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 August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Kalispell Rehabilitation And Nursing Llc during CMS and state inspections, most recent first.
A resident with AFib and renal dialysis dependence missed 27 doses of Eliquis when an LPN discontinued the anticoagulant instead of placing it on hold. The resident’s fistula surgery was then cancelled twice because pre-op hold orders were not followed, including Ozempic being given in error and Eliquis being administered when it should have been held. The resident and family reported frustration and fear over the repeated cancellations.
A resident with a Braden score of 13 developed facility-acquired heel pressure injuries that were not effectively tracked or managed. OT noted large blood blisters on both heels, and wound records showed the left heel progressed from a fluid-filled blister to a stage II plantar heel pressure injury while the right heel deep-tissue injury enlarged over time. Documentation was incomplete at times, a scheduled weekly skin assessment was missed, and the care plan did not reflect ongoing modification despite worsening wounds.
Delayed recognition and response to severe weight loss and malnutrition: The facility failed to promptly identify and act on clinically significant weight loss for three residents. One resident with dementia, aphasia, poor PO intake, sedation, and wounds had a severe 14% weight loss and the POA was not notified until after the loss occurred. A second resident had progressive severe weight loss with inaccurate nutritional assessment data and delayed OT/NAR review. A third resident with pressure injuries, dementia, pain, and a language barrier had early malnutrition identified but later developed an 11% severe weight loss before NAR review and care plan revision occurred.
Failure to reposition residents and support ambulation led to a resident developing an avoidable Stage III sacral PU, while three other residents were repeatedly observed lying on their backs without positioning support. Family and staff interviews described missed turning, limited ambulation, and inconsistent transport to wound care, and no repositioning documentation was provided for the affected residents.
Catheter care was not completed correctly for one resident with an indwelling Foley catheter, who reported frequent UTIs and said clean care was only done when requested. Staff observed a full drainage bag with urine backing up into the tubing and incomplete perineal care because the glans was not fully exposed. For another resident with a suprapubic catheter, the ordered catheter change was missed, the site was not assessed or dressed as ordered, and the drainage bag was repeatedly observed overfilled and later completely full.
A resident who had walked with a walker before admission was not frequently encouraged or facilitated to ambulate after being admitted for PT/OT for deconditioning. Family members reported staff often left him in a chair or bed, avoided ambulation because he was a fall risk or sometimes combative, and that he lost mobility and became bed-bound. Record review showed PT/OT was ordered, but staff stated the orders never reached the resident and no PT/OT services were provided; the family also reported poor dementia care and that the resident later developed pneumonia and a Stage III pressure wound.
The facility failed to employ a certified dietary manager or a full-time dietician to direct food and nutrition services. Record review showed staff member M had a ServSafe certification but no current Certified Dietary Manager certification, and M stated she was only enrolled in the training after the certification request. Staff member A confirmed the previous dietician was not full time and acknowledged that ServSafe did not meet the requirement for a Certified Dietary Manager.
Multiple residents reported that meals were cold, bland, visually unappealing, or served in forms they could not identify or eat comfortably. Complaints included burgers served with only a bun, eggs that were hard or burnt, soggy biscuits and gravy, repetitive salad dressing, and meals that left residents hungry. Observations confirmed some residents were served hard or burnt eggs and other unappetizing items, consistent with the facility policy requiring food and drinks to be palatable, attractive, and at a safe and appetizing temperature.
Unsafe food storage, temperature monitoring, and kitchen sanitation were observed in the dietary area. Expired food items were found in storage, food and debris were on the kitchen, freezer, cooler, and dry storage floors, a box of foam containers was stored on the floor, and kitchen surfaces and storage shelves had dirt, grease, and food buildup. The walk-in-cooler logs showed repeated temps above 41 degrees with no documented follow-up and multiple missed entries, and a pitcher of orange liquid in the cooler was left undated.
Unsanitary resident rooms and shower areas: The facility failed to keep multiple resident bathrooms, resident rooms, and the A/B hall shower room clean. Observations found dried stains, hair, and visible soil on bathroom floors, drip stains running from a bathroom to a bed, and brownish/black staining around shower drains and across the shower room floor. Staff said the memory care unit had sometimes gone up to a week without housekeepers, and the shower room did not look like it had been cleaned.
EBP signage was missing for two residents, and staff did not consistently follow EBP during catheter care for residents with a suprapubic catheter and a Foley catheter. Staff were observed handling catheter care without the proper PPE, performing incomplete perineal care, and emptying a full catheter bag with poor hand hygiene practices. Hand sanitizer in four resident rooms was not working or was empty, and one resident reported frequent UTIs and prior sepsis related to catheter care issues.
POA Not Informed of Psychotropic Medication Use: A resident’s POA was not kept informed about the resident’s Ativan use and was not told the medication had been started or continued. The resident received Ativan PRN and later scheduled BID for anxiety/agitation, and the POA stated she had asked for it to be stopped but later learned it was still being given.
Failure to obtain representative consent for psychotropic medication: A resident on the memory care unit was given Ativan without the POA/rep’s prior knowledge or permission. The rep stated she later learned the med had been administered for months, and staff reported she had not been informed during the care conference when Ativan was discussed. The facility’s resident rights and care planning policy required advance notice and participation in treatment decisions, including the right to refuse treatment.
Failure to hold timely care conferences with a resident’s POA on the memory care unit. The POA stated she had not been involved in a care conference since August, and staff reported care conferences were being scheduled only on admission and annually, with no documentation of invitations to the POA. Staff also stated they were unaware care conferences should occur quarterly, include the POA, or be held after a change in condition, despite the facility policy requiring routine conferences and discussion of the care plan with the resident and/or representative.
Failure to Report Alleged Neglect Involving Dislodged Nephrostomy Tube A resident with a nephrostomy tube reported that a CNA pulled the tube out during care, and the tube was later found displaced with no urine output. Staff knew about the allegation, but one staff member did not report it to the administrator, and the facility did not submit the incident to the State Survey Agency because the IDT did not view it as neglect. The NHA later spoke with the resident about the incident, but that conversation occurred after the allegation.
A resident reported that a CNA pulled out his nephrostomy tube, leaving it displaced and no longer draining urine. Staff did not immediately investigate the allegation to rule out neglect because the IDT did not consider it reportable, and a later discussion with the resident about whether the event was abusive or neglectful occurred after the allegation rather than at the time it was made.
Failure to Position Resident Safely for Medications: A resident was observed lying flat with his head kinked forward when taking morning meds. He asked an staff member to adjust his head so he would not choke, but the HOB was raised too quickly, the resident winced, and the staff member did not reposition him again or provide education about swallowing at a 30-degree angle. The resident coughed and spat out pudding used with the medication, and the care plan did not document the need to sit him up for meals or med pass.
Failure to provide needed ADL assistance with grooming and showering. A resident who required help with personal hygiene, grooming, and weekly showers was observed over multiple days with numerous long gray chin and neck hairs, along with eye rheum and a slight musty odor. The resident indicated she wanted help removing facial hair, while staff stated showers were usually weekly and facial hair removal occurred during showers. The shower log showed only two baths that month and no documented refusals.
Failure to Meet Resident Food and Care Needs: A resident reported poor-quality, unappetizing meals, inadequate portions, and repeated dietary concerns that had been raised by the family and staff but not addressed. Staff said the resident was crying over the food served, wanted to discharge from the facility, and had swollen feet with BGs over 400 for 3 days because therapeutic diets were not followed; the care plan noted nutritional risk, a chronic non-healing LLE wound, and confusion with DM lifestyle management.
A resident with chronic hypoxic respiratory failure and COPD was found without oxygen in bed, with the concentrator off and tubing disconnected, despite an order for continuous O2 at 2 LPM via NC and a care plan calling for oxygen use and HOB elevation. The resident was later observed in a wheelchair with an empty portable O2 tank, and on another occasion the NC was out of the nose while the resident slept. Staff stated the resident’s O2 sats could drop into the low 70s without continual oxygen and that the resident needed continuous oxygen to stay above 88 percent.
Staff lacked the competency to care for a resident with nephrostomy tubes. The resident stated staff had pulled on the tubes during care and that one tube had been dislodged. Several staff members said they had not received training on nephrostomy tube care and learned by working with the resident, while the staff member responsible for admission review said the need for training was not identified before the resident was admitted.
Missing Current Hospice Agreement: The facility failed to have an updated written hospice agreement signed by authorized representatives before hospice care was provided for two residents receiving services from NF6 Hospice. Staff confirmed the only agreement available was an old document from companies that no longer exist, and the facility did not have a current agreement in place. The facility policy required written agreements with hospice providers to define care and communication processes.
A resident with severe dementia and a history of falls was not provided with adequate supervision or individualized interventions to address her wandering and behavioral risks. Despite multiple injuries, including a compression fracture and a fractured hip, the care plan lacked specific strategies for fall prevention and behavioral management. Staff interviews and documentation revealed inconsistent monitoring, insufficient staffing, and a lack of effective interventions, resulting in repeated accidents and injuries.
A resident with severe dementia and a history of wandering and aggression was not provided with adequate supervision or individualized interventions, resulting in repeated incidents of entering other residents' rooms, altercations, falls, and injuries. Care plans were not tailored to the resident's needs, pain management was inconsistent, and required monitoring was not properly documented, leading to distress and harm for both the resident and others.
