SWEET MEMORIAL NURSING HOME
Non profit - Corporation
42 Beds
Independent
Data: November 2025
Trust Grade
45/100
#46 of 59 in MT
Photo by Adam Murphy
Last Inspection: December 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Sweet Memorial Nursing Home in Chinook, Montana, has received a Trust Grade of D, indicating below-average quality and some concerns about care. It ranks #46 out of 59 nursing homes in the state, placing it in the bottom half, but it is the only option available in Blaine County. The facility is showing signs of improvement, with the number of reported issues reducing from 13 in 2024 to 6 in 2025. Staffing is a strength, achieving a rating of 4 out of 5 stars and a turnover rate of 38%, which is well below the state average, meaning staff are likely to be familiar with residents. However, there have been specific incidents of concern, such as a resident being able to wander outside due to inadequate supervision and staff failing to follow proper hand hygiene practices, which raises questions about infection control. Overall, while there are strengths in staffing, the facility still has significant areas that need attention.
- Trust Score
- D
- In Montana
- #46/59
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ○ Average
- 38% turnover. Near Montana's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Montana facilities.
- Skilled Nurses ✓ Good
- Each resident gets 56 minutes of Registered Nurse (RN) attention daily — more than average for Montana. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 42 deficiencies on record. Higher than average. Multiple issues found across inspections.
45/100
Bottom 23%
Needs review
13 → 6 violations
★★☆☆☆
2.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 13 issues
2025: 6 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (38%)
10 points below Montana average of 48%
Facility shows strength in staffing levels, fire safety.
The Bad
2-Star Overall Rating
Below Montana average (2.9)
Below average - review inspection findings carefully
Staff Turnover: 38%
Near Montana avg (46%)
Typical for the industry
The Ugly 42 deficiencies on record
1 actual harm
Aug 2025
6 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0745
(Tag F0745)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure the residents' highest practicable level of physical and psychosocial well-being was met for 2 (#s 13 and 34) related to medically r...
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Based on interview and record review, the facility failed to ensure the residents' highest practicable level of physical and psychosocial well-being was met for 2 (#s 13 and 34) related to medically related social services, of 16 sampled residents. Resident #34 felt isolated after her move, and #13 was upset over an abuse event; neither resident had a social service follow-up after the abuse event. Findings include:During an interview on 8/5/25 at 1:00 p.m., resident #34 said she did have some problems with another resident coming into her room. Resident #34 said the other resident was in her room, and stated, She squirted my eyes with some hand sanitizer. Resident #34 said she is still having problems with her left eye being blurry. Resident #34 said it made her feel very vulnerable. Resident #34 said she was moved to another area of the building, and she feels isolated now. Review of resident #34's progress notes showed no additional interventions related to social services or the resident's emotional well-being, following the physical abuse by resident #9. A review of Facility Reported Events showed resident #9 acted out on #34 on two occasions, on 3/11/25 and 6/11/25. During an interview on 8/6/25 at 12:09 p.m., staff member E said she was not even aware of resident #9 squirting hand sanitizer in resident #34's eyes. Staff member E said she only assesses the residents quarterly, or as needed, if she thinks it is necessary. Review of resident #34's medical record showed resident #34 had a (PHQ-9) Patient Health Questionnaire-9 completed on 1/7/25 and 7/1/25. The assessment was not completed quarterly, as stated by staff member D. The PHQ-9 is used to assess the resident for depression. 2. Review of resident #13's nursing progress notes dated 7/27/25 showed resident #13 was crying and upset. Resident #9 grabbed #13's face and and would not let it go. The nurse intervened and removed resident #9, but resident #13 was upset. The progress notes did not contain any information regarding interventions for the prevention of abuse or to address the resident being upset.During an interview on 8/7/25 at 8:20 a.m., staff member B said resident #13 is either usually very happy or she cries. The staff thought her crying was just part of her usual behavior, and did not correlate it to the other resident grabbing her face. Review of resident #13's progress notes reflected that there was no documentation to show the resident's psychosocial or emotional health was assessed specifically following the abuse that caused her to cry and become upset.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure vulnerable residents were free from physical abuse by another resident for 5 (#s 9, 13, 34, 73, and 98); and protect residents from ...
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Based on interview and record review, the facility failed to ensure vulnerable residents were free from physical abuse by another resident for 5 (#s 9, 13, 34, 73, and 98); and protect residents from misappropriation of medications for four (#s 34, 40, 57 and 67) of 16 sampled residents. Resident #9 was involved in 5 resident-to-resident altercations within the last five months. Findings include:1. Resident to Resident Abuse Events:a. Review of resident #13's nursing progress notes, dated 7/27/25, showed that resident #13 was crying and upset. Resident #9 had grabbed #13's face and would not let it go. The nurse intervened and removed resident #9, but resident #13 was instantly upset. The progress notes did not contain any information regarding interventions for the prevention of abuse for #13, by resident #9. During an interview on 8/7/25 at 8:20 a.m., staff member B said the event between residents #9 and #13 was not reported to the State Survey Agency as abuse. Staff member B said resident #13 is either usually very happy or she cries. The staff thought her crying was just part of her usual behavior. The facility did not identify this event as reportable event or put safety interventions in place for future prevention of abuse by #9.Review of Facility-Reported Incidents, dated 3/11/25 through 6/11/25, submitted to the State Survey Agency, showed resident #9 was responsible for three resident-to-resident altercations in which resident #9 was the aggressor and one altercation where resident #9, was the victim, due to her wandering into another resident's room. b. Review of resident #34's nursing progress notes, dated 6/18/25 at 5:08 p.m., showed the nurse reported another resident (#9) attempted to choke resident #34. The note showed this altercation had happened the week prior, when there was a singing activity in the activity room. Resident #9 initially had her hands on resident #34's shoulders, but when the staff asked her to stop, resident #9 put her hands around resident #34's neck. Review of resident #34's progress notes showed no further actions were taken to prevent abuse or altercations between the two residents to ensure #34 was safe. During an interview on 8/5/25 at 2:10 p.m., staff member H said she was in the activity area when resident #9 had her hands on resident #34's throat. Staff member H said she asked the resident to remove her hands, but resident #9 wouldn't let go. Staff member H said she had the certified nurse assistant help the residents. Staff member H said she reported to the charge nurse on duty. The nurse in charge told her to mind her own business. Staff member H said she did not tell anyone else and did not make a report. Staff member H was unaware who was designated as the facility abuse coordinator. During an interview on 8/6/25 at 8:37 a.m., staff member J said a report was given to the nurse regarding resident #9 choking resident #34 in the activity room. Staff member J could not identify the date the event occurred. Staff member J said the activity was a movie. Staff member J said resident #34 was sitting in a chair, and resident #9 was standing behind her, rubbing her shoulders. Resident #9 then began rubbing the front of #34's neck. Staff member J said she heard resident #34 say, Don't you're choking me. Record review of a Facility-Reported Incident, dated 6/11/25, submitted to the State Survey Agency, showed resident #34 was at an activity when resident #9 came up behind #34 and put her hands on resident #34's shoulders. When resident #9 was asked to stop, she put her hands around resident #34's neck and grasped her firmly by the neck. c. Review of the Facility Reported Incident, submitted 3/18/25, to the State Survey Agency, showed resident #9 was in resident #98's room. Resident #98 was upset with resident #9 taking things out of her room, and resident #9 was hit on the head by the door. Review of the investigative files for the incidents noted above, showed the facility failed to identify any possible triggers for the physical abuse perpetrated by resident #9. 2. Review of a Facility-Reported Incident, dated 6/11/25, submitted to the State Survey Agency, showed resident #13 wandered into resident #73's room. Resident #13 yelled at resident #73. Resident #73 then slapped resident #13. The Facility Reported Incident, with the section of the report showing corrective actions taken, was blank. There were no interventions put into place to prevent further abuse or altercations or for the protection of either resident involved. During an interview on 8/5/25 at 11:00 a.m., staff member B said if the staff observed the residents and saw what was happening, there would not be any further investigation. Staff member B said the facility event reports are the only documentation the facility uses for investigations. Staff member B said a review of the resident event reports is only completed once a week. 3. Misappropriation of Drugs: During an interview on 8/5/25 at 9:11 a.m., staff members B and C were present for the interview. Staff member B said starting in May 2025, resident #46 ran out of Seroquel about 14 days earlier than she should have. This was the first missing medication identified. Staff member B said she emailed the Drug Enforcement Agency for guidance but has not received any feedback from them. The investigation for the missing medications continued through 7/30/25. No prevention for the misappropriation or diversion of the drugs was initiated during the investigation. The resident's representative was not notified of the medications missing, which were paid for privately by the representative. Staff member B said the common denominator with all the missing medication was a nurse, and she was not terminated until 7/30/25. During the interview, it was reported that the nurse refused to write a statement related to the diversion for the facility. Review of a drug investigation packet, provided to the surveyor, showed potential drug diversion, with the investigation starting in May 2025. Refer to F609 Abuse Reporting
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
Based on interviews and record reviews, the facility failed to report initial allegations or final summaries of abuse or misappropriation of property to the State Survey Agency in the required timelin...
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Based on interviews and record reviews, the facility failed to report initial allegations or final summaries of abuse or misappropriation of property to the State Survey Agency in the required timelines established by the federal regulations, to meet the initial or final summary reporting requirements, for 7 (#s 5, 9, 13, 21, 34, 73, and 98) of 16 sampled residents. Findings include: 1. Review of a drug investigation packet, provided to the surveyor by the facility, showed that potential drug diversion occurred with resident medications, with the investigation starting in May 2025. The facility did not report the allegation or suspicion of drug diversion immediately at the time of the event. A review of the facility's Facility Reported Events showed they reported the drug diversion to the State Survey Agency on 7/30/25; they were delayed in reporting. During an interview on 8/5/25 at 9:11 a.m., with staff members B and C, staff member B said that starting in May 2025, resident #46 ran out of Seroquel, which was about 14 days earlier than she should have. These were the first missing medications, and the facility began investigating the situation. Staff member B said she emailed the Drug Enforcement Agency for guidance, but has not received any feedback from them as of the survey. Staff member B said she had not called the local law enforcement agency. Staff member B said the facility wanted to complete its medication audit before reporting anything to the police or the State Survey Agency. The facility did not report this information through a Facility Reported Incident to the State Survey Agency at the time of the initial allegation or suspicion of diversion. The facility did report the event to the State Survey Agency on 7/30/25. Review of a final drug diversion report the facility submitted to the State Survey Agency, on 8/8/25, showed the local police department was not contacted until 8/7/25, and the board of nursing was contacted on 8/7/25. 2. Review of the Facility Reported Incident, submitted to the State Survey Agency on 3/18/25, showed residents #9 and #98 were involved in a physical altercation. The final summary was not submitted until 3/26/25, eight days later, which did not meet the timely reporting requirements. 3. Review of the Facility Reported Incident, submitted to the State Survey Agency, on 5/3/25, showed residents #9 and #73 were involved in a resident-to-resident altercation. The final summary report was not submitted to the state survey agency until 5/12/25, but should have been sent in by 5/9/25. 4. Review of Facility Reported Incident, submitted to the State Survey Agency on 6/11/25, showed residents #13 and #73 had a physical altercation. This abuse report showed the altercation took place on 6/2/25, nine days before the report was submitted to the State Survey Agency, so the abuse event was not reported timely.5. Review of Facility Reported Incident, submitted on 6/16/25, to the State Survey Agency, showed residents #9 and #34 had an altercation on 6/11/25. The initial report of abuse was submitted to the State Survey Agency five days after the altercation. Therefore, the allegation was not reported timely per the federal regulations. 6. Review of an untitled facility report dated 6/11/25, showed resident #5 had a bruise of unknown origin on her left foot, right thigh, and left upper calf. Review of the Facility Reported Events for the facility showed the initial report for #5's bruising was submitted on 6/11/25 to the State Survey Agency. The final summary was not submitted until 6/19/25. During an interview on 8/5/25 at 1:50 p.m., staff member B said she talked to resident #5's son, and he said the resident always bruised easily. Staff member B said there were no further actions taken on the investigation into the causes of the bruising. Staff member B said she did not know why the final summary report sent to the State Survey Agency was late in being finalized.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to thoroughly investigate resident-to-resident altercations, alleged to be abuse, for 5 (#s 9, 13, 34, 73, and 98) and failed to...
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Based on observation, interview, and record review, the facility failed to thoroughly investigate resident-to-resident altercations, alleged to be abuse, for 5 (#s 9, 13, 34, 73, and 98) and failed to investigate bruising of unknown origin, for 1 (#5) of 16 sampled. Findings include:1. Review of an untitled facility report, dated 6/11/25, showed resident #5 had a bruise on her left foot, right thigh, and left upper calf. The bruises were of an unknown origin. A Facility Reported Incident was submitted on 6/11/25 to the State Survey Agency.Review of Resident #5's nursing progress notes showed there was no progress note written to clearly identify or describe the bruises or the causes for them in resident #5's medical record. During an interview on 8/5/25 at 1:50 p.m., staff member B said she had talked to resident #5's family member, and he said the resident always bruised easily. Staff member B said there was no further investigation completed as to the cause of the bruises. A thorough investigation into potential causes or interventions to prevent the unknown bruising or potential abuse was not completed. 2. Review of a Facility-Reported Incident, dated 6/2/25 and submitted to the State Survey Agency, showed that resident #73 yelled at and slapped resident #13. The incident findings, reported on 6/11/25, failed to show what the potential causes were for #73 slapping and yelling at #9, and there were no interventions to prevent future abuse. 3. Review of Facility-Reported Incidents showed abuse events involving resident #9 and other residents, including: a. The 3/11/25 incident showed resident #9 sprayed alcohol and sanitizer on resident #34's face. The investigation failed to show observations of resident #9's interactions with other residents, interviews with other residents and staff regarding the incident, and or any other similar interactions, or corrective actions implemented to protect resident #34 and other vulnerable residents from abuse. The medical record did not show the responsible party was notified. b. Review of Facility-Reported Incidents, dated 3/18/25, showed a physical altercation which occurred between resident #9 and resident #98. Resident #98 hit resident #9. The untitled facility risk report did not show the root causes, interviews obtained from staff or other residents, or any actions taken to investigate this event.c. Review of the Facility Reported Incident, submitted on 5/3/25, showed resident #9 punched resident #73 in her back. The facility provided an untitled risk event report, which was said to be the only investigation for the abuse event. The facility failed to investigate further to identify root causes or precipitating factors for the abuse, or to identify or implement interventions for future prevention of abuse. d. The 6/11/25 incident showed resident #9 choked resident #34. The investigation failed to show interviews with residents and staff regarding the incident, or any corrective actions or interventions implemented to protect resident #34 and other vulnerable residents from abuse by resident #9. e. Review of the Facility-Reported Incident, dated 6/11/25, submitted to the State Survey Agency, showed resident #9 came up behind resident #34 and put her hands on resident #34's shoulders and choked her.Review of resident #9's nursing progress notes, dated 6/11/25, showed no progress note was written for the resident on this day. A request was made on 8/4/25 for an investigation into the event between #9 and #34, and no investigation was received by the end of the survey. f. Review of resident #13's nurse progress notes dated 7/27/25 showed resident #13 crying and upset. Resident #9 grabbed her face and would not let it go. The nurse intervened and removed resident #9, but resident #13 was instantly upset. The progress notes did not contain information regarding precipitating factors or interventions for the prevention of further abuse. During an interview on 8/5/25 at 11:00 a.m., staff member B said, Well, if the staff observed the residents and saw what was happening, there would not be any further investigation. Staff member B said the facility reviews the event reports every week, and the event reports are what the facility uses for investigations. There isn't anything else for investigations, as the facility uses the risk management forms. During an interview on 8/7/25 at 8:20 a.m., staff member B said resident #13 is either usually very happy or she cries. The staff members thought her crying was just part of her usual behavior.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to revise and individualize comprehensive care plans to reflect the individualized needs or interventions to protect residents, for 6 (#s 5, 9...
