Montana Mental Health Nursing Home

Based on interview and record review, the facility failed to ensure resident medical record documentation was dated appropriately, labeled with the resident's information, and completed in entirety, for 4 (#s 11, 43, 60, and 66) of 29 sampled residents. Findings include: Incomplete Medical Record Documenation: 1. Review of resident #11's hard-copy POLST form, showed: - In the section for the person preparing the form and date section, the form was incomplete for the person preparing the form and the form was not dated when signed by the resident's legal decision maker. - The section for the provider phone number was incomplete. 2. Review of resident #43's hard-copy POLST form, showed: - In the mandatory section, where the signature was for the person completing the form, was blank. - The phone numbers for the person completing the form, and the physicians phone number, were incomplete. Resident #43 said she remembered being asked about code status by the staff at the facility. 3. Review of resident #60's hard-copy POLST form, showed: - In the mandatory phone number section, the form…

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 the guardian of a transfer to the emergency department, for 1 (#9) of 29 sampled residents. Findings include: Review of Emergency Department Reports from [Hospital] for resident #9, dated 10/20/24 at 11:34 p.m., showed the resident was admitted to the emergency department on 10/20/24 at 9:49 p.m. Review of resident #9's medical record lacked documentation that showed the resident's guardian was notified of the transfer to the emergency department on 10/20/24. During an interview on 10/23/24 at 1:47 p.m., NF1 stated she was not notified of the transfer to the emergency department on 10/20/24. During an interview on 10/23/24 at 3:40 p.m., staff member I stated the resident's guardian should have been notified when the resident was transferred to the emergency department. Staff member I stated the guardian for resident #9 was not notified of the 10/20/24 transfer to the emergency department. Review of the facility's policy, Scope of Social Services, revised 2/6/2023, showed, .Procedure: . D. Family Contact: . Contacts…

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 record review and interview, the facility failed to implement an effective discharge planning process for 1 (#67) of 1 sampled resident, who left the facility Against Medical Advice. Findings include: A review of court documents, dated [DATE] showed resident #67 was required to stay at the facility due to a court commitment which showed he was to be there for a minimum of 90 days. A review of resident #67's medical record showed an admit date of [DATE]. A review of nurse's notes, dated [DATE], showed resident #67 did not want to remain at the facility and was exit seeking. A review of nurse's notes, dated [DATE], showed resident #67 wanted to go home. A review of case management notes, dated [DATE], showed resident #67 wanted to return home. A review of the interdisciplinary team admission assessment, dated [DATE], showed the resident#67's primary mode of locomotion was a wheelchair. A review of a note written by the nurse summarizing the nurse practitioner's visit, dated [DATE], showed resident #67…

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 1 (#43) of 29 sampled residents was administered oxygen at the rate the physician had prescribed, and ensure respiratory equipment was maintained in a manner of acceptable parameters. Findings include: During an observation on 10/22/24 at 8:59 a.m., resident #43 was observed using oxygen per a nasal cannula connected to an oxygen concentrator. The oxygen cannula was lying on the floor, and the nose pieces were directly in contact with the floor. The oxygen concentrator was turned on at a rate of two and one-half liters per minute. The oxygen air inlet filter, on the right side of the machine, had a fine layer of gray particles present. The air inlet filter, on the left side of the machine, had a heavy layer of particles and hair-like substance present. Resident #43 said she did not know there was even a filter on the other side, and she had not cleaned it. Resident #43 took the filter and was observed to peel the layer of debris off the filter. Review of a physician's order written on 5/24/23, showed…

