Glendive Medical Center N H

Based on observation, interview, and record review, the facility failed to ensure the dietary manager completed a certification program approved by a national certifying body or had higher education in a related field. This had the potential to affect residents and their nutritional status or meal safety for those who consumed food prepared and served by the facility. Findings include:During the initial tour of the kitchen, on 9/8/25 at 11:56 a.m., no documentation of advanced training for the dietary manager was posted.During an interview on 9/9/25 at 3:45 p.m., staff members A, G, and K were present. Staff member G said he did not have the CDM certificate.During an interview on 9/10/25 at 8:50 a.m., staff member E and Q were present. Staff member Q said he coordinates nourishment for the facility. He assesses the residents and recommends diets and textures for the residents. Staff member Q said he does not complete any kitchen sanitation tours and does not go into the kitchen to monitor the dietary requirements. Staff member E said staff member K is the kitchen manager's…

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 clean and sanitary conditions were maintained throughout the kitchen and the dietary storage areas; fand failed to ensure kitchen staff labeled and dated food in the coolers. This deficient practice increased the risk for the development of foodborne illnesses and deficient practices related to sanitary conditions for all residents who received food from the kitchen. Findings include:During the initial tour of the kitchen, on 9/8/25 at 11:56 a.m., the following observations were made:-The coffee machine nozzles were soiled.-The juice machine nozzles and the plates behind the nozzles were heavily soiled with a sticky substance.-Three fans were observed in the kitchen, and all fans were coated with fuzzy brown material. One fan blew air directly on a food prep area, the industrial fan blew air directly into the kitchen, and the third fan blew air into the clean dish area. -Staff member L had her personal food and drink stored in the resident reach in refrigerator.-Chicken and ham soup base paste was open and 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 report allegations of resident abuse to the State Survey Agency within 24 hours of the incident for 2 (#s 13 and 34) of 15 sampled residents. Findings include:Review of the facility reported incident dated 9/11/24 at 8:40 a.m., showed a resident representative reported to social services resident #13's roommate (resident #34) had been making resident #13 feel uncomfortable by rubbing resident #13's thigh and groin area. The allegation of resident-to-resident abuse was not reported to the State Survey Agency until 9/11/24.During an interview on 9/11/25 at 8:10 a.m., staff member D stated she received a call from resident #13's representative on 9/11/24 requesting a potential room change for resident #13. Staff member D stated the residents representative stated resident #13 had felt uncomfortable with her roommate (resident #34) due to unwanted touching of resident #13's leg. Staff member D stated it was then reported to the State Survey Agency on 9/11/24. Staff member D stated during the facility's investigation it 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 complete a Significant Change minimum data assessment within fourteen days after the facility identified a major decline in 1 (#6) of 15 sampled residents. The decline had the potential to impact the resident's physical and health status. Findings include:Review of resident #6's nursing note, dated 6/28/25 at 4:04 p.m., showed resident #6 was diagnosed with a non-displaced tibial plateau fracture. The resident was to wear a knee immobilizer and was non-weight bearing for two to three months. Review of resident #6's MDS, with an assessment reference date of 5/8/25, showed the resident needed partial to moderate assistance with performing oral care, getting herself on and off the toilet, showering, removing her footwear, personal hygiene, toilet transfer, transfer from bed to chair, and moving from a sitting to a standing position. Comparing the minimum data assessment with an assessment reference date of 7/17/25, showed the resident had declined and needed substantial to maximum assistance. During an interview on 9/11/25 at…

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 update the comprehensive care plan for a resident who developed avoidable pressure ulcers for 1 (#6) of 15 sampled residents. Findings include:During an interview on 9/11/25 at 9:30 a.m., staff member C said she updated the care plans when needed and reviewed care plans quarterly. Staff member C said she was not sure how she failed to identify the wounds on resident #6's ankle which were caused by the immobilizer. Review of resident #6's nurse's note, dated 7/19/25 at 11:12 a.m., showed the brace on resident #6's right leg had rubbed an open area on the outer Achilles area on the ankle with some purple bruising related to pressure. Review of resident #6's care plan, dated 8/1/25, showed an open area to resident #6's right ankle below the ankle was identified. The care was not updated timely as the Bunny Boots were added to the care plan on 8/1/25, a delay of 13 days following the development of pressure ulcers on resident #6's ankle area. The care plan did not include the pressure ulcer to resident #6's right…

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 staff failed to have the necessary knowledge and skill set related to the proper monitoring and documentation of quality control checks for a blood glucose testing machine, and it was found a system was not in place for the checks. This deficient practice had the potential to affect all residents who require blood glucose monitoring, as inaccurate readings could lead to improper assessment, delayed interventions, or incorrect treatment decisions.During an interview on 9/10/25 at 9:40 a.m., staff member F stated a blood glucose control solution test was completed daily, but not on her shift. Staff member F stated she did not know where to find documentation showing a controlled test was completed on the glucose monitoring system.During an interview on 9/10/25 at 9:45 a.m., staff member B stated the blood glucose monitoring system was new and she was not sure if the controlled test was completed weekly or monthly. Staff member B stated she would need to review 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 ensure social services were provided to assist 2 (#s 19 and 26) of 15 sampled residents with emotional and psychosocial support following allegations of abuse. The deficient practice had the potential to cause emotional distress for the residents. 1. Review of a facility reported event, submitted to the State Survey Agency, on 10/4/24, showed resident #19 was spoken to harshly by a staff member. Review of resident #19's medical record progress notes, dated 10/4/24 through 10/25/25, failed to show any allegations of abuse, and there was no follow-up to the alleged incident of a staff member talking harshly to resident #19. There were not social service notes to determine if the resident had any negative outcomes from the event or if the resident was comfortable with care provided by the staff member. 2. Review of resident #19's nurse's note, dated 10/6/24 at 4:40 a.m., showed the resident was picking frequently at the skin on her face and chest, causing open areas. The behavior was difficult to direct. There were no social…

