Not rated by CMS — ratings are suppressed for new or low-volume facilities.
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 Whitefish Care And Rehabilitation during CMS and state inspections, most recent first.
A resident had a chronic Foley without a clear clinical indication documented in the chart, and the facility did not complete a void trial or catheter change while he resided there. The care plan lacked catheter-specific goals and interventions, and the incontinence plan did not address the Foley or related monitoring. Records also showed conflicting catheter orders, including a PRN change order and a later monthly change order, while hospital documentation described the Foley as unchanged for months and noted purulent discharge at the urethral meatus.
Expired meds and supplies were found in active storage during an observation with an LPN. In the med room and med cart, staff found expired Prevnar 20, IV dextrose, and a blood sugar control dose. In two supply rooms, staff found multiple expired catheters and suction swab kits, along with supplies stored on the floor and trash/debris present. The LPN stated monthly checks were done but did not know how the expired items were missed, and noted the facility was changing the layout and function of the med and supply rooms.
A resident repeatedly asked to discharge to North Dakota to be closer to family, but the facility did not document meaningful discharge planning actions or referrals to support that goal. Staff said referrals were sent only after surveyor inquiry, while the care plan focused on adjustment to the facility rather than identifying placement options or coordinating out-of-state LTC referrals.
The facility failed to complete person-centered care plans for a resident with an indwelling urinary catheter and for two residents with PTSD. A resident with a catheter had a care plan for neurogenic bladder and urinary infection prevention, but it did not include EBP for infection control. Two residents with PTSD reported anxiety, claustrophobia, and other triggers, yet their care plans did not identify PTSD triggers or include interventions to help staff manage behaviors, anxiety, or stress.
Care plans were not updated for two residents after Foley catheters were placed, with one resident's plan still focused on urinary incontinence and another resident's catheter interventions not appearing until months after the MDS showed an indwelling catheter. The facility also did not involve a cognitively intact resident's family in the care conference, despite the resident stating he wanted family participation and a family member reporting the facility never called for the meeting.
Failure to identify and care plan PTSD and trauma-related needs affected three residents. Two residents with PTSD said staff did not listen to their trauma concerns, and records did not identify their triggers, including one resident’s claustrophobia and another resident’s trauma-related screaming after paralysis. A third resident with a positive trauma screen and severe PHQ-9 score was observed yelling and angry, but his care plan did not include trauma interventions or measures to prevent re-traumatization.
A resident with DNR: Comfort-focused status had a POLST prepared by staff, but the physician/APRN/PA signature section was left unsigned even though it was marked mandatory. Staff later stated they were unaware a physician signature was required, and the facility policy did not include instructions for completing the POLST form.
A resident whose Part A Medicare services ended remained in the facility, but the facility did not provide the required ABN notice explaining which services would and would not be covered. Staff reported the notice was not given because the initial plan was for the resident to go home, and only later was it decided the resident would stay long term.
Staff failed to ensure residents and families knew how to file grievances and did not promptly investigate or follow up on missing-property complaints. A resident reported missing clothing without receiving a grievance form, and a family member reported missing personal items and could not get a response or meeting to review the inventory list. Grievance logs did not include these complaints, and one grievance form was left incomplete.
Failure to document the need for an antipsychotic and complete GDRs for a resident with dementia. A resident was receiving quetiapine 25 mg HS for dementia, but the record lacked supporting documentation for the indication, and staff stated there was no evidence of GDRs or concern noted in the monthly med review. The resident had started quetiapine during a prior hospital stay, and the facility policy required documentation of why other treatments were contraindicated and GDRs unless clinically contraindicated.
Failure to notify the Ombudsman of a resident AMA discharge. A resident left the facility after stating it was his choice to go, and staff documented that he did not return and was later considered AMA after being noted as AOx4 and independent with decision making. The record included an AMA form, but the resident signature line was blank, and the facility could not produce evidence that the Ombudsman was notified as required by policy.
A resident with confusion, verbal aggression, and impaired speech after a stroke was observed yelling in his room while staff could not understand what he wanted. Staff said he became angry when they could not interpret his speech, and record review showed no baseline care plan was available for his communication needs within 48 hours of admission, despite a speech eval documenting that he was unintelligible most of the time.
Fall Prevention Interventions Not Consistently Implemented: A resident with prior falls and poor safety awareness was repeatedly observed with the call light clipped to the foot of the bed or mattress and out of reach, and no floor mat was seen in the room. The resident stated he could not reach his call button or the urinal and did not know how to use the bed remote. Records showed multiple falls with poor bed mobility, confusion, illness, and tangled blankets, while the care plan called for the call light within reach, a low bed, and a floor mat at bedside.
Failure to provide discharge planning and Social Security assistance: A resident who wanted discharge back to his home state reported repeated but unproductive discussions about placement, with referrals not sent until surveyors asked about the issue. The same resident also lost his Social Security income, relied on family for cash, and staff gave him limited help with the benefit issue, with no meaningful follow-up after an initial denied disability application.
Nursing staff failed to consistently obtain weekly weights and did not recognize severe weight loss in a resident, despite physician orders. Multiple residents were not properly monitored or tracked for hydration status, resulting in hospitalizations for dehydration-related conditions. Staff interviews revealed confusion about responsibilities and inconsistent documentation of food and fluid intake, with hydration tracking removed from the charting system for most residents.
Nursing staff did not consistently assess, monitor, or document a resident’s clinical decline, including changes in mental status, vital signs, intake, and weight. This lack of documentation and communication led to the resident developing severe complications such as dehydration, acute renal failure, and sepsis, ultimately resulting in hospitalization.
Multiple residents and family members reported that staff frequently failed to address all resident needs, displayed poor attitudes, and sometimes mocked or used inappropriate language toward residents. Observations and grievance records revealed instances of staff refusing reasonable requests, neglecting basic care, and making insensitive remarks, leading to residents feeling disrespected and uncared for. These actions and inactions resulted in a lack of confidence in the grievance process and fear of retaliation among residents.
Several residents did not consistently receive or have documented their scheduled showers, with gaps in care and incomplete records. Family members and residents reported unmet hygienic needs, missed showers, and concerns about safety and documentation practices. Staff interviews and record reviews confirmed inconsistencies between paper and electronic documentation, and facility protocols for shower provision and refusal documentation were not reliably followed.
Multiple residents experienced unmet needs and safety concerns due to inaccessible or non-functional call lights, including one resident unable to locate his call light, a wheelchair-bound resident left unattended in a shower room without a reachable call system, and several residents reporting long wait times or repeated requests for assistance. Staff interviews and facility records confirmed frequent call light malfunctions and numerous related grievances.
Three residents were found to have unclean rooms, with visible dirt and garbage such as paper and medical items under beds and in living areas. Residents and staff reported inconsistent cleaning practices, and facility cleaning records were incomplete or missing for the relevant days.
A resident who was unable to independently perform oral care did not receive assistance with teeth brushing as required, despite reminders and staff awareness. Interviews revealed inconsistent ADL support among CNAs, and the facility's policy to provide necessary hygiene services for dependent residents was not followed.
A staff member who was not wound certified did not follow physician orders for a resident's wound care, applying an unprescribed calcium alginate dressing and failing to perform proper hand hygiene during the dressing change.
Surveyors found that the facility failed to maintain accident-free areas and provide adequate supervision, including leaving a wheelchair-bound resident unattended in a shower room without a call light, not ensuring fall prevention interventions such as fall mats and accessible call lights for a high-fall-risk resident, and not providing consistent hydration or oxygen for another resident who experienced multiple falls with head injuries.
A resident with a dental abscess did not receive necessary dental care due to lack of coordination among staff regarding insurance coverage and payment resources. The resident's dental procedure was canceled after staff believed payment could not be arranged, despite the facility having resources and the resident's Medicaid status pending. This led to ongoing dental infection, pain, difficulty eating, and significant weight loss.
The facility did not provide timely COVID-19 vaccination to two residents who later became ill, despite requests and expressed willingness to receive the vaccine. Staff cited physician recommendations and vaccine unavailability from the pharmacy as reasons for the delay, and documentation for vaccination consent or declination was missing for one resident. The outbreak began before vaccines were available, and most residents were only offered the vaccine after the outbreak had started.
A suspected sexual abuse event occurred between two residents, where one was found in another's room with inappropriate contact. Although staff notified police shortly after the incident, the required report to the State Survey Agency was not submitted within the mandated two-hour window, instead being sent over 21 hours later. Staff interviews indicated misunderstanding of the regulatory reporting timelines.
