Pavilion at Glacier Valley

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure adequate supervision and staff education were provided for 1 resident (R) (R1) of 10 sampled residents following two incidents of familial abuse. On [DATE], staff heard Family Member (FM)-G yell at R1 and observed them slap R1 on the arm. On [DATE], staff entered R1's room and observed FM-H with a hand in R1's groin. FM-H was arrested and a no contact order was issued. Information was not posted or available at the nursing station on R1's unit to alert staff that FM-H was not allowed in the building and could not visit R1. In addition, R1's care plan was not updated to alert staff of the abuse and no contact order and the incidents were not documented in R1's medical record.

Inspectors wroteBased on observation, interview, and record review, the facility did not post required direct care staffing levels in a timely or accurate manner. This practice had the potential to affect all 67 residents residing in the facility. The 6/11/26 daily direct care staff was not posted in a timely manner. In addition, daily direct care staff postings did not list the hours worked per shift or correct shift times.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure menus and serving sizes were followed. This practice had the potential to affect all 67 residents residing in the facility. On 2/17/26, the lunch menu indicated the vegetable was seasoned broccoli. Residents were served wax beans instead and were not notified of the menu change. On 2/17/26, the lunch menu included a fresh baked roll and cheesecake. Residents with pureed diets did not receive a roll and received applesauce instead of cheesecake. On 2/17/26, residents with consistent carbohydrate diets were served a dinner roll for lunch but were not supposed to receive a dinner roll. On 2/17/26, lunch portion sizes were not followed in accordance with the menu.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 67 residents residing in the facility. Temperature logs for meal service were not consistently completed. Hand hygiene was not completed appropriately during the lunch meal on 2/17/26. Staff did not consistently test the internal temperatue of the dishwasher. Serving utensils and bowls were not stored properly to prevent contamination. Staff did not consistently document the parts per million (PPM) of the sanitizing solution in sanitizing buckets.

Inspectors wroteBased on staff and resident representative interview and record review, the facility did not ensure a Power of Attorney for Healthcare (POAHC) was notified of a change in condition for 1 resident (R) (69) of 18 sampled residents. R1's primary POAHC was not notified of two new skin abrasions that were discovered on 1/22/26.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a comprehensive resident-centered care plan was implemented for 1 resident (R) (R11) of 1 sampled resident. R11 had a diagnosis of dementia. R11's care plan did not contain goals or interventions for dementia care.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure care and treatment was provided in accordance with professional standards of practice for 2 residents (R39 and R55) of 17 sampled residents. R39 was hospitalized for low blood sugar from 1/25/26 to 1/29/26. R39's physician orders did not include parameters for notification of high or low blood sugars. R39 continued to have high blood sugars after the hospitalization. The facility did not notify R39's physician or develop a diabetes care plan. R55 was hospitalized from [DATE] to 1/9/26 for significant weight gain, worsening lower extremity edema, and failed outpatient diuretic escalation. Hospital discharge paperwork indicated R55 should have a consistent carbohydrate/no added salt diet with a fluid restriction. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food preferences were followed for 2 residents (R) (R16 and R58) of 14 sampled residents. R16's meal ticket indicated R16 disliked sausage. R16 was served sausage for lunch on 2/17/26. R58's meal ticket indicated R58 should receive a half cup of super potatoes for lunch. R58 did not receive a half cup of super potatoes for lunch on 2/17/26.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R39) of 4 sampled residents. R39 was on contact precautions due to loose stools. Staff brought R39 to the dining room to eat breakfast and seated R39 at a table with other residents.

Inspectors wroteBased on staff interview and record review, the facility did not ensure Hospice services during end of life care were coordinated for 1 resident (R1) of 2 sampled residents. On the 9/6/25 AM shift, Hospice Registered Nurse (HRN)-C informed Certified Nursing Assistant (CNA)-E that R1 was actively passing and should not be gotten out of bed. The information was not communicated to PM or night shift staff. R1 was gotten out of bed in accordance with R1's routine by night shift staff who were unaware that R1 was actively passing.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 2 residents (R) (R6 and R7) of 10 sampled residents. Staff did not ensure enhanced barrier precautions (EBP) were followed during high-contact cares for R6 and R7.

Inspectors wroteBased on staff interview and record review, the facility did not designate a person to serve as the food and nutrition services director who was a certified dietary manager, had a national certification for food service management and safety from a national accrediting body, or had an associates or higher level degree in food service management or hospitality. This had the potential to affect all 72 residents residing in the facility. Dietary Manager (DM)-N did not have an approved dietary manager or food service manager certification course or other related education.