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 protect a resident's right to privacy for 1 (#2) of 2 residents sampled for hoarding tendencies. This deficient practice caused the resident mental anguish and distrust of her caregivers. Findings include: During an interview on 4/8/24 at 2:33 p.m., NF1 stated there had been an incident where staff went into resident #2's room while she was out of the building and did a room clean. She stated the facility didn't have a policy or procedure to dictate how the room clean should happen for consistency. She stated this surprise room cleaning had caused mental anguish for resident #2 when she returned to find all her stuff moved. NF1 stated the facility said they only went into throw away garbage, and she had to argue that everyone's definition of garbage is different. During an observation and interview, on 4/9/24 at 9:20 a.m., resident #2 was seated on her bed. She had stuffed animals lining the side of her bed that touched the wall. Her shelves were cluttered, but they appeared clean. There was no odor 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 investigate and protect other vulnerable residents from potential financial exploitation after 1 (#1), of 3 sampled residents, was approached by a staff member to become a financial payee. Findings include: Review of a facility reported incident, dated 3/7/24, showed NF2 was terminated. This was after resident #1 told her caseworker NF2 offered to become her financial payee. Review of the investigation showed there had been some concerns brought forth by a former coworker of NF2 about NF2's relationship with resident #1. These concerns were voiced when NF2 started working at the facility in September 2023. As a result of these concerns, NF2 was never scheduled to work on the wing where resident #1 resided. During an interview on 4/9/24 at 11:40 a.m., staff member A stated NF2 was never scheduled with resident #1. She stated they were monitoring NF2 to make sure she was not having payee conversations with other residents. Staff member A stated they had considered the September information from the former coworker about NF2…

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 follow professional standards related to a resident's hoarding behavior and interventions, for 1 (#2) of 2 residents sampled for hoarding tendencies. This deficient practice resulted in a resident's mental anguish including crying, distrust of staff, and fear of leaving her room. During an interview on 4/9/24 at 9:20 a.m., resident #2 stated staff had gone into her room when she was out of the facility and cleaned it out. She stated she was missing items like a Starbucks cup, a card from her sister, and a small pencil she liked to write with. Resident #2 stated these things were not on the ground or creating any type of tripping hazard. Resident #2 stated she was bothered because she had trusted staff and had been taken by surprise. During an interview on 4/9/24 at 10:15 a.m., staff member B stated they had been told by staff member E the best practice for a hoarder was to just go in the space and clear out the trash. It had been decided to do the cleanup while the resident was out of the facility to reduce her anxiety.…

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 update and revise care plans for 2 (#'s 13 and 43) of 21 sampled residents. This deficient practice did not show updated problems or interventions that would give staff the correct information to properly care for the residents. Findings include: 1. A review of resident #13's care plan, with a date of 8/23, showed, resident #13 had had a scratch to his chest, with an intervention for weekly skin checks by LN (Licensed Nurse). During an interview on 11/7/23 at 9:10 a.m., staff member E stated resident #13 did not have any skin concerns or scratches even though his care plan stated he did. A review of resident #13's weekly skin checks, dated 7/1/23-9/30/23, showed no mention of any scratches or skin concerns. 2. During an observation on 11/7/23 at 12:10 p.m., resident #43 was sitting in his wheelchair, leaning far to the right, at the dining room table. Staff member F sat down and fed resident #43. Resident #43 was not repositioned in his wheelchair prior…

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 safeguard a resident from recurring aspiration pneumonia for 1 (#43) of 21 sampled residents. The resident was admitted to the hospital on three occasions for aspiration pneumonia. Findings include: During an observation on 11/7/23 at 12:10 p.m., resident #43 was sitting in his wheelchair, leaning far to the right, at the dining room table. Resident #43 was not repositioned in his wheelchair prior to being fed by staff member F. Resident #43 coughed throughout lunch. No interventions were observed from staff in the dining room. During an interview on 11/7/23 at 2:16 p.m., Staff member F stated, I know what the signs of aspiration are because I have been a CNA for so long. If I noticed anything I let my nurse know. During an interview on 11/7/23 at 2:18 p.m., staff member E stated she had not been notified that resident #43 was coughing in the dining room and she was not aware that resident #43 should be monitored for signs or symptoms 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 interview and record review, the facility failed to follow a dietician's recommendation for a resident with severe weight loss for 1 (#28) of 1 resident sampled for weight loss. Findings include: Review of resident #28's weight and height record, dated February 2023- November 2023, showed: - May 2023 the resident weighed 100 lbs. - June 97 lbs. - July 101 lbs. - August 94 lbs. - September 89 lbs. - October 87 lbs. - November 1, 2023, the resident weighed 86 lbs. This represented a 14% severe weight loss over six months. Review of resident #28's dietary note, dated 8/8/23, showed, the resident was being monitored for unplanned weight loss. Recommendations included: - Start 60 cc med pass supplement TID - Weigh weekly - Offer magic cup at lunch and dinner - Notify provider and POA of significant loss . Review of resident #28's weight and height record, dated February 2023- November 2023, showed the resident was being weighed monthly. There were no documented weekly weights after the August 2023 note. During an interview on 11/8/23 at 8:07 a.m., staff member C stated weekly…

