Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Blackfeet Care Center during CMS and state inspections, most recent first.
A resident with a history of hematuria, renal failure, anemia, and recent blood transfusions was readmitted from the hospital with discharge instructions to pause apixaban, but the facility failed to obtain admission orders and did not clarify the incomplete anticoagulant order. The resident’s care plan did not address anticoagulant use or monitoring, and staff administered multiple doses of apixaban after readmission. Nursing notes documented blood in the nephrostomy drainage bag on two days without provider notification or intervention, followed by worsening weakness, poor intake, and hypoxia that led to hospital transfer. Hospital records showed the resident had gross hematuria, hypotension, respiratory distress, acute kidney injury, and a critically low Hgb requiring transfusion, and a late entry note acknowledged that the discharge order to hold apixaban had been overlooked.
Inaccurate PBJ staffing data was submitted to CMS after nursing hours were not fully reflected in the quarterly report when compared with staffing schedules and payroll records. An employee responsible for PBJ submission stated she entered the data quarterly, reviewed a copy for errors, and did not compare the submission with the nursing dept schedule.
The facility failed to thoroughly investigate, monitor, and document multiple abuse allegations involving staff-to-resident and resident-to-resident incidents. In one case, a resident reported that a staff member blew marijuana vape smoke in his face, but there was no related nursing documentation or post-incident monitoring. In another case, a resident reported being hit by another resident, was found with a red mark on the head, and was sent to the ER, yet nursing notes for both residents lacked documentation of the incident and follow-up monitoring. In a third case, a cognitively impaired resident with developmental delay was found in another resident’s room while that resident’s hands were being removed from inside the resident’s pants and shirt, after which the resident complained of pain and was sent to the ER; again, nursing notes for both residents contained no documentation of the event or post-incident monitoring, and the investigator did not fully interview or obtain written statements from all involved as required by facility policy.
A facility failed to keep care plans updated for three residents with changed needs. One resident with a suprapubic catheter had no care plan focus for catheter care, catheter changes, or infection monitoring; another resident taking mirtazapine for depression had no care plan details for the medication, nonpharmacologic interventions, depression symptoms, or adverse effects; and a third resident receiving comfort care had no care plan interventions for end-of-life needs, including fear of dying, terminal restlessness, positioning, reorientation, or family education.
A facility failed to ensure required face-to-face physician visits were completed for multiple residents. Several residents went far beyond the required visit intervals, one resident had no dated physician note to confirm compliance, and one resident had 155 days between provider visits. Staff reported the physician did not follow a set resident visit schedule and was unsure whether other providers were assessing residents between visits.
Failure to obtain informed consent for psychotropic meds: A resident was started on an antidepressant and an antianxiety medication without documented consent in the chart. The resident’s representative said she was notified when meds were started or stopped, but the facility did not explain the risks, benefits, or alternatives before initiation, and staff confirmed consent was expected before psychotropic meds were started or changed.
Restricted Visitation Hours: A posted sign and staff interviews showed that residents were limited to visiting hours from 8:00 a.m. to 8:00 p.m., and visitors arriving outside those times were turned away or told to return later. Two residents stated they did not like the limits and believed they should be able to decide when to receive visitors. The admission agreement also stated that residents have the right to visit anyone during visiting hours.
A resident’s MDS was coded to show insulin injections when the physician order was for Ozempic, a GLP-1 used for diabetes and not insulin. The staff member who completed Section N said she coded Ozempic as insulin because it treated diabetes and stated she had not received formal MDS training or was familiar with the RAI Manual. The facility policy on Resident Assessments was not updated to reflect current guidance for distinguishing insulin from non-insulin injectable meds.
A resident with diabetes had persistently elevated blood sugars, including frequent readings above 200 mg/dL and multiple readings over 300 mg/dL. Staff stated the resident’s diabetes was not adequately controlled and that the insulin regimen should have been evaluated for adjustment, but there were no SSI orders and the last insulin change had been made months earlier. A physician visit documented a blood glucose of 205 mg/dL and stated the resident was doing well, despite ongoing high readings and snack intake contributing to poor control.