Inspectors wrote4. From 11/10/24 to 11/12/24, Surveyor reviewed R12's medical record. R12 was admitted to the facility on [DATE] and had diagnoses including obesity, overactive bladder, chronic kidney disease (CKD), and chronic peripheral venous insufficiency. R12's MDS assessment, dated 8/23/24, had a BIMS score of 15 out of 15 which indicated R12 was not cognitively impaired. On 11/10/24 at 12:17 PM, Surveyor interviewed R12 about care at the facility. R12 stated call light response times ranged from ten minutes to one hour. R12 indicated R12 asked for a bedpan which an unnamed CNA would not provide. R12 stated R12 thought the refusal was cruel and inhuman treatment. R12 also indicated R12 asked staff to hold down a bed pan while R12 turned to get off the bed pan. R12 said the CNAs didn't do it which caused the bed pan to spill. [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure sufficient staffing was provided to meet the needs of 5 residents (R) (R30, R11, R17, R50, and R26) of 25 sampled residents with the potential to affect additional residents. The facility had low staffing on 4/14/24, 5/11/24, 5/12/24, and 6/23/24. On 11/10/24, R30 activated R30's call light for assistance with toileting on multiple occasions. Staff turned off R30's call light without providing assistance. On 11/10/24, R11 activated R11's call light for assistance to bed. Certified Nursing Assistant (CNA)-Y turned off R11's call light and left the room without assisting R11. On 11/10/24, R17 activated R17's call light for assistance to bed. CNA-Z turned off R17's call light and left the room without assisting R17. On 11/10/24, R50 activated R50's call light for an evening snack. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure all drugs and biologicals were stored in accordance with the facility's policy. One of five medication carts was observed unlocked and unattended in a resident hallway. One of two medication storage rooms contained expired medication and medical supplies. A prescription label on a medication card was not labeled according to the provider's order for 1 resident (R) (R33) observed during medication administration. This practice had the potential to affect more than 4 of the 72 residents residing in the facility. On [DATE], a medication cart on the 600 wing was unlocked and unattended. In addition, a cup that contained medication was on top of the cart and a computer screen that contained residents' personal information was open. [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure a call light was within reach for 1 resident (R) (R1) of 25 sampled residents. R1 was dependent on staff for mobility and other cares. During an observation on 11/10/24, R1's call light was not within reach.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a grievance was thoroughly investigated and resolution was provided for 1 resident (R) (R7) of 25 sampled residents. R7 told staff that R7 was missing items from laundry. Staff did not follow the facility's grievance process or follow-up with R7.

Inspectors wroteBased on observation, staff, resident and family interview, and record review, the facility did not ensure 3 residents (R) (R67, R17 and R1) of 5 sampled residents reviewed for pressure injuries received the necessary care and services to promote healing and/or prevent pressure injuries from developing. R67 had a pressure injury on the right heel. R67 did not have interventions in place that were recommended by the wound care provider. In addition, R67's care plan did not contain the wound care provider's recommendations. R17 developed a pressure injury from oxygen tubing that was not padded. R1 had a self determination care plan that indicated R1 chose to have a urinal propped against R1's scrotal area. R1's care plan did not contain an intervention to monitor for or prevent potential skin injury to R1's scrotal area.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure the appropriate care and services were provided to increase and/or prevent further decrease in range of motion for 3 residents (R) (R14, R6, and R7) of 3 sampled residents. R14 did not receive restorative therapy per therapy discharge recommendations. Staff did not correctly enter the recommendations in R14's medical record, therefore, R14's Minimum Data Set (MDS) assessment was not coded correctly. R6 did not consistently receive restorative therapy. R7 did not consistently receive range of motion (ROM) per R7's orders and care plan.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide the necessary care and services to prevent a urinary tract infection (UTI) for 1 resident (R) (R17) of 4 residents reviewed for catheter care. On 11/10/24, R17's uncovered catheter drainage bag was observed on the floor.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R17) of 25 sampled residents received the necessary care and treatment related for oxygen therapy. During an observation on 11/10/24, R17's oxygen tubing did not contain a date or initials to indicate when the tubing was last changed.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure medications were administered within the ordered timeframe for 1 resident (R) (R1) of 6 sampled residents. R1's medications were administered late on 7/29/24, 8/2/24, 10/28/24, 10/30/24, and 11/7/24.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure preferences for dietary needs were met for 1 resident (R) (R276) of 25 sampled residents. R276 did not receive consistently receive the dietary preferences that R276 specified to dietary staff.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable disease and infection for 1 resident (R) (R275) of 25 sampled residents. R275 was on enhanced barrier precautions (EBP). R275 did not have EBP signage outside of R275's room to inform staff of infection prevention precautions needed during the provision of care.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure the accurate administration of medication for 3 residents (R) (R2, R6, and R7) of 5 residents observed during medication administration. In addition, the facility did not provide pharmaceutical services to ensure the safe handling of drugs and biologicals for 2 (R4 and R7) of 5 residents observed during medication administration. On 7/10/24, R2, R6 and R7's AM medications were administered late. During medication pass on 7/10/24, Surveyor observed Registered Nurse (RN)-E drop R4's aspirin on the floor and dispose of the tablet in the garbage. RN-E also did not administer R4's carvedilol (used to treat high blood pressure). During medication pass on 7/10/24, Surveyor observed Medication Technician (MT)-J dispose of R7's sertraline (used to treat depression) tablet in a Sharps container.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a physician was notified of a change in condition for 1 resident (R) (R3) of 10 sampled residents. R3's physician was not notified when R3 had a nearly 12 pound weight loss in one week.

