Clark Fork Valley Nursing Home

Inspectors wroteBased on observation, interview, and record review, the facility failed to document a thorough investigation of an allegation of sexual abuse for 1 (#8) of 14 sampled residents. This had the potential to cause the facility to miss key parts of the investigation.

Inspectors wroteBased on interview and record review, the facility failed to refer a resident with a new diagnosis of bipolar disorder to the appropriate state-designated mental health authority (PASRR) for review for 1 (#6) of 14 sampled residents. This deficient practice had the potential to cause a delay or missed services for resident #6 to meet their highest practicable mental health status.

Inspectors wroteBased on interview and record review, the facility failed to address the aggressive and intrusive behavior of a resident with dementia toward others, and she was involved in many resident-to-resident abuse events. The resident's MDSs showed various declines occurred over the period of time, and the resident's mobility, pain, incontinence level, and mood/behaviors changed during the time many of the events were identified. The facility did not report the events as abuse or investigate the events fully (Refer to F609 and F610). The facility failed to assess the resident's individualized behaviors and antecedents to them, in a proactive attempt to prevent future events or alleviate the resident's anger/frustration. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to complete proper hand hygiene during resident medication pass, and use proper PPE when transporting dirty housekeeping equipment, to the washing machine. This deficient practice had the potential to spread infection to all residents in the facility receiving care.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from resident to resident abuse incidents, and failed to provide protection before or following each event to prevent further resident to resident abuse, by resident #19, who was the aggressor; and, the abuse resulted in injury for 1 (#10) of 17 sampled residents and affected many others.

Inspectors wroteBased on interview and record review, the facility failed to report resident to resident abuse allegations to the State Survey Agency within the required reporting period, for 1 (#19) of 17 sampled residents. The events occurred over many months and involved different residents, without staff taking appropriate action for reporting the events.

Inspectors wroteBased on interview and record review, the facility failed to recognize abuse and thoroughly investigate the potential for abuse; and failed to take appropriate action to prevent and protect other residents from further resident to resident abuse events which occurred repeatedly over a period of time, for 1 (#19) of 17 sampled residents, and the resident acted out aggressively towards others to include causing minor injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete MDS assessments accurately for restraint use for 3 (#s 8, 16, and 24), and accurately identify an antidepressant medication for 1 (#10) of 17 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of expired stock medication, and ensure the medication cart was secure prior to leaving the area where the medication cart was located. This deficient practice had the potential to affect residents receiving medications dispensed from the medication cart.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive care plan reflected a high risk medication and side effects for 1 (#8), and account for the sleeping preferences for 1 (#20) of 17 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a care plan was revised to include comfort care for 1 (#22) of 17 sampled residents. This deficient practice increased the risk of the resident's needs to be unmet by facility staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure a program was in place to maintain or restore bladder function for 2 (#s 8 and 18) of 17 sampled residents. This deficient practice had the potential to cause an increase in urinary incontinence.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure weights were accurate and correct in the medical record and failed to ensure a process was in place and followed for re-weights, for 1 (#24) of 17 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to identify and address past trauma for a resident; and provide trauma informed care, within professional standards that accounted for a resident's experiences and preferences, for 1 (#24) of 17 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to provide medical social services for 1 (#24) of 17 sampled residents. This deficient practice had the potential to negatively impact the resident's mental well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure an as needed antianxiety medication was limited to 14 days, or provide a rationale for continued extension of the medication, for 1 (#24) of 17 sampled residents.

Inspectors wroteBased on observation and interview, the facility failed to post a list of names and contact information for state regulatory and advocacy groups, the State Survey Agency or State licensure office, or include information for residents wishing to file a complaint with the State Survey Agency. This deficient practice had to potential to affect all residents, resident representatives, or staff wishing to view or know the information.

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

Inspectors wroteBased on interview and record review, the facility failed to establish and maintain an antibiotic stewardship program with the required elements, including using a standardized assessment tool and criteria for the evaluation of infections, and a system to monitor the use of antibiotics for the duration of treatment, for 2 (#s 8 and 20) sampled residents. This deficient practice had the potential to affect any resident with an antibiotic prescribed.