Residents repeatedly reported issues with inadequate housekeeping and missing laundry items over several months, with concerns documented in Resident Council meetings and confirmed by staff interviews. Despite these ongoing complaints, the facility did not resolve the problems, resulting in continued deficiencies in cleaning and laundry services.
The facility failed to provide a clean and homelike environment and did not properly manage residents' laundry, resulting in persistent cleanliness issues and frequent loss or misplacement of personal clothing. These failures led to repeated resident complaints and an altercation between two residents over misidentified clothing, with staff confirming ongoing problems in both housekeeping and laundry processes.
The facility did not report allegations and findings of abuse within the required timeframes for a resident involved in a physical abuse incident with staff and for two residents involved in a verbal altercation. Delays were attributed to technical issues and failure of staff to promptly report incidents, resulting in late notifications to the State Survey Agency.
A resident with dementia who exhibited aggressive behaviors, wandering, frequent falls, pain, and elopement risk did not have a care plan with specific, person-centered interventions. The care plan relied on vague redirection strategies and lacked individualized pain management, fall prevention, and activity planning. Staff were unaware of the full extent of the resident's behaviors, and meaningful activities were not provided for residents in the memory care unit, resulting in inconsistent and unsafe care and unmet psychosocial needs.
The facility did not provide daily, individualized or group activities for residents with dementia in the secure memory care unit. Observations and interviews with family and staff confirmed a lack of meaningful engagement, with residents often left sitting in silence without activities. Requested documentation of activity participation was not provided, and facility policies requiring special consideration for dementia care were not followed.
A resident with dementia and a diagnosis of wandering was not accurately assessed for daily wandering behaviors on the MDS, as staff did not review all relevant medical diagnoses or interview family members. This led to incomplete documentation and care planning that did not address the resident's actual wandering frequency.
The facility failed to respond to residents' call lights in a timely manner, resulting in inadequate pain management and feelings of insecurity. Residents reported waiting over 30 minutes for assistance, particularly at night, due to understaffing. Staff confirmed insufficient staffing, leading to delays in addressing residents' needs. One resident with multiple health conditions experienced daily pain and inadequate repositioning assistance. The facility's call light audit goal of a 5-minute response time was not met, contributing to resident dissatisfaction.
The facility failed to implement proper infection control measures, including adherence to transmission-based precautions and documentation of COVID-19 testing. Staff entered rooms without PPE, and there was confusion about which residents required contact precautions. Additionally, COVID-19 testing for close contacts was not documented, and the facility lacked a system for monitoring waterborne illnesses.
The facility failed to maintain a clean environment in resident shower areas and did not adequately safeguard residents' personal belongings from loss or theft. Observations showed unclean shower rooms with used washcloths and pooled dirt, while interviews revealed frequent reports of missing clothing and personal items. The facility's grievance process and inventory management were ineffective, with insufficient staff training contributing to the deficiencies.
The facility failed to maintain an effective grievance program, particularly regarding lost resident belongings. Staff interviews revealed inconsistencies in elevating issues to a formal grievance level, and a missing grievance log was noted. A resident discharged with missing items, including an iPad and Apple Watch, had unresolved grievances despite these items being inventoried.
The facility failed to manage pain effectively for several residents, including one with advanced dementia who showed signs of distress without receiving scheduled pain medication. Another resident experienced delays in receiving pain relief, affecting mobility and increasing the risk of skin breakdown. Additionally, a resident reported unmanaged pain with missed assessments, and another was unfamiliar with the pain scale, indicating systemic issues in pain management.
The facility failed to follow up on dental care referrals for several residents, resulting in unresolved dental issues and ill-fitting dentures. A resident had multiple dental concerns identified by a hygienist, but no follow-up was documented. Other residents experienced difficulties eating due to poorly fitting dentures, with one resident experiencing significant weight loss. No documentation of dental appointments was provided.
The facility's dietary department failed to serve meals on time, resulting in cold food for residents. Breakfast and lunch were consistently delayed, with residents reporting dissatisfaction with the food quality. Some residents received meals that did not match their dietary needs, and staff members confirmed the poor quality of the food.
The facility failed to provide adequate supervision in the memory care unit, leading to resident confrontations and unsafe conditions. A resident eloped due to ineffective wanderguard systems, and two residents were improperly positioned during meals, increasing choking risks. Staff shortages and non-compliance with care plans contributed to these deficiencies.
A facility failed to refer a resident for a PASARR Level II assessment after a PTSD diagnosis was added. The resident, with a history of military service and being a prisoner of war, had a PASARR Level I assessment that did not include PTSD. A staff member acknowledged the need for a new Level I assessment, but no Level II request was made before the survey ended.
A facility failed to document a resident's need for enteral tube feeding in their baseline care plan, despite the resident's history of spinal cord injury, Parkinson's, and aspiration pneumonia, and being NPO. The admitting nurse did not include this critical information, and the floor nurse did not complete the care plan, contrary to facility policy.
The facility failed to provide necessary assistance to two residents with activities of daily living (ADLs). One resident, dependent on staff for eating, was observed struggling to feed himself without assistance. Another resident with Parkinson's disease was found struggling to dress herself after using the bathroom, despite needing supervision and assistance as per her care plan.
The facility failed to ensure timely hospice referrals for two residents, resulting in significant delays in care. One resident experienced a delay in hospice referral despite a fall and a request from their POA, while another resident faced confusion over palliative care orders, leading to unmanaged pain and immobility concerns. Staffing issues and lack of a palliative care policy contributed to these deficiencies.
A facility failed to provide necessary treatment for a resident diagnosed with PTSD. The resident, a veteran with a history of combat and imprisonment, expressed the need for psychiatric or counseling services. Despite the diagnosis, no referral for treatment was made, and staff confirmed the lack of action. No documentation was provided to show any referral for PTSD treatment.
The facility did not follow the posted menus for two out of three observed meals, serving different items than those listed. This included missing whole grain toast at breakfast and serving an entirely different lunch menu, potentially affecting residents relying on the posted menus for their nutritional needs.
The facility failed to adhere to physician-ordered therapeutic diets for three residents. A resident on a CCHO diet reported high blood sugar levels due to inappropriate meal content, while another had to remind staff to provide sugar-free syrup. A resident with end-stage renal disease was not provided a renal diet, and staff were unaware of specific dietary needs. Budget constraints and lack of awareness contributed to these deficiencies.
A resident did not receive two prescribed medications, Cefdinir and Potassium Chloride, during an evening medication pass, resulting in a 6.4% medication error rate. Staff interviews confirmed that the absence of documentation in the MAR indicated a medication error. The facility's policy requires timely administration and documentation of medications, which was not followed in this instance.
A significant medication error occurred when a staff member in an LTC facility pre-poured medications and mistakenly gave a resident high-dose opioids instead of Tylenol. The staff member failed to follow the facility's medication administration procedures and did not monitor the resident's health adequately after the error. The resident was found unresponsive and required hospital treatment for an opioid overdose.
A LTC facility failed to prevent significant medication errors for two residents, leading to an Immediate Jeopardy situation. A resident was mistakenly given high doses of opioids instead of Tylenol, resulting in an opioid overdose and hospitalization. Another resident received an incorrect dosage of Trospium due to a transcription error, although no adverse effects were reported. The facility's medication administration and error monitoring policies were not adequately followed, contributing to these errors.
A resident was given incorrect medications, leading to an opioid overdose and hospitalization. The facility also failed to assess two residents' ability to consent to sexual contact, resulting in an incident in the memory care unit. Additionally, a resident-to-resident abuse event occurred when a wandering resident was pushed, causing a fall.
The facility failed to protect two residents from falls and hazards, resulting in multiple injuries. One resident experienced eight falls in 17 days, with significant injuries, while another was pushed by a fellow resident due to wandering. Staff were unaware of care plan updates, and interventions were not effectively communicated or enforced, leading to inadequate supervision and safety measures.
Missed anticoagulant doses and failure to follow pre-op medication holds led to cancelled fistula procedures
Penalty
Summary
The facility failed to provide ordered anticoagulant therapy and failed to follow physician-ordered medication hold instructions for a resident with atrial fibrillation and dependence on renal dialysis. The resident’s physician ordered Eliquis 5 mg twice daily, with instructions to hold the medication 48 hours before a vascular procedure. Facility records showed the Eliquis order was discontinued instead of placed on hold, and the resident did not receive Eliquis from 3/26/26 through 4/8/26, resulting in 27 omitted doses. Staff later documented that the medication had been discontinued in error rather than held. The resident’s fistula surgery was scheduled and then cancelled on two separate occasions because medications that were supposed to be held were administered. For the first scheduled procedure, the resident received Ozempic despite orders to stop it before surgery, and the hospital cancelled the procedure. When the procedure was rescheduled, the resident again received Eliquis despite instructions to hold it 48 hours before surgery, and the procedure was cancelled a second time. The resident was already on the procedure table when the cancellations occurred. Interviews with the resident’s family and the resident described frustration and fear related to the repeated cancellations. Facility documentation showed the medication errors were identified as order management problems, including Eliquis being discontinued instead of held and Ozempic being given in error after the hold order changed. The record also showed the second cancellation was attributed to Eliquis not being placed on hold for the surgical procedure.
