the tray consisted of Famous Amos chocolate chip cookies, Ritz Bits cheese crackers, peanut butter crackers, Fig Newtons, plain Lays Potato chips, and sugar free sugar waffle cookies. During an interview on 12/13/16 at 12:28 p.m., staff member G stated when an diet change was ordered by the physician, the nurse would take the order, enter the order into the electronic health record, then would provide her with the pink slip with the new diet order. The staff member stated she would take the diet order, and update the resident's diet ticket in the kitchen. Staff member G stated she prepared the snack options on the snack cart. Staff member G stated the snack carts did not have a list of diet alternatives or show which resident's receiveed an altered diet. She stated the resident refrigerators on the each unit had a list of alternate diets, and showed what was an approved alternative, per the diet. The refrigerators were stocked with snack options, such yogurts, applesauce, and puddings. Staff member G stated it was important for staff to follow the diet order to prevent a resident from choking or aspirating. The staff member stated resident #8 had a preference for potato chips. She stated the potato chips were not on the approved dysphagia diet. She stated resident #8 could get demanding about having his snack of choice (the potatoes chips). Staff member G stated the resident could deviate from his therapeutic diet, as long as the resident was aware of the risks and benefits, and it was documented on the resident's care plan. A review of resident #8's Care Plan, dated 9/29/16, showed, alteration in nutrition: Dysphagia, (resident) receives a mechanically altered diet. The interventions showed, provide diet as ordered: regular with nectar thickened liquids, report any chewing or swallowing difficulties to nurse. Offer snacks at HS and PRN. The care plan failed to reflect resident preferences for snack alternatives, such as, chips or cookies. During an interview on 12/13/16 at 12:40 p.m., staff member I stated it was the expectation of staff to follow the diet order for each resident. If the resident would like a food item not on the recommenced diet, the facility would need to educate the resident of the risk and benefits, then update the care plan. Staff member I stated if the staff did not follow the prescribed therapeutic diet, the resident could choke, or aspirate. During an observation on 12/13/16 at 3:11 p.m., staff member T brought the snack tray into resident #8's room and asked the resident if he would like anything off the snack tray. Resident #8 removed a bag of potato chips from the tray. During an interview on 12/13/16 at 3:15 p.m., staff member T stated she was not aware resident #8 was on an altered diet. Staff member T stated she was not aware of which residents had an altered diet, and may need a snack alternative. During an interview on 12/13/16 at 5:59 p.m., staff member D stated it was the expectation of staff to know what diets were ordered for residents. Staff member D stated the CNAs could look up what type of diet a resident was on, before passing snacks. The nurses had the orders in the electronic medical record. She stated there was a list on the refridgerator of the different altered diet snack options available for residents. It was the expectation of staff to follow the diet orders for residents as prescribed by the physician. During an observation on 12/14/16 at 4:06 p.m., resident #8 was eating Famous Amos chocolate chip cookies, while laying in bed. The head of the bed was up at 30 degrees, which was common for a person with a risk of aspiration. A review of the facility's policy and procedure titled, Therapeutic Diets, showed, Therapeutic diets, ordered by the health care provider, are supported in the community. Residents are encouraged to follow their prescribed diet; however, resident compliance cannot be ensured . 2. The community supports the following diet consistencies: a. Mechanical Soft/Soft to Chew Consistency served in ground of soft form . 5. Notify the Food Service leadership, in writing, of resident's dietary order. 6. Add the resident's name and diet to the Diet Roster. (The Diet Roster was a list of all residents and their specific diet as ordered by their health care provider). 7. Post the Diet Roster in the kitchen and in the dining areas. 8. Update the Diet Roster as needed with any diet changes (DON and Dietary Manager). 9. Add new residents to the Diet Roster immediately upon admission. 10. Maintain all diet orders received from the resident's health care provider in the resident's file. 11. Provide education to nursing and culinary staff regarding special diets. 12. Provide education to residents with special dietary needs and encourage compliance. 13. Provide supervised dining for residents with pureed foods and/or thickened liquids. A review of the facility's Suggested Snacks, for therapeutic diets, showed, Mechanical Soft Diet: Banana (ripe), Canned Fruit (soft), Cereal (No Raisins) Milk, Soft Cookies (No Nuts or Raisins), Fruit Juice, Grahan (sic) Crackers, Cottage Cheese, Applesauce, Pudding, Ice Cream, Jello, Yogurt, Milkshake, Vanilla Wafers, Cheese and Crackers, Sandwiches (Meat salad, P&J). 3. Review of resident #7's Care Plan, dated 9/13/16 to present, showed the resident was lactose intolerant. The interventions showed the resident would be on a lactose-free diet. Review of resident #7's Treatment Record, dated (MONTH) (YEAR), showed the resident diet to be regular lactose-free. Review of resident #7's Dining Card, dated 12/13/16, showed the resident was lactose intolerant. Review of Resident #7's Physician order [REDACTED]. During an observation on 12/13/16 at 11:30 a.m., resident #7 was served tuna casserole, pickled beets with a lettuce garnish, and ice cream for dessert. The resident ate greater than 50 percent of her tuna casserole, and 100 percent of her ice cream. The tuna casserole and ice cream contained lactose. During an interview on 12/13/16 at 12:10 p.m., staff member G stated that at the current time, they did not have any residents on a lactose free diet. During an interview on 12/13/16 at 12:25 p.m., staff member H stated the tuna casserole, served to resident #7, contained cream of mushroom soup, milk, and cheese. During an interview on 12/13/16 at 2:45 p.m., staff member I stated resident #7 had always been on a lactose free diet. He had also stated the Registered Dietitian would be the one who would update the interventions on a resident's care plan. During an interview on 12/13/16 at 3:00 p.m., staff member J stated resident #7 had a [DIAGNOSES REDACTED]. She also stated the resident was lactose intolerant, and noted the resident had been served ice cream with her lunch. Review of the facility's Lactose-Free Diet guideline, showed all lactose products must be eliminated, which would have included foods that would have been prepared with milk. The guideline also showed food groups that would contain lactose such as: - Milk - Cheese - Ice cream - Cream soup, canned, and dehydrated soup mixes containing milk products Review of the facility's tuna and noodles recipe from the Food for 50 book, showed the recipe contained cheese, canned cream of mushroom or celery soup, and milk. Review of the facility's policy on therapeutic diets, dated 11/10/16, showed that individuals who would present with lactose intolerance should avoid dairy products.",2020-09-01
61,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2016-12-15,425,D,0,1,PSRD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews the facility failed to ensure accurate dispensing and administration of a medication to one resident (#7) of 19 sampled residents. Findings include: Review of resident #7's (MONTH) (YEAR) MAR, showed the resident was allergic to sulfa (Sulfonamide Antibiotics). The resident had received a medication, Bactrim DS, 800 mg, on (MONTH) 1, (YEAR), to be given at the a.m. medication pass. Bactrim DS was a medication that contained sulfa. During an interview on 12/14/16 at 9:30 a.m., staff member K stated that to determine what medications a resident would be allergic to, she would have looked on the residents MAR. She stated she would have asked the resident what allergies [REDACTED]. She also stated that if a resident had received a medication they had an allergy to, the pharmacy should have been notified. A resident assessment should have been completed, including vital signs, and an incident report or risk watch form, should have been completed. During an interview on 12/13/16 at 5:00 p.m., staff member NF2 stated the pharmacy had original admission orders [REDACTED]. He stated it was a pharmacy medication error that resident #7 had been given a medication she was allergic to. He also stated he was not sure how the medication containing sulfa slipped through the cracks. During an interview on 12/14/16 at 5:00 p.m., staff member D stated a risk watch form was an internal facility investigation tool. She also stated resident #7 had told the nurse she was allergic to Bactrim after she had already been given the medication. Staff member D stated there had not been a risk watch form, or an incident report filed for the medication administration error. She also stated she was not sure how the error slipped through the physician and the pharmacy. Review of the facility's Resident Accident Incident Policy, dated 2/10/16, showed that upon identification of an incident, the information should be documented on an incident report. A note should be placed into the resident's medical record of the incident and the facts, which would include the physician and family responsible party notification. The policy also showed that an investigation would be completed within 5 days and appropriate action would be taken. The facility policy was not followed relating to the deficient practice.",2020-09-01
62,BELLA TERRA OF BILLINGS,275020,1807 24TH ST W,BILLINGS,MT,59102,2016-12-15,441,E,0,1,PSRD11,"Based on observation, interview, and record review, the facility failed to utilize standard precautions to prevent the spread of infections by failing to disinfect a glucose monitor between uses to prevent indirect transmission for 2 (#s 12 and 22); and staff failed to wear gloves during a glucometer check for 1 (#22) of 22 sampled and supplemental residents. These deficient practices had the potential to affect all residents receiving glucometer monitoring and testing. Findings include: 1. During an observation on 12/12/16 at 4:40 p.m., staff member L checked resident #12's blood sugar with the Even Care glucometer. Staff member L returned to his medication cart and removed the used test strip and placed the strip in the sharps container. Staff member L placed the glucometer down on top of the medication cart. The staff member did not clean the glucometer with disinfecting wipes after checking resident #12's blood sugar. During an observation on 12/12/16 at 4:50 p.m., staff member L checked resident #22's blood sugar with the same, soiled, Even Care Glucometer, which was used to check resident #12's blood sugar. Staff member L returned to his medication cart after checking resident #22's blood sugar, removed the soiled test strip, and placed the test strip in the sharps container. Staff member L placed the glucometer on top of his medication cart. He did not disinfect the glucometer after checking resident #22's blood sugar. During an interview on 12/12/16 at 5:00 p.m., staff member L stated he was aware he needed to wash the glucometer between resident uses. The staff member stated he should use the disinfecting wipes with the purple top between each resident use. Staff member L stated he forgot due to being nervous. Staff member L stated he received his last training on the maintenance of the glucometers about one year ago. During an interview on 12/12/16 at 5:15 p.m., staff member D stated it was the expectation of all nurses and certified medication aides to wipe the glucometers with the purple top disinfecting wipes between each resident use. The staff member stated staff had training on the disinfection of the glucometers after the last annual survey. A review of the facility's policy and procedure titled, Blood Glucose Monitoring, showed, Disinfect glucometer after each use with 0.52% sodium hypochlorite solution or equivalent wipes and follow infection prevention guidelines to prevent carry-over of blood and infectious agents. A review of the facility's user's guide titled, Even Care G3, Professional Blood Glucose Monitoring System User's Guide, showed, Cleaning and Disinfecting Procedures for the Meter. The Even Care G3 Meter should be cleaned and disinfected between each patient. The meter is validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years. To disinfect your meter, clean the meter surface with approved disinfecting wipes. 2. During an observation on 12/12/16 at 5:03 p.m., Staff member L did not wash his hands or put on gloves before he approached resident #22. He cleaned the residents finger with an alcohol wipe. Waited for the resident's finger to dry, took the lancet and punctured the resident's finger. Staff member massaged the finger to bring a drop of blood to the surface of the finger. Staff member L applied the droplet of blood to the test strip which was docked in the glucometer. Staff member L did not wear gloves during the procedure. Staff member L did not disinfect his hands before or after the procedure. During an interview on 12/12/16 at 5:05 p.m., staff member L stated he was aware half way through the procedure that he was not wearing gloves. Staff member L stated he knew he should have washed his hands prior to donning gloves, and should not have checked the resident's blood sugar without wearing gloves. Staff member L stated the last training he had on hand hygiene was at the last monthly meeting. During an interview on 12/12/16 at 5:15 p.m., staff member D stated it was the expectation of staff to wear gloves when an encounter with known blood contamination may occur, such as, during blood glucose monitoring. Staff member D stated all facility staff were educated and trained monthly on hand hygiene. A review of the facility's policy and procedure titled, Blood Glucose Monitoring, showed, Wear proper PPE during blood glucose testing and administration of insulin. A review of the facility's user's guide titled, Even Care G3, Professional Blood Glucose Monitoring System User's Guide, showed, Step 1. Wash hands with soap and water. Step 2. Put on single-use medical protective gloves.",2020-09-01
63,VALLE VISTA MANOR,275021,402 SUMMIT AVE,LEWISTOWN,MT,59457,2020-01-28,684,G,1,0,65C211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to monitor a resident for change of condition and follow through to obtain physician consultation, which resulted in a delay in treatment and ultimately a hospitalization , for 1 (#1) of 5 sampled residents. Findings include: During an interview on 1/28/20 at 12:24 p.m., NF1 stated he had noticed a difference in resident #1's cognition and status the two days prior to the hospitalization . NF1 stated he was in to see resident #1 on Saturday, 1/4/20, around one or two in the afternoon. NF1 stated he noticed a puddle on the floor around resident #1's foot and thought it was urine. He notified the nurse, and the nurse took resident #1's sock off, and NF1 immediately noted resident #1's foot was swollen like a balloon, and the fluid matter on the floor was not urine but was coming from resident #1's foot. NF1 stated he asked the nurse if he should take resident #1 to the hospital. The nurse stated no we have a wound nurse consult scheduled for Monday (six days later). NF1 stated it should have been obvious resident #1's foot was infected. NF1 stated he had not been notified of the swelling on resident #1's foot prior to seeing it in person. NF1 stated he received a phone call around 4:30 a.m., on Sunday 1/5/20, notifying him resident #1 was being sent to the emergency room . NF1 stated resident #1 was septic (infection) by the time he was admitted to the hospital, and the resident had [MEDICAL CONDITION]. During an interview on 1/28/20 at 1:27 p.m., staff member B stated she was not present in the facility when resident #1 had been sent out to the hospital. During the weekend it was the Registered Nurse that was in charge of overseeing cares. Staff member B stated the facility had been aware of the redness and swelling of resident #1's foot on 1/3/20. On 1/4/20 it was assessed, but resident #1 did not have a temperature until 1/5/20. Staff member B stated it would be alarming if a resident presented with a swollen foot with drainage, and she would have cleaned the wound then notified the doctor and wound care nurse. During an interview on 1/28/20 at 2:25 p.m., staff member E stated resident #1 was neither resistive, nor refused cares, when provided to the resident. During an interview on 1/28/20 at 2:46 p.m., staff member A stated, during the time of resident #1's admission, since the Director of Nursing was gone, the floor nurse was in charge of overseeing and ensuring cares. Staff member A stated if there were any issues, the floor nurse could not handle the Regional Clinical Nurse would have consulted in the matter. Staff member A stated he was confused on the matter of resident #1's foot, as it was noted the resident had a fall with mention of resident #1's socks, and all extremities were checked, but there was no mention of swelling noted. It was noted on 1/3/20 and 1/4/20 the resident experienced leg pain, and the foot was swollen red and hot to the touch. Staff member A stated he did not know what happened. During an interview on 1/28/20 at 3:50 p.m., with staff member A, B, and C, staff member B stated all skin checks would be either Braden scale assessments or documented in the progress notes if they occurred. Staff member B stated there was not a physician note for 1/3/20 or 1/4/20 to show facility staff made contact with a doctor to get direction on what to do with resident #1's foot condition. Staff member B stated on 1/3/20, a wound nurse consultation had already been set up, due to the resident's avoidable pressure ulcer to his buttocks, and back. Staff member B stated there was not an official process to document the completion of a head to toe assessment after falls to ensure they were completed. Staff member B stated she did not find any other skin checks for the resident, except the skin checks completed on admission, and 1/2/20. Staff member B stated she had just implemented skin checks on bath days. Staff member C stated she was in the facility for a few hours on 1/4/20, Saturday morning. She stated she performed catheter care and wound care for the resident and did not recall if the resident had socks on or not. Staff member C stated she could not recall looking at resident #1's foot. A review of resident #1's care plan, with a last revision date of 12/31/19, showed no documentation for catheter care, wound care, or skin checks to be performed. A review of resident #1's skin and wound assessments, dated 12/12/19 and 1/2/20, showed no documentation of resident #1's foot or swelling. A review of resident #1's Nursing progress notes, showed the following: - On 1/3/20 - Residents foot is red swollen and red to the touch. Will be trying to be getting ahold of the doctor to possibly get ABX (antibiotics). - On 1/4/20 at 2:14 p.m. - Pt very lethargic and unable to perform therex to lower ext 's., R. foot is badly swollen and in need of wound care. Nurse redressing foot and calling doctor.(sic) - On 1/4/20 at 3:15 p.m. - Res (family member) in today. He is Concerned that (resident) is declining. Res has been hiccupping again this day. Upon assessing res, RLE has +3 [MEDICAL CONDITION]. R foot hs developed 4 fluid filled blisters on top of foot and one blister on sm toe that has popped. There is necrotic tissue present on toe. R foot is seeping large amounts of fluid. Tissue under blisters appears to be very dark below fluid. Foot cleansed with normal saline and super absorbent pads placed on foot, then wrapped with gauze. Foot is elevated at this time. Will send note to provider and wound care nurse. (sic) - On 1/5/20 at 4:00 a.m. - CNA reports that this resident has a temp of 101. Temporal P 110 BP 110/57 R17. Resident is very confused .MD notified, and orders received to transfer to ER for evaluation and treatment. A review of resident #1's hospitalization documentation, dated 1/5/20, showed the following: - Resident #1 was noted to have had confusion, by family, on Friday the third and Saturday the fourth, of January. - (Family Member) saw (resident #1's) right foot yesterday the surface of the little toe was blackened, swollen, and red. Family member was told by nurse they would rewrap toe and get Wound Care involved Monday (the 6th). (sic) - Resident #1 was admitted to the hospital with [REDACTED]. A request for all physician communication for resident #1's length of stay was made on 1/28/20, and no further documentation was provided by the facility. A phone call was placed to staff member F, the floor nurse during the time of resident #1's stay, on 1/28/20 at 3:17 p.m A message was left for a return call. The phone call was not returned.",2020-09-01