The facility failed to keep meds, biologicals, and medical supplies secured and removed expired items from storage. A med supply room was found propped open and later unlocked and unsupervised, with needles and syringes left outside a locked cabinet. An opened vial of PPD was past its discard date, and multiple expired blood tubes and Xeroform dressings were also found in the supply room. Staff gave conflicting statements about who checks for expired items, and the facility policy required meds and biologicals to be stored in locked compartments.
Medical Director Not Active in QAPI and Policy Review. The facility failed to ensure the medical director was active in QAPI and in the review, development, and revision of facility policies and procedures. Staff reported the medical director was not always present at QAPI meetings, and the medical provider stated he was not the medical director, worked full-time at another healthcare entity, and saw residents about every other week. The facility did not provide documentation showing the medical director’s involvement, and a QAPI at Risk Meeting document did not list the medical director among the IDT members who attended.
Failure to follow infection control practices during a med pass affected two residents. An LPN prepared and administered meds while wearing gloves without hand hygiene, touched multiple potentially contaminated surfaces, changed gloves without hand hygiene, and entered residents' rooms after touching door handles without performing hand hygiene before medication administration.
The facility did not complete thorough investigations into multiple abuse allegations, failing to interview other residents cared for by the accused staff or assess psychosocial harm for affected residents. In several cases, residents expressed fear, discomfort, or distress following incidents involving staff, but investigations were incomplete and did not follow facility policy.
A resident with dementia, low vision, and hearing impairment was frequently observed wandering, entering other residents' rooms, and displaying combative behavior, but the care plan was not updated with specific interventions. Staff did not conduct a formal assessment of the resident's behaviors, and interventions were inconsistently applied and undocumented, contrary to facility policy requiring individualized strategies for residents at risk of wandering.
A resident with dementia who exhibited wandering and intrusive behaviors did not receive a formal behavioral assessment or individualized interventions. Staff relied on general distractions and were unclear about documented interventions, while the care plan lacked specific strategies to manage or anticipate the resident's actions. The facility's root cause analysis also failed to identify underlying factors or effective interventions for the resident's behaviors.
A resident with a history of diabetes and dementia, identified as high risk for falls, continued to fall due to the facility's failure to conduct root cause analyses. Despite multiple falls, the facility did not complete necessary documentation, and the resident sustained a head injury from a subsequent fall. Staff interviews confirmed inadequate documentation, and the facility's fall prevention policy lacked a root cause analysis step.
The facility failed to implement enhanced barrier precautions for several residents and did not ensure adherence to standard precautions during medication administration via tube feeding. Observations showed a lack of EBP signage and PPE availability, and staff did not wear gowns during high-contact activities. Additionally, a staff member placed medications on an unclean surface without a protective barrier. Interviews revealed a lack of understanding and implementation of EBP among staff.
A facility failed to report the findings of an alleged abuse incident involving a resident to the State Survey Agency within the required five-day period. The resident reported being assaulted by her son outside the facility and was considered an elopement risk. Despite security alerting the charge nurse, the responsible staff member did not submit the investigation report. The resident returned once but then left against medical advice. The facility's policy requires reporting within five days, which was not followed.
A facility failed to protect a resident's dignity and privacy by posting a sign on her door with her name and instructions for her nephrostomy tube bag care. The resident expressed discomfort with the sign, and staff acknowledged it should not have been there.
A facility failed to ensure proper care and documentation for a resident with a nephrostomy tube. The resident required dressing changes, but the facility did not obtain physician orders or document the changes in the medical record. Staff indicated changes were done as needed, while the resident stated they occurred during doctor visits every three months. The facility's policy required more frequent changes and documentation, highlighting a deficiency in care.