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Based on interview and record review, the facility failed to revise and individualize comprehensive care plans to reflect the individualized needs or interventions to protect residents, for 6 (#s 5, 9, 13, 34, 73, 98) of 16 sampled residents, and the staff responsible for updating the care plans were not aware of what to add to the care plans for resident concerns related to abuse or protecting the resident. Findings include: 1. Review of resident #98's nursing progress notes, dated 7/5/25 at 3:34 p.m., showed the resident was found on the floor in the bathroom. Review of #98's untitled facility risk management report for the fall failed to show that a root cause was identified. The resident sustained a laceration to her face. The fall was not investigated for a cause, and there was no evidence that the facility reviewed the fall to prevent further falls. Review of resident #98's care plan with a revision date of 6/16/25, failed to show if the care plan was reviewed or updated related to the fall with injury on 7/5/25, or if interventions were identified to prevent future falls. 2. A review of resident #34's medical record showed the resident was the recipient of a physical assault by another resident on 3/11/25 and again on 6/11/25. Review of resident #34's care plan failed to show if any interventions were identified or added by the facility staff to ensure the protection of the resident, or if the resident was vulnerable to other residents for specific reasons. During an interview on 8/5/25 at 1:00 p.m., resident #73 said the resident who had been coming into her room does not bother her as much anymore, since she moved downstairs (to another wing of the facility). Resident #73 said the other resident threw alcohol on her face, and it got into her eyes, and she thinks her vision is blurrier since that time. Resident #34 said she feels more isolated in the new room, but she likes her own company. The resident's care plan had not been updated to address her vulnerability related to abuse and the physical aggression, or the isolation resident #34 is feeling since she moved rooms. 3. Review Facility-Reported Incident, dated 6/11/25, was submitted to the State Survey Agency, and it showed resident #5 had bruising of unknown origin to her her left foot, her right thigh and her left upper calf. A review of the resident's current care plan failed to include the risk factors for bruising and the interventions for managing the potential for bruising. During an interview on 8/5/25 at 1:50 p.m., staff member B said the care plan for #5 should have been updated. 4. Review of Facility-Reported Incident, dated 6/2/25, and submitted to the State Survey Agency on 6/11/25, showed residents #13 and #73 were involved in a physical altercation. Review of resident #13's care plan was not updated and did not show any potential problems with resident-to-resident altercations, either as the aggressor or the resident being personally abused.5. Review of resident #9's nursing progress notes, dated 5/25/25 at 6:21 p.m., showed resident #9 was observed coming back into the building after she eloped. The nursing note showed the staff observed resident #9 leave the building at 5:10 p.m., as well. Resident #9's care plan failed to include interventions to prevent elopement when attempting to follow her family or other people through the exit door, and the resident is cognitively impaired. 5. Review of the Facility Reported Incident, dated 5/2/25, and submitted to the State Survey Agency on 5/3/25, showed that resident #73 was involved in a physical altercation. Review of resident #73's care plan showed there were no interventions to prevent resident #73 from continuing to be involved in physical altercations. During an interview on 8/5/25 at 11:00 a.m., staff member B said the facility talked about making changes to the care plans during shift reports, but the care plans may not have been updated. Staff member B said she was not sure what could be done as there were many residents with dementia and the facility could not just restrain them. During an interview on 8/5/25 at 12:47 p.m., staff member D said she works part-time doing MDS assessments and care plans. Staff member D said the nurses will reach out to her when a care plan need to be updated. Staff member D said she also checks notes and incident reports weekly to identify things that need to have care plan updates on, and she will update care plans as needed. Staff member D said she believes she always gets notified when a care plan needs to be updated, and the care plans should be current. During an interview of 8/5/25 at 1:43 p.m., staff member E said she completed the behaviors, mood, psychosocial, communication, and dietary areas on the resident care plans. Staff member E said she only adds to the care plan to separate the residents if there has been an altercation. Staff member E said she did not know what to put on a care plan for the prevention of resident-to-resident abuse altercations. Staff member E said the interdisciplinary team does not work on the care plans as a group. Staff member E said half the time she is not in the facility when an altercation occurs, and she is not always informed of the issues. During an interview on 8/5/25 at 3:21 p.m., staff member I said investigations should occur after incidents to determine the cause of the event Staff member I said the investigations should include interviews with other residents and other staff. Staff member I said the care plans are updated by the MDS (minimum data set-care plan) nurse. Staff member I was not sure what other disciplines helped and what parts of the care plans those staff completed.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on interview, and record review, the facility failed to maintain a system to store and monitor controlled drugs was in a manner to contain sufficient detail to enable an accurate reconciliation;...
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Based on interview, and record review, the facility failed to maintain a system to store and monitor controlled drugs was in a manner to contain sufficient detail to enable an accurate reconciliation; and prevent diversion for 5 (#'s 34, 40, 46, 57, and 67) of 16 sampled residents. 1. Review of a facility investigation file showed the facility began an investigation for missing medications in May of 2025. 2. During an interview on 8/5/25 at 9:11 a.m., staff members B and C were present for the interview. Staff member B said beginning in May 2025, resident #46 ran out of Seroquel about 14 days earlier than she should have. This was the first missing medication identified. Staff member B said she emailed the Drug Enforcement Agency for guidance but has not received any feedback from them. 3. During an interview on 8/5/25 at 12:32 p.m., staff member B said the investigation continued through 7/ 30/25. Staff member B said the common denominator with all the missing medication was NF5. Staff nurse NF5 continued working and signing for narcotics until she was terminated 7/30/25, over two months after the first narcotic was missing. NF5 refused to write a statement for the facility. 4. Review of the narcotic sheets showed the facility used three-hole punched loose-leaf paper placed in a binder for the tracking log. The pages were not numbered chronologically and did not correspond to the card of narcotics. The process did not provide a security check. This system allowed the card of medication to be removed from the secured medication cart, and the notebook paper was easily removed. 5. The facility completed its investigation and found: - Resident #46 was missing Seroquel of unknown quantity, - Resident # 40 was missing 3 tablets of Alprazolam, - Resident #57 was missing 17 tablets of Mirtazapine,- Resident #67 was missing 73 tablets of Tramadol, and- Resident #24 was missing 153 tablets of Norco. 6. Review of a final drug diversion report the facility submitted to the survey agency on 8/8/25, showed the local police department was not contacted until 8/7/25, and the board of nursing was contacted on 8/7/25. 7. During an interview on 8/5/25 at 4:04 p.m., staff member M said she was the consultant pharmacist for the facility. She said she was made aware of the drug diversion only a couple of weeks ago but did not remember the exact date. Staff member M said she did not assist the facility in any way with the drug diversion investigation. Staff member M said she does not look at assessments to determine if residents are experiencing freedom from pain. Staff member M said the facility used to be pretty good, and they would call her, and she would help with narcotics destruction. This had changed, and now the facility uses two people to destroy narcotics. Staff member M said she did not monitor any narcotics reconciliation logs because there are two nurses counting and signing off between shifts. 8. The facility policy titled Controlled Substances from MED-PASS, revised November 2022, was provided. The policy showed, Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection and follow-up.If a major discrepancy or pattern of discrepancies occurs, or if there is apparent criminal activity, the director of nursing notifies the and administrator and consultant pharmacist immediately. The administrator, consultant pharmacist, and /or the director of nursing services determine whether other actions are needed, e.g. notification of police or other enforcement personnel. the medication regimen of residents using medications that have discrepancies are reviewed to assure the resident has received all medications order and the goal of therapy is met (example: a resident receiving a pain medication complaints of unrelieved pain). The consultant pharmacist or designee routinely monitors controlled substance storage records.
Dec 2024
13 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a vulnerable resident was free from physical a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a vulnerable resident was free from physical abuse by another resident for 2 (#s 29 and 30) of 19 sampled residents and supplemental residents. Resident #30 was struck on two separate occasions by resident #29. Findings include:
During an observation on 12/4/24 at 10:13 a.m., resident #30 was wandering throughout the facility, including going behind the nursing station. Resident #30 mumbled nonsensical words to herself, while ambulating alone, in the hallways. The resident was also wandering around the activity room during story time. Resident #30 would not sit down in the activity room or listen to the story being read.
Review of a Facility-Reported Incident, dated 10/17/24, submitted to the State Survey Agency, showed resident #30 was struck on her right shoulder by resident #29. The report showed resident #29 was having difficulty adjusting to her new environment. Neither of the residents were able to recall or discuss the circumstances surrounding the incident.
Review of the investigative file showed the facility failed to identify any possible triggers for the physical abuse perpetrated by resident #29 or how resident #30 would be protected from further abuse by resident #29.
Review of resident #30's admission MDS, with an ARD of 10/16/24, showed the resident was admitted to the facility on [DATE], had severe cognitive impairment associated with wandering behaviors. The wandering behaviors occurred daily and impacted other residents and staff at the facility.
Review of resident #30's care plan, dated 10/22/24, failed to show the resident's wandering behaviors made her vlunerable and placed her at an increased risk of abuse by other cognitively impaired residents, specifically resident #29.
During an interview on 12/4/24 at 2:16 p.m., staff member A stated she investigated the altercation between resident #29 and #30, which occurred on 10/17/24. Staff member A stated the incident did occur, but she felt it did not rise to the level of abuse because neither resident was able to remember the interaction, due to cognitive impairments, and resident #30 did not sustain an identifiable injury. Staff member A stated the facility identified the interaction as mistreatment rather than abuse.
Review of a second Facility-Reported Incident, dated 10/24/24, submitted to the State Survey Agency, showed resident #29 and resident #30 were sitting in the TV area across from the nursing station. The report showed resident #29 stood up, walked approximately eight feet toward resident #30. Resident #29 said, Why don't you get up and do something. Resident #29 then hit resident #30 on the top of the head and pulled her hair. Staff who were present immediately separated the residents and assessed resident #30 for any injuries. The facility failed to protect resident #30 from further abuse as evidenced by a second incident involving resident #29 striking resident #30.
Review of resident #29's care plan, dated 11/14/24, showed the resident was admitted to the facility on [DATE], was cognitively impaired, and was having difficulty adjusting to her new surroundings. The care plan identified the need to monitor the resident for potentially abusive interactions, but failed to identify resident #30 as a target of the potentially abusive interactions.
During an interview on 12/4/24 at 2:47 p.m., staff member B investigated the incident which occurred on 10/24/24. Staff member B stated she did not feel the interaction was abuse because neither resident could recall the incident and resident #30 did not sustain any injuries. Staff member B stated she believed the incident involved mistreatment rather than abuse.
Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, not dated, showed the purpose of the policy was to prevent any type of abuse (physical, verbal, mental, or sexual), including abuse by a resident towards another resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to provide a copy of the baseline care plan to the resident or resident's representative for 1 (#20) of 12 sampled residents. Findings include:...
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Based on interview and record review the facility failed to provide a copy of the baseline care plan to the resident or resident's representative for 1 (#20) of 12 sampled residents. Findings include:
During an interview on 12/2/24 at 3:08 p.m., resident #20 stated she did not receive any information or communication regarding her baseline care plan from the facility.
During an interview on 12/3/24 at 4:10 p.m., NF1 stated she had not received any communication from the facility regarding resident #20's baseline care plan.
Review of resident #20's medical record lacked documentation or evidence the baseline care plan was provided to the resident, or the resident's representative.
A request was made on 12/4/24 at 1:08 p.m. for documentation regarding the provision of a copy of the baseline care plan, which was to be given to resident #20 and NF1. There was no information or documentation provided prior to the end of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to create a comprehensive resident centered care plan for 1 (#20) of 12 sampled residents. Findings include:
During an observation on 12/2/24 ...
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Based on interview and record review, the facility failed to create a comprehensive resident centered care plan for 1 (#20) of 12 sampled residents. Findings include:
During an observation on 12/2/24 at 3:08 p.m., resident #20 was observed to have broken teeth in her lower jaw.
Review of resident #20's Social Service History & Initial Assessment, dated 9/10/24, showed, . 13. Are you having any dental problems? The response was marked, A. Yes . 13a. If yes, specify: broken and decayed teeth .
During an interview on 12/4/24 at 12 :47 p.m., staff member C stated when a resident was assessed to have broken or decayed teeth it would be care planned.
Review of resident #20's care plan, dated 9/12/24, lacked any documentation related to broken or decayed teeth or dental services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to identify and assess wheelchair positioning needs for 1 (#20) of 12 sampled residents. This deficient practice caused the resi...
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Based on observation, interview, and record review, the facility failed to identify and assess wheelchair positioning needs for 1 (#20) of 12 sampled residents. This deficient practice caused the resident discomfort due to a poor fitting wheelchair. Findings include:
During an interview on 12/2/24 at 3:08 p.m., resident #20 stated her wheelchair was too narrow, and the oxygen tank was positioned on the back of her wheelchair causing her discomfort.
During an interview on 12/3/24 at 10:12 a.m., when asked if she had informed anyone of the pain, resident #20 stated she had informed the CNAs.
During an interview on 12/4/24 at 11:23 a.m., staff member E said she had not had any communication or awareness of resident #20 caused by her poorly fitted wheelchair.
During an interview on 12/5/24 at 8:16 a.m., staff member L stated resident #20 had informed her of pain from the position of the oxygen tank on her wheelchair. Staff member L stated she had informed the maintenance department regarding the resident's wheelchair.
During an interview on 12/5/24 @ 8:47 a.m., staff member K stated, Today is the first time I am hearing of it (wheelchair maintenance).
During an interview on 12/5/24 at 8:51 a.m., staff member B stated a referral to therapy was made when there was a concern related to wheelchair fitting.
Review of resident #20's physical therapy initial examination, dated 9/10/24, showed resident #20 was not evaluated for proper wheelchair positioning.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure a resident received proper foot care for 1 (#20) of 12 sampled residents. The deficient practice resulted in the resid...
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Based on observation, interview, and record review, the facility failed to ensure a resident received proper foot care for 1 (#20) of 12 sampled residents. The deficient practice resulted in the resident experiencing pain due to a callus. Findings include:
During an interview on 12/2/24 at 3:08 p.m., resident #20 stated she had pain in her left foot because of a callus. Resident #20 stated the facility had done nothing about it.
Review of resident #20's progress note, dated 9/6/24, showed, . There is a callus located at mid plantar surface of the left foot. The foot clinic has been treating the callus most recently and resident states they wanted [podiatrist name] to evaluate the residual callus .
During an observation on 12/4/24 at 8:25 a.m., there appeared to be a callus on the bottom of resident #20's left foot.
Review of resident #20's physician order, dated 9/9/24, showed . Podiatry appointment/consult for callus on pad of L foot .
During an interview on 12/4/24 at 11:14 a.m., staff member D stated she scheduled resident appointments after the doctor entered an order for a consult. The consult was not scheduled to address the resident's foot callus.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an as needed antipsychotic medication was limi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an as needed antipsychotic medication was limited to 14 days unless evaluated by the physician, and reordered, for 1 (#29) of 5 sampled residents reviewed for unnecessary medications. Findings include:
During an observation and interview on 12/3/24 at 8:53 a.m., resident #29 was sitting in her room. She stated she liked to clean and cook. Resident #29 stated she knew she was not at home and did not know why. Resident #29 stated she lived alone prior to coming to the facility.
Review of resident #29's EHR showed the resident was admitted to the facility on [DATE], with diagnoses of dementia with other behavioral disturbance, anxiety, and depression.
Review of resident #29's physician orders, dated 9/20/24, showed an order for olanzapine 2.5 mg twice daily, as needed, for agitation. The order did not contain a duration or stop date.
Review of resident #29's MAR, dated September of 2024, showed the resident received six doses of olanzapine during September.
Review of resident #29's MAR, dated October of 2024, showed the resident received 16 doses of olanzapine during October.
Review of resident #29's MAR, dated November of 2024, showed the resident received five doses between 11/1/24 and 11/10/24. No doses of the olanzapine were documented as given from 11/10/24 through 11/30/24.
Review of resident #29's MAR, dated December of 2024, showed no doses of the as needed olanzapine were given during December.
Review of resident #29's pharmacy progress note, dated 10/21/24, showed the order for as needed olanzapine needed to be reordered every two weeks.
Review of resident #29's pharmacy progress note, dated 11/11/24, failed to show the olanzapine had been reordered every 14 days, as recommended, on the October monthly medication regimen review.
During an interview on 12/4/24 at 12:30 p.m., staff member E stated she was aware of the 14-day limit on as needed psychotropic medications. When asked why the olanzapine for agitation was not reordered after 14 days, staff member E stated she did not document she wanted the medication continued. Staff member E stated she thought the EHR system automatically discontinued as needed psychotropic medications after 14 days.
During an interview on 12/5/24 at 9:12 a.m., staff member F stated she was responsible for the monthly medication regimen reviews. Staff member F stated she was aware of the 14-day limit on as needed psychotropic medications. Staff member F stated she was not sure why she did not mention the need to reorder every 14 days on the medication review done in November.
Review of the facility's policy titled, Psychotropic Medication Use, not dated, showed, . For psychotropic medications that ARE antipsychotics: PRN orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to discard numerous containers of Half and Half stored in the facility's walk-in cooler, by the use by date. Findings include:
During an observa...
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Based on observation and interview, the facility failed to discard numerous containers of Half and Half stored in the facility's walk-in cooler, by the use by date. Findings include:
During an observation on 12/4/24 at 8:05 a.m., 11 cartons of Half and Half, with a use by date of 12/3/24, were observed on the top shelf, to the right of the entrance, in the walk-in cooler.
During an observation on 12/5/24 at 8:07 a.m., eight cartons of Half and Half, with a use by date of 12/3/24, were observed on the top shelf, to the right of the entrance, in the walk-in cooler.
During an interview on 12/5/24 at 8:09 a.m., staff member I said dairy products should have been discarded by the use by date.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure residents were screened for the pneumococcal vaccines (Prevnar 13, Prevnar 20, and PPSV23), and failed to offer or obtain a declinat...