A facility failed to thoroughly investigate and implement protective measures after a resident-to-resident sexual incident. Staff did not provide targeted monitoring for sexual behaviors or update the care plan to address these behaviors, and there was no evidence of additional staff education on abuse prevention following the event.
A resident's care plan was not updated to address sexual behaviors directed towards others, despite an incident involving inappropriate contact between two residents. The care plan only included interventions for bipolar disorder symptoms and did not address the new behavioral concern, contrary to facility policy requiring care plan revisions after a status change.
The facility did not maintain documentation showing that staff received education on COVID-19 vaccination, were offered information about obtaining the vaccine, or had their vaccination status recorded, as confirmed by staff interviews and the absence of records when requested.
A nurse pre-poured medications into unlabeled cups and stored them in the medication cart, then administered these medications to multiple residents without proper labeling or verification. The nurse also documented medications as given on the MAR before actual administration and transferred pills between unlabeled cups, contrary to facility policy requiring one-at-a-time administration and post-administration documentation.
Staff did not consistently follow infection control protocols, including failure to use required gowns during enteral medication administration, inadequate hand hygiene before and between glove changes during medication administration and wound care, improper handling of wound care supplies, and returning a cigarette from the floor to a resident's possession without hand hygiene. These actions were not in accordance with facility policies and were confirmed through direct observation and staff interviews.
Three residents who had consented to pneumococcal vaccination did not receive the appropriate vaccine, as documented in their medical records. In two cases, no pneumococcal vaccine was administered after consent, and in another, the recommended Prevnar20 was not given despite prior PPSV23 administration. Staff reported limited vaccine documentation and were awaiting access to the state immunization system to update records.
Two residents experienced a lack of dignity when one witnessed the removal of a deceased resident through a populated hallway, causing emotional distress, and another was left waiting in wet clothing after an incontinence episode, leading to frustration and anger. Staff did not follow established privacy protocols or timely incontinence care as outlined in care plans and facility policy.
Staff failed to supervise and document the self-administration of medications for two residents, resulting in unsupervised access to pain pills and a rescue inhaler left at the bedside. Facility policy required RN assessment, documentation, and care plan updates for self-administration, but these steps were not completed or reflected in the residents' records.
A resident's advance directives and code status were not accurately maintained or readily accessible to staff, resulting in conflicting POLST forms and uncertainty among staff regarding the resident's current wishes. Staff relied on electronic records and binders, but inconsistent documentation and lack of up-to-date information led to confusion during care and emergency planning.
Three residents were affected by unclean wheelchairs and unpainted, non-cleanable surfaces in their rooms and bathrooms. Observations showed wheelchairs with caked-on debris and walls with chipped or missing paint, creating unsanitary conditions. Staff interviews revealed that maintenance and cleaning tasks were not completed as required due to prioritization of other duties and lack of time, and maintenance logs showed few repairs had been made.
A resident's care plan was not updated to reflect a change from full code to DNR status as documented in the most recent POLST. Staff reported that care plan updates were assigned during morning meetings, but the care plan continued to show outdated information despite the resident's new DNR election.
Two residents who required assistance with bathing did not receive regular showers as scheduled, resulting in feelings of uncleanliness and dissatisfaction. Observations showed both had oily hair, and records confirmed infrequent bathing over a 30-day period. Staff interviews indicated that CNAs often missed baths due to time constraints, despite facility policy requiring regular assistance with hygiene.
A staff member did not follow provider orders for administering medications through a gastrostomy tube for a resident, failing to check tube placement by auscultation and not using the correct amount of water flushes as ordered. All medications were given together instead of one at a time with appropriate water flushes, contrary to both provider orders and facility policy.
Two residents did not receive medications as ordered, including one who was given midodrine without confirmation of food intake and another who received multiple medications via PEG tube in a single cup with insufficient water flushes. Staff admitted to not following prescriber orders, resulting in a medication error rate of 20%.
A nurse administered both a scheduled dose of long-acting insulin and an additional dose of fast-acting insulin intended for another resident to a single resident, due to distraction and improper labeling of insulin pens. The error resulted in the resident being sent to the ER for continuous glucose monitoring. Environmental factors such as poor lighting and noise contributed to the incident, and the facility's medication administration policies were not followed.
A resident and their representative reported missing personal items, including clothing, after discharge. Despite notifying the facility, no response or investigation was documented, and the required inventory list was not found in the medical record. The facility's grievance log did not reflect the complaint, and staff could not provide the necessary documentation, indicating a failure to follow established policies for inventory and grievance handling.
Two residents experienced cardiac arrest events and expired in the facility due to the lack of staff CPR certification, inadequate training, and missing essential supplies such as Ambu bags and protective barriers on the crash cart. Staff were unclear about their responsibilities, the crash cart was not easily accessible or routinely checked, and there was no process in place to track CPR certifications or ensure emergency supplies were available.
The facility failed to maintain accessible and properly stocked crash carts, resulting in delays in emergency respiratory care for two residents. Staff were unable to locate essential supplies such as Ambu bags and barriers during code situations, and there was no clear responsibility or documentation for checking or restocking crash carts. The facility's assessment and policies did not adequately address respiratory care services, equipment, or staff training related to respiratory emergencies.
The facility did not update its Facility Assessment to reflect the addition of a pulmonary program, omitting key information about respiratory care services, staffing changes, equipment, staff training, and necessary medical supplies. Staff interviews confirmed the program had been in place for about a year, but the assessment failed to address these changes, increasing the risk for residents needing pulmonary care.
The facility did not ensure staff received adequate training on supply locations, ordering procedures, crash cart management, or CPR certification. Multiple staff, including contracted personnel, reported not being shown where supplies were kept, how to order them, or how to restock the crash cart. Some staff had not received CPR training or certification, and there was no clear policy or documentation outlining these requirements.
The facility did not provide required infection prevention and control training to new, existing, and contracted staff, and several staff members were unaware of the Infection Preventionist's identity. The facility had a gap in Infection Preventionist coverage, and staff education on infection control policies and procedures was not conducted as outlined in facility protocols.
Licensed staff administered medications with specific blood pressure and pulse parameters without consistently checking or documenting vital signs, resulting in multiple instances where medications were given outside of ordered parameters for three residents. Staff interviews confirmed a lack of adherence to physician orders and facility policy regarding medication administration.
Three residents received medications outside of physician-ordered parameters, including administration of Midodrine and Atenolol without appropriate blood pressure or pulse checks or despite readings that should have resulted in the medication being held. Staff interviews confirmed knowledge of the requirement to check vital signs prior to administration, but this was not consistently followed or documented.
Staff failed to consistently perform hand hygiene and implement enhanced barrier precautions, with multiple staff members entering and exiting resident rooms, handling medication and meal trays, and providing care without washing hands or using sanitizer. Several staff were unaware of infection prevention protocols or which residents required enhanced precautions, and there was a gap in infection prevention oversight due to staff turnover. Facility records showed limited recent training on infection control.
Failure to Manage Long-Term Foley Catheter Care
Penalty
Summary
The facility failed to ensure there was a clinical indication for a resident’s long-term use of a Foley catheter, failed to follow up timely on a physician’s PRN order for catheter changes for over four months, failed to establish a voiding pattern, and failed to develop a comprehensive individualized care plan for the resident’s long-term catheter use. The deficiency involved one resident sampled for catheter use and care, identified as resident #37. During observation, the resident had a Foley catheter bag attached to the underside of his wheelchair and stated he had the Foley for a while. Review of prior urology documentation showed that before the catheter was placed, the resident had BPH with obstructive/lower urinary tract symptoms, did not have a Foley catheter at that visit, and had a post-void residual of 12 ml. The record also showed no further urology follow-up after catheterization for acute urinary retention in the hospital in October 2025, and the resident did not have a Foley catheter on admission to the facility. The resident’s care plan included a fall care plan noting the Foley catheter, but it did not identify contributing factors, a diagnosis supporting catheter use, or goals and interventions for monitoring or catheter care. The incontinence care plan did not include catheter-related information, although it included interventions to establish voiding patterns. The record showed no void trial and no catheter change while the resident resided at the facility, despite historical and current physician orders including a PRN catheter change order and a later order to change the Foley monthly and PRN for obstruction. Hospital documentation later described the resident as having a chronic indwelling Foley that had not been changed in months, with purulent discharge noted at the urethral meatus.