Failure to Clarify Anticoagulant Orders Leads to Unnecessary Drug Administration and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary drugs when nursing staff did not clarify and correctly implement anticoagulant orders upon the resident’s readmission. The resident had been hospitalized for hematuria, renal failure, and anemia, received multiple blood transfusions, and was discharged back to the facility with an After Visit Summary instructing that apixaban (an anticoagulant) be paused, with no restart date specified. Despite this, the facility’s admission documentation for the readmission date showed no admission orders, and the apixaban order was not clarified with the physician. The medication was restarted and administered after readmission, even though the hospital documentation indicated it was to be paused and later discontinued. Following readmission, the resident’s Medication Administration Record showed that seven doses of apixaban were given. The resident’s care plan, initiated on the readmission date, did not identify any problems, goals, or interventions related to anticoagulant use, safety, or monitoring for side effects. Nursing progress notes documented that the resident had a right-sided nephrostomy with yellow urine drainage on the day of readmission, and then documented blood in the nephrostomy drainage bag on two consecutive days. However, there was no documentation that the provider was notified about the hematuria or that any action was taken in response to this change. Subsequently, nursing notes described the resident as weak, not eating, unable to maintain a sitting position, and having low oxygen saturation that did not adequately improve with increased supplemental oxygen, leading to transfer to the emergency department. Hospital records from that visit showed the resident presented with hypoxia, hypotension, profound weakness, respiratory distress, gross hematuria, acute kidney injury, and a critically low hemoglobin of 6.9 g/dL, and that the resident had received an anticoagulant and required blood transfusions. A late entry nursing note at the facility later documented that the hospital discharge summary had been overlooked, the order to hold apixaban was not implemented, and the resident continued to receive apixaban until readmission to the hospital. The facility’s root cause analysis attributed the event to ambiguity in discharge communication and medication reconciliation workflow and noted that the apixaban order was incomplete and not clarified before administration.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to ensure the accuracy of staffing data submitted to CMS through the PBJ system for the quarter covering 10/1/25 through 12/31/25. Review of the PBJ Staffing Data Report showed that the facility did not include all nursing staff hours when compared with facility staffing schedules and payroll records for six days in October 2025, six days in November 2025, and three days in December 2025. During an interview on 3/25/26 at 11:10 a.m., staff member B stated she was responsible for submitting PBJ data on a quarterly basis, that she ran a copy of the information and checked for errors after inputting the data, and that she was uncertain why nursing hours were not correctly reflected. Staff member B also stated she did not compare the submitted information with the nursing department schedule.
Failure to Thoroughly Investigate and Document Multiple Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to complete thorough investigations, monitoring, and documentation for multiple abuse allegations. In one incident, a resident reported that a staff member blew marijuana vape smoke in his face. The staff member later admitted to vaping marijuana in the resident’s room. Despite this, the resident’s nursing progress notes for the period following the incident contained no documentation of the event or any post-incident monitoring, and the psychosocial impact assessment tool indicated that no ALERT charting had been done by nursing or social services. In a second incident, a resident sitting in a wheelchair by the nurse’s station told a staff member that another resident had hit him; assessment revealed a red mark on the resident’s head, and the resident was sent to the emergency room at the family’s request. However, nursing progress notes for both the alleged victim and the alleged aggressor for the days following the incident contained no documentation of the incident or any post-incident monitoring. The staff member responsible for the investigation stated that he relied on video footage and interviews with the two residents, but these interviews were only documented in the incident report, and no other staff or residents on shift were interviewed. In a third incident, staff found one resident in another resident’s room and observed the second resident removing his hands from inside the first resident’s pants and shirt; the first resident later stated, “It hurts down there,” and was sent to the emergency room. The first resident had diagnoses including unspecified symptoms involving cognitive functions and awareness, anxiety, depression, cerebral infarct, and was described as having a developmental delay with the mentality of an 8-year-old, while the second resident was cognitively intact based on a BIMS score of 14. Nursing progress notes for both residents for the days following the incident contained no documentation of the event or any post-incident monitoring. The staff member overseeing the investigation acknowledged that he did not document his post-incident checks, did not interview staff on shift or other residents, and no abuse education or protective measures for staff were documented, contrary to the facility’s abuse prevention policy that requires interviews with all involved, retrieval of written statements, and documentation of assessments and monitoring.