64,VALLE VISTA MANOR,275021,402 SUMMIT AVE,LEWISTOWN,MT,59457,2020-01-28,686,D,1,0,65C211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to monitor an identified reddened skin area, and implement interventions for prevention of further deterioration, for the skin area, and the area worsened to an avoidable Stage II Pressure Ulcer; and the facility failed to identify the risk of the pressure ulcer development and revise interventions for a resident with a reoccurring pressure ulcer, for 2 (#s 1 and 2) of 5 sampled residents. Findings include: 1. During an interview on 1/28/20 at 12:24 p.m., NFI stated resident #1 had a red spot on admission that was not open. NF1 stated resident #1 was not repositioned, and the pressure ulcer worsened at the facility to the point resident #1 was uncomfortable when sitting. NF1 stated he was not sure if resident #1 moved nearly enough. NF1 stated he was aware of an order from the doctor for the pressure ulcer but was not sure if it had been adhered to. During an interview on 1/28/20 at 1:27 p.m., staff member B stated she was not in the facility for resident #1's admission, and she was not sure how resident #1 acquired the avoidable Stage II pressure ulcer. Staff member B stated the facility has not had many pressure ulcers and had recently implemented a system of caring for pressure ulcers. Staff member B stated the system included that a nurse would complete a skin assessment weekly, on a bath day, for a resident. Staff member B stated the implementation of the system was evaluated and is an ongoing process. Staff member B stated the resident had a head to toe evaluation in his progress note, after the abundant number of falls the resident had, during his stay at the facility. Staff member B stated resident #1 had Braden Scale skin assessments completed on the 19th, and the 26th of December, 2019, as well as on January 2nd, of 2020. During an interview on 1/28/20 at 2:46 p.m., staff member A stated resident #1 had a pressure skin injury he acquired during his stay at the facility. A review of resident #1's Comprehensive Skin Assessment, dated 12/12/19, showed redness to resident #1's coccyx. No other comprehensive skin assessments were provided by the facility for resident #1. A review of resident #1's Progress notes, showed the following: - On 12/12/19, resident #1 had a reddened area on his coccyx. -On 1/2/20, resident #1's, Skin check performed today, and mid coccyx area has a 0.5 cm X 0.5 cm X 0.1 stage 2 pressure sore noted. Area around is sore on bilateral coccyx is slightly macerated, red, scabby and fragile. This area cleansed with NS, patted dry with gauze, Opti foam adhesive placed with [MEDICATION NAME] around other closed areas of skin. Resident reported that it was sore and tolerated the procedure well. Resident then placed in his bed to help alleviate pressure and will plan to help turn and reposition often to relieve pressure and to continue with dressing changes. (Physician) will be notified via fax with this nurse note and TAR updated. (sic) -No monitored skin checks were noted in the medical record from 12/13/19 to 1/1/20 for resident #1. A review of resident #1's Care plan, last revision date of 12/31/19, showed no documentation of resident #1 being at risk for developing pressure sores, and no preventative interventions were noted for the prevention of pressure sores. A review of resident #1's Braden Scale Assessments, showed the following: - On 12/12/19, upon admission resident #1 scored a 16 on the assessment, and the score showed he was at risk for developing pressure sores. -On 12/19/19, 12/26/19, and 1/2/20, resident #1's assessment showed the resident scored a 17, and the score showed he was at risk for developing pressure sores. A review of resident #1's Initial Weekly Wound Documentation Form, dated 1/2/20, showed a Stage II Pressure Ulcer to the middle coccyx, measuring .5 cm x .5 cm x .1 cm, which was intact, macerated, [DIAGNOSES REDACTED], calloused edges, and no drainage. A box for pain associated with the wound was checked on the form. Under wound treatment and pain it showed, Change dressing daily with NS, gauze, [MEDICATION NAME] and [MEDICATION NAME] to bordered areas as needed. A review of resident #1's Physician Order, dated 1/2/20, showed Pressure ulcer of unspecified site, stage 2. Instruction to nursing home. Note to provider: 1) Start burst of [MEDICATION NAME] for back; 2) [MEDICATION NAME] to pressure ulcer in coccyx; 3) Frequent repositioning to off load; 4) Gel cushion (if available); 5) Wound nurse consulted. A review of resident #1's Verbal Physician Order, dated 1/2/20, showed, Assess bilateral coccyx daily and provide wound care: Cleanse with NS, pat dry with gauze to secure. Apply [MEDICATION NAME] to surrounding areas as needed. Discontinued when healed. every shift for Skin Care. A review of resident #1's Treatment Administration Record, showed the following: - In December 2019, resident #1 was to have weekly skin checks. No documentation of skin checks was provided by the facility, but they were initialed as completed on 12/19/19 and 12/26/19. Also, noted with a start date of 12/12/19, and an end date of 12/22/19, was, Please complete assessments. Do not sign off if not finished scheduled for two times a day. Resident #1 was monitored for pain for the month of December 2019 and January 2020. Resident #1 rarely had pain in the month of December 2020 and no pain was indicated on his pain assessments during the month of January 2020. Resident #1 had an as needed order for Tylenol for pain. - In January 2020, resident #1's wound care treatments were documented on 1/2/20 with a skin assessment, however the resident had no documented treatments on 1/4/20 to apply [MEDICATION NAME] to pressure ulcer on coccyx; reapply as needed. Frequent repositioning. A review of resident #1's emergency room Report, dated 1/5/20 showed the following: - (Resident #1) was then seen in the clinic on January 2nd by (Physician). At that time, he was noted to have pressure ulcers starting on his coccyx and buttock with a small, open wound. - Exam of his coccyx, shows an approximately 10 x 12 cm area of [DIAGNOSES REDACTED] consistent with an early pressure ulcer. On the superior aspect there is an area of about 1 to 1.5 cm that is an open wound. A review of resident #1's bathing record tasks for December 2019 and January 2020, showed no task for a bath skin check. A phone call was placed to staff member F, the floor nurse during the time of resident #1's stay, on 1/28/20 at 3:17 p.m A message was left for a return call. The phone call was not returned. 2. During an interview on 1/28/20 at 1:27 p.m., staff member B stated resident #2's pressure ulcer had been going on before her time at the facility. Staff member B stated resident #2's pressure ulcer would heal and then reopen. Staff member B stated resident #2 had recently had a wound nurse consult for the pressure ulcer. Staff member B stated the interventions utilized for prevention of pressure ulcers included an air pressure relieving mattress, and a pressure relieving cushion, for resident #2's wheelchair. Staff member B stated resident #2's wound care order was to cleanse and apply collagen to the pressure ulcer. Staff member B stated the wound is monitored through weekly wound assessments. Staff member B stated resident #2 had an increase in her [MEDICATION NAME] for pain management and receives health shakes for nutritional intervention. Staff member B stated due to resident #2's dementia, staff remind her to reposition herself in her chair. During an interview on 1/28/20 at 2:28 p.m., staff member D stated resident #2 received skin checks every week. Staff member D stated resident #2's treatment was collagen with collagen powder, hoping to thicken the skin that keeps opening. Staff member D stated resident #2 tends to slide on surfaces that cause the wound to reopen. Staff member D stated resident #2 had a pressure relieving mattress and cushion for her chair. A review of resident #2's Initial Weekly Wound Documentation Form, dated 8/23/19, showed resident #2's left buttock had a skin shear measuring 2.5 cm long, 1 cm wide, and .2 cm deep. Resident #2's wound was noted to not have drainage or odor. The wound edges were described as pink and rolled. The wound treatment was noted as, Apply [MEDICATION NAME] Lotion on left buttock 3 times a day with each bowel movement. A review of resident #2's Physician Order, dated 1/21/20, showed, Cleanse area of left buttock with normal saline. Apply collagen to wound bed. Cover site with hydrogel dressing. Change dressing QOD. Discontinue when healed. A review of resident #2's Braden Scale Assessments showed the following: - On 2/28/19, resident #2's assessment score was a 23, which was not at risk for developing a pressure sore. - On 6/3/19, resident #2's assessment score was a 19, which was not at risk for developing a pressure sore. - On 9/3/19, resident #2's assessment score was a 19, which continued as not being at risk for developing a pressure sore. - On 12/2/19. resident #2's assessment score was a 17, and the resident was at risk for developing a pressure sore. A review of resident #2's Skin/Wound Notes showed the following: - On 8/25/19, The left coccyx was shearing and was being treated with [MEDICATION NAME] cream. The documentation did not specify the cause of the shearing noted. - On 9/7/19, Soiled dressing removed from bilateral coccyx today, Wound to L. coccyx remains open with serosanguineous drainage and R. coccyx is very dry with pinpoint opening with serosanguineous drainage. - On 11/28/19, The weekly skin check was not noted to have any issues. - On 12/6/19, RN observed open area on left buttock and redness to right buttock. - On 12/9/19, Resident #2 had no open areas to buttocks. - On 1/1/20, Resident #2's, Bilateral coccyx continues to have irritated/scabbed skin and were cleansed today with NS, patted dry with gauze and [MEDICATION NAME] put in place for protection. Will continue to monitor. (sic) - On 1/15/20, Resident #2 had an Open area noted on residents left buttocks. Size 3 cm x .5 cm. MD notified via fax. Daughter called. No staging of resident #2's pressure ulcer was documented. - On 1/20/20, The open areas are decreasing in size and a dressing was applied. A review of resident #2's Care plan, with a revision date of 3/19/19, showed the following: - A focus for resident #2 as, My skin is intact. I am diabetic which increases my risk for developing pressure related breakdown. - A goal for resident #2 as, I want to keep my skin intact and healthy. - Interventions for resident #2 include, I want staff to monitor for any potential skin breakdown. I am able to reposition myself. I have a pressure redistributing mattress on my bed. No revisions were made to the care plan to reflect the current intervention and treatment to resident #2's current pressure sores. A request for resident #2's Medication and Treatment Administration record for the last three months was made on 1/28/20. No documentation was provided by the facility. A review of the facility's Skin Program Policy, with a revision date of 3/18/19, showed the following: - To ensure a resident who enters a facility with a pressure sore ulcer/pressure injury does not develop unless the residents clinical condition demonstrates that they were unavoidable. To provide care and services to prevent pressure ulcer development, to promote the healing of pressure ulcer/wounds development of additional pressure ulcers/wounds. - 1. On admission a baseline assessment of a resident's skin status will be completed within two hours of admission. It is recommended to repeat weekly x4. This will include a physical exam of the resident's skin, a risk assessment using a Risk Assessment tool, and a comprehensive assessment of the resident's history and physical condition. A temporary plan of care (POC) will be put into place for residents that are identified at-risk for breakdown. - 4. Nursing personnel will utilize the results of the physical exam and the Pressure Ulcer Assessment tools to determine an individualized pressure ulcer prevention program for each at-risk resident. This will include interventions to: a) Protect skin against the effects of pressure, friction, and shear; b) Protect the skin from moisture; . f) Immediate prevention plan instituted when potential areas are identified. - 7. Nursing personnel will develop a POC with interventions consistent with resident and family preferences, goals and abilities, to create an environment to the resident's adherence to the pressure ulcer prevention/treatment plan. POC to include; Impaired mobility, Pressure relief, Nutritional status and interventions. Incontinence, Skin condition checks, Treatment, Pain, Infection Education of resident and family, Possible causes for pressure ulcers and what interventions have been put in place to prevent. Skin checks are to be completed at least weekly by a Licensed Nurse. - 10. Monitoring results will be brought to the IDT workgroup (Pressure Ulcer team) who will meet to review current practices, assessment tools and schedules and to identify person(s) responsible for monitoring .",2020-09-01
65,VALLE VISTA MANOR,275021,402 SUMMIT AVE,LEWISTOWN,MT,59457,2017-10-12,201,D,1,1,BU9C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure a resident was assisted with an appropriate discharge plan, when the resident wanted to immediately leave the facility, to ensure the resident's ongoing needs were met, but the facility had determined that long term care was necessary, for 1 (#1) of 10 sampled residents. Findings include: During an interview on [DATE] at 6:00 p.m., staff member C stated that resident #1 was discharged from the facility on [DATE]. Staff member C stated that resident #1 was discharged because the facility could not meet his needs per staff member B. Staff member C stated that resident #1 did not have an initial discharge plan, as he was considered to be a long term resident, and could not return to live in the community. Staff member C stated that after the resident left the facility, and had been taken to the hospital, the hospital had not notified the facility directly when resident #1 was discharged from the hospital. Review of the resident's Discharge Return Anticipated MDS, with an ARD date of [DATE], showed in Section Q, under Discharge Plan, A was coded as a 1 which is for a yes meaning active discharge planning was already occurring for the resident to return to the community. The MDS contradicted what staff member C had stated relating to long term care placement. Review of resident #1's Resident Incident Report, dated [DATE] at 9:18 p.m., showed resident #1 became increasingly verbally angry with facility staff, and he stated he wanted to leave in his vehicle. When resident #1 would not calm down, staff member P phoned staff member B and was informed of the situation. Staff member B advised staff member P to contact law enforcement, due to the resident's behavior. Resident #1 was escorted from the facility by law enforcement, although a discharge plan had not been initiated for the resident, prior to the resident leaving the facility. Further review of the incident report for resident #1 showed: -NF4 had not been notified by the facility of the incident that occurred on [DATE]. -NF3 reported concerns about resident #1 to NF4 on [DATE], after the resident was no longer at the facility. -The report showed that the facility had contacted the hospital and informed the hospital staff they would not accept the resident back at the nursing home. -The resident was not allowed back on the facility's premises, therefore, the facility would not accept the resident as return resident. When resident #1 was discharged from the hospital on [DATE], he did not have shoes, and did not have a location to live. -NF3 had came to the facility, and obtained the resident's shoes, and he then found the resident shelter. -The report reflected that the resident did not have placement assistance from the hospital or any discharge follow up care in place by the facility. The resident had been released into the community without any support. During an interview on [DATE] at 9:45 a.m., staff member B stated that the facility had discharged resident #1 right away. Staff member B also stated the facility staff had heard resident #1 had gone to the hospital, but the facility staff had not been notified of this. Staff member B stated that she thought the resident did come back to the facility later (with NF3) but would not come inside to get his personal items. During an interview on [DATE] at 2:30 p.m., NF4 stated that she was a case manager for resident #1 for a long time when he resided in the community. NF4 said that resident #1 was not known to be an aggressive person and it was out of character for him to be a drinker. NF4 wondered why the resident had not been checked for an infection, prior to his discharge, referring that this may have been the cause of the resident's behavior change. During an interview on [DATE] at 4:45 p.m., staff member P stated that resident #1 would not calm down and wanted to leave. Staff member P attempted to talk to resident #1 on [DATE], but the resident did not make sense. Staff member P told the resident he could leave but it would be AMA (against medical advice). The medical record did not show attempts of the facility to set up community services for ongoing care. During an interview on [DATE] at 9:05 p.m., staff member Q stated the resident thought the staff were stealing from him. He began to bring his clothes up and stack them by the handicap door to load them into his van. Staff member Q stated the resident said I will kill anyone who tries to stop me. The resident did not target anyone specifically, he just thought staff were going to detain him. He was able to read his rights from the Resident Right's board and the staff all agreed he had a right to leave. The facility had not addressed the resident's change, or concerns with his not making sense to ensure the change was not potentially a contributing factor in the resident's drive to leave to leave the facility, in an attempt to ensure safety. Review of resident #1's nurses' Progress Note dated [DATE] at 2:21 a.m., staff member P had wrote that staff member B was phoned a second time, updated on the situation, and staff member P was advised to call the physician. The physician on call was reached and staff member P had explained the situation occurring with the resident, as it occurred. Staff member B was notified a third time, updated on the situation, and staff member P was instructed to document the events. Review of another nurses' Progress Noted dated [DATE] at 8:48 a.m. showed resident #1 was unwilling to consent to an assessment. At 8:30 a.m. that same date, a peace officer was given resident #1's medication administration sheet and medications. No welfare check by the facility was initiated. Review of resident #1's Care Plan, with last review date of [DATE], showed under the Focus area: Behavior - The resident had exhibited rage which is evidenced by yelling and shaking fists when he became overwhelmed and does not comprehend complex questions. The intervention was to offer reassurance and attempt to redirect me when I am exhibiting indicators of psychosocial distress and notify nurse. Also, under the Focus area: Discharge Planning - showed the resident elected to stay at the facility for long term placement as his needs could not be met in the community. The last revision date was [DATE], and this was documented by staff member C. Information was requested for the incident that occurred on [DATE], and discharge information relating to the resident, which had not yet been provided. The following information was not received prior to the end of the survey: - A discharge order from the physician - A discharge summary - A discharge plan, or a follow up discharge plan. During an interview on [DATE] at 2:50 p.m., NF1 stated she was not notified of the resident's discharge from the facility, which took place on [DATE]. During an interview on [DATE] at 11:20 a.m., staff member C stated that if the resident had remained in the hospital on [DATE], she would have followed up with the resident to assist with a discharge plan. Since the incident happened over the weekend, and it happened so quickly, the situation did not allow time for her to complete this. The investigation showed the resident had expired after a motor vehicle accident on the early morning of [DATE].",2020-09-01