Expired Medications and Supplies Left in Active Storage
Penalty
Summary
Expired medications and supplies were found in active storage areas during an observation and interview with staff member B. In the 200-hall medication room, staff found Prevnar 20 x 37 doses expired [DATE] and 1000 mL IV bags of 5% dextrose x 2 expired 2/2026. In the 400-hall medication cart, Blood sugar control Assure dose was expired 2/28/26. Staff member B stated the medication and supply rooms were checked monthly, but did not know how the expired items were missed during those checks. Expired supplies were also observed in two central supply rooms. In the CNA back supply room, there were 19 cases of sterile gloves, 15 cases of cleaning cloths, 4 cases of Jevity 1.5, 3 cases of urinals, 6 cases of chucks, and trash/debris on the floor. In the nurse's back supply room, expired items included 9 22Fr catheters expired 1/15/26, 2 14Fr catheters expired 6/28/25, 1 20Fr catheter expired 3/4/25, 1 16Fr catheter expired 6/22/25, 38 red rubber catheters expired 5/20/25, and 2 suction swab kits expired 10/2023. Staff member B stated the facility was in the middle of changing the functionality of the medication and supply rooms and moving things, and suspected this was why the items were missed.
Discharge Planning Did Not Address Resident’s Request to Return Closer to Family
Penalty
Summary
The facility failed to ensure the discharge planning process addressed the resident’s goals, needs, and referrals related to his repeated request to discharge to North Dakota to be closer to family. Resident #81 stated he was from North Dakota, wanted to return there, and had no support system in Montana. His family member also reported that the resident’s goal had been to return to North Dakota and that the family would love to have him back there. The resident reported that he had asked the facility to investigate placement in North Dakota since admission, but he had not received updates despite the issue being raised at quarterly meetings. Staff member E stated that referrals related to the North Dakota placement request were sent only after the State Survey Agency asked about discharge planning efforts, and she did not know what actions had been taken previously. The resident’s care plan focused on helping him adjust to the facility and included interventions such as checking in with him about a potential return to North Dakota, but it did not document discharge planning actions such as identifying facilities, coordinating with out-of-state providers, or initiating placement referrals. An OT evaluation also documented that the resident stated he wanted to go home to North Dakota but was aware he did not have anywhere to live.
Incomplete care plans for catheter infection prevention and PTSD triggers
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan that included enhanced barrier precautions for a resident with an indwelling urinary catheter. Resident #81 had an admission date of 7/24/24 and was observed lying in bed with an indwelling urinary catheter in place. The resident’s comprehensive care plan identified a catheter focus related to neurogenic bladder and included a goal that the resident would show no signs or symptoms of urinary infection, but it did not include enhanced barrier precautions as an intervention for infection prevention associated with the catheter. The report also found that the facility did not include PTSD triggers and interventions on the comprehensive care plans for two residents. Resident #57 stated that she had been started on Prozac for anxiety and that no one from the facility had talked to her about her PTSD diagnosis, and she linked her anxiety to her PTSD, especially when she felt unable to move due to paralysis. Resident #53 stated that no one had listened to his severe PTSD, that he was claustrophobic, and that confinement caused high anxiety. He also stated that staff had never talked to him about his PTSD or associated triggers. Staff interviews showed that staff member E stated PTSD diagnoses and identified triggers should be care planned, and staff member N stated she was aware of only two residents with PTSD and did not know that resident #57 had PTSD. Resident #53’s care plan did not show identified triggers or interventions specific to mitigating behaviors, anxiety, or stress associated with PTSD, and resident #57’s care plan also did not show identified triggers or interventions specific to PTSD. The facility’s Trauma Informed Care document stated that trauma survivors’ needs should be addressed by minimizing triggers and re-traumatization, identifying triggers, and adding trigger-specific interventions to the care plan.
Care Plans Not Updated for Foley Catheters and Family Not Included in Care Planning
Penalty
Summary
The facility failed to update care plan interventions for two residents after they had new Foley catheters. One resident was observed with a catheter drainage bag hanging from the side of the bed and stated the catheter had been placed after recent surgery; a urology note documented acute urinary retention after hospitalization, but the care plan still addressed urinary incontinence and did not acknowledge the new urinary catheter. Another resident was observed with a Foley catheter bag attached to the underside of a wheelchair, and records showed an indwelling catheter on the 5-day MDS, but the historical and current care plans did not include urinary catheter interventions until several months later. The facility also failed to involve a resident's family members in the care planning process. The resident had a BIMS score of 15 and was cognitively intact, and he stated he wanted his family involved in his care. His family member reported the facility said it would call for the care plan meeting but never did. The social service note documented that the resident and family were notified of the care conference, but the care conference summary listed no family participants. The facility policy stated the comprehensive care plan should be prepared by an interdisciplinary team that includes the resident's representative and family members or others desired by the resident.
Failure to Identify and Care Plan PTSD and Trauma-Related Needs
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for residents with PTSD and trauma-related behaviors, including residents #53, #57, and #102. Resident #53 stated that no one listened to his severe PTSD concerns and that he was claustrophobic with high anxiety, while resident #57 stated that his screaming behavior was related to past trauma after becoming paralyzed and that no one had spoken to him about his PTSD or triggers. Resident #102 had a Trauma-Informed Care Evaluation score of 30 and a PHQ-9 score of 24, but his baseline and comprehensive care plans did not reflect trauma care interventions or interventions to prevent re-traumatization. For resident #53, the Trauma Informed Care Evaluation dated 12/17/25 did not identify any PTSD triggers, and social service progress notes also failed to identify triggers. Staff stated they knew he did not like to be startled, but did not know he was claustrophobic, and one staff member stated that resident #53 was a tough case and got angry a lot. Resident #53’s room was observed to be clean and organized with bare walls and not homelike. For resident #57, the Trauma Informed Care Evaluation dated 2/23/26 also failed to identify any PTSD triggers, and social service progress notes did not show trigger identification. Staff stated they would talk to him but did not identify any triggers for his PTSD. For resident #102, staff observed him yelling loudly in his room while multiple staff attempted to calm him, but they could not understand what he wanted or was saying. A staff member stated he was angry because he wanted to go home, could not safely go home yet, and was upset because his wife had dropped him off at the emergency room and had not returned. Staff member E stated the trauma score was positive and the PHQ-9 score was severe, but she was not sure what to do and had not yet notified the DON. The facility’s Trauma Informed Care policy stated that trauma triggers should be identified and added to the care plan, including triggers such as lack of privacy or confinement in a crowded or small space, but the records for these residents did not show identified triggers or trauma-specific care planning.
Unsigned POLST Activated in EHR
Penalty
Summary
The facility failed to ensure a physician signature was obtained for a POLST directive before the order was activated in the resident's EHR for resident #102. Review of the EHR showed the resident had a code status of Do Not Resuscitate: Comfort-focused. The resident's POLST, dated 3/5/26, showed that staff member F prepared the form for Do Not Resuscitate: Comfort-focused Treatment, but the physician/APRN/PA signature section had not been signed even though it was marked mandatory. During interview, staff member B stated she was not aware that a POLST needed a physician signature and said the state where she previously practiced did not require one for validity. The facility policy, Residents' Rights Regarding Treatment and Advance Directives, did not include instructions for completing the POLST form with mandatory sections.
Failure to Provide Required Medicare Coverage Notice
Penalty
Summary
The facility failed to ensure a resident who was being discharged from Part A Medicare services and continued living in the facility was fully informed of which services would and would not be covered. Resident #86’s record showed that Medicare A services ended on 1/20/26, and the resident received and signed CMS form 10123, but did not receive CMS form 10055. The resident remained a current resident at the facility. During an interview, staff member L stated the resident had not been given the ABN because the initial plan was for her to go home, but after discussion with family it was decided she would stay in the facility long term. Staff member L stated they discussed whether the ABN should have been given after the discharge plan changed and agreed that it should have been.
Grievance Process Not Followed for Missing Resident Property
Penalty
Summary
The facility failed to ensure staff and residents were aware of the process for filing grievances, failed to promptly investigate grievances, and failed to follow up with resident representative grievances for 2 of 25 sampled residents. Resident #53 stated he was missing multiple items of clothing and had spoken to facility staff about it, but the facility never provided him with a form to complete and did not offer to replace the missing clothes. He stated the laundry department was terrible and that he never got his clothes back after they were taken to wash. A resident representative stated he had called staff member E about six months earlier regarding missing items belonging to his father, including a gold cross necklace, a winter coat, and other belongings, but he had been unable to get a response or coordinate a meeting to create a new inventory list. Staff member E stated she would initiate the grievance process when a family member voiced a concern, but she did not fill out a grievance form for resident #53 when he reported missing clothing. She also stated she could be better at following up with families on grievance results. Review of the grievance logs showed residents #40 and #53 were not listed for their missing items, and the grievance form for resident #40's representative was incomplete, with no grievance official signature and no resolution documented.
