Yellowstone River Nursing And Rehabilitation

Based on observation and interview, the facility failed to provide a wheelchair-accessible grievance box, so residents could submit a grievance independently or anonymously, and the box was not within reach for all the facility residents who used wheelchairs for mobility; and this failure affected 1 (#112) of 26 sampled residents. Findings include: During an observation and interview on 8/26/25 at 4:19 p.m., a grievance box was observed on top of a counter, next to the receptionist's desk, in the main lobby. There was a trash can on the floor in front of the counter, creating a barrier for someone wishing to reach the grievance box. The grievance box had a lid that needed to be pulled down for a resident or person to deposit a grievance form. Staff member G stated she sometimes had to help residents put their grievance forms into the grievance box when they were unable to reach the box themselves, especially if they were in a wheelchair.During an interview on 8/27/25 at 7:52 a.m., staff member A stated he felt any resident in a wheelchair could access the grievance box easily.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure resident meal trays were served to the residents' rooms in a timely manner and according to the posted mealtimes for 3 (#s 19, 42, and 97) of 26 sampled residents, and it was reported the meals could be lukewarm and residents felt hungry due to having to wait so long for the room trays to be served. Findings include:Review of a facility document, titled Meal Times, not dated, showed: Breakfast 7:30 a.m. through 8:30 a.m.; Lunch 12:00 p.m. through 1:00 p.m.1.During an interview on 8/25/25 at 1:59 p.m., resident #97 stated the food was consistently served thirty minutes late in the resident's rooms. Resident #97 stated he always ate in his room, and his food was often late and was usually lukewarm, which he did not like.During an observation and interview on 8/27/25 at 12:27 p.m., there was no lunch served in resident #97's room, and resident #97 stated, Apparently they're running late. Resident #97 stated he thought lunch was served in the dining room at 12:00 p.m., with the room trays being delivered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to respect a resident's personal items. The staff cleaned the resident's room, disposing of personal resident items without the resident being present or aware of what was disposed. The lack of respect for the resident's belongings and environment caused the resident frustration, for 1 (#53) of 26 sampled residents. Findings include:During an observation and interview on 8/26/25 at 10:01 a.m., resident #53 was proudly showing off personal items he had collected. There were rocks, some painted and arranged along the windowsill, and a small plant [NAME] he had made from tree branches. Various papers were scattered around the room. The sink was full of apples. There was no smell, and the walkways were clear, therefore, the items in the room did not appear to create a safety hazard at the time.Review of resident #53's care plan, with an initiation date of 7/31/25, showed, Focus: I enjoy spending time in nature-based activities such as picking…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to follow the doctor's orders for edema treatment for 2 (#s 12 and 80) of 26 sampled residents. This deficient practice increased the risk for serious complications related to the edema, especially due to their mobility issues. Findings include:1.Resident #12 During an observation on 8/25/25 at 1:22 p.m., resident #12 was sitting in her wheelchair with noticeable swelling in both of her lower legs and feet. Resident #12 was not wearing elastic bandages or compression stockings. Resident #12 stated the swelling in her legs and feet started months ago, and said, The staff do nothing about it since I got here. During an observation on 8/26/25 at 8:48 a.m., resident #12 was in bed, her legs were not elevated, and there were no pillows at the foot of her bed. There were no items available to be used to assist with the resident elevating her leg(s). During an observation on 8/26/25 at 4:36 p.m., resident #12 was sitting in the dining room, and the resident was not wearing elastic bandages or compression stockings.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to follow doctor's orders for oxygen treatment related to CPAP administration for 1 (#80) and nasal canula administration for 1 (#12); and failed to post an oxygen sign on the door or have full oxygen tanks for 1 (#12) of 26 sampled residents. Findings include:1.Resident #12During an observation and interview on 8/25/25 at 1:22 p.m., the doorway to resident #12's room did not have an oxygen sign posted. Resident #12 was sitting in her wheelchair with a nasal cannula in her nostrils which was connected to an oxygen tank on the back of her wheelchair. The oxygen tank was empty. Resident #12 stated, I think I am supposed to have oxygen on all of the time. There were 11 other oxygen tanks noted in her room. During an interview on 8/25/25 at 1:28 p.m., staff member O stated, Oh, the oxygen tank shouldn't be empty, that's why we have so many tanks in her [resident #12's] room. During an observation on 8/26/25 at 8:48 a.m., resident #12 was resting in bed with no nasal cannula in her nostrils supplying oxygen. During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure staff had the necessary education to monitor the functionality of the facility's wander guard alarm system for 6 (#s 1, 10, 11, 12, 13, and 14) of 6 residents sampled