66,VALLE VISTA MANOR,275021,402 SUMMIT AVE,LEWISTOWN,MT,59457,2017-10-12,241,D,0,1,BU9C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident had clothing available in his closet to attend the evening meal for 1 resident (#8); and failed to return laundered clothing to resident owners for two residents (#s 9 and 11) of 13 sampled and supplemental residents. This had the potential to affect all residents who receive clothing from the facility laundry. Findings include: 1. Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #8's care plan, with a revision date of 10/6/17, reflected staff was to anticipate the resident's needs and address them. Review of the resident #8's Admission MDS, with the ARD of 9/21/17, reflected the resident required the extensive assistance of one staff member to dress. During an observation and family interview on 10/11/17 at 5:00 p.m., resident #8 was wearing a white T-shirt and had no clothes hanging in his closet. Resident #8's family member voiced the resident did not have any clothes hanging in his closet, and this was not the first time he did not have clothes available to him from the laundry. The family member stated the resident had several pairs of sweat bottoms and shirts in the facility, and stated the resident would not want to go to dinner without a shirt on. Staff member H came into the resident's room to assist him to the evening meal in the dining room. Staff member H was told resident #8 did not have any clothes in his closet. Staff member H was told by the family member that the resident needed a shirt to go to dinner. Staff member H stated she would look in the laundry for the resident's clothing. Staff member H returned to the resident's room and stated his clothing was clean, in the laundry room, and would probably be delivered the following day. Staff member H had brought one of the resident's shirts with her. Staff member H assisted resident #8 to put on his shirt. During an interview on 10/12/17 at 9:10 a.m., staff member J stated the resident's clothing was passed on Tuesday, Thursday and Friday. Staff member J stated the resident did have clean clothes to include sweat bottoms and shirts. Staff member J stated if a resident doesn't have any clothing the CNA caring for that resident would come and let her know and she would make sure the resident had clothing to wear. Staff member K joined the interview and stated the residents should always have clothing in their closets available to wear. Staff member K stated she was not aware that residents had complained about not getting their laundry in resident council. Staff member K stated the policy and procedure was the CNA would report to the Social Service director and the Social Service director would complete a grievance or just report the concern to the laundry. Staff member K stated the facility would consider delivering resident clothing daily. During an observation of a resident group meeting held on 10/11/17 at 10:50 a.m., several residents voiced the concern that it was taking too long, up to 7 or 8 days, for laundry staff to return clothing items to the residents after they were washed. 2. A review resident #9's MDS, with an ARD of 7/7/17, showed she had a BIMS score of 15 coded on the assessment, which was cognitively intact. During a resident group meeting, held on 10/11/17 at 10:50 a.m., resident #9 stated that in some cases missing clothing items have not ever turned up again. She says after an unsuccessful visit to the laundry, when she did not find her missing clothing, she was eventually reimbursed for a few of her items by the facility, with the help of the facility's activity director. 3. A review of resident #11's MDS, with an ARD of 10/31/16, showed she had a BIMS score of 15, cognitively intact. During a resident group meeting held on 10/11/17 at 10:50 a.m., resident #11 stated that she had been missing a pair of jeans after she had sent them to the facility laundry. Several weeks went by and she saw another resident in the facility wearing the jeans. She said she recognized them by the several tiny holes she knew her jeans had. After she complained to the facility, it was arranged for her to get her jeans back. She found her name, as she had written it, on the label inside her jeans: but, underneath it, the resident who she saw wearing her jeans had written her name also. She said she questioned whether any staff efforts were being made to return laundry items to their correct owners. She stated all clothing is suppose to be labeled with the resident owner's name.",2020-09-01
67,VALLE VISTA MANOR,275021,402 SUMMIT AVE,LEWISTOWN,MT,59457,2017-10-12,243,E,0,1,BU9C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to make all residents aware of upcoming resident group meetings in a timely manner and encourage resident attendance. This had the potential to discourage all residents from attending group meetings and prevent expression of resident concerns regarding care received by the facility, and affected 3 (#s 9, 11, and 12) of the 13 sampled residents. Findings include: During an interview on 10/10/17 at 4:50 p.m., staff member [NAME] was requested to assist to notify residents of a special resident group meeting planned to allow residents to express concerns and complaints to state surveyors, without the presence of facility staff. She agreed to do so, saying she would advertise it like she did resident group council meetings. She stated she would post the scheduled meeting on the activities calendar outside her office in the hall and also would verbally invite residents who she knew were active members in the facility's regular resident group meeting. Staff member [NAME] was asked to recruit some of the facility CNA staff to speak with all the residents and let them know they were all invited to the meeting. During an observation of a resident group meeting, scheduled for 10/11/17 at 10:45 a.m., the following was noted: Ten minutes before the meeting, staff member [NAME] said that residents were not showing interest in attending the meeting, and said she thought maybe only 2 or 3 were planning on attending. NF1 overheard this statement, and went from resident to resident relaying the purpose of the meeting. Within ten minutes, eight residents had gathered, and the meeting was started at 10:55 a.m. Two of the residents, #s 9 & 11, stated during the meeting they had not been previously informed of the meeting. Resident #12 said the resident group council meetings were not well advertised and sometimes only two or three residents attended, even though the meetings were held at the same time and day every month. She said she wanted the facility staff to verbally remind all of the residents, before scheduled resident group meetings, that they were invited to attend. During an interview on 10/11/17 at 11:45 a.m., NF1 stated that the prior facility administration had a history of [REDACTED]. She said the prior administrator said residents had to have a certain level of mental capacity and ability to verbally communicate to be able to participate in the group resident council. She said that staff members were told by the administrator which residents to invite to the resident group meetings. She said staff had been told not to make resident group council meetings a priority. NF1 expressed concern that staff members remaining in the facility, as a part of the present administration, would continue to sort of have the same attitude. A review of the Resident Council Minutes for the months of (MONTH) through (MONTH) of (YEAR), showed six residents attended on 5/11/17; five residents attended on 6/15/17; six residents attended on 7/13/17; three residents attended on 8/17/17; and four residents attended on 9/28/17. On 10/10/17, the facility had a total of 36 residents.",2020-09-01
68,VALLE VISTA MANOR,275021,402 SUMMIT AVE,LEWISTOWN,MT,59457,2017-10-12,244,E,0,1,BU9C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to consider the views of the facility's group resident council and respond to resident grievances and recommendations. This had the potential to affect all the residents in the facility, and did affect resident #12 and #13. Findings include: A review of resident #12's MDS, with an ARD of 8/10/17, showed a BIMS of 13: cognitively intact. During an observation and interview of the resident group meeting held on 10/11/17 at 10:55 a.m., resident #12 said she felt there was a need for greater communication between the group council members and the facility administration. She said during resident council meetings the residents have been given only a short time to express their concerns, and have not been given any time for discussion. She said the meeting minutes have been being taken by a facility staff member, who relayed the resident concerns to the administration or other facility departments. She said the resident group members did not hear back about their expressed concerns. The group was not sure their complaints were even being heard. She described the group meetings as rushed and driven by the agenda as verbalized by the staff person taking the meeting minutes. The meeting was not ran by the residents. She said many of the residents don't even get a chance to talk, especially if they have slow speech or speech impairments, and Then we're just blown off because we don't matter. During an observation and interview of the resident group meeting held on 10/11/17 at 10:55 a.m., resident #13 said that the reason he had quit coming to the resident group council meetings was because the facility did not respond to the resident's complaints. He said that he felt that the facility nurses and CNAs worked hard and did excellent work, but that there were too few of them to be able to meet the needs of all the residents who needed care at the same time. He said he had complained of a lack of staff several times and had never received any feedback as to whether anything was planned to be done about it. He also said that he was getting tired of being told that requests for additional activities or attention to cares would not be considered at this time due to the lack of staff. A review of the monthly resident group council meeting minutes, for the months of (MONTH) through (MONTH) (YEAR), showed minimal documentation of the concern areas expressed by residents. How many residents were affected by the concerns was not mentioned. The documentation did not show to whom the concern was communicated to, when or if investigations of problems were conducted, and whether or not resident questions were provided a response. There was no indication to show the prior month concerns had been addressed and resolved to the satisfaction of the residents. During an interview on 10/12/17 at 11:00 a.m., staff member [NAME] said she attended the resident group council meetings for the purposes of taking the meeting minutes. She said she was also responsible for investigating the residents' concerns and communicating them to administration and other appropriate facility department directors as needed. She also said she did the follow up and reporting back to the residents about their concerns. She said she did not have written documentation on any of these activities except for the meeting minutes. During an interview on 10/11/17 at 11:45 a.m., NF1 stated that the prior facility administration had a history of [REDACTED]. She said staff had been told not to make resident group council meetings a priority. NF1 expressed concern that staff members remaining in the facility as a part of the present administration would continue to have the same attitude. During an observation and interview of the resident group meeting held on 10/11/17 at 10:45 a.m., a consensus was determined amongst the residents, to invite a member of the facility's administration to a resident group council meeting for the purpose of making sure resident complaints were heard. This occurred after residents discussed amongst themselves a need to meet face to face with administration to have someone they could hold accountable for responding to their concerns.",2020-09-01
69,VALLE VISTA MANOR,275021,402 SUMMIT AVE,LEWISTOWN,MT,59457,2017-10-12,253,D,0,1,BU9C11,"Based on observation and interview, the facility failed to maintain exterior doors for pest control due to impaired doors seals for 1 of 1 kitchen exterior door. Findings include: During an observation on 10/10/17 at 3:14 p.m., the exit door from the kitchen to the outside was inspected. The rubber seal at the bottom of the door was peeled away and was bent preventing a proper seal under the door. The screen door installed in the same place also lacked proper seal on the bottom of the door to accommodate proper pest control. Staff member D, who accompanied the surveyor, stated the rubber seal would be replaced.",2020-09-01
70,VALLE VISTA MANOR,275021,402 SUMMIT AVE,LEWISTOWN,MT,59457,2017-10-12,280,D,0,1,BU9C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to update and revise the care plan for 1 (#4) out of 10 sampled residents. This failure had the potential to confuse staff members as to the appropriate precautions to be taken to prevent the resident from potential harmful falls. Findings include: Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. He was not ambulatory, secondary to lower extremity weakness, and required staff assistance to transfer. During an observation of the facility's South Dining Room, on 10/10/17 at 3:45 p.m., resident #4 was observed in his Broda chair with his feet resting on the lower footrests. His upper torso was stretched forward, out of the chair, with his arms and full upper body weight resting on the dining room table before him. With his right facial cheek against the table cushioning his head, his eyes were closed, and he appeared to be sleeping. His Broda chair was not locked in position. Two other residents were in the room sitting in wheelchairs at dining tables several feet away. They were calling out for staff help for unknown reasons. No staff was in the room or in the nearby hall. Resident #4 had been in the dining room since lunch. A review of resident #4's fall incident reports and care plan showed the resident had multiple falls from (MONTH) (YEAR) through (MONTH) (YEAR). Resident #4's care plan also showed the following: I need staff to transfer me into a recliner in South Dining Room after all my meals. Initiated: 04/18/17. A review of resident #4's care plan, under a focus regarding him as a high fall risk, showed the following on page number eight: Do not leave me unsupervised in my Broda at any time. If I stay in my Broda I must be in a location where staff can supervise my activity. Otherwise I should be transferred into a recliner or into my bed. Date initiated: 04/18/2017. During an interview, on 10/12/17 at 12:10 p.m., staff member A said that Resident #4 no longer needed to be supervised while he was in his Broda chair. She explained that originally the resident had a Broda chair that was much too large for him, and he slipped down and fell out of it often. She said the resident was using a different Broda chair, one made to fit him, and he no longer had falls. When she was shown the resident's care plan regarding the need to transfer the resident to a recliner and not leave him unsupervised in his Broda chair, she stated resident 4's care plan should have been updated a long time ago. She said his care plan did not show that the resident's physical condition had improved since his readmission on 4/14/17.",2020-09-01
71,VALLE VISTA MANOR,275021,402 SUMMIT AVE,LEWISTOWN,MT,59457,2017-10-12,281,D,0,1,BU9C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform physician ordered urinary catheter irrigations for 1 (#4). This failure had the potential to increase the resident's risk of [MEDICAL CONDITION] and urinary tract infection; and the facility failed to monitor a resident for dysphagia symptoms of choking, coughing, and emesis during meals, and failed to monitor lung sounds before and after meals for 1 (#8) resident out of 10 sampled residents. Findings include: 1. A review of resident #4's medical record showed the [DIAGNOSES REDACTED]. He had an indwelling urinary catheter with a [DIAGNOSES REDACTED]. He was readmitted on [DATE]. During an observation and interview with resident #4, on 10/10/17 at 3:45 p.m., it was noted that the resident's urine, as it flowed through his urinary catheter tubing, contained a large amount of white particle sediment in yellow clear urine. A review of resident #4's TARS for (MONTH) and (MONTH) of (YEAR) showed the following: Flush catheter with sterile water and vinegar solution daily and PRN, one time a day related to urinary tract infection, site not specified. Start Date - 08/26/17 0730. Further review of resident #4's TARS, showed that between the dates of 9/1/17 and 10/10/17, the resident received urinary catheter irrigations every day except for 9/1/17, 9/11/17, 9/12/17, 9/13/17, 9/22/17, 9/28/17, 9/29/17, 9/30/17, 10/2/17, 10/5/17, and 10/6/17. Out of a period of 40 days the resident did not receive catheter irrigations as ordered for 11 days, or 27.5 % of the time. It was noted that on 10/7/17 and 10/8/17 the resident received catheter irrigations that were signed off as given on a PRN (as needed basis). During an interview on 10/11/17 at 7:30 a.m., staff member G stated that resident #4 had a history of [REDACTED]. She said that whenever resident #4 received his urinary catheter irrigations, two staff people needed to be present because the resident's behavior can be inappropriate and he makes false accusations. She was unable to explain why resident #4 did not receive catheter irrigations every day, as ordered, for the period between 9/1/17 and 10/10/17. She stated that if a resident refuses a procedure it was supposed to be recorded as a refusal by signing the MARS box with a 2 and there was no documentation present to show the resident had refused treatment. An interview on 10/12/17 at 8:55 a.m., staff member A said resident #4 had a UTI on readmission on 4/14/17 that was treated and resolved. A repeat urine specimen on 4/26/17 showed a repeat UTI that was again treated [MEDICATION NAME] resolved. She said resident #4 had only one UTI since he was readmitted . During an interview on 10/12/17 at 11:10 a.m., staff member I stated she did not know why resident #4 had not received catheter irrigations as ordered by his physician. She stated it was one employee that had not provided the irrigations on her shifts. She also said the employee was no longer employed by the facility and would not be available for survey interview. 2. Review of resident #8's treatment administration record reflected an order to assess the resident's lung sounds before and after meals for seven days. The order start date was 10/5/17. The treatment administration record did not include documentation that the assessment had been done on the following days and times: 10/6/17 at 8:00 a.m., 12:00 p.m. and 6:00 p.m. 10/7/17 at 12:00 p.m. and 6:00 p.m. 10/8/17 at 6:00 p.m. 10/9/17 at 12:00 p.m. and 6:00 p.m. 10/10/17 at 8:00 a.m., 12:00 p.m. and 6:00 p.m. 10/11/17 at 6:00 p.m., and 10/12/17 at 8:00 a.m. Review of resident #8's nursing progress notes did not include documentation of the resident's lung assessments for the dates and times listed above. Review of resident #8's speech therapy progress notes, dated 9/27/17 at 2:29 p.m., reflected, consult with NSG to update on swallow precautions. Printed swallow precautions list for pt (patient) was faxed to B (facility) at 1:00 p.m. Pt will be seen to evaluate tomorrow. Review of a speech therapist progress note, dated 10/4/17 at 12:54 p.m., for resident #8, reflected, Data sheets were provided to NSG staff to document lung sounds and temperatures as well as other comments regarding signs of aspiration during each meal of the day over the next week. During an observation on 10/11/17 at 8:00 a.m., resident #8 was sitting at a table where other residents were assisted to eat. Resident #8's family member was seated next to him and encouraging him to eat. Staff were observed to guide resident #8 in chewing his food and swallowing before he placed more food in his mouth. Resident #8 was eating without noted difficulty at the time of the observation. During an interview on 10/12/17 at 8:50 a.m., staff member G stated the nurses were to check lung sounds after each meal and snacks. Staff member G stated she was not sure where the documentation was in the electronic medical record for the monitoring. During an interview on 10/12/17 at 9:15 a.m., staff member L stated the CNA charts in the medical record have the percent of each meal eaten, but the program did not have an area that CNA staff could document if the resident had symptoms of dysphagia such as choking, coughing, or emesis. Staff member L stated if he was assisting resident #8 and observed symptoms of dysphagia he would report the concern to the nurse. During an interview on 10/12/17 at 10:45 a.m., staff member M stated resident #8 received a soft regular diet and no bread as the bread was causing most of the choking. DeLaune, S. & Ladner, S., Fundamentals of Nursing, Standards and Practice, Albany, NY., (1998), pg. 237. Nurses are obligated to follow the orders of a licensed physician or other designated health care provider unless the orders would result in client harm.",2020-09-01