Incomplete Care Plans for Catheter Care, Psychotropic Use, and Comfort Care
Penalty
Summary
The facility failed to revise individualized, comprehensive care plans for three sampled residents when their conditions and treatments changed. Resident #5 had a suprapubic catheter, but the revised care plan dated 2/26/26 did not address catheter care, scheduled catheter changes, or monitoring for signs or symptoms of infection related to catheter use. Resident #6’s care plan dated 3/10/26 did not include the use of mirtazapine for depression and did not identify non-pharmacological interventions, signs or symptoms of increased depression, or monitoring for adverse side effects from the medication. Resident #8 was receiving end-of-life/comfort care, but the care plan did not include comfort care as a focus or list interventions related to the resident’s end-of-life needs. The care plan did not address fears about dying, terminal restlessness, positioning for comfort, changes in cognitive status, increased sleeping, reorientation needs, or education of the resident and family related to the dying process. The record also showed a medical visit on 1/9/26 for end-of-life care, during which the family agreed to comfort care measures, and the care area assessment noted the resident had been increasingly agitated, was sleeping more, needed more reorientation, and expressed fear about dying at night.
Physician Visit Frequency Not Maintained
Penalty
Summary
The facility failed to ensure that residents were seen face-to-face by a physician within the required timeframes for 6 of 17 sampled residents. Resident #1’s last documented physician visit was on 6/11/25, resident #3’s was on 6/3/25, resident #6’s was on 6/13/25, and resident #28’s was on 6/2/25; each had not been seen for more than 225 days. Resident #5’s medical visit note was undated, and there was no documentation confirming that this resident had been seen by a physician within the last 60 days. Resident #15 was seen on 7/24/25 and again on 2/26/26, with 155 days between visits, exceeding the required frequency. During interviews, NF1 stated that resident #6 had not seen a physician in the facility for many months and expressed concern because of the resident’s ongoing medical conditions. Staff member N stated he did not have a set schedule for seeing residents and that his visits depended on his hospital schedule; he was unsure whether any other providers assessed residents between his visits. Staff member A stated physicians were expected to evaluate residents when due and document the visit in the medical record.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure resident #6’s representative was provided the information needed to make an informed decision before psychotropic medications were started, including the risks, benefits, and alternatives. During interview, the resident’s representative stated she was notified when medications were started or discontinued, but the facility did not explain the risks, benefits, or alternatives before initiation, and she had sometimes been asked to sign forms without the medications being explained to her. Record review showed resident #6 was prescribed mirtazapine for depression and clonazepam for anxiety, with mirtazapine started on 2/24/26 and clonazepam started on 3/16/26. The pharmacy medication regimen review noted no informed consent in the chart for mirtazapine and that consent was also needed for clonazepam. The electronic medical record contained no documentation of informed consent forms for either medication before they were initiated. Staff interviews confirmed informed consent forms were expected before psychotropic medications were started or changed, and the facility policy stated residents and/or representatives have the right to decline psychotropic medications and that staff and the physician will review the risks of not taking the medication and appropriate alternatives.
Restricted Visitation Hours
Penalty
Summary
The facility failed to honor residents’ right to receive visitors of their choosing at the time of their choosing for 2 sampled residents. During observation, a sign posted above the double doors near the security desk stated, “Resident Visiting Hours 8:00 A.M. - 8:00 P.M.” During interview, one resident stated she did not like the limitations on visiting hours and believed she should be able to have visitors at a time she chose. Another resident stated the facility did not allow visitors outside the posted visiting hours and said she thought residents should be allowed to decide when they have visitors. Staff interviews confirmed the restriction. One staff member stated residents were not allowed to have visitors before 8:00 a.m. or after 8:00 p.m. Another staff member stated visiting hours were between 8:00 a.m. and 8:00 p.m., that visitors were not allowed outside those times, and that if visitors came outside visiting hours they would be told to come back during visiting hours. A third staff member stated the facility did not have a separate visitation policy and that the visiting hours were included in the admission agreement, which stated that all residents have the right to visit anyone during visiting hours.