Failure to Monitor and Manage Progressive Heel Pressure Injuries
Penalty
Summary
The facility failed to effectively and systematically identify, assess, implement, monitor, and modify interventions after facility-acquired pressure injuries were identified for one resident. The resident had a Braden Scale score of 13 on two assessments, indicating moderate risk for pressure injury development. On admission/readmission screening, skin findings were documented for the sacrum, right gluteal fold, and right trochanter, but no heel pressure injuries were documented at that time. During the resident’s stay, occupational therapy noted that the resident did not have socks on and observed what appeared to be large blood blisters on the backs of both heels, immediately notifying nursing. Weekly wound documentation later identified a left heel deep-tissue injury described as a fluid-filled blister measuring 5 cm by 4 cm, with treatment limited to wiping with sure prep twice daily. The wound record did not show whether the injury was avoidable. The left heel wound later remained the same size, then was documented as resolved, and a new facility-acquired pressure injury developed on the plantar aspect of the left heel. That new wound was documented as a stage II pressure injury with granulation tissue and drainage, and no debridement was performed. The right heel was also documented as a facility-acquired deep-tissue injury that progressed over time. It was first measured at 2 cm by 2 cm and later increased to 3 cm by 4 cm and then 4.5 cm by 5 cm, while treatment remained sure prep and heel floating. No debridement was performed throughout the documented progression. Progress notes showed the physician documented the heel wounds, including blistering, rupture, drainage, discoloration, and worsening size, but the nursing assessments and wound notes were incomplete, including missing measurements at times. The care plan included wound care and monitoring interventions, but it did not reflect ongoing attempts to add or modify interventions based on the worsening wounds, and a scheduled weekly skin assessment was not completed. The resident’s diagnoses list also lacked diagnoses related to the bilateral heel pressure injuries.
Delayed recognition and response to severe weight loss and malnutrition
Penalty
Summary
The facility failed to promptly identify, evaluate, and implement interventions for clinically significant weight loss and nutritional decline for three residents, and failed to timely notify a resident representative of severe weight loss for one resident. The report states that one resident had advanced dementia, severe expressive aphasia, bilateral heel DTIs, poor oral intake, frequent meal refusals, and medication-related sedation that limited intake. Although a Mini Nutritional Assessment shortly after admission reflected malnourishment and the record later documented severe malnutrition, the resident experienced a 19.2-pound loss, or 14.0%, within about 30 days. Weekly weights were ordered, but one weekly weight was missed, the baseline weight in the nutritional assessment was inaccurate, and the resident’s representative was not notified until after the severe loss had already occurred. A second resident experienced progressive weight loss that became severe, with a 10.2% loss within about 60 days and an 8.5% loss within less than 90 days. The resident’s records showed multiple weights declining from the low 130s to the low 120s and then to 117.8 pounds, with later weights continuing to fall. The resident had prior swallowing and feeding-related therapy involvement, but occupational therapy did not address feeding or nutritional goals until weeks after those goals were established. The resident’s Mini Nutritional Assessment underestimated the amount of weight loss, and the Nutrition at Risk meeting documentation did not address the resident until later, when severe malnutrition was formally identified and supplementation was initiated. A third resident had multiple nutritional risk factors, including severe pressure injuries, recent pelvic fractures, adult failure to thrive, severe dementia, acute agitation, pain, and a German language barrier affecting intake. The resident’s Mini Nutritional Assessment showed malnourishment early in the stay, but the resident then experienced an 11% severe weight loss in about 35 days. The Nutrition at Risk meeting notes did not discuss the resident until after the significant loss had occurred, and the notes contained blank or incomplete weight-loss documentation. The care plan identified nutritional problems and later revised the focus to severe malnutrition, but the record showed that review through the Nutrition at Risk process, recognition of severe malnutrition, and care plan revision occurred only after the clinically significant weight loss had already taken place.
Failure to Reposition Residents and Prevent Pressure Injuries
Penalty
Summary
The facility failed to reposition and facilitate ambulation for one resident, which resulted in the development of an avoidable Stage III pressure ulcer. Resident #98 had a reddened area on the coccyx that was first identified as pressure-related and later progressed to a Stage III sacral pressure ulcer. The record also showed the resident had been fairly independent at home before a fall, then became more bedbound after admission to the skilled nursing facility, and the wound care physician documented that frequent moving and repositioning were recommended to prevent further deterioration. The record and interviews described that resident #98 was not walked with staff and was not repositioned consistently. Family members stated they repeatedly tried to remind staff to turn the resident every two hours, but the reminders were only posted briefly. They also reported that the resident was not always sent to wound care appointments with the lift sling needed for transport, causing at least one appointment to be rescheduled. Wound care notes later described the sacral injury as unstageable and measured 13 cm x 11 cm x 0.1 cm, with provider comments noting the resident had become somewhat combative and confused and, when sedated, more bedbound. The facility also failed to provide necessary positioning and repositioning for skin protection for three other residents. Resident #73 was repeatedly observed lying on his back without pillows for positioning and stated staff did not rotate him in bed and that his buttock area hurt from sitting too long. Resident #2 was repeatedly observed lying on his back with his left elbow directly on the bed, including while the elbow wound was open and undressed. Resident #71 was observed lying directly on his back without positioning pillows and stated staff did not rotate him in bed. No repositioning documentation was provided for residents #2, 71, 73, and 98, despite the facility policy requiring turning and repositioning for residents at risk of or with existing pressure injuries.
Catheter Care, Site Care, and Drainage Bag Management Not Completed as Ordered
Penalty
Summary
Proper catheter care was not provided for a resident with an indwelling Foley catheter who reported frequent facility-acquired UTIs and said he had been septic from prior infections. During interview, the resident stated he did not receive catheter care often enough and that clean catheter care was only done once a day if he asked for it. The record showed multiple UTIs in the prior year, including on 4/16/25, 4/29/25, 5/11/25, 7/2/25, and 8/13/25. During observation, staff member V stated the resident’s catheter bag should not have been that full, but no one had emptied it that morning because a staff member had called off. The bag was observed to be full, with urine backing up into the tubing. When staff member V performed perineal care, the glans penis was not exposed because the surrounding tissue was not retracted enough, and the cleaning was incomplete. A whitish buildup was observed around the glans. For a second resident with a suprapubic catheter, the facility did not complete the ordered monthly catheter change on the scheduled date, and there was no documentation of a refusal or completed change at that time. The resident’s suprapubic site was also not assessed and the dressing was not changed as ordered, and the site was observed with thick yellow-green drainage and dried drainage on the tubing. In addition, the resident’s drainage bag was observed multiple times to be over 2000 ml and later completely full to the top and backing up into the tubing. Staff stated the bag should be emptied when half to one-third full or at least once per shift, but the bag remained full during observations.
Failure to Encourage Ambulation and Provide Ordered Rehab Services
Penalty
Summary
The facility failed to frequently encourage and facilitate ambulation for a resident who had been admitted for PT/OT evaluation and treatment for deconditioning. The resident had previously ambulated independently with a walker before a fall at home and hospital admission, and the family stated the plan was for him to regain strength so he could move to assisted living. Instead, the family reported that staff often left him in a chair or in bed, did not ambulate him because he was considered a high fall risk and sometimes combative, and that he lost mobility while at the facility. The family also stated staff had a poor dementia approach and did not complete cares when the resident showed behaviors. Record review showed a physician order for PT/OT evaluation and treatment, but staff later showed a blank screen indicating the resident never received PT or OT services. Staff stated the orders never got to him and that, because he was private pay, rehab services were discussed with the family instead, but the conversation was not documented. Another staff member stated the resident was usually workable and only had a couple of agitated days, and that the missed PT/OT appeared to involve multiple disciplines, including admissions, nursing, and PT/OT. The family also reported the resident developed pneumonia and a pressure ulcer while at the facility, and the report references a Stage III pressure wound in relation to the resident's decline.
Lack of Qualified Food and Nutrition Services Director
Penalty
Summary
The facility failed to employ a certified dietary manager or a full-time dietician to serve as the director of food and nutrition services. During record review, the facility could not provide a current Certified Dietary Manager certification for staff member M and instead provided a ServSafe certification dated 12/7/23. In interview, staff member M stated she did not have a current Certified Dietary Manager certification and said she was enrolled in the training only after the certification request was made. Staff member K stated she was employed full time by the facility, worked 35 to 40 hours per week, and had worked there for two weeks. Staff member A confirmed that staff member K was a full-time employee, stated the previous dietician was not employed full time, and stated he had not previously known that ServSafe certification did not meet the requirement for a Certified Dietary Manager.
Unpalatable and Poorly Served Meals
Penalty
Summary
Food and drink were not kept palatable, attractive, or at a safe and appetizing temperature for multiple sampled residents. Several residents stated the food was cold, unappetizing, poorly flavored, or difficult to identify, and some reported being hungry because they either were not served enough food or did not eat what was served. One resident said the food was sometimes cold by the time it was delivered to the room, another said the food had no good flavor and was not cooked right, and others described meals as terrible, pathetic, or not worth eating. Residents also reported specific problems such as burgers served with only a bun, biscuits and gravy arriving soggy and cold, eggs being hard or burnt, and salads being served with the same dressing repeatedly or with large pieces of spinach that were unappealing visually. During observation, residents were served meals that matched these complaints. One resident’s eggs were super hard and another resident’s eggs were burnt on the bottom, with both leaving the eggs uneaten. A resident stated she could not cut a pork chop because it was too hard, and another said she was served a plate full of cooked carrots and soup with tofu or ham and water, which left her crying. The facility policy titled Food Preparation Guidelines stated that food and drinks shall be palatable, attractive, and at a safe and appetizing temperature, and that resident complaints about foods and drinks should be addressed.