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Based on interview and record review, the facility failed to ensure residents were screened for the pneumococcal vaccines (Prevnar 13, Prevnar 20, and PPSV23), and failed to offer or obtain a declination for the vaccines, for 2 (#s 16 and 27) of 5 residents sampled for immunizations (influenza, COVID-19, and pneumococcal). Findings include:
1. Review of resident #27's vaccination history, not dated, failed to show the resident received any pneumococcal vaccines.
During an interview on 12/5/24 at 9:27 a.m., staff member J stated she had only been responsible for resident immunizations for two months. Staff member J stated she did not have any other information regarding the offering, receipt, or declination of any of the pneumococcal vaccinations, since the resident's admission to the facility, on 10/30/23.
2. Review of resident #16's vaccination history, not dated, showed the resident received the Prevnar 13 vaccine on 1/14/20. The history form failed to show either the Prevnar 20 or the Pneumovax 23 was offered, given, or declined by the resident or their representative.
During an interview on 12/5/24 at 9:27 a.m., staff member J stated she had only been responsible for tracking resident immunizations for the previous two months. Staff member J was not able to explain why the recommended pneumococcal vaccines were not offered or declined by the resident.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to thoroughly investigate resident to resident altercations, alleged to be abuse, for 3 (#s 19, 29, and 30) of 19 sampled and su...
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Based on observation, interview, and record review, the facility failed to thoroughly investigate resident to resident altercations, alleged to be abuse, for 3 (#s 19, 29, and 30) of 19 sampled and supplemental residents. Findings include:
1. During an interview on 12/4/24 at 2:50 p.m., staff member A stated she submitted the initial report and findings for the incident, which occurred on 10/17/24. The incident involved an injury of unkown orgin for resident #19. Staff member A felt the injury of unknown origin found on resident #19's forehead was not from an unwitnessed fall. Staff member A stated if resident #19 had fallen, she would not have been able to get back in her wheelchair without assistance. Staff member A stated there were no reports of any unwitnessed falls for resident #19. Staff member A stated resident #19 and resident #29 were roommates on 10/17/24 when resident #29 was observed being the aggressor in an altercation with another resident. Staff member A stated she felt there was a possibility the injury to resident #19 was sustained during an unwitnessed altercation between resident #19 and resident #29. Resident #19 would not have been able to defend herself due to her physical and cognitive limitations. Staff member A stated resident #19 was moved to a different room, away from resident #29.
Review of a Facility-Reported Incident, dated 10/17/24 and submitted to the State Survey Agency, showed resident #19 was found to have a new bruise on her forehead, above her left eye. The incident findings, reported on 10/22/24, failed to show what the potential causes were for the injury to resident #19, including staff member A's feeling the injury may have been caused by resident #19's roommate, resident #29. The report submitted also failed to show resident #19 was moved to a different room for her safety.
2. Review of two Facility-Reported Incidents, dated 10/17/24 and 10/24/24, showed the physical altercations which occurred between resident #29 and resident #30. The 10/17/24 incident showed resident #29 was seen punching resident #30 in the right shoulder. The investigation failed to show observations of resident #29's interactions with other residents, interviews with other residents and staff regarding the incident and any other similar interactions, and corrective actions implemented to protect resident #30 and other vulnerable residents from abuse. The second incident occurred on 10/24/24 and showed resident #29 hit resident #30 on the top of the head and pulled her hair. The investigation failed to show interviews with residents and staff regarding the incident or any corrective actions implemented to protect resident #30 and other vulnerable residents from abuse by resident #29.
During an interview on 12/04/24 at 2:27 p.m., staff member B stated she investigated the altercation which occurred on 10/24/24. Staff member B stated both residents were cognitively impaired, and therefore it was only mistreatment rather than abuse by resident #29. Staff member B was not able to describe how residents were protected from abuse other than monitoring residents and separating residents if any incidents occur.
Review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, not dated, showed the follow-up investigation report contained sufficient information to describe the incident and any corrective action taken. The policy failed to show what was done when the incident involved residents rather than staff and residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During an interview on 12/2/24 at 3:08 p.m., resident #20 stated she had not been asked about her care plan, and she had not ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During an interview on 12/2/24 at 3:08 p.m., resident #20 stated she had not been asked about her care plan, and she had not contributed to the care planning process.
During an interview on 12/3/24 at 4:10 p.m., NF1 stated she had not been contacted or received any communication from the facility regarding resident #20's plan of care.
Review of resident #20's EHR lacked any documentation about the resident's or resident's representative involvement in the care planning process.
During an interview on 12/4/24 at 12:57 p.m., staff member B stated a care plan meeting was not held for resident #20 after the development of the comprehensive care plan.
Review of the resident #20's comprehensive care plan, dated 9/12/24, showed the resident was admitted to the facility on [DATE].
A request was made on 12/4/24 at 1:08 p.m., for the care plan meeting documentation and invite for resident #20. Nothing was received by the end of the survey.
Based on observation, interview, and record review, the facility failed to revise an individualized comprehensive care plan to reflect the discontinuation of a catheter for 1 (#18); the use of oxygen for 1 (#15); the use of bed rails for 3 (#s 12, 18, and 27) of 12 sampled residents; and failed to involve the resident or the resident's representative in the care planning process for 1 (#20) of 12 sampled residents. Findings include:
1. During an observation on 12/2/24 at 3:14 p.m., resident #18 was sleeping in her bed and did not have a catheter in place.
Review of resident #18's physicians order, dated 11/12/24, showed, Begin bladder training, Clamp for 2 hours, unclamp for 2 hours. After 24-48 hours, discontinue the foley catheter in the morning. Dx: Foley catheter, TTWB as 'ok'd' by ortho. [sic]
Review of resident #18's care plan, with a revision date of 7/29/24, showed, The resident has Foley Catheter: s/p repair of left leg fracture and impaired mobility. [sic]
Resident #18's comprehensive care plan failed to show the removal of resident #18's catheter.
2. During an observation on 12/2/24 at 2:43 p.m., resident #15 was seen wearing oxygen while in bed. The nasal cannula was on the resident's forehead and not in his nose. Resident #15 was sleeping at the time.
During an observation on 12/3/24 at 8:27 a.m., resident #15 was in his room and was having difficulty breathing, and the resident did not have oxygen on. Resident #15 stated he should have oxygen on.
Review of resident #15's care plan failed to show when and how much oxygen resident #15 should have been receiving.
3. During an observation on 12/2/24 at 2:37 p.m., resident #27's bed had two, half bed rails, attached to it.
During an observation on 12/2/24 at 2:49 p.m., resident #12's bed had two, half bed rails, attached to it.
During an observation on 12/2/24 at 3:14 p.m., resident #18's bed had two, half bed rails, attached to it.
Review of resident #s 12, 18, and 27's care plans failed to show the use of bed rails or their purpose.
During an interview on 12/5/24 at 7:51 a.m., staff member B stated, The interdisciplinary team is supposed to update the care plans. I have been doing them, and I know they are needing some work. The facility is looking to hire a new director of nursing, and I will be able to go back to doing MDSs and care plans. Yes, if a catheter was discontinued it should reflect that in the care plan and bed rails and oxygen should also be care planned.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5% for 3 (#s 5, 23, and 30) of 19 sampled and supplemental residents. The calc...
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Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5% for 3 (#s 5, 23, and 30) of 19 sampled and supplemental residents. The calculated medication error rate was 8.16%. Findings include:
1. Review of resident #30's MAR, dated 12/4/24, showed the resident was supposed to be receiving 1 ml (50 mg) of a gabapentin 250 mg/5 ml liquid, in the morning.
During a medication administration observation on 12/4/24 at 7:35 a.m., staff member G prepared the gabapentin medication for resident #30. The medication bottle had a label which showed the strength of the gabapentin was 250 mg/5 ml. Staff member G used a 1 ml syringe and filled the syringe to the 0.1 ml line. Staff member G put the 0.1 ml of gabapentin liquid into a drinking cup and added water. Staff member G gave the cup to resident #30, and the resident drank all the mixture. When asked what size syringe was used, staff member G pointed to a 1 ml syringe which was stored in the medication cart. After being shown the packaging for the syringe, staff member G stated, Oh. I'm sorry. So, I need to give another 0.9 ml. Staff member G then filled a 1 ml syringe to the 0.9 ml line, mixed it with water and administered the remaining 0.9 ml of gabapentin liquid to resident #30.
2. Review of resident #5's MAR, dated 12/4/24, showed the resident was supposed to receive vitamin B-12 - 5000 mcg in the morning.
During a medication administration observation on 12/4/24 at 7:46 a.m., staff member G removed one tablet from a bottle of over-the-counter vitamin B-12 - 500 mcg per tablet label. Staff member G administered the vitamin B-12 - 500 mcg tablet to resident #5.
During a follow-up observation and interview on 12/5/24 at 10:45 a.m., when asked to identify the correct medication bottle for resident #5's vitamin B-12, staff member H located the bottle of vitamin B-12 - 500 mcg per tablet. When asked to confirm the correct dose of vitamin B-12 to be given to resident #5, staff member H stated, I don't suppose we are giving 10 of these (500 mcg times 10 tablets equals 5000 mcg) to one resident.
3. During a medication administration observation and interview, on 12/5/24 at 7:48 a.m., staff member H stated she was holding two of resident #23's medications due to a systolic blood pressure less than 110 mmHg. Staff member H stated she was holding amiodarone 100 mg and furosemide 20 mg.
Review of resident #23's MAR, dated 12/5/24, showed a morning blood pressure of 106/56.
Review of a facility standing order, dated 2/22/22, showed, . 2. If the blood pressure systolic is <110 (unless otherwise noted) needs to have BP (medication) held, As well as lasix (furosemide) & bumex.
Review of resident #23's Medication Admin (administration) Audit Report, dated 12/5/24, showed the amiodarone 100 mg was given at 7:49 a.m., and the furosemide 20 mg, was given at 7:50 a.m. on 12/5/24.
During a follow-up interview on 12/5/24 at 10:46 a.m., staff member H stated she did hold the amiodarone and furosemide but must have forgotten to correctly document the medications were held. Staff member H stated she needed to go back into the medication administration module in the EHR and document the two medications as held because of a systolic blood pressure less than 110 mmHg.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to provide proper oversight for the use of personal refrigerators in a resident's rooms for 3 (#s 1, 3, and 4) of 3 sampled residents with perso...
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Based on observation and interview, the facility failed to provide proper oversight for the use of personal refrigerators in a resident's rooms for 3 (#s 1, 3, and 4) of 3 sampled residents with personal refrigerators. The deficient practice put any resident with a personal refrigerator at risk for consuming food not stored at safe temperatures and consuming outdated food. Findings include:
During an observation on 12/3/24 at 8:27 resident #4's personal refrigerator contained no means to measure the temperature of the refrigerator. The freezer contained an unidentified substance in a clear plastic bag that was not labeled or dated. The freezer had a thick layer of ice built up inside and outside of the freezer compartment. There was an unidentified food item wrapped in a napkin in the refrigerator door which did not have a label or date. There was a food item wrapped in brown deli paper with no label or date. There were two green, plastic bags, which contained what resembled fruit which were not labeled or dated.
A request was made on 12/3/24 at 1:10 p.m. for the facility's personal refrigerator policy. There was no information received prior to the end of survey.
During an observation on 12/4/24 at 10:00 a.m., resident #1's personal refrigerator did not have a temperature gauge inside of the refrigerator to measure the temperature. There was granola bar in an opened wrapper not dated or labeled.
During an observation on 12/4/24 at 10:04 a.m., resident #3's personal refrigerator did not have a temperature gauge to measure the temperature or to ensure the temperature was maintained at a safe level.
During an interview on 12/4/24 at 10:07 a.m., when asked who managed the personal refrigerators in resident's rooms, staff member M stated, I guess we (housekeeping department) do. When asked how it was managed staff member M stated the housekeeping supervisor did it. When asked what happened when the housekeeping supervisor was not in the facility staff member M stated, I don't know.
During an interview on 12/5/2024 at 10:07, staff member A stated she did not know how many residents had personal refrigerators in their room, and could not explain how they were managed for food safety.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility staff failed to perform hand hygiene when passing medications to residents for 3 (#s 13, 21, and 23) of 19 sampled and supplemental residents. Findings...
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Based on observation and interview, the facility staff failed to perform hand hygiene when passing medications to residents for 3 (#s 13, 21, and 23) of 19 sampled and supplemental residents. Findings include:
During an observation in the main dining room, on 12/5/24 at 7:45 a.m., staff member H administered medications to resident #13. After completion, staff member H returned to the medication cart and began the preparation of medications for another resident. Staff member H did not perform hand hygiene between residents.
During an observation on 12/5/24 at 7:48 a.m., staff member H prepared the medications for resident #23. Staff member H administered the resident's medications, returned to the medication cart, and began preparation of medications for another resident. Staff member H did not perform hand hygiene between residents.
During an observation on 12/5/24 at 7:55 a.m., staff member H prepared the medications for resident #21. After administering the resident's medications, staff member H returned to the medication cart and began preparation of medications for another resident. Staff member H did not perform hand hygiene between residents.
During an interview on 12/5/24 at 8:00 a.m., staff member H stated she periodically washed her hands. Staff member H stated she did not touch the pills with her hands, so did not have to perform hand hygiene between residents. When told she was observed touching the resident's eating utensils and dishes, when assisting them with eating during the medication pass, staff member H stated she should have been performing hand hygiene between residents.
Dec 2023
12 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, facility staff failed to identify and address dignity concerns for 1 (#16) of 19 sampled residents. Findings include:
During an observation on 12/4/...
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Based on observation, interview, and record review, facility staff failed to identify and address dignity concerns for 1 (#16) of 19 sampled residents. Findings include:
During an observation on 12/4/23 at 1:50 p.m., staff member I and staff member G were in the process of completing peri-care for resident #16. Resident #16 was lying on her right side; staff member G was in front of her, and staff member I was behind resident #16. Both staff members spoke to the resident, covered the resident with her comforter, and left the room. The staff members did not put a brief or pants on resident #16 prior to leaving the room.
During an interview on 12/4/23 at 1:52 p.m., resident #16 said she did not like not having bottoms on when she was in bed. Resident #16 said she had a couple of sores on her bottom, and staff would leave her in bed with no bottoms on.
During an interview on 12/6/23 at 3:37 p.m., staff member B said she was not aware resident #16 was embarrassed to not have bottoms on when she was in bed. Staff member B said staff left resident #16's bottoms off in order to leave the MASDs open to air.
Review of resident #16's medical record failed to identify any interventions related to the MASDs on the resident's bottom.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to accuately code a restraint on a resident's Minimum Data Set for 1 (#36) of 19 sampled residents. Findings include:
During an ...
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Based on observation, interview, and record review, the facility failed to accuately code a restraint on a resident's Minimum Data Set for 1 (#36) of 19 sampled residents. Findings include:
During an observation on 12/4/23 at 4:25 p.m., resident #36 was seated in a high-backed, reclining type wheelchair. Resident #36 had a seatbelt across her lap.
A review of the Significant Change Minimum Data Set, with an ARD of 10/3/23, showed: Resident #36 was not coded for any type of restraint in section P.
During an interview on 12/6/23 at 1:05 p.m., staff member B stated the restraint should have been coded on the MDS.
A review of a facility document titled, POINT CLICK CARE CP & MDS, with a revision date of 2/1/22, showed:
. The guidelines for the resident assessment are consistent with the requirements for the State-specified Resident Assessment Instrument (RAI) .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide on-going daily care and monitoring of indwell...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide on-going daily care and monitoring of indwelling urinary catheters based on recommended standards, which increased the risk of catheter associated urinary tract infections for 2 (#s 3 and 29) of 19 sampled residents. Findings include:
During an interview on [DATE] at 8:38 a.m., staff member L said she was not sure who was responsible for indwelling catheter assessments for residents. She thought it might be the treatment nurse but staff member B would be able to answer who was responsible.
During an interview on [DATE] at 9:19 a.m., staff member G said she was not sure who does the catheter assessments and documents them in the resident chart. Staff member G said she had never documented an assessment for a resident with an indwelling catheter and assumed the treatment nurse would do the assessment and it would be documented on the TAR. Staff member G reviewed resident #3's TAR and the foley catheter irrigation had not been documented for resident #3. Staff member G said she would check with the resident and the treatment nurse to see if it had been done. Staff member G said she was not sure when the vinegar solution for irrigation expired.
During an interview on [DATE] at 9:30 a.m., staff member B said the facility did not have assessments specific to residents with indwelling foley catheters. Staff member B said she did not have enough staff to do all of the assessment paperwork for residents daily. Staff member B said the catheter would be documented on weekly skin assessments and if the resident had a significant change.
During an observation and interview on [DATE] at 1:36 p.m., resident #3 said her catheter would get plugged and needed to be changed. Her catheter was flushed every morning when she got dressed for the day. Resident #3 said the urologist recommended a suprapubic catheter for her, but she had declined. Resident #3 said she gets urinary tract infections frequently and she had no symptoms. Resident #3 pointed out the irrigation supplies for her catheter. A bottle of normal saline with vinegar added, with a very loose top, was dated for [DATE] and initialed by the staff member who mixed solution. Resident #3 was not sure when the bottle of irrigation was mixed or if a new one was mixed daily.
