Blackfeet Care Center

Based on observation and interview, the facility staff failed to ensure staff adhered to accepted infection control standards, including proper hand hygiene and glove use, during a medication pass for 2 (#s 3 and 5) of 17 sampled residents. This deficient practice had the potential for an increased risk of the transmission of infections. Findings include:During an observation on 3/24/26 at 8:35 a.m., staff member H was observed at the medication cart preparing medications. Staff member H donned a pair of nitrile gloves without performing hand hygiene prior to donning the gloves. While wearing gloves staff member H touched multiple potentially contaminated surfaces including the medication cart, computer, computer mouse, personal hair, shirt pocket, medication keys, and door handles. Staff member H removed packaged medication cards and bottles and placed them on top of the medication cart and prepared the medications into a clear plastic cup. Staff member H doffed her gloves and donned a new pair without performing hand hygiene between glove changes.Staff member H pushed the…

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 complete thorough incident investigations and address psychosocial impacts of abuse for those affected, for (#s 3, 7, 31, 32, and 34) of 9 sampled resident abuse allegations and investigations. Resident #32 was then reportedly afraid, #31 was uncomfortable with the employee's actions and lack of follow up by the facility, and #3 was tearful during the investigation. Findings include: 1. Review of a Facility Reported Event, submitted to the State Survey Agency on 2/4/25, showed resident #34 reported NF3 refused to change her soiled brief. During an interview on 6/18/25 at 3:25 p.m., staff member B stated he investigated the incident. Staff member B stated NF3 was sent home pending investigation and CNAs were interviewed. Staff member B stated he determined the incident to be a personality conflict between resident #34 and NF3. Staff member B stated his investigation did not include interviews with any other residents cared for by NF3, and did not include an assessment of any psychosocial impact for 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, the facility failed to assess and update a care plan with interventions for wandering for 1 (#7) of 9 sampled residents. This deficient practice increased the risk of injury to resident #7 and increased the risk of lack of privacy for other. Review of a facility reported event, dated 3/20/25, showed resident #7 was wandering and opening and closing other residents' doors, causing other residents to become angry. Review of resident #7's electronic health record showed resident #7 had dementia, low vision, and was hard of hearing. During an interview on 6/18/25 at 10:16 a.m., staff member B stated, Interventions for resident #7 are to work with the doctor on medication management. We don't do a formal assessment of behaviors. During an observation on 6/18/25 at 2:05 p.m., resident #7 was observed wandering the halls in the facility. She went behind the nursing station and was grabbing items on the desk. During an interview on 6/18/25 at 2:15 p.m., staff member E stated, When she is wandering around or bothering others, we usually…

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 care and services for the assessment and identification of underlying cause(s) of behaviors displayed for a resident with dementia, for 1 (#7) out of 9 sampled residents. Findings include: Review of a Facility Reported Event, submitted to the State Survey Agency on 3/20/25, showed resident #6 hit resident #7 for opening and closing his door multiple times. During an interview on 6/18/25 at 10:16 a.m., staff member B stated, Interventions for resident #7 are to work with the doctor on medications. We don't do a formal assessment for behaviors. During an observation on 6/18/25 at 2:05 p.m., resident #7 was observed wandering the halls in the facility. She went behind the nursing station and was grabbing items on the desk. During an interview on 6/18/25 at 2:15 p.m., staff member E stated, When she (resident #7) is wandering around or bothering others, we usually give her a drink or take her outside. I think she just wants attention. I'm not sure if there are interventions documented for her. I would ask…

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 implement and follow enhanced barrier precautions (EBP) for 4 (#s 3, 9, 14, and 19) of 17 sampled residents; and failed to ensure staff member H adhered to standard precautions during medication administration via a tube feeding, by placing medications to be administered on an unclean surface without a protective barrier in place, for 1 (#14) of 2 sampled residents observed during enteral medication and nutritional supplement administration. Findings include: 1. Enhanced Barrier Precautions During an observation on 1/27/25 at 3:22 p.m., resident #19 was lying in bed and talked about her accident which caused paralysis. Resident #19 had a urinary catheter in place. No EBP signage was observed on the room door to alert staff of the precautions. No personal protective equipment (PPE), such as gowns, were observed in the room, outside of the room, or in the hallway. During an observation on 1/27/25 at 3:25 p.m., resident #9 was not present in her room. Resident #9 was supplied her medications and nutritional…