Unsafe Food Storage, Temperature Monitoring, and Kitchen Sanitation
Penalty
Summary
The facility failed to store food in a safe, sanitary manner, maintain cooler temperatures within a safe range, and keep the kitchen and food preparation/storage areas clean. During observation, expired ground [NAME] and ground sage were found in storage, a box of foam containers was sitting directly on the floor, paper towels were on the floor beside an overflowing garbage can, stovetop burners had a thick black buildup, a slice of white bread was on the kitchen floor, and crumbs, food particles, dirt, and grease were observed on shelves and boxes where pan liners and foil were stored. Food and garbage were also observed on the floor in the walk-in-freezer, and additional debris was later seen on the floor in the dry storage area, outside the walk-in-freezer door, and inside the walk-in-cooler. The walk-in-cooler temperature logs showed repeated temperatures above 41 degrees Fahrenheit in January, February, and March 2026, with no documented follow-up, and multiple temperatures were not recorded. Staff member M stated cold food should be stored at or below 41 degrees Fahrenheit and said the walk-in-cooler was old and sometimes ran above that temperature. Staff member M also stated there were no follow-up temperatures recorded to show adjustments. During observation, a pitcher containing an orange liquid was found on a cart inside the walk-in-cooler with no date on it. Staff member A stated he checked food temperature logs weekly and would point out areas needing cleaning, while the facility policy required food service areas to be kept clean and sanitary and required daily inspection of refrigerators, coolers, freezers, storage area temperatures, and dishwasher temperatures.
Unsanitary resident rooms and shower areas
Penalty
Summary
The facility failed to maintain a sanitary environment by not keeping resident rooms, resident bathrooms, and the community bathing/shower room on the A and B halls clean. During observations, the bathroom floor in room B10 had dried light black spots in several places, the bathroom floor in room B7 had a dried light brownish/black stain covering over half of the one-foot square tile under the toilet, and when wiped with a wet paper towel the area left a brownish/yellow stain with black specks and hair. The floor in room B9 had multiple dried drip stains running from the bathroom to the bed on the left side of the room, and the same stains were still present on a later observation. The community bath/shower room had a light gray/black stain around the drain outside one shower, a brownish stain around part of the drain with hair partially occluding it, and the second shower had the hand-held shower head lying on the shower floor next to the stool. Later observations of the community bath/shower room found brownish/black staining across the linoleum floor just outside the showers, and wiping the floor with a wet tissue left the tissue stained brownish/black. Staff interviews indicated the memory care unit had gone up to a week without housekeepers at times, and staff stated the shower room should be cleaned after each resident shower and that housekeeping staff would do a deeper clean two times a week. Staff also stated the observed shower room did not look like it had been cleaned and that the bathroom and room floor conditions did not meet expectations. The facility policy required routine cleaning and disinfection of visibly soiled surfaces in common areas, resident rooms, and at discharge.
EBP signage, catheter care, and hand hygiene failures
Penalty
Summary
The facility failed to have enhanced barrier precaution (EBP) signage posted for two residents who were on EBP. On the outside of the doors to two rooms, a hanging PPE caddy was present, but there was no sign indicating what precautions were required. Staff stated one resident was on EBP because of an upper right chest port for dialysis, and the other resident was on EBP related to an indwelling catheter. In both instances, staff left to get a sign to place on the door after the omission was identified. The facility also failed to ensure EBP PPE was used during catheter care for a resident with a suprapubic catheter and during Foley catheter care for another resident. During catheter site care for the resident with the suprapubic catheter, staff did not don the appropriate PPE before beginning care, and stated they knew PPE was needed but did not expect to be changing the dressing at that time. For the resident with the Foley catheter, staff emptied a full catheter bag that had been on the ground, moved it into a basin under the bed, and used only gloves at first; the same gloves were then used when a gown was put on. The resident’s perineal care was also incomplete because the glans was not exposed for cleaning, and whitish buildup was observed around the glans. The facility further failed to ensure hand sanitizer was available in four resident rooms. In one room, the sanitizer did not work when pushed; in another, the sanitizer was empty; and in two other rooms, the sanitizer did not work during repeated observations. Staff stated they did not know the sanitizers were empty and said they usually washed their hands when entering and leaving rooms. During the catheter care and catheter emptying observations, staff also failed to wash hands or use hand sanitizer before and after the tasks. One resident with a Foley catheter reported not receiving catheter care often enough and stated he had frequent facility-acquired UTIs, had gone septic from some UTIs, and had nearly died. Records showed multiple UTIs over the prior year.
POA Not Informed of Psychotropic Medication Use
Penalty
Summary
The facility failed to honor a POA’s wishes regarding treatment for a resident who was identified in the record as having the POA as Responsible Party, Care Conference Person, Emergency Contact, and Responsible Care. The POA stated she was not contacted for a care conference after August 2025 and had not heard from the facility since then. During that August care conference, she was told the resident had been receiving Ativan for depression since February 2025, and she stated she never gave consent for the medication and told the facility to stop administering it. Record review showed Ativan orders beginning in February 2025 for PRN use related to aggression with showering, later changed in May 2025 to scheduled dosing twice daily for anxiety and agitation, and then changed again in June 2025 to PRN use for aggression with showering. The MAR showed the medication was administered seven times PRN from February through April 2025 and then given twice daily every day from June through October 2025. A care conference summary documented that the POA participated by phone and was not aware of Ativan, and staff later stated the facility never informed her that the resident was taking Ativan. The POA reported she was contacted again in October 2025 for updated consent and then learned the resident was still receiving Ativan after she had asked for it to be stopped.
Failure to Obtain Representative Consent for Psychotropic Medication
Penalty
Summary
The facility failed to consult with and obtain permission from a resident representative before ordering and administering Ativan, a psychotropic medication, for a resident on the memory care unit. The resident’s Clinical Resident Profile identified NF1 as the Responsible Party, POA, Care Conference Person, Emergency Contact #1, and Responsible Care. NF1 stated she learned the facility had been giving the resident Ativan for six months without her consent. Staff member E stated NF1 had not been informed that the resident was receiving Ativan, and that during an August 2025 care conference NF1 was on the phone and hung up when told the resident had been prescribed Ativan without her knowledge. NF1 later stated she received a call from a nurse in October 2025 asking for verbal consent to continue Ativan, and said that was when she learned the medication was still being given after she had told the facility to stop in August 2025. The facility’s Resident Rights document stated the facility must treat the decisions of a resident representative as the decisions of the resident to the extent required by law, and that the resident has the right to request, refuse, and/or discontinue treatment. The facility policy on Care Planning-Resident Participation stated the facility will notify the resident and/or resident representative in advance of care to be furnished and changes to the plan of care, and will encourage participation in treatment decisions, including initial decisions, changes, and the right to refuse treatment.
Failure to Hold Timely Care Conferences With POA
Penalty
Summary
The facility failed to schedule timely care conferences with the POA for a resident on the memory care unit, resulting in only two care conferences being held in the last 12 months, one on 3/12/25 and another on 8/8/25. The resident’s POA stated she had not been notified or involved in a care conference since August 2025. Staff member E stated she scheduled care conferences within 48 hours of admission and then annually, and there was no documentation of invitations to care conferences for the POA. During interviews, staff member E stated she was unaware that resident care conferences were supposed to be conducted quarterly, that the POA was supposed to be invited, and that a care conference should have been held when a resident had a change in condition. Another staff member stated care conferences should have been done on admission, then quarterly, and when there was a change in the resident’s condition. The facility policy titled Care Planning-Resident Participation stated the facility would discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, initially, at routine intervals, and after significant changes.
Failure to Report Allegation of Neglect Involving Dislodged Nephrostomy Tube
Penalty
Summary
The facility failed to submit an initial incident report to the State Survey Agency for an allegation of neglect involving resident #11 and a nephrostomy tube that became dislodged during care. A progress note documented that the tube was out 5 inches from the stitches with no urine output, and the resident stated the tube had been pulled out by a CNA and had stopped draining urine. Staff member C stated he was aware of the allegation that a CNA had caused the tube to become dislodged, but he did not report it to staff member A and said it was not his job. Staff member A and staff member B stated the facility did not report the allegation to the State Survey Agency because the Interdisciplinary Team reviewed it and did not feel it was neglect. A later progress note stated the NHA spoke with the resident about the incident with the CNA and that the resident did not feel it was an abusive or neglectful act, and staff member A later clarified that this conversation occurred on 3/11/26, not at the time of the allegation. The facility policy required reporting all alleged violations to the administrator, state agency, adult protective services, and other required agencies within specified timeframes.
Failure to Immediately Investigate Alleged Neglect
Penalty
Summary
The facility failed to identify and investigate an allegation of potential neglect for one resident when the resident reported that a CNA had pulled out his nephrostomy tube and that it had stopped draining urine. A progress note documented that the tube was out 5 inches from the stitches with no urine output, and the resident stated the tube had been pulled out by a CNA on Wednesday or Thursday. During interview, staff stated the facility had not investigated the allegation to rule out neglect because the IDT did not feel it was a reportable incident. A later progress note documented that the NHA spoke with the resident about the nephrostomy tube incident and that he did not feel it was abusive or neglectful, but staff later stated this conversation occurred on 3/11/26, not at the time of the allegation. The facility policy required an immediate investigation when suspicion of abuse, neglect, or exploitation occurs.