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 educate and complete skill competencies for staff in the areas of feeding and aspiration for 1 (#43) of 21 sampled residents. Findings include: During an observation on 11/7/23 at 12:10 p.m., resident #43 was sitting in his wheelchair, leaning far to the right, at the dining room table. Staff member F sat down and fed resident #43. Resident #43 was not repositioned in his wheelchair prior to being fed. Resident #43 coughed throughout lunch. During interviews on 11/7/23 at 3:30 p.m., staff members E and F stated they had not received any education on aspiration precautions. Staff member F also stated she did not know who to talk to if the nurse could not answer her questions. Staff member E stated she was not aware resident #43 had problems with aspiration. During an interview on 11/7/23 at 3:36 p.m., staff member I stated she was not sure if any interventions were in place for resident #43's aspiration issues. A request for staff education, skills competencies, and policies on feeding and signs and symptoms 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 interview and record review, the facility failed to ensure missing resident dentures were reported to the IDT and investigated/replaced for 1 (#28) of 1 sampled resident. Findings include: During an observation on 11/7/23 at 8:21 a.m., resident #28 was in the dining room for breakfast. She was spooning around her pureed food while waiting for assistance. She had no natural teeth or dentures present. Review of resident #28's care plan, with a revision date 8/23, showed the resident had upper and lower dentures, but they were currently missing. During an interview on 11/7/23 at 12:37 p.m., staff member I was not aware resident #28's dentures were missing. During an interview on 11/8/23 at 8:07 a.m., staff member C stated she was not aware resident #28's dentures had been missing. During an interview on 11/8/23 at 8:38 a.m., staff member C stated the missing dentures had not been reported and the only documentation she could find was a nursing note. She stated resident #28 was not able to be refitted for dentures due to her inability to tolerate the molding procedure. 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 provide a pneumovax vaccination for 1 (#64); and failed to have a signed declination in the medical record for 1 (#13) of 21 sampled residents. This deficient practice had the potential to cause an increased risk of infection during pneumonia and influenza season. Findings include: 1. A review of resident #64's paper medical record, showed resident #64 was admitted into the facility on 4/11/23. A review of a facility document titled, [Facility Name] Immunization Record, showed resident #64 had not been offered the pneumonia vaccine, Pneumovax. During an interview on 11/8/23 at 8:13 a.m., staff member D stated, I have not offered this to him yet. I was trying to get other vaccines caught up first. 2. A review of resident #13's paper medical record, showed no declination was on file for the 2023 influenza vaccine. During an interview on 11/7/23 at 4:30 p.m., staff member D stated, There is no declination (for resident #13), I have emailed the physician twice to get it. A review of a facility document titled, [Facility Name]…

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 protect 1 resident (#1) of 22 sampled residents from staff to resident abuse, causing resident #1 to be shoved out of a chair onto the floor by a staff member. Findings include: Review of a facility document titled, Reportable Incident, dated 3/11/23, showed staff member I was working at the facility with resident #1. Staff member I was taking resident #1 to the shower room, staff member I asked resident #1 to get up from her chair and resident #1 refused. Staff member I shoved the back of the chair the resident was sitting in which caused the resident to fall out of the chair onto the floor. During an interview and observation on 8/15/23 at 2:07 p.m., resident #1 was not able to answer questions. Resident #1 was nonverbal and required two staff members interacting with her to keep her calm. Resident #1 was making repetitive sounds, and she was making a rhythmic sound hitting the chair with a toy she was holding. Staff member L stated the CNAs take turns taking care of resident #1. Staff member L stated…

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, a facility licensed nurse failed to uphold and provide competent nursing services, and administered an incorrect dose of medication after being advised it was an incorrect dose/process, to 1 (#18) out of 22 sampled residents, and the resident had a change in status. Findings include: Review of a facility document titled Medication Error Report Form, dated 12/11/22, showed staff member N gave resident #18 6.4 mg of Morphine instead of the ordered 4 mg of Morphine when he flushed the subcutaneous injection line with saline. Causing the resident to have decreased respirations and his oxygen saturations dropped below 90%. Review of the facility's root cause analysis form for the event showed two RN's advised staff member N not to flush the subcutaneous line per facility policy, but staff member N argued with them and did it anyway. The document showed staff member N did not chart all the doses of medication he gave to resident #18, and staff member N failed to place oxygen on resident #18 when he determined resident #18's respirations had decreased,…