Failure to Document Need for Antipsychotic and Complete GDRs
Penalty
Summary
The facility failed to ensure documentation of the need for an antipsychotic was reflected in the medical record and failed to complete attempted gradual dose reductions for resident #60, who was receiving quetiapine fumarate 25 mg at bedtime for a diagnosis of dementia. The physician order dated 2/19/26 identified the medication as being related to dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, mood disturbance, and anxiety. The resident’s History and Physical dated 1/20/26 stated that quetiapine had been started during a hospital admission from 1/7/26-1/13/26 before the resident was admitted to the facility on 1/26/26. The resident’s Informed Consent for Psychoactive Medications, dated 2/18/26, reflected that the representative gave verbal consent for quetiapine at bedtime on 2/23/26. During an interview on 3/11/26 at 11:45 a.m., staff member B stated the resident should not be on an antipsychotic for a dementia diagnosis and that the facility did not have supporting documentation for the resident’s need for the antipsychotic, any gradual dose reductions, or concern with quetiapine in the monthly medication review dated 2/22/26. The facility policy on psychotropic medications stated that, without documentation explaining that other treatments were clinically contraindicated, the indication for use is inadequate, and that residents using psychotropic drugs shall receive gradual dose reductions unless clinically contraindicated.
Failure to Notify Ombudsman of AMA Discharge
Penalty
Summary
The facility failed to ensure the Ombudsman was notified of a resident discharge when a resident left the facility against medical advice. Resident #98 reported that leaving was his choice, and he stated that it was cold outside, he was eating poorly, and he feared for his safety when he discharged. Facility staff documented that the resident left the facility, did not sign out, and did not return, and later considered him AMA after noting that he was alert and oriented times four and independent with decision making. The record included a Discharge Against Medical Advice Form dated 12/10/25 showing the resident was advised to contact a personal representative or emergency services for further medical care and acknowledged the risks and consequences of leaving against medical advice, although the resident signature line was blank. When asked for evidence of Ombudsman notification, the facility reported it was unable to find a record that the Ombudsman had been notified. The facility policy titled Transfer and Discharge (including AMA) stated that the facility would maintain evidence that the notice was sent to the Ombudsman.
Baseline Care Plan Not Completed for Communication Needs
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours for resident #102 after admission. During an observation, the resident was in his room yelling loudly while multiple staff members entered and attempted to calm him, but they could not understand what he wanted or was saying. NF4 stated the resident appeared angry because he wanted to go home, and when she tried to explain that he could not safely go home yet, he became angrier. NF4 also stated the resident needed speech therapy because he could not be understood since his stroke. Record review showed the resident was admitted with confusion, verbal aggression, and speech aphagia. The speech therapy evaluation and plan of care documented that the resident had a communication level of 4, meaning unintelligible most of the time, even to known listeners. During review of the CNA kiosk information, staff member H showed that the resident did not have a baseline care plan available for communication needs. Staff member H stated the kiosk and pocket sheet were used so CNAs knew what care the resident needed, and that he tried to have the resident point to things when communicating, but it was often difficult to determine what he needed when he was angry or frustrated. Staff member J stated the resident was not interested in a writing board and the facility was working on a picture board, and also stated the resident became angry when staff could not understand him.
Fall Prevention Interventions Not Consistently Implemented
Penalty
Summary
The facility failed to consistently implement fall prevention interventions for a resident with prior falls and poor safety awareness. Resident #77 was observed in bed on multiple occasions with the call light clipped to the foot of the bed or mattress and out of reach, and no floor mat was observed in the room during those observations. The resident stated he did not know how to work the bed remote, could not reach his call light, and reported having had a couple of falls since being in the facility. He also stated he could not reach his call button or the urinal when he had urinated on himself. Record review showed resident #77 had multiple post-event notes documenting falls and related circumstances, including being found on the floor, poor bed mobility, confusion, illness, and becoming tangled in blankets while trying to remove them. The resident’s fall care plan included interventions such as keeping the call light within reach, placing the bed in a low position, having a floor mat at bedside, prompt response to the call light, and a fan in the room. Facility staff acknowledged that the call light should not have been attached to the foot of the bed and stated they were not aware of a floor mat being used, while observations continued to show the call light out of reach and the bed not in a low position.
Failure to Provide Discharge Planning and Social Security Assistance
Penalty
Summary
Medically-related social services were not provided to meet resident needs because the facility did not implement discharge planning services for resident #81, who stated he wanted to return to North Dakota where his family lived and where he had no support system in Montana. The resident reported he had requested placement in North Dakota since admission, but staff told him they were looking into discharge options without providing updates. NF8 stated it had been the resident’s goal to return to North Dakota and that the facility had kept saying it was working on it. Staff member E stated referrals for placement in North Dakota were not sent until after the State Survey Agency asked about discharge planning, and she did not know what actions had been taken previously to address the request. The facility also failed to assist resident #81 with securing Social Security benefits. The resident stated he had been receiving $30 per month but the payments suddenly stopped, and he did not know why. NF3 reported the resident no longer received Social Security funds and that family members had been sending cash. Staff member P stated she gave the resident the Social Security number to call and assisted with a disability application, but the first application was denied and there was no further follow-up. Staff member E stated she was unaware the resident was no longer receiving Social Security funds and believed the business office handled those responsibilities, while the Social Services Director job description stated the director was responsible for helping residents access financial and community resources.
Failure to Monitor and Document Nutrition and Hydration Status
Penalty
Summary
Facility nursing staff failed to obtain weekly weights and did not recognize severe weight loss in one resident, despite physician orders to monitor weight weekly and reweigh if there was a significant change. The resident experienced a 14-pound weight loss over a short period, with no weight documented for three weeks. Staff interviews revealed that the resident often refused weights, and when finally weighed, a significant decline was noted. The resident also had poor dentition, a dental infection, and was experiencing decreased appetite, nausea, and loose stools, all of which contributed to poor intake. Staff were not consistently monitoring or documenting food and fluid intake, and there was confusion about responsibilities for monitoring hydration and nutrition. Additionally, the facility failed to ensure that residents were monitored and tracked for maintenance of proper hydration status. Multiple residents were hospitalized with conditions related to dehydration, including acute renal failure, hyponatremia, and hypovolemia. Staff interviews indicated that hydration status was not routinely tracked or monitored unless residents showed overt signs of dehydration. Documentation of fluid intake was inconsistent or missing, and some staff were unaware of the need to monitor for the effects of diuretic use beyond checking for edema. The facility's own policy required systematic assessment and monitoring of hydration status, but this was not consistently implemented. Staff reported that hydration tracking had been removed from the charting system for most residents, and only a few had active hydration monitoring. There was a lack of clear communication and accountability regarding who was responsible for monitoring and documenting hydration and nutritional intake, leading to missed signs of decline and delayed interventions for residents at risk.
Failure to Ensure Nursing Staff Competency in Resident Assessment and Documentation
Penalty
Summary
Nursing staff failed to demonstrate appropriate competencies in assessing, monitoring, and recognizing clinical changes in a resident who experienced ongoing clinical decline. The resident, an elderly female, was admitted with multiple health concerns including a dental infection, use of a diuretic for congestive heart failure, and was at risk for weight loss. Over the course of her stay, she developed recurrent vomiting, hypotension, altered mental status, and ultimately required hospitalization for aspiration pneumonia, severe hyperkalemia, acute renal failure, and sepsis. Staff interviews and record reviews revealed that changes in the resident’s condition, such as increased confusion, falls, and weakness, were not consistently documented or communicated among the care team. Daily skilled nursing assessments were not completed as required, and there was a lack of clear documentation regarding the onset and progression of the resident’s decline. Further review showed that vital signs, intake and output, and weights were not consistently recorded in the medical record, despite physician orders and facility policies requiring such documentation. The resident experienced a significant, unmonitored weight loss and there was no evidence that the dietitian or physician was notified of her declining intake. Staff members reported that they relied on their own assessment and critical thinking skills due to the absence of clinical pathways, and that training on assessment skills was primarily delivered through computer modules or infrequent staff meetings. Additionally, the facility’s electronic health record system had issues with hydration tracking, and some documentation was deleted or not entered, further impeding the ability to monitor the resident’s status. The facility’s policies required accurate, complete, and timely documentation of assessments, observations, and services provided, as well as systematic approaches to optimize hydration status. However, these protocols were not followed for this resident. Staff interviews confirmed that documentation of the resident’s change in condition, interventions, and communication with providers was lacking or missing entirely. The failure to document and respond appropriately to the resident’s clinical changes resulted in her developing severe complications and requiring hospitalization.