Failure to Position Resident Safely for Medications
Penalty
Summary
The facility failed to implement safe interventions for swallowing medications and food for resident #73. During an interview and observation, the resident stated that only the physical therapist helped him sit up to eat later in the day, and that he had already eaten breakfast while lying flat on his back with his head kinked forward. He said he often choked or threw up when a nurse rushed him taking medications, but had no problem swallowing food, and that he swallowed medications better at home when he was sitting up in a chair before taking pills. During a later observation, resident #73 asked staff member X to adjust his head so he would not choke before morning medications were given. Staff member X raised the head of the bed too quickly, causing the resident to wince and ask to be moved back down; the staff member did not try to reposition him again or provide education about swallowing with the head of the bed at a 30-degree angle. The staff member then administered a medication with a large amount of pudding, and the resident chewed the pudding, swallowed, then coughed and spat out some pudding onto his chest. Review of the care plan showed no documented need for the resident to be sat up during meals and medication administration to prevent choking, and a speech therapy note stated that posture impacts function and is modifiable with intervention.
Failure to Provide Needed ADL Assistance With Grooming and Showering
Penalty
Summary
The facility failed to ensure a resident who was unable to independently complete ADLs received needed assistance with grooming and showering. Resident #6 had decreased shoulder ROM and fatigue, and her care plan identified that she required partial to substantial or dependent assistance with personal hygiene and grooming, needed staff help every morning with hair care, and preferred weekly showers with assistance from two staff members. During observation, the resident was found in bed and later in common areas with numerous sporadic gray chin and neck hairs approximately 1 to 1.5 inches long, and she indicated she wanted help having her facial hair removed. She also had a moderate amount of dried white scaly and moist yellow eye rheum in both eyes and a slight musty odor emanating from her person. Staff stated the resident usually had a shower once a week and that facial hair would be removed during the shower, with refusals to be reapproached and documented if they occurred. However, the shower/bathing log showed only two baths in March 2026, and no refusals were documented for that month. A nurse progress note later documented that the resident received assistance with showering and personal hygiene, including removal of facial hair per her request, but the observations before that note showed the resident continued to have the same facial hair over multiple days while sitting in the day room, dining hall, and near the nurses' station.
Failure to Meet Resident Food and Care Needs
Penalty
Summary
The facility failed to provide necessary care and services, including resident preferences, goals, and standards of care, for one sampled resident. Resident #74 stated that the food served was terrible, that she could never eat the eggs because they were served as two big scoops with no taste, and that she had been served a pork chop she had to eat with her fingers. She also reported being served a plate full of cooked carrots with no other items on the tray other than soup, and said she was often hungry because she was not served enough calorie-dense or filling foods. Resident #74 stated she did not like being at the facility and that NF5 had spoken to staff many times about concerns. Staff member E stated the floor staff had been aware of resident #74 and the family's concerns, but nothing had been done. Staff member E also stated she did not want to enter a progress note because it would sound bad, and said she had not been told that resident #74 wanted to be discharged from the facility. NF5 reported that resident #74 was crying because of the poor care she received, and that the meal consisting of a plate full of carrots and watery soup was the last straw. Staff member E further stated resident #74's feet were swollen and her blood sugar had been over 400 for three days because therapeutic diets were not followed. The care plan identified resident #74 as being at risk for altered nutritional status related to inadequate protein intake and inconsistent carbohydrate distribution, with increased demands for wound healing, chronic non-healing LLE wound, and confusion regarding DM lifestyle management.
Failure to Provide Ordered Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with chronic hypoxic respiratory failure and COPD. The resident had physician orders for continuous oxygen at 2 LPM via nasal cannula, with PRN supplemental oxygen to keep oxygen saturations above 88 percent, and the care plan included continuous oxygen use and head-of-bed elevation due to shortness of breath. During observations, the resident was found in bed without oxygen on, with the oxygen concentrator turned off and no tubing attached, while the head of the bed was in the lowest position. The resident was also observed in a wheelchair with oxygen attached to a portable tank that was empty. On another observation, the resident was asleep in the wheelchair with the nasal cannula out of the nose and resting over the shoulder, and the portable oxygen tank was again empty. Staff interviews indicated the resident’s oxygen levels could drop into the low 70s without continual oxygen, and staff stated the resident usually needed oxygen at 2 liters continuous to remain above 88 percent saturation. One staff member also stated the resident should have oxygen from the concentrator while in bed and from the portable tank while in the wheelchair. The record review showed the resident had previously been found without oxygen on at the skilled nursing facility and had been admitted with oxygen saturations in the 70s. The facility’s oxygen administration policy required oxygen to be given under physician orders and for the care plan to identify the type of delivery system, when to administer oxygen, equipment settings, and monitoring. Despite these orders and the resident’s known oxygen needs, staff were observed with the resident off oxygen in bed, with an empty portable tank, and with the nasal cannula displaced while the resident was asleep in the wheelchair.
Staff Lacked Competency for Nephrostomy Tube Care
Penalty
Summary
The facility failed to ensure nurses and nurse aides had the competencies and skills needed to care for a resident with nephrostomy tubes. Resident #11 stated that staff had at times pulled on his nephrostomy tubes during care, and that one of the tubes had been dislodged as a result. The resident also stated that staff needed training on nephrostomy tube care. Multiple staff members stated they had not received training on how to care for a resident with nephrostomy tubes. One staff member said she learned on the fly after the resident was admitted, and that the resident taught her how to care for the tubes. Another staff member said the resident showed her how to care for the nephrostomy tubes and that this was her first resident with that type of tube. A staff member responsible for reviewing admissions and arranging staff training stated the resident was an interfacility transfer, but the need to train staff on nephrostomy tube care was not identified before admission.
Missing Current Hospice Agreement
Penalty
Summary
The facility failed to have an updated written agreement with a hospice, signed by authorized representatives of both the hospice and the facility, before hospice care was furnished at the facility for 2 of 3 residents sampled for hospice services. During the entrance conference, the facility provided a hospice agreement dated 6/24/00 for Coordination of Services Agreement Between NF7 and NF8, and it was noted that neither company exists any longer. Staff member A stated this was representative of the agreement the facility had between NF6 Hospice and the facility, but also stated the facility did not currently have an updated hospice agreement. Resident #29 was receiving hospice services from NF6 Hospice with a start of care date of 12/17/25 and a benefit period from 12/17/25 to 3/16/26. Resident #65 was also receiving hospice services from NF6 Hospice with a start of care date of 1/7/26. Staff member N later confirmed with staff member A that the facility did not have an updated hospice agreement with NF6 Hospice other than the one provided at the entrance conference. The facility policy titled Coordination of Hospice Services, implemented 4/11/25, stated the facility maintains written agreements with hospice providers that specify the care and services to be provided and the process for hospice and nursing home communication of necessary information regarding the resident's care.
Failure to Provide Adequate Supervision and Fall Prevention for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and monitoring for a resident with a significant history of falls and cognitive impairment. The resident, who resided in the memory care unit and had severe dementia, was known to wander frequently and had altercations with other residents. Despite being identified as a high fall risk with previous injuries, the care plan did not include sufficient or specific interventions to address her safety needs, wandering behavior, or fall prevention. The care plan goals were unrealistic given her cognitive status, and interventions lacked detail regarding her pain management, mobility limitations, and behavioral triggers. Multiple incidents were documented where the resident sustained injuries, including a compression fracture and a fractured hip requiring surgery. These injuries resulted from both witnessed and unwitnessed falls, as well as altercations with other residents. Progress notes and staff interviews revealed that supervision was inconsistent, and staff were often unaware of the resident's whereabouts. There was a lack of documentation regarding the direct causes of falls, the effectiveness of interventions, and whether appropriate supervision was in place at the time of each incident. Staff reported being too busy to provide adequate oversight, and 1:1 observation, when implemented, was not maintained as a long-term intervention. The facility's policies required systematic monitoring and management of residents at risk for elopement or unsafe wandering, but these were not effectively implemented for this resident. The care plan did not address specific needs such as toileting schedules, safe wandering paths, or individualized behavioral interventions. Staff interviews confirmed that interventions were limited to redirection, and additional measures such as visual cues or environmental modifications were not consistently used. The lack of adequate supervision and failure to implement effective, individualized interventions directly contributed to the resident's repeated falls and injuries.
Failure to Provide Adequate Supervision and Individualized Dementia Care
Penalty
Summary
A resident with severe dementia, poor safety awareness, and a history of aggressive behaviors and wandering was admitted to the memory care unit. The resident exhibited continuous wandering, entered other residents' rooms, displayed aggression, and had multiple falls, some resulting in significant injuries such as a hip fracture and a compression fracture. Despite being identified as high risk for elopement and falls, the resident was not consistently provided with individualized interventions or adequate supervision to address her specific behavioral and safety needs. Documentation showed that staff were often unaware of her whereabouts, and interventions such as 1:1 observation were implemented only temporarily and not maintained, even though staff reported these measures were effective in ensuring safety. The care plans developed for the resident were not sufficiently individualized or tailored to her needs. Goals set for the resident, such as developing coping skills for cognitive decline, were unrealistic given her severe cognitive impairment. Interventions lacked specificity, and there was no clear plan for managing her pain, which may have contributed to her behaviors. The care plan also failed to identify patterns in her wandering or provide detailed strategies to prevent her from entering other residents' rooms. Staff interviews revealed a lack of consistent use of visual cues or other non-pharmacological interventions, and staff expressed concerns about insufficient staffing and supervision. Additionally, the facility failed to consistently administer pain medications as ordered, which was noted by the provider as a concern and may have contributed to the resident's ongoing agitation and behavioral issues. Monitoring tools, such as 15-minute checks, were not completed as required, and documentation was often incomplete or inaccurate. The lack of adequate supervision and oversight resulted in repeated incidents where the resident intruded into other residents' rooms, leading to altercations and injuries, and caused distress and fear among other residents. The facility's actions and inactions did not meet the resident's behavioral, safety, and cognitive needs as required.