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 have a system in place to notify the resident and the resident's representative, in writing, of transfers to the hospital for 4 (#s 1, 14, 31, and 41) of 4 sampled residents. Findings include: 1. During an interview on 8/16/22 at 3:05 p.m., staff member N stated resident #41's condition had decompensated over the past several months. She stated resident #41 had become more aggressive, agitated, and was exit seeking. Staff member N stated resident #41 was transferred to another facility on 7/19/22 for evaluation and stabilization. During an interview on 8/17/22 at 11:36 a.m., staff member B stated the process for an inter facility transfer was to notify the ombudsman and the resident's representative of the transfer. She stated a bed hold notice, in writing, would also be completed. During an interview on 8/17/22 at 11:47 a.m., staff member G stated he had only completed a bed hold notice, not a transfer notice for any transfers. During an interview 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 ensure staff had a COVID-19 vaccine, or an exemption or delay for the vaccine, prior to providing care, for 1 (staff member K) of 7 sampled staff members. This deficiency had the potential to increase the incidence of COVID-19 amongst residents and staff in the facility. Findings include: A request for COVID-19 staff vaccination documentation was made on 8/16/22 at 4:36 p.m. Record review of a facility provided document, imMTrax-Patient Vaccination View/Add, dated 8/16/22, showed staff member K received the first dose of COVID-19, mRNA vaccine on 3/29/22. Record review of a facility provided vaccine list for staff member K showed, COVID-19 vaccination of mRNA, 0.5ml intramuscular injection given on 3/29/22. Record review of a facility provided vaccination record for staff member K showed, Moderna, given on 8/17/22. This second vaccination was administered after documentation was requested. Record review of a facility provided staffing schedule, dated 7/30/22-8/26/22, showed staff member K worked 6:00 p.m. to 6:30 a.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, interview, and record review, the facility failed to ensure direct care staff implemented care planned interventions related to fall prevention for 2 (#s 5 and 14) of 7 sampled residents. Findings include: 1. During an observation on 8/16/22 at 8:57 a.m., resident #5 was in a group area, sitting at a table, and sleeping in a chair. The resident had a walker in front of her, with loose fitting socks, and a gait belt fastened around her midsection. During an interview on 8/16/22 at 3:41 p.m., staff member I stated the staff always assumed resident #5 would fall, and she had a history of falls. Staff member I stated the staff were careful with her when transferring her. During an observation on 8/17/22 at 8:00 a.m., resident #5 was sitting in a chair, at a table, in a group area on hall G. The resident was leaning to the left, with her eyes closed. The resident had non-slip socks on, with a gait belt around her waist, and a walker by her right side. Staff member H came to the resident, touched her arm to wake her up, and had her stand immediately. The resident 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 observation, interview, and record review, the facility failed to revise and implement effective interventions for a resident with declining ambulation ability. This failure resulted in injury to 1 (#14) of 1 sampled resident. During an observation and interview on 8/15/22 at 3:59 p.m., resident #14 was noted to have a healed wound in the middle of her forehead, near the scalp line. The resident stated she got the wound on her head when she fell. During an observation and interview on 8/16/22 at 2:43 p.m., resident #14 stated, I fell out of bed (this morning), I was trying to get up. Resident #14 had a new bandage and bruising above the left eye. During an interview on 8/16/22 at 3:55 p.m., staff member P stated resident #14 was walking around frequently and was involved in activities around three months ago, and had experienced a large decline recently. During an interview on 8/17/22 at 8:55 a.m., staff member L stated, [Resident #14] was super independent, but staff member L had noticed a decline in her ambulation. During an interview on 8/17/22 at 12:49 p.m., 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.