Record review of a facility document, Vinegar Solution, not dated, showed:
-Mix 3 tablespoons of vinegar in 1 liter of cooled boiled water
-Insert 30-60mls into the bladder through the catheter with the syringe
-Let vinegar set in bladder for 20 minutes
-Flush catheter bag with the unused vinegar solution using 60ml syringe
-Reattach catheter bag
-Use solution once or twice a day until directed to discontinue .
Review of a facility policy, Catheter Irrigation Procedure, not dated, showed:
. Nursing Interventions
1. Catheter irrigation requires strict sterile technique to prevent bacteria from entering the bladder.
2. The end of the catheter and drainage tube and tip of the syringe must be kept sterile throughout the procedure.
2. During an observation on [DATE] at 8:06 a.m., resident #29 was seated in his recliner, in his room, the door to the room was open over halfway. Resident #29 was only wearing a shirt and his foley catheter drainage bag was hanging from his walker, above the level of his bladder.
During an observation and interview on [DATE] at 8:22 a.m., resident #29 was seated in his recliner, in his room. He was awake and had a foley catheter draining to a large drain bag, still hanging from his walker above the level of his bladder. Resident #29 said he had been waiting for someone to come change out his catheter drain bag so he could get dressed and go to breakfast with his wife.
Review of resident #29's history and physical dated [DATE], resident #29 had a history of urinary tract infections that caused him to have exit seeking behaviors.
Review of resident #29's care plan, dated [DATE] showed catheter interventions of monitoring for pain and discomfort and documentation of input and output. No individualized interventions of changing out his drain bag were documented. No personalized preference for a leg bag for day use, drainage bag for nighttime use, no interventions for washing his drainage bag were listed in the care plan, treatment administration record or the CNA tasks.
During an observation and interview on [DATE] at 1:24 p.m., staff member I said catheter care was provided for resident #29 when the foley drain bag was changed over to a leg drain bag. Peri care was provided with specific antiseptic wipes, green wipes that staff member I could not remember the name. Staff member I said an alcohol wipe was used to wipe the end of the drainage tube and the bag was flushed with vinegar water. The gallon of vinegar water was changed when the gallon bottle was empty. Staff member I was not aware of the concentration of the mixture or how it was mixed. A cap was then placed on the end of the drain tube to the bag and the drainage bag was placed in a linen bag that was attached to the handrail behind the resident's toilet. The gallon of irrigation was sitting in a plastic basin next to the toilet and on the floor. The gallon had no lid, was not dated, no initials were present, no solution concentration was written on a label, and the only label was for vinegar. The gallon was ¼ full. In the basin with the gallon was a paper drinking cup, wrinkled and appeared to have been used multiple times. Staff member I explained the flushing procedure, she removed a [NAME] syringe from the linen bag holding the urine drainage bag, showed how she would insert the syringe in the end of the drainage tube, without cleaning, pour the solution into the paper cup and then pour it into the [NAME] syringe. The drainage bag would then be drained, and a cap applied to the end of the tube. Staff member I did not know when the [NAME] syringe had been changed or when the paper cup had been changed. Staff member I did not know who was responsible for changing out the linen storage bag or when it had been changed or washed. Staff member I said she had been trained on the process by another CNA.
During an interview on [DATE] at 2:15 p.m., staff member G said she was not familiar with the protocol for the urine drain bag mixture. Staff member G said she did not know if the vinegar was diluted to flush the bag or if it was full strength.
During an interview on [DATE] at 3:49 p.m., staff member B said the facility had a lot of new staff and they would need some training.
Record review of a facility policy, Caring for Residents with Indwelling Catheters, revised [DATE], showed:
.To clean the leg bag and night drainage bag:
-After disconnecting bag, wash the bag that is not being used in soap and warm water.
-Rinse with warm water.
-Disinfect the leg bag with a mixture of white (distilled) vinegar and water.Mix 1 ¼ cups of white vinegar with 2 quarts of water. Rinse the bag well with this solution and do not rinse with water after using the vinegar solution.
-Clean and store catheter bags in the resident's bathroom.
Review of CDC recommendations, Guideline for Prevention of Catheter-Associated Urinary Tract Infections, updated [DATE], showed:
. III. Proper Techniques for Urinary Catheter Maintenance
.2. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor.
.E. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised.
.G. Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place. Routine hygiene (e.g. cleansing the meatal surface during daily bathing or showering) is appropriate.
.J. Routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags is not recommended.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to label a vinegar bottle with the date opened, the mixture concentration, and the individual mixing the concentration for 1 (#29) of 19 sampled...
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Based on observation and interview, the facility failed to label a vinegar bottle with the date opened, the mixture concentration, and the individual mixing the concentration for 1 (#29) of 19 sampled residents. Findings include:
During an observation and interview on 12/6/23 at 1:24 p.m., staff member I said catheter care was provided for resident #29 when the foley drain bag was changed over to a leg drain bag and the large drain bag was rinsed. A gallon of irrigation was sitting in a plastic basin next to the toilet and on the floor. The gallon container had no lid, was not dated, no initials were present, no solution concentration was written on a label, and the only label was for vinegar. The gallon was ¼ full. Staff member I did not know what the solution concentration was or who had mixed the solution for irrigation.
During an interview on 12/6/23 at 2:15 p.m., staff member G said she was not familiar with the protocol for the urine drain bag mixture. Staff member G said she did not know if the vinegar was diluted to flush the bag or if it was full strength.
During an interview on 12/6/23 at 3:49 p.m., staff member B said the facility had a lot of new staff and they would need some training.
Record review of a facility policy, Caring for Residents with Indwelling Catheters, revised 9/21/21, failed to show an expiration time or date for the solution once mixed.
Record review of a facility document, Vinegar Solution, not dated, failed to show an expiration time or date for the solution once mixed.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to keep residents free from physical restraints fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to keep residents free from physical restraints for 3 (#s 12, 28, and 36) of 19 sampled residents. This deficient practice caused the residents the inability to move independently. Findings include:
1. During an observation on 12/4/23 at 3:33 p.m., resident #36 was in her room sitting in a recliner. Resident #36 was trying to get out of her recliner and was yelling out.
During an observation on 12/4/23 at 4:25 p.m., resident #36 was sitting in a high-back, reclining type wheelchair. Resident #36 had a seatbelt across her lap.
During an observation on 12/5/23 at 8:45 a.m., resident #36 was sitting in her wheelchair with a seatbelt fastened across her lap, by the nurse's station. Resident #36 was trying to unlock her wheelchair brakes and climb over the side of her wheelchair. Resident #36 was unable to release the seatbelt on her own.
During an interview on 12/5/23 at 8:47 a.m., staff member M stated the seatbelt was to help keep resident #36 in her wheelchair, so she did not fall. Staff member M stated when resident # 36 was in her room, she had an alarm and fall mat.
On 12/5/23 at 11:07 a.m., a call was placed to resident #36's power of attorney. No call back was received prior to the end of the survey.
During an observation on 12/6/23 at 7:40 a.m., resident #36 was in the dining room. Resident #36 was sitting in her wheelchair with a seatbelt across her lap. Resident #36 was pulling herself around the dining room by grabbing tables and moving forward. Staff member F took resident #36 out of the dining room and placed her by the nurse's station, and locked her wheelchair breaks.
During an observation on 12/6/23 at 8:40 a.m., resident #36's wheelchair breaks were locked. Resident #36 tried to unlock her wheelchair brakes three times with no success. Resident #36 tried to climb over the side of her wheelchair stating, I have to use the bathroom.
During an interview on 12/6/23 at 8:45 a.m., staff member M could not state how often the seatbelt was to be released. Staff member M stated, I am not sure exactly how often we are supposed to remove the seatbelt, but we toilet her before meals and it is released then.
During an interview on 12/6/23 at 8:50 a.m., staff member B stated the seatbelt was placed because her POA requested it, and resident #36 was having frequent falls. Staff member B stated the seatbelt was to be released every two hours and as needed.
A review of resident #36's nursing progress notes show multiple falls. Resident #36 fell six times between 7/12/23 and 7/31/23. All of resident #36's falls were in her room, where she was found on the floor by the door, bed, or recliner. There were no documented falls from her wheelchair.
A review of resident #36's physicians orders, dated 8/1/23 showed: 8/1/23 seatbelt to wheelchair for safety and positioning. Signed: [Staff member].
2. During an observation on 12/4/23 at 3:41 p.m., resident #28 was wearing a blue vest type device. It crisscrossed the resident's back, and the straps are hooked around the handles of her wheelchair. The vest prevented the resident from rising from her wheelchair, and the releases for the vest, which resembled lift and release seatbelt catches were behind the resident. Resident #28 could not release the restraint device on her own.
During an observation on 12/5/23 8:20 a.m., resident #28 was wheeling herself past the nurse's station. The resident was not wearing the restraint device.
During an observation on 12/6/23 at 8:40 a.m., resident #28 was wearing the restraint device at breakfast.
During an observation on 12/6/23 at 9:11 a.m., resident #28 was brought to the unit from the dining room. Resident #28's restraint device was still on.
During an interview on 12/6/23 at 9:22 a.m., staff member I said resident #28 was wearing a posey because she tended to lean forward a lot and fall out of her wheelchair. Staff member I said the doctor ordered the posey vest for resident #28. Staff member I said there was no set schedule for release of the posey vest. We take it off when she lays down.
During an interview on 12/06/23 at 1:05 p.m., staff member B said, Resident #28's posey vest should be on her care plan. Staff member B said, We should be following our policy.
Review of resident #28's physician order, dated 10/31/23, showed, Posey vest while in chair for positioning every shift for help with eating and reduce falls.
Review of resident #28's medical record failed to show the facility had completed a restraint assessment for the resident.
Review of resident #28's December 2023 MAR and TAR failed to show the facility had a restraint release program in place for the posey vest.
Review of resident #28's current care plan, with a target date of 1/18/23, failed to identify focus, goals, or interventions in place to the address the use of a posey vest restraint.
3. During an observation on 12/6/23 at 9:16 a.m., resident #12 was seated in a wheelchair. Staff members G and J were fitting foot rests to the wheelchair. Resident #12 was wearing a seatbelt, and the resident was attempting to stand up before the foot rests were in place. After the foot rests were in place on the wheelchair, staff member G placed resident #12's feet on the foot rests. The resident continued to scoot and fidget in the wheelchair.
During an observation on 12/6/23 at 9:20 a.m., staff member L was seen to whisper to staff member I, and point at resident #12's waist. Staff member I released resident #12's
seatbelt.
On 12/5/23 at 8:08 a.m., a phone call was made to resident #28's power of attorney. The call was not answered, and a voicemail was left. The power of attorney did not return the phone call prior to the end of the survey.
During an interview on 12/6/23 at 9:22 a.m., staff member I said resident #12 typically did not wear a seat belt. Staff member I said the seatbelt was put on yesterday (12/5/23) due to the falls she had been having. Staff member I said she thought the doctor had ordered the wheelchair and the seatbelt because of resident #12's recent falls.
Review of resident #12's Quarterly MDS, with an ARD of 10/31/23, showed the resident was severely cognitively impaired.
Review of resident #12's medical record, dated 12/5/23 to 12/6/23, failed the show a physician's order for the seatbelt restraint; failed to show a restraint assessment had been completed; failed to show resident #12's family members had been contacted about the use of the seatbelt restraint; and failed to show resident #12's care plan, CNA flow sheet, CNA [NAME], and the TAR had been updated to include the use of the restraint, and the frequency of monitoring.
During an interview on 12/6/23 at 2:16 p.m., staff member B said resident #12 was no longer in the wheelchair. Staff member B said the wheelchair and seatbelt would cause more harm to resident #12 than just falling. Staff member B said the wheelchair was taken away today (12/6/23).
A review of a facility document titled, RESTRAINTS, with a revision date of 8/23/23, showed:
POLICY: All residents have the right to be free from restraints .
.Restraint means any method (chemical or physical) of restricting a person's freedom of movement that prevents them from independent and purposeful functioning. This includes controlling physical activity .
-When a restraint or safety device is used, the following items must be addressed and documented in the resident's medical record:
-Frequency of monitoring (toileting and repositioning needs must be addressed every 2 hours).
-assessment and provision of treatment if necessary for skin care, circulation, and range of motion .
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to complete a thorough investigation involving elopement ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to complete a thorough investigation involving elopement for 2 (#s 19 and 26); and falls for 1 (#36) of 19 sampled residents. This deficient practice failed to included interventions to prevent further elopements or falls, root cause analysis, or staff education. Findings include:
1. A review of a Facility Reported Incident, dated 11/3/23 showed, Incident Description: 0742 resident had left the dining room after breakfast attempted to open the boiler room door, [NAME] room door and shower room door, proceeded to the South hall attempted to open the interior boiler room door in south hall than tried to open the south door exit and proceeded out to the smoking area. resident was found by staff 0750 at the boiler room exterior exit after his wheelchair became stuck. staff alerted by dining room staff that resident was seen through the dining room windows prior to becoming stuck, but no nursing staff was notified. Charge nurse was notified of elopement upon resident return into the building.[sic]
During an observation and interview on 12/4/23 at 3:21 p.m., resident #19 was sitting in a wheelchair, in his room. Resident #19 did not remember leaving the building or trying to leave the building. Resident #19 stated he like being at the facility. Resident #19 had a BIMS score of 6. This indicated resident #19 had cognitive impairment.
During an observation on 12/5/23 at 7:42 a.m., resident #19 was sitting in his wheelchair in the dining room. Resident #19 had a wander-guard attached to his wheelchair.
During an interview on 12/6/23 at 7:35 a.m., staff member L stated she was not on shift the day resident #19 had left the building. Staff member L stated she knew that a wander-guard was placed on resident #19's wheelchair and it was the responsibility of the treatment nurse to check the wander-guards daily. Staff member L stated no education was provided about elopements or falls.
During an interview on 12/6/23 at 8:45 a.m., staff member M stated she did not recall anyone talking to her about the incident or having any education on elopements or falls.
During an interview on 12/6/23 at 1:10 p.m., staff member B stated resident #19 took the wander-guard off of his wheelchair and the wander-guard was replaced, so no further investigation needed to be done.
A review of a facility document titled, Elopement Risk Assessment, with a completion date of 2/25/19 showed:
Summary/Conclusion/Recommendations
Pt does not seek elopement @ this time. Overall is fairly content here. [staff initials]. No reassessment was completed after resident #19 had eloped.
2. A review of a Facility Reported Incident, dated 11/23/23, showed, Incident description: Un-witnessed elopement-Resident was exit seeking when alarm went off and resident was seen walking out the door. Staff witnessed and escorted resident back in. She was without injury. Resident was only outside 1-2 minutes. [sic]
During an interview on 12/6/23 at 7:35 a.m., staff member L stated she was on shift when resident #26 eloped. Staff member L stated resident #26 had exited though the North doors and was out by the sidewalk. Staff member L stated if a resident tried to go out the doors an alarm sounded, and if they stood there long enough the doors unlocked and they could get out. Staff member L stated she thought the alarm sounded for about 15 seconds before the doors unlocked. Staff member L stated, The incident with resident #26 happened after breakfast and there was no staff down in that direction, but we were able to get her back inside. Staff member L stated no education was completed after the incident.
During an observation and interview on 12/6/23 at 9:02 a.m., resident #26 had a wander-guard on her ankle area. Resident #26 did not remember leaving the building.
A review of a facility policy titled, Elopement Policy, with a revision date of 11/9/23, showed:
.Assess each resident's behavior on admission and as needed to identify a potential wanderer early on.
. The Charge Nurse should be notified immediately .,
. Respond promptly to alarm, Check outside immediately for a resident that has left the building.[sic]
3. A review of a Facility Reported incident, dated 7/31/23, showed, Incident Detail: Un-witnessed fall-RN at nurses station heard mat alarm in resident room and investigated. Found resident in front of her recliner on the floor laying on her right side, recliner tipped forward with the foot rest up, this RN assessed resident, denies pain when asked if she hit her head resident states well slightly no other information is given resident denies pain or injury. neuro checks started due to resident reports of hitting their head no bumps noted no marks noted, no injuries noted at this time. resident assisted to her recliner mat replaced. Staff to collect a urine for UTI d/t increased confusion. [sic]
During an observation on 12/4/23 at 3:33 p.m., resident #36 was in her room sitting in a recliner. Resident #36 was trying to get out of her recliner and yelling out.
During an interview on 12/5/23 at 8:47 a.m., staff member M stated the seatbelt was to help keep resident #36 in her wheelchair, so she does not fall. Staff member M stated when resident #36 was in her room, she had an alarm and fall mat.
During an interview on 12/6/23 at 1:10 p.m., staff member B stated that resident #36 was tested for a UTI and was started on antibiotics because of her confusion, and an order for the seatbelt was received on 8/1/23 from the physician.
During an interview on 12/6/23 at 11:30 a.m., staff member N stated she had completed the physical therapy evaluation for resident #36 as soon as she had come out of isolation. Staff member N stated after the evaluation she had recommended a restorative program to increase residents #36's activity, mobility, and strength.