Failure to Address Resident Concerns with Housekeeping and Laundry Services
Penalty
Summary
The facility failed to address ongoing concerns raised by residents regarding housekeeping and laundry services, as documented in Resident Council minutes over several months. Residents repeatedly reported issues such as inadequate cleaning of their rooms, particularly toilets and floors, and missing laundry items that were not returned for extended periods. Despite these concerns being brought up consistently from September through December, the problems persisted without resolution. Observations and interviews confirmed that laundry items were often unlabeled, inventory records were incomplete or not updated, and mesh bags intended to help track laundry were not consistently used by nursing staff. Staff interviews further revealed that complaints about insufficient cleaning and missing laundry were common and had been discussed both in Resident Council meetings and through individual grievances. Specific areas, such as the B hall, were noted as not being cleaned frequently, and residents expressed dissatisfaction with the thoroughness of housekeeping. The facility's failure to respond effectively to these repeated concerns resulted in ongoing deficiencies in both laundry and housekeeping services, affecting any resident whose needs in these areas were not met.
Failure to Maintain Clean Environment and Proper Laundry Management
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for residents, as evidenced by persistent cleanliness issues and mismanagement of residents' personal laundry. Observations over several days revealed multiple dried spills, dirt, debris, and bug traps with accumulated dust and insects throughout various hallways and resident rooms. Specific rooms and common areas were noted to have unclean floors, uncollected trash, and visible stains, despite cleaning logs indicating recent cleaning. Residents and staff reported ongoing complaints about inadequate housekeeping, with grievances and Resident Council minutes documenting repeated concerns about insufficient cleaning, especially in resident rooms, bathrooms, and dining areas. Laundry management was also deficient, with staff interviews and observations indicating that residents' clothing was frequently unlabeled, leading to confusion and loss of personal items. Laundry staff described a process where unmarked clothing was hung on racks in hallways, as they were unable to identify the owners. Missing item forms and grievance forms were often completed when residents reported lost clothing, but inventories were not consistently updated when new items were brought in. This resulted in a significant accumulation of unclaimed clothing and limited storage space. Staff also noted that families sometimes resisted labeling clothing, further complicating the process. These deficiencies culminated in an altercation between two residents when one resident recognized his clothing being worn by another. The clothing in question had been relabeled with the second resident's name after the original label was crossed out. Facility records showed multiple grievances related to missing clothing and laundry delays, as well as complaints about room and facility cleanliness. Staff interviews confirmed that these issues were ongoing and had been raised repeatedly by residents and staff alike.
Failure to Timely Report Abuse Allegations and Investigation Results
Penalty
Summary
The facility failed to report allegations and findings of abuse in a timely manner to the State Survey Agency for three sampled residents. In one instance, an alleged incident of physical abuse involving two staff members and a resident occurred, but the event was not reported within the required two-hour timeframe, and the final findings were not submitted within the required five working days. Staff attributed the delay to technical issues with the abuse reporting system. In another case, a verbal altercation between two residents was not reported until two days after the event, as it was only discovered during a chart review. The nurse involved did not report the incident immediately, resulting in late notification. The facility's policy requires immediate reporting of abuse allegations, but these procedures were not followed in the cited incidents.
Failure to Develop Person-Centered Care Plan and Provide Individualized Dementia Interventions
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with dementia who exhibited aggressive behaviors, wandering, frequent falls, pain, and was at risk for elopement. The care plan lacked specific dementia-related interventions and relied primarily on nonspecific redirection strategies. Staff interviews revealed that key team members were unaware of the full extent of the resident's behaviors, such as constant wandering, and therefore did not include appropriate interventions in the care plan. The care plan did not provide measurable or detailed actions for staff to follow, and interventions were often generic or unrealistic given the resident's cognitive status. Record reviews showed that the care plan did not address the resident's pain management needs, as interventions for pain in the right knee were missing, and pain goals were not individualized or specific to the resident's condition. The plan for cognitive decline included unrealistic goals, such as developing coping skills, despite severe cognitive impairment. Interventions for falls, elopement, and aggressive behaviors were vague, lacked specificity, and did not reflect the resident's actual patterns or needs. For example, the falls care plan did not address the resident's weakness, confusion, or poor safety awareness, and did not specify which items should be kept within reach or how to anticipate the resident's needs. Additionally, the facility failed to provide meaningful activities for residents in the memory care unit, as reported by both family and staff interviews. The care plan for elopement risk referenced offering preferred activities, but none were listed, and interventions were generic and not tailored to the resident. The lack of individualized, person-centered interventions and activities resulted in staff lacking clear guidance to effectively meet the resident's needs, leading to inconsistent and potentially unsafe care, as well as unmet psychosocial needs for multiple residents.
Failure to Provide Individualized Activities for Dementia Residents in Memory Care Unit
Penalty
Summary
The facility failed to provide an ongoing program of daily, individualized or group activities and meaningful engagement for residents with dementia residing on the secure memory care unit. Observations revealed that several residents were sitting in the common room without any music, television, or interactive activities occurring. Multiple interviews with family members and staff confirmed that there were no consistent activities provided for residents in the secure unit, with staff noting a lack of time and resources to conduct such activities. Family members reported never witnessing activities during their visits, and staff expressed concern about the absence of daily engagement, which they identified as important for redirecting and ensuring the safety of dementia residents. Documentation regarding activity participation for three sampled residents in the secure memory care unit was requested but not provided by the facility. Review of facility policies indicated that special considerations should be made for developing meaningful activities for residents with dementia and that appropriate treatment and services should be provided to meet their highest practicable well-being. Despite these policies, the facility did not demonstrate that activities were planned or implemented for residents in the secure memory care unit, leading to a deficiency in meeting their cognitive and psychosocial needs.
Failure to Accurately Assess and Document Resident Wandering Behaviors
Penalty
Summary
The facility failed to accurately identify and document wandering behaviors on the MDS Resident Assessments for one resident with dementia and a known history of daily wandering. Staff responsible for completing the admission MDS assessment did not review the resident's medical diagnoses or fully consider behaviors prior to admission, instead assuming the assessment only pertained to current behaviors observed within the facility. The staff member also did not interview the resident or family members, relying solely on progress notes, which resulted in the omission of the resident's daily wandering behavior from the assessment. The resident's electronic health record indicated a diagnosis of wandering at admission and contained multiple progress notes documenting daily incidents of wandering and exit-seeking from the day of admission onward. Despite this, the admission MDS assessment indicated no wandering behaviors, and the subsequent quarterly MDS assessment understated the frequency of wandering. This inaccurate documentation limited the facility's ability to implement appropriate care plan interventions to address the resident's actual care needs.
Inadequate Staffing Leads to Delayed Call Light Response and Pain Management
Penalty
Summary
The facility failed to ensure timely response to residents' call lights, leading to inadequate pain management and feelings of insecurity among residents. Multiple residents reported waiting over 30 minutes for their call lights to be answered, particularly during night shifts. One resident mentioned waiting over an hour for assistance, while another expressed concerns about the facility being understaffed, especially at night, with only two CNAs available for over 60 residents. Staff interviews corroborated these concerns, with reports of insufficient staffing due to budget constraints, leading to delays in addressing residents' needs. Additionally, residents experienced delays in receiving pain medication, with one resident waiting over an hour for Tylenol to manage hip pain. Another resident, with a history of spondylosis, arthropathic psoriasis, and other conditions, reported daily pain and inadequate repositioning assistance. Staff members acknowledged the staffing issues, noting that nurses were often overburdened with responsibilities, including administering medications and conducting assessments, without adequate support. The facility's call light audit indicated a goal of a 5-minute response time, which was not being met, contributing to resident dissatisfaction.
Infection Control and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure proper implementation of transmission-based precautions, documentation, and notification of COVID-19 tracing, and lacked a system to prevent and monitor waterborne illnesses. Observations revealed that staff members did not adhere to contact precautions, as they entered rooms of residents under such precautions without wearing personal protective equipment (PPE). Specifically, staff members were seen in a resident's room without PPE despite the resident being on contact precautions for shingles. Additionally, there was confusion among staff regarding which residents required contact precautions, leading to incorrect signage on room doors. The facility also failed to document COVID-19 testing for residents who were close contacts of a staff member who tested positive. Although testing was conducted, progress notes for several residents did not reflect the testing or results. Furthermore, a resident who was a close contact was placed on oxygen due to low saturation levels, but staff were unaware of the resident's status in the COVID-19 testing protocol. Lastly, the facility lacked procedures or systems to address waterborne microorganisms, as confirmed by a staff member, despite having a policy that required such measures.