Incorrect MDS Coding of Injectable Diabetes Medication
Penalty
Summary
The facility failed to ensure accurate coding of medications on the Minimum Data Set (MDS) for one resident. On the MDS with an Assessment Reference Date of 2/7/26, Section N was coded to show 1 injection received in the last 7 days and 1 day of insulin injections received in the last 7 days. However, the resident’s physician orders dated 11/17/25 showed Ozempic, 1 mg subcutaneously every Monday for diabetes. Ozempic is a GLP-1 medication and is not insulin. During interview, staff member C stated she completed Section N of the MDS and acknowledged she coded Ozempic as insulin because it was used to treat diabetes. She also stated she had not received formal training on MDS completion and was not familiar with the RAI Manual. The facility policy on Resident Assessments stated that persons completing any portion of the MDS must sign attesting to the accuracy of the information, and the policy had not been updated to reflect current RAI Manual guidance for distinguishing insulin from non-insulin injectable medications.
Physician Assessment Did Not Address Persistently Elevated Blood Sugars
Penalty
Summary
The facility failed to ensure physician services provided appropriate assessment and adjustment of treatment for a resident with diabetes, resulting in frequently elevated blood sugar levels for resident #15. The resident stated her blood sugars had often been high, sometimes over 300 mg/dL. Staff interviews confirmed awareness that the resident’s blood sugars were frequently above 200 mg/dL and that her diabetes was not adequately controlled. Staff also stated that if blood sugars were frequently above 200 mg/dL, the insulin regimen should be evaluated for adjustment, and that resident #15 should have been evaluated for sliding scale insulin because snack foods were contributing to the elevated readings. Record review showed resident #15 had no sliding scale insulin orders, and the last insulin adjustment was made on 12/8/25. Blood sugar review from 1/30/26 to 2/26/26 showed 47 readings over 200 mg/dL and 4 readings over 300 mg/dL. The medical visit on 2/26/26 documented a blood glucose of 205 mg/dL and noted the resident was doing well, with the endocrine review section left blank. A later review of blood sugars from 2/27/26 to 3/25/26 showed 47 readings over 200 mg/dL and 9 readings over 300 mg/dL, with an increase in readings over 300 mg/dL after the physician assessment.
Improper Storage and Expired Medications/Supplies
Penalty
Summary
The facility failed to ensure that drugs, biologicals, and medical supplies were stored securely and that expired items were removed from use. During an observation, the medical supply room door was propped open with an ice chest and left unsupervised, and later the same room was observed unlocked and unsupervised. In the medication supply room, one vial of Tuberculin Purified Protein Derivative was found with an open date of 1/26/26 and a discard date of 2/25/26. The medical supply room also contained items that were not secured in a locked cabinet, including one box of 25-gauge 1-inch needles and one box of 1 cc, 27-gauge 1/2 inch needles and syringes. Expired supplies were found in the room, including four blue top blood tubes with an expiration date of 1/31/26, three green top blood tubes with an expiration date of 7/31/25, eight green top blood tubes with an expiration date of 12/31/25, and 47 Xeroform petrolatum dressings with an expiration date of 1/2026. Staff interviews indicated one staff member did not check expired medications or supplies, while another stated nursing staff and night shift staff would look for expired items before use. The facility policy stated medications and biologicals are to be stored in locked compartments and multi-dose vials are to be dated and discarded within 28 days.
Medical Director Not Active in QAPI and Policy Review
Penalty
Summary
The facility failed to ensure the medical director was active in his role for QAPI and for the review, development, and revision of facility policies and procedures. During interview, staff member A stated the medical director was not always present at QAPI meetings and that staff member N did not always participate in reviewing and revising the facility’s policies and procedures, though he sometimes did. Staff member A also stated there was a new medical director expected to start in the near future. Staff member N stated he was not the medical director but was the medical provider, that he worked full-time at another healthcare entity, and that he came to see residents about every other week. He also stated he had just gained access to the facility’s EMR. When documentation was requested to show the medical director’s involvement in QAPI activities and policy review, the facility did not provide records before the end of the survey. Review of a QAPI at Risk Meeting document showed the medical director’s name was not listed among the IDT members who attended.