A review of a facility document titled, Falling Star Program, with a review date of 11/9/23, showed:
PROCEDURE FOR CURRENT RESIDENTS:
1. Residents who incur a fall will be put on the falling star program on the shift the fall occurs.
2. Residents who incur a fall will be monitored and assessed in order to implement and develop an individualized plan of care to address the fall.
. 6. Communicate to all staff members .
During the investigations, no education, root cause, or additional interventions were identified or placed to prevent further elopements or falls.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement a baseline care plan within 48 hours of res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement a baseline care plan within 48 hours of resident admissions for 3 (#s 33, 36 and 142) of 19 sampled residents. This deficient practice had the potential for the residents not to receive the required care needed. Findings include:
1. During an interview on 12/6/23 at 13:20 p.m., staff member B stated, The baseline care plan for [resident #33] is the [NAME] and CNA care sheets.
During an interview on 12/5/23 at 11:10 a.m., NF2 stated she did not recall anybody asking her about how to care for resident #33 on admission. NF2 stated it was not until later in the month at a care planning meeting where she was asked questions about resident #33.
2. During an interview on 12/6/23 at 13:20 p.m., staff member B stated, The baseline care plan for [resident #36] is the [NAME] and CNA care sheets.
On 12/5/23 at 11:07 a.m., a call was placed to resident #36's POA. No call back was received prior to the end of the survey.
Baseline care plans were requested for resident #33 and #36. An untitled, undated document was received. The document did not have an initiation date, who initiated the document, or a signature from who completed the document. A hand written sticky note stated, CNA Care sheet/[NAME] is the baseline care plan.
3. Review of two facility incident reports to the State Agency showed resident #142 had a fall on 11/22/23 and a fall on 11/23/23. The resident had been residing at the facility 13 days.
A baseline care plan for resident #142 was requested on 12/6/23 at 8:35 a.m The facility did not provide the requested information by the end of the survey.
During an interview on 12/6/23 at 2:16 p.m., staff member B said the facility's MAR, TAR, physician orders, CNA [NAME], and CNA flow sheets were part of the resident's baseline care plan.
Review of resident #142's December 2023 CNA [NAME], CNA flow sheets, physician's orders, MAR, and TAR failed to show a focus, goals, or interventions for the resident's falls on 11/22/23 and 11/23/23.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
4. A review of a Facility Reported Incident, dated 11/23/23, showed, Incident description: Un-witnessed elopement-Resident was exit seeking when alarm went off and resident was seen walking out the do...
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4. A review of a Facility Reported Incident, dated 11/23/23, showed, Incident description: Un-witnessed elopement-Resident was exit seeking when alarm went off and resident was seen walking out the door. Staff witnessed and escorted resident back in. She was without injury. Resident was only outside 1-2 minutes. [sic]
A review of a facility document titled, Elopement Risk Assessment, dated 2/2/21, showed:
Wandergard on. Deemed a risk for elopement r/t desire to shop independently and smoke. [staff signature]. [sic]
During an interview on 12/6/23 at 7:35 a.m., staff member L stated she was on shift when resident #26 eloped. Staff member L stated, The incident with resident #26 happened after breakfast and there was no staff down in that direction, but we were able to get her back inside. Staff member L stated resident #26 had a history of elopements. Staff member L stated no education was completed after the incident.
During an observation and interview on 12/6/23 at 9:02 a.m., a wander-guard was present on resident #26's ankle. Resident #26 stated she did not remember trying to leave the building.
A review of resident #26's comprehensive care plan, with a revision date of 6/2023, showed:
No goals, interventions, or revisions for resident elopements or the use of a wander-guard to help prevent elopements. Resident #26 had a history of elopements from the facility.
A review of a facility document titled, POINT CLICK CARE CP & MDS, with a revision date of 2/1/22, showed:
Care Plan Policy:
Our facility will develop a comprehensive Care Plan for each resident, including measurable objectives and timetables to meet a resident's medical nursing, mental, and psychological needs as identified in the comprehensive assessment.[sic]
Based on observation, interview, and record review, the facility failed to complete a person-centered, comprehensive care plan for 2 (#s 3 and 29) for UTI and indwelling catheter interventions; interventions for repeated falls for 1 (#17); and elopement interventions for 1 (#26) of 19 sampled residents. Findings include:
1. During an observation on 12/5/23 at 8:06 a.m., resident #29 was seated in his recliner, in his room, the door to the room was open over halfway. Resident #29 was only wearing a shirt.
During an observation and interview on 12/5/23 at 8:22 a.m., resident #29 was seated in his recliner, in his room. He was awake and had a foley catheter draining to a large drain bag. Resident #29 said he had been waiting for someone to come change out his catheter drain bag so he could get dressed and go to breakfast with his wife.
During an interview on 12/5/23 at 8:29 a.m., staff member R said resident #29 was waiting for his catheter drain bag to be changed out to a leg bag for day use. Staff member R would let the CNA know so it could be switched to a leg bag.
Review of resident #29's care plan, dated 11/4/23, showed catheter interventions of monitoring for pain and discomfort, and documentation of input and output. No individualized interventions of changing out his drain bag were documented. No personalized preference for a leg bag for day use, drainage bag for night time use or preference for not wearing pants were documented. No interventions for assessment and care of resident #29's foley catheter were found in the care plan, nursing treatments, or CNA tasks.
2. During an observation and interview on 12/5/23 at 11:01 a.m., resident #3 was seated in the activity room in a wheelchair. She had a foley catheter drainage bag under the wheelchair, covered with a black bag. Resident #3 said nursing staff would irrigate her catheter every morning when she got up and dressed. Resident #3 said she liked to get up early and be dressed between 6:30 and 7:00 a.m.
Record review of resident #3's treatment administration record, dated 11/1/23 through 11/30/23, showed an order to irrigate her foley catheter every am, scheduled at 9:00 a.m.
Review of resident #3's care plan, dated 8/31/22, showed catheter interventions of monitoring for pain and discomfort, and documentation of input and output. No interventions of resident preference for catheter irrigation to be done in the morning when getting dressed. No interventions for assessment and care of resident #3's foley catheter were found in the care plan, nursing treatments, or CNA tasks.
Review of a facility policy, Point Click Care CP & MDS, revision date 2/1/22, showed:
.During the Comprehensive Assessment and Care Planning process, each team member will consult with the resident, resident's family, and other persons significant to the resident to obtain information, consents, desires and priorities for care.
3. Review of a Facility Reported Incident, reported to the State Survey Agency, resident #17 had unwitnessed falls on:
-8/11/23- Resident #17 was attempting to self-transfer from the toilet to his wheelchair. Resident was attempting to have a bowel movement and experienced pelvic pressure and weakness. Resident #17 was checked for a possible UTI. Urinalysis was found to be in normal limits.
-8/17/23- Resident #17 was found in his room, seated on the floor in front of his recliner. The CNA stated she had assisted resident #17 into his recliner and moved his walker and wheelchair out of reach. Resident #17 said he was too close to the edge of his chair and fell out, landing on his buttocks. Resident #17 was reminded to use his call light and his floor alarm was to remain in place at all times.
-8/22/23- Resident #17 was found in his room, seated on the floor in front of his recliner. He was attempting to self-transfer and said he was unable to seat himself far enough back in the recliner. Resident #17 was assisted into his recliner, reminded to use his call light, and the floor alarm in place. A CNA intervention to assist resident #17 to the toilet and to transfer to the recliner after meals was added.
-8/23/23- Resident #17 was found in his room, seated on the floor next to his bed. He said he was attempting to get up to his chair, by himself. Resident #17 was reminded to use his call light for assistance. The floor mat alarm remained in place to alert staff to resident #17's attempts to transfer without assistance.
During an observation and interview on 12/5/23 at 9:24 a.m., resident #17 was seated in his recliner, his wheelchair at his side, within reach, and the foot of the recliner not reclined. Resident #17 was watching television, and no floor alarm was noted in the resident's room. Resident #17 did not remember ever falling while at the facility.
During an interview on 12/5/23 at 2:09 p.m., staff member A said residents at risk for falls were discussed at the weekly care plan meetings and then interventions were added to the CNA tasks.
During an interview on 12/6/23 at 1:24 p.m., staff member I said resident #17 did not like to use his call light to ask for assistance. Staff member I said resident #17 had a fall mat alarm at one time but it was no longer being used. Resident #17 began going around the mat to avoid triggering the alarm.
Record review of resident #17's care plan, showed a focus area on falls, dated 1/10/22 and revised on 4/10/22. A goal of resident #17 to not have falls was revised on 9/5/23. The list of interventions included activities to promote exercise and strength training (revision 4/10/22), PT strength and mobility (revision 1/10/22), and floor mat alarm beside bed at night, initiated on 9/15/23. Resident #17 fell after meals and when transferring to his recliner, not at night.
Record review of resident #17's CNA tasks showed, Help resident to toilet and to sit in recliner after meals, dated 8/23/23.
Record review of resident #17's RN tasks showed, Floor mat alarm beside bed, check placement and proper function, dated 9/15/23.
Resident #17 had multiple falls over a one-month period of time and no root cause was identified for the placement of interventions on his care plan, CNA or RN tasks. The resident's fall mat intervention was not placed in the RN tasks until the resident had fallen 4 times. Resident #17 did not have an intervention of CNA assistance for toileting and assistance into his recliner until he had fallen three times.
Review of a facility policy, Falling Star Program, reviewed 11/9/23, showed:
.Interventions may include floormat alarms, transfer with assist, use of gait belt, scheduled toileting program, reminders to use call light, non-slip material under wheelchair cushion, positioning bed in lowest position when staff is not in attendance.
.4. If the resident had an additional fall since being placed on the Falling Star Program, the resident will remain on the Falling Star Program, but the interdisciplinary team will re-assess current interventions in place to prevent falls.
5. Steps utilized for reduction in falls will be included on the care plan for at least all residents scoring 10 or greater indicating high risk for falls.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During an observation and interview on 12/4/23 at 2:27 p.m., resident #1 was seated in a wheelchair. A foley catheter was pre...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During an observation and interview on 12/4/23 at 2:27 p.m., resident #1 was seated in a wheelchair. A foley catheter was present. Resident #1 refused to speak with the surveyor and asked the surveyor not to return to his room.
A review of resident #1's physician order, dated 9/13/23 showed:
Sulfamethoxazole-Trimethoprim oral tablet 800-160 mg.
Order summary: Sulfamethoxazole-Trimethoprim Oral Tablet 800-160 mg Give 1 tablet orally one time a day for UTI suppression per [Physician Name].
Ordered by staff member K.
A review of resident #1's Care Plan, with a revision date of 5/2023, did not show any information about resident #1 being on a prophylactic antibiotic for chronic UTI suppression.
5. During an observation and interview on 12/4/23 at 3:21 p.m., resident #19 is seated in a wheelchair in his room. The resident stated he did not remember leaving the building and being outside recently.
A review of a Facility Reported Incident, dated 11/3/23 showed, Incident Description: 0742 resident had left the dining room after breakfast attempted to open the boiler room door, [NAME] room door and shower room door, proceeded to the South hall attempted to open the interior boiler room door in south hall than tried to open the south door exit and proceeded out to the smoking area. resident was found by staff 0750 at the boiler room exterior exit after his wheelchair became stuck. staff alerted by dining room staff that resident was seen through the dining room windows prior to becoming stuck, but no nursing staff was notified. Charge nurse was notified of elopement upon resident return into the building.[sic]
During an observation on 12/5/23 at 7:42 a.m., resident #19 was seated in his wheelchair in the dining room. Resident #19 had a wander-guard attached to his wheelchair.
During an interview on 12/6/23 at 7:35 a.m., staff member L stated she was not on shift the day resident #19 had left the building. Staff member L stated she knew a wander-guard was placed on resident #19's wheelchair and it was the responsibility of the treatment nurse to check the wander-guards daily. Staff member L stated she did not recall seeing any interventions on resident #19's care plan.
A review of resident #19's treatment administration record, dated November 2023-December 6, 2023, showed: No area for the wander-guard. There was no place for the nurse to sign off that the wander-guard was checked and working properly.
A review of resident #19's care plan showed: No focus, goals, or interventions regarding the use of a wander-guard for elopement treatment and prevention.
6. During an observation on 12/4/23 at 4:13 p.m., resident was sitting in his room yelling out. Resident #33 would yell, Help or make loud sounds.
During an interview on 12/5/23 at 11:10 a.m., NF2 stated that resident #33 had worsening dementia and could be aggressive and verbal with staff. NF2 stated staff member K started resident on an antianxiety medication and felt it had helped some.
A review of resident #33's physician orders, dated 8/22/23, showed resident #33 was started on buspirone HCL oral tablet 5 mg in the morning related to anxiety disorder and give 10 mg by mouth in the afternoon related to anxiety disorder, unspecified.
A review of resident #33's care plan with an initiation and revision date of 6/5/23, did not show any focus, goals, or interventions regarding the use of an antianxiety medication or what side effects resident #33 should be monitored for.
7. During an observation on 12/4/23 at 3:33 p.m., resident #36 was in her room seated in a recliner. Resident #36 was trying to get out of her recliner and yelling out.
During an observation on 12/4/23 at 4:25 p.m., resident #36 was seated in a high-back, reclining type wheelchair. Resident #36 had a seatbelt across her lap.
During an observation on 12/5/23 at 8:45 a.m., resident #36 was seated in her wheelchair with a seatbelt fastened across her lap, by the nurse's station. Resident #36 was trying to unlock her wheelchair brakes and climb over the side of her wheelchair. Resident #36 was unable to release the seatbelt on her own.
During an interview on 12/5/23 at 8:47 a.m., staff member M stated the seatbelt was to help keep resident #36 in her wheelchair, so she did not fall. Staff member M stated when resident # 36 was in her room, she had an alarm and fall mat.
A review of resident #36's care plan, with a revision date of 10/10/23, showed no focus, goals, or interventions about the seatbelt use. There was no direction on the care plan that stated when the seatbelt needed to be released.
During an interview on 12/6/23 at 8:45 a.m., staff member M could not state how often the seatbelt was to be released. Staff member M stated, I am not sure exactly how often we are supposed to remove the seatbelt, but we toilet her before meals and it is released then.
During an interview on 12/6/23 at 8:50 a.m., staff member B stated the seatbelt was placed because her POA requested it and resident #36 was having frequent falls.
During an interview on 12/6/23 at 1:05 p.m., staff member B stated, I am trying to keep up and do the best I can.
A review of a facility document titled, POINT CLICK CARE CP & MDS, with a revised date of 2/1/22, showed:
.9. The care plan will be reviewed as often as changes occur in the resident's condition and will be revised to maintain accuracy .
3. Review of Facility Reported Incidents, reported to the State Survey Agency, resident #17 had unwitnessed falls on:
-8/11/23- Resident #17 was attempting to self-transfer from the toilet to his wheelchair. Resident was attempting to have a bowel movement and experienced pelvic pressure and weakness. Resident #17 was checked for a possible UTI. Urinalysis was found to be in normal limits.
-8/17/23- Resident #17 was found in his room, seated on the floor in front of his recliner. The CNA stated she had assisted resident #17 into his recliner and moved his walker and wheelchair out of reach. Resident #17 said he was too close to the edge of his chair and fell out, landing on his buttocks. Resident #17 was reminded to use his call light and his floor alarm was to remain in place at all times.
-8/22/23- Resident #17 was found in his room, seated on the floor in front of his recliner. He was attempting to self-transfer and said he was unable to seat himself far enough back in the recliner. Resident #17 was assisted into his recliner, reminded to use his call light, and the floor alarm was in place. A CNA intervention to assist resident #17 to the toilet and to transfer to the recliner after meals was added.
-8/23/23- Resident #17 was found in his room, seated on the floor next to his bed. He said he was attempting to get up to his chair, by himself. Resident #17 was reminded to use his call light for assistance. The floor mat alarm remained in place to alert staff to resident #17's attempts to transfer without assistance.
During an observation and interview on 12/5/23 at 9:24 a.m., resident #17 was seated in his recliner, his wheelchair at his side, within reach, and the foot of the recliner not reclined. Resident #17 was watching television, and no floor alarm was noted in the resident's room. Resident #17 did not remember ever falling while at the facility.
During an interview on 12/5/23 at 2:09 p.m., staff member A said residents at risk for falls were discussed at the weekly care plan meetings and then interventions were added to the CNA tasks.
During an interview on 12/6/23 at 1:24 p.m., staff member I said resident #17 does not like to use his call light to ask for assistance. Staff member I said resident #17 had a fall mat alarm at one time but it was no longer being used. Resident #17 began going around the mat to avoid triggering the alarm.
Record review of resident #17's care plan, showed a focus area on falls, dated 1/10/22 and revised on 4/10/22. An intervention of a floor mat alarm at beside bed at night was initiated on 9/15/23, after the resident had fallen 4 times. Review of the Facility Reported Incidents showed resident #17 fell after meals and when transferring to his recliner, not at night. On the unwitnessed fall report for 8/17/23, it was indicated that resident #17 was not wearing proper footwear, there were no intervention placed following that fall. A CNA intervention of assisting the resident to the toilet and his recliner after meals was initiated after resident #17's third fall.
