Avantara Of Billings

F-F825. Findings include:

Observations during the initial tour of the kitchen, on 7/15/24 at 12:25 p.m., showed:

- A staff member was observed serving the lunch meal and not wearing a covering over their beard.

- Grease and dust buildup was observed on the handles of the stove burners.

- Grease was built up under the grill and around the area of the stove.

- The ovens that were nonfunctional had a box of gloves and a long lighter stored in them.

- The microwave had debris and dirt in it and underneath it.

- There was a puddle of water on the kitchen floor and no wet floor sign present.

- Mouse droppings were observed on the floor in the food storage area and the chemical storage area.

- A thick layer of black dirt and mouse droppings went all the way around the storage areas along the floor at

the bottom of the walls.

- A bag of white cake mix that was stored in a covered plastic tote had a hole in it, and mouse droppings were observed inside the tote.

- Several items stored in the walk-in refrigerator were not labeled or dated.

- Equipment in the kitchen was nonfunctional. (Ice machine, dessert fridge, ovens, and the refrigerator in the serving area.)

Review of the facility grievance logs showed, on 12/5/23, a grievance was filed for bugs being in the food. Staff member A signed the grievance as complete on 12/5/23.

During an interview on 7/16/24 at 3:21 p.m., staff member A stated, I'm not sure how often pest control comes to the facility; I will have to look. I am aware there was an issue with mice in the kitchen.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 24 275029 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 275029 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Yellowstone River Nursing and Rehabilitation 2115 Central Ave Billings, MT 59102

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 During an interview on 7/16/24 at 3:00 p.m., staff member E stated, We (the facility) have a contract dietician that comes every other week. I have never met her. She is available for me to call if I have questions. I have Level of Harm - Minimal harm or only been in this position for about three months. I am currently enrolled in a Certified Food Manager potential for actual harm program, but I haven't had the time to complete it, due to my working in the kitchen so much.

Residents Affected - Few During an interview on 7/16/24 at 3:25 p.m., staff member A stated, The dietician has not worked with the dietary manager directly; she works with the IDT. I had to promote from within (the facility) for the Dietary Manager position. We couldn't find anyone else to hire. The dietary manager is enrolled in a certification course but has not completed it.

During an interview on 7/18/24 at 9:18 a.m., staff member A stated, We had identified issues with the kitchen and implemented them into our QAPI process. We have been working on it since April, and our last walk-through was 6/27/24, where the only identified issue was a dirty cart, ovens needed to be wiped out, and juice was not dated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 24 275029 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 275029 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Yellowstone River Nursing and Rehabilitation 2115 Central Ave Billings, MT 59102

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Minimal harm or potential for actual harm 49554

Residents Affected - Many Based on observation, interview, and record review, the facility failed to identify, correct, and monitor quality-deficient practices effectively related to the kitchen cleanliness and pest control using the QAPI program. This failure increased the risk of negative outcomes for any resident who received food and or services from the dietary department. Findings include:

Observations during the initial brief tour of the kitchen on 7/15/24 at 12:25 p.m. showed:

- Grease and dust buildup were observed on the handles of the stove burners.

- Grease was built up under the grill and around the area of the stove.

- The oven that was nonfunctional had a box of gloves and a long lighter stored in them.

- The microwave had debris and dirt in and underneath it.

- There was a puddle of water on the kitchen floor, and no wet floor sign was present.

- Mouse droppings were observed on the floor in the food storage area and the chemical storage area.

- A thick layer of black dirt and mouse droppings went all the way around the storage areas along the floor at

the bottom of the walls.

- A bag of white cake mix which was stored in a covered plastic tote had a hole in it, and mouse droppings were observed in the tote.

- Several items stored in the walk-in refrigerator were not labeled or dated.

- Some of the equipment in the kitchen was nonfunctional. (Ice machine, dessert fridge, two ovens, and the refrigerator in the serving area).