Failure to Perform Hand Hygiene and Proper Glove Use During Medication Pass
Penalty
Summary
Staff failed to follow accepted infection control practices during a medication pass for two sampled residents. During observation, staff member H prepared medications at the medication cart while wearing nitrile gloves but did not perform hand hygiene before putting the gloves on. While wearing the gloves, staff member H touched multiple potentially contaminated surfaces, including the medication cart, computer, computer mouse, personal hair, shirt pocket, medication keys, and door handles, then removed packaged medication cards and bottles and placed them on the cart before preparing medications into a clear plastic cup. Staff member H then removed the gloves, put on a new pair without hand hygiene between glove changes, and continued the medication pass. Staff member H pushed the medication cart to resident #3's room, touched the door handle, entered, and administered medications without performing hand hygiene before giving the medications. After leaving resident #3's room, staff member H removed gloves, performed hand hygiene, and donned a new pair of gloves, then touched the medication cart, computer, and computer mouse while preparing resident #5's medications. Staff member H entered resident #5's room after touching the door handle without performing hand hygiene and administered medications without hand hygiene prior to administration. During interview, staff member H stated she had been educated on proper hand hygiene and acknowledged she should have performed hand hygiene between donning and doffing gloves, prior to administering medications, and between residents.
Failure to Conduct Thorough Abuse Investigations and Assess Psychosocial Impact
Penalty
Summary
The facility failed to conduct thorough investigations into multiple alleged abuse incidents involving several residents. In each case, the staff member responsible for the investigation did not interview other residents who had received care from the accused staff, nor did they assess the psychosocial impact on the affected residents. For example, one resident reported that a staff member refused to change her soiled brief, but the investigation was limited to interviewing CNAs and did not include other residents or an assessment of the resident's emotional well-being. Another resident reported rough and abrupt care, resulting in her being tearful during the investigation, yet no further interviews or psychosocial assessments were conducted. Additional incidents included a resident who was reportedly afraid and hesitant to receive showers after an alleged rough interaction with a staff member, and another resident who felt uncomfortable and believed a staff member may have taken pictures of him during a shower. In both cases, the investigations did not extend to other residents or include any evaluation of the emotional or psychological effects on the residents involved. Documentation also showed that staff education on abuse was not provided immediately following the incidents. In another case, a resident was reportedly sprayed in the face with water by a staff member during a shower, causing distress. The investigation did not include interviews with other residents, a review of the bath schedule, or a direct interview with the accused staff member. The investigation was not updated with findings, and there was no documentation of abuse education for the staff member upon return to work. Across all incidents, the facility's own policy requiring comprehensive investigations and documentation was not followed.
Failure to Update Care Plan for Wandering Behavior
Penalty
Summary
The facility failed to assess and update the care plan with appropriate interventions for wandering for one resident. Despite the resident having a history of dementia, low vision, and hearing impairment, and being observed wandering the halls, entering other residents' rooms, and displaying combative behavior, the care plan was not adequately revised to address these behaviors. Staff interviews revealed that there was no formal assessment of the resident's behaviors, and interventions were inconsistently applied, such as offering a drink or taking the resident outside, without clear documentation or individualized planning. The resident's electronic health record showed a low risk of wandering based on an outdated assessment, despite frequent documented incidents of wandering and intruding on others' privacy. The care plan listed the resident as an elopement risk/wanderer but lacked specific, individualized interventions and did not specify de-escalation strategies. Facility policy required that residents identified as at risk for wandering have care plans with strategies and interventions to maintain safety, which was not followed in this case.
Failure to Assess and Address Behavioral Causes in Dementia Resident
Penalty
Summary
The facility failed to provide appropriate care and services for a resident diagnosed with dementia by not adequately assessing or identifying the underlying causes of the resident's behaviors. The resident was involved in an incident where another resident hit her after she repeatedly opened and closed his door. Staff interviews revealed that there was no formal behavioral assessment process in place, and interventions were limited to working with the physician on medications or providing distractions such as drinks or outdoor time. Staff were unsure if interventions were documented, and the care plan lacked specific strategies for managing or anticipating the resident's behaviors. Record review showed that the resident was consistently wandering, entering other residents' rooms, and displaying combative behavior. The facility's root cause analysis did not identify underlying factors contributing to the behaviors or specify effective interventions. The care plan noted the resident as an elopement risk and wanderer but only listed general triggers such as age, disease, and smoking, without detailing actionable interventions for staff. As a result, the facility did not provide a comprehensive approach to address or prevent the resident's behavioral issues.