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 dignity and privacy of a resident was protected for 1 (#25) of 17 sampled residents. Resident #25 had a sign on the outside of her door which showed her name and instructions for the emptying of her nephrostomy tube bag. Findings include: During an observation of the outside of resident #25's door, on 1/29/25 at 2:40 p.m. and again on 1/30/25 at 8:00 a.m., the following sign was posted on the resident's door. [Resident's name] is requesting for her urine bag to be checked and emptied every two hours please and thank you. During an interview on 1/30/25 at 8:15 a.m., staff member B stated resident #25 had a nephrostomy tube. Staff member B stated the bag for the tube was emptied as needed. Staff member B stated the sign should not be on the outside of the resident's door. During an interview on 1/30/25 at 9:00 a.m., resident #25 stated the sign on the door for her nephrostomy tube bothered her because everybody could see it, and it had her name on it. Resident #25 stated a staff member put it up, but she…

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 report the findings of an alleged allegation of abuse to the State Survey Agency, within five days for 1 (#83) of 17 sampled residents. Findings include: A review of a Facility Reported Incident related to resident #83, showed an event which occurred on 5/23/24. The report showed, Security reports that resident states that she was assaulted outside of the facility by her son. Security went to alert charge nurse . Resident is considered an elopement because she did not sign out of the facility . During an interview on 1/29/25 at 2:17 p.m., staff member D stated the facility staff member responsible for incident reporting stated he did not submit his investigation into the incident. Staff member D stated the resident's family member tried to get the resident to come back into the facility. Staff member D stated she did come back one time, but after that she never came back, and the facility documented she left AMA (against medical advice). The facility failed to report the required 5-day investigation findings to the State…

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 the care and services for a nephrostomy tube were completed and documented in the medical record for 1 (#25) of 17 sampled residents. Resident #25 had a nephrostomy tube which required dressing changes. The facility failed to obtain orders for dressing changes for the nephrostomy tubing. The facility failed to document the care of the nephrostomy tube in the medical record. Findings include: During an interview on 1/30/25 at 8:15 a.m., staff member B stated resident #25 had a nephrostomy tube and colostomy. Staff member B stated the dressing change was as needed. Staff member B stated there were no orders for dressing changes for the nephrostomy tube. Staff member B stated any dressing changes should be documented in the medical record. During an interview on 1/30/25 at 8:28 a.m., staff member H stated there was not an order for changing the dressing on resident #25's nephrostomy tube. Staff member H stated the dressing is changed when the resident wants it changed which was every two to three days. 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 interview and record review, the facility failed to ensure staff had abuse training, while an investigation was in progress for 2 (#s 9 & 11) of 21 sampled residents. Findings include: Review of a facility reported incident reflected a sexual abuse allegation was reported to have occurred on 12/7/23 at 6:00 a.m. During an interview on 1/3/24 at 1:31 p.m. staff member B stated staff member F reported the allegation to her at 12:00 p.m., six hours after the allegation occurred. Staff member F had received the allegation from staff member H during morning report. During an interview on 1/4/24 at 7:27 a.m., staff member H stated he did not report the incident to the administration because he was not sure of what to think of what he observed, and did not want to be responsible for ruining others' lives, if he was not sure. Staff member H reported the incident to the oncoming nurse. Staff member H stated he suspected a sexual activity was occurring, but did not fully see the act in progress. During an interview on 1/4/24 at 7:42 a.m., staff member F stated she did not report…

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 ensure the code status for 3 (#s 3, 12, and 18) were consistent between the paper and electronic records; and failed to ensure a POLST was dated by the provider for 1 (#20) of 21 sampled residents. Findings include: 1. Review of resident #12's EMR dashboard, on [DATE], showed the resident's code status was CPR. In the resident's scanned documents in the EMR, the POLST showed the resident's code status was DNR, which was different than what was reflected on the resident's EMR dashboard. During an interview on [DATE] at 10:03 a.m., staff member G stated the resident's POLST information was kept in a book at the nurse's station. During an interview on [DATE] at 10:43 a.m., staff member F stated the facility's daily report sheets showed whether a resident had a DNR or full code (CPR) status. Staff member F stated the report sheet showed resident #12 had a DNR code status. During an interview on [DATE] at 10:45 a.m., staff member C stated she expected the…