72,VALLE VISTA MANOR,275021,402 SUMMIT AVE,LEWISTOWN,MT,59457,2017-10-12,371,E,0,1,BU9C11,"Based on observation, interview, and record review, the facility failed to monitor and remove outdated food items stored in the resident snack storage refrigerator, in the locked pantry across the hall from the nurses' station. This failure had the potential to affect all residents who consumed outdated food from the snack storage refrigerator. Findings include: During an observation of the facility's locked pantry across the hall from the nurse's station on 10/11/17 at 1:55 p.m., inspection of the snack storage refrigerator contents showed the following: - A 16 oz. container of[NAME]Caramel Dip, previously opened and dated 9/14/17. - A round glass container of soup, labeled with a first name, and dated 9/30/17. - A jar of Famous Dave's pickle chips, labeled with a first name, and dated 9/14/17. - A container of cranberry juice, dated 10/10/17. - Four half bologna and cheese sandwiches in sandwich bags, all dated 10/8/17. During an interview during the observation of the facility's locked pantry, on 10/11/17 at 1:55 p.m., staff member H said that all food kept in the refrigerator for longer than three days was considered outdated and needed to be disposed of. She stated that it was the responsibility of the CNAs on night shift to monitor and discard outdated food in the resident snack refrigerator. She said she would dispose of the above outdated items, and then she proceeded to do so. During an interview on 10/12/17 at 8:02 a.m., staff member F stated the dietary department was responsible for the monitoring and disposal of foods outdated in the resident snack refrigerator. A review of the facility's policy, titled Foods Brought by Family/Visitors, showed the following: Perishable foods must be stored in re-salable containers with tightly fitting lids in the refrigerator. The nursing staff is responsible for discarding perishable foods on or before the use by date. The nursing and/or food service staff must discard any foods on or before the use by date.",2020-09-01
73,VALLE VISTA MANOR,275021,402 SUMMIT AVE,LEWISTOWN,MT,59457,2017-10-12,514,E,0,1,BU9C11,"Based on record review and interview, the facility failed to ensure residents received a bath or shower at least one time per week, and the medical record reflected the provision of baths/showers, for 3 (#s 5, 7, and 10) out of 10 sampled residents. This had the potential to affect all resident's receiving baths in the facility. Findings include: 1. Review of resident #7's care plan, with a review date of 8/2/17, reflected resident #7 required extensive assistance of one staff member to take a bath. The care plan reflected resident #7 needed nail care weekly, usually on her bath days. Review of resident #7's bath record reflected she received two baths in the month of (MONTH) (YEAR). Resident #7 did not receive a bath from (MONTH) 1 through (MONTH) 11, at which time she was given a bath on (MONTH) 12. The bath record reflected resident #7 did not receive a bath from (MONTH) 20 through (MONTH) 1, (YEAR). She received a bath on (MONTH) 2, (YEAR). The medical record lacked evidence of the nail care and bathing each week. During an interview on 10/12/17 at 8:45 a.m., staff member N stated if the resident refuses a bath the electronic charting has a refused option that can be chosen that will show the resident refused. Staff member N stated residents received their baths at least weekly. A request for the facility policy and procedure for resident baths was requested. No policy and procedure was received prior to the end of the survey. 2. A review of resident #10's medical record showed he entered the facility on 9/21/17 with an open left knee wound, which was draining. A review of the facility's resident Bath Schedule showed resident #10 was scheduled to receive a shower/bath twice a week. A review of resident's #10's care documentation showed he received his first shower/bath in the facility 15 days after his admission. During his 21 days in the facility he received only one scheduled bath on 10/7/17, and another unscheduled two days earlier on 10/05/17. The medical record lacked evidence of the showers or baths twice a week. 3. A review of the facility's resident Bath Schedule showed resident #5 was scheduled to receive a shower/bath once a week on Fridays. A review of resident #5's documentation showed she received a shower/bath on 9/2/17, after 16 days she received a second shower/bath, and after 12 more days she received a third shower/bath. The resident's record lacked evidence of the showers or baths provided once a week.",2020-09-01
74,VALLE VISTA MANOR,275021,402 SUMMIT AVE,LEWISTOWN,MT,59457,2018-11-15,641,D,0,1,MIUW11,"Based on record review and interview, the facility failed to accurately code a Quarterly MDS for 1 (#41) of 12 sampled residents. Findings include: Review of resident #41's Quarterly MDS, with the ARD of 10/23/18, showed the resident had an ostomy, but was always incontinent of bowel; had a catheter, but was incontinent of urine; had experienced dehydration, vomiting, fever, and internal bleeding during the 7 day look-back period. Review of resident #41's medical record did not show an ostomy, or an episode of illness in October, (YEAR). During an interview on 11/14/18 at 1:32 p.m., staff member L did not know why those items were coded on the MDS. She stated, I don't think the resident has an ostomy, and he wasn't sick. It is because I am new at the job.",2020-09-01
75,VALLE VISTA MANOR,275021,402 SUMMIT AVE,LEWISTOWN,MT,59457,2018-11-15,658,D,0,1,MIUW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the faciltiy staff failed to meet professional standards of quality by not wearing gloves when removing and replacing a narcotic patch, [MEDICATION NAME], for 1(# 31) of 14 sampled and supplemental residents; and staff failed to dispose of a [MEDICATION NAME] appropriately. Findings include: 1. No Glove Use During an observation and interview on [DATE] at 4:25 p.m., staff member A removed a narcotic patch from resident #31. Staff member A did not wear gloves to remove the existing patch and to apply a new patch. Staff member A stated she was not sure if, and why, she should be wearing gloves to remove and replace a [MEDICATION NAME]. During an interview on [DATE] at 8:45 a.m., staff member A stated she should have worn gloves during the patch change for resident #31 to prevent self-contamination from direct skin contact with the narcotic patch. Review of the facility's policy, Medication Administration and Ordering, read, .7. Never handle medications with bare hands. 2. [MEDICATION NAME] disposal During an observation and interview on [DATE] at 4:27 p.m., staff member A disposed a [MEDICATION NAME] removed from resident #31. Staff members A and B co-signed in the Controlled Substance Record Book indicating the used patch was disposed of. Staff member A stated the co-signature was not always obtained when disposing of the [MEDICATION NAME]es. During an interview on [DATE] at 4:31 p.m., staff member F stated two nurses should have witnessed the disposal of a [MEDICATION NAME], and co-signed the destruction of the patch. Staff member F stated the destruction of [MEDICATION NAME]es were not always witnessed and co-signed by a second staff member because, We sometimes get too busy. A review of the Controlled Substance Record Books #25 and #26, for the North corridor, showed the following for resident #31: - [DATE]; only one staff member signed on page 82 when then [MEDICATION NAME] was disposed of. - [DATE]; one staff member signed on page 11 when the [MEDICATION NAME] was disposed of. - [DATE]; one staff member signed on page 11 when the [MEDICATION NAME] was disposed of. During an interview on [DATE] at 12:54 p.m., staff member M stated two licensed staff members should always witness the destruction of a [MEDICATION NAME]. Staff member M stated two signatures were required to prevent medication diversion. During an interview on [DATE] at 1:22 p.m., staff member B stated she should have had a licensed staff member witness the disposal and destruction of a replaced [MEDICATION NAME] for resident #31. Staff member B could not recall why two signatures had not been obtained. During an interview on [DATE] at 1:56 p.m., staff member [NAME] stated staff did not always follow the policies and procedures with co-signing the destruction of [MEDICATION NAME]es, but staff should have. Review of the facility's policy, Disposal/Destruction of Expired or Discontinued Medications, read, .10. Facility should record destruction of controlled substances on: 10.1 Medication Disposition/Destruction Form; 10.2 Controlled Substance Count Form; or, 10.3 Medication Destruction Log Book .12.1 Facility should destroy (Scheduled II-IV) controlled substances in the presence of a registered nurse and a licensed professional in accordance with Facility policy or Applicable Law. 12.2 Destruction of controlled medications should be documented on the controlled medication count sheet and signed by the registered nurse and witnessing licensed professional who should record: 12.2.1- Quantity destroyed; 12.2.2- Date of destruction; and, 12.2.3- Signature of registered nurse and pharmacist. References: http://www.sahealth.sa.gov.au/wps/wcm/connect/eefc0c804dec81cab734ff6d722e1562/Circ+[MEDICATION NAME].pdf?MOD=AJPERES 4. Disposal process is recorded in the drug of dependence register, and countersigned by the witness.",2020-09-01
76,VALLE VISTA MANOR,275021,402 SUMMIT AVE,LEWISTOWN,MT,59457,2018-11-15,686,D,0,1,MIUW11,"Based on observation, records review, and interview, the facility failed to prevent and identify the development of a Stage II pressure ulcer, and failed to assess the progress of the pressure area for 1 (#20) of 12 sampled residents. Findings include: During an observation on 11/15/18 at 9:13 a.m., resident #20's coccyx showed evidence of a healing pressure area. Calazine was applied to the areas by staff member F. Staff member F put on gloves and opened a drawer, and applied the lotion without changing to clean gloves. Review of resident #20's progress note, dated 9/26/18, showed residents wife brought to this RN's attention that resident had a sore on his bottom. Resident does not report pain, has difficulty remembering to alert staff of needs, is incontinent at times, and prefers to sit in recliner throughout the day. The wound was assessed measuring 1.0 x. 6 x 0.2, Stage II. No intervions were implemeneted for the pressure sore, despite the above identified causes. During an observation on 11/13/18 at 11:30 a.m., resident #20 was sitting in his recliner; he did not have a pressure reducing cushion in his recliner, or on his wheelchair. During an interview on 11/15/18 at 9:13 a.m., staff member F stated the wife took the ROHO cushion for the recliner home. She did not know why. Review of a progress note dated, 11/5/18, showed the wound was closed with some scabbing. Review of the medical record showed no other assessments or measurements regarding the pressure area. Review of the Admissions MDS, with the ARD of 8/23/18, showed no pressure reducing device for the bed or chair, and no turning and reposition program. During observations on 11/13/18 at 11:35 a.m., 11/14/18 at 10:41 a.m., 11/14/18 at 1:57 p.m., and 11/15/18 at 10:26 a.m., resident #20 was sleeping in his recliner without a pressure reducing cushion, or position changes. Review of resident #20's weight report showed a significant weight loss, with no additional calories or protein to promote healing. Review of the Care Plan, dated 10/18/18, did not include the presence of a Stage II pressure sore. It showed a Braden score of 20, meaning no risk factors for the developing a pressure sore. During an interview on 11/15/18 at 12:20 p.m., NF1 stated she was not sure why resident #20 developed a pressure area, but guessed it was from not getting cleaned up adequately. During an interview on 11/15/18 at 1:08 p.m., staff member [NAME] stated she did not know why resident #20 developed a pressure area with out reviewing his chart. She stated the facility should have had an initial skin assessment report, and completed a weekly assessment until resolution of the pressure area.",2020-09-01
77,VALLE VISTA MANOR,275021,402 SUMMIT AVE,LEWISTOWN,MT,59457,2018-11-15,692,D,0,1,MIUW11,"Based on observation, interview, and record review, the facility failed to identify a significant weight loss for 1 (#20) of 12 sampled residents. Findings include: During an interview on 11/12/18 at 11:40 a.m., resident #20's family member was getting the resident ready for lunch out of the facility. She stated the resident did not like the food at the facility. Upon their return to the facility, resident #20's family stated he loved his lunch, and it was the most she had seen him eat in a long time. She stated he had lost 77 pounds in the past year. During an observation on 11/15/18 at 8:36 a.m., resident #20 ate 1/2 of a piece of ham and drank his liquids. He did not eat his eggs, English muffin, or cereal. He was not offered any other meal replacement. Review of resident #20's Food Preferences Interview showed it was blank, other than Oatmeal at breakfast every day. During an interview on 11/15/18 at 1:05 p.m., staff member H stated it was the responsibility of the Account Manager to collect food likes and dislikes. She was not aware of resident #20's significant weight loss. Review of resident #20's Nutritional Assessment, dated 8/28/18, showed, Resident is sleeping soundly at this time and no family present. No nutrition concerns at this time. Review of resident #20's Weight Summary, dated 11/2/18, showed a 5 percent weight loss in one month and a 7.5 percent loss in 3 months. Review of resident #20's Care Plan, dated 8/28/18, showed, I need staff to observe for and report changes in my abilty to feed myself or amount eaten for meals. Review of resident #20's Meal Record, from 9/15/18 to 11/14/18, showed the resident ate less than 51 percent or refused 80 meals out of 130 meals recorded. During an interview on 11/15/18 at 12:41 p.m., staff member N stated resident #20 does not have a big appetitie.",2020-09-01
78,VALLE VISTA MANOR,275021,402 SUMMIT AVE,LEWISTOWN,MT,59457,2018-11-15,732,B,0,1,MIUW11,"Based on observation, interview, and record review, staff failed to ensure the Daily Posting of staffing information had been updated daily, was accurate and current, had all data requirements; including the facility name. This practice has the potential of affecting all residents residing at, and visitors of, the facility. Findings include: During an observation on 11/13/18 at 12:45 p.m., the Daily Posting of Hours of Nurse Staffing sheet, posted near the nurse's station, had not been updated since 11/5/18. The posted information sheet also lacked the facility's name. During an interview on 11/13/18 at 4:06 p.m., staff member A stated she was not sure when, or by whom, the Daily Posting of Hours for nurse staffing was completed. A review of the Daily Posting of Hours showed the sheets had not been updated from 10/16/18 through 10/24/18, and 10/26/18 through 11/3/18. The posted information sheet lacked the facility's name. During an observation on 11/14/18 at 4:44 p.m., the Daily Posting of Hours had not been updated since 11/13/18. The posted information sheet lacked the facility's name. During an observation and interview on 11/15/18 at 1:15 p.m., staff member [NAME] stated the Daily Posting of Hours had not been updated since 11/13/18. Staff member [NAME] stated, The Night-shift (nurse) was responsible for initiating the Daily Posting of Hours, but that nobody was currently responsible for making sure it had been completed.",2020-09-01
79,VALLE VISTA MANOR,275021,402 SUMMIT AVE,LEWISTOWN,MT,59457,2018-11-15,759,E,0,1,MIUW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5%, which affected 1 (#35) of 14 sampled and supplemental residents. The facility medication error rate was 12%. Findings include: During an observation and interview on 11/14/18 at 7:48 a.m., staff member B prepared medications for resident #35. Staff member B stated resident #35 was independent and could self-administer the Metered Dose Inhalers (MDIs) without assistance. At 7:55 a.m., staff member B identified resident #35, seated in the dining room drinking coffee, and the staff member handed the resident her MDIs. Resident #35 inhaled one puff of the [MEDICATION NAME] MDI, then two puffs from the [MEDICATION NAME] simultaneously. Staff member B did not instruct resident #35 to wait 60 seconds between inhalations, or have the resident rinse her mouth with water and spit after the [MEDICATION NAME]. During an interview on 11/14/18 at 2:40 p.m., staff member B stated she should have asked resident #35 to rinse her mouth with water and spit after inhaling the [MEDICATION NAME] (steroid) MDI. Staff member B stated she was not aware the resident should have waited 60 seconds between use of the MDIs. A review of resident #35's (MONTH) (YEAR) Medication Administration Record [REDACTED] - [MEDICATION NAME]; one inhalation one time a day related to [MEDICAL CONDITIONS] with exacerbation. The start date was 10/5/18. - [MEDICATION NAME]; two puffs twice a date related to [MEDICAL CONDITION] with exacerbation. The start date was 10/4/18. During an observation on 11/15/18 at 8:18 a.m., staff member C identified resident #35, seated in the dining room drinking water, and staff member C handed resident #35 her MDIs. Resident #35 inhaled one puff of the [MEDICATION NAME] MDI, then two puffs from the [MEDICATION NAME] simultaneously. Staff member C did not instruct resident #35 to wait 60 seconds between inhalations, or have the resident rinse her mouth with water and spit after use of the [MEDICATION NAME]. During an interview on 11/15/18 at 8:30 a.m., staff member C stated she was not aware resident #35 needed to wait 60 seconds between puffs of the [MEDICATION NAME]. Staff member C stated she was not aware resident #35 should have rinsed and spit with water after inhaling the [MEDICATION NAME] MDI. Review of the facility's policy, General Dose Preparation and Medication Administration, read, .5.7- Provide the resident with any necessary instructions (e.g., using an inhaler); 5.8- Follow manufacturer medication administration guidelines. Review of the facility's policy, Medication Administration and Ordering, read, 1. The nurse or TMA/CMA administering a medication is responsible for knowing: a. Nature of medication .f. Factors that affect or modify action of medication.",2020-09-01
80,VALLE VISTA MANOR,275021,402 SUMMIT AVE,LEWISTOWN,MT,59457,2018-11-15,805,D,0,1,MIUW11,"Based on observation, interview and record review, the facility failed to provide a consistent textured diet prescription, re-evaluate the effectiveness of the prescribed diet, and establish the nutrient content for 1 (#15) of 12 sampled residents. Findings include: During an observation on 11/13/18 at 12:20 p.m., resident #15 received her lunch meal in mugs, which included pureed baked beans, vegetable salad, and chicken, all thinned to the consistency of water. Review of resident #15's meal card showed, Regular Pureed, drinkable pureed. During an interview on 11/13/18 at 12:30 p.m., staff member J stated he had been told the diet was to be thinned to a water-like consistency. During an observation on 11/13/18 at 12:40 p.m., resident #15 was not able to drink out of the mugs. Staff spooned the liquid into her mouth. During an interview on 11/14/18 at 12:40 p.m., staff member N stated resident #15's ability to eat varied day to day. Some days she could use a straw, and mostly drank her chocolate ensure. During an interview on 11/14/18 at 1:43 p.m., staff member H stated resident #15's food should be pudding thick. She then stated it should be nectar thick. Staff member K stated he was just discussing the diet with the dietitian, and they were going to decide what the diet prescription should be. We all need to be on the same page. The nutrient content of the diet was not consistent or identified by the facility. Review of resident #15's weight record showed a weight loss of 25 pounds from 11/17/17 to 11/9/18. During an observation and interview on 11/14/18 , resident #15's food was in a regular pureed form. Staff member I stated it was to be pudding thick and thinned as needed by the CNA's. She stated the dietary department was not allowed to alter any textures. During an interview on 11/15/18 at 1:20 p.m., staff member O stated it was acceptable to have the CNA's thin the pureed food, because it was with water and the resident could drink water.",2020-09-01