Based on observation, interview, and record review, the facility staff failed to identify and provide necessary care for a skin rash for 1 (#45) of 1 sampled resident. Findings include: During an observation and interview on 8/16/22 at 8:09 a.m., when resident #45 was asked if he had any sores on his skin, he lifted his shirt, and showed he had a rash on his abdomen. The rash was red, oval, and approximately 3 cm by 6 cm in size. Resident #45 stated the rash was a reaction he had from the metal in his belt buckle. Resident #45 stated he pulls his incontinence brief up, so his belt buckle did not touch his skin. He stated he did not know how long he had the rash, but it (rash) comes and goes. During an interview on 8/17/22 at 10:42 a.m., staff member E stated weekly skin checks were performed by the CNA during baths/showers. She stated the CNA would report to the nurse any skin issues observed. Staff member E stated nurses did not perform weekly skin checks on the residents. Staff member E stated nurses did not perform skin checks at all unless a CNA reported an issue. She stated 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.

Based on interview and record review, the facility failed to directly monitor and document the intake of meals for 1 resident (#1) of 3 sampled residents healing from a fracture. Findings include: During an interview on 8/16/22 at 8:06 a.m., resident #1 said she ate some of her meals, but was not hungry. During an interview on 8/16/22 at 2:26 p.m., staff member I stated resident #1 was in a failure to thrive situation since her return from the hospital and the surgical repair of her hip fracture. Resident #1 was offered food and hydration but would often refuse. Staff member I said resident #1 had been instructed regarding the need for additional protein to heal her hip fracture. Staff member I stated even though resident #1 had refused to eat, resident #1's intake should still have been documented. During an interview on 8/17/22 at 4:24 p.m., staff member J said resident #1 was eating in her room and her meal consumption should have been documented when she was done eating. The documentation would get missed due to a change of shift or the CNAs would all go down to the 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 ensure nursing personnel had the knowledge necessary for providing resident care regarding fall prevention and care plan interventions, after orientation for 1 (#5) of 7 sampled residents. Findings include: During an observation on 8/17/22 at 8:00 a.m., staff member H assisted a resident who was shaky when standing, and she sat on her walker. Staff member H then left the resident to search for a wheelchair, and the resident was assisted further by staff member A. Refer to F689 for more detail on the event. During an interview on 8/17/22 at 8:06 a.m., staff member A stated the resident should not have been allowed to sit on the walker because the seat was slanted and resident #5 could have slipped off the seat. Staff member A stated the facility needed to educate staff member H. During an interview on 8/17/22 at 8:30 a.m., staff member L stated all nursing and associated staff were responsible for looking in the resident's care plan to know what was included in the fall interventions. During an interview 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 observation, interview, and record review, the facility failed to dispose of floor stock expired medications. This deficient practice had the potential to affect all residents who utilized the facility's medication floor stock. Findings include: During an observation on 8/17/22 at 7:38 a.m., the A-wing medication cart had the following expired medications: - One a day multi-vitamin, expired 5/22, and - bisacodyl 5 mg, expired 3/22. During an interview on 8/17/22 at 7:38 a.m., staff member D stated medication aides checked for expired medications. She stated medication aides were not on the unit very much, so the responsibility would fall on the nurses to check for expiration dates. During an observation and interview on 8/17/22 at 8:07 a.m., the D-wing medication cart had a bottle of aspirin 325 mg in the drawer, which expired on 6/22. Staff member C stated medication aides and pharmacy personnel checked for expired medications on the units. Staff member C stated nurses checked for expiration dates before they gave medications. Review of the facility's policy titled,…

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 staff performed hand hygiene during toileting, and the handling of food for 1 (#8) of 17 sampled residents. Findings include: 1. During an observation on 8/17/22 at 7:41 a.m., staff member H was wearing gloves and assisting resident #8 with toileting. Staff member H used two wipes to clean the resident, then pulled up the resident's brief and pants. Staff member H then took off his gloves, and assisted the resident to her bed. Staff member H then wheeled the resident's wheelchair to her bedside, locked the wheels, and assisted the resident into the wheelchair. Staff member H wheeled the resident to the sink, wet a washcloth, and gave it to the resident to wipe her face. Staff member H then combed the resident's hair, and wheeled the resident out to the group area. Staff member H did not perform hand hygiene after taking his gloves off, or before he left the resident's room. During an interview on 8/17/22 at 7:47 a.m., staff member H stated he would normally perform hand hygiene after taking off his…

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.