During an interview on 7/16/24 at 3:21 p.m., staff member A stated, I'm not sure how often pest control comes to the facility; I will have to look. I am aware there was an issue with mice in the kitchen.

During an interview on 7/18/24 at 9:18 a.m., staff member A stated, We had identified issues with the kitchen and implemented them into our QAPI process. We have been working on it since April, and our last walk-through was 6/27/24, where the only identified issue was a dirty cart, ovens needed to be wiped out, and juice was not dated. The current areas of concern in the kitchen were not identified by the QAPI program through monitoring or oversight, although the QAPI program had identified it as an issue.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 24 275029 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 275029 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Yellowstone River Nursing and Rehabilitation 2115 Central Ave Billings, MT 59102

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Review of a facility document titled, [Facility Name] Quality Assurance and Performance Plan, with a review date of 1/2024, showed: Level of Harm - Minimal harm or potential for actual harm Governance and Leadership:

Residents Affected - Many . Our committee will prioritize topics for PIPs based upon current needs . This team will follow steps and processes that are needed to achieve quality improvement and respond in a timely manner to ensure momentum is maintained.

Scope:

. encompasses all service lines at [Facility Name].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 24 275029 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 275029 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Yellowstone River Nursing and Rehabilitation 2115 Central Ave Billings, MT 59102

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 14005 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure enhanced barrier precautions Residents Affected - Few were followed when performing wound care and medication administration through a feeding tube, for 1 (#86) of 1 sampled resident; and failed to repair a worn recliner, resulting in an uncleanable surface, for 1 (#65) of 43 sampled residents. This deficient practice had the potential to increase the transmission of infectious agents for the residents. Findings include:

1. During an observation and interview on 7/17/24 at 11:16 a.m., staff member H was observed providing a wound treatment to resident #86's sacral pressure ulcer. Staff member H did not wear a gown when performing care on this wound. Staff member H said gowns would only need to be worn for tube feedings and catheters. When asked directly, staff member H said she would not need a gown with pressure ulcers because there would not be a splash onto the nurse.

During an observation and interview on 7/17/24 at 1:20 p.m., staff member H said staff would wear a gown for tube feeding and catheter care. Staff member H then prepared to administer resident #86's medication. Staff member H crushed, dissolved, and administered the medication properly. Staff member H administered

the medication through the feeding tube. When staff member H was asked about gowning for the procedure, staff member H said she should have worn a gown.

During an interview on 7/17/24 at 3:15 p.m., staff members B and Q said the facility had hired a new infection control preventionist and this nurse had completed some observational audits of care and infection practices. When asked when gowns should be worn, staff members B and Q both stated gowns were needed when caring for a central intravenous line, chronic-non healing wound care, and during administering medication or fluids/formula through feeding tubes. Staff members B and Q stated education on enhanced barrier precautions was started initially in April of 2024 and additional, ongoing training, had been done.

Review of the facility policy titled, Enhanced Barrier Precautions, dated August 2022, showed enhanced barrier precautions and gowning was required for residents with devices (feeding tube) or with wound care which required a dressing.

51133

2. During an observation on 7/15/24 at 12:48 p.m., the recliner to the right of the entrance to resident #65's room had wearing, tearing, and scratches on the right arm and footrest. The recliner's material was flaking off to the right of the recliner onto the floor. This presented an uncleanable surface.

During an observation on 7/16/24 at 9:07 a.m., the same recliner as noted the day prior, had flakes of the material on the floor to the right of the recliner.

