Wibaux County Nursing Home

F-F689 - Accidents and Hazards shows:

A situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision, if necessary, would be considered an elopement. This situation represents a risk to the resident's health and safety and places the resident at risk of heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle.

Facility policies that clearly define the mechanisms and procedures for assessing or identifying, monitoring and managing residents at risk for elopement can help to minimize the risk of a resident leaving a safe area without the facility's awareness and/or appropriate supervision .

1. Review of resident #23's current MDS, dated [DATE REDACTED], showed resident #23 had a BIMS of 4, reflecting severe cognitive impairment.

Review of resident #23's nursing progress notes, dated 2/16/25, showed resident #23 had opened a dining room window and climbed out of the window. Resident #23 had obtained a shovel, and when found, he was already shoveling snow in the courtyard. Resident #23 was wearing a jacket, a baseball hat, and medical gloves. Resident #23 refused to return to the facility until he was finished shoveling and staff remained with him. The facility did not assess the resident for injuries following this elopement.

Review of resident #23's nurses notes, dated, 2/23/25 at 1:37 p.m., showed, CNA alerted this nurse 10 minutes ago that resident had crawled through his window and was headed toward the facility garage. Resident #23 was returned to the facility by staff, and had no injury.

Review of resident #23's nursing note, dated 2/27/25, showed the CNA alerted the nurse at 10:50 a.m., that resident #23's window was open, and he was missing. All staff were notified, and a search was started. Resident #23 was located behind the nursing home, at the clinic, unharmed.

Review of resident #23's elopement evaluation, with an observation date of 2/23/25 at 8:14 p.m., was completed on 3/10/25 at 5:15 p.m., by staff member B. Review of resident #23's elopement evaluation, with

an observation date of 2/27/25, was also not completed until 3/10/25. The assessments were not completed until all three elopements occurred. No other elopement assessments were located in the resident's medical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 16 275079 Department of Health & Human Services Printed: 09/04/2025 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 275079 B. Wing 03/13/2025

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

Wibaux County Nursing Home 712 Wibaux St S Wibaux, MT 59353

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 0689 During an interview on 3/10/25 at 2:39 p.m., NF1 said the [Clinic Name] called him and alerted him about the resident being at the clinic, and the clinic was trying to figure out where he belonged. NF1 said that was the Level of Harm - Minimal harm or only elopement he was aware of for resident #23. NF1 said he was not aware of what the facility was doing potential for actual harm to prevent any more elopements for the resident. Resident #23 was at the clinic long enough for him to give his phone number to the clinic staff. Residents Affected - Some

Review of resident #23's baseline care plan showed elopements were not initially identified as a problem, and there were no interventions to prevent elopements. The baseline care plan was to be completed within

the required 48 hours of the resident's admission, which would have been by 2/14/25. Interventions for elopements were implemented after the second elopement on 2/23/25. The care plan directed the staff to do

a window audit to ensure the windows were secured. Although this intervention for the window security was implemented, resident #23 climbed out the window again on 2/27/25.

Review of resident #23's care plan approach, dated 2/27/25 showed, the facility initiated an Apple air tag to be placed for monitoring the resident, however resident #23 had removed the tag, so it was not beneficial at

the time of resident #23's third elopement.

During an observation on 3/10/25 at 1:20 p.m., the secure unit's sitting room window was observed to have a Velcro device attached to it. The device would prevent the window from opening to far, in an attempt to prevent elopements. This same device, was attached to a different window, and it was removed by resident #23, and then he eloped out the window on three occasions. The sitting room was not observed 100% of the time, so it created a risk for this resident if he removed the device in an attempt to elope.

During an interview on 3/10/25 at 2:57 p.m., staff member F said resident #23 went out the dining room window, the one that had the air conditioner in it, and he got into the courtyard. Staff member F said no stops were put on the windows in the dining room because it wasn't identified as a potential problem. Staff member F said following resident #23's first elopement, he went around and put in child proof stoppers on the windows where the exit was to the non-secured courtyard. Staff member F said the next time resident #23 eloped, staff assumed he took off the stop, because the stops were only secured by Velcro. After that incident, the facility bought new locks that clamped onto the side of the windows, and a tool was needed to get the stops off the window. The TV room and some of the courtyard windows were not secured yet because the facility was waiting on the order of the devices to arrive. The devices initially received were too small and did not fit the windows. Staff member F stated he monitors the windows every day, but it had not been done yet that day. Staff member F stated if resident #23, took the stops off once, he could do it again.

Based on observations on 3/10/25 3:10 p.m., staff member F and this surveyor were able to open the windows to a level of 16 inches on the secure unit for rooms [ROOM NUMBER]. The Velcro closure was screwed into the window incorrectly in room [ROOM NUMBER], and the other windows had the Velcro stops removed.