Review of a facility policy, Falling Star Program, reviewed 11/9/23, showed:
.Interventions may include floormat alarms, transfer with assist, use of gait belt, scheduled toileting program, reminders to use call light, non-slip material under wheelchair cushion, positioning bed in lowest position when staff is not in attendance.
.4. If the resident had an additional fall since being placed on the Falling Star Program, the resident will remain on the Falling Star Program, but the interdisciplinary team will re-assess current interventions in place to prevent falls.
5. Steps utilized for reduction in falls will be included on the care plan for at least all residents scoring 10 or greater indicating high risk for falls.Based on observation, interview, and record review, facility staff failed to revise and implement new focus, goals, and interventions on care plans for 7 (#s 1, 12, 17, 19, 28, 33, and 36) of 19 sampled residents. Findings include:
1. During an observation on 12/4/23 at 3:41 p.m., resident #28 was wearing a blue vest type device. The device crisscrossed her back, and the straps going over her shoulders were hooked around the handles of her wheelchair. This device prevented the resident from rising out of her wheelchair. The releases for the device which resemble lift and release seatbelt catches were behind her. Resident #28 could not release the device on her own.
During an observation on 12/5/23 at 8:20 a.m., resident #28 was wheeling herself past the nurse's station. She was not wearing her restraint device.
During an observation on 12/6/23 at 8:40 a.m., resident #28 was wearing the restraint device at breakfast.
During an observation on 12/6/23 at 9:11 a.m., resident #28 was brought to the unit from the dining room. The resident was still in her wheelchair with the restraint device on.
During an interview on 12/4/23 at 4:09 p.m., staff member S said, We use our tablets to view the [NAME] for each resident. The [NAME] tells us what care each resident needs, any behaviors they might have. Things like that.
During an interview on 12/6/23 at 9:22 a.m., staff member I said resident #28 wears a posey (restraint device) because she leans forward in her wheelchair, and tends to fall out of it. Staff member I said, We take it off when she (resident #28) lays down.
Review of resident #28's medical record, including the CNA [NAME], the CNA flow sheet, the monthly physician's order summary, the medication administration record, the treatment administration record, and the care plan failed to show a restraint device was being used by resident #28.
During an interview on 12/6/23 at 1:05 p.m., staff member B said the physician ordered the posey vest to keep resident #28 more upright in her wheelchair so she could eat better, and to prevent her from falling forward out of her wheelchair.
2. During an observation on 12/6/23 at 9:16 a.m., resident #12 was wearing a seatbelt. The resident tried repeatedly to stand up from the wheelchair.
During an interview on 12/6/23 at 9:22 a.m., staff member I said the doctor ordered the wheelchair and the seatbelt for resident #12 because of her recent falls.
Review of resident #12 nursing progress notes showed:
- 12/4/23 at 3:25 p.m., Rt (resident) was found sitting on their floor next to their bed alert and w/o (without) injuries. Assisted to their feet and then to couch to rest.
- 12/4/23 at 10:47 a.m., At 1030 (10:30 a.m.) resident was walking over to her couch and tripped over her baby doll stroller in her room.
- 11/26/23 at 11:11 p.m., Rt (resident) had a witnessed fall the approximately 1530 (3:30 p.m.) this afternoon at the nurse's station. Rt leaned up against the wall and their feet slipped out from under them. As they fell resident hit their head off of the hand rail on the wall then fell to their buttock. No initial injuries.
Review of resident #12's Plan of Care Note, dated 11/28/23, showed: Both of resident's daughters in attendance for family care conference via phone call. Discussed her last fall and inability for staff to be successful in having resident wear proper footwear regularly. This information was not included on resident #12's care plan, CNA [NAME], CNA flow sheets, treatment records, medication records, or physician's monthly summary orders.
Review of resident #12's medical record showed no evidence the facility had completed a fall risk assessment for the resident for the last 12 months.
Review of resident #12 Falls care plan, last revised on 8/5/23, showed the fall interventions were last revised on 2/7/22. One of the interventions was: Ensure that the resident is wearing appropriate footwear when ambulating. Date initiated: 2/7/2022, Revision on: 2/7/2022
Review of resident #12's medical record, including the CNA [NAME], the CNA flow sheet, the monthly physician's order summary, the medication administration record, the treatment administration record, and the care plan failed to show new interventions for her falls had been identified.
During an interview on 12/6/23 at 2:16 p.m., staff member B said, The facility's policy indicates the MAR and TAR are part of the care plan, physician's order sheets, CNA [NAME] and task sheets are too.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of a Facility Reported Incident, dated 11/3/23 showed, Incident Description: 0742 resident had left the dining room ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of a Facility Reported Incident, dated 11/3/23 showed, Incident Description: 0742 resident had left the dining room after breakfast attempted to open the boiler room door, [NAME] room door and shower room door, proceeded to the South hall attempted to open the interior boiler room door in south hall than tried to open the south door exit and proceeded out to the smoking area. resident was found by staff 0750 at the boiler room exterior exit after his wheelchair became stuck. staff alerted by dining room staff that resident was seen through the dining room windows prior to becoming stuck, but no nursing staff was notified. Charge nurse was notified of elopement upon resident return into the building.[sic]
During an observation and interview on 12/4/23 at 3:21 p.m., resident #19 was seated in a wheelchair, in his room. Resident #19 did not remember leaving the building or trying to leave the building.
During an observation on 12/5/23 at 7:42 a.m., resident #19 was seated in his wheelchair in the dining room. Resident #19 had a wander-guard attached to his wheelchair.
During an interview on 12/6/23 at 7:35 a.m., staff member L stated she knew a wander-guard was placed on resident #19's wheelchair.
During an interview on 12/6/23 at 1:10 p.m., staff member B stated resident #19 took the wander-guard off of his wheelchair and the wander-guard was replaced so no further investigation needed to be done.
A review of a facility document titled, Elopement Risk Assessment, with a completion date of 2/25/19 showed:
Summary/Conclusion/Recommendations
Pt does not seek elopement @ this time. Overall is fairly content here. [staff initials]. No further elopement assessment had been completed.
4. A review of a Facility Reported Incident, dated 11/23/23, showed, Incident description: Un-witnessed elopement-Resident was exit seeking when alarm went off and resident was seen walking out the door. Staff witnessed and escorted resident back in. She was without injury. Resident was only outside 1-2 minutes. [sic]
During an interview on 12/6/23 at 7:35 a.m., staff member L stated she was on shift when resident #26 eloped. Staff member L stated resident #26 had exited out the North doors and was out by the sidewalk by the time staff got to her. Staff member L stated she thought the alarm sounded for about 15 seconds before the doors unlocked and the resident went outside.
During an observation and interview on 12/6/23 at 9:02 a.m., resident #26 had a wander-guard on her ankle area. Resident #26 did not remember leaving the building.
A review of a facility document titled, Elopement risk assessment, dated 2/2/21, showed resident #36 was at risk for elopements.
A review of a facility policy titled, Elopement Policy, with a revision date of 11/9/23, showed:
. Assess each resident's behavior on admission and as needed to identify a potential wanderer early on.
Based on observation, interview, and record review, the facility failed to keep residents safe from falls for 2 (#s 12 and 142); and elopements for 2 (#s 19 and 26) of 19 sampled residents. Findings include:
1. During an observation on 12/6/23 at 9:16 a.m., resident #12 was seated in a wheelchair. She was wearing a seatbelt. Staff member G and staff member J were putting foot rests on the wheelchair resident #12 was seated in. The resident repeatedly tried to stand up from the wheelchair.
During an interview on 12/6/23 at 9:22 a.m., staff member I said the doctor ordered the wheelchair and the seatbelt for resident #12 because of her recent falls.
Review of resident #12's nursing progress notes showed:
- 12/4/23 at 3:25 p.m., Rt (resident) was found sitting on their floor next to their bed alert and w/o (without) injuries. Assisted to their feet and then to couch to rest.
- 12/4/23 at 10:47 a.m., At 1030 (10:30 a.m.) resident was walking over to her couch and tripped over her baby doll stroller in her room.
- 11/26/23 at 11:11 p.m., Rt (resident) had a witnessed fall the approximately 1530 (3:30 p.m.) this afternoon at the nurse's station. Rt leaned up against the wall and their feet slipped out from under them. As they fell resident hit their head off of the hand rail on the wall then fell to their buttock. No initial injuries. [sic]
Review of resident #12's medical record, dated 1/1/23 to 12/6/23 showed no evidence the facility had completed a fall risk assessment for the resident for the last 12 months.
Review of resident #12 Falls care plan, revised on 8/5/23, showed her fall interventions were last revised on 2/7/22.
During an interview on 12/6/23 at 2:16 p.m., staff member B said resident #12 was no longer in the wheelchair. Staff member B said the wheelchair and seatbelt would cause more harm to resident #12 than just falling. Staff member B said the wheelchair was taken away today (12/6/23). Staff member B said the facility needed to address resident #12's recent falls.
2. Review of two facility incident reports to the State Agency showed resident #142 had a fall on 11/22/23 and a fall on 11/23/23. The resident had been residing at the facility 13 days.
Review of resident #142's medical record, dated 11/22/23 to 12/6/23, failed to show a fall risk assessment had been completed for the resident.
A baseline care plan for resident #142 was requested on 12/6/23 at 8:35 a.m The facility did not provide the requested information by the end of the survey.
During an interview on 12/6/23 at 2:16 p.m., staff member B said the facility's MAR, TAR, physician orders, CNA [NAME], and CNA flow sheets were part of the resident's baseline care plan.
Review of resident #142's December 2023 CNA [NAME], CNA flow sheets, physician's orders, MAR, and TAR failed to show a focus, goals, or interventions for the resident's falls on 11/22/23 and 11/23/23.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
During an observation on 12/5/23 at 8:05 a.m., staff member P entered the dining room, no hand hygiene was completed upon entering the dining room, and staff member P had her mask was positioned below...
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During an observation on 12/5/23 at 8:05 a.m., staff member P entered the dining room, no hand hygiene was completed upon entering the dining room, and staff member P had her mask was positioned below her nose. Staff member P left the dining room at 8:06 a.m. No hand hygiene was completed.
During an observation on 12/5/23 at 8:07 a.m., staff member P walked back into the dining room, no hand hygiene was completed, and her mask was positioned below her nose.
During an interview on 12/5/23 at 8:12 a.m., staff member P stated she had been properly educated on how to complete proper hand hygiene and wear a mask properly.
During an observation on 12/5/23 at 8:16 a.m., staff member M was pushing a mechanical lift down the hall and placed it in an alcove type area for storage. Staff member M stated the mechanical lift should have been cleaned prior to storage. Staff member M stated she had been educated on how and when to clean the mechanical lifts.
During an observation and interview on 12/5/23 at 8:29 a.m., staff member Q was in the hallway. Staff member Q had her mask positioned below her nose. Staff member Q stated she had been educated on how to wear a mask properly.
During an interview on 12/6/23 at 11:45 a.m., staff member H stated, Staff are trained at least annually using different types of training. We did a skills day with the CNAs and the nurses in June and refreshers are done during staff meetings. I have reminders up though out the facility about hand hygiene.
A review of a facility document titled, Infection control, with an approval date of 6/27/23, showed:
.staff members should perform hand hygiene with ABHR or soap and warm water hand washing.
.all employees required to provide direct patient care will be educated .
A review of a facility document titled, Infection control: Respiratory Illness, With an approval date of 6/27/23, showed:
To ensure early recognition and source control of respiratory illness at this facility .,
The policy does not address COVID-19 specific outbreak requirements for the facility, just the positive employee or resident. The policy does not address how long masks will be required for staff or visitors to wear.
A review of a facility document titled, Infection control: Low level disinfection, with an approval date of 10/31/23, showed:
.All low-level instruments that are to be used for multiple residents will undergo an appropriate disinfection process per the manufacturer of the item.
There was no policy describing how mechanical lifts should be disinfected or how to disinfect the mechanical lifts.
Based on observation, interview, and record review, the facility staff failed to complete proper hand hygiene during resident medication pass, properly wear masks during a facility outbreak of COVID-19, and sanitize a mechanical lift after resident use, prior to storing. This deficient practice has the potential to spread infection to all residents in the facility. Findings include:
During an observation and interview on 12/5/23 at 8:46 a.m., staff member R was observed passing medication to multiple residents without performing hand hygiene between residents. Staff member R said she knows she was not good about performing hand hygiene and should be either hand sanitizing or doing a full wash with soap and water.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to have an antibiotic stewardship program in place. This deficient practice had the potential to affect all residents residing in the facility...
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Based on interview and record review, the facility failed to have an antibiotic stewardship program in place. This deficient practice had the potential to affect all residents residing in the facility. Findings include:
During an interview on 12/4/23 at 2:06 p.m., staff member A stated the facility was in outbreak status for COVID-19. Staff member A stated no residents tested positive, but one staff member was positive.
During an interview on 12/4/23 at 3:06 p.m., staff members A and B stated they would be the back up for the infection prevention program. Staff members A and B were unsure how staff member H was tracking antibiotics, or what kind of criteria or programs she used. Staff member A stated they did not have a current antibiotic stewardship program and staff member H was in the process of implementing one.
A review of a facility document titled, Infection control: Antimicrobial stewardship Program (ASP), was in draft form and had not been approved by the QAPI comittee or the facilities Board of Directors for use at that time.
During an interview on 12/6/23 at 11:45 a.m., staff member H stated she was new to the position and there had been a big gap in infection control. Staff member H stated the antibiotic stewardship committee would include herself, the medical director, and the pharmacist, but it was still a new process. Staff member H stated, no meetings had been held specifically for antibiotic stewardship at that time, but it was talked about in QAPI. Staff member H stated, The program was so new she had not had a chance to work with the providers or staff on education regarding antibiotic stewardship. Staff member H stated, the facility did not have a specific criteria at this time for antibiotic use and the policy had not been approved.
During an interview on 12/6/24 at 4:34 p.m., staff member K stated, As the primary care provider, I determine what the policy and procedure will be regarding antibiotic use. I follow the Journal of American Medical Directors Association, this is probably not the most recent information, but that is what I use for prescribing criteria. I do not even know what McGreer criteria is. I have instructed the nurses at the facility to send a urine culture with any type of behavior change. If the preliminary results show positive nitrates or leukocytes (white blood cells), I will start an empiric antibiotic and wait for the culture results. I will wait to start antibiotics if the resident is afebrile. Once I get the culture report back, I will always treat the infection if the white blood cell count is greater than 10 to the 5th. If I have started antibiotics prior to the culture and sensitivity, I wait for the sensitivity report and change the antibiotic at that time if the infection is not sensitive to what I have started. Staff member K stated she would also treat residents that were colonized with bacteria if there was only behavioral changes noted.
Dec 2022
11 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
Based on observation, interview, and record review, the facility failed to prevent a resident from eloping and wandering the facility from the facility for 1 (#12) failed to implement interventions fo...
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Based on observation, interview, and record review, the facility failed to prevent a resident from eloping and wandering the facility from the facility for 1 (#12) failed to implement interventions for #12's wandering behaviors causing resident's to be upset, for 2 (#s 12 and 15) of 4 sampled residents. Findings include:
Review of a facility reported incident regarding resident #12, dated 6/3/22, showed, Facility under COVID outbreak lockdown since Tuesday 5/31/22. Residents are all a little out of sorts being isolated to their rooms. Also, this resident is normally quite busy and does roam around the facility, occasionally trying to open the doors. When staff have been busy with other residents, there has just not been anyone available to redirect resident before she is able to get outside. Our wander guard system is functioning properly, but if you hold the exit bar long enough, even when the alarm is sounding, the door eventually opens - It is a safety feature. Some residents hold onto the exit bar long enough for this to happen. If the alleged violation(s) was verified, what corrective action has been taken? Staff are doing more one on one with resident as able .Incident Description: Elopement - resident once again able to get out the north door. All staff were assisting other residents when the door alarm sounded. Resident was found standing in the parking lot looking around and easily came back in.
Review of a facility reported incident regarding resident #12, dated 11/7/22, showed, .Incident Description: Un-witnessed elopement - Resident entered building through Kitchen door. Method of elopement unknown. Wanderguard in place and functioning properly. Wanderguard doors checked and functioning properly, service doors checked and locked as appropriate.
Facility document titled, Elopement for resident #12's elopement, dated 11/6/22, showed, .Nursing Description: Notified by Kitchen staff member that resident had come in to kitchen from outside and was cold. Unsure how resident left the building as wanderguard was on and had been functioning prior to the Incident .Assisted resident to nurses station provided warm blanket to resident comfort. Confirmed wanderguard placement. Family and DON notified of incident. [sic]
Review of a facility document titled, Manager's Agenda dated, 11/9/22 showed, .[Resident #12] elopement -out kitchen door? Wanderguard on kitchen door that hasn't been working, other doors that go outside that don't have alarm *lock hallway door all the time. [sic]
There was not any documentation provided which showed the investigation of how the resident exited the facility or for how long the resident was outside the building.