Deficiencies in Cleanliness and Personal Item Management
Penalty
Summary
The facility failed to maintain a clean and safe environment in the resident shower areas and did not adequately safeguard residents' personal belongings from loss or theft. Observations revealed that the shower rooms, particularly outside the memory care unit, were not properly cleaned, with used washcloths, pooled dirt, and malodorous smells present. Additionally, there were brown stains near the drain and a dirty brief on the floor, indicating a lack of proper sanitation and infection control measures. The facility also failed to exercise reasonable care in managing residents' clothing and personal items, leading to frequent reports of missing belongings. Several residents and staff members reported missing clothes and personal items, such as an iPad and an Apple Watch, which were not adequately addressed through the facility's grievance process. The facility's system for tracking and returning lost items was ineffective, with staff spending significant time searching for missing items and a lack of a clear policy or procedure for handling such issues. Interviews with staff revealed that the facility's inventory process for residents' personal belongings was insufficient, with only a small portion of the staff having received training on completing inventory listings. The facility's failure to provide a comprehensive and effective system for managing residents' personal items and maintaining a clean environment contributed to the deficiencies identified during the survey.
Deficient Grievance Program for Lost Resident Belongings
Penalty
Summary
The facility failed to maintain an effective grievance program to address resident concerns, particularly regarding lost belongings. Observations and interviews revealed that grievances related to missing items were not consistently elevated to a formal grievance level by management. Staff member C, identified as the grievance officer, indicated that the administrator and director of nursing were responsible for determining which issues were considered grievances. Staff member A noted that the grievance log for August 2024 was missing and acknowledged that not all concerns were documented as grievances, sometimes resulting in incomplete records. Resident #67, who had recently been discharged, was still missing personal items, including an iPad, an Apple Watch, and clothing, which were documented in the resident's personal belonging inventory. Despite these items being inventoried, a grievance was not resolved for the lost belongings. The report highlights that grievances were not being addressed effectively, as evidenced by the grievance report forms dated 3/1/24, which expressed dissatisfaction with the grievance process. This deficiency increased the risk of negative outcomes for residents with unresolved grievances or lost items.
Deficiencies in Pain Management for Residents
Penalty
Summary
The facility failed to ensure proper pain management for several residents, leading to deficiencies in care. Resident #14, who has advanced dementia, was observed to be in distress and exhibiting behaviors indicative of pain, such as grimacing and rocking. Despite these signs, the resident's medication administration reports showed no scheduled pain medication, only PRN orders, and there were numerous missed opportunities for pain assessments. The resident's care plan and progress notes indicated behaviors consistent with pain, yet there was a lack of consistent pain management interventions. Resident #29 reported frequent pain in her left hip and experienced delays in receiving pain medication, affecting her ability to move and increasing the risk of skin breakdown. Despite a physician's order for palliative care, the facility did not have such services, and staff were unclear about the order's implementation. This lack of clarity and delay in pain management contributed to the resident's discomfort and potential health risks. Resident #10 also reported unmanaged pain and a lack of regular pain assessments, with several missed assessments documented in the electronic health record. The resident's diagnoses included conditions that could cause significant pain, yet the facility failed to document pain progress notes when pain levels were reported at 5/10 or higher. Similarly, resident #30 was unfamiliar with the pain scale and had several missed pain assessments, with most assessments inaccurately recorded as 0/10. The facility's failure to provide a pain management policy further highlights the systemic issues in addressing residents' pain needs.
Failure to Follow Up on Dental Care Referrals
Penalty
Summary
The facility failed to follow up on dental care referrals for several residents, leading to unresolved dental issues. Resident #5 had been seen by a dental hygienist who identified multiple dental concerns, including possible decay, broken teeth, and root tips. Despite a physician's order for a dental referral dated April 15, 2024, there was no evidence of follow-up or treatment for these issues in the resident's electronic health record (EHR) as of January 13, 2025. Staff member B acknowledged the referral was received in May 2024 but was not acted upon. Additionally, residents #48, #3, #6, and #280 experienced issues with ill-fitting dentures, impacting their ability to eat properly. Resident #48 reported difficulty eating certain foods due to poorly fitting dentures and experienced a significant weight loss of 6.15% over two months. Residents #3 and #6 also reported problems with their dentures slipping or not fitting, leading to difficulties in eating. Resident #280 was observed leaving food on his plate due to his dentures not fitting well, which he stated affected his ability to consume enough protein for his renal diet. No documentation of dental notes or appointments for these residents was provided by the end of the survey.
Delayed and Unappetizing Meals Served to Residents
Penalty
Summary
The facility's dietary department and staff failed to serve meals in a timely manner, resulting in cold food being served to residents. Observations and interviews revealed that breakfast was consistently served late, with some residents reporting delays of up to an hour. For instance, a resident in the dining room noted that breakfast was typically 30 minutes late, while another resident in the E wing reported receiving cold eggs when her tray was delivered. Additionally, lunch was also served late, as evidenced by a resident in the A wing who frequently received cold meals. Furthermore, several residents expressed dissatisfaction with the quality of the food. One resident relied on family members to bring in meals due to disliking the facility's food. Another resident found her oatmeal too thick and was not provided with the lactose-free milk indicated on her meal ticket. Additionally, a resident was observed picking out burnt pieces from her eggs, expressing displeasure with the food quality. Staff members corroborated these complaints, with one describing the food as "disgusting" and another stating that residents compared it to "jail food."
Inadequate Supervision and Positioning in LTC Facility
Penalty
Summary
The facility failed to provide adequate staff supervision on the memory care unit, affecting three residents. Staff members reported that the unit had a high number of residents with behavioral issues, yet staffing levels were insufficient, with only three staff in the mornings and two in the afternoons. This lack of supervision was evident when a surveyor had to intervene in a confrontation between two residents, as no staff were present to manage the situation. Additionally, a resident was observed walking barefoot with an unstable gait and holding a fork, posing a risk of injury, while staff were occupied elsewhere. The facility also failed to implement effective interventions for a resident who eloped. Staff expressed concerns about the inefficiency of the wanderguard system, noting that some doors did not lock when a wanderguard was near, allowing the resident to exit the facility. The transitional care unit, where the resident resided, was unsupervised and had multiple exit points, further contributing to the elopement risk. Furthermore, the facility did not ensure proper positioning for two residents during meals, increasing the risk of choking. One resident was observed coughing and struggling to swallow while slouched in a chair, contrary to dietary orders requiring an upright position. Another resident was left in a flat position with a kinked neck while eating, which staff acknowledged could be a choking hazard. These observations highlight the facility's failure to adhere to care plans and dietary orders, compromising resident safety during meals.
Failure to Refer Resident for PASARR Level II Assessment
Penalty
Summary
The facility failed to refer a resident for a PASARR Level II assessment after a diagnosis of Post Traumatic Stress Disorder (PTSD) was added. The resident, who had a history of serving in the special forces during the Korean and Vietnam wars and was a prisoner of war, had a PASARR Level I assessment dated 6/21/24 that did not include the PTSD diagnosis. The resident's Minimum Data Set (MDS) dated 6/27/24 also did not reflect the PTSD diagnosis, but a subsequent MDS dated 9/22/24 did include it. During an interview, a staff member acknowledged that a new PASARR Level I should have been completed when the PTSD diagnosis was added to determine if a Level II assessment was necessary. However, no Level II request was made before the survey concluded.
Failure to Document Enteral Feeding in Baseline Care Plan
Penalty
Summary
The facility failed to include critical information on a resident's baseline care plan regarding their need for enteral tube feedings. This oversight was identified for one of the sampled residents who had a history of spinal cord injury, Parkinson's disease, and aspiration pneumonia, and was designated as NPO (nothing by mouth) due to the risk of aspiration. Despite the resident's medical history and specific provider orders for continuous tube feeding with Isosource 1.5 at 70 ml/hr and free water flushes, the baseline care plan did not reflect these essential care requirements. During an interview, a staff member indicated that the admitting nurse is responsible for initiating the baseline care plan for new admissions, and if incomplete, the floor nurse should finalize it. However, the care plan for this resident failed to document the need for enteral feeding, which was acknowledged as a necessary inclusion by the staff. The facility's policy mandates a comprehensive, person-centered care plan to address each resident's needs, but this was not adhered to in this instance, increasing the risk of improper care.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide necessary assistance to a resident during meals. Observations revealed that a staff member was the only one available to pass medications and food trays, which led to a situation where a resident, who was marked as dependent on their MDS for eating, was left attempting to feed himself without assistance. On multiple occasions, the resident was observed struggling to eat and drink without staff assistance or cueing, despite the care plan indicating the need for extensive assistance by one staff member. Another deficiency was noted in the facility's failure to assist a resident with toileting and dressing. The resident, who has Parkinson's disease, expressed that her ability to use the bathroom fluctuates and that she needed assistance. Despite this, she was found struggling to dress herself after using the bathroom, visibly upset and crying, with her call light on. The care plan indicated that she required supervision for toileting and setup assistance for dressing, but these needs were not met, as evidenced by the resident's struggle and the lack of staff assistance.
