Whitefish Care and Rehabilitation

Inspectors wroteBased on observation, interview, and record review, 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 changing the catheter for over four months1 in an attempt to prevent infections or complications; failed to establish a voiding pattern; and failed to ensure a comprehensive individualized care plan was developed for the resident's long term catheter use, to include goals and interventions for the monitoring and care of the catheter, for 1 (#37) of 3 residents sampled for catheter use and care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure expired medications and supplies were removed from active stock for one medication room, one medication cart, and two central supply rooms. This deficient practice had the potential to affect all residents receiving medications and requiring supplies for care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the discharge planning process addressed goals, needs and referrals necessary to support a resident's request for discharge to another location closer to family for 1 (#81) of 25 sampled residents, and this was upsetting to the resident as it was an ongoing issue over the last year, although the resident had requested assistance with looking into other facilities multiple times.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive, person-centered care plan that included enhanced barrier precautions for a resident with an indwelling urinary catheter for 1 (#81); and failed to include PTSD triggers and interventions on a resident's comprehensive care plan for 2 (#s 53 and 57) of 25 sampled residents. The deficient practice increased the risk for transmission of multidrug-resistant organisms for resident #81 and made it difficult for staff to assist in managing the residents' environment and identify what residents suffered from PTSD and their triggers for residents #53 and #57.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update care plan interventions for 2 (#s 4 & 37) residents with new foley catheters; and failed to ensure a resident's family members were involved in the care planning process for 1 (#81) of 25 sampled residents. This failure limited the resident's representative involvement in resident #81's care and treatment decisions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and address the needs of residents with PTSD, to include their psychosocial well being related to past traumatic events, for residents' who displayed and or voiced concerns related to trauma, and or who had a diagnosis of PTSD, in an attempt to assist the residents' and staff in being able to meet the needs of the residents (refer to F656 Comprehensive Care Plan), for 3 (#s 53, 57, and 102) of 25 sampled residents. Resident #53 voiced being upset that no one listened to him about his trauma. Resident #57 stated his behavior was stemming from past trauma related to a significant injury, and resident #102 was often angry.

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician signature was obtained for a POLST (Montana Provider Orders for Life-Sustaining Treatment) directive prior to activating the order on the resident's EHR for 1 (#102) of 25 sampled residents. This deficient practice had the potential to result in a POLST being implemented during an emergency without a physician's order.

Inspectors wroteBased on interview and record review, 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 for 1 (#86) of 3 residents sampled for beneficiary notices.

Inspectors wroteBased on interview and record review, the facility failed to ensure the staff and residents were aware of the process for filling out and filing grievance forms, failed to promptly investigate grievances, and failed to follow up with resident representative grievances for 2 (#s 40 and 53) of 25 sampled residents. This practice had the potential to affect anyone wanting to file a grievance or who had filed a grievance.

Inspectors wroteBased on interview and record review, the facility failed to ensure documentation of the need for an antipsychotic was reflected in the medical record and to complete attempted gradual dose reductions for a resident receiving an antipsychotic for a diagnosis of dementia for 1 (#60) of 25 sampled residents. This deficient practice had the potential to result in resident #60 remaining on an antipsychotic unnecessarily.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Ombudsman was notified of a resident discharge for a resident who left against medical advice for 1 (#98) of 25 sampled residents. This failure increased the risk that the resident would not have access to independent advocacy and oversight during the discharge process.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to complete a baseline care plan within 48 hours for 1 (#102) of 25 sampled residents. This deficient practice resulted in staff difficulty communicating with resident #102, causing frustration and anger for resident #102.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to consistently implement fall prevention interventions for a resident with previous fall(s) and poor safety awareness for 1 (#77) of 25 sampled residents. This deficient practice placed resident #77 at risk of additional falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure medically related social services were provided to meet resident needs by failing to implement discharge planning services and failing to assist with securing Social Security benefits for 1 (#81) of 25 sampled residents. This deficient practice resulted in resident #81 remaining in the facility without progress toward his expressed discharge goal of returning to North Dakota and without receiving Social Security income needed to meet personal financial needs, causing the resident to rely on family members for financial support.

Inspectors wroteBased on interview and record review, the facility nursing staff failed to obtain weekly weights and failed to recognize a resident's severe weight loss for 1 (#3) of 4 sampled residents; and failed to ensure residents were monitored and tracked for maintenance of proper hydration status for 3 (#s 1, 3, and 4) of 4 sampled residents. This deficient practice contributed to resident #3's decline in weight and for the development of dehydration, requiring hospitalization for residents #1, 3, and 4.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff were competent in assessing, monitoring, and recognizing clinical changes for a resident with an ongoing clinical decline for 1 (#3) of 4 sampled residents. This deficient practice resulted in the resident developing an altered mental status, dehydration, and acute renal failure which resulted in a hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents felt respected and cared for due to concerns with staffing customer service approach for 9 (#s 1, 5, 6, 8, 9, 10, 11, 12, and 15) of 12 sampled residents. This deficient practice resulted in residents feeling: disrespected, not properly cared for, and that their needs were not all met.