During an interview on 12/6/22 at 1:38 p.m., staff member K stated resident #12 has eloped out of the facility multiple times. She stated resident #12 will try to go out any time and any door. There does not seem to be any pattern at all. Staff member K stated she did have a wander guard on her ankle. When a resident with a wander guard went up to an exit door, the door will lock, and the electrical panel at the nurses station would indicate a resident with a wander guard was at the door with a blinking red light. If the resident pushed on the door long enough the door would eventually unlock and the door alarm would sound. Staff member K stated resident #12 often pushed on the door long enough to exit the facility. If staff saw resident #12 trying to get out of the building, they were instructed to redirect her. Staff member K stated there was not anything that kept the resident busy. Resident #12 would also wander into other residents' rooms and take their things or move their stuff to other resident's rooms. Some of the residents get pretty upset by this, and staff redirect her and return the items she had taken or moved.
During an interview on 12/6/22 at 2:09 p.m., staff member L stated, resident #12 wandered and was exit seeking all day long, she was very busy. Staff member L stated she was constantly going into other resident rooms. If staff noticed this, they redirect her. Staff member L stated last week resident #12 took the entire water fountain off of the hallway wall. Staff member L stated she was hard for staff to redirect, but it usually worked if a male staff member redirects her.
During an observation on 12/6/22 at 4:12 p.m., staff members were busy taking residents to the dining room for dinner. Resident #12 was wandering the north hall by resident #1's room. Resident #12 started to push and knock on resident #1's door, which had a wooden ½ door in front of the main door. Resident #10 yelled at resident #12 to not go in that room, and to stop banging on the door. Resident #12 walked away from the door and proceeded to attempt to exit the facility out of the east hallway exit door. Resident #12 pushed on the door until it unlatched. Staff member J stopped her before she exited the facility.
During an observation on 12/6/22 at 4:19 p.m., resident #12 got up from a chair in the hallway by the nurse's station, walked over to the TV, and picked up the rack of TV stands and carried them to the middle of the hallway. Staff member J grabbed them from resident #12 and put them back under the TV.
During an interview on 12/7/22 at 8:50 a.m., staff member M stated, the ½ wooden doors that are in front of some resident rooms are to keep resident #12 from entering their room. Staff member M stated she thought it helped.
During an observation and interview on 12/7/22 at 9:55 a.m., resident #15 had a ½ wooden door on the entrance of her room. She stated it was so resident #12 did not go in her room. Resident #15 stated there was one time resident #12 wandered in her room in the middle of the night and fell asleep on her couch. Resident #15 stated it scared her because she woke up in the middle of the night, and she did not know who it was right away. She stated it felt unsettling to know that the resident was able to go in her room without her knowing, and fall asleep on her couch. Resident #15 stated there was another time resident #12 came in her room and tried to take her things.
During an observation on 12/7/22 at 2:03 p.m., resident #12 attempted to elope out of the main entrance from the facility. The door alarm went off and the resident was able to open the first set of doors. Resident #12 was stopped before she exited the facility.
Review of resident #12's care plan showed:
Focus: The resident is an elopement risk/wanderer, r/t Disoriented to place, History of attempts to leave facility unattended, Impaired safety awareness, Resident wanders aimlessly, significantly intrudes on the privacy or activities Date Initiated: 2/8/22 .
Goal: The resident's safety will be maintained through the review date. Target Date: 1/31/22
The resident will not leave facility unattended through the review date. Target date of 1/23/22
.Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: Date Initiated: 2/8/22
Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate Date Initiated: 2/8/22
.WANDER ALERT: Resident will have wander guard on at all times to prevent eloping. Date Initiated: 2/8/22.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to ensure a call device was accessible for 1 (#3) of 6 sampled residents. Findings include:
During an observation on 12/7/22 at 10:00 a.m., resi...
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Based on observation and interview, the facility failed to ensure a call device was accessible for 1 (#3) of 6 sampled residents. Findings include:
During an observation on 12/7/22 at 10:00 a.m., resident #3 was asleep in her recliner. Her wheelchair was on the opposite side of the room, and her call light was on her bed, out of reach from her position.
During an interview on 12/7/22 at 10:15 a.m., staff member G stated resident #3 was unable to get up on her own. Staff member G stated resident #3 was wheelchair dependent and required one assist for transfers.
During an observation and interview on 12/7/22 at 1:15 p.m., resident #3 was back in her recliner after lunch. Her wheelchair was on the opposite side of the room, and her call light was on her bed, out of reach from her position. Resident #3 stated she was, trapped when discussing how she would call for assistance from the recliner.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to obtain a consent for a video camera in a resident's room for staff tomonitor him for 1 (#31) of 1 sampled resident. Findings ...
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Based on observation, interview, and record review, the facility failed to obtain a consent for a video camera in a resident's room for staff tomonitor him for 1 (#31) of 1 sampled resident. Findings include:
During an observation on 12/7/22 at 9:16 a.m., a video monitor was on at the nurse's station with a screen showing resident #31's bed, in his room. Resident #31 was not in his room at this time, he was sitting by the nurse's station.
During an interview on 12/7/22 at 9:18 a.m., staff member N stated resident #31 had a video camera in his room that could be pointed at his bed or at his chair to monitor him, wherever he was in his room. Staff member N stated this was so staff could see when resident #31 was trying to get up.
During an interview on 12/7/22 at 9:40 a.m., staff member B stated, resident #31 did have a video monitor in his room that can be viewed at the nurseing station. Staff member B stated this was to monitor the resident, so the staff knew when he was trying to get up. Staff member B stated the monitor was also helpful to view resident #31's behaviors from afar to give him his own space until he settled down. Staff member B stated staff knew to turn the monitor screen at the nurseing station, face down when they were doing cares. Staff member B stated, she did not think staff had been instructed to face the screen down during cares, I would think that would just be a standard of care. Staff member B stated she did not have a consent form for the video camera in resident #31's room, however she stated she had a note written down discussing it with his family.
During an interview on 12/7/22 at 10:25 a.m., staff member G stated, when resident #31 was getting cares she faced his video camera down for privacy. Staff member G stated she was never told to do this.
Review of resident #31's care plan showed, Focus: The resident is (High) risk for falls r/t Gait/balance problems .Interventions: .Floor mat alarm and video monitor in room to alert staff of resident being up and night. Date Initiated: 6/3/22. [sic]
Documentation of a family discussion regarding resident #31's video camera in his room was not provided by end of survey.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a thorough investigation regarding resident-to-resident ab...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a thorough investigation regarding resident-to-resident abuse including interventions to stop further abuse for 2 (#s 12 and 31) of 4 sampled residents. Findings include:
Review of a facility incident, dated 9/8/22 showed, Incident Description: Resident to Resident - RN was assisting another resident when she observed [Resident #12] trying to reposition a chair at nurses station close to [Resident #31], he reached over and pushed [Resident #12] roughly. [Resident #12] was then adjusting a tv [NAME] when [Resident #31] shoved the tv [NAME] roughly pinching other [Resident #12] hand and fingers. Intervention was initiated and redirected [Resident #31] and separated the two from each other. Separated residents from each other out of harm and remained within direct supervision of staff at nurses station. Staff did attempt to ambulate this [Resident #31] to his room but he refused. [Resident #12] fingers show no signs of injury at this time. Findings submitted on 9/12/22, No signs of injury or pain for [Resident #12] regarding incident. Staff has monitored both [Residents #12 and #31] for further altercation or mistreatment toward each other or other residents in the facility. [Resident #31] has showed no further signs of aggression toward other residents. [sic]
During an interview on 12/7/22 at 12:02 p.m., staff member B stated when there was an altercation between two residents, she reviewed the facility's camera footage if they were in a common area that was under video surveillance. She would interview residents and staff regarding the incident and behaviors between the two residents involved in the altercation.
During an interview on 12/7/22 at 12:23 p.m., staff member B stated she did not interview staff or other residents regarding the incident between residents #12 and #31 on 9/8/22. Staff member B stated the only staff member with comments regarding the incident was the nurse on shift who witnessed the incident. Staff member B stated the two residents were seperated then staff watched them, probably until they came back from dinner. Staff member B stated if a resident was aggressive with another resident their behaviors would be documented for five days, once per shift.
Review of a facility policy titled, Abuse Prevention Program with a revision date of 7/6/21 showed, .Reporting/Response:
.1. date and time of the incident
2. who the victim(s) and aggressor(s) are
3. The details of the incident with first and last names as appropriate including ay injuries and subsequent changes in either resident and
4. The plan to stop further abuse or provide safety during the rest of the investigation
5. The LN should also obtain written statements of witnesses and statements from the resident as appropriate. These should be placed in the box in the medication room for the director of nursing or administrator.
Full facility investigation was requested on 12/6/22 at 11:33 a.m. and was not recived by end of survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to recognize a decline in status for 1 (#21) of 1 sampled resident with dementia, which resulted in changes to eating habits and...
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Based on observation, interview, and record review, the facility failed to recognize a decline in status for 1 (#21) of 1 sampled resident with dementia, which resulted in changes to eating habits and an inability to effectively take prescribed medications. Findings include:
During an observation on 12/6/22 at 12:34 p.m., resident #21 was observed sleeping in bed. A lunch tray was covered and sitting on a TV tray next to the recliner.
During an observation on 12/6/22 at 2:29 p.m., resident #21 was not in her room, and the meal tray had been removed.
Review of nutrition charting for 12/6/22, time entered 12:54 p.m., showed resident #21 ate 0-25% of the lunch meal.
During an observation on 12/6/22 at 4:15 p.m., resident #21 was observed walking the hallway around the dining room area independently. She then entered the dining room, where dinner was served at 4:30 p.m per facility schedule.
Review of nutrition charting for 12/6/22, time entered 4:51 p.m., showed resident #21 ate 0-25% of the dinner meal.
During an interview on 12/7/22 at 9:03 a.m., staff member K stated recently resident #21 had progressed to where she frequently just doesn't want to eat and staff can't get her to eat. She was unsure what food the resident preferred, but she thought sweet stuff.
During an interview on 12/7/22 at 9:29 a.m., staff member E stated staff had trouble getting resident #21 to eat her meals and take her medications, and she often staunchly refused to open her mouth for medications or food no matter what they tried. She said resident #21 refused medications four to five days per week.
During an interview on 12/7/22 at 1:35 p.m., staff member B stated resident #21 had been eating very well and had in fact gained weight for a period after she was admitted (6/24/20) to the facility. Staff member B stated there was no concerns regarding any difficulty swallowing, and resident #21 frequently refused medications.
Review of a physician progress note for resident #21, dated 10/24/22, showed .Dementia beginning to get some behavioral disturbance .increase Aricept to 10mg p.o. b.i.d. for her dementia . [sic]
Review of nursing progress notes for resident #21, dated 10/2/22 through 12/6/22, showed 19 occasions where the resident refused or spit out whole or crushed medications. There were six occasions noting resident #21 had difficulty swallowing whole pills.
Review of resident #21's MAR, from 11/1/22 through 12/6/22, showed:
-Resident #21 refused her once daily oral Zoloft pill 23 out of 36 possible administrations, and was sleeping 7 of 36 possible administrations. Resident #21 received 17% of the prescribed medication.
-Resident #21 refused or was sleeping for 25 of 72 possible administrations of the twice daily oral Aricept pill, she received 65% of the prescribed medication.
-Resident #21 was prescribed once daily oral Levofloxacin antibiotic pill for an infection from 11/14/22-11/20/22. She refused three of the seven doses and received 57% of the prescribed medication.
-Resident 21 was prescribed once daily oral Doxycycline pill for a possible hand infection from 11/29/22-12/6/22, of which she refused six of seven doses and received 15% of the prescribed medication.
-Resident #21 took 33 of 36 doses (92%) of MiraLAX, a powdered solution that was drinkable.
Review of pharmacy consult note for resident #21, dated 10/13/22, showed, (resident) was triggered for a significant change, but it was noted she is over all stable and no change in care plan needed.
Record review of documentation for nutrition charting-amount eaten for resident #21, from 8/1/22 to 12/6/22, showed:
-Resident #21 had three days of a possible 61 where she did not eat at all, ate only one meal of 26-50% for the day, or ate three meals 0-25% for the whole day during August and September.
-Resident #21 had 19 days of a possible 67 with no or minimal eating from 10/1/22 to 12/6/22.
Review of Quarterly MDS, ARD of 9/27/22, showed no difficulties swallowing noted under section K- swallowing and nutrition status. Section E- Behavior showed rejection of care (including medications) was marked as occurring 1 to 3 days (over seven-day period).
Review of the current care plan for resident #21 showed, The resident has unplanned/unexpected weight gain r/t overeating, which was last revised on 12/30/21. The goal The resident will lose weight at four lbs per month/week through the review date, was last revised on 4/8/22 with a target date of 7/11/22. There was no goal weight listed. There was no focus or interventions for difficulty taking medications, refusal of medications, refusal of meals, or food preferences.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to accurately reflect a resident's status on the MDS as having less than a six month life expectancy for 1 (#29) of 1 sampled res...
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Based on observation, interview and record review, the facility failed to accurately reflect a resident's status on the MDS as having less than a six month life expectancy for 1 (#29) of 1 sampled residents. Findings include:
During an observation and interview on 12/5/22 at 2:38 p.m., resident #29 was lying in bed, wearing only briefs and a boot on his right foot. His skin was dusky, and his lips appeared to have a bluish tint. The resident was not making sensical words, grasping in the air towards the ceiling, and was unable to respond to questions. There was an oxygen mask on the side of the bed that was running at 12 liters per minute. A CNA entered the room and replaced the oxygen mask. Resident #20's oxygen saturations were noted to be anywhere from 12-50%, and then rose to 96% after several minutes on the oxygen mask. Staff member E stated resident #29 was constantly removing the oxygen, and he did not have much longer to live.
During an interview on 12/7/22 at 10:40 a.m., staff member O stated when resident #29 was admitted (in August 2022) he had an aneurysm that could burst at any moment, and was only expected to live for a few months.
During an interview on 12/7/22 at 1:35 p.m., staff member B stated on admission the facility expectation was resident #29 did not have long (to live), maybe 6 months.
Review of physician progress note for resident #29, dated 10/10/22, showed, . [resident #29] .is here for hospice basically and comfort cares due to nonoperative presence of this significant suprarenal aortic aneurysm/mycotic aneurysm.
Review of a nursing progress note for resident #29, dated 11/22/22, showed Family care conference held . [family member] stated 'well he is close to his 6 months that the doctors said he had left.
Review of resident #29's admission MDS, with ARD of 8/15/22, showed:
-Section J: Prognosis Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months, was marked as no.
Review of resident #29's Quarterly MDS, with ARD of 11/8/22, showed:
-Section J: Prognosis Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months, was marked as no.
Review of a physician order sheet for resident #29, dated 12/5/22, showed, .6) comfort cares.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to create a person centered care plan for a resident with a hearing difficulty for 1 (#28), and a resident who required oxygen a...
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Based on observation, interview, and record review, the facility failed to create a person centered care plan for a resident with a hearing difficulty for 1 (#28), and a resident who required oxygen at night for 1 (#23) of 4 sampled residents. Findings include:
1. During an observation on 12/5/22 at 2:40 p.m., resident #28 was seated in her recliner, in her room. She had a very hard time hearing. This surveyor leaned in to talk to her and had to talk very loudly for her to understand.
During an interview on 12/7/22 at 9:08 a.m., staff member E stated she thought resident #28 had some sort of hearing aides but she was not sure.
During an interview on 12/7/22 at 9:40 a.m., staff member B stated the resident had a communication device in her room. Staff member B stated they were headphones. She stated the staff use them occasionally when she can not hear them. Staff member B stated resident #28 had not had a hearing evaluation completed.
Review of nursing progress notes dated, 5/31/22 showed, .She showed me that her family brought her a dry erase board. She says it is because she cannot hear, and that staff could write on it with chalk if she cannot hear them. I told her that was a great idea she said she didn't figure that staff would want to use it. I assured her that the staff has used dry erase boards and written communication tools with other residents and that it is a great tool for her to have .She said the staff feels she should come out of her room more. I explained that we don't like to see her isolated and that we would like to see her make friends and visit. She says it is difficult to visit related to hearing and the hearing of others .
Review of resident #28's care plan showed:
Focus the resident has a communication problem r/t hearing deficit Date initiated: 6/7/22
Goal: The resident will maintain current level of communication function, she often lets staff know her needs. Date initiated: 6/7/22 Revision on: 8/30/22 Target Date: 9/6/22
Interventions/Tasks: Be conscious of resident position when in groups, activities, dining room to promote proper communication with others. Date Initiated: 6/13/22
COMMUNICATION: Allow adequate time to respond. Repeat as necessary, Do not rush, Request clarification from the resident to ensure understanding, Face when speaking, make eye contact, Turn off TV/radio to reduce environmental noise, Ask yes/no questions if appropriate, Use simple brief, consistent words/cues, Use alternate communication tools as needed. Date initiated: 6/13/22
Speak on an adult level, speaking clearly and slower then normal. Date Initiated: 6/13/22. [sic]
The care plan does not include an alternate hearing device, or a dry erase board, for alternate communication tools.