for wandering and elopement risk. This failure increased the risk for the resident's attempting to elope. Findings include: During an interview on 6/2/25 at 5:00 p.m., staff member I stated she did not know who checked the wander guard alarm system, but she believed it worked because when a resident with a wander guard alarm device would get close to an exit door, the alarm would start to beep. During an interview on 6/3/25 at 9:00 a.m., staff member L stated she had one resident who was an elopement risk and wore a wander guard device. Staff member L stated the facility doors exiting outside to a public area have a wander guard alarm system installed on the door. Staff member L stated it was a facility policy for the system to be installed on all doors exiting the facility. Staff member L stated she was not aware some exit doors in the facility were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to complete a thorough investigation involving a resident who had access to, and went out of, a door which was not alarmed with a wander guard alarm system. The resident left the facility property, accessing a public road, traveling 0.2 miles on foot without staff supervision. The facility failed to identify exit doors not equipped with a wander guard alarm system which would alert staff to redirect a resident prior to exiting an emergency egress door as a hazard for 1 (#1) of 9 sampled residents for wandering and elopement risk. The facility's failure to address these concerns placed this resident, and any others at risk of eloping, at continued risk of imminent harm. Findings include: A Facility Reported Incident, dated 3/28/25, was submitted to the State Survey Agency for an incident involving resident #1 who eloped from the facility. Review of the facility's report of findings, dated 4/2/25, included the following information: Resident #1 eloped from the facility on 3/28/25 at 7:30 p.m. Facility staff identified an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to update a resident care plan with a new fall intervention identified by the IDT, for 1 (#7) of 9 sampled residents. The failure placed the resident at risk for recurrent falls and injuries. Findings include: Review of resident #7's nursing progress note, dated 5/31/25, showed the resident had an unwitnessed fall. The progress note showed resident #7 was sitting in a chair in the dining room. Resident #7 attempted to scoot forward in the chair, but she slid out, landing on her buttocks. Review of resident #7's current care plan, undated, failed to show a new fall intervention to address why or how the resident slid from her wheelchair, for the resident's fall on 5/31/25, as identified by the IDT. A review of resident #7's IDT event review note, dated 6/4/25, showed, New Interventions suggested following current IDT review: Intervention is redirect resident to the couch to sit in instead of the chairs as she is able to get up off the couch without any difficulty, care plan reviewed and updated. [sic] The intervention…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to ensure meals were served at an appetizing temperature to ensure resident satisfaction for 4 (#s 15, 16, 17 and 18) of 4 sampled residents for food satisfaction. Findings include: During an interview on 3/26/25 at 3:58 p.m., resident #18 stated when meals are served, they are not hot. During an interview on 3/27/25 at 8:33 a.m., staff member I stated she receives complaints from residents that room trays are cold all the time. During an interview on 3/27/25 at 8:47 a.m., resident #15 had just received her breakfast tray and reported her food was cold. During an interview on 3/27/25 at 12:51 p.m., resident #16 had just received her lunch meal in her room and stated she was disappointed because her food was not warm. During an interview on 3/27/25 at 1:25 p.m., resident #17 stated the food which is delivered to resident rooms is mostly cold. Resident #17 reported she often eats yogurt at lunch and more often than not, her yogurt is served warm, and she prefers yogurt to be served cold. A review of resident council minutes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to provide equal access to quality care for 1 (#7) of 18 sampled residents. The resident was placed in a room without a sink, bathroom, or call light. The resident slept on a mattress placed on the floor. Findings include: During an interview on 3/25/25 at 12:05 p.m., NF3 stated she was at the facility on the morning of 3/5/25. NF3 stated she was unable to locate resident #7 in his assigned room. An unknown staff member directed NF3 to the Country Store, located in the secure memory care unit. NF3 stated she found resident #7 lying on a mattress, on the floor, in the Country Store. NF3 stated the lights were turned off and the door was partially closed. NF3 stated the room looked like a storage room of sorts, with no bathroom or call light seen. NF3 stated the staff on the unit told her resident #7 had been sleeping there for a couple of nights because there was not an empty, available, room on the secure unit. NF3 stated she was told the facility had tried to place resident #7 on a regular unit, rather than the secure memory…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide written notice for a room change, including the reason for the change, for 2 (#s 7 and 8) of 3 residents sampled for room changes. Findings include: 1. Review of resident #7's Census tab in the EHR, viewed on 3/24/25, showed the following room changes for the resident: - 2/25/25, moved from room [ROOM NUMBER] to