Beartooth Rehabilitation and Nursing LLC

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement and operationalize a smoking policy when there were smokers residing at the facility, who were unsafe and kept their smoking materials. Residents smoked in a designated and unmonitored smoking area; one resident (#12) utilized oxygen and kept her nasal cannula and oxygen cannister in close proximity while smoking, to include using a lighter with an open flame; resident (#20) was often in proximity to resident #12 when smoking, which placed her at a higher risk of injury due to the unsafe smoking practices of resident #12. The facility did not identify and address individualized smoking safety risk factors, and care plans were not implemented with individualized safety interventions to mitigate smoking-related risks for 6 (#s 5, 12, 20, 23, 24, and 35); [...]

Inspectors wroteBased on observation and interview, the facility failed to employ a certified dietary manager who provided necessary oversight to the kitchen or a full-time dietician to oversee the dietary department. This deficient practice had the potential to affect all residents who received meals and nutritional services by increasing the risk for nutritional concerns, inadequate oversight of food service operations, and compromised food quality and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food, thaw potentially hazardous food, handle food for meal service, and maintain kitchen equipment in a clean and sanitary manner to prevent potential contamination and growth of bacteria. These deficient practices were observed in the dry storage area, dish room, food preparation area, and during meal service, and resulted in unsanitary conditions in the kitchen. These failures would affect any resident who received food and or services from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to provide effective administrative oversight of day-to-day operations to ensure regulatory compliance related to abuse prevention processes, infection control, housekeeping, dietary services, and activities, for 8 (#s 9, 17, 27, 28, 29, 30, 37 and 46) of 28 sampled residents. The failures increased the risk of facility residents to experience inadequate protection from abuse, inadequate protection from communicable disease, unmet care needs, unsanitary environment, inadequate dietary services, and an ineffective activity program.

Inspectors wroteBased on interview and record review, the facility's governing body failed to ensure necessary oversight was provided for the identification and correction of quality deficient practices directly involving staff member A and oversight of the facility's systems and services. The facility had two consecutive surveys with findings of Immediate Jeopardy in the areas of F689 - Accidents and Hazards, and multiple deficiencies were identified directly involving staff member A's failures to take necessary or appropriate action on a concern. This deficient practice placed residents in the facility at continued risk of their needs not being met related to safety, care, and services provided.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete a facility assessment and failed to identify 1 resident (#46) of 1 resident sampled for care needs. The failure resulted in elevated risk for resident needs not to be accurately and safely met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective QAPI program that identified quality-deficient practices for corrections to needing to be made. There was no documentation or evidence of an ongoing comprehensive quality assurance program. The failure resulted in residents not being monitored for accidents and safety concerns related to smoking, and other system concerns identified during the survey, and administration was aware of the concerns, but appropriate action was not taken to implement a plan to correct them.

Inspectors wroteBased on interview and record review, the facility failed to implement an infection prevention and control program which ensured pre-employment TB screening was completed upon hire in accordance with facility policy and nationally recognized standards. The failure placed residents at elevated risk for exposure to communicable disease.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain a clean, comfortable, and homelike environment for 2 (#s 9 and 29) of 30 sampled residents, and may affect others who were bothered by the lack of services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect residents from inappropriate physical contact between residents for 3 (#s 17, 28, and 37), failed to ensure a resident was free from verbal abuse by a staff member for 1 (#42) and failed to ensure a resident was free from neglect related to elopements for 1 (#46) of 7 residents sampled for abuse. With each elopement, the facility neglected to address it thoroughly for future prevention, thus continuing the risk of elopement and harm.

