Ivy at Deer Lodge

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to correctly position a mechanical lift sling to prevent an accident, which caused injury to a resident when she fell from the lift, for 1 (#5) of 14 sampled residents. This deficient practice caused the resident to experience pain, she had an injury to the head, and a fear of the lift, which has not subsided.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify psychosocial harm after a resident's traumatic experience and fall from a mechanical lift, and failed to provide medically necessary social services for 1 (#5) of 14 sampled residents. This deficient practice caused the resident to continue to be fearful of transfers with the lift and falling, which increased her anxiety.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure staff performed appropriate hand hygiene during meal service; failed to ensure laundry staff removed personal protective equipment appropriately after working with dirty laundry and linens; and failed to ensure staff performed all resident cares wearing personal protective equipment for Enhanced Barrier Precautions per CDC guidelines. These failures placed residents at increased risk for transmission of infectious organisms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an assessment was completed to evaluate the safety of residents who desired to self-administer medications for 2 (#8 and #43) of 4 observed medication administration residents.

Inspectors wroteBased on interview and record review, the facility failed to revise a resident's comprehensive care plan with interventions after an incident with a mechanical lift and failed to include psychosocial interventions for 1 (#5) of 14 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff member C primed an insulin pen prior to administration of insulin for 1 (#43) of 4 observed medication administration residents.

Inspectors wroteBased on observation, interview, and record review, facility failed to identify, assess, document, measure, obtain, and follow physician orders for wound care for 3 (#s 2, 3, and 4) of 6 sampled residents. The facility failed to identify changes in the resident's skin status, which occurred over a short period of time, and failed to address wound changes timely for the provision of medical assistance or needed interventions. The facility failed to have a wound management system in place that provided the necessary oversight for care and treatment of wounds, based on professional standards of practice. Resident #4 was admitted to the facility with multiple wounds in various stages of breakdown, and the wounds were documented to be getting worse, in part due to his uncontrolled pain. On 11/20/24 at 2:02 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of neglect for 3 (#s 2, 3, and 4) of 6 sampled residents. The facility failed to have systems in place for wound care, which resulted in three Immediate Jeopardy deficiencies being identified. Resident outcomes included: a. Resident #2 showed progressive worsening of pressure ulcers from a Stage II (blisters) worsening to Unstageable in ten days, and the resident was admitted to the hospital for the worsening wounds with foul odor, increased assistance with ADLs, and edema. b. Resident #3 showed progressive worsening of pressure ulcers and was placed on hospice, following a hospital stay with sepsis, and passed away at the facility, upon returning. c. Resident #4 was admitted to the facility with skin tears, with varying stages of healing, and pressure injuries. [...]

Inspectors wroteBased on interview and record review, the facility failed to assess, document, treat, and monitor pain for 1 (#4) of 6 sampled residents. Resident #4 had severe pain during pressure ulcer dressing changes and turning and repositioning, which caused the resident to refuse care and dressing changes. Resident #4 expressed to the staff the pain regimen he had in place had not worked in relieving his pain during dressing changes and cares, resulting in increased skin breakdown. Resident #4 was transferred to the hospital on [DATE], and he passed away on 11/10/24. The facility failed to provide adequate pain management in a timely and effective manner to meet the resident's pain needs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items in the refrigerator and freezer were labeled and dated, failed to maintain a clean and sanitary environment in the kitchen, and the facility failed to ensure kitchen staff wore beard coverings while serving food. This deficient practice had the potential to affect all residents receiving food from the facility's kitchen.

Inspectors wroteBased on observation and interview, the facility failed to remove and dispose of expired medical supplies in the medication room. These failures increased the risk of expired medical supplies being used for any resident at the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide written notice of the reason for a facility-initiated transfer to a resident or the resident's representative, for 3 (#s 36, 54, and 149) of 3 sampled residents for transfers, and staff were not aware of the process of the transfer notices, who completed them, and a policy and procedure was not provided to show it was operationalized; and the facility failed to notify the Office of the State Long-Term Care Ombudsman, for 1 (#36) of 3 residents sampled for hospitalizations.