room [ROOM NUMBER], - 3/5/25, moved from room [ROOM NUMBER] to room [ROOM NUMBER]; and, - 3/12/25, moved from room [ROOM NUMBER] to room [ROOM NUMBER]. Review of resident #7's Assessment tab, viewed on 3/24/25, failed to show a Notification of Room/Roommate Change forms for the 3/5/25 and 3/12/25 room changes. Review of resident #7's Progress Notes tab, viewed on 3/25/25, failed to show any of the room or unit changes which occurred on 2/25/25, 3/5/25, and 3/12/25. During an interview on 3/25/25 at 8:50 a.m., NF1 stated he had been made aware of the room change from the secure memory unit to a regular unit. NF1 stated he was not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to notify a resident's representative when a change in condition necessitating a transfer to a higher level of care for 1 (#1) of 4 residents sampled for appropriate transfer. Findings Include: During an interview on 3/25/25 at 11:05 a.m., NF5 stated she was not notified when resident #1 was admitted to an acute care hospital on 2/16/25. NF5 stated she was notified when resident #1 attempted to elope and became very agitated. But was not notified when the decision was made to transfer resident #1 to the hospital for a psychiatric evaluation. NF5 stated she did not know about the transfer or the admission until another family member arrived at the facility to visit and was told he was in the hospital. Review of resident #1's documents received from the acute care hospital, dated between 2/16/25 and 2/24/25, showed the following: - 2/16/25, History and Physical, increased confusion and agitation, unclear etiology, - 2/17/25, Hospital Progress Note, worsening confusion secondary to steroids, baseline dementia, and dehydration…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure each resident room was equipped with a sink and toilet for 1 (#7) of 18 sampled residents. Findings include: During an interview on 3/25/25 at 12:05 p.m., NF3 stated she was at the facility on the morning of 3/5/25. NF3 stated she was unable to locate resident #7 in his assigned room. An unknown staff member directed NF3 to the Country Store. located in the secure memory care unit. NF3 stated the room looked like a storage room of sorts, with no sink or bathroom seen. NF3 was told the resident was placed in the Country Store temporarily, and she was not sure how long resident #7 was in the Country Store. During an interview on 3/27/25 at 8:45 a.m., staff member G stated resident #7 did not have a bed or room on the secure unit as they were all occupied. Staff member G stated, on 3/4/25, a message from facility management was relayed to her by the day staff to figure it out and the room situation would be resolved in the morning (3/5/25). Staff member G stated she knew there was no sink or bathroom in the Country…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure each resident's sleeping area had functioning call light for 1 (#7) of 18 sampled residents. Findings include: During an interview on 3/25/25 at 12:05 p.m., NF3 stated she was at the facility on the morning of 3/5/25 and was unable to locate resident #7 in his assigned room. An unknown staff member directed NF3 to the Country Store. located in the secure memory care unit. NF3 stated the Country Store looked like a storage room of sorts. NF3 stated she noted there was no call light for the resident, who was lying on a mattress on the floor. During an interview on 3/27/25 at 8:45 a.m., staff member G stated resident #7 was in the secure memory unit during the day on 3/4/25 and 3/5/25. Staff member G stated resident #7 did not have a bed or room on the unit as they were all occupied. Staff member G stated, on 3/4/25, a message from facility management was relayed to her by the day staff to figure it out and the room situation would be resolved in the morning (3/5/25). Staff member G stated she knew there was no call…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure PRN (as needed) anti-anxiety medication was limited to 14 days for 1 (#49) of one sampled resident and failed to ensure an adequate indication of use for an antipsychotic for 1 (#99) of 1 sampled resident. Findings include: Review of resident #49's March 2024 Medication Administration Report, showed resident #49 was started on routine Diazepam 2 mg (milligram) oral tablet one time a day for anxiety. In addition, resident #49 could also receive Diazepam 1 mg by mouth every twenty-four hours as needed for six hours after the scheduled dose. This psychotropic medication was ordered approximately every fourteen days for more than eight months. Review of resident #49's Treatment Administration Record dated 10/2024, showed the resident was assessed as a zero or no signs of anxiety during shifts when resident #49 received the as needed dose of diazepam. Review of resident #49's pharmacy drug regimen review dated 8/21/24, showed the pharmacy had identified the resident was receiving, Diazepam 2 mg every day since 3/2024 and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interviews, the facility failed to employ a Certified Dietary Manager, to carry out the functions of the food and nutrition services, for the facility. This failure increased the risk of negative outcomes for all residents residing at the facility and receive nutritional services. Findings include: During the initial observation of the kitchen, on 7/15/24 at 12:25 p.m., concerns with employee hygiene supplies (beard covers and soap), soiled kitchen equipment, improper food storage, cleanliness of the dietary department, and pest control, were identified (refer to F812, F908, and F925 for more information). During an interview on 7/16/24 at 3:00 p.m., staff member E stated, We (the facility) have a contract dietician that comes every other week. I have never met her. She is available for me to call if I have questions. I have only been in this position for about three months. I am currently enrolled in a Certified Food Manager program, but I haven't had the time to complete it, due to my working in the kitchen so much. During an interview on 7/16/24 at 3:21…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to ensure sanitary conditions were maintained throughout the kitchen, and the dietary storage areas. The facility failed to ensure kitchen staff wore beard coverings while serving food, failed to label and date food items in the walk-in cooler, failed to maintain a clean (dietary/kitchen) environment, and failed to have appropriate pest control. This deficient practice had the potential to cause foodborne illness to all who received food from the kitchen. Findings include: During the initial tour of the kitchen, on 7/15/24 at 12:25 p.m., the following observations were made: - There were no paper towels or soap in the soap dispensers, located near the two sinks, used for washing hands prior to entering the kitchen. - A wall vent in the dry storage area had black drip marks running from it. - There was grease and dirt buildup on the handles to the gas stove. - Grease and grime was built up under the grill and around the table it was on. - Mouse droppings were observed in the dry storage area, and the chemical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to identify, correct, and monitor quality-deficient practices effectively related to the kitchen cleanliness and pest control using the QAPI program. This failure increased the risk of negative outcomes for any resident who received food and or services from the dietary department. Findings include: Observations during the initial brief tour of the kitchen on 7/15/24 at 12:25 p.m. showed: - Grease and dust buildup were observed on the handles of the stove burners. - Grease was built up under the grill and around the area of the stove. - The oven that was nonfunctional had a box of gloves and a long lighter stored in them. - The microwave had debris and dirt in and underneath it. - There was a puddle of water on the kitchen floor, and no wet floor sign was present. - Mouse droppings were observed on the floor in the food storage area and the chemical storage area. - A thick layer of black dirt and mouse droppings went all the way around the storage areas along the floor at the bottom of the walls. - A bag of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assure pest control in the kitchen, 200 and 300 halls, and a resident room for 1 (#65) of 43 sampled residents. This deficient practice had the potential to affect all residents served food from the kitchen, and all residents residing on the 200 and 300 halls. Findings include: 1. During an observation on 7/15/24 at 12:48 p.m., an ant was observed crawling on the floor to the right of resident #65's recliner, among crumbs. During an observation on 7/16/24 at 8:02 a.m., dead insects were scattered in multiple places on the floor in the 300 hallway. During an observation on 7/16/24 at 4:20 p.m., a beetle was crawling to the right of room [ROOM NUMBER] in the hallway, and a beetle was crawling near the exit doors in the 200 unit. During an interview on 7/17/24 at 9:02 a.m., staff member K stated he had observed ants in the facility. During an interview on 7/17/24 at 9:25 a.m., staff member L said bugs flew through the residents' screenless…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to invite residents to care plan meetings for 4 (#s 21, 63, 89, and 91) of 43 sampled residents. Findings include: 1. During an interview on 7/16/24 at 11:19 a.m., resident #89 stated, The staff come and tell me they are going to have a care meeting, but they either never have one or something, because I haven't gone to the meetings. Review of resident #89's EHR showed there was no evidence the resident had been invited to the care plan meetings. 2. During an interview on 7/16/24 at 9:51 a.m., resident #63 said he was not invited to any care plan meetings. Resident #63 stated he would like to go to the meetings to provide input into his care. Review of resident #63's social services care plan invitation information showed the last documented care plan invitation was on 12/12/23. 3. During an interview on 7/16/24 at 8:49 a.m., resident #21 said she had not gone to a care plan meeting in eight or nine months. Resident #21 said she would like to go to a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a clean and sanitary environment for 3 (#s 32, 63, and 89); and failed to consistently clean the 300 hallway and resident rooms for 2 (#s 39 and 65) of 43 sampled residents. Findings include: 1. During an observation and interview on 7/15/24 at 2:55 p.m., resident #89 stated she had told the facility staff there were bugs in her room. Resident #89 said the management gave her bug spray to kill the bugs when she saw them. During an observation and interview on 7/16/24 at 10:26 a.m., a large spider was seen on the floor by the sitting room on unit one. Staff member O stepped on and killed the spider. Staff member O said she just saw small bugs on the floor in the sitting room on unit one. 2. During an observation on 7/15/24 at 2:15 p.m., resident #63 stated his bathroom was dirty and told the surveyor not to walk in there because the floor was