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 prevent further potential abuse while an investigation was in progress for 2 (#s 9 and 11) of 21 sampled residents, and concerns related to the relationship between the two residents had been ongoing over an extended period of time. Findings include: Review of a facility reported incident, involving resident #s 9 and 11, reflected a sexual abuse allegation was reported to have occurred on 12/7/23 at 6:00 a.m. During an interview on 1/3/24 at 10:21 a.m., staff member C stated she was notified at 12:00 p.m. on 12/7/23, when staff member F told staff member C about the allegation of sexual abuse from resident #11 to resident #9. Staff member B stated residents #9 and #11 were separated at that time. Staff member C stated residents #9 and #11 did have contact on several occasions after the report was filed, but the facility notified the police and Adult Protective Services to address the contact. Staff member B stated no monitoring or checks were in place to ensure no physical contact occurred between resident #11 and other…

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 residents' tube feeding enteral nutrition formula met the caloric content ordered by the physician, for 3 (#s 4, 13, and 17) of 21 sampled residents. Findings include: During an observation and interview on 1/3/24 at 11:20 a.m., staff member F prepared medications for administration for resident #17. Resident #17's orders included Jevity 1.5 calorie. Staff member F prepared Jevity 1.2 calorie and administered the medications and Jevity 1.2 calorie formula via gravity feed. Upon request, staff member F reviewed the order with the surveyor and determined the order stated Jevity 1.5 calorie. Staff member F stated the facility only provided Jevity 1.2 calorie while she had been employed at the facility, since June 2023. Staff member F then pulled up resident #4 and #13's charts and stated the orders were also for Jevity 1.5 calorie. Staff member F stated she would be contacting the physician for new orders since the facility did not have Jevity 1.5 calorie formula. During an interview on 1/3/24 at 11:41…

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 proper infection control and prevention was used during use of a communial glucometer machine for 1 (#24) of 21 sampled residents. Findings include: During an observation and interview on 1/3/24 at 11:20 a.m., staff member F returned from a glucose monitoring check, grabbed a caviwipe, and wrapped it around the glucometer, without cleaning it. Staff member F placed the glucometer on her cart. Staff member F stated, I always clean the glucometer this way, wait two minutes, and then put the glucometer back in the cart. After the glucometer was placed back in the cart, it was observed to be dirty around the area where the glucometer test strips went into the meter, between the buttons of the meter, and the print on the back of the glucometer was no longer legible. Staff member F stated, We don't really clean that part. I just rub the top a little. During an interview on 1/3/23 at 11:34 a.m., staff member C stated the glucometer should be thouroughly cleaned by rubbing all surfaces and placed on a wipe for…

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 report and submit incident findings, within the required five-day timeframe, for 1 (#13); and failed to submit an initial incident report within the two-hour timeframe for a possible crime, for 2 (#s 9 and 11) of 21 sampled residents. Findings include: 1. Review of a facility reported incident involving unexplained bruising on resident #13's legs, showed the incident was reported on 8/31/23. The report showed the findings were reported on 9/7/23, seven days later. During an interview on 1/3/24 at 1:25 p.m., staff member B stated staff member E was responsible for reporting incidents to the State Survey Agency, and sometimes staff member C would report as well. During an interview on 1/3/24 at 1:27 p.m., staff member E stated he reported incidents to the State Survey Agency, along with staff members B or C. Staff member E stated the date popped up on his screen, telling him when findings were to be submitted. Staff member E stated the facility tried to adhere to the five-day findings submission requirement. Staff member E…

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 accurately complete MDS assessments for 3 (#s 14, 21, and 22) of 21 sampled residents. Findings include: 1. Review of resident #14's Quarterly MDS, with an ARD of 11/28/23, showed the resident was on an anticoagulant. Review of the resident's medications showed the resident was not on an anticoagulant. Review of resident #22's Quarterly MDS, with an ARD 11/25/23, showed the resident was taking an anticoagulant. Review of resident #22's medications showed the resident was not on an anticoagulant. During an interview on 1/3/24 at 10:17 a.m., staff member D stated staff member C was responsible for completion of the medication portion of the MDSs, and the orders were to be looked at to determine which type of medication the resident was on. During an interview on 1/3/24 at 10:37 a.m., staff member C stated she was responsible for multiple portions of the residents' MDSs, including the medication portion. Staff member C stated she determined which medications the residents were on by looking at their MARs for the…