During an interview on 3/10/25 at 3:17 p.m., staff member H said resident #23 had gone into a different resident's room, shut the door, and went through the window. Staff member H said resident #23 went out the window twice during one of her shifts. He was found in the courtyard both times, but one time he was back around the courtyard by the back door. Staff member H said it was snowing the day he eloped through the window, but staff member H was unable to remember when the elopement occurred, and said it was maybe two weeks ago.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 16 275079 Department of Health & Human Services Printed: 09/04/2025 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 275079 B. Wing 03/13/2025

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

Wibaux County Nursing Home 712 Wibaux St S Wibaux, MT 59353

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 0689 During an interview on 3/10/25 at 3:30 p.m., staff member G said resident #23 is on 15-minute observations for monitoring his location, which was implemented after the 2/27/25 elopement, which was his third one. Level of Harm - Minimal harm or Staff member G said due to only one staff person caring for the ten residents on the secured unit, resident potential for actual harm #23 is left unsupervised for longer periods of time, therefore, the 15-minute checks were not always timely.

Residents Affected - Some Review of resident #23's nursing progress notes, did not show any documentation of the times resident #23 left through the window twice in one day.

During an interview on 3/11/25 at 10:19 a.m., staff members A, B, and C did not identify the resident breaking through a window screen and crawling out the window in attempt to leave the facility as an elopement. The staff said he was still on the property and in a courtyard, so they did not think of this as an elopement. The three staff members (A, B, and C) were unable to identify if climbing through a window was authorization to leave and if supervision was necessary.

Review of the facility policy titled, Elopement and Wandering Residents, dated 9/3/24, showed the definition of elopement as, Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. The policy showed a systematic approach to monitoring and managing residents at risk for elopement, to include the identification and assessment of risk, implementing interventions to reduce hazards and risks, and monitoring for effectiveness. The policy showed residents were to be assessed for risk of elopement on admission and throughout their stay. The policy included a procedure for post-elopement that included having the nurse complete a physical assessment and documentation of the assessment. The policy included details for how the social services designee will re-assess the resident and make referrals for counseling or consults; and, documentation in the medical record will include findings from nursing and social service assessments, physician and family notification, care plan discussion, and consultant notes.

Review of resident #23's IDT progress notes did not include any social services notes to reflect a social services re-assessment was completed after the elopements, or the need for referrals for counseling.

During and interview on 3/12/25 3:50 p.m., staff member D said the first time resident #23 eloped, the CNA was on the unit, and staff member D was on the main hall. The CNA saw resident #23 walking toward the garage, so resident #23 was out just a few minutes. Staff member D said the second time resident #23 eloped, the CNA and staff member D had both just checked on him, and within a minute or two of the CNA and staff member D checking on him, he got out the window. Resident #23 was probably gone 15 minutes or more the second time.

2. Review of resident #20's elopement assessment showed an observation date of 1/3/25, however it was not completed until 1/17/25, 14 days after his admission. The assessment identified the resident as being at risk for eloping.

Review of resident #20's baseline care plan failed to identify elopement as a problem. Resident #20's care plan did not include the risk of elopement until 1/14/25, and the interventions were minimal, to include, resident #20 resides on a secure unit and the staff will attempt to redirect resident and distract him when upset and wanting to leave.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 16 275079 Department of Health & Human Services Printed: 09/04/2025 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 275079 B. Wing 03/13/2025

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

Wibaux County Nursing Home 712 Wibaux St S Wibaux, MT 59353

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 0689 During an observation on 3/10/25 at 1:17 p.m., resident #20 was observed standing at the exit door, pushing

on the door handle. The resident stood at the door for 3-4 minutes, then turned around, and began pacing up Level of Harm - Minimal harm or and down the hall several times. There were no staff observed attempting to redirect the resident from the potential for actual harm door or engage him in to intervene in the behavior.

Residents Affected - Some During an observation on 3/11/25 at 4:14 p.m., resident #20 was wandering up and down the hallway of the secure unit, which he did several times. Resident #20 came to the exit door of the unit, and pushed against

the door that had wallpaper the resembled a library. Resident #20 walked from the door into the TV room, located right next to the exit door, and pushed up against the unsecured window. Resident #20 then sat in a recliner, located next to the window, and stared out of the TV room window.

During an observation on 3/12/25 at 12:30 p.m., resident #20 was observed going out the secured unit door into the main area of the facility. Staff member K and M observed the resident exiting the door, stopped him, and returned him to the secure unit. Staff members K and M turned the resident around and allowed him to continue pacing in the hall. No staff were observed to follow the care plan interventions identified and implemented for the prevention of elopements, or try to engage the resident when he was exit seeking.