so dirty. Observation of the bathroom showed a brown build-up stain around the edges of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure discontinued medications were properly disposed of or destroyed for 2 (#s 6 and 318) of 43 sampled residents. Findings include: During an observation of medications in the medication cart, on 7/17/24 at 10:20 a.m., an Insulin Aspart FlexPen was found with a label for resident #6 on it. Resident #6 was discharged from the facility on 7/11/24. During an observation of medications in the medication cart, on 7/17/24 at 10:40 a.m., three (3) Insulin Lispro KwikPens, labeled for resident #318, were found. Resident #318 was discharged from the facility on 7/1/24. The following medications were found stored in the medication cart for the TCU, with either partially removed, illegible labels, or no labels: - Four (4) Insulin Lispro KwikPens, - One (1) Victoza injector pen, - Four (4) Levemir FlexPens, - One (1) Humalog KwikPen, - Five (5) Admelog SoloStar insulin pens, - One (1) Insulin Aspart FlexPen, and - One (1) Lantus Solostar pen. During an interview on 7/17/24 at 10:42 a.m., staff member Q was asked what…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5 percent, for 2 (#s 37 and 309) of 43 sampled residents. The medication error rate calculated to 11.54 percent, and there were multiple errors made for each resident, increasing the risk of a negative outcome. Findings include: 1. During a medication administration observation, on 7/17/24 at 8:12 a.m., staff member G prepared medications for administration to resident #37. Staff member G gave the resident one tablet of calcium 600 mg with vitamin D 10 mcg, one half tablet of vitamin D 10 mcg, and one tablet of a multivitamin with minerals. Review of resident #37's MAR, dated 7/17/24, showed the following medication orders: - order date 4/24/21, calcium carbonate 600 mg tablet once a day, - order date 4/24/21, vitamin D3 1000 IU (25 mcg) tablet once a day, and - order date 4/24/21, multiple vitamin one tablet once a day. When the medications administered were compared to the medications documented as given, the medication observation showed the resident received…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide services to enable the residents to maintain their highest practicable level of functioning for 1 (#16) of 43 sampled residents. Findings include: During an observation and interview on 7/16/24 at 9:34 a.m., resident #16 was sitting in his electric wheelchair. Resident #16 was observed to attempt to reposition himself using his hands and forearms. During the 10-minute conversation, resident #16 was observed attempting to reposition himself four times, using both hands and forearms. Review of resident #16's nurse progress notes, dated 6/10/24, showed resident #16 was, . having pain in his left wrist, was favoring his wrist, and not using it as much. The nurse progress note showed the medical provider would be notified. Review of a facility document titled, Billings Clinic Outreach Services, dated 6/11/24, showed the provider identified resident #16's motorized wheelchair armrest did not accommodate the length of his left forearm. The provider note showed resident #16 had to make frequent position…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure residents were free from abuse by a staff member, for 2 (#s 304 and 305) of 43 sampled residents. Findings include: Review of a Facility-Reported Incident, submitted to the State Survey Agency, dated 3/22/24, showed resident #s 304 and 305 reported NF4 was rough with them during a transfer and when providing ADL assistance. The report showed NF4 was immediately suspended pending the completion of the investigation. Review of resident #304's investigative file, dated 3/22/24, showed the resident reported NF4 came in to provide care and asked her to move her right leg. When resident #304 told NF4 she could not move it, he grabbed her leg to turn her to her side. Resident #304 also reported NF4 used the word diaper when assisting with incontinence care. Resident #304 reported she felt the use of that word was degrading. Later on 3/22/24, resident #304 reported she was having right knee and leg pain. Resident #304 stated she did not want NF4 caring for her anymore. Review of resident #305's investigative file, dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to identify a concave mattress as a potential restraint and did not complete a risk assessment, consent, or monitoring for 1 (#88) of 2 residents sampled for restraints. Findings include: During an observation on 7/15/24 at 3:15 p.m., a concave mattress was observed on resident #88's bed. Resident #88 was not in the room at the time of observation. During an interview on 7/16/24 at 8:12 a.m., staff member B reported resident #88 had a concave mattress on his bed, . to keep him from falling out of bed. During an interview on 7/17/24 at 9:50 a.m., staff member U stated the concave mattress was on resident #88's bed, . because I think he kept getting up and would fall. Review of resident #88's care plan, showed the following entry on 11/29/23: I am at risk for falls/injuries r/t fracture from fall at home, medication use, change in BP . Scoop (concave) mattress is to be provided. [sic] Review of resident #88's medical record failed to show documentation of a restraint risk assessment, written consent, or monitoring…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, and record review, the facility failed to ensure there was an effective process for providing foot care to diabetic