Inspection Reports for
Yellowstone River Nursing and Rehabilitation

F 0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights: the facility disposed of a resident's personal items without ensuring the resident was present or aware, causing frustration and lack of respect for the resident's belongings.

F 0585 Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances: the facility failed to provide a wheelchair-accessible grievance box, making it difficult for residents using wheelchairs to submit grievances independently or anonymously.

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: the facility failed to follow doctor's orders for edema treatment for two residents, who were observed not wearing prescribed compression stockings or having legs elevated as ordered.

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing: the facility failed to prevent worsening of a pressure ulcer for a resident, with inconsistent and incomplete wound assessment and documentation, and inadequate repositioning due to staffing and resident refusal.

F 0692 Provide enough food/fluids to maintain a resident's health: the facility failed to follow interventions for a resident with severe weight loss and malnutrition, including lack of assistance with eating and failure to monitor and implement dietary interventions timely.

F 0695 Provide safe and appropriate respiratory care for a resident when needed: the facility failed to follow doctor's orders for oxygen therapy for two residents, including use of empty oxygen tanks, lack of oxygen signage, and use of an obsolete CPAP machine.

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: the facility failed to serve resident meal trays in a timely manner according to posted mealtimes, resulting in residents receiving late and lukewarm meals and expressing hunger and dissatisfaction.

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: staff failed to respond timely to a resident's call light for personal care, resulting in a delay of over four hours and increased risk of psychosocial harm and skin integrity issues.

F 0656 Administrator: the facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for meeting medical, nursing, and psychosocial needs for sampled residents.

F 0711 Resident care: the facility failed to ensure a provider reviewed a resident's total program of care during a single visit, resulting in incomplete assessments and risk of inadequate treatment.

F 0740 Behavioral health services: the facility failed to provide necessary behavioral health care and services to a resident with documented emotional behaviors and concerns.

F 0745 Social services: the facility failed to provide individualized medically-related social services and to assess and address a resident's mood, behavior, and psychosocial status, including failure to refer for needed mental health services.

F 0850 Social worker staffing: the facility failed to hire and employ a qualified full-time social worker as required for a facility licensed for more than 120 beds.

F 0610 Respond appropriately to all alleged violation: the facility failed to complete a thorough investigation and failed to identify exit doors not equipped with a wander guard alarm system, allowing a resident to elope and be at risk of imminent harm.

F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: the facility failed to update a resident's care plan with a new fall intervention identified by the interdisciplinary team, placing the resident at risk for recurrent falls.

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to prevent immediate jeopardy level accidents by not securing doors with wander guard alarms, allowing a resident with traumatic brain injury to elope and placing other residents at risk due to unsecured exit doors and inadequate wander guard checks.

F 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being: the facility failed to ensure staff had the necessary education and procedures to monitor the functionality of the wander guard alarm system, including failure to use the manufacturer's device to verify functionality for residents and facility doors.

F 0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights: the facility placed resident #7 in a room without a sink, bathroom, or call light, and the resident slept on a mattress on the floor in a storage-like area called the Country Store.

F 0559 Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made: the facility failed to provide written notice for room changes for residents #7 and #8, including the reason for the changes.

F 0580 Immediately tell the resident, the resident's doctor, and a family member of situations that affect the resident: the facility failed to notify the representative of resident #1 when the resident was transferred to an acute care hospital for psychiatric evaluation.

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature: meals served to residents #15, 16, 17, and 18 were often cold, leading to resident dissatisfaction.

F 0918 Provide a bathroom in or located near each resident's room: the facility failed to ensure resident #7's room was equipped with a sink and toilet, placing the resident temporarily in the Country Store which lacked these facilities.

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area: the facility failed to provide a functioning call light for resident #7's sleeping area in the Country Store.

F 0758 Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited: the facility failed to limit PRN anti-anxiety medication to 14 days for one resident and did not ensure adequate indication for antipsychotic use for another resident, with insufficient documentation and monitoring of medication effects and behaviors.

F 0553 Allow resident to participate in the development and implementation of his or her person-centered plan of care: the facility failed to invite 4 of 43 sampled residents to care plan meetings, limiting their participation in care decisions.

F 0558 Reasonably accommodate the needs and preferences of each resident: the facility failed to provide services enabling one resident to maintain highest practicable functioning due to unresolved wheelchair armrest issues.

F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely: the facility failed to provide a clean and sanitary environment, with persistent bug infestations and unclean floors in multiple resident rooms and hallways.

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: the facility failed to ensure residents were free from abuse by a staff member, substantiated after investigation and staff training.