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 the care plan post incident for 1 (#13) of 21 sampled residents. Findings include: Review of a facility reported incident, dated 8/31/23, showed resident #13 had bruises on her legs that looked like handprints, in various stages of healing. The resident was found to have a susceptibility to bruising. During an interview on 1/3/24 at 10:02 a.m., staff member G stated resident #13 needed a Hoyer lift to transfer, and two people to take care of her. Staff member G stated resident #13 seemed to bruise easily, and she was not sure where the bruises came from. During an interview on 1/3/24 at 1:39 p.m., staff member C stated there was nothing added to resident #13's care plan, and there was no specific staff training, after the incident involving resident #13 and her bruising on 8/31/23. Staff member C stated, I can probably put that in (the care plan) to address the bruising. We talk about updating care plans during our at-risk and fall meetings. During an interview on 1/4/24 at 9:26 a.m., staff member B stated care plan…

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 develop a comprehensive care plan to address individual care and service needs for physical therapy for 1 (#21) of 21 sampled residents, related to the resident's ability to carry out his ADLs, without decline, and desire to return to another level of living. Findings include: During an interview on 1/2/24 at 1:57 p.m., resident #21 stated, It really bothers me they aren't doing anything to assist me in regaining my strength . It is my goal to get strong enough to go home . I struggle with eating and doing things on my own. During an interview on 1/3/24 at 10:08 a.m., staff member J stated the facility offered physical therapy most of the time, but there was not any physical therapy over the holidays. During an interview on 1/4/24 at 8:43 a.m., staff member C stated, I review the records quarterly to ensure therapy is documented and orders are being followed . I have noticed a slight decline in resident #21's ADL's . We do not have a restorative program in place at this time . Review of resident #21's electronic medical…

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 a psychotropic medication consent was obtained for 1 (#22) of 21 sampled residents. Findings include: During an interview on 1/3/24 at 2:54 p.m., staff member B stated resident #22 should have had a consent for her Clonazepam when she was admitted to the facility. During an interview on 1/4/24 at 9:28 a.m., staff member B stated psychotropic medication consents were staff member C's responsibility. Staff member B stated, We just kind of assumed they (the residents) had consent if they come in (to the facility) on the medication. Review of resident #22's MAR showed the resident was taking 0.5 mg of Clonazepam, once a day, every Monday, Wednesday, and Friday. The medication was started 5/11/23. Review of resident #22's MRRs, dated August, September, and October 2023, showed the pharmacist was requesting documentation for an informed consent for Clonazepam. On 1/3/24, staff member C provided the surveyors with a consent for resident #22's Clonazepam, dated 1/3/24. Review of the facility's policy, Psychotropic…

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 ensure a resident was assessed and treated in a timely manner by physical therapy for 1 (#21) of 21 sampled residents. Findings include: During an observation and interview on 1/2/24 at 1:57 p.m., resident #21 was lying in bed, and tried to sit up on his own multiple times, until he finally grabbed for the bedside table to pull his body to a sitting position. Resident #21 stated, It really bothers me they aren't doing anything to assist me in regaining my strength. I would like to go home . During an interview on 1/4/24 at 8:43 a.m., staff member C stated, [Resident #21] should be receiving physical therapy . I was sure that he was being seen weekly. Review of resident #21's electronic medical record showed the resident was admitted on [DATE], and physical therapy was ordered on 7/13/23. Review of resident #21's progress notes showed the physical therapist attempted to see resident #21 on 7/25/23. There was no other documentation in the…

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 signed consents for administered pneumococcal vaccines for 2 (#s 18 and 21 ) of 21 sampled residents. Findings include: Review of resident #18's immunizations showed the vaccine PCV20 was administered on 6/7/23. Review of resident #21's immunizations showed the vaccine PCV20 was administered on 6/22/23. During an interview on 1/3/24 at 3:05 p.m., staff member C stated the facility had a different infection preventionist during the time resident #18 and 21's PCV20 vaccines were given. The facility could not find the informed consents for the pneumococcal vaccines administered to residents #18 and #21. During an interview on 1/3/24 at 4:20 p.m., resident #18 stated she did not remember receiving education or signing a consent for the pneumococcal vaccine she received on 6/7/23. Review of facility's policy, Pneumococcal Vaccine, Revised March 2022, showed: . Before receiving a pneumococcal vaccine, the resident or legal representative receives information and education regarding the benefits and potential side effects…

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.