Inspectors wroteBased on interview and record review, the facility failed to report investigative findings for reportable events within the required timeframe for 4 (#s 27, 28, 37, and 46) of 8 residents sampled for event reporting. The failure placed the residents at elevated risk for delayed protective interventions, emotional distress, and injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident's care plan was reviewed and revised by an interdisciplinary team when a resident had a change in condition for 1 (#4); failed to ensure the resident representative was involved in the care planning process or invite the resident's representative to care plan meetings for 1 (#8) of 30 sampled residents, and failed to ensure a resident-centered care plan was updated to include information about oxygen and safety precautions for 2 (#s 12 and 20) of 6 residents sampled for smoking. These deficient practices limited the staff's ability to perform care and communicate effectively, limited the resident representative's involvement in treatment and care decisions, and posed hazards related to unsafe smoking for residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure binding arbitration agreements were presented in a manner allowing informed and voluntary consent, and failed to ensure arbitration agreements were not effectively treated as routine admission paperwork, for 3 (#s 6, 12, and 25) of 30 sampled residents. The failure placed the residents at elevated risk for signing binding legal agreements without informed choice and limiting access to the court system.

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's representative of changes in resident care and treatment for 1 (#25) of 30 sampled residents. The failure resulted in the POA's missed opportunity to be informed of changes to the resident's care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure a thorough investigation of facility-reported events for 1 (#46) of 8 residents sampled for facility-reported events. The failure placed the resident at risk for inadequate protection from harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to address the limited range of motion of the right hand for 1 (#1) of 30 sampled residents. This deficient practice increased the risk for further decline in the resident's functional ability and range of motion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an activity program to meet the individual needs and interests for 2 (#s 9 and 29) of 30 sampled residents. The failure resulted in resident dissatisfaction with the activities program and boredom.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services to prevent a decline in range of motion for 1 (#1) of 30 sampled residents, and the range of motion limitations affected the resident and her ability to complete or participate in ADL care and increased the resident's risk of a continued deterioration in the resident's range of motion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and provide services for 1 (#41) of 30 residents who exhibited signs of depression and was having a difficult time adjusting to the facility. The failure resulted in the resident feeling lonely, isolated and depressed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain complete and accurate clinical records by failing to include a documented admission agreement in the medical record for 1 (resident #17) of 30 sampled residents. The failure placed the resident at elevated risk for lack of clarity regarding services, responsibilities, and resident rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and monitoring and ensure the safety and well-being of a cognitively impaired resident who displayed frequent wandering patterns, and the resident had an unwitnessed fall with major injury. This failure resulted in the resident being transferred to the ER, a hospitalization, a surgical procedure, and a total loss of independent ambulation for 1 (#4) of 6 residents sampled for falls; and the facility staff failed to follow the established policies and procedures. These failures were identified to be an Immediate Jeopardy situation. [...]

Inspectors wroteBased on interview and record review, the facility failed to recognize and protect a resident's right to be free from neglect, following a resident's major injury from an unwitnessed fall, and the resident had severe cognitive impairment; for 1 (#4) of 12 sampled residents. The deficient practice resulted in the resident experiencing pain, was not thoroughly assessed after the fall, and there was a delay in timely care, which resulted in the resident's surgery and hospitalization.

Inspectors wroteBased on interview and record review, the facility staff failed to perform a thorough head-to-toe assessment, pain assessment, or transfer a resident appropriately after an unwitnessed fall with injury, which was consistent with professional standards of nursing practice, for 1 (#4) of 12 sampled residents. This deficient practice caused an increase in the resident's signs and symptoms of pain, due to a fall that resulted in a hip fracture.

Inspectors wroteBased on interview and record review, the facility failed to maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the regulatory requirements, and show systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities. The facility failed to implement a comprehensive QAPI plan that would sufficiently identify and correct quality concerns, and this failure may affect all residents of the facility.

Inspectors wroteBased on interview and record review, the facility failed to have the required members for attendance and participation in Quality Assurance and Performance Improvement (QAPI) meetings, including the Medical Director (or Designee), which were at a minimum, required to be completed quarterly. This deficient practice had the potential to affect all residents who received care in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure a routine written notification of a resident transfer and discharge was completed and maintained, with information regarding the transfer and discharge to the local Ombudsman for 4 (#s 3, 4, 10, and 12) of 12 sampled residents reviewed for a transfer and or discharge from the facility. The deficient practice increased the risk of residents being inappropriately transferred or discharged due to the lack of communication to the resident or advocate.