Inspectors wroteBased on staff interview and record review, the facility did not ensure grievances were documented, investigated, and thoroughly resolved for 1 resident (R) (R5) of 10 sampled residents. R5's representative submitted grievances to the facility via email or phone on the following dates: 4/7/24, 4/27/24, 5/23/24, 5/29/24, 5/30/24, 5/31/24, 6/19/24, and 6/24/24. The facility did not ensure the grievances were documented, thoroughly investigated, or resolved.

Inspectors wroteBased on observation, staff interview, and record review, staff did not immediately report a resident-to-resident physical altercation to Nursing Home Administrator (NHA)-A per the facility's policy for 2 residents (R) (R7 and R8) of 2 sampled residents. Staff did not report a resident-to-resident altercation between R7 and R8 to NHA-A which delayed a report to the State Agency (SA).

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure a hand splint and passive range of motion (PROM) was provided for 1 resident (R) (R2) of 1 sampled resident . R2's hand splint was not included on R2's care plan. In addition, PROM was not completed as ordered and was not included on R2's care plan.

Inspectors wroteBased on staff and resident interview, and record review, the facility did not ensure 2 Residents (R) (R6 and R2) of 3 residents received appropriate care and services to increase and/or prevent further decrease in range of motion (ROM). R6's therapy screen contained recommendations for staff to assist R6 with restorative exercises. R6's restorative program was not consistently followed. R2's therapy screen contained recommendations for staff to assist R2 with restorative exercises. R2's restorative program was not consistently followed.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure medications were administered timely for 3 Residents (R) (R6, R2, and R1) of 5 residents reviewed. R6, R2, and R1's scheduled medications were not administered timely.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain an infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of disease and infection. The facility did not ensure the proper handling and storage of linens to prevent the spread of infection. This has the potential to affect multiple residents (R) in the facility. In addition, staff did not complete appropriate hand hygiene during the provision of care for R330. The top and side of a storage rack used for clean resident linens contained dust and debris. In addition, Surveyor observed clean linens touch the floor during the folding process. Staff did not complete appropriate hand hygiene during the provision of care for R330.

Inspectors wroteBased on staff interview and record review, the facility did not ensure protective placement was obtained for 1 Resident (R) (R25) of 1 sampled resident. R25 had a legal guardian. The facility did not file a petition for protective placement when R25's stay at the facility exceeded 60 days from admission on [DATE].

Inspectors wroteBased on staff interview and record review, the facility did not ensure an injury of unknown origin was thoroughly investigated for 1 Resident (R) (R40) of 2 sampled residents. On 9/25/23, R40 was found on the floor and initially refused an injury assessment. Later in the day, staff noted R40 had a laceration on the left arm that required 19 sutures. The facility did not conduct a thorough investigation related to R40's injury of unknown origin.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the required Minimum Data Set (MDS) assessment data was completed, encoded, and transmitted timely for 1 Resident (R) (R6) of 3 residents reviewed. R6's MDS assessment, dated 10/25/23, did not have a completed transmission as of 12/12/23.

Inspectors wroteBased on staff interview and record review, the facility did not ensure Minimum Data Set (MDS) assessments were accurate for 2 Residents (R) (R50 and R3) of 3 residents reviewed for MDS completion. R50's medical record contained a Preadmission Screen and Resident Review (PASRR) Level II, dated 5/12/22, that indicated R50 met the federal definition of a serious mental illness. R50's MDS assessment, dated 5/12/23, was incorrectly coded for the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or related condition? R3's medical record contained a PASRR Level II, dated 2/8/22, that indicated R3 met the federal definition of a serious mental illness. [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 1 Resident (R) (R330) of 3 sampled residents received the appropriate treatment and services to prevent urinary tract infections (UTIs). R330 had a suprapubic catheter (a catheter inserted in the bladder through a small hole in the abdomen) and a history UTIs. R330's plan of care indicated R330's catheter drainage bag should be emptied every 2 hours which was not consistently completed.