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 submit complete and accurate Payroll Based Journal information quarterly, for licensed nursing coverage 24 hours each day to the Centers for Medicare and Medicaid Services. Findings include: Record review of the Centers for Medicare and Medicaid Services report titled, PBJ Staffing Data Report, dated Fiscal Year Quarter 2, 2024 (January 1 - March 31), showed: . Metric . Failed to have Licensed Nursing Coverage 24 Hours/Day, Triggered . Record review of the facility timecards for the following dates: 1/1/24, 2/20/24, 2/27/24, 3/5/24, 3/19/24, and 3/26/24, showed licensed nursing staff in the facility 24 hours each day. During an interview on 7/31/24 at 1:44 p.m., staff member H stated the facility had licensed nursing coverage 24 hours each day. Staff member H stated the facility was able to identify a job code (LPN2) was missing from the file application. Staff member H stated when the facility's information was transferred electronically to the payroll-based journal the system did not recognize the job code (LPN2) and did…

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 update resident care plans when changes to the resident's care occurred for 4 (#s 13, 14, 24, and 137) of 19 sampled residents. Findings include: 1. During an observation and interview on 7/31/24 at 8:36 a.m., resident #137 was seen with an ostomy appliance on his stomach, and a white adhesive bandage located just below the resident's ostomy. Resident #137 also had a urinary drainage bag hanging from the bed frame. Resident #137 stated he had a small wound below his ostomy which was covered with a dressing because it drained on occasion. Staff member P pointed out the ladybug sticker on the resident's name plate which indicated the resident was on enhanced barrier precautions because of his ostomy, urinary catheter, and abdominal wound dressing. Staff member P stated she had to wear a gown if she changed the resident's wound dressing. Review of resident #137's care plan, dated 7/16/24, showed the resident had rectal cancer resulting in the placement of a colostomy and urinary retention necessitating a urinary…

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 a registered pharmacist performed medication regimen reviews at least monthly for 1 (#33); and failed to ensure the physician addressed the pharmacy recommendations and irregularities timely for 2 (#s 4 and 24) of 19 sampled residents. The facility also failed to maintain a policy and procedure for monthly medication regimen reviews which identified documentation required and the time frames for the steps taken by the pharmacist when an irregularity was identified. The deficient practice had the potential to affect all residents receiving medication at the facility. Findings include: 1. Review of resident #4's MRR, dated 4/18/24, showed staff member Q recommended a GDR for mirtazapine, paroxetine, and risperidone. The physician did not address the recommendation until 5/31/24, resulting in a six week delay (4/18/24 to 5/31/24). Review of resident #4's mood and behavior team note, dated 6/19/24, failed to show documentation a physician or…

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 implement a comprehensive, resident-centered care plan which identified the resident's history of recurrent urinary tract infections and the interventions related to prevention of urinary tract infections for 1 (#9) of 19 sampled residents. Findings include: During an interview on 7/29/24 at 1:40 p.m., resident #9 was sitting up in her recliner. Resident #9 stated she has a history of urinary tract infections and has been on antibiotics for them. Resident #9 stated she experienced frequency in the past when she was diagnosed with a urinary tract infection. During an interview on 7/31/24 at 8:54 a.m., staff member N stated resident #9 needed assistance with toileting and appropriate perineal care after urinating and was encouraged to increase fluid intake. During an interview on 7/31/24 at 9:20 a.m., staff member F stated resident #9 had received antibiotics for treatment of urinary tract infections. The resident was also started 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure orders for as needed psychotropic medications did not exceed 14 days unless the rationale was documented by the provider for 1 (#33) of 19 sampled residents. Findings include: During an observation and interview on 7/29/24 at 1:56 p.m., resident #33 was walking in the hallway using a front-wheeled walker. When asked what brought her to the facility, resident #33 stated her memory was not very good and she was not sure. No pacing or exit-seeking behavior was seen. Review of resident #33's medication orders, dated 7/7/24, showed an order for lorazepam 0.5 mg every four hours as needed for anxiety. The order was still in place and active as of 7/30/24. During an interview on 7/31/24 at 8:28 a.m., staff member F stated resident #33 became restless, began pacing or looking for her purse when she was anxious. Staff member F stated the resident responded well to redirection and distraction techniques. During an interview on 7/31/24 at…

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 record review, two licensed nursing staff members failed to follow the manufacturer's recommendations for an Unsulin Aspart FlexPen, when administering medications, for 1 (#22) of 1 sampled resident. This failure had the potential to affect all residents in the facility receiving insulin by a FlexPen. Findings include: During an observation on 8/15/23 at 9:33 a.m., staff member D administered four units of Insulin Aspart FlexPen into resident #22's right arm. Staff member D did not prime the Flexpen before administering the insulin. During an observation on 8/16/23 at 9:06 a.m., staff member E administered four units of Insulin Aspart Flexpen into resident #22's left arm. Staff member E did not prime the FlexPen before administering the insulin. Review of a facility document titled, Subcutaneous Injection Policy showed the following: Procedure: 1. Check physician's order. 2. Check patient allergies. 3. To prepare appropriate dose of medication: clean rubber stopper with alcohol. Attach pen safety needle to insulin pen. Turn dial to 2 units and prime needle…

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.