residents for 1 (#91) of 43 sampled residents. Findings include: During an observation and interview on 7/15/24 at 3:33 p.m., resident #91 stated her toenails were very long and starting to curl over. Resident #91's toenails were observed to be long and curling at the top. Resident #91 stated she did not recall them being cut since she came to the facility on 3/11/24. During an interview on 7/15/24 at 3:55 p.m., NF1 stated, I wish [#91] could be seen by a podiatrist. The staff won't touch her nails due to her health conditions. I don't feel comfortable doing it myself either. I know that her nails are bothering her. I'm not sure if it's my responsibility to set up those appointments or if it is the facility's responsibility. During an interview on 7/17/24 at 1:42 p.m., staff member I stated Social Services coordinated with the facility scheduler to schedule appointments for the residents. During an interview on 7/17/24 at 2:00 p.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to identify the risk of a trip hazard by using a twin-size scoop mattress as a bedside fall mat for 1 (#91); and failed to protect a resident from hazardous materials for 1 (#89) of 43 sampled residents. Findings include: 1. During an observation and interview on 7/15/24 at 3:33 p.m., a twin-size scoop mattress was observed next to resident #91's roommate's bed. Resident #91 stated, That mat over there (pointing across the room) is so big and (staff) often put on my side of the room. I have seen a housekeeping staff member trip over it; luckily, she didn't get hurt. I have almost tripped over it myself. The staff put it on my side of the room when they were helping my roommate, and then I couldn't get to the restroom. During an interview on 7/17/24 at 3:07 p.m., staff member U stated, I think they use the mattresses for falls. It does make it hard to perform cares because it is so big and hard to move. There really isn't anywhere to put it when we do have to get the residents up. I do think it could cause an accident. It's just…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, it was found facility administration failed to hire and employ a Dietary Manager with appropriate competencies and skills sets to carry out the necessary functions of the food and nutritional services; and the facility dietitian did not schedule regular consultations and go onsite to work with the dietary manager and assist with oversight of nutritional services. This failure resulted in numerous concerns being identified in the dietary department (Refer fo F825. Findings include: Observations during the initial tour of the kitchen, on 7/15/24 at 12:25 p.m., showed: - A staff member was observed serving the lunch meal and not wearing a covering over their beard. - Grease and dust buildup was observed on the handles of the stove burners. - Grease was built up under the grill and around the area of the stove. - The ovens that were nonfunctional had a box of gloves and a long lighter stored in them. - The microwave had debris and dirt in it and underneath it. - There was a puddle of water on the kitchen floor and no wet floor sign…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure enhanced barrier precautions were followed when performing wound care and medication administration through a feeding tube, for 1 (#86) of 1 sampled resident; and failed to repair a worn recliner, resulting in an uncleanable surface, for 1 (#65) of 43 sampled residents. This deficient practice had the potential to increase the transmission of infectious agents for the residents. Findings include: 1. During an observation and interview on 7/17/24 at 11:16 a.m., staff member H was observed providing a wound treatment to resident #86's sacral pressure ulcer. Staff member H did not wear a gown when performing care on this wound. Staff member H said gowns would only need to be worn for tube feedings and catheters. When asked directly, staff member H said she would not need a gown with pressure ulcers because there would not be a splash onto the nurse. During an observation and interview on 7/17/24 at 1:20 p.m., staff member H said staff would wear a gown for tube feeding and catheter care. Staff member H…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure safe and proper operation of the kitchen equipment (the oven, dessert refrigerator, cooks' refrigerator, and ice machine). This deficient practice had the potential to affect any resident receiving food from the kitchen when the equipment is used for the preparation or storage of food. Findings include: During the initial tour of the kitchen, on 7/15/24 at 12:25 p.m., there were no paper towels in the dispensers, located near the two sinks, outside of the kitchen, in the serving area. The ice machine was warm, and there was no ice present. Kitchen staff stated the ice machine did not work. The dessert refrigerator was warm, and there were several cans of unopened V8 juice in it. During an observation and interview on 7/16/24 at 2:12 p.m., there were still no paper towels in the dispensers near the two sinks in the serving area. The ice machine was still not working. The dessert refrigerator was still warm and not working. The ovens below the gas stove were not working and were being used for storage.