51111

During an observation on 3/12/25 at 4:10 p.m., resident #20 was in the TV room of the secure unit, sitting in

the recliner next to the unsecured window. No other residents or staff were in the room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 16 275079 Department of Health & Human Services Printed: 09/04/2025 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 275079 B. Wing 03/13/2025

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

Wibaux County Nursing Home 712 Wibaux St S Wibaux, MT 59353

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 0700 Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed Level of Harm - Minimal harm or consent; and (4) Correctly install and maintain the bed rail. potential for actual harm 14005 Residents Affected - Few Based on observation, interview, and record review, the facility failed to review the risks and benefits of using grab/assist bars attached to the bed, for 2 residents (#s 4 and 12) of 16 sampled residents. Findings include:

During an observation on 3/10/25 at 1:10 p.m., a grab bar was observed on the left side of resident #12's bed.

During an observation on 3/10/25 at 1:15 p.m., a grab bar was observed on both sides of resident #4's bed.

1. During an interview on 3/12/25 at 12:10 p.m., staff member K said resident #4 does not use his side rails

during personal cares. Staff member K said he does not use them to help turn himself in bed at all. Staff member K said resident #4 may occasionally grab onto the assist bar when he is being transferred while he is sitting on the edge of the bed. Staff member K said resident #12 doesn't use the grab bars every time he gets up and out of bed.

During an interview on 3/13/25 at 9:56 a.m., staff member H said resident #4 does not use his grab bars at all when she provides care or when she transfers him in or out of bed.

Review of resident #4's MDS with an ARD date of 9/16/24, showed resident #4 had a BIMS (Brief Interview for Mental Status) score of 1. A score from 0-7 suggests severe cognitive impairment. The observation detail list report completed on 3/17/24 showed the resident was:

- not expressing a desire to use a restraint,

- cognitively impaired with fluctuations in level of consciousness,

- resident has visual impairments,

- resident has problems with balance and trunk control,

- takes psychotropic medication, which would require safety precautions.

Review of resident #4's care plan, with an intervention date of 3/27/24, showed resident #4 gets restless if he is left in bed too long. Review of resident #4's side rail assessment and consent dated 7/16/24, showed the resident was using bilateral turn and repositioning bars. The assessment failed to show detail related to the consideration of the increased risk his restlessness could have on his safety in relationship to the grab bars.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 16 275079 Department of Health & Human Services Printed: 09/04/2025 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 275079 B. Wing 03/13/2025

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

Wibaux County Nursing Home 712 Wibaux St S Wibaux, MT 59353

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 0700 2. During an interview on 3/12/25 at 10:47 a.m., staff member B said resident #12 asked for her side rails to be put back on the bed after the rails had been removed. Staff member B said the staff did not consider Level of Harm - Minimal harm or entrapment hazards due to the resident's weakness when assessing resident #12. Staff member B said she potential for actual harm was unaware of any scheduled maintenance on the bed and grab bars. Staff member B said there were no safety measurements completed by nursing when the resident's grab bar assessment was completed on Residents Affected - Few 7/16/24. Staff member B said no alternative interventions were attempted before using the grab bar.

Review of resident #12's bed rail safety assessment, completed on 7/10/24, showed:

- resident #12 had a fluctuation in levels of consciousness or a cognitive deficit,

- received medication that would require safety precautions,

- had a BIMS of 6; severe cognitive impairment.

Review of resident #12's restraint assessment, completed on 7/16/24, showed, negative outcomes were a possibility, however, entrapment and death were not considered a risk for resident #12.

Review of resident #12's medication administration record for February 2025, showed resident #12 took clonazepam for anxiety, Prozac for depression, and Zyprexa for schizophrenia. The effects of these psychotropic medications were not documented as being taken into consideration when the assessment for side rails was completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 16 275079 Department of Health & Human Services Printed: 09/04/2025 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 275079 B. Wing 03/13/2025

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

Wibaux County Nursing Home 712 Wibaux St S Wibaux, MT 59353

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 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. Level of Harm - Minimal harm or potential for actual harm 14005

Residents Affected - Many Based on observation, interview, and record review, the facility failed to ensure the dietary manager completed a certification program approved by a national certifying body or had higher education in a related field. This had the potential to affect residents and their nutritional status or meal safety for those who consumed food prepared and served by the facility. Findings include:

During the initial tour of the kitchen, on 3/10/25 at 11:50 a.m., no documentation of advanced training for the dietary manager was posted.