Inspectors wroteBased on interview and record review, the facility failed to ensure scheduled showers were consistently completed and documented for 4 (#s 1, 5, 6, 7) residents of 12 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to place call lights in reachable and seen areas for 1 (#5); ensure there was safety during showers for 1 (#6); and ensure all call lights worked consistently and appropriately for 8 (#s 1, 8, 9, 10, 11, 12, 13, 14) of 12 sampled residents leading to residents feeling their needs were unmet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a clean room for 3 (#s 5, 7, and 9) of 12 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the basic ADL (activities of daily living) of teeth brushing was completed and documented for 1 (#9) of 12 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician wound orders were followed correctly for 1 (#1) of 12 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: a shower room contained a pull cord attached to the call light system for 1 (#6), appropriate interventions were consistently in place to prevent falls for 1 (#5), and failed to ensure 1 (#10) had appropriate interventions resulting in falls with head injuries for 12 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure necessary dental services were provided for a resident with a documented dental abscess who was pending Medicaid approval for insurance coverage, for 1 (#3) or 4 sampled residents. This deficient practice caused resident #3 to have difficulty eating with a resulting severe weight loss.

Inspectors wroteBased on interview and record review, the facility failed to provide covid vaccines in a timely manner for 2 (#s 5 and 8) who both got sick with covid, but the facility offered a covid vaccine to 1 (#9) of 12 sampled residents. The failure could have contributed to the size of the COVID-19 outbreak or its spread of it.

Inspectors wroteBased on interview and record review, the facility failed to submit an initial report within two hours to the State Survey Agency for a suspected resident to resident sexual abuse event, for 2 (#s 1 and 2) of 8 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to complete a thorough investigation and take necessary action to protect a resident from ongoing abuse for a resident-to-resident sexual incident, and the facility failed to implement monitoring for the initiating resident, and failed to incorporate staff education for the prevention of abuse, for 2 (#s 1 and 2) of 8 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to update a resident's care plan to include sexual behaviors towards others, which could be abuse, for 1(#1) of 8 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to maintain documentation in which each staff member was provided education regarding the benefits and potential risks associated with the COVID-19 vaccine, that staff members were offered information on obtaining the COVID-19 vaccine, and records of the COVID-19 vaccine status of each staff member.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff member Z provided care consistent with professional standards during medication administration, resulting in residents possibly receiving the wrong medication(s) and having adverse outcomes from pre-poured and unlabeled medications, for 9 (#s 24, 27, 36, 43, 50, 58, 64, 65, 77) of 12 residents sampled for medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff member N followed enhanced barrier precautions during the administration of medications via enteral tube feeding for 1 (#2) of 1 sampled enteral tube feeding resident; failed to ensure staff members N and Z adhered to proper infection control practices related to hand hygiene when changing of gloves and during medication administration for 6 (#s 2, 24, 58, 64, 67, and 77) of 30 sampled residents; failed to ensure staff member O adhered to proper infection control practices during wound care for 1 (#67) of 1 sampled resident for wound care; and failed to ensure staff member V followed infection control procedures to prevent potential contact transmission of an infectious agent or communicable disease for 1 (#38) of 8 sampled smoking residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who were screened and consented to pneumococcal immunizations (Prevnar13, Prevnar20, and PPSV23) were provided the vaccine for 3 (#s 2, 8, and 67) of 5 sampled residents for immunizations (influenza, COVID-19, and pneumococcal).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain dignity for other residents when providing postmortem discharge of a resident for 1 (#47) of 30 sampled residents, which caused feelings of sadness; and failed to maintain dignity of a resident during an incontinent episode for 1 (#36) of 30 sampled residents, which caused them to be frustrated and angry.

Inspectors wroteBased on observation, interview, and record review, the facility failed to supervise the self-administration of a metered-dose inhaler for 1 (#6) and two pain pills for 1 (#35) of 30 sampled residents. This deficient practice increased the risk for medication errors to resident's #6 and #35, as well as to confused residents, who may have wandered into resident #6 and #35's rooms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it had an effective process in place for the most current and accurate code status and advance directives to be readily known and available to staff, in the event of an emergency, for 1 (#7) of 30 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that was clean and well-maintained for 3 (#s 24, 30, and 36) of 30 sampled residents. This deficient practice bothered resident #30, wheelchairs were not cleaned for residents as needed, and unpainted surfaces were not corrected.