Failure to Ensure Resident Dignity and Respect Due to Deficient Staff Attitudes and Communication
Penalty
Summary
The facility failed to ensure that residents were treated with dignity, respect, and a customer service approach, as evidenced by multiple resident and family interviews, observations, and grievance reviews. Residents reported that staff often did not address all their needs during care, such as not assisting with oral hygiene or washing in the morning, and sometimes made residents feel like they were a burden. Several residents described staff as having poor attitudes, lacking caring mannerisms, and being dismissive or even mocking toward residents. One resident recounted witnessing a CNA cussing at a hospice patient in pain, while others described staff as being loud, using inappropriate language, and making residents feel disrespected or uncared for. Grievance records further documented concerns about staff approach, including staff refusing reasonable food substitutions, failing to provide timely incontinence care, and making racially insensitive or inappropriate remarks. Residents expressed a lack of confidence in the grievance process and reported fear of retaliation if they voiced concerns. Family members also noted that staff were not invested in resident care, leading to increased stress and concerns about the quality of care provided. These findings collectively demonstrate a pattern of deficient staff behavior and communication that compromised residents' rights to dignity, self-determination, and respectful treatment.
Failure to Consistently Provide and Document Scheduled Showers
Penalty
Summary
The facility failed to consistently provide and document scheduled showers for four of twelve sampled residents. Interviews and record reviews revealed that one resident's hygienic needs, including showering, shaving, hair trimming, and fingernail clipping, were not met frequently enough, resulting in a family member performing these tasks. Documentation showed gaps of up to seven days without a recorded shower or refusal, despite a set schedule. Another resident had only one documented shower refusal since admission, with no other records of completed or refused showers, and inconsistencies were found between paper and electronic documentation. Staff interviews confirmed issues with documentation practices, including reliance on paper records and double documentation, which contributed to the inconsistencies. Two additional residents expressed concerns about missed scheduled showers, with one reporting being left unattended in the shower room for 45 minutes without access to a pull cord, despite being wheelchair-bound. Review of the shower schedule and electronic health records showed significant gaps between documented showers, sometimes up to 14 days. Facility policy required showers to be provided per schedule or resident request, with documentation on both paper and electronic systems, and a specific process for documenting refusals. However, these protocols were not consistently followed, leading to incomplete records and unmet resident care needs.
Failure to Ensure Accessible and Functional Call Light System
Penalty
Summary
The facility failed to ensure that call lights were consistently available, accessible, and functional for multiple residents, resulting in unmet needs and safety concerns. Observations revealed that one resident, identified as a fall risk, was unable to locate his call light, which was draped over a fall mat and lacked a clip for proper placement. Staff were uncertain about the correct placement of call lights for residents with dementia. In the shower room, a wheelchair-bound resident was left unattended for an extended period without access to a reachable call light, as the pull cord was missing and the call light station was obstructed by shower chairs. Staff confirmed that residents should not be left alone in the shower room, and the lack of accessible call lights posed a safety risk. Interviews with several residents indicated prolonged wait times for call light responses, with some reporting waits of up to four hours or having to repeatedly request assistance. Residents described situations where call lights were not working, had to be pulled from the wall, or were not reachable due to their physical limitations. Staff interviews and facility work order records showed that multiple call lights required repairs within a single month, and some staff expressed concern about the frequency of these issues. Facility grievance records further documented complaints about non-functional call lights and delayed responses, with some residents' needs not being met even after staff responded to the call light.
Failure to Maintain Clean and Homelike Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and homelike environment for three of twelve sampled residents, as evidenced by multiple observations and interviews. One resident's room had visible dirt and pieces of paper under the bed, with staff and the resident confirming that garbage was often present and that cleaning under beds was not routinely performed. Another resident's room had visible dirt near the wheelchair area, and the resident noted inconsistent cleaning depending on the staff member, while a staff member admitted to only cleaning as needed. A third resident had oxygen tubing ear protectors and a green piece of garbage under the bed on consecutive days. Facility cleaning records were incomplete or missing for the relevant dates, further indicating lapses in routine cleaning practices.
Failure to Provide Assistance with Oral Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who required assistance with activities of daily living (ADLs), specifically oral care, did not receive help with teeth brushing throughout the day. The resident reported on multiple occasions that he had not brushed his teeth and that staff had not assisted him, despite a visible reminder in his room indicating the need for oral care as recommended by speech therapy. Staff interviews confirmed inconsistent provision of ADL care, with some CNAs performing all required tasks and others not. The facility's policy states that residents unable to perform ADLs should receive necessary services to maintain personal and oral hygiene, but this was not followed in the resident's case.
Failure to Follow Physician Wound Orders and Proper Hand Hygiene
Penalty
Summary
A deficiency occurred when a staff member, who was not wound certified, failed to follow physician orders for wound care for one resident. During a dressing change, the staff member applied calcium alginate to the resident's wound, despite the physician's order specifying to cleanse with wound cleanser and apply a collagen pad secured with a dry dressing. The staff member stated they added the calcium alginate because the wound had not been healing and believed it would help with drainage, even though this was not part of the prescribed treatment. Additionally, the staff member did not perform proper hand hygiene after removing the old dressing and before applying the new one. The facility's policy required wound treatments to be provided in accordance with physician orders.
Failure to Prevent Accidents and Ensure Adequate Supervision
Penalty
Summary
The facility failed to ensure that a shower room was free from accident hazards and provided adequate supervision, as evidenced by a wheelchair-bound resident being left alone in the shower room for 45 minutes without access to a call light pull cord. The call light station was not only missing the required pull cord but was also out of reach due to obstructing shower chairs, creating a hazardous environment. Staff confirmed that residents should not be left unattended in the shower room and that the lack of call light accessibility was unsafe. Another resident, identified as having a high risk for falls, did not consistently have fall prevention interventions in place. Observations revealed that the resident's fall mat was folded and not positioned on the floor as required, and the call light was not within reach, with its button hidden behind the mat. The resident was observed attempting to get out of bed without assistance, and the bed was found to be unlocked on multiple occasions. Staff interviews indicated that interventions such as ensuring the call light was within reach and the fall mat was in place were not always followed, and concerns about the adequacy and consistency of fall prevention measures were raised by both staff and family. A third resident experienced multiple falls, some resulting in head injuries, with documentation indicating possible causes such as orthostatic hypotension, dehydration, and a potential seizure. Despite these incidents, observations showed that the resident did not have water readily available at the bedside and was not using prescribed oxygen. The facility's fall prevention policy required individualized interventions and routine rounding, but the lack of consistent implementation of these measures contributed to the resident's repeated falls and injuries.
Failure to Provide Necessary Dental Services for Resident with Dental Abscess
Penalty
Summary
The facility failed to provide necessary dental services for a resident who had a documented dental abscess and was awaiting Medicaid approval for insurance coverage. Upon admission, the resident had a known dental infection and was prescribed antibiotics, with a follow-up dental appointment scheduled prior to hospital discharge. Staff interviews and record reviews revealed that the social services assessment identified dental needs, but no dental visit request was filed, and staff were unaware of the abscessed tooth. When the dental office contacted the facility regarding payment for the scheduled extraction, staff found that the resident lacked dental insurance and was unable to pay the $1200 fee. The appointment was subsequently canceled after discussing the cost with the resident, and staff were not aware of available facility resources or the resident's pending Medicaid status. Further review of the resident's records showed ongoing dental infection, difficulty chewing, and significant weight loss since admission. The care plan included a focus on dental care, but no arrangements were made for the necessary procedure due to the perceived lack of payment options. Communication breakdowns between nursing, social services, and the business office contributed to the failure to secure dental care, despite the resident's Medicaid approval being effective shortly after admission. The deficiency resulted in the resident experiencing pain, difficulty eating, and severe weight loss.