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment: the facility failed to identify a concave mattress as a restraint and did not complete required assessments or monitoring.

F 0687 Provide appropriate foot care: the facility failed to ensure effective foot care for a diabetic resident, with no podiatry appointments or documentation of needs.

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to identify a trip hazard from a large scoop mattress and failed to protect a resident from hazardous bug spray stored openly in their room.

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist: the facility failed to ensure discontinued medications were properly disposed of or removed from the medication cart.

F 0759 Ensure medication error rates are not 5 percent or greater: the facility had a medication error rate of 11.54 percent, including incorrect dosages and administration errors for two residents.

F 0801 Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician: the facility failed to employ a certified dietary manager and the dietitian did not provide regular onsite oversight.

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: the facility failed to maintain sanitary kitchen conditions, including lack of beard coverings, unlabeled and undated food items, pest infestations, and unclean equipment.

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently: the facility failed to employ qualified dietary staff and failed to adequately address ongoing kitchen sanitation and pest control issues despite QAPI efforts.

F 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action: the facility failed to identify and monitor ongoing kitchen cleanliness and pest control deficiencies effectively through the QAPI program.

F 0880 Provide and implement an infection prevention and control program: the facility failed to follow enhanced barrier precautions during wound care and feeding tube medication administration and failed to repair a worn recliner creating an uncleanable surface.

F 0908 Keep all essential equipment working safely: the facility failed to ensure safe and proper operation of kitchen equipment including ovens, dessert refrigerator, cook's refrigerator, and ice machine.

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests: the facility failed to maintain an effective pest control program with evidence of mouse droppings, insect infestations, and lack of recent pest control services.

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: the facility failed to ensure residents were free from abuse by a staff member who was rough during care and used degrading language toward two residents.

F 0550 Administrator: nursing staff failed to respect resident dignity by drawing a smiley face on a resident's buttocks and speaking disrespectfully to another resident during care.

F 0552 Medications, practitioner orders: the facility failed to obtain verbal or written consent or document risks versus benefits with the resident's POA prior to administering an anti-psychotic medication.

F 0558 Call light accessibility: the facility failed to ensure a resident had her call light within reach, causing the resident to yell for help instead of using the call light.

F 0610 Investigation: the facility failed to thoroughly investigate a reported incident involving a smiley face drawn on a resident's buttock and failed to implement protective measures for the resident.

F 0758 Psychotropic medication use: the facility failed to limit an as needed anti-psychotic medication order to 14 days as required.

F 0880 Infection control: the facility failed to adhere to infection control practices for transmission-based precautions during a COVID-19 outbreak, including improper PPE use and improper disposal of testing materials.

F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment: facility staff failed to provide a clean environment, with numerous dead insects in lighting fixtures noticed by residents.

F 0637 Assess the resident when there is a significant change in condition: the facility failed to complete a Significant Change MDS Assessment for one resident receiving hospice services.

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: staff failed to use sit-to-stand lift safely and did not provide fall prevention interventions, resulting in falls with fractures for two residents.

F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift: the facility failed to provide adequate staffing to respond to call lights timely and provide scheduled showers for multiple residents.

F 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being: staff failed to prevent worsening pressure ulcers and lacked education on cleaning shared bathrooms.

F 0880 Provide and implement an infection prevention and control program: staff failed proper hand hygiene, failed to clean sit-to-stand lifts after use, lacked infection surveillance, failed to maintain water management flushing records, and did not adequately clean shared resident bathrooms.

F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment: facility staff failed to maintain clean lighting fixtures, which contained numerous dead insects visible to residents.

F 0677 Provide care and assistance to perform activities of daily living: facility staff failed to provide timely incontinent care and assistance to residents, resulting in pain, distress, and unsanitary conditions for two residents.

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing: facility failed to prevent and properly treat pressure ulcers for one resident, resulting in multiple Stage II ulcers, deep tissue injuries, infections, and eventual resident death.

F 0689 Ensure nursing home area is free from accident hazards and provides adequate supervision: facility staff failed to safely use a sit-to-stand mechanical lift and failed to implement fall prevention interventions, resulting in falls with fractures for two residents.

F 0725 Provide enough nursing staff every day to meet resident needs and have a licensed nurse in charge on each shift: facility failed to provide adequate staffing, causing delayed response to call lights and missed or delayed showers for multiple residents.

F 0726 Ensure nurses and nurse aides have appropriate competencies: facility failed to ensure staff competency in wound care and cleanliness, contributing to worsening pressure ulcers and unsanitary bathroom conditions.