Delayed Hospice Referrals and Care Plan Confusion
Penalty
Summary
The facility failed to ensure timely hospice referrals for two residents, leading to significant delays in care. For one resident, an order for a hospice referral was received due to weight loss and senile degeneration of the brain, but the referral was not completed until eleven days later. This delay was compounded by a significant fall that resulted in an emergency room visit. Despite the resident's power of attorney expressing a desire to start hospice, the process was delayed by a month. Staff interviews revealed that the facility struggled with managing lab results, new orders, and referrals due to staffing issues, and hospice admissions were reportedly delayed by two weeks. Another resident experienced severe pain post-CVA and had a physician's order for hospice referral, but there was confusion regarding the implementation of palliative care. The resident reported significant pain and delays in receiving pain medication, and there was concern about skin breakdown due to immobility. Despite a physician's order for palliative care, staff indicated that the facility did not have a palliative care policy, leading to further confusion and inaction. The lack of communication and clarity regarding the resident's care plan contributed to ongoing pain management issues.
Failure to Provide PTSD Treatment for Veteran Resident
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident, a veteran who experienced combat in Korea and Vietnam and was a prisoner of war, expressed the need for psychiatric or counseling services for PTSD. Despite having a medical diagnosis of PTSD, the resident had not been referred for appropriate treatment. Staff confirmed that no referral had been made, and no documentation was provided to show that a referral for PTSD treatment had been initiated by the facility.
Failure to Follow Posted Menus
Penalty
Summary
The facility failed to adhere to the posted menu for two out of three observed meals, which could potentially affect any resident relying on the posted menu. During observations on January 14, 2025, at 8:33 a.m., 8:37 a.m., and 8:41 a.m., whole grain toast was not present on a resident's plate, despite being listed on the breakfast menu for that day. Additionally, on January 15, 2025, at 12:37 p.m., the lunch served included potato soup, ham and cheese on a croissant, watermelon, and a cupcake, which did not match the posted lunch menu that listed garden vegetable soup, classic beef stroganoff, lemon buttered broccoli, a baked roll, and raspberry jello salad. These discrepancies indicate a failure to follow the planned and posted menus, which are intended to meet the nutritional needs of the residents.
Failure to Follow Physician-Ordered Therapeutic Diets
Penalty
Summary
The facility failed to ensure that physician-ordered therapeutic diets were followed for three residents. Resident #12, who was on a consistent carbohydrate (CCHO) diet, reported that the meals provided were not suitable for her diabetic condition, as they contained too many carbohydrates. She mentioned that her blood sugar levels were often high since her admission, and she had to bring her own food. Resident #48, also on a CCHO diet, had to remind staff to provide sugar-free syrup, as they would often serve regular syrup with her breakfast. Staff member F confirmed that therapeutic diets, particularly for dialysis and diabetic residents, were not being followed due to budget constraints. Resident #280, who had end-stage renal disease and required a renal diet, expressed difficulty in consuming enough protein due to ill-fitting dentures, which made it hard to chew meats. Despite his condition, his electronic health record indicated a regular diet with soft and bite-sized textures, rather than a renal diet. Staff member J noted that diabetic residents were receiving the same diet as others without dietary restrictions, and there were no sugar-free snack options available. Staff member L was unaware of the renal diet and misunderstood the requirements of a carbohydrate diet. The facility's document on therapeutic diets stated that snacks should be compatible with the therapeutic diet, which was not being adhered to in practice.
Medication Administration Error
Penalty
Summary
Facility nursing staff failed to administer two medications during the evening medication administration time for a resident, resulting in a 6.4 percent medication error rate. The medications involved were Cefdinir, an antibiotic prescribed to be taken twice daily for pneumonia, and Potassium Chloride, prescribed twice daily for encephalopathy. The resident's electronic health record (EHR) showed physician orders for these medications, but the medication administration record (MAR) did not document them as given during the scheduled medication pass. Interviews with staff members confirmed that if a medication is not marked off in the MAR as given, it is considered a medication error. The facility's policy on administering medications, revised in December 2012, requires that medications be administered safely, timely, and as prescribed, with documentation in the MAR after each administration. The failure to document the administration of these medications as per the policy led to the identified deficiency.
Significant Medication Error Due to Non-compliance with Medication Administration Procedures
Penalty
Summary
The facility experienced a significant medication error involving a resident who was given incorrect medications by a staff member. The staff member, while administering medications, pre-poured medications for two residents to save time, which is against the facility's policy. During this process, the staff member mistakenly gave a resident a 10 mg Vicodin and 60 mg OxyContin, both high-dose opioids, instead of the requested Tylenol. This error occurred because the staff member did not adhere to the facility's medication administration procedures, which require verifying the resident's identity and checking the medication label three times. Following the medication error, the staff member failed to implement appropriate health monitoring for the resident. The staff member did not take baseline vital signs, did not monitor the resident's oxygen saturation continuously, and did not look up the side effects of the medications administered. Approximately two hours after the error, the resident was found unresponsive with low blood pressure and low oxygen saturation. Narcan was administered to reverse the effects of the opioids, and the resident was sent to the hospital. The resident's medical records showed a lack of documentation of vital signs or consciousness state between the time of the medication error and the hospital transfer. The hospital records indicated that the resident was treated for an opioid overdose and developed aspiration pneumonia. The facility's policies clearly outlined the procedures for medication administration and monitoring after a medication error, which were not followed by the staff member involved.
Significant Medication Errors in LTC Facility
Penalty
Summary
The facility failed to prevent significant medication errors for two residents, resulting in an Immediate Jeopardy level deficiency for one resident. A staff member mistakenly administered a high dose of opioid medications, Vicodin and OxyContin, to a resident who requested Tylenol. The staff member pre-poured medications for efficiency, which led to the error. After realizing the mistake, the staff member contacted the on-call provider but did not take immediate vital signs or monitor the resident's oxygen saturation. The resident was later found unresponsive with low blood pressure and oxygen saturation, requiring emergency medical intervention and hospitalization for an opioid overdose. Another resident received an incorrect dosage of Trospium due to a transcription error in the electronic medical record. The order was entered incorrectly as 60 mg four times a day instead of the intended 60 mg once daily. This error went unnoticed for several days until the pharmacy identified the mistake. The resident received double the recommended dose for a week, although no adverse effects were reported. The facility's policies on medication administration and error monitoring were not followed, contributing to these errors. The staff failed to verify the resident's identity and medication details adequately, and the double-check system for entering medication orders was not effectively implemented. These lapses in protocol led to significant medication errors, posing serious risks to the residents' health and safety.
Medication Error and Inadequate Resident Protection
Penalty
Summary
The facility failed to protect a resident from neglect of medical care when a licensed staff member administered incorrect medications, resulting in a significant medication error. The staff member gave the resident 10 mg of Vicodin and 60 mg of OxyContin, which were not prescribed for the resident. Following the error, the staff member did not take baseline vital signs or place the resident on continuous oxygen saturation monitoring. Approximately two hours later, the resident was found hypotensive, with low oxygen saturation levels, and unresponsive. Narcan was administered to reverse the effects of the opioids, and the resident was sent to the emergency room, where they were treated for an opioid overdose and aspiration pneumonia. The facility also failed to protect two residents in the memory care unit from engaging in sexual contact without prior assessment of their ability to consent. Staff members found the two residents naked in bed together, but there was no documentation of an assessment to determine their capacity to consent to sexual activity. Both residents had cognitive impairments, with one having a diagnosis of unspecified dementia and the other having a diagnosis of Frontotemporal Neurocognitive Disorder and unspecified dementia. The facility's policy required an evaluation of the residents' capacity to consent, which was not conducted. Additionally, the facility failed to protect a resident from a resident-to-resident abuse event that resulted in a fall. A resident with a history of wandering entered another resident's room, leading to a confrontation where the second resident pushed the first, causing them to fall. The facility's policy on abuse prevention was not adequately enforced, as the staff was aware of the wandering behavior but did not prevent the incident. The resident who fell had diagnoses of repeated falls, muscle weakness, altered mental status, Alzheimer's disease, and dementia.
Failure to Prevent Falls and Ensure Resident Safety
Penalty
Summary
The facility failed to protect two residents from accidents and hazards, leading to multiple falls and injuries. Resident #9 experienced eight falls within 17 days, resulting in significant injuries, including a traumatic subarachnoid hemorrhage and compression fractures. Despite being identified as a high fall risk, interventions were not effectively implemented or communicated among staff. Staff member F admitted to not knowing how to access or update care plans, and there was a lack of staff signatures on a document outlining interventions for Resident #9. Resident #10, who has a history of wandering due to Alzheimer's and dementia, was pushed by another resident, resulting in a fall. The incident occurred in a memory care unit where residents frequently wander into each other's rooms. Staff member K acknowledged the difficulty in preventing such incidents, and staff member F used Google Translate to communicate with Resident #10, who only speaks Russian. The care plan for Resident #10 included wearing appropriate footwear and redirecting her from other residents' rooms, but these measures were not effectively enforced. The facility's documentation and communication regarding fall risks and interventions were inadequate. Staff members were not fully aware of care plan updates, and incidents were not consistently logged. Resident #9's falls were not included in the fall log because she had been discharged, indicating a lack of comprehensive tracking and follow-up on fall incidents. These deficiencies highlight a failure in ensuring a safe environment and adequate supervision for residents at risk of falls.
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What surveyors actually found near you
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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.
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Nursing homes near Kalispell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brendan House | 0.3 mi | ★★★★★ | 0 | 0 |
| Immanuel Skilled Care Center | 0.7 mi | ★★★★★ | 11 | 0 |
| Montana Veterans Home N H | 12 mi | ★★★★★ | 0 | 0 |
| Whitefish Care And Rehabilitation | 12.9 mi | — | 30 | 0 |
| Lakeview Rehabilitation And Nursing Llc | 15.5 mi | — | 27 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.