Delayed COVID-19 Vaccination and Documentation Failures During Outbreak
Penalty
Summary
The facility failed to provide COVID-19 vaccines in a timely manner to eligible residents, specifically two residents who subsequently contracted COVID-19. One resident reported being asked about receiving the vaccine approximately a month prior but had not received it despite expressing a desire to be vaccinated. Another resident's family member stated they had repeatedly requested the vaccine for the resident, but no consent or declination form was provided, and the vaccine was not administered. The family member also reported a lack of communication from the facility during a COVID-19 outbreak, leading them to contact the health department for information. Staff interviews revealed that vaccines were not administered because the primary physician recommended waiting until residents were off isolation, and the facility did not have COVID-19 vaccines on hand due to unavailability from the pharmacy. Documentation showed that one resident was offered and received the vaccine, while another had only been asked about it but had not received it. The facility was unable to provide vaccination or declination documentation for one resident. The COVID-19 outbreak began before vaccines were available at the facility, and staff reported that a significant portion of the building had been offered the vaccine only after the outbreak had started.
Failure to Timely Report Suspected Sexual Abuse Incident
Penalty
Summary
The facility failed to submit an initial report to the State Survey Agency within the required two-hour timeframe following a suspected resident-to-resident sexual abuse incident involving two residents. According to the incident documentation, one resident was found in another resident's room by two staff members; the second resident was lying in bed with his brief undone while the first resident had her hand on his penis. The incident occurred at 1:30 a.m., but the report was not received by the State Survey Agency until over 21 hours later. Staff interviews revealed confusion regarding the reporting requirements, with one staff member incorrectly believing that only incidents involving serious bodily injury needed to be reported within two hours, and others could be reported within 24 hours.
Failure to Investigate and Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation and implement necessary protective measures following a resident-to-resident sexual incident involving two residents. On the date of the incident, one resident was found in another resident's room with her hand on his penis, and the second resident's brief was undone. Both residents were assessed for injury, and the incident was reported to the appropriate staff. However, the facility's investigation documents did not include evidence of staff education for abuse prevention related to the incident, nor did they show that monitoring for sexual behaviors was implemented for the initiating resident. Additionally, although staff were reportedly charting behavior monitoring for the initiating resident, there was no indication that sexual behaviors were specifically identified or targeted for ongoing monitoring. The care plan for the initiating resident referenced behavioral issues such as shouting and wandering, but did not address sexual behaviors, focus areas, goals, or interventions related to the incident. The most recent documented staff in-service training on abuse/neglect occurred three weeks prior to the incident, with no documentation of additional training provided after the event.
Failure to Update Care Plan for Sexual Behaviors
Penalty
Summary
The facility failed to update a resident's care plan to address sexual behaviors directed towards others, which could constitute abuse. Specifically, a review of a facility-reported incident showed that one resident was found in another resident's room, with the second resident's hand on the first resident's genitals. Despite this incident, the comprehensive care plan for the resident involved did not include any focus area, goals, or interventions related to sexual behaviors or the potential for sexual abuse towards others. The care plan only addressed manifestations of bipolar disorder, such as shouting and wandering, but omitted any mention of sexual behaviors. During an interview, a staff member confirmed that the resident's sexual behaviors had not been added to the care plan and acknowledged that such behaviors should have been care planned. Facility policies reviewed indicated that care plans are to be developed and revised upon a resident's status change, but this process was not followed in this case. The deficiency was identified through both interview and record review, with documentation supporting that the care plan was not updated as required.
Failure to Document Staff COVID-19 Vaccination Education and Status
Penalty
Summary
The facility failed to maintain required documentation regarding COVID-19 vaccination for staff members. Specifically, there was no evidence that staff had been provided education about the benefits and potential risks of the COVID-19 vaccine, nor that they had been offered information on obtaining the vaccine. During interviews, staff members confirmed the absence of documentation related to staff COVID-19 vaccination status or declination. Additionally, when a written request was made for documentation on five randomly selected staff members, the facility was unable to provide any records prior to the survey exit. Review of the facility's own policy indicated that such documentation was required, including education, offering of the vaccine, and recording of vaccination status.
Failure to Follow Professional Standards During Medication Administration
Penalty
Summary
Staff member Z failed to follow professional standards during medication administration by pre-pouring medications into unlabeled cups and storing them in the medication cart. During multiple observations, staff member Z administered medications to several residents from these unlabeled cups, stating she knew which medications belonged to which residents but could not find the residents at the time. She also admitted to marking medications as given on the Medication Administration Record (MAR) before actually administering them, acknowledging that this was not the correct procedure. On one occasion, staff member Z transferred pills from one unlabeled cup to another prior to administration, and at the end of her medication pass, there were still three unlabeled cups remaining in the cart for which she was unsure of the intended recipients. The facility's policy requires that medications be administered one at a time, observed for consumption, and signed off on the MAR only after administration. Staff member Z's actions, including pre-pouring, using unlabeled cups, and documenting administration before actual delivery, were inconsistent with these professional standards and facility policy. These practices were observed for nine residents during the medication pass, with staff member Z expressing confusion about the process and the identity of the medications in some cups.
Failure to Follow Infection Control Protocols During Medication Administration, Wound Care, and Resident Assistance
Penalty
Summary
Staff failed to adhere to infection prevention and control protocols in several instances involving multiple residents. During medication administration via a PEG tube for a resident under Enhanced Barrier Precautions (EBP), a staff member donned gloves but did not wear a protective gown as required for high-contact activities involving device care. The staff member later acknowledged that a gown should have been worn during the procedure. Facility policy specified that EBP includes the use of gowns and gloves during care activities such as feeding tube management. Hand hygiene practices were not consistently followed by staff during medication administration and wound care. One staff member did not sanitize hands between glove changes while administering medications via PEG tube, and another did not perform hand hygiene before donning gloves or between glove changes during wound care for a resident with multiple wounds. Additional staff members failed to perform hand hygiene before preparing or administering medications to several residents. Facility policies required hand hygiene before donning gloves and before medication administration, but these were not followed as observed. In wound care, a staff member placed supplies directly on unclean surfaces without protective barriers and used scissors stored in an unclean pocket to cut bandages, which were then applied to a resident's wound. Additionally, another staff member picked up a cigarette from the floor and returned it to a resident's cigarette box without performing hand hygiene. These actions were contrary to infection control procedures and facility policies, as confirmed by staff interviews and policy reviews.
Failure to Administer Pneumococcal Vaccines After Consent
Penalty
Summary
The facility failed to ensure that residents who had been screened and provided consent for pneumococcal immunizations actually received the vaccine. Specifically, three residents who had signed informed consent forms for the pneumococcal vaccine did not have documentation of receiving the vaccine in their electronic health records. For two of these residents, there was no record of the pneumococcal vaccine being administered after consent was obtained. For the third resident, although a previous dose of PPSV23 was documented, the recommended Prevnar20 vaccine had not been administered as per current CDC guidelines. During interviews, staff members reported that they had recently started working at the facility and noted that there was limited documentation available regarding resident vaccinations. They also indicated that they were waiting for access to the state immunization information system to update and verify the facility's vaccine records. The facility's policy requires a signed consent form prior to vaccine administration and specifies that the type of pneumococcal vaccine offered should align with CDC recommendations, but these procedures were not followed for the residents in question.
Failure to Maintain Resident Dignity During Postmortem Care and Incontinence Episode
Penalty
Summary
The facility failed to maintain resident dignity in two separate incidents. In the first incident, after a resident's death, two unidentified individuals removed the deceased resident on a stretcher covered with a blanket through a hallway where other residents and visitors were present. This action was observed by another resident, who expressed sadness and distress at witnessing the event. Staff later confirmed that the usual practice is to clear the hallway and use the closest exit to maintain privacy, as outlined in the facility's post-mortem care policy, but this was not followed in this instance. In the second incident, a resident who experienced an episode of incontinence was left waiting in wet clothing for assistance. The resident had activated the call light and reported that staff entered the room but only told him they would return, causing him frustration and anger. The resident's care plan indicated a need for dependent assistance by two staff for toileting and a check and change schedule every two hours, but the electronic medical record did not reflect this schedule. Staff confirmed the resident should be checked and changed every two hours.
Failure to Supervise and Document Resident Self-Administration of Medications
Penalty
Summary
Facility staff failed to properly supervise the self-administration of medications for two residents. One resident was observed with two blue pills, identified as Ibuprofen and Tramadol, left on the bedside table in a plastic medicine cup without staff present. The resident reported that some nurses would leave medications for later self-administration, while others would not. Another resident had a metered-dose inhaler left on the bedside table, which she stated was her rescue inhaler that she rarely used but preferred to keep in her room. In both cases, there was no staff supervision at the time the medications were accessible to the residents. Interviews with staff revealed inconsistent practices regarding medication administration and storage. Staff members indicated that facility policy required an RN assessment and documentation before allowing self-administration of medications, and that the MAR should reflect such authorization. However, there were no self-administration assessments or care plan documentation for the two residents involved. The facility's policy also required that medications not be left at the bedside unless authorized and that storage arrangements be documented in the care plan, which was not done for these residents.