81,ST JOHN'S LUTHERAN HOME,275024,3940 RIMROCK RD,BILLINGS,MT,59102,2019-03-08,609,D,0,1,SJ2F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility administration failed to report missing narcotic medication concerns to the required State Survey Agency. The failure had the potential to affect any resident having narcotics delivered or stored at the facility, and this failure increased the risk of misappropriation of resident property related to narcotic medications, due to the lack of thorough management and tracking of missing medications. Findings include: During an interview on 3/7/19 at 10:00 a.m., staff member C was outlining the facility practice for the accounting and security of controlled substances. During the conversation, staff member C stated, We had one episode of a missing controlled substance reported to the DE[NAME] Medication was sent back to pharmacy for re-labeling, and the card [MEDICATION NAME](hypnotic) went missing. See F755 and F761 for event details. During an interview on 3/8/19 at 8:01 a.m., staff member B stated she misspoke the other day (3/7/19), when she said they did not have any issues with missing medications. Staff member B described an incident with missing [MEDICATION NAME] (for pain) and missing Ambien, which occurred on 11/16/18, stating they investigated the incident and reported it to the DE[NAME] Staff member B was asked if the facility reported the incident to the police, and the State Survey Agency, and she stated, No. A review of the facility policy, Loss of Controlled Substances at (facility name), not dated, showed, On 11/16/18, #28 [MEDICATION NAME]/APAP 5/325 and #5 [MEDICATION NAME] (for [MEDICAL CONDITION]) 5 mg were returned from TCN nursing to (facility name) Pharmacy to be relabeled with updated sig/instructions. Pharmacy staff state that these meds were placed in the pick-up basket and the basket was picked up by TCN nursing. Since this was not a dispense, no signature log was created for these meds. When nursing checked in the basket full of meds, the [MEDICATION NAME]/APAP and [MEDICATION NAME] were not in it . (sic) Review of the facility Abuse Policy, dated (MONTH) (YEAR), showed the following for reporting allegations of abuse: [NAME] Reporting and Response: It is the policy of (facility name) that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and Montana State Law. (Facility name) will ensure that all alleged violations involving abuse, neglect, elopement, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported. Abuse is reported no later than 24 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do no result in serious bodily injury, to the Director of Nursing or designee of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident at (facility name) .",2020-09-01
82,ST JOHN'S LUTHERAN HOME,275024,3940 RIMROCK RD,BILLINGS,MT,59102,2019-03-08,656,D,0,1,SJ2F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete a person centered care plan that included interventions for the personal safety of 1 (#76); and failed to develop a comprehensive, person centered activity care , for 1 (#125) of 34 sampled residents. Findings include: 1. During an interview on 3/7/19 at 9:53 a.m., staff member B stated, He is able to go out on the bus independently. He had cigarettes in his pocket when the bus driver picked him up. I know that, because my husband is the driver. She further stated resident #76 had an order for [REDACTED].#76, and had reminded him of the no smoking policy. During an interview on 3/7/19 at 11:00 a.m., staff member L stated when she met with the families she let them know about the no smoking policy. She stated, If I feel that there is a concern identified with regards to smoking, then I would include a Tobacco Free flyer. She stated when resident #76 was admitted , he did sign something acknowledging the no smoking policy. During an interview on 3/7/19 at 1:24 p.m., resident #76 stated he was aware of the no smoking policy in the facility when he was admitted . He stated I don't know why I did that. Review of resident #76's physician progress notes [REDACTED].#76 had recently been caught smoking in his room. The resident had severe [MEDICAL CONDITION] and used oxygen. The progress note showed, He says he smoked because he was stressed about the move to new unit. Review of resident #76's Significant Change MDS, dated [DATE], Section C, showed a BIMS of 15; cognitively intact. Review of the facility document, titled Resident and Service Agreement, dated 6/1/18, and signed by resident #76, showed, under section XII, Miscellaneous, Subsection D, Smoke Free Policy, Resident acknowledges and agrees to comply with Facility's 'Smoke Free' policy as defined in Appendix D. Failure to comply with said policy constitutes Material non-compliance with Agreement. Review of resident #76's Non Fall Incident Report, dated 2/16/19, showed, under #7 Incident type: Smoking in bathroom, with a description of Nurse found elder had been smoking in bathroom and confiscated items after explaining policy. Notified Security. Review of a facility email, dated 2/18/19, from the DON to Administrator, showed resident #76 had been spoken to regarding the seriousness of smoking in the bathroom. The email showed resident #76 understood the concerns, and what the DON and Administrator has spoke to him about. Review of resident #76's care plan, dated 11/18, showed no problem areas, goals, or interventions that addressed the safety concerns regarding the resident smoking in the bathroom. 2. During an interview on 3/8/19 at 12:15 p.m., staff member K said she completed the Resident History and Preferences LTC Form for all the residents on the TCN. The staff member said the information in this form was added, by her, to section F of the comprehensive MDS. Staff member K said she would write an activities care plan for TCN residents if indicated. Staff member K said if residents needed reading material or something similar, she would get it for them. Staff member K said no directed activity program was provided on the TCN. Staff member K said she had not written an activity care plan for resident #125 because concerns with activities had not triggered on Section V of the Admission MDS. Review of resident #125's The Resident History and Preferences LTC Form, dated 2/1/19, showed it was very important for the resident to participate in group activities, and somewhat important to do favorite activities. Review of resident #125's Admission MDS, with an ARD of 2/8/19, Section F, F0500, Interview for Activity Preferences, showed it was somewhat important for the resident to participate in group activities and very important for her to do her favorite activities. This information did not coincide with the 2/8/19 Admission assessment. Review of resident #125's comprehensive care plan failed to address the resident's need for an activities program, although the resident felt it was important to participate in group and favorite activities.",2020-09-01
83,ST JOHN'S LUTHERAN HOME,275024,3940 RIMROCK RD,BILLINGS,MT,59102,2019-03-08,679,D,0,1,SJ2F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the residents on the transitional care north (TCN) unit with a meaningful activity program for 2 (#s 100 and 434) of 34 sampled residents. Findings include: During an observation 3/6/19 at 1:10 p.m, no activity calendar was posted on the TCN unit. During an interview on 3/06/19 at 1:27 p.m., staff member J said the TCN did not have a formal activities program. She said most of the residents on the TCN unit have OT, PT, and/or ST (therapy services) several times a day, and by the times the residents are done with all that, they just want to rest. a. During an interview on 3/7/19 at 9:39 a.m., resident #434 said she would like to participate in activities. The resident said she was admitted to the facility on [DATE]. She said a staff member had come by and talked to her about what kind of things the resident was interested in. Resident #434 said no one had asked her if she wanted to participate in any activities. Review of resident #434's baseline care plan, dated 3/4/19, failed to identify any activities for the resident. The baseline care plan did not include an activity care plan. Review of resident #434's The Resident History and Preferences LTC Form, dated 3/5/19, showed it was somewhat important for the resident to participate in group activities, and very important for her to participate in her favorite activities. b. During an interview on 3/8/19 at 10:23 a.m., staff member B said, We don't have activities on TCN. The elders (residents) are here to get well and they don't need activities. They have therapy and doctor appointments. They need to rest when they are not at therapy or at other appointments. Review of resident #100's physician's progress note, dated 1/24/19, showed, At this time, she again reiterates that she is not a person that is used to sitting around and being in the nursing facility is causing boredom and depression. She states she is interested in trialing an antidepressant, and Her family also brought in a coloring book to help keep her mind busy and preoccupied. The physician's progress note also showed [MEDICATION NAME] 25 mg was started for the resident. Review of resident #100's physician's progress note, dated 2/6/19, showed, Discussed with nursing and feels patient is slightly depressed. Explained that she is encouraged to leave her room on occasion. For example to go look at the birds in the main lobby, watch the SuperBowl game this last Sunday, etc. Patient, however, prefers to stay in her room. Does not watch tv. Often seen sleeping. Discussed with patient and she states that her mood is stable, she just isn't used to not being active. She used to be a very active/busy person. She reports the more inactive she is the easier it gets to just sit around. We discussed increasing her [MEDICATION NAME] to 50 mg qhs. She is in agreement with this plan. Will start this tonight. Review of the resident #100's The Resident History and Preferences LTC Form, dated 1/10/19, showed it was very important for the resident to do group activities and to do her favorite activities. Review of resident #100's Admission MDS, with an ARD of 1/17/19, Section F, F0500, Interview for Activity Preferences, showed, it was not very important for the resident to participate in group activities, and it was somewhat important to participate in her favorite activities. The information varied from the assessment completed seven days prior. During an interview on 3/8/19 at 10:32 a.m., staff member A said the TCU was a short stay unit. The usual length of stay was about 20 days. The staff member said social services did a short assessment on admission regarding resident preferences, and we address those as appropriate. Staff member A said the residents were in the TCU for intensive therapy, and they would be too tired to participate in an activities program. Staff member A said, I do not feel it was worth having an activity staff for the TCU, or was it was a good use of resources, for an area (the residents) that would not participate in activities. During an interview on 3/8/19 at 12:15 p.m., staff member K said the facility did not provide directed activities for the TCN unit residents.",2020-09-01
84,ST JOHN'S LUTHERAN HOME,275024,3940 RIMROCK RD,BILLINGS,MT,59102,2019-03-08,755,E,0,1,SJ2F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an adequate system was in place for the tracking and control of controlled substances, which were received, stored at, and administered by the facility. The facility failed to identify the risk of diversion for high abuse medications. This failure had the potential to affect any resident who had controlled substances sent to, stored at, or administered by the facility. Findings include: During an observation and interview on 3/6/19 at 9:15 a.m., an opened 30 ml bottle of liquid [MEDICATION NAME] was in an unlocked refrigerator in the medication room. Staff member N stated, We don't count [MEDICATION NAME] with change of shift narc counts, you can't see it through the bottle. We usually measure what's wasted at the end (when bottle was empty). During an interview with staff members A, B, and C, on 3/6/19 at 12:30 p.m., staff member B stated the facility only locks and counts Schedule II medications. Staff member B handed a sheet of paper with language from regulations (Federal) under the old regulatory system, and stated, The language cross walked to the new regs. Staff member B stated, [MEDICATION NAME] (antianxiety) is a Schedule IV not Schedule II. -Staff member C stated, How are we supposed to measure the [MEDICATION NAME] with the dark bottle, you can't see it? -Staff members A & C both stated, Reconciling is not counting. During an interview on 3/6/19 at 1:00 p.m., staff member Q stated, We have never counted liquid [MEDICATION NAME] before, I think we have even discussed it at our administrative meetings. During an interview on 3/7/19 at 10:00 a.m., staff member C stated the system for monitoring the accuracy for Schedule III-V medications coincided with the date on the medication card, and if the nurse tried to order that medication too soon it would be a red flag (alert) in our system. Staff member C stated, The nurses have to document they gave the medication on the MAR, so we can look at that to see what was administered. If there is a discrepancy we investigate. Staff member C stated if she would need to make a recommendation to administration regarding policy, she would not recommend counting all controlled medications, it would take too much time. During an observation and interview on 3/7/19 at 1:33 p.m., staff member [NAME] demonstrated the current system of keeping track of Schedule III-V medications, as only Schedule II medications are counted each shift. Staff member [NAME] first demonstrated the system for [MEDICATION NAME] scheduled TID. The process included: - There were three cards, each card had originated with 30 tablets, with a corresponding label for morning, noon and evening doses. - For the month of (MONTH) (2019), the medication was started on the 22nd, so that date was circled. - The month of (MONTH) ended on the 28th (due to the number of days in the month), so on (MONTH) 1st the nurse would move down to #1 on the card. - Because there are two left over pills from the 29th and 30th of (MONTH) 2019, staff member [NAME] stated, You would use those pills before starting a new medication card, which would end up being on the 24th of (MONTH) (2019). Staff member [NAME] stated, If I dropped one, I would either go to the 29th or 30th and use one of those pills, or if there were no left over pills, I would go to the start date and one back. Staff member [NAME] said, If a pill was taken from the wrong card, the staff would either replace the pill and tape the back of the card, or go to another card and take a pill from it. Staff member [NAME] stated, I write on the card the date I removed the medication and why. Some (nurses) don't write on the card. For medication that is scheduled PRN, staff member [NAME] stated, You really have no way of knowing if the count is accurate. Staff member [NAME] stated the information passed on, in report, and knowing your resident, would hopefully give you a red flag (alert), but if the medication wasn't used often, you wouldn't recognize a discrepancy timely. Staff member [NAME] stated the on-coming nurse would not know if the total number of tablets was accurate for any of the Schedule III-V medications when they started their shift, because they do not count them. During an interview on 3/7/19 at 1:20 p.m., staff member D stated, If I dropped a pill, I would waste it and get a new one by going backwards one, from the start date. I would verbally pass it on to the next shift. I don't routinely write on the card. During an interview on 3/8/19 at 8:01 a.m., staff member B described the process of accountability for Schedule II medications, and the double check process. When discussing the process of accountability for Schedule III-V medications, staff member B said the pharmacy knew the date the medication was started, and, We circle that on the card. Staff member B stated, If somebody sends that card back too quickly (to pharmacy), the pharmacy would know that. We have great accountability. Staff member B stated if a medication was refused, or needed to be wasted, it would be documented. Staff member B stated, I would have to double check for you, I don't know if wasting is documented on the MAR or somewhere else. I think they write on the back of the bubble pack. Staff member B stated if there were two [MEDICATION NAME] (contracted nurses working) in a row, a discrepancy wouldn't be identified until the next shift when a facility nurse worked. Then, the facility would immediately start an investigation. When asked how the facility would be alerted that PRN medications were missing, staff member B stated, You would discover it when you needed it. It may not be timely. Staff member B stated the facility would have to go back to the MAR and count how many times the medication was given. A review of the facility Medication Pass Procedure, which was not dated, showed, If a medication is dropped or contaminated, mark on bubble pack that it was destroyed/wasted and then take pill from earliest remaining date on the bubble pack to replace current dose .",2020-09-01
85,ST JOHN'S LUTHERAN HOME,275024,3940 RIMROCK RD,BILLINGS,MT,59102,2019-03-08,761,E,0,1,SJ2F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the supply of Schedule III-V medications were kept to a minimal level; and failed to ensure the Schedule III-V medications were separately locked; and not locked under the same access system used to obtain non-scheduled medications. The above practices had the potential to affect all residents with Schedule III-V medications stored and maintained at the facility. Findings include: During an observation and interview on 3/6/19 at 9:15 a.m., an opened 30 ml bottle of [MEDICATION NAME], a Schedule IV medication, was observed in the refrigerator in the medication room. The refrigerator did not have a separate locking mechanism. Staff member N stated the medication room had a lock, but the refrigerator did not. Staff member N stated the main door to the nursing area needed to be locked if the nurse left the area, but the nurse needed to have a visual on the room if they stepped out. Staff member N stated, We do not count [MEDICATION NAME]. During an interview and observation on 3/6/19 at 12:50 p.m., staff member H stated [MEDICATION NAME], if in liquid form, was in the refrigerator, locked in the closet in the nurses' room. The staff member unlocked the closet door to show where the refrigerator was located. The refrigerator had a clasp and lock, but was not locked. The staff member stated [MEDICATION NAME] and [MEDICATION NAME] were not double locked in any of the facility cottages. Residents with orders for [MEDICATION NAME], in a pill form, or [MEDICATION NAME], had the medications secured with a single lock system, which was in a cabinet, in the resident's room. These medications were not counted in the same manner as the the narcotics and PRN (as needed) medications. Staff member H showed where a resident's single locked medication cabinet was located. The staff member unlocked the cabinet and showed where the resident's [MEDICATION NAME] was located. During an observation and interview on 3/6/19 at 1:10 p.m., staff member P demonstrated the location of a card of PRN [MEDICATION NAME]. The card was located in the main compartment of the medication cart with the non-scheduled medications. Staff member P stated, We were taught that only narcotics get locked and counted, not [MEDICATION NAME]. Only things like [MEDICATION NAME], and [MEDICATION NAME] get locked and counted. During an interview and record review on 3/7/19 at 10:00 a.m., staff member C stated that Schedule III-V medications are in a different category than Schedule II medications and there are different dispensing laws for Schedule II medications. When discussing if the facility practiced double locking all controlled substances, staff member C stated, I believe they are. Staff member C stated, I would recommend to double lock Schedule III-V medications if we were meeting to determine policy. Staff member C said the facility had one episode of missing controlled substances reported to the DE[NAME] Review of the facility document, Loss of Controlled Substances at (facility name), not dated, showed an outline of an investigation for the loss of twenty eight [MEDICATION NAME] tablets, and [MEDICATION NAME], on 11/16/18. During an observation on 3/7/19 at 1:33 p.m., three, pre-filled cards of [MEDICATION NAME] 50 mg TID, were found in the medication cart. Each card held up to thirty tablets, and were labeled with a sticker indicating the time of day the card was to be used. The cards with the [MEDICATION NAME], a Schedule IV medication, were located with the other non-scheduled medications in the cart, and were not separately locked. During an interview and observation on 3/8/19 at 7:40 a.m., staff member I stated the long term care cottages did not count [MEDICATION NAME] ([MEDICATION NAME]), [MEDICATION NAME], or [MEDICATION NAME] as narcotics, and were not counted at the change of shift. The staff member stated these medications were located in the residents' rooms, along side non scheduled medications. The staff member showed where the narcotics were located in the nurses room, in a stationary cupboard, inside a locked closet. The staff member stated for the medications discussed, if there was a physician's orders [REDACTED]. The cupboard had a single lock. Staff member I stated the facility was the only place where she had worked that did not require the above named medications be counted during shift change. During an interview on 3/8/19 at 8:01 a.m., staff member B said the facility did not double lock Schedule III-V medications because the DEA has different dispensing rules for those medications, than for Schedule II medications. Staff member B said the facility double locks and counts every Schedule II medication, each shift. In reference to the Schedule III-V medications, staff member B stated, There are only nurses and med aids, and they are not messing with narcotics at all. Staff member B said she misspoke the other day (3/7/19), when she said they did not have any issues with missing medications. Staff member B described the incident of missing [MEDICATION NAME] and missing [MEDICATION NAME], which occurred on 11/16/18, stating the facility investigated the incident and reported it to the DE[NAME] A review of the facility document titled Loss of Controlled Substances at (facility name), not dated, showed, It is the consensus of the DON, HR Director and Pharmacy Director that the [MEDICATION NAME]/APAP and [MEDICATION NAME] are lost. They do not suspect theft because of the long term employment of the staff members involved and the solid answers they gave during the interview which were consistent with the available security video. As a result, police were not called, but a DEA 106 for (sic) is being submitted. Review of facility policy titled Ordering And Receiving Controlled Medications, dated 10/1/12, showed, The pharmacy dispenses medications listed in Schedules II, III, IV and V in readily accountable quantities and containers designed for easy counting of contents Medications listed in Schedule III, IV, and V are stored under single lock. Alternatively, in a unit dose system, Schedule III, IV and V medications may be distributed with other medications throughout the cart, while Schedule II medications are kept under double lock.",2020-09-01