During an interview on 7/17/24 at 10:28 a.m., staff member N stated she did not know what was being done about the damaged recliner in resident #65's room. Staff member N said if something was in disrepair, the request was put into maintenance for repair. Staff member N stated her personal opinion was, the recliner needed to go into the garbage.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 24 275029 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 275029 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Yellowstone River Nursing and Rehabilitation 2115 Central Ave Billings, MT 59102

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 7/17/24 at 11:25 a.m., a request was made for any maintenance requests for resident #65's damaged recliner. None were provided by the end of the survey period. Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 24 275029 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 275029 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Yellowstone River Nursing and Rehabilitation 2115 Central Ave Billings, MT 59102

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or 49554 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure safe and proper operation of Residents Affected - Few the kitchen equipment (the oven, dessert refrigerator, cooks' refrigerator, and ice machine). This deficient practice had the potential to affect any resident receiving food from the kitchen when the equipment is used for the preparation or storage of food. Findings include:

During the initial tour of the kitchen, on 7/15/24 at 12:25 p.m., there were no paper towels in the dispensers, located near the two sinks, outside of the kitchen, in the serving area. The ice machine was warm, and there was no ice present. Kitchen staff stated the ice machine did not work. The dessert refrigerator was warm, and there were several cans of unopened V8 juice in it.

During an observation and interview on 7/16/24 at 2:12 p.m., there were still no paper towels in the dispensers near the two sinks in the serving area. The ice machine was still not working. The dessert refrigerator was still warm and not working. The ovens below the gas stove were not working and were being used for storage. The sink (behind the steam table) drain was plugged and was half full of standing water.

The cook's refrigerator by the steam table had two gallons of milk in it which looked chunky. Staff member E stated, Nothing should be in that fridge. It doesn't work; it freezes everything. The dessert fridge hasn't been working for quite a while. The ice machine is down as well.

During an interview on 7/17/24 at 4:23 p.m., staff member S stated the equipment had been down for quite a while. The ice machine was the most recent thing to act up.

During an interview on 7/18/24 at 8:11 a.m., staff member V stated, Dietary enters their issues into the TELS system, and it pops up on my computer as a notification. I try to fix things as soon as possible. I am aware that the kitchen is having quite a few issues. I'm working on getting them addressed.

Review of facility monthly maintenance logs, dated from January 2024 to present, failed to show which kitchen equipment was not functional. The logs also failed to show any equipment was removed from service or repaired during this time period.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 24 275029 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 275029 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Yellowstone River Nursing and Rehabilitation 2115 Central Ave Billings, MT 59102

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51133 potential for actual harm Based on observation, interview, and record review, the facility failed to assure pest control in the kitchen, Residents Affected - Many 200 and 300 halls, and a resident room for 1 (#65) of 43 sampled residents. This deficient practice had the potential to affect all residents served food from the kitchen, and all residents residing on the 200 and 300 halls. Findings include:

1. During an observation on 7/15/24 at 12:48 p.m., an ant was observed crawling on the floor to the right of resident #65's recliner, among crumbs.

During an observation on 7/16/24 at 8:02 a.m., dead insects were scattered in multiple places on the floor in

the 300 hallway.

During an observation on 7/16/24 at 4:20 p.m., a beetle was crawling to the right of room [ROOM NUMBER]

in the hallway, and a beetle was crawling near the exit doors in the 200 unit.

During an interview on 7/17/24 at 9:02 a.m., staff member K stated he had observed ants in the facility.

During an interview on 7/17/24 at 9:25 a.m., staff member L said bugs flew through the residents' screenless windows, she noticed them occasionally. Staff member L stated she did not know what the facility had done about it.

During an interview on 7/17/24 at 9:31 a.m., staff member J stated, We have a bug problem . most of our problems are ants.

During an interview on 7/17/24 at 3:45 p.m., staff member A stated she recognized the pest concern and had brought the concern to staff member J for follow-up.

49554

2. During the initial tour of the kitchen on 7/15/24 at 12:25 p.m., mouse droppings were observed in the dry food storage area and the chemical storage area of the kitchen. There was a thick amount of mouse droppings along the floor, where the wall meets the floor, all the way around the room. There was a plastic tote with bags of white cake mix in it. One of the bags had a hole in it that looked like it had been chewed through. There were mouse droppings at the bottom of the plastic tote. There were mouse traps placed in areas of the kitchen.