Failure to Maintain Accurate and Accessible Advance Directives
Penalty
Summary
The facility failed to maintain an effective process to ensure that the most current and accurate code status and advance directives for a resident were readily known and available to staff in the event of an emergency. Multiple staff interviews revealed inconsistent knowledge about the location and content of the resident's advance directives and POLST forms. Staff reported that advance directives were requested on admission and updated during care conferences, with copies uploaded to the electronic medical record. However, it was discovered that a resident had completed multiple POLST forms with conflicting instructions—one indicating full code with brief CPR and another indicating DNR—without the facility having all relevant documents on file or clearly identifying the most current directive. The resident's son also indicated that advance directives had been completed and should be present in the resident's room, but these were not on file with the facility until staff made copies after the fact. Record review showed two different POLSTs uploaded in the electronic medical record, with no other advance directives present. The care profile listed the resident as full code/full treatment, while the physician's orders reflected an active order for full code and full treatment, with no other orders for advance directives or code status documented. Staff interviews indicated reliance on the electronic medical record and binders at the nurses' station for code status information, but the presence of conflicting documents and lack of clear, up-to-date information created confusion about the resident's actual wishes. The deficiency was identified for one resident out of a sample of thirty.
Failure to Maintain Clean and Homelike Environment for Residents
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for three sampled residents, as evidenced by multiple observations of unclean wheelchairs and unpainted, non-cleanable surfaces in resident rooms and bathrooms. Specifically, paint was chipped or missing on walls near beds and sinks, exposing drywall and creating surfaces that could not be properly cleaned. Residents expressed dissatisfaction with the appearance of their environment, noting that the condition of the walls was bothersome. Additionally, wheelchairs used by the residents were observed to have accumulated debris, including caked-on white and brown substances on the seats, footrests, and metal parts, which were not cleaned between observations on consecutive days. Interviews with staff revealed that maintenance requests for paint repairs were deprioritized in favor of fire life safety issues, and that routine cleaning of wheelchairs was assigned to night shift CNAs, who reported insufficient time to complete these tasks. Review of maintenance logs indicated a lack of documented work orders for paint repairs in the current year and minimal touch-ups in the previous year. The facility's own policy required routine inspections and immediate correction of identified issues, but these procedures were not followed, resulting in the observed deficiencies.
Failure to Update Care Plan After Code Status Change
Penalty
Summary
The facility failed to ensure the accuracy of a resident's care plan following a change in code status. Specifically, a resident's care plan initially indicated full code status based on the POLST in the referral packet, with interventions to request and review advance directives upon admission and at least quarterly. However, the most recent POLST, signed by the provider, indicated the resident had elected Do Not Resuscitate (DNR) status. Staff interviews revealed that care plan updates were typically handled by the affected department and assigned during morning meetings if needed, but the care plan was not updated to reflect the resident's current DNR status as documented in the latest POLST.
Failure to Provide Regular Showers to Dependent Residents
Penalty
Summary
Facility staff failed to provide regular showers to two residents who required assistance with bathing, as evidenced by observations and interviews. One resident, who had been in the facility for approximately seven months, reported that baths had not been consistent and expressed dissatisfaction with the use of dry shampoo as a substitute. Observation revealed the resident's hair was oily and stringy, and a review of the electronic medical record showed only two baths were provided in a 30-day period. The resident's care plan indicated a need for set-up assistance with showers or bathing. Another resident was observed with oily, matted hair and reported not receiving regular baths as scheduled, which made her feel unclean. This resident was supposed to receive baths twice weekly but had only one documented bath in the same 30-day period. Her care plan required limited to extensive assistance with showering, depending on her energy and fatigue levels. A staff member confirmed that CNAs were responsible for baths but often lacked time to complete them, resulting in missed showers. Facility policy required staff to assist residents with bathing according to requests or the facility schedule.
Failure to Follow Provider Orders for Medication Administration via Feeding Tube
Penalty
Summary
Staff member N failed to follow provider orders during the administration of medications via a gastrostomy tube (GT) for a resident. Specifically, the staff member did not check for correct placement of the GT by auscultation prior to administering medications, as required by the provider's orders. Instead, the staff member flushed the tube with 10 ml of water, administered all medications mixed together, and then flushed the tube again with 10 ml of water, using a total of 30 ml of water. The provider's orders specified that medications should be given one at a time with a 10 ml water flush between each medication, and that the tube should be flushed with 30 ml of water before and after medication administration, totaling 110 ml of water per administration. During an interview, the staff member acknowledged that the method used did not match the provider's written orders and that the total volume of water used was incorrect. Facility policy also required verification of tube placement before administering medications, which was not performed during the observed medication pass. The resident involved had an active order for medication administration via GT, and the deficiency was identified through direct observation, interview, and record review.
Medication Administration Errors Result in 20% Error Rate
Penalty
Summary
The facility failed to properly administer medications according to prescriber orders for two residents, resulting in a medication error rate of 20%. In one instance, a staff member administered midodrine 2.5 mg to a resident without confirming if the resident had eaten, despite the medication order specifying administration with meals. The staff member admitted to not knowing whether the resident had eaten and stated that nurses had told her it was acceptable to give the medication without food. Review of the facility's medication administration policy confirmed that medications are to be given as ordered by the physician, including at the right time. In another case, a staff member administered multiple medications via PEG tube to a resident by combining them in one cup and using only 30 ml of water, contrary to the provider's order, which required medications to be given one at a time with 10 ml water flush between each, and a total of 110 ml water per administration. The staff member acknowledged that she routinely administered the medications in this manner and did not follow the specific order for water flushes. These actions directly contributed to the facility's medication error rate exceeding the acceptable threshold.
Significant Medication Error: Insulin Administered to Wrong Resident
Penalty
Summary
A significant medication error occurred when a nurse administered both a scheduled dose of long-acting insulin and an additional dose of fast-acting insulin intended for another resident to a single resident. The nurse was distracted and brought two pre-filled insulin pens into the resident's room, one containing 18 units of long-acting insulin for the resident and the other containing 42 units of fast-acting insulin for the roommate. Both doses were given to the same resident, which was not in accordance with physician's orders or the facility's medication administration policy. The error was realized after administration, and the resident required immediate transfer to the emergency room for continuous glucose monitoring. Interviews and record reviews revealed that the insulin pens were not properly labeled, with labels only on the lids and not on the bodies of the pens. Contributing environmental factors included poor lighting and noise during the medication pass. The nurse involved had received initial training on medication management and injections, but direct observation of competency was not documented. Other staff members reported not receiving specific education regarding the incident at the time, and the facility's policies required adherence to the six rights of medication administration, which were not followed in this case.
Failure to Document and Investigate Resident Grievance Regarding Missing Personal Items
Penalty
Summary
The facility failed to maintain an accurate inventory of a resident's personal items and did not properly identify or investigate a grievance related to missing clothing following the resident's discharge. Interviews with staff and the resident's representatives revealed that concerns about missing items, including a gray hooded jacket, pajama sets, shoes, shirts, and pants, were communicated to the facility, but no response was provided. The facility's grievance log did not document any grievance related to the missing clothing, and the resident's electronic medical record lacked an inventory list of personal items. Despite requests, the facility was unable to provide documentation of the inventory for the resident in question. Facility policy requires that all resident personal items be inventoried at admission, with documentation retained in the medical record, and that inventories be reviewed and signed off at discharge. Additionally, the grievance policy mandates that grievances be tracked, investigated, and concluded with a written decision. In this case, these procedures were not followed, as evidenced by the absence of inventory documentation and the lack of a recorded or investigated grievance regarding the missing items.
Failure to Ensure CPR Training, Certification, and Emergency Supplies
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary skills and training to perform CPR, as well as to maintain a process for identifying and tracking staff CPR certifications. Two residents, both identified as full code with active physician orders for resuscitation, experienced cardiac arrest events in the facility. During these emergencies, staff were unable to provide high-quality CPR due to missing essential supplies, such as Ambu bags and protective barriers, on the crash cart. Staff interviews revealed that some nurses were not CPR certified, had not been offered training, and did not know who was responsible for checking or stocking the crash cart. In both incidents, the crash cart was not easily accessible, and staff had to search for necessary respiratory supplies during the code events, resulting in delays in care. The crash cart was found to be located in a difficult-to-access area, sometimes blocked by other equipment, and was not routinely checked or restocked. Staff reported that there was no designated person responsible for ordering or stocking emergency supplies, and requests for additional supplies were not fulfilled in a timely manner. Documentation showed that Ambu bags were ordered only after the first code event, and supplies did not arrive before the second code event occurred. The facility's policies stated that staff would maintain current CPR certification and that crash carts would be routinely checked and stocked with critical supplies. However, interviews and record reviews indicated that these policies were not followed. Staff were unclear about their responsibilities regarding emergency preparedness, and there was no system in place to ensure that staff were trained or that crash carts were properly maintained. The facility assessment also failed to identify the need for emergency respiratory supplies.