86,ST JOHN'S LUTHERAN HOME,275024,3940 RIMROCK RD,BILLINGS,MT,59102,2019-03-08,880,D,0,1,SJ2F11,"Based on observation, interview, and record review, facility staff failed to ensure safe hand hygiene practices, for the prevention of the spread of infections, during the provision of ADL care, when staff moved from a dirty task to a clean task, for 1 (#85) of 34 sampled residents. Findings include: During an observation on 3/6/19 at 7:35 a.m., staff member F assisted resident #85 with toileting and peri care. Staff member F sanitized her hands and put on a pair of gloves, placed a gait belt around resident #85's waist, and transferred him from the bed to the wheel chair. Staff member F wheeled resident #85 to the bathroom, assisted him to stand, pulled his incontinent brief and pants down, and assisted him to sit on the toilet. Staff member F removed, and threw the dirty incontinent brief in the garbage, removed her gloves, and sanitized her hands. Staff member F put a clean a pair of gloves on, placed a clean incontinent brief around resident #85's legs, and assisted resident #85 to stand. Staff member F cleansed resident #85's peri area, and removed her gloves. Staff member F pulled resident #85's clean incontinent brief and pants up and assisted him to sit in the wheel chair. Staff member F did not wash or sanitize her hands after she cleansed resident #85's peri area and removed her gloves. During an interview on 3/7/19 at 8:14 a.m., staff member G stated CNAs are to wash or sanitize hands after changing gloves. Review of a facility hand out, titled, Glove changing and sanitizing during cares showed, . always wash or sanitize before putting on and removing gloves .",2020-09-01
87,ST JOHN'S LUTHERAN HOME,275024,3940 RIMROCK RD,BILLINGS,MT,59102,2019-08-22,580,G,1,1,P5VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the nurse failed to notify a physician for a change of condition that resulted in a hospitalization for 1 (#238) of 38 sampled and supplemental residents. Findings include: During an interview on 8/21/19 at 1:54 p.m., staff member J stated changes of condition such as swelling and desaturation, would be documented in notebooks used by physicians that round in the facility, and then the nurse would call a provider depending on the seriousness of the resident's condition. During an interview on 8/22/19 at 11:16 a.m., staff member B stated a resident that was exhibiting swelling and desaturation, would receive oxygen right away, because it is in the facility's standing orders. The staff are always to let the physician know when a resident exhibited new signs and symptoms by filling out the SBAR form in the folder that the physcians use when rounding in the facility. The nurse should then monitor and use good nursing judgement, in accordance with what the physician recommends, and orders for the resident. Review of resident #238's Respiratory Measurements showed the following: -On 6/20/19 resident #238 had a non-productive spontaneous cough, lungs were clear, and oxygen saturation was measured at 97% on room air. -On 6/26/19 resident #238's cough was described as, Able to clear secretions, Dry, Harsh, Non-productive, Sponateous, Strong. (sic) -On 6/27/19 resident #238's lungs were noted to be clear and diminished at the bases, and was noted to have had, difficulty breathing with activity, Difficulty breathing at rest, Shortness of breath. (sic) Resident #238's oxygen saturation was measured at 89% on room air. -On 6/28/19 resident #238's cough was occasional, productive, spontaneous, strong, and able to clear secretions. Resident #238's oxygen saturation was measured at 88% and 84% on room air. -On 6/29/19 resident #238's lungs were noted to be clear and diminished at bases. Resident #238's oxygen saturation was measured at 88% on room air. -On 6/30/19 resident #238's lungs were noted to have had crackles at the bases of both her lungs. Resident #238's oxygen saturation was measured at 88% on room air. -On 7/1/19 resident #238's cough was described as barking, productive, spontaneous, strong, and able to clear secretions. Resident #238's left lung was noted to have an expiratory wheeze. Review of resident #238's Physical Therapy Long Term Care Progress Notes, showed the following: - On 6/27/19, Pt (patient) desaturation to 87 after ambulation . - On 6/29/19, Pt (patient) continues to be on 1L of oxygen with activity. Review of resident #238's Care Management Progress Note, dated 7/2/19, showed resident #238 was sent to the emergency room related to, .increased [MEDICAL CONDITION] today and needing more supplemental oxygen, and persistant cough. She was admitted to (hospital) for acute [MEDICAL CONDITION] secondary to heart failure exacerbation. A request on 8/22/19 at 12:15 p.m., for physician communication and visit documentation of resident #238 was not provided by the facility.",2020-09-01
88,ST JOHN'S LUTHERAN HOME,275024,3940 RIMROCK RD,BILLINGS,MT,59102,2019-08-22,623,D,1,1,P5VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to notify the resident or resident's representative, in writing, of the reason for a transfer for 4 (#s 22, 100, 135, and 238) of 38 sampled and supplemental residents. Findings include: 1. During an interview on 8/21/19 at 8:55 a.m., staff member F stated that resident #100 had sustained a fall with a [MEDICAL CONDITION] which required hospitalization in (MONTH) of 2019. During an interview on 8/22/19 at 10:10 a.m., staff member D stated when a resident has been transferred, she has not given the resident or resident's representative any written documentation related to the reason for the residents's transfer. During an interview on 8/22/19 at 10:15 a.m., staff member C stated when a resident has been transferred, she has not given the resident or the resident's representative any documentation related to the reason for the resident's transfer. During an interview on 8/22/19 at 10:25 a.m., staff member F stated she has done the communication notice, which informs the facility of the change for a resident. She stated the written notices to the resident, or the resident's representative, were done by the staff in Medical Records and Admissions. During an interview on 8/22/19 at 10:30 a.m., staff member [NAME] stated she had not done any written notification to the resident, or the resident's representative, when a resident had been transferred. Review of resident #100's medical record showed she was hospitalized from [DATE] through 6/3/19 for a [MEDICAL CONDITION]. The medical record failed to show a written transfer notification was provided in writing, identifying the reason for the transfer, and given to resident #100 or her representative. The transfer notification documentation was requested for resident #100 on 8/21/19 at 3:10 p.m. No documentation was received prior to the end of the survey. 2. During an interview on 8/21/19 at 3:14 p.m., staff member B stated the facility does not notify the resident or resident's representative of a transfer to the hospital, in writing. Review of resident #22's Iview Notification, dated 7/24/19, showed, Nurse left voicemail for (name) to return call-called and spoke with (name) and given ok to send to ED (emergency department). (sic) A request on 8/21/19 at 11:00 a.m. and 8/22/19 at 9:08 a.m., for the written transfer notification documentationfor resident #22 was not received from the facility. 3. During an interview on 8/22/19 at 9:18 a.m., staff member M stated she did not know what they currently do for transfer notifications for residents or resident's representatives. During an interview on 8/22/19 at 10:03 a.m., staff member A stated the facility had not been doing the transfer notifications right and had skipped the regulation all together. Review of resident #135's Progress note, dated 7/12/19, showed, Son (Name) notified of decline of condition and to be sent to the hospital. A request on 8/21/19 at 11:00 a.m. and 8/22/19 at 9:08 a.m., for the written transfer notification for resident #135 documentation was not received from the facility. 4. During an interview on 8/22/19 at 9:28 a.m., staff member L stated upon transfer to the hospital the facility calls the resident's representative and documents it in the electronic record. Review of resident #238's Care Management Progress Note, dated 7/2/19, showed resident #238 was hosptalized on [DATE]. A request on 8/22/19 at 9:08 a.m., for the written transfer notification documentation for resident #238 was not received from the facility. Review of facility's Transfer and Discharge Policy, dated (MONTH) 2008, showed the following: - When (Facility) transfers or discharges a resident under any circumstances above, the resident's clinical record will include the documentation by the resident's physician as to why transfer or discharge is necessary according to (a),(b), and (e) above. Documentation regarding transfer or discharge for any reason will be done by the nurses in the resident's clinical record. - The resident and/or the legal representative will be notified of the transfer or discharge thirty (30) days before the transfer or discharge is to take place except if health or safety is endangered due to medical needs. - The written notice will include the reason for transfer or discharge, the effective transfer or discharge, the location being transferred or discharged to, and the right to appeal the transfer or discharge .",2020-09-01
89,ST JOHN'S LUTHERAN HOME,275024,3940 RIMROCK RD,BILLINGS,MT,59102,2019-08-22,625,D,1,1,P5VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure a resident or a resident's representative received written information regarding the Bed Hold Policy prior to a transfer, for 3 (#s 22, 100, and 135) of 29 sampled residents. Findings include: 1. During an interview on 8/20/19 at 9:55 a.m., staff member F stated that resident #100 was transferred to the hospital for a [MEDICAL CONDITION] in (MONTH) of 2019. Review of resident #100's medical record failed to show any documentation of the provision of bed hold policy information prior to her transfer to the hospital on [DATE]. During an interview on 8/22/19 at 9:55 a.m., staff member B stated the only bed hold information given to the resident and/or resident's representative was upon admission by the Admission Director. Staff member B stated the facility had not provided any bed hold information upon the transfer to the hospital. During an interview on 8/22/19 at 10:10 a.m., staff member D stated she had not provided any written information to the resident or resident's representative prior to transfer to the hospital. During an interview on 8/22/19 at 10:25 a.m., staff member F stated she had not done any written notifications to the resident or resident's representative regarding the bed hold policy. Staff member F stated she did the communication notice that informed the facility of the change for a resident upon transfer. Staff member F stated the written notices were completed by medical records, and the admissions director. 2. During an interview on 8/21/19 at 3:14 p.m., staff member B stated the facility did not notify the resident or resident's representative of a the bed hold policy upon transfer, but resident #22 was notified at admission. Review of resident #22's Iview Notification, dated 7/24/19, showed, Nurse left voicemail for (name) to return call-called and spoke with (name) and given ok to send to ED (emergency department). (sic) A request on 8/21/19 at 11:00 a.m. and 8/22/19 at 9:08 a.m., for bed hold information notification documentation on resident #22's most recent hospital transfer was not received from the facility prior to the end of the survey. 3. During an interview on 8/22/19 at 10:03 a.m., staff member A stated the facility had not been doing the bed hold notifications right and had skipped the regulation all together. Review of resident #135's Progress Note, dated 7/12/19, showed, Son (Name) notified of decline of condition and to be sent to the hospital. A request on 8/21/19 at 11:00 a.m. and 8/22/19 at 9:08 a.m., for bed hold notification information documentation on resident #135's most recent transfer to the hospital was not received from the facility. Review of the facility's Bed hold Policy Readmission Policy, dated (MONTH) 2019, showed the following: -Due to the excellence in care that our nursing facility provides to its residents and patients, it is not uncommon for our facility to be 98%-100% full. Therefore, some of our future and existing residents elect to pay bed holds when not occupying beds in order to ensure that these beds will be available when entering or returning to our facility. -No mention of notification of the bed hold information given to resident or resident's representative upon transfer to the hospital was addressed within the policy document.",2020-09-01
90,ST JOHN'S LUTHERAN HOME,275024,3940 RIMROCK RD,BILLINGS,MT,59102,2019-08-22,658,D,1,1,P5VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to provide services which met professional standards of practice, which involved allowing a resident without an order for [REDACTED]. 1. During a medication administration observation on 8/22/19 at 8:31 a.m., staff member D provided all morning medications to resident #23, and then left the room without waiting until resident #23 had taken all of her medications. During an interview on 8/22/19 at 8:35 a.m., staff member D stated, If the elder is alert, we usually leave the meds (sic) with the elder. Staff member D denied knowledge of a self-administration of medication assessment for resident #23. Staff member D stated she goes back later and checks to make sure the medications were taken. Staff member D was unaware of any order, from the provider, which allowed the medications to be left at the bedside. During an interview on 8/22/19 at 9:14 a.m., staff member B stated there was no policy related to self-administration of medications. Staff member B stated the facility expected the nursing staff to use good judgement when leaving medications at the bedside. Staff member B stated there should be a self-administration of medications assessment, and a physician's orders [REDACTED]. Review of resident #23's Self Administration of Medication Assessment, dated 8/13/15, showed the resident did not desire to self medicate. The handwritten note showed, Nursing to administer meds while pt. @ TCN. All self-administration of medication assessments for resident #23 were requested. No other documents were provided prior to the end of the survey. Review of resident #23's physician orders, dated (MONTH) 2019, failed to show any documentation regarding allowing the self-administration of medications. A policy related to self-administration of medications was requested. No documentation was provided prior to the end of the survey. 2. During an observation and interview on 8/20/19 at 9:07 a.m., resident #76 was taking medications which were in four small medication cups. Resident #76 had taken pills during the interview from at least two of the four medication cups. No facility staff was present in the room during this interview. The resident took the medications unsupervised by facility staff. During an interview on 8/22/19 at 9:14 a.m., staff member B stated nurses were administering the medications. She stated the resident was not self-administering the medications because they were prepared by the nurse. Review of resident #76's medical record did not show any assessments regarding her ability to self-administer medications. Review of resident #76's physician orders, dated (MONTH) 2019, did not show an order for [REDACTED].",2020-09-01
91,ST JOHN'S LUTHERAN HOME,275024,3940 RIMROCK RD,BILLINGS,MT,59102,2019-08-22,758,D,1,1,P5VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to ensure PRN orders for [MEDICAL CONDITION] medications were limited to 14 days, for 1 (#30) of 29 sampled residents. Findings include: During an observation and interview on 8/19/19 at 3:57 p.m., resident #30 was in her wheelchair with a baby doll in her lap. Resident #30 stated, Isn't my baby beautiful? Resident #30 then became tearful when discussing that she had nothing to feed the baby, and would have to give him up because of this. Resident #30 stated, What can you do when you are old and have no money? Review of resident #30's Physician's hospice orders, dated 4/17/19, showed, [MEDICATION NAME] 0.5 mg .take 1 tablet by mouth/sublingual every 4 hours as needed. During an interview on 8/20/19 at 9:55 a.m., staff member F stated that resident #30's moods were like a rollercoaster, and it varied from day to day. Staff member F stated that resident #30 had a gradual decline in mental status, and was placed on hospice in (MONTH) 2019. During an interview on 8/21/19 at 1:00 p.m., staff member I stated, I thought the 14 day limit (for [MEDICAL CONDITION]) was only for prn antipsychotic medications. Staff member I stated that she would review the regulations and follow-up with hospice to see if they have any different rules. No additional information was provided by staff member I. Review of resident #30's Care Team Meeting notes, dated 3/13/19, showed behaviors for the resident included, .shoving, cursing, threatening, yelling . Review of resident #30's Nursing Home Recertification documentation, dated 5/24/19, showed a [DIAGNOSES REDACTED]. [MEDICATION NAME] was listed as a prn medication. The note failed to include documentation of the reason for continuing the use of [MEDICATION NAME] on an as needed (PRN) basis, beyond the 14 day limit. The Impression and Plan section showed, .8. [MEDICAL CONDITION] with anxiety: Well-managed with [MEDICATION NAME] and [MEDICATION NAME]. No mention of the use of lorazapam was found. Review of resident #30's Nursing Home Annual Assessment, dated 7/30/19, showed, .6. (A) Patient has chronic depression and anxiety, .Continue [MEDICATION NAME] 100 mg daily and [MEDICATION NAME] . There was no documentation related to the continued use of [MEDICATION NAME] on an as needed basis. Review of resident #30's MAR, dated (MONTH) 2019, showed [MEDICATION NAME] 0.5 mg had been given 14 times between 8/4/19 and 8/21/19.",2020-09-01
