Blackfeet Care Center

In the surveyor’s words

From the most serious findings on record at Blackfeet Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 9, 2026

  Based on interview and record review, the facility failed to identify risks, provide training for van drivers, and ensure the safety of two unrestrained residents who fell to the floor when the van made abrupt stops for 2 (#s 1 and 2) of 9 sampled residents. This deficient practice increased the risk of negative outcomes and injury for residents required to use the facility van.On 7/9/26 at 9:55 a.m., an Immediate Jeopardy (IJ) was announced to the Administrator and Director of Nursing related to F689-Free of Accidents and Hazards and Supervision affecting two residents. The Severity and Scope identified for the Immediate Jeopardy were identified to be at the level of J, and upon verification for the removal of the immediacy, lowered to a D. […]

• Immediate jeopardy, isolatedF757Mar 26, 2026

  Based on interview and record review, the facility nursing staff failed to ensure a resident's anticoagulant medication was clarified on admission for 1 (#36) of 19 sampled and supplemental residents, and the resident received a medication that was discontinued while in the hospital before being admitted . Therefore, the medication was unnecessary and should not have been provided to the resident. The resident experienced a significant change and decline in status due to the medication being given, which resulted in a low hemoglobin of 6.9 g/dl and required a blood transfusion. On 3/25/26 at 4:22 p.m., the facility Administrator and Office Manager were notified of an immediate jeopardy situation for F757. This involved one resident, #36. […]

• Actual harm, isolatedF689Jan 30, 2025

  Based on interview and record review, the facility failed to identify the root causes of falls for 1 (#12) of 17 sampled residents, and the resident continued to fall, and this resulted in the resident sustaining a head injury from a subsequent fall. Findings include: During an interview on 1/29/25 at 9:29 a.m., NF1 stated resident #12 had fallen five times this year. NF1 further stated she had asked why resident #12 kept falling and the facility staff could not tell her why. A review of resident #12's Morse Fall Scale, dated 11/12/24 at 9:59 a.m., showed resident #12's score was 75, and was at high risk of falling. […]

• No harm, potential for more than minimal, widespreadF940Jul 9, 2026

  Based on observation, interview, and record review, the facility failed to develop and implement an effective training program for all staff who transported residents in the facility vans to ensure the residents were safe when transported and seat belts and safety harnesses were secured properly. This failure contributed to the Immediate Jeopardy situation(s) identified in F869 - Accidents and Hazards, and if not corrected, this failure may affect any resident not transferred properly by untrained staff. Findings include: During an interview on 7/8/26 at 9:45 a.m., staff member B said resident #1 fell out of her wheelchair because staff member H tethered resident #1's wheelchair to the van but did not place a waist/lap belt on resident #1 for resident safety. […]

• No harm, potential for more than minimal, widespreadF851Mar 26, 2026

  Based on interview and record review, the facility failed to ensure the accuracy of staffing data submitted to CMS (the Centers for Medicare and Medicaid Services) through the PBJ (Payroll-Based Journal) system for October 1, 2025, through December 31, 2025. Findings include:Review of the PBJ Staffing Data Report for quarter 1 (10/1/25-12/31/25) showed the facility failed to include all nursing staff hours when compared to 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 and submitted the PBJ information on a quarterly basis. […]