Inspectors wroteBased on interview and record review, the facility failed to maintain a list of a resident's personal items and identify and investigate a grievance brought forth by a resident and their representative related to missing clothing for 1 (#85) of 30 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the care plan was accurate for a residents' code status change, for 1 (#7) of 30 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to provide regular showers for 2 (#s 28 and 30) of 30 sampled residents, which made the residents feel dirty and/or upset.

Inspectors wroteBased on observation, interview, and record review, staff member N failed to follow provider orders for the administration of medications via gastrostomy tube (GT) and check for placement of the GT prior to administration of medications for 1 (#2) of 1 sampled enteral tube feeding observation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer seven medications per prescriber's orders for 2 (#s 2 and 58) residents, out of 35 sampled resident medication orders, which led to a 20% medication error rate.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff member X administered insulin in a safe manner resulting in a significant medication error, which put the resident's health and safety at risk and requiring immediate transfer to an emergency room for 1 (#6) resident of 30 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff had the necessary skills and training for CPR for 2 (#s 1 and 3) of 26 sampled residents. Resident #s 1 and 3 expired in the facility. The facility failed to ensure a process was in place for identifying and tracking staff CPR certifications. The facility failed to obtain the supplies necessary, and ensure they were in stock and on the crash cart, for staff to perform high-quality CPR during emergent situations, which affected 2 (#s 1 and 3). The facility failed to have a process in place to identify and ensure supplies, including respiratory supplies, were on hand and readily available. On [DATE] at 11:09 a.m., an Immediate Jeopardy was announced to the Administrator and the Corporate Clinical Recourse Nurse related to F678 - Cardiopulmonary Resuscitation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper respiratory supplies were readily available during emergencies, for 2 (#s 1 and 3) of 26 sampled residents. This deficient practice caused a delay in care during emergent situations, and an Immediate Jeopardy was cited for F678 - Cardio Pulmonary Resuscitation, which included concerns with the lack of supplies and availability.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Facility Assessment was reviewed and updated as necessary when a new pulmonary program was planned and initiated. This deficient practice increased the risk of any resident needing pulmonary care and services to have a negative outcome, which did occur, and cited in other deficient practice areas.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was an affective training program for new staff, existing staff, staff providing contracted services; failed to ensure staff received training during orientation, and ongoing through employment, related to supply locations, supply ordering procedures, the crash cart, and CPR certification for 6 (staff members D, E, H, Q, M, and one anonymous staff member) of 26 staff sampled. This deficient practice increased the risk of any resident having a negative outcome related to the lack of training.

Inspectors wroteBased on interview and record review, the facility failed to ensure new staff, existing staff, and contracted staff were trained on the facility's infection prevention and control program standards, policies, and procedures. This deficient practice increased the risk of a negative outcome for all residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to adhere to accepted standards of practice by administering medications and not following physician's medication orders for 3 (#s 18, 23, and 24) of 26 sampled residents, when standards of practice and physician's orders dictated the medication should not have been administered.

Inspectors wroteBased on interview and record review, the facility failed to properly administer medications with physician-ordered parameters for 3 (#s 18, 23, and 24) of 26 sampled residents. This deficient practice increased the risk of a negative outcome as failing to follow the physician's order could cause an increase or decrease in a resident's blood pressure.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to adhere to standards of infection prevention and control practices, and hand hygiene, for 5 (#s 16, 17, 18, 19, and 20), and for enhanced barrier precautions, for 1 (#25) of 26 sampled residents. This deficient practice had the ability to negatively affect all residents in the facility by increasing the risk for spreading infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide proper indwelling Foley catheter care daily to 2 (#s 21 and 26) of 26 sampled residents. This deficient practice caused resident discomfort and had the potential for an increased risk of catheter associated urinary tract infections.

Inspectors wroteBased on interview and record review, the facility failed: to ensure a staff member's job duties were current and accurate; to ensure a staff member was practicing within their scope of practice/job description shown in a social services note in 1 (#12)'s chart; and to follow up for 1 (#15) and attempt to prevent or improve for the 21 AMA discharges in the facility from January 2024 to current; and to provide behavioral health services for 1 (#4) of 15 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to professionally, properly, and sufficiently document the situation regarding AMA discharges for 2 (#s 4 and 12); provide proper notice before discharge for 2 (#s 4 and 12); and report the AMA discharge to the appropriate entities for 1 (#4) of 15 sampled residents. This deficient practice resulted in 3 residents (#s 3, 4, 12) not trusting staff member F, and 2 (#s 4 and 12) residents requesting to leave AMA from the facility.