Inspectors wroteBased on interview and record review, the facility failed to implement and uphold policies and procedures for the reporting of an unwitnessed fall, for a resident who was not a reliable reporter, and the resident sustained a hip fracture, had surgery, and was hospitalized for it, or 1 (#4) of 6 residents sampled for falls; and facility staff neglected to provide necessary services to the resident after the fall, which was not identified as neglect of care, and reported to the State Survey Agency following the event.

Inspectors wroteBased on interview and record review, the facility failed to initiate an abuse or neglect investigation following an event when a resident experienced an unwitnessed fall resulting in major injury, which required surgery and hospitalization for 1 (#4) of 6 residents sampled for falls, and the licensed nursing staff failed to ensure the resident was provided necessary care and services related to the fall and negative outcomes from it, or follow the facility policies or procedures, or standards of practice for nursing care. This deficient practice caused a delay of the allegation of abuse or neglect being sent to the State Survey Agency and increased the risk for residents in the facility due to the facility not identifying, thoroughly investigating, and failing to report facility reported events.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a Significant Change MDS for a resident's decline, for 1 (#4) of 12 sampled residents. This deficient practice increased the risk of the resident not receiving necessary care due to the lack of changes being identified using the MDS assessment process.

Inspectors wroteBased on interview and record review, the facility failed to submit a Quarterly MDS (Minimum Data Set) assessment within the required time frame for 1 (#3) of 12 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to code medications accurately on the MDS assessment for 1 (#3) of 12 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to revise a comprehensive care plan to include behavioral health services being provided for 1 (#3) of 12 sampled residents. This deficient practice increased the risk of the resident not receiving necessary services for mental health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a facility policy which contained the name and contact information for the grievance official; failed to provide residents with readily available grievance forms; and failed to provide residents with the option to file grievances anonymously for 2 (#s 1 and 7) of 8 sampled residents. This deficient practice affected current residents residing in the facility who wished to know information for, review the information from, or use, the grievance process.

Inspectors wroteBased on observation and interview, the facility failed to post the results of the most recent certification survey in an area readily accessible to residents, family members, and residents' legal representatives. This deficient practice had the potential to affect all residents or resident representatives wishing to view the most recent certification survey results.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's room was kept clean and hazard-free as needed, and this concerned the resident and family, for 1 (#7) of 8 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive, resident-centered care plan which identified residents' physical and psychosocial needs to help the residents reach their highest practicable level of well-being, and failed to identify preventative interventions, for 4 (#s 155, 156, 157 and 163) of 13 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff member H adhered to proper infection prevention and control practices during medication administration for 1 (#157) of 4 sampled residents for medication administration; failed to ensure enhanced barrier precautions were implemented and followed, for 3 (#s 154, 156, and 157) of 13 sampled residents; and failed to follow proper infection control practices were used when transferring dirty and clean laundry.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean and sanitary environment for 2 (#s 151 and 155) of 13 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update resident care plans when changes to the resident's care occurred for 2 (#s 157 and 164) of 13 sampled residents.

Inspectors wroteBased on observation, interview, and record review, staff member F failed to adhere to professional standards of practice by crushing a delayed release medication not recommended to crush, for 1 (#155) of 4 sampled residents for medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a dependent resident was getting turned frequently enough to prevent skin breakdown, for 1 (#154) of 13 sampled residents, and the resident was identified to have new skin redness to the coccyx and perineum.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure BiPAP parameter orders were in place for 1 (#154) of 3 sampled residents with respiratory concerns.

Inspectors wroteBased on interview and record review, the facility failed to ensure prn psychotropic medications were limited to 14 days, for 1 (#156) of 13 sampled residents.