2. During an observation on 12/5/22 at 2:38 p.m., resident #23 was in her room. The oxygen concentrator was running next to her bed with the oxygen tubing wrapped around her bed side rail.
During an interview on 12/7/22 at 8:42 a.m., staff member K stated resident #23 had orders to wear her oxygen at night time. Staff member K stated resident #23 turned on her oxygen concentrator during the day because she thought it was a heater.
Review of resident #23's physician orders dated, 5/6/21 showed, 1 Oxygen 2L/NC @ night.
Review of resident #23's care plan did not show the resident used oxygen.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
During an observation and interview on 12/5/22 at 2:38 p.m., resident #29 was lying in bed, wearing only briefs and a boot on his right foot. His skin was dusky, and his lips appeared to have a bluish...
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During an observation and interview on 12/5/22 at 2:38 p.m., resident #29 was lying in bed, wearing only briefs and a boot on his right foot. His skin was dusky, and his lips appeared to have a bluish tint. The resident was not making sensical words, grasping in the air towards the ceiling, and was unable to respond to questions. There was on oxygen mask on the side of the bed that was running at 12 liters per minute. A CNA entered the room and replaced the oxygen mask. Resident #29's oxygen saturations were noted to be anywhere from 12-50%, and then rose to 96% after several minutes on the oxygen mask. Staff member E stated resident #29 was constantly removing his oxygen, and he did not have much longer to live.
During an interview on 12/6/2022 at 8:36 a.m., staff member A stated resident #29 had been changed to comfort care on 12/5/2022.
Review of a physician order sheet for resident #29, dated 12/5/22, showed, .6) comfort cares.
Review of nursing progress notes from 11/18/22-11/29/22 for resident #29 showed 7 instances of low oxygen saturations or saturations less than 80% related to the resident's removal of oxygen. Several notes state that nursing staff were reminding resident #29 to keep his oxygen on.
Review of Resident #29's Quarterly MDS, with ARD of 11/8/22, showed a BIMS of 10- moderate cognitive impairment.
Review of a physician progress note for resident #29, dated 10/10/2022, showed, [resident #29] is completely unable to add to his history today .he is completely unable to follow any directions .
Review of resident #29's current care plan showed a lack of interventions to aid the resident in keeping the oxygen on, from the date of initiation of oxygen use (11/18/22 per nursing progress notes) up to the change in status to comfort care.
Based on observation, interview, and record review, the facility failed to update a resident's care plan with fall interventions for 1 (#31), and interventions to prevent removal of an oxygen device for 1 (#29) of 4 sampled residents. Findings include:
During an observation on 12/5/22 at 2:27 p.m., resident #31 was in his room, reclined in his recliner chair, with a mat under his feet, at the edge of his recliner.
During a interview on 12/7/22 at 9:40 a.m., staff member B stated, when a resident has a fall the nurse is supposed to assess them. They look for reasons the resident had fallen, and make sure the resident was not injured. An Un-witnessed fall or falls with injury are reported in risk management, and the risk management team writes up an incident report to find interventions for the fall, without restraining the resident.
Review of resident #31's care plan showed:
Focus: The resident is (High) risk for falls r/t Gait/balance problems. Interventions: Anticipate and meet the resident's needs. Date initiated: 6/3/22 Revision On: 12/5/22
Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Date initiated: 6/3/22
Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility such as NuStep. Date initiated: 6/3/22
Ensure that The resident is wearing appropriate footwear when ambulating or mobilizing in w/c. Date initiated: 6/3/22
Floor mat alarm and video monitor in room to alert staff of resident being up and night. Date initiated: 6/3/22. [sic]
Review of a facility report for resident #31 titled, un-witnessed dated, 11/21/22 showed, During a shift change, activity staff alerted nursing that [Resident #31] was laying on the floor in their room. Upon entering the room, [Resident #31] noted to be laying on their back, head at the bottom of their book shelf and pictured knocked over. Wheel chair close by. [Resident #31] unable to give Description. Immediate action taken: Assessed for injuries, none noted, although head was laying on their bottom shelf. [Resident #31] alert and able to assist w/standing up and getting into their wheelchair. Neuros started and DON notified. [Resident#31] remained by nurses station for close observation for safety.
No new interventions were noted on the resident #31's care plan after the fall on 11/21/22 was reviewed.
Review of a facility report for resident #31 titled, un-witnessed dated, 12/4/22 showed, This RN was doing evening med pass and assisting residents in the Dining room noted [resident #31] was on the floor in front of bedroom sink. Resident reports that he was attempting to get up and walk to the dining room for supper when he slipped on the floor. Resident denied hitting his head did report that he hit his right elbow. Neuro exam negative at this time, grips equal bilaterally nc distress. This Rn and CNAs assisted resident up off the floor and into wheel chair. Skin on right elbow intact resident has full range of motion at this time .Immediate Action Taken: This RN assessed resident before moving him to wheel chair neuro assessment intact. DON and family notified. [sic]
No new interventions were noted on the resident #31's care plan after the fall on 12/4/22 was reviewed.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to consider a rapid decline in condition and prevent the development of one unstageable pressure ulcer on the heel, and one unas...
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Based on observation, interview, and record review, the facility failed to consider a rapid decline in condition and prevent the development of one unstageable pressure ulcer on the heel, and one unassesed pressure ulcer on the coccyx, for 1 (#29) of 1 sampled resident. Findings include:
During an observation on 12/5/22 at 2:38 p.m., resident #29 was lying in bed, wearing only briefs and a boot on the right foot.
During an interview on 12/7/22 at 1:35 p.m., staff member B stated she was unsure if resident #29 had any pressure ulcers on admission, or what interventions were in place to prevent pressure ulcers, and would have to look at the resident's admission forms and care plan. She said the facility's expectation was resident #29 did not have long to live on his admission, six months or less.
Review of the admission MDS for resident #29, dated 8/15/22, showed the resident was marked as not at risk for pressure ulcers, and the resident did not have any unhealed pressure ulcers.
Review of a physician progress note for resident #29, dated 9/12/22, showed, .CVA with resultant inability for self-care based on the right hemiplegia, right neglect .
Review of a skin evaluation for resident #29, dated 9/30/22, showed the resident had a new unstageable blister to the right heel.
Review of the Quarterly MDS for resident #29, dated 11/8/22, showed the resident was marked yes for at risk for pressure ulcers, and the resident had an unhealed pressure ulcer. Resident #29 was marked as needing extensive assistance with bed mobility and transfers. Resident #29 was marked as using a wheelchair.
Review of a nursing progress note for resident #29, dated 11/27/22, showed .1/4 cm circular open (wound) noted to resident's coccyx.
Review of resident #29's current care plan showed:
Documented Pressure Ulcer Has a unstageable blister on the right heal .Interventions-evaluate ulcer characteristics . [sic]
There were no interventions for pressure reducing devices on the bed or wheelchair, no turning schedule noted, and no additional interventions related to the pressure ulcer on the coccyx.
There was no skin assessment provided by the facility for the coccyx wound noted on 11/27/22.
Review of a physician order for resident #29, dated 12/5/22, showed, .6) comfort cares .
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to protect a resident from harm for two separate incident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to protect a resident from harm for two separate incidents during a resident-to-resident altercation due to a lack of continuous interventions and proper supervision, for 5 (#s 1, 10, 12, 15 and 31) out of 5 sampled residents. Findings include:
1. Review of a facility reported incident dated, 2/25/22 showed, Findings .No further details to add to incident. [Resident #10's] scratches to arms are showing signs of healing. Families of both parties have been notified as well .[resident #12] had been increasingly harder to redirect, despite staff attempts to limit her wandering by distraction or 1:1 activities.Incident Description: Resident to resident altercation. [Resident #10] stated that when she returned to her room. [Resident #12] was in her room looking through her things. [Resident #10] asked her what she was doing and then to get out of her room. [Resident #10] stated [Resident #12] reached out and scratched [resident #10] on her arm, then [resident #12] left her room. LN on duty noted [resident #10] had 8 scratches to her right forearm and one small circular area near her inner elbow. Some of these scratches have the appearance of linear hematomas per LN's report. Areas have been assessed and cleansed and will monitor daily until healed. [Resident #12] was noted to small scratches on bottom inner lip. No other signs of pain or injury to either resident. Staff will continue to provide [resident #12] with activities in her room or near the nurses station to decrease her wandering. [sic]
Review of nursing progress notes for resident #15, dated 2/25/22 showed, Staff reported altercation between this resident and another resident. Went to resident's room to assess injuries. Observed scratches on resident's right forearm. Asked resident what happened. Resident stated when she returned to her room, [resident #12] was in room [ROOM NUMBER] looking for things. This resident asked what she was doing and then to get out. Then [resident #12] reached out and scratched this resident on the right forearm .Resident denied any discomfort but did state when first scratched, arm did hurt. Ask if she was ok and felt safe. Resident stated she was ok and felt safe but she wished other resident [#12] would stay out of her room . [sic]
Review of nursing progress note for resident #12, dated 2/25/22 showed, Staff reported altercation between this resident and another resident and stated this resident was holding mouth which had been bleeding. Observed mouth. No active bleeding observed. Small scratch noted on bottom inner lip. Resident seemed unaware of scratch and was no longer holding mouth when this RN observed . [sic]
During an observation on 12/6/22 at 4:12 p.m., staff members were busy assisting residents to the dining room for dinner and were not in eyesight of resident #12. Resident #12 was wandering the north hall by resident #1's room. Resident #12 started to push and knock on resident #1's door, which had a wooden ½ door in front of the main door. Resident #10 yelled at resident #12 to not go in that room and to stop banging on the door. Resident #12 walked away from the door and preceded to attempt to exit the facility out of the north hallway exit door. Resident #12 pushed on the door until it unlatched. Staff member J stopped her before she exited the facility.
During an interview on 12/7/22 at 8:42 a.m., staff member K stated resident #12 often wandered into other resident's rooms and would take their things and move their stuff around. Staff member K stated residents got really upset by this. Staff member K stated resident #10 did not get along with resident #12 so staff have to watch them closely.
During an interview on 12/7/22 at 9:40 a.m., staff member B stated, the staff were aware that resident #12 wandered into other resident's rooms but stated it was unrealistic to have someone watch resident #12 all the time. Staff member B stated other residents did get frustrated with her wandering into their rooms because she would move things around and take things out of their room. Staff member B stated resident #12 was not cognitively doing this. Staff would redirect her when they find her in other resident's rooms and replace items from other resident's rooms when they find them throughout the facility. Staff member B stated after a resident to resident altercation, the residents who were involved have behavior monitoring for 5 days, once per shift. Staff member B stated she did not think the behaviors were monitored specifically between the residents involved, more so in general towards any resident in the facility.
Review of resident #12's care plan showed:
Focus: The resident is an elopement risk/wanderer, r/t Disoriented to place, History of attempts to leave facility unattended, Impaired safety awareness, Resident wanders aimlessly, significantly intrudes on the privacy or activities Date Initiated: 2/8/22
.Goal: The resident's safety will be maintained through the review date. Target Date: 1/31/22 .
.Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: Date Initiated: 2/8/22
Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate Date Initiated: 2/8/22 .
2. Review of facility incident dated, 9/8/22 showed, Incident Description: Resident to Resident - RN was assisting another resident when she observed [Resident #12] trying to reposition a chair at nurses station close to [resident #31], he reached over and pushed [Resident #12] roughly. [Resident #12] was then adjusting a tv [NAME] when [resident #31] shoved the tv [NAME] roughly pinching other [Resident #12] hand and fingers. Intervention was initiated and redirected [Resident #31] and separated the two from each other. Separated residents from each other out of harm and remained within direct supervision of staff at nurses station. Staff did attempt to ambulate this [Resident #31] to his room but he refused. [Resident #12] fingers show no signs of injury at this time. Findings submitted on 9/12/22, No signs of injury or pain for [Resident #12] regarding incident. Staff has monitored both [Resident #12 and #31] for further altercation or mistreatment toward each other or other residents in the facility. [Resident #31] has showed no further signs of aggression toward other residents. [sic]
Review of nursing incident description dated, 9/8/22, showed, Immediate action Taken: Redirected [Resident #12] and assessed [Resident #12] hand/fingers for injury. [Resident #12] was crying and holding their hand. No initial injury noted. Separated [Residents #s 12 and 31] from each other.
During an interview on 12/7/22 at 12:02 p.m., staff member B stated when there was an altercation between two residents, she reviewed the facility's camera footage if they were in a common area that was under video surveillance. She would interview residents and staff regarding the incident and behaviors between the two residents involved in the altercation.
During an interview on 12/7/22 at 12:23 p.m., staff member B stated she did not interview staff or other residents regarding the incident between residents #12 and #31 on 9/8/22. Staff member B stated the only staff member with comments regarding the incident was the nurse on shift who witnessed the incident. Staff member B stated the two residents were separated then staff watched them, probably until they came back from dinner. Staff member B stated if a resident was aggressive with another resident their behaviors would be documented for five days, once per shift.
Review of the facility's policy and procedure titled, Abuse Prevention Program revised 2/22/19, showed, .Investigation: Initial investigations shall be accomplished by the charge nurse on duty as it is his/her responsibility to make an initial determination on the allegation in order to ensure that any/all residents will be safe. All allegations of abuse shall be strenuously investigated by the Director of Nursing or Administrator. The Director of Nursing or Administrator is responsible for the following:
Investigation results are to be sent to the Certification Bureau within 5 working days of the receipt of the report of abuse.
.The outcome of the investigation. The plan to prevent the same sort of incident of abuse/neglect in the future
The action taken against the aggressor (staff to resident)
The name and date of the person who conducted and completed the investigation.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility staff failed to perform hand hygiene during dirty to clean linen changes, and failed to have a process and measures in place to prevent...
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Based on observation, interview, and record review, the facility staff failed to perform hand hygiene during dirty to clean linen changes, and failed to have a process and measures in place to prevent the growth of opportunistic waterborne pathogens per national standards. These deficient practices had the potential to affect all residents in the facility. Findings include:
1. During an observation on 12/6/22 at 8:35 a.m., a staff member was observed dropping bagged dirty linen into a hallway hamper and grabbing clean linen from a cart with no hand hygiene in between.
During an observation on 12/7/22 at 7:57 a.m., two staff members, at opposite hallway ends, were observed bringing bagged dirty linen from a resident room to the bin in the hallway, placing the bag into the hallway hamper, and gathering clean linen from a supply cart. Neither staff member performed hand hygiene between the dirty to clean task.
During an interview on 12/7/22 at 8:31 a.m., staff member B stated that staff should not be performing dirty to clean linen tasks without hand hygiene in between.
Review of a facility document titled, Montana Department of Public Health and Human Services Nurse Aide Competency Skill Checklist, no date, showed, Disposal of contaminated supplies, and, Proper linen handling storage disposal as skills for staff.
2. During an interview on 12/7/22 at 8:31 a.m., staff members A and B did not know the facility measures to prevent the growth of Legionella or other opportunistic waterborne pathogens. They stated the maintenance man was new and probably did not know either.
Request for facility water testing logs/protocol/policy for waterborne pathogens was requested on 12/7/22 at 2:38 p.m. The facility responded, Temp only, city H2O system.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Montana facilities.
- • 38% turnover. Below Montana's 48% average. Good staff retention means consistent care.
Concerns
- • 42 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • Grade D (45/100). Below average facility with significant concerns.
Bottom line: Trust Score of 45/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Sweet Memorial's CMS Rating?
CMS assigns SWEET MEMORIAL NURSING HOME an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Montana, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Sweet Memorial Staffed?
CMS rates SWEET MEMORIAL NURSING HOME's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 38%, compared to the Montana average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Sweet Memorial?
State health inspectors documented 42 deficiencies at SWEET MEMORIAL NURSING HOME during 2022 to 2025. These included: 1 that caused actual resident harm and 41 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Sweet Memorial?
SWEET MEMORIAL NURSING HOME is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 42 certified beds and approximately 36 residents (about 86% occupancy), it is a smaller facility located in CHINOOK, Montana.
How Does Sweet Memorial Compare to Other Montana Nursing Homes?
Compared to the 100 nursing homes in Montana, SWEET MEMORIAL NURSING HOME's overall rating (2 stars) is below the state average of 2.9, staff turnover (38%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Sweet Memorial?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Sweet Memorial Safe?
Based on CMS inspection data, SWEET MEMORIAL NURSING HOME has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Montana. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Sweet Memorial Stick Around?
SWEET MEMORIAL NURSING HOME has a staff turnover rate of 38%, which is about average for Montana nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Sweet Memorial Ever Fined?
SWEET MEMORIAL NURSING HOME has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Sweet Memorial on Any Federal Watch List?
SWEET MEMORIAL NURSING HOME is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.