Failure to Ensure Readily Available Respiratory Supplies During Emergencies
Penalty
Summary
The facility failed to ensure that proper respiratory supplies were readily available and accessible during emergencies, resulting in delays in care for two residents. Observations revealed that crash carts were not easily accessible, with one cart wedged between a treatment cart and a wall, and another blocked by equipment in a utility room. Staff interviews confirmed that essential supplies such as Ambu bags and barriers were missing from the crash carts during code situations. Multiple staff members reported having to leave the resident's room to search for necessary respiratory equipment, causing further delays in providing life-saving interventions. Staff members consistently stated they did not know who was responsible for checking or stocking the crash carts, and there was no documentation of regular crash cart checks or supply inventories. During at least two separate code events, staff were unable to immediately locate Ambu bags or respiratory barriers, and in one instance, a staff member had to use a personal barrier due to the lack of available supplies. The lack of clear responsibility and oversight for maintaining emergency equipment contributed to the deficiency. A review of the facility's assessment and policies showed that respiratory care and services, including the Pulmonary Program, were not adequately addressed. The assessment did not include information on the types of respiratory care provided, changes in staffing, equipment needs, or staff training and competencies related to respiratory care. Additionally, the medical supplies section failed to address emergency respiratory supplies such as Ambu bags, CPAP, or BIPAP equipment, further indicating gaps in preparedness for respiratory emergencies.
Facility Assessment Not Updated for Pulmonary Program Implementation
Penalty
Summary
The facility failed to review and update its Facility Assessment when a new pulmonary program was planned and implemented. The assessment, dated 1/7/25, did not include any information regarding respiratory care and services, the addition of a pulmonary program, changes in staffing related to the program, necessary equipment for participating residents, staff training or competencies for the program, or medical supplies such as CPAP, BIPAP, or emergency respiratory supplies like Ambu bags. This omission was identified through record review and interviews with staff, who confirmed the pulmonary program had been in place for about a year and that respiratory therapists had recently started working in the facility. Staff interviews revealed that the administrator was unsure why the pulmonary program was not included in the facility assessment, despite being in the position when the program was implemented. Another staff member described the ongoing development of the respiratory program, including recruitment of respiratory therapists and the program's intended benefits for residents. However, this staff member was not involved in the facility assessment process. The lack of updates to the facility assessment increased the risk for negative outcomes for residents requiring pulmonary care, and a negative outcome did occur, as cited in other deficient practice areas.
Failure to Provide Effective Staff Training on Supplies, Crash Cart, and CPR
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for new and existing staff, including contracted staff, as evidenced by multiple staff interviews and record reviews. Several staff members reported not receiving training on the location of supplies, supply ordering procedures, the contents and management of the crash cart, and CPR certification. Staff members indicated they were not shown where supplies were kept, how to order them, or how to document supply needs. In emergency situations, staff were unable to quickly locate necessary equipment such as Ambu bags, and there was confusion regarding the stocking and checking of the crash cart. Some staff had not received CPR training or certification during their employment, and there was no clear documentation or policy outlining these training requirements. The facility's employee handbook provided only general statements about orientation and in-service training, without specific guidance or policies related to the identified deficiencies. Staff interviews revealed a lack of designated responsibility for stocking supplies and the crash cart, and inconsistent knowledge among staff about procedures for ensuring supplies and emergency equipment were available and properly maintained. The absence of a structured and documented training program contributed to staff being unprepared to perform essential duties, particularly in emergency situations.
Failure to Train Staff on Infection Prevention and Control Program
Penalty
Summary
The facility failed to ensure that new staff, existing staff, and contracted staff received training on the infection prevention and control program, including written standards, policies, and procedures. Multiple staff members, including newly hired and contracted personnel, reported during interviews that they had not received any education on infection prevention or hand hygiene policies and procedures. Additionally, these staff members were unaware of the identity of the Infection Preventionist. Further interviews revealed that the facility had not had an Infection Preventionist since the end of November 2024, and the new Infection Preventionist only started on January 21, 2025. Review of the facility's Infection Prevention and Control Program document indicated that all staff were required to receive training relevant to their roles, but this was not being implemented as described.
Failure to Follow Physician Orders and Medication Administration Parameters
Penalty
Summary
The facility failed to adhere to professional standards of practice by administering medications contrary to physician orders for three residents. For one resident, Midodrine was given 20 times despite blood pressure readings outside the ordered parameters, which specified the medication should be held if systolic blood pressure exceeded 120 or diastolic exceeded 60, and the provider should be notified if the medication was held. Another resident received Midodrine 13 times when their blood pressure was outside the prescribed limits. In both cases, staff interviews confirmed that vital signs should be checked immediately prior to administration and that medications with parameters should not be given if those parameters are not met. A third resident was administered Atenolol 15 times without documentation of blood pressure or pulse prior to administration, despite orders to hold the medication if blood pressure was below 100/60 or heart rate below 60. Staff interviews revealed a lack of adherence to the requirement to obtain and record vital signs before administering medications with specific parameters. Facility policy also required that medications be administered according to physician orders and professional standards, including obtaining and recording vital signs when applicable.
Failure to Follow Physician-Ordered Medication Parameters
Penalty
Summary
The facility failed to properly administer medications according to physician-ordered parameters for three residents. For one resident with orthostatic hypertension, Midodrine HCL was administered multiple times when blood pressure readings were outside the specified parameters, contrary to the physician's order to hold the medication if systolic blood pressure exceeded 120 or diastolic exceeded 60. Another resident with hypotension also received Midodrine HCL on several occasions when blood pressure readings were above the ordered hold parameters. In both cases, the medication was given despite documented blood pressure readings that should have resulted in the medication being withheld. Additionally, a third resident prescribed Atenolol for essential hypertension received the medication on numerous occasions without any documentation of blood pressure or pulse prior to administration, despite orders to hold the medication if blood pressure was below 100/60 or heart rate below 60. Interviews with multiple staff members confirmed that vital signs should be checked immediately before administering medications with such parameters, and that this practice is part of the standard medication administration protocol. Facility policy also requires adherence to the six rights of medication administration, including proper documentation.
Failure to Adhere to Infection Control and Hand Hygiene Practices
Penalty
Summary
Facility staff failed to adhere to infection prevention and control practices, specifically regarding hand hygiene and the implementation of enhanced barrier precautions. Multiple staff members were observed not performing hand hygiene before or after resident contact, after touching potentially contaminated surfaces, or when moving between resident rooms. For example, one staff member handled medication cups and a computer before administering medications to a resident without performing hand hygiene, while another staff member entered and exited several resident rooms, handled meal trays, and assisted with meals without washing hands or using sanitizer. Staff members also demonstrated a lack of awareness and training regarding infection prevention protocols. Several staff could not recall the last time they received infection prevention or hand hygiene training, and some were unaware of which residents required enhanced barrier precautions. In one instance, a staff member was not aware that a resident with a suprapubic catheter and tube feeding should have been on enhanced barrier precautions, and there was no signage or personal protective equipment available for that resident. The facility had a lapse in infection prevention oversight, as the previous Infection Preventionist had resigned and there was a gap before a new person assumed the role. During this period, monitoring and education on infection control practices were not consistently provided. Review of facility documents showed that only a limited number of staff had attended recent infection control in-services, and the infection control policy required hand hygiene and proper use of enhanced barrier precautions, which were not being followed in practice.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 54 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Whitefish
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Montana Veterans Home N H | 7 mi | ★★★★★ | 0 | 0 |
| Kalispell Rehabilitation And Nursing Llc | 12.9 mi | ★★★★★ | 43 | 0 |
| Brendan House | 13.2 mi | ★★★★★ | 0 | 0 |
| Immanuel Skilled Care Center | 13.4 mi | ★★★★★ | 11 | 0 |
| Lakeview Rehabilitation And Nursing Llc | 26 mi | — | 27 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.