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to adhere to infection control practices for transmission-based precautions during a COVID-19 outbreak for 1 (#11) of 15 sampled residents. This deficient practice had the increased potential to spread COVID -19 in the facility. Findings include: During an observation on 10/25/23 at 7:40 a.m., a room off of the main entrance, and close to the dining room, had the doors open, and a printed sign which showed, employees only. Five used BINAX COVID-19 test swabs were on the counter. A trash can had a red biohazard liner and testing materials, gloves, and paper towels had overflowed on to the floor. During an observation on 10/25/23 at 9:10 a.m., the five BINAX COVID-19 swabs remained on the countertop, and used testing materials remained on the floor, overflowing the trash can. During an observation and interview on 10/25/23 at 10:45 a.m., staff member J was standing in the doorway of resident #11's room. The door was open to the hallway and staff member J was talking to the staff member inside resident #11's room.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, nursing staff failed to respect a resident's dignity by drawing a smiley face on a resident's buttocks when providing care for 1 (#10) of 15 sampled residents; failed to speak to a resident with respect while assisting with care for 1 (#12) of 15 sampled residents. Findings include: 1. Review of a facility reported incident, dated 9/3/23, showed a smiley face was discovered on resident #10's left buttock/hip area, when providing cares. Resident #10 was not upset about the incident and could not provide information on the incident. During an interview on 10/25/23 at 10:26 a.m., staff member N said she had checked resident #10's brief at 7:45 a.m. and it did not need to be changed, it was dry. Staff member N said she did not remove the brief to check, she just checked to see if the line on the brief had changed colors to indicate the brief was wet. Staff member N said residents were checked every two hours, and she had not checked resident #10 until she was asked to assist staff member O with resident #10, when the smiley face was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to obtain verbal or written consent, or complete an explanation of risks versus benefits with a resident's POA prior to giving an anti-psychotic medication, for 1 (#12) of 15 sampled residents. Findings include: A review of resident #12's physician's order showed an order had been placed on 10/25/23 at 7:11 p.m., for haloperidol 1 mg by mouth every 4 hours as needed for agitation and Give 2 mg by mouth every 4 hours as needed for agitation. Resident #12's medication administration record showed, resident #12 received haloperidol (Haldol) on 10/26/23 at 1:37 a.m. A review of resident #12's electronic medical record showed, no documentation was present for the risks versus benefits or documentation of a consent for the administration of an anti-psychotic medication was received from resident #12's POA prior to the medication administration. During an interview on 10/26/23 at 9:00 a.m., staff member B stated the interdisciplinary team does the risks and benefits for psychotropic medications. Staff member B stated nurses have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a resident had her call light with in reach for 1 (#10) of 15 sampled resident. This deficient practice caused the resident to yell out for help instead of using the call light. Findings include: A review of a facility reported incident to the State Survey Agency, dated 10/2/23, showed resident #10 was concerned about her cares, and having access to her call light and bedside table which contained her personal items. The report showed staff had been educated by staff members A and C on ensuring the resident's call light was accessible and with in reach. A review of a written staff statement in regard to the Facility Reported Incident on 10/2/23, showed: [Staff Name] and I went into [Resident #10's] room to check on her .call light was on the floor. During an observation and interview on 10/25/23 at 2:45 p.m., resident #10 was lying in bed wearing a hospital gown. Her head was positioned by the upper left corner of the bed and her feet were positioned by the lower right corner of the bed. Resident #10…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to investigate a facility reported incident thoroughly for a resident found, during cares, to have a smiley face on her buttock, and implement protective measures for the resident, for 1 (#10) of 15 sampled residents. Findings include: Review of a facility reported incident, dated 9/3/23, showed a smiley face was discovered on resident #10's left buttock/hip area, when providing cares. Resident #10 was not upset and laughed about the incident. Resident #10 was not aware of the smiley face and did not know how it had happened. During an interview on 10/25/23 at 10:26 a.m., staff member N said she had checked resident #10's brief at 7:45 a.m. and it had not needed to be changed, it was dry. Staff member N said she had not removed the brief to check, she just checked to see if the line on the brief had changed colors to indicate the brief was wet. Staff member N said residents were checked every two hours and she had not checked resident #10 until she was asked to assist staff member O. The smiley face was found at that time on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to limit an as needed anti-psychotic medication order to 14 days for 1 (#12) of 15 sampled residents. Findings include: A review of resident #12's electronic medical record showed a physician's order, dated 10/25/23, for Haloperidol tablet 1 mg. Give 1 mg by mouth every 4 hours as needed for agitation and Give 2 mg by mouth every 4 hours as needed for agitation. No stop date was identified on the medication order. Haloperidol is the generic name for Haldol, an antipsychotic. During an interview on 10/26/23 at 9:00 a.m., staff member B stated, PRN psychotropic medications were tracked by the interdisciplinary team every day to make sure there were proper diagnosis and time frames in place. A review of resident #12's medication administration record, dated 10/26/23, showed resident #12 had received haloperidol 2 mg by mouth at 1:37 a.m. A review of a facility document titled, Psychotropic Medication Use, dated July 2022, showed: .12. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, facility staff failed to provide a clean homelike environment, and clean bugs out of light fixtures, for 2 (#s 44 and 85), and the soiled light fixtures were noticed by the two residents; one specifically felt the bugs were creepy. Findings include: 1. During an observation on 6/20/23 at 7:40 a.m., the dome shaped lighting fixtures in the Sapphire unit hallway had numerous dead insects in them. During an interview on 6/20/23 at 8:05 a.m., resident #44 said the hallway lighting fixtures were, full of dead bugs and it is kind of creepy. During an interview on 6/21/23 at 10:26 a.m., resident #85 said the lighting fixtures in the Sapphire hallway needed to be cleaned out because there was a ton of dead bugs in them. During an observation on 6/21/23 at 12:00 p.m., the lighting fixtures in the Sapphire unit hallway continued to have numerous dead insects in them. During an interview on 6/21/23 at 12:04 p.m., staff member G said the maintenance department was responsible for cleaning the lighting fixtures in the hallways of the facility.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to provide adequate staffing to assist with resident care needs, with respect to answering call lights in a timely manner, for 8 (#s 26, 29, 60, 89, 93, 98, 158, and 159) of 20 sampled residents; and, failed to provide showers as scheduled for 10 (#s 6, 25, 26, 29, 44, 45, 60, 89, 93, and 98) of 20 sampled residents. Findings include: 1. During an interview on 6/20/23 at 8:15 a.m., resident #60 stated, There isn't enough help at night. I take insulin between 9:00 p.m. and 9:30 p.m., and sometimes it's pretty late if they don't have enough help. Sometimes we don't get showers because there isn't enough help, or they pull the scheduled help to work somewhere else. During the interview, staff member O walked in to greet the resident. Resident #60 stated, Where have you been? Staff member O responded, I have been pulled to another wing again, but hopefully I will be back soon. As she left, resident #60 stated, She (staff member O) is our bath aide, and this is exactly why people don't get showers on a regular basis here. Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, facility staff failed to maintain proper hand hygiene practices for 3 (#s 20, 21 & 70) of 5 sampled residents; clean and disinfect sit-to-stand lifts after use for 2 (# 20 and 21) of 2 sampled residents; failed to maintain a documented infection prevention surveillance program; failed to maintain a water management program to minimize the growth and spread of waterborne pathogens; and, failed to address unsanitary conditions in resident bathrooms, for 3 (#s 35, 45, and 89) of 7 sampled residents. Findings include: 1. During an observation on 6/20/23 at 8:14 a.m., resident #21's call light was on, and she was loudly asking to get up. Staff member V stated she still could not find her CNA. Resident #21 stated she had to meet someone in less than an hour. Resident #21 stated, I need help to get up. Staff member V told resident #21, I'll go find your CNA, your lights on, right? Resident #21 stated, I need to meet physical therapy at 9, I'm not worried about breakfast. At 8:20 a.m., staff member W arrived in resident #21's room. Staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a Significant Change MDS Assessment, for 1 (#105) of 2 sampled residents, who received hospice services. Findings include: Review of resident #105's medical record showed a physician order, dated [DATE], ordering hospice services for resident #105. Review of resident #105's medical record showed no MDS updates from [DATE] through [DATE]. Review of resident #105's medical record showed an MDS entry on [DATE] with coding reflecting the resident was deceased . During an interview on [DATE] at 12:45 p.m., staff member N stated a Significant Change MDS Assessment was not completed for resident #105. Staff member N also stated she did not recall why the Significant Change MDS was not completed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff were competent in providing care and services for 1 (#108) of 2 sampled residents to prevent the worsening of facility aquired pressure ulcers; and failed to ensure direct care staff had the education to address cleanliness of resident bathrooms and for necessary cleaning, for 1 (#35) if 2 sampled residents. Findings include: 1. Review of resident #108's EMR, dated 4/10/23 to 5/18/23, showed staff member H was in charge of pressure ulcer care and treatment for the resident during his stay in the facility. Resident #108 developed seven pressure ulcers after he was admitted on [DATE]. The pressure ulcers worsened, and the resident's overall condition deteriorated. Resident #108 passed away on 5/18/23. During an interview on 6/21/23 at 4:30 p.m., staff member A stated [staff member H] had been suspended and removed from the position. Staff member A stated the facility had made attempts to address staff member H's wound…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.