Inspectors wroteBased on interview and record review, the facility failed to complete Quarterly MDS (Minimum Data Set) Assessments for 4 (#s 2, 4, 6, and 7), failed to complete an Annual MDS Assessment for 1 (# 5), and failed to complete a Discharge MDS for 1 (#4) of 15 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to submit MDS information within 14 days of completion for 5 (#s 2, 4, 5, 6, and 7) of 15 sampled residents.

Inspectors wroteBased on interview and record review, the facility quality assurance and performance improvement committee failed to identify and act on concerns for why a high number of residents discharged against medical advice during the last year, which included 1 (#15), and there was a total of 21 residents who discharged AMA during this time period. All 21 residents were at risk for a negative outcome due to each one leaving without a physician's discharge approval or a completed plan of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed: to ensure residents were smoking at a minimum of 25 feet away from the facility doors for 1 (#14); to ensure residents with a low BIMS score were not independently smoking for 2 (#s 6 and 13); and ensure all smoking materials were stored in the appropriate place for 1 (#5) of 15 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents or resident representatives understood the risks and benefits of psychotropic medication for 2 (#s 6 and 9) of 15 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure MDS assessments were coded correctly for resident diagnoses and psychotropic medications used, for 2 (#s 9 and 10) of 15 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to provide an appropriate discharge plan consisting of sufficient and thorough documentation throughout the discharge planning process for 1 (#12) of 15 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to identify any DSM diagnoses on the Resident Matrix; or consistently document behaviors and offer behavioral health services to residents with a DSM diagnosis, for 1 (#4) of 15 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to provide services which meet professional standards for care necessary to promote healing of wounds for 1 (#9) of 3 sampled residents with wounds. This deficiency had the potential to affect healing for residents with wounds.

Inspectors wroteBased on interview and record review, the facility failed to provide evidence of a thorough investigation for allegations of abuse for 5 (#s 1, 2, 4, 7, and 10) of 7 sampled residents for abuse. This deficient practice had the potential to allow residents to be exposed to further abuse.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of abuse within 24 hours of the incident for 2 (#s 1 and 4) of 7 sampled residents for abuse. This deficient practice had the potential to delay investigation activities to identify the presence of abuse.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide ordered medications for 8 (#s 1, 3, 5, 10, 11, 12, 14, and 16) of 16 sampled residents, which resulted in significant discomfort for at least 1 (#5) resident.

Inspectors wroteBased on interview and record review, the facility failed to have a certified director of food and nutrition services in the absence of a full-time qualified dietician. This deficient practice had the potential to affect all residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post signs to alert family members and visitors of a COVID-19 outbreak; failed to properly wear PPE throughout the facility; failed to wear appropriate PPE in a room with droplet precautions for a COVID-19 outbreak; failed to maintain isolation for 1 (#72) of 42 sampled residents; failed to implement preventative measures for monitoring and prevention of Legionella in the facility's water supply; and failed to analyze surveillance data to address patterns/trends of infections. These deficient practices had the potential to affect all residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain comfortable and safe temperatures in resident rooms for 7 (#s 3, 9, 39, 44, 55, 57, and 180) of 42 residents sampled.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide or arrange for respiratory care, according to standards of quality, for 1 (#49), resulting in resident #49 feeling distressed; and failed to change oxygen tubing and respiratory supplies for 8 (#s 9, 16, 18, 20, 41, 45, 57, and 179), increasing the risk of respiratory infections, of 9 sampled residents with respiratory care needs.

Inspectors wroteBased on interview and record review, the facility failed to promote and implement a facility-wide system to monitor the use of antibiotics to improve resident outcomes. This deficient practice had the potential to affect residents taking antibiotics.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents non-disposable cutlery during meals for 3 (#s 10, 13, and 27) of 42 sampled residents. The residents voiced this made them sad or embarrassed, and #27 felt having to use plastic utensils was an insult.

Inspectors wroteBased on interview and record review, the facility failed to ensure written grievances received had a full investigation, to include decisions/resolutions decided upon and documented, and residents notified of the resolution, for 2 (#s 31 and 227) of 42 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to accurately code clopidogrel as an antiplatelet in the MDS assessment for 1 (#50 ) of 42 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to enter physician orders, in the resident's EMR, received upon admission, for 1 (#49) of 1 sampled residents. This deficient practice resulted in the resident not receiving prescribed respiratory treatments.

Inspectors wroteBased on interview and record review, the facility failed to implement a GDR for 1 (#50) of 42 sampled residents.