Failure to Identify Root Causes of Falls
Penalty
Summary
The facility failed to identify the root causes of falls for a resident, who continued to experience falls, resulting in a head injury from a subsequent fall. The resident, who had a history of Type 2 diabetes and dementia, was identified as being at high risk of falling with a Morse Fall Scale score of 75. Despite this, the facility did not complete the Fall Root Cause Analysis portion of the Post-accident/Follow-up Investigation Form Team Meeting documents for the resident's falls on multiple occasions throughout the year. On one occasion, a staff member was present when the resident attempted to get out of bed and fell, hitting her forehead. The resident sustained a 2x2 egg-shaped bump on the left side of her forehead, and her vital signs indicated elevated blood pressure and low oxygen saturation. The incident was reported to the emergency room, and the resident was transported via ambulance. Interviews with staff revealed that falls were not documented as they should have been, and the facility's policy on managing falls did not include root cause analysis as a step in the fall prevention process.
Failure to Implement Enhanced Barrier Precautions and Adhere to Standard Precautions
Penalty
Summary
The facility failed to implement and follow enhanced barrier precautions (EBP) for four of the sampled residents and did not ensure adherence to standard precautions during medication administration via tube feeding. Observations revealed that residents with urinary catheters and those receiving medications and nutritional supplements via tube feeding did not have EBP signage on their room doors, nor was personal protective equipment (PPE) such as gowns available in or outside their rooms. Staff members were observed not wearing gowns during high-contact activities, such as administering medications and nutritional supplements via enteral feeding tubes, which are activities that require gown and glove use according to the facility's policy. Additionally, during medication administration for a resident, a staff member placed medications and nutritional supplements on an unclean surface without using a protective barrier. The bedside dresser had unidentified, dried spills, and the staff member admitted to not cleaning the surface or using a barrier before placing the items. Interviews with staff members revealed a lack of understanding and implementation of EBP, with some staff unaware of the need for gowns during certain procedures. The facility's policy outlined the need for EBP signage and PPE availability, which was not observed during the survey.
Failure to Report Abuse Investigation Findings Timely
Penalty
Summary
The facility failed to report the findings of an alleged abuse incident involving a resident to the State Survey Agency within the required five-day period. The incident involved a resident who reported being assaulted by her son outside the facility. The resident was considered an elopement risk as she did not sign out of the facility. Security personnel alerted the charge nurse about the incident. During an interview, a staff member revealed that the responsible staff member did not submit the investigation report. The resident's family attempted to bring her back to the facility, but she returned only once and subsequently left against medical advice. The facility's policy mandates that findings of an abuse investigation be reported within five days, which was not adhered to in this case.
Failure to Protect Resident's Dignity and Privacy
Penalty
Summary
The facility failed to protect the dignity and privacy of a resident by posting a sign on the outside of her door that included her name and instructions for the care of her nephrostomy tube bag. The sign instructed staff to check and empty the resident's urine bag every two hours. This was observed on two separate occasions. During interviews, a staff member acknowledged that the sign should not have been on the door, and the resident expressed discomfort with the sign being visible to everyone. The resident mentioned that a staff member, who was no longer at the facility, had put up the sign. Another staff member was unaware of who placed the sign on the door.
Failure to Document and Order Nephrostomy Tube Care
Penalty
Summary
The facility failed to ensure proper care and documentation for a resident with a nephrostomy tube. The resident required dressing changes for the nephrostomy tube, but the facility did not obtain physician orders for these changes. Interviews with staff members revealed that there were no orders for the dressing changes, and the changes were performed as needed or when the resident requested, approximately every two to three days. However, the resident mentioned that the dressing was only changed during doctor visits every three months. The facility's policy required dressing changes every one to three days using a sterile technique, with documentation of the procedure, the resident's response, and a nursing assessment. The review of the resident's physician orders and medical records from the specified period showed no orders or documentation of dressing changes for the nephrostomy tube. This lack of documentation and adherence to the facility's policy indicates a deficiency in the care and services provided to the resident. The facility's failure to document the dressing changes and obtain necessary orders for the nephrostomy tube care contributed to the deficiency identified by the surveyors.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the citations issued around you in the last 12 months — including the immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Blackfeet Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.