During an observation and interview on 7/16/24 at 3:00 p.m., staff member E stated, I am aware of the mice

in the kitchen, but have not seen one in a while. The pest control company comes in once a month to check

the traps. We usually only see mice in the dish room. We knew there was a mouse problem, and that's why

we use covered plastic totes for our food storage. I don't know how the mice got into the tote with the cake mix.

Review of a facility document titled, Pest Control, undated, showed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 24 275029 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 275029 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Yellowstone River Nursing and Rehabilitation 2115 Central Ave Billings, MT 59102

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Policy Statement: Our facility shall maintain an effective pest control program.

Level of Harm - Minimal harm or Policy Interpretation and Implementation: potential for actual harm 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects Residents Affected - Many and rodents.

2. Pest control services are provided by: (this section was blank on the document)

3. Windows are screened at all times.

Review of facility provided invoices for ORKIN pest control services showed the pest control services had not been completed since March of 2024:

Dates of services provided by ORKIN are as follows: 6/22/23, 7/5/23, 8/1/23, 8/15/23, 9/1/23, 10/10/23, 11/6/23, 12/29/23, 1/23/24, 2/5/24, 3/15/24

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 24 275029

F-F925 for more information).

During an interview on 7/16/24 at 3:00 p.m., staff member E stated, We (the facility) have a contract dietician that comes every other week. I have never met her. She is available for me to call if I have questions. I have only been in this position for about three months. I am currently enrolled in a Certified Food Manager program, but I haven't had the time to complete it, due to my working in the kitchen so much.

During an interview on 7/16/24 at 3:21 p.m., staff member B stated, The dietician is here every two weeks. While she (dietitian) is here, we discuss weight loss, and skin issues. She is part of the IDT.

During an interview on 7/16/24 at 3:25 p.m., staff member A stated, The dietician has not worked with the dietary manager directly; she works with the IDT. I had to promote from within (the facility) for the Dietary Manager position. We couldn't find anyone else to hire. The dietary manager is enrolled in a certification course but has not completed it.

During an interview on 7/17/24 at 8:01 a.m., staff member F stated, I try to be there every other week. I have only been working for that facility for a couple of months. I primarily meet with the IDT to discuss nutrition and diets. We have been trying to work on a schedule for me to meet with the dietary manager, but we haven't met yet. I have not spent time in the kitchen, and I haven't had a chance to meet the dietary manager.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 24 275029 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 275029 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Yellowstone River Nursing and Rehabilitation 2115 Central Ave Billings, MT 59102

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 49554

Residents Affected - Many Based on observations, interviews, and record review, the facility failed to ensure sanitary conditions were maintained throughout the kitchen, and the dietary storage areas. The facility failed to ensure kitchen staff wore beard coverings while serving food, failed to label and date food items in the walk-in cooler, failed to maintain a clean (dietary/kitchen) environment, and failed to have appropriate pest control. This deficient practice had the potential to cause foodborne illness to all who received food from the kitchen. Findings include:

During the initial tour of the kitchen, on 7/15/24 at 12:25 p.m., the following observations were made:

- There were no paper towels or soap in the soap dispensers, located near the two sinks, used for washing hands prior to entering the kitchen.

- A wall vent in the dry storage area had black drip marks running from it.

- There was grease and dirt buildup on the handles to the gas stove.

- Grease and grime was built up under the grill and around the table it was on.

- Mouse droppings were observed in the dry storage area, and the chemical storage area along the wall.

- The microwave had food debris in and under it.

- A Ziploc bag of sliced onions was not labeled or dated.

- A Ziploc bag of diced onions was not labeled or dated.

- A Ziploc bag of diced ham was not labeled or dated.

- A metal pan with Jello in it was not labeled or dated.