92,ST JOHN'S LUTHERAN HOME,275024,3940 RIMROCK RD,BILLINGS,MT,59102,2019-08-22,759,D,1,1,P5VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to ensure a medication error rate less than 5%. The observed error rate was 12.35%. The errors involved not remaining with the resident to ensure the medications were taken, which included a narcotic, which is a Schedule II medication, for 1 (#23) of 38 sampled and supplemental residents. Findings include: 1. During a medication administration observation on 8/22/19 at 8:31 a.m., staff member D administered the following medications to resident #23: - aspirin 81 mg - calcium with vitamin D 600/400 mg - vitamin D 1000 IU - [MEDICATION NAME] 500/400 mg - Senna Plus 8.6/50 mg - [MEDICATION NAME] 40 mg - [MEDICATION NAME] 600 mg, 2 tablets - [MEDICATION NAME] 20 mg - potassium chloride 20 mEq - [MEDICATION NAME] with [MEDICATION NAME] 5/325 mg After handing the cup containing medications, staff member D left resident #23's room. Staff member D did not observe resident #23 taking the medications given to her. During an interview on 8/22/19 at 8:35 a.m., staff member D stated, If the elder is alert, we usually leave the meds (sic) with the elder. Staff member D denied knowledge of a self-administration of medications assessment for resident #23. Staff member D stated we go back and check later to make sure the medications were taken. Staff member D was unaware of any order from the provider which allowed the medications to be left at the bedside. During an interview on 8/22/19 at 9:14 a.m., staff member B stated there is no policy related to self-administration of medications. Staff member B stated the facility expected the nursing staff to use good judgement when leaving medications at the bedside. Staff member B stated there should be a self-administration of medications assessment and a physician's orders [REDACTED]. Review of resident #23's Self Administration of Medication Assessment, dated 8/13/15, showed the resident did not desire to self medicate. The handwritten note showed, Nursing to administer meds while pt. @ TCN. (sic) All self-administration of resident #23's medication assessments were requested. No documention was provided prior to the end of the survey. Review of resident #23's physician orders, dated (MONTH) 2019, failed to show any documentation regarding the self-administration of medications. A policy related to self-administration of medications was requested. No documentation was provided prior to the end of the survey.",2020-09-01
93,ST JOHN'S LUTHERAN HOME,275024,3940 RIMROCK RD,BILLINGS,MT,59102,2019-08-22,761,E,1,1,P5VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to dispose of expired pain, antiemetic, and over-the-counter (OTC) medications for 7 (#s 4, 18, 67, 83, 105, 116, and 117) of 38 sampled and supplemental residents. The facility failed to dispose of an expired floor stock medication and medical supplies; this deficient practice had the potential to affect all residents who utilized the facility's floor stock medication and supplies in the storage area. Findings include: 1. During an observation on 8/21/19 at 10:38 a.m., of the Garden Court (Wing 7) medication cart, the following occured: -one syringe of [MEDICATION NAME] 100 mg/5ml had an expiration date label attached to the syringe barrel which showed 4/19. The Ziplock bag, which the syringe was located in, with the resident label attached, showed an expiration date of 11/19. The syringe was labeled with the name of resident #67. -one syringe of [MEDICATION NAME] HCL 1mg/ml showed no expiration date. The syringe was labeled with the name of resident #83. -one syringe of [MEDICATION NAME] 100 mg/5ml showed no expiration date. The syringe was labeled with the name of resident #18. -one bottle of sodium chloride nasal spray showed an expiration date of 7/19. The bottle was labeled with the name of resident #4. -one box of [MEDICATION NAME] 4mg tablets showed an expiration date of 4/19. The box was labeled with the name of resident #116. -one bottle of Geri-Lanta showed an expiration date of 6/19. The bottle was labeled with Wing 7 stock. During an interview on 8/21/19 at 10:54 a.m., staff member G stated she checked the expiration dates, and looked at them when she pulled tickets for re-order, on Mondays and Thursdays. Staff member G stated, I try to glance at things. I guess that is when I do it. Staff member G did not state how the lack of expiration dates or expired medications were missed during her checks. During an interview on 8/21/19 at 10:56 a.m., staff member H stated, The night nurse does the checking for expiration dates and the resource nurse checks the carts when she comes through. Last time she checked the dates was 8/19/19. During an interview on 8/21/19 at 12:48 p.m., staff member I stated the procedure was to have the expiration date on both the Ziplock bag that holds the syringe, and the barrel of the syringe. Staff member I stated, The usual pharmacy tech that works was on vacation. Staff member I stated if expiration dates were missing, her expectation, was to be notified. During an interview on 8/21/19 at 1:30 p.m., staff member I stated the medications with a missing expiration date label, had been fixed, and no residents had received expired medications. 2. During an observation on 8/21/19 at 2:05 p.m., in the Transitional Care Cottage, one bottle of Metaxalone 800 mg showed no expiration date. The bottle was labeled with the name of resident #117. During an interview on 8/21/19 at 1:48 p.m., staff member J stated, We look for expired meds one time a month. 3. During an observation on 8/21/19 at 2:25 p.m., in the Hansen Cottage, the following occurred: -four syringes, in one Ziplock bag, of [MEDICATION NAME] 20 mg/ml, filled to 1 ml, showed no expiration date on the syringes or the pharmacy label attached to the Ziplock bag. The Ziplock bag was labeled with the name of resident #105. -15 syringes, in one Ziplock bag, of [MEDICATION NAME] 20 mg/ml, filled to 1 ml, showed no expiration date on the syringes or the pharmacy label attached to the Ziplock bag. The Ziplock bag was labeled with the name of resident #105. -five 21 guage x one inch needles showed an expiration date of 3/18. -three 21 guage x one inch needles showed an expiration date of 1/19. -four 23 guage x one inch needles showed an expiration date of 9/18. -one female catheter showed an expiration date of 3/31/19. -one Ultrasite injection site supply showed an expiration date of 1/18. -five IV Ultra pac showed an expiration date of 1/18. -one IV universal showed an expiration date of 9/18. During an interview on 8/21/19 at 2:47 p.m., staff member K stated the resource nurse was in the cottage last night, 8/21/19, checking expiration dates.",2020-09-01
94,ST JOHN'S LUTHERAN HOME,275024,3940 RIMROCK RD,BILLINGS,MT,59102,2019-08-22,880,E,1,1,P5VQ11,"> Based on observation, interview, and record review, the facility failed to minimize risks of infection, and to prevent environmental contamination by disposing of sharps containers when the internal contents reached the fill line, subsequently by closing the lid on the sharps containers in four out of four areas. Findings include: 1. During an observation on 8/21/19 at 10:51 a.m., on the Garden Court medication cart, the sharps container, located in the bottom drawer, contained hazardous waste that was filled above the fill line, and the lid was open. During an interview on 8/21/19 at 10:52 a.m., staff member G stated she believed the fill line was at the very top of the container, where the lid is located, not where the actual fill line was marked on the container. 2. During an observation on 8/21/19 at 1:46 p.m., in the Transitional Care Cottage, in the locked medication/supply storage closet, three, overfilled sharps containers were on the floor. The lids on the sharps containers were open, and the containers were filled above the fill line mark. During an interview on 8/21/19 at 1:48 p.m., staff member J stated, When the sharps container is full, we stash them in the medication closet, and then put them in a room in the back. Staff member J stated, Every Friday, environmental services comes and empties them. 3. During an observation on 8/21/19 at 2:31 p.m., in the Hansen Cottage, in the locked medication/supply storage closet, one, full sharps container was on the floor. The lid on the sharps container was open. 4. During an observation on 8/22/19 at 9:18 a.m., in the Liggett Cottage, in the locked medication/supply storage closet, two, full sharps containers were on the floor. The lids on the sharps containers were open. A review of the facility's policy titled, Exposure Control Plan, showed: - Sharps disposal containers are inspected and maintained or replaced by Housekeeping and Nursing Staff whenever necessary to prevent overfilling. -During use, containers for contaminated sharps shall be: -Easily accessible and located as close to the immediate area where sharps are used or found. -Maintained upright throughout use. -Replaced routinely and not be allowed to overfill. -When moving containers of contaminated sharps from the area of use, the container will be: -Closed immediately prior to removal to prevent spillage or protrusion of contents. -Place in a secondary container if leakage is possible.",2020-09-01
95,ST JOHN'S LUTHERAN HOME,275024,3940 RIMROCK RD,BILLINGS,MT,59102,2017-11-08,253,E,0,1,8YVD11,"Based on observation and interview, the facility failed to maintain and repair areas on Wing #7's bath house and the transitional care unit's kitchen to provide a sanitary environment. The facility failed to maintain 2 of 5 cottage exterior doors to prevent potential pest control issues. The facility failed to deep clean one resident's room on Wing #7. This deficiency had the potential to affect the residents who used or occupied these spaces. Findings include: 1. During a fire safety tour observation and interview with staff F on 11/7/17 at 8:53 a.m., Wing #7's bath house was inspected. The door frame of the bath house was damaged, and was not cleanable. The trim at the bottom of the door was hanging off the door and dragging on the floor with sharp nails exposed. The lower portion of the door frame was rotted. The paint, was bubbled and chipped, and rendered the surface uncleanable. Staff member F called the maintenance department on his cellular phone and reported the issue. 2. During a fire safety tour observation and interview with staff G on 11/7/17 at 8:28 a.m., the door to room #727 was open on Wing #7. From the hallway, a heavy accumulation of dust, food (Cheetos and fish shaped crackers), plastic packaging, a piece of garment, and other debris were observed under the bed. The resident was not in the room for interview. Staff member G stated the resident did not refuse housekeeping services. Staff member G stated the resident frequently ate snacks in the bed. Staff member G stated the housekeeping staff worked from 9:00 a.m. to 3:00 p.m., but he did not know the deep cleaning frequencies and procedures. Staff member G did not provide additional information on the room cleaning protocol, including the deep cleaning frequencies, schedules and/or the logs to show when the room was last cleaned, and when the rooms were regularly cleaned. 3. During a fire safety observation and interview with staff L on 11/7/17 at 8:55 a.m., a rectangular piece (measuring approximately 2 inches by 3 inches), of the wood cabinet housing the dish sanitizer in the transitional care unit's kitchen, was torn off and missing. The surface was rotted and uncleanable. The floor along the edge of the sanitizer was covered in a heavy accumulation of dirt and food debris. Staff member L was asked about the procedures for notifying the maintenance staff for concerns and issues. Staff member L stated they notified the maintenance via an email. She said she notified the maintenance about a month ago about the damaged cabinet. 4. During a fire safety tour observation and interview with staff F on 11/7/17 at 10:09 a.m., the east exit door in the Liggett cottage was warped and prevented a proper seal (light shining through the gaps) at the top and along the door and the frame, creating a potential for improper pest control. Staff member F, who accompanied the surveyor, stated the maintenance department would be notified. 5. During a fire safety tour observation and interview with staff F on 11/7/17 at 12:10 p.m., the west exit door in the Jensen cottage lacked a proper seal with the door frame, creating a potential for improper pest control. The light shone through the gaps between the door and the door frame. Staff member F stated the door would be repaired.",2020-09-01
96,ST JOHN'S LUTHERAN HOME,275024,3940 RIMROCK RD,BILLINGS,MT,59102,2017-11-08,278,D,0,1,8YVD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately code the communication, cognition, mood, and pain status, for 2 (#s 11 and 19) of 25 sampled residents. Findings include: 1. Review of resident #11's Significant Change MDS, with the ARD of 9/26/17, showed the resident was always understood and sometimes understands. The Brief Interview for Mental status, showed a score of 0, which reflected severe cognitive impairment. The Mood interview and Pain interview were conducted with the resident. The interviews showed no pain, and no mood indicators. During an interview on 11/7/17 at 3:30 p.m., staff member C stated she did not realize the BIMS assessment should be stopped at question #4 if the resident was unable to answer. She also stated she never looked at Section B, the ability to communicate, and that resident #11's pain and mood interviews may not be accurate, because of her severe cognitive impairment. 2. Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #19's Quarterly MDS, dated [DATE], showed she only sometimes understood communication; she had a BIMS score of 0 (zero) severely impaired, and a PHQ9 of 0 (zero) no mood symptoms. Resident #19's MDS showed her behaviors of inattention, disorganized thinking, and altered level of consciousness, which were continuously present and did not fluctuate. The prior two Annual MDS assessments showed the BIMS assessment and the mood assessment had not been completed by the resident. During an interview on 11/7/17 at 3:35 p.m., staff member [NAME] said she was relatively new to her position and to the MDS process. She said she had not understood that if a person could not respond to the BIMS questions during an interview, the BIMS assessment should be ended. During the BIMS assessment for resident #19, the resident had not been able to directly respond to any of the assessment questions posed. The facility coded 0 for the BIMS summary score, when 99 (unable to complete the interview) should have been entered as the summary score. During the same interview on 11/7/17 at 3:35 p.m., staff member [NAME] said resident #19 was unable to complete the PHQ9 mood assessment using direct interviewing. Staff member [NAME] said she completed the mood assessment using general conversation with resident #19. She said that resident #19 would not have been, and was not, cooperative with answering questions, and that resident #19 tended to be suspicious of people. Staff member [NAME] said she used her knowledge of resident #19 to fill out the information on the mood assessment. An error was made when filling out the mood assessment as the resident, rather than as a staff member.",2020-09-01
97,ST JOHN'S LUTHERAN HOME,275024,3940 RIMROCK RD,BILLINGS,MT,59102,2017-11-08,314,D,0,1,8YVD11,"Based on observation, interview, and record review, the facility failed to prevent the development of two avoidable pressure ulcers, and failed to adequately investigate the cause, (with no assessed risk factors) for 1 (# 12) of 25 sampled residents. Findings include: a. Review of resident #12's Quarterly MDS, with the ARD of 8/23/17, showed the development of a Stage II pressure ulcer on the resident's buttocks, on 8/22/17. Review of resident #12's Pressure Injury Report, dated 8/22/17, showed yellow slough. Review of resident #12's Braden Scale, dated 8/30/17, showed a score of 20, meaning no risk factors for developing pressure ulcers. The resident was independent for all care needs. During an interview on 11/8/17 at 2:15 p.m., staff member G stated the pressure ulcer may have developed because resident #12 slept in his recliner. Staff member G stated the facility added a ROHO cushion to the recliner, and resident #12 was a very private man who did not always permit care. Review of resident #12's Care Plan showed as a Stage I to the gluteal cleft, 1 cm x 1 cm on the left side, and 1 cm x 1 cm on the right side. Interventions were the cushion in the recliner, and encourage elder to side lie in bed. The pressure ulcer was documented as healed on 9/18/17. During an interview on 11/8/17 at 3:00 p.m., staff member M stated the pressure ulcer did have yellow drainage and slough. He stated he did not know that slough does not occur with Stage II pressure ulcers. Staff member M stated he believed the pressure ulcer was from friction, and resident #12 needed to be greased up. During an observation and interview on 11/8/17 at 9:20 a.m., resident #10 had a skin cream at his bedside. When asked, he stated he put it on by himself, but it was better when the staff put it on. Staff member M stated it reduced the friction on his bottm. The resident was sitting in his recliner without a cushion. The cushion was next to the recliner. b. Review of resident #12's Care Plan, dated 11/5/17, showed a discoloration to the left medial/dorsal foot, 3.3 cm x 3 cm. Elder wearing regular cowboy boots per his preference. Elder advised by medical staff boots can worsen Charcot's foot and cause pressure injury. Elder often refuses to remove boots. The intervention was to leave open to air, and monitor every 24 hours. During an observation and interview with staff O on 11/8/17 at 12:40 p.m., resident #12 was sitting in his recliner, with his boots off. He stated the nurse was going to take care of the sore on his foot. His [NAME] Hose had bloody drainage on it. Staff member O came in to clean the pressure sore, and covered it with a dressing. She stated it was now a Stage II pressure ulcer, and about the size of a quarter. During an interview on 11/8/16 at 12:10 p.m., staff member H stated the area had been charted as a bruise to the foot. She stated if the boots were the cause, the area would have developed long ago. She said the facility attempts to have one nurse look at skin issues, so the same pair of eyes see the progression, but staff do not have specific wound education.",2020-09-01