Inspectors wroteBased on staff interview and record review, the facility did not ensure Physician visits were timely for 1 Resident (R) (R27) of 1 resident reviewed. R27 was admitted to the facility on [DATE]. R27 not seen by a Physician or Nurse Practitioner every 60 days as required.

Inspectors wroteBased on staff interview and record review, the facility did not ensure monitoring for adverse consequences of high-risk medications for 2 Residents (R) (R52 and R3) of 5 residents reviewed for unnecessary medications. R52 was prescribed tramadol and hydrocodone-acetaminophen (both high-risk medications in the opioid class used to treat moderate to severe pain). R52's care plan did not contain monitoring for adverse consequences of tramadol or hydrocodone-acetaminophen. R3 was prescribed tramadol. R3's care plan did not contain monitoring for adverse consequences of tramadol.

Inspectors wroteBased on staff and resident interview, and record review, the facility did not ensure 1 Resident (R) (R58) of 5 sampled residents was free from a significant medication error. R58 was readmitted to the facility on [DATE] with a hospital discharge order to take one 125 milligram (mg) capsule of vancomycin (an antibiotic) every 12 hours for 7 days. The order was transcribed without an end date and R58 received vancomycin through 12/12/23.

Inspectors wroteBased on interview and record review the facility did not provide the opportunity for 1 (R1) of 2 Residents reviewed to participate in the development and implementation of their person-centered plan of care by not facilitating the inclusion of R1 in the care planning process. Findings Include: Surveyor requested a facility policy and procedure on the care planning process for Residents and was not provided a policy during the survey process. R1 was admitted to the facility on [DATE] with diagnoses of Unspecified Focal Traumatic Brain Injury with Loss of Consciousness, Primary Carnitine Deficiency, Muscle Weakness, Overactive Bladder, Morbid Obesity, Lymphedema, Anxiety, Delusional Disorders, Major Depressive Disorder, Schizoaffective Disorder of Bipolar Type, and Other Schizophrenia. R1 is currently R1's own person. [...]

Inspectors wroteBased on interview and record review the facility did not develop and implement a comprehensive person- centered care plan for 1 (R2) of 5 residents reviewed. R2 did not have a comprehensive care plan addressing impaired skin integrity, pressure injuries, or risk for falls when admitted to the facility.

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure quality of care was provided for 1 (R1) of 5 Residents. R1 was not wearing a compression glove on his right hand according to physician orders on 10/3/23 & 10/4/23.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents were free from accident hazards and were provided supervision and assistive devices to prevent avoidable accidents for 3 (R2, R4, and R5) of 4 residents reviewed for accidents. * R2 did not have fall interventions in place for falls that occurred on 1/4/2023, 1/6/2023, and 1/7/2023. R2 did not have an investigation or root cause analysis done for a fall on 4/18/2023. * R4 did not have an investigation or root cause analysis done for a fall on 6/29/2023. * R5's bed was observed not at the lowest level as identified as a fall prevention in R5's care plan.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents received routine drugs or obtain them as ordered for 1 (R1) of 5 residents. On 02/13/23, R1 was prescribed Levocarnitine three times per day (8:00 AM, 12:00 noon, and 8:00 PM), by their Medical Doctor (MD). R1 did not receive Levocarnitine as ordered on 6/6/23, 6/7/23, 6/8/23 and 6/9/23 before the Nurse Practitioner (NP) was notified and the Levocarnitine put on hold. Findings Include: The facility policy, entitled, Pharmacy Services Policies and Procedures, dated 04/01/22, states: Section 3 0 General Information Subject: 3.1 Provision of Pharmacy Services Policy: 1. The Facility will ensure that the provision of pharmaceutical services meets the needs of the residents for prescription and non-prescription medications, infusion therapy and equipment, supplies and services as they relate to pharmacy. [...]

Inspectors wroteBased in interview, and record review the facility did not ensure and as needed (PRN) psychotropic medication was not utilized more than 14 days unless an alternate duration with rationale was provided for 1 (R2) of 3 residents reviewed for psychotropic medication use. R2's PRN Lorazepam (anti-anxiety medication) order was not discontinued after 14 days or obtained an alternate duration with rationale.