- The freezer had 3 Ziploc bags of pancakes, and 2 Ziploc bags of waffles, that were not labeled or dated.

- There were bags of powdered Jello in a plastic tote. They were covered in a powdered substance and did not have a label or date.

- Bags of white cake mix were in a plastic tote with no label or date. One of the bags had a hole in it and was spilling out.

- A bag of tortilla chips was open with no date.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 24 275029 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 275029 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Yellowstone River Nursing and Rehabilitation 2115 Central Ave Billings, MT 59102

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 - A 25 lb. bag of breadcrumbs was open and was not dated.

Level of Harm - Minimal harm or During an observation on 7/15/24 at 1:01 p.m., staff member T was serving the lunch meal. Staff member T potential for actual harm did not have a beard covering over his facial hair.

Residents Affected - Many During an observation and interview on 7/16/24 at 2:12 p.m., there were still no paper towels or soap at the two sinks outside of the kitchen. The sink behind the steam table was full of debris and water. The cook's fridge, next to the steam table, had two gallons of chunky (curdled) 2% milk. Staff member E stated the fridge should not be used since it freezes everything. Staff member E stated, We don't check it (the cook's fridge) as often as we should. Mouse droppings were observed in the dry storage area on the floor, in the corners, and along the wall. The walk-in cooler had Ziploc bags with sliced onion, diced onion, diced ham, and peeled cucumber; all were not labeled or dated. There was a pitcher of a yellow substance that was not covered, labeled, or dated. There was grease and dirt buildup on the handles to the stove. There was grease and dirt buildup on the vents to the juice machine. Grease buildup was observed under the grill and around it. Food debris was observed in and under the microwave.

During an interview on 7/16/24 at 3:00 p.m., staff member E stated, We have had mice in the kitchen, but I haven't seen one in a while. They are usually seen in the dish room. We were aware that there was an issue with mice; that's why we put our dry goods in the plastic totes. We have a cleaning schedule that staff should be following. I have also had multiple meetings about labeling and dating foods that are open or not in the original packaging.

During an observation and interview on 7/17/24 at 4:23 p.m., staff member S was preparing food on the stove, and staff member S did not have a beard covering over his facial hair. Staff member S stated, We don't have any beard covers. When we open any food in the kitchen, it should be labeled with the date that it was open, and then after three days it should be thrown out.

During an observation and interview on 7/18/24 at 8:34 a.m., staff member R stated, I asked when I was hired if I should be wearing a covering over my beard and was told they would get me one. I have not seen any or seen anyone wearing one. I felt uncomfortable, so I cut my beard; it used to be really bushy.

During an interview on 7/18/24 at 8:54 a.m., staff member E stated, I do not have any beard coverings available for staff. I know they should be wearing them, and it's my bad, I haven't ordered any.

Review of kitchen cleaning logs, from 4/8/24 to 7/14/24, showed the storeroom was cleaned a total of 15 days out of 98 days.

Review of the facility's policy titled, Food Receiving and Storage, showed:

Dry Food Storage:

1. Non-refrigerated foods, disposable dishware, and napkins are stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean.

Refrigerated/Frozen Storage:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 24 275029 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 275029 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Yellowstone River Nursing and Rehabilitation 2115 Central Ave Billings, MT 59102

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 All foods stored in the refrigerator or freezer are covered, labeled, and dated.

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Many

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 24 275029 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 275029 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Yellowstone River Nursing and Rehabilitation 2115 Central Ave Billings, MT 59102

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Minimal harm or 49554 potential for actual harm Based on observations, interviews, and record review, it was found facility administration failed to hire and Residents Affected - Few employ a Dietary Manager with appropriate competencies and skills sets to carry out the necessary functions of the food and nutritional services; and the facility dietitian did not schedule regular consultations and go onsite to work with the dietary manager and assist with oversight of nutritional services. This failure resulted

in numerous concerns being identified in the dietary department (Refer fo