98,ST JOHN'S LUTHERAN HOME,275024,3940 RIMROCK RD,BILLINGS,MT,59102,2017-11-08,323,E,0,1,8YVD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify the root cause analysis to address medications known to contribute to falls, and monitor and modify the effectiveness of interventions for repetitive falls for 3 (#s 10, 12, and 16) of 25 sampled residents. Findings include: 1. Review of resident #10's Fall Data and Plan of Action forms, showed the resident fell four times, which included the following dates: 2/10/17, 4/13/17, 7/2/17, and 10/4/17. Review of resident #10's Root Cause for the fall, dated 2/10/17, showed, Elder - up walking in room. The Plan for new interventions showed, Keep door cracked at night in order to give her a bit of light and so we can keep an eye on her. The facility did not identify why the resident fell while she was walking. Review of resident #10's Root Cause for the fall dated 4/13/17, showed, was looking for a seat in day room after supper and fell trying to maneuver in a tight spot. The Plan for new intervention was walk her back from meal and sit her down in a chair - don't let her wander. The facility did not address the contributing cause of the fall. Review of resident #10's Root Cause for the fall dated 7/2/17, showed, tried turning around to sit down while maneuvering walker and lost balance and fell . The Plan for new interventions showed assist elder in backing up and sitting down. The facility did not address why the residents was unsteady while turning. During an observation on 11/7/17 at 12:40 p.m., resident #10 was walking in the day room with a walker and no assistance. Review of resident #10's Root Cause for the fall, dated 10/4/17, showed, fell when unassisted walk (stand by) on way to bathroom. The Plan for new interventions showed use gait belt and walker while ill with URI. The facility did not identify the contributing factors causing the fall. Review of resident #10's Comprehensive Fall Management Program form, for the falls dated 4/13/17, 7/2/17, and 10/4/17, showed no risk factors or interventions were marked on each form. During an interview on 11/7/17 at 8:35 a.m., staff member H stated the Fall Data form and the Comprehensive Fall Management Program form, replaced a fall care plan. Review of resident #10's Physician Orders, dated 11/7/17, showed resident #10 received a routine antianxiety, twice a day. During an interview on 11/8/17 at 9:05 a.m., staff member H stated the facility addressed the medication as a possible contributing factor to resident #10's falls, but did not attempt to reduce or eliminate the medication. 2. Review of resident #12's Post Fall Evaluation form, dated 7/6/17, showed the resident fell five times, which occurred on: 2/21/17, 6/18/17, 6/27/17, 7/6/17, and 9/29/17. Review of resident #12's Root Cause for the fall, dated 2/21/17, showed, Elder slid out of recliner onto floor. The Plan for a new intervention showed Encourage elder to have feet elevated in recliner. The facility did not identify why the resident slid out of his chair. Review of resident #12's Root Cause for the fall, dated 6/18/17, showed, Elder rolled out of bed. The Plan for new intervention showed Keep bed in lower position and keep garbage and other hard object away from the bed. Elder was positive for a UTI. The facility did not identify why the resident rolled out of bed. During an observation and interview on 11/6/17 at 4:15 p.m., resident #12's room had three large bags of pop cans, stacked upon each other. A fall mat was folded up and against the wall, away from the bed. Resident #12 stated he did not use the mat. The mat was identified on the Fall Action Plan form as a fall intervention. Review of resident #12's Root Cause for the fall dated 6/27/17, showed, Elder lost balance. The Plan for new interventions showed positive for UTI. The analysis did not include the possible need for increased assistance or supervision for the resident. Review of resident #12's Root Cause for the fall dated 7/6/17, showed the resident had slid out of the recliner again. The Plan for a new intervention showed start 30 minute checks, and these were discontinued on 9/11/17. Review of resident #12's Root Cause for the fall dated 9/30/17, showed the elder rolled out of bed again. The Plan for a new intervention showed re-initiate 30 minute checks, and check urine for UTI. The facility did not identify why the resident rolled out of bed. During an interview on 11/6/17 at 4:15 p.m., resident #12 stated he was afraid of falling more than anything. Review of resident #12's Physician order [REDACTED]. The facility failed to attempt a dose reduction for the Seroquel (see F329). 3. Review of resident #16's Fall Data and Plan of Action forms showed the resident fell six times, from 10/1/17 through 10/28/17. Resident #16 was admitted to the long term care unit on 9/25/17. Review of resident #16's Root Cause for the fall, dated 10/1/17, showed elder was self transferring and fell . The Plan for a new intervention was, Therapy placed a second handle next to the toilet to assist with transfers. The analysis showed the elder had poor cognition and continued to attempt to transfer independently. The Root Cause did not show how toileting contributed to the fall. Review of resident #16's Root Cause for the fall, dated 10/5/17, showed the elder rolled herself out of bed. The Plan for a new intervention showed use a body pillow and fall mat. The Analysis showed elder continued to self transfer. The Root Cause did not show how or why the resident rolled out of bed, and how self transferring contributed to the fall. Review of resident #16's Root Cause for the fall dated 10/12/17, showed, Elder climbed out of bed, stood up at closet and when attempting to sit in the wheelchair, she fell . The Plan for a new intervention showed Place elder in recliner or bed when in room and remove wheelchair and walker from sight. If elder want (sic) to remain in wheelchair, encourage her to be in the day room. The facility did not address why she wanted to get out of bed, or the need for staff to anticipate and meet her needs. During an observation on 11/16/17 at 10:45 a.m., resident #16 was in her wheelchair, in her room. The walker was next to the recliner. The call light was placed on the recliner. When asked if she could reach her call light, resident #16 attempted to reach it, but her wheelchair got stuck by the recliner, and she was not able to reach it, therefore not able to call for assistance. Review of resident #16's Root Cause for the fall, dated 10/12/17, showed the elder was getting up to change the TV channel. The Plan for a new intervention showed 15 minute checks secondary to toileting, encourage elder to be in day room as much as she is willing. The intervention did not address why resident #16 was getting up to change the channel or why she fell when up. Review of resident #16's Root Cause for the fall dated 10/21/17, showed the elder attempted to get out of recliner while the resident's legs were extended. Staff caught her and lowered her to the floor. The plan for a new intervention showed Continue with 15 minute checks and keep recliner legs elevated, and pancake light strategically placed. Continue to encourage elder to be in dayroom. Elder continues to be impulsive. Review of resident #16's Root Cause for the fall dated 10/28/17, showed the elder attempted to get out of bed at 9:00 a.m., to go to the bathroom. The Plan for a new intervention was to toilet the elder during rounds and get resident up at night to use the bathroom. During an interview on 11/8/17 at 9:05 a.m., staff member H stated the facility had implemented a new fall prevention program, which included fall reviews for three residents one day a week. She stated the team may not understand what root cause analysis meant. She stated the unit nurse managers were responsible for monitoring and evaluating the effectiveness of the fall interventions. Record review of Fall Action Plans and progress notes showed no documented monitoring or evaluation for the effectiveness of the interventions, after repeated falls. Staff member H stated, If they fall again, the intervention did not work.",2020-09-01
99,ST JOHN'S LUTHERAN HOME,275024,3940 RIMROCK RD,BILLINGS,MT,59102,2017-11-08,328,E,1,1,8YVD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to ensure respiratory care, specifically oxygen therapy, was provided for 3 (#s 6, 26 and 27) of 27 sampled and supplemental residents. Findings include: 1. Resident #6 was admitted with [DIAGNOSES REDACTED]. Review of resident #6's Significant Change MDS, with an ARD of 8/3/17, reflected the resident had a cognitive decline with a BIMS score of 12, moderately impaired. The cognitive decline was added to resident #6's care plan. The MDS reflected resident #6 received the respiratory treatment of [REDACTED].#6 required supervision and set up for her activities of daily living. Review of resident #6's physician orders, dated 4/27/17, reflected an order for [REDACTED]. Review of resident #6's care plan reflected a problem, with the effective date of 4/27/17, for a potential for alteration in gas exchange and ineffective breathing pattern related to heart failure. The goal listed reflected the resident's oxygen saturation level would be maintained at 90%. The interventions listed reflected the resident was to be provided oxygen at up to 2 lpm to maintain a saturation level at or above 90% per nasal cannula. Another intervention reflected resident #6 could operate her concentrator, but generally needed help with turning the portable cylinders on and off that she used to go to activities and meals outside of her room. Another care plan problem, with the effective date of 8/19/17, reflected the resident had a compromised short-term memory as manifested by a BIMS score of 12 (down from 15 on admission). Interventions listed for the problem reflected the resident required staff to reassure her when she was confused, explain all procedures before performing them, and give verbal reminders and cues to assist the resident in orientation. Another care plan problem, with the effective date of 8/10/17, reflected an actual/potential alteration in self-care/ADL ability related to heart failure. Listed in the interventions were instructions for staff to supervise and assist resident #6 as needed during tasks. During an observation and interview on 11/6/17 at 2:50 p.m., resident #6 was sitting in her room in her wheelchair looking out of her window. The resident's nasal cannula was in her nose, and was attached to the oxygen concentrator. The oxygen concentrator was not turned on. Resident #6 stated the staff had put her cannula on her when she got back from lunch. Resident #6 stated she did not notice the oxygen concentrator was not turned on. Staff member I turned on resident #6's oxygen concentrator and stated it should have been turned on. During an interview on 11/7/17 at 9:30 a.m., resident #6 stated she normally takes care of her oxygen and turns on her concentrator when she gets back to her room. Resident #6 stated she forgets to turn it on sometimes. Resident #6's Significant Change MDS, with an ARD of 8/19/17, reflected she had a decline in her short-term memory and required reminders and cues to assist her in her orientation. During an interview on 11/7/17 at 10:10 a.m., staff member J stated resident #6 turns her oxygen on independently. Staff member J stated the resident knows she needs to use the oxygen. Staff member J stated staff reminds her she needs to use the oxygen. During an observation and interview on 11/7/17 at 12:32 p.m., resident #6 was sitting in the dining room eating lunch. The oxygen cylinder was hanging on the back of her wheelchair, and the needle on the gauge reflected the cylinder was on empty. The resident did not exhibit signs of being short of breath and did not have any complaints. The resident was not aware the oxygen cylinder was empty. At 12:47 p.m., resident #6 left the dining room and went to her room. Her oxygen cylinder reflected empty and no staff assisted the resident to get another cylinder or check to ensure it still had oxygen in it. When the resident entered her room, she sat looking out of her window. The oxygen concentrator was running in the on position, but the resident did not put on the nasal cannula that went to the concentrator. At 12:49 p.m., staff member K entered the resident's room and asked her if she would like some ice water. Resident #6 stated she would like some ice water. At 12:50 p.m., resident #6 stood up from her wheelchair and staff member K brought in the ice water and asked the resident if she wanted to lay down and if she needed assistance. Resident #6 stated she was going to go to the bathroom. Staff member K left the room and did not check the oxygen tank or concentrator prior to leaving. At 1:02 p.m., resident #6 came out of the bathroom, removed the nasal cannula that was attached to the oxygen cylinder, and put on the nasal cannula attached to oxygen concentrator. Resident #6 had been without oxygen therapy from the time of the dining room observation at 12:32 p.m. until she placed herself on the oxygen concentrator at 1:02 p.m. During an interview on 11/7/17 at 3:40 p.m., resident #6 stated she did not know how to check her oxygen cylinder. She stated she thought staff needed to check the cylinder to make sure they had oxygen in them. Resident #6 stated when she woke up this morning she wasn't feeling well. Resident #6 stated she woke up with her nasal cannula in her hand. Resident #6 stated she believed she was not feeling well because she had taken off her oxygen in her sleep. Resident #6 stated she would want staff to wake her to put on her oxygen if they saw it was off. 2. Resident #26 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #26's Quarterly MDS, with an ARD of 8/24/17, reflected the resident received the respiratory treatment of [REDACTED]. The MDS reflected the resident did not resist care and required extensive assistance of one person with her ADLs. Review of resident #26's physician orders, dated 1/19/16, reflected the resident was to be provided with oxygen therapy per nasal cannula at 2 lpm to maintain a saturation level of 90% or above. Review of resident #26's care plan reflected a problem, with the effective date of 6/8/17, of alteration in resident #26's thought process related to a history of stroke with [MEDICAL CONDITION]. Interventions listed included for staff to give resident #6 short simple instructions, and provide a consistent routine environment. Another problem, with the effective date of 6/8/17, reflected a potential for alteration in gas exchange and ineffective breathing pattern related to [MEDICAL CONDITION]. Interventions listed included oxygen at 2 lpm per nasal cannula to maintain oxygen saturation at or above 90%, encourage resident #26 to deep breathe, and breathe through the nasal cannula if in place. During a meal time observation on 11/7/17 at 12:30 p.m., resident #26's oxygen cylinder was on empty. The empty oxygen cylinder was reported to staff member P by this surveyor. Staff member P observed the oxygen cylinder and instructed staff member K to obtain a new oxygen cylinder to replace the empty one. At 12:40 p.m. staff member K returned with a new oxygen cylinder and changed out the empty cylinder. Staff did not check resident #26's oxygen saturation prior to applying the new oxygen cylinder. 3. Resident #27 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #27's physician orders reflected the resident required oxygen at 2 lpm per nasal cannula. Review of resident #27's most current Annual MDS, with an ARD of 8/24/17, reflected the resident was not receiving a respiratory treatment during that assessment time. Resident #27's MDS reflected he had a BIMS of 14, cognitively intact. Resident #27 required extensive assistance of one person with his activities of daily living. Review of resident #27's care plan reflected a problem, with an effective date of 9/12/16, for an alteration in resident #27's thought process related to dementia. Interventions listed included for staff to give short simple instructions and reorient as needed. Another problem, with the effective date of 9/12/17, reflected an actual/potential alteration in self-care/ADL ability related to dementia with mild confusion. Interventions listed included for staff to supervise and assist as needed during tasks. During an observation on 11/7/17 at 1:05 p.m., resident #27 was in the dining room for lunch and had an oxygen cylinder attached to his wheelchair that he was receiving oxygen from, per nasal cannula. The gauge on the oxygen cylinder was in the red zone and was at the 200 psi mark. The resident was assisted back to his room from the dining room. The resident was not placed on his oxygen concentrator from the oxygen cylinder. The resident was sitting next to his bed and was visible from the doorway. At 1:07 p.m., staff member Q passed by the resident's room with the medication cart and did not place the resident on the oxygen concentrator. At 1:09 p.m., staff member R walked past resident #27's room, looked in on the resident from the door and did not place the resident on the concentrator. The resident was reading a newspaper and facing the window away from his door. The surveyor interviewed the resident as soon as staff member R walked away. The resident stated he was ok and did not notice his oxygen tank was on empty. During an interview on 11/7/17 at 1:10 p.m., staff member J was notified by the surveyor that resident #27 was not placed on his oxygen concentrator and his tank gauge showed it was in the red zone. Staff member J stated resident #27 had a health issue last Friday for a GI bleed and [MEDICAL CONDITION]. Staff member J stated resident #27 needed to be on oxygen continuously. Staff member J went into resident #27's room, and placed him on his oxygen concentrator. During an interview on 11/7/17 at 3:20 p.m., staff member S stated the night shift CNAs check the oxygen cylinders and change them out if needed. Staff member S stated staff should check the oxygen cylinder before they take the resident out of their room to ensure it had enough oxygen in it. During an interview on 11/7/17 at 3:30 p.m., staff member T stated staff check the oxygen cylinders on night shift and throughout the day, usually at the end of the shift. Staff member T stated it depended on if the resident was mobile and if the oxygen was continuous or had a gauge with an on-demand setting. Staff member T stated sometimes it was hard to check if the resident was independent. Staff member T stated the oxygen cylinders lasted approximately two hours if they were on continuously. During an interview on 11/8/17 at 8:35 a.m., staff member J questioned if resident #27's oxygen was in the red zone. Staff member J stated if the gauge got to the beginning of the red zone, 500 psi, the resident would have approximately 1.25 hours left. Staff member J showed a picture of resident #27's gauge at the time she was notified of the concern on 11/717 at 1:10 p.m. The picture showed the needle to be at the 200-psi mark. The staff should have changed out the oxygen cylinder according to the facility policy and procedure to ensure it did not go below the 200 psi mark. Review of the facility policy titled, St. [NAME]'s Lutheran Portable Oxygen Therapy Use, reflected instructions for staff to, change the cylinder when the needle gets to the lower part of the red section. The policy reflected, Be sure to change the cylinder before the needle gets below 200-psi. During the interview on 11/7/17 at 8:35 a.m., staff member J stated if staff took a resident to their room they should place the resident on the oxygen concentrator from the oxygen cylinder. Staff assisted resident #27 to his room and did not place him on the oxygen concentrator.",2020-09-01
100,ST JOHN'S LUTHERAN HOME,275024,3940 RIMROCK RD,BILLINGS,MT,59102,2017-11-08,329,D,0,1,8YVD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to attempt a dose reduction for an antipsychotic and an antianxiety medication for 2 (#s 10 and 12) of 25 sampled residents. Findings include: 1. Review of resident #12's Quarterly MDS, with the ARD of 8/23/17, showed the resident had a [DIAGNOSES REDACTED]. Review of resident #12's Care Plan, initiated 4/4/16, showed a problem for Thought process related to dementia, [MEDICAL CONDITION] with use of [MEDICAL CONDITION] medication, history of chronic pain that can affect thought process, depression, [MEDICAL CONDITION]. The goals included I will be oriented to self daily by responding to my name - by looking at the speaker. The goals and interventions had not been updated since 4/4/16. During an interview and observation on 11/7/17 at 3:30 p.m., resident #12 was alert and oriented, able to respond to all questions, and was friendly and pleasant. Review of resident #12's certification visit by the physician, dated 6/23/16, showed Patient's baseline behavior has improved. He has been receiving [MEDICATION NAME] XR 50 mg (antipsychotic) twice a day. He has been tired in the mornings, most likely due to his [MEDICATION NAME] dose. I'm discontinuing the morning dose keeping [MEDICATION NAME] 50 mg XR daily at 1600. Review of resident #12's Social Service note dated 8/29/17, showed (Resident's) depression score is related to his experienced pain. (Resident) is very independent and travels in the community without assistance. He states that he does worry about falling and hurting himself. (Resident's) memory is good and he has good problem solving capability, if he is not in pain. Pain does cloud his judgement. (Resident) is social and has many friends in the facility. Review of a Pharmacy Note, dated 5/11/17, showed Resident receiving [MEDICATION NAME] at bedtime for [MEDICAL CONDITION]. No mood or behavior documented this review period. Review of a Pharmacy Note, dated 7/18/17, showed Resident stable. No [MEDICAL CONDITION] noted. Resident has failed reduction in the past. Review of a Pharmacy Note, dated 8/29/17, showed Gradual Dose reduction declined by provider due to previously failed attempt. Review of a Pharmacy Note, dated 10/24/17, showed Caretracker showed no mood or behavior indicators. Provider declined GDR of [MEDICATION NAME] (10/10/17) due to previously failed attempt. During an interview on 11/7/17 at 3:45 p.m., staff member G stated no GDR's were attempted for resident #12 since his arrival to the unit, in April, (YEAR). Record review showed the reduction in [MEDICATION NAME] occurred on 4/23/16, and was successful. 2. Review of resident #10's Physician orders, dated 11/7/17, showed the resident was receiving [MEDICATION NAME] (anti-anxiety), routinely, twice a day. Review of resident #10's Care Plan, dated 5/5/16, showed a problem for dementia, thought process, and depression with anxiety. The interventions had not been updated since 5/5/16. Review of a Pharmacy Note, dated 7/10/17, showed the resident failed a dose reduction of the [MEDICATION NAME] 11/2016. Review of resident #10's Physician visit, dated 12/5/16, showed She recently had her [MEDICATION NAME] decreased to once a day. Nursing staff report that she was more irritable and would pick on other residents with this decrease. Therefore, her [MEDICATION NAME] was increased back to twice a day. Review of resident #10's Pharmacy Note, dated 10/2/17, showed Please evaluate [MEDICATION NAME] and [MEDICATION NAME] for dosing appropriateness, including rationale if no dose reduction attempted at this time. Record review showed no dose reduction occurred for the antianxiety medication [MEDICATION NAME] or the [MEDICATION NAME], for 2 years. Review of resident #10's Behaviors and Behavior Management forms, showed behaviors of agitation and hitting occurred on 10/31/16, 10/30/17, 1/20/17 and 4/5/17. During an interview on 11/8/17 at 9:05 a.m., staff member H stated the facility had addressed the medication as a possible contributing factor to resident #10's falls, but did not attempt to reduce or eliminate the medication. She said the facility could not override the doctor.",2020-09-01