Inspectors wroteBased on interview and record review, the facility failed to provide evidence to show the facility took action to acknowledge and resolve, or attempt to resolve, all concerns brought forth by the resident council. The failure had the potential to affect all residents who attended the resident council or who had interest in the council's activities, and specifically 3 (#s 4, 7, and 21) of 3 sampled residents who attended resident council.

Inspectors wroteBased on interview and record review, the facility failed to provide the required bed hold notice to the resident or the resident's representatives prior to, or timely after, a transfer, for 2 (#s 54 and 149) of 3 residents sampled for hospitalizations.

Inspectors wroteBased on interviews and record reviews the facility failed to allow the residents a choice for their attending physician for 3 (#s 2, 3, and 4) of 3 sampled residents for physician services.

Inspectors wroteBased on observation and interview the facility failed to provide a clean homelike environment for 3 (#s 2, 3, and 4) of 3 sampled residents and had the potential to affect all residents who go to the dining room.

Inspectors wroteBased on interview and record review the facility failed to allow free access to visitors for 1 (#2) of 2 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards for medications being administered, per the physician's order, and the resident had insomnia, for 1(#2) of 1 sampled resident.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide hospice services in coordination with the management and staff of the nursing home per the hospice agreement for 1 (#2) of 2 sampled residents.

Inspectors wroteBased on interviews and record review, the facility failed to refund the resident or resident representative refunds within 30 days from the resident's date of discharge from the facility for 2 (#s 1 and 2) of 2 sampled residents for refunds. This practice had the potential to affect any residents discharging with a refund due.

Inspectors wroteBased on interviews and record review, it was identified the facility had a system breakdown when a new CNA was hired and left alone prior to the end of the new hire orientation period, and the employee did not have the necessary competencies, skills, or supervisory oversight; and, the employee failed to provide incontinence care, resulting in neglect, for 5 (#s 5, 6, 7, 8, and 9) of 14 sampled residents. The neglect of care increased the risk of skin breakdown for those residents.

Inspectors wroteBased on interviews and record review, the facility failed to thoroughly investigate allegations of neglect, misappropriation of resident property, and abuse for 7 (#s 3, 4, 5, 6, 7, 8, and 9) of 14 sampled residents. This practice increased the risk of ongoing neglect, abuse, or misappropriation, for any resident who was found to have been allegedly neglected, abused, or a victim of misappropriation of property.

Inspectors wroteBased on interviews and record review, the facility failed to provide to provide necessary staff training for a new employee, and ensure the employee was competent, and then provide sufficient supervision and assistance, to meet resident care needs, for 5 (#s 5, 6, 7, 8, & 9) of 14 sampled residents. This failure led to neglect of care for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oversight to ensure the dietary manager had the appropriate competencies and skills to carry out the functions for the food and nutritional services department. This deficiency had the potential to affect all residents consuming food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify quality deficiencies through the utilization of their QAPI process related to qualified dietary staff and resident food preferences and choices. These deficient practices had the potential to affect all residents which consumed food in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident POLST forms were complete, and included the patients/legal decision maker signature, date, and time, for 4 (#s 3, 6, 11, and 18) of 15 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean environment, related to housekeeping services, for 5 (#s 7, 10, 24, 26, and 34) of 15 sampled residents. This deficiency had the potential to affect all residents at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an effective discharge planning process which focused on the resident's discharge goals; updated a resident's comprehensive discharge plan; and discussed the plan with the residents for 3 (#s 8, 37, and 46) of 15 sampled residents.

Inspectors wroteBased on observation and interview, the dietary department failed to honor resident food preferences and provide choices for 2 ( #s 41 and 46) of 15 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, including the resident's preferences and future discharge planning for 1 (#46) of 15 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify the extent of the weight loss for 1 (#34) of 15 sampled residents. This deficient practice had the potential to have contributed to resident #34's loss in 32 days, and the resident stated she was on a diet and not eating some foods provided.

Inspectors wroteBased on record review and interview, the facility failed to complete and provide a NOMNC (CMS-10123) for 3 (#s 48, 154, 155) of 6 sampled residents.

Inspectors wroteBased on observation and interview, the facility failed to change oxygen tubing and supplies for 2 (#s 11 and 27) of 5 sampled residents having oxygen in their rooms, increasing the risk for respiratory infections.