During an interview on 3/13/25 at 9:47 a.m., with staff members A, B, C, and N, staff member N stated one of

the issues the facility continued to review monthly had to do with staff member M's lack of certification as a dietary manager. Staff member N stated she received weekly email reports from staff member M about progress on completing the dietary manager certification. Staff member N stated staff member M worked full-time and was still not certified in the role. Staff member N stated this process was ongoing since the last plan of correction was started after last year's survey process, which was on 2/29/24.

During an interview on 3/13/25 at 11:07 a.m., staff member M said she did not have the CDM certificate, but

she was enrolled in an online program titled, Certified Dietary Manager/Certified Food Protection Professional, and was only on the third lesson. She did not identify when she would have the course completed.

51111

Review of a facility document titled, Facility Assessment For [Facility Name], dated 8/8/2024, showed:

. Food and Nutrition Services

. having a Dietary Manager who is working on her CDM who has a vast knowledge and experience of food and nutrition .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 16 275079 Department of Health & Human Services Printed: 09/04/2025 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 275079 B. Wing 03/13/2025

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

Wibaux County Nursing Home 712 Wibaux St S Wibaux, MT 59353

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 14005

Residents Affected - Some Based on interview and record review, the facility failed to maintain medical records which were accurately documented, dated, labeled, and completed in their entirety, for 5 (#s 4, 14, 18, 20 and 23) of 16 sampled residents. Findings include:

1. The following incomplete records were located in resident #4's medical records:

a. A review of resident #4's hard-copy POLST form and alternate medical records, dated 3/17/20, showed:

- In the section for the resident's full name, date of birth, and sex, the form had been altered by blocking out information with white out. Resident #4's name had been added to the form in the area which had been altered with white out.

- In the mandatory section, where there should be a medical provider signature, the date, the time, and the providers phone number, was incomplete. The POLST form would be invalid due to the altered and missing information.

b. Resident #4's staff assessment of daily and activity preference, completed on 3/12/25, was incomplete.

c. Resident #4's consent for Zoloft and Zyprexa was incomplete. The observation information included the creator, the date of the observation, the date recorded, completion date, and who completed the form was incomplete. The consent was obtained by verbal consent on 12/13/24 and had not been signed by the POA by 3/13/25.

2. The following records were found to be incomplete for resident #23:

- Resident #23 had an elopement evaluation with an observation date of 2/23/25. The form was incomplete until 3/10/25, the first day of the survey. - Resident #23 had an elopement assessment initiated on 2/27/25 at 6:15 p.m., and the date the record was completed was 3/10/25.

During an interview on 3/11/25 at 10:19 a.m., staff member B said completing assessments later than the

observation date would not be the normal practice. Staff member B said the assessments should be completed at the time of the observation. Staff member B said the elopement assessments for resident #23, dated 2/23/25 and 2/27/25, were completed on 3/10/25.

3. Resident #20 had an elopement evaluation which had an observation date on 1/3/25 that was not completed until 1/17/25.

51111

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 16 275079 Department of Health & Human Services Printed: 09/04/2025 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 275079 B. Wing 03/13/2025

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

Wibaux County Nursing Home 712 Wibaux St S Wibaux, MT 59353

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 0842 4. Review of resident #18's POLST form, dated 6/20/24, showed the form was left blank in the required fields of: the signature of provider, provider printed name, date and time signed by provider, and provider phone Level of Harm - Minimal harm or number. potential for actual harm

During an interview on 3/13/25 at 10:43 a.m. with staff members A, B, C and N, staff member C stated Residents Affected - Some admission forms, including advance directives and POLSTs should be filled out completely.

A request was made for a facility POLST policy on 3/12/25, and no specific POLST document was received by the end of the survey.

5. Review of resident #14's care plan showed a short term goal associated with the mood state that included, Target Date: 04/12/2025 kkk [sic] and the associated approaches for the goals showed, Approach Start Date: 01/22/2025 [Male name] loves [staff member C] [sic] and Approach Start Date: 01/22/2025 [Male name] loves [staff member B] [sic]

During an interview on 3/13/25 at 10:59 a.m., staff member A stated the information in resident #14's care plan was something she had never seen in a medical record before. Staff member A stated she would check

on how the information was added in to the medical record, and stated, Hopefully it's not because of a virus. It's weird though because that's staff member B's husband's name, and the other name is staff member C's husband's name. Staff member A returned to provide information on the documentation seen on the care plan. Staff member A stated staff member N added the information in to the care plan as a way to have staff members B and C notice the care plans needed updated. The information did not pertain to the resident's care or needs.

Review of a facility policy titled, Confidentiality of Personal and Medical Records, revised 7/11/2024, showed:

. [Facility Name] staff should exercise caution . in using medical record information for documentation purposes .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 16 275079