Northern Pines Rehabilitation And Nursing

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

of an offer of employment or contract agreement and completed prior to employment. [sic]A review of a facility policy titled, Background Investigations, implemented 4/11/25 showed: Policy:Job reference checks, drug screenings, licensure verifications and criminal conviction record checks are conducted on all personnel making application for employment with this company.Policy Explanation and Compliance Guidelines:1. The Human Resource department will conduct all applicable background investigation(s) on each individual making application for employment with this company and on any current employee if such background investigation is appropriate for position for which the individual has applied. [sic]

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Northern Pines Rehabilitation and Nursing

707 3rd St SE Cut Bank, MT 59427

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on interview and record review, the facility failed to report two allegations of abuse to the State Survey Agency within the required two-hour time frame for 1 (#1); and failed to report investigation findings to the State Survey Agency for 3 (#s 2, 5, and 10) of 12 sampled residents. Findings include: 1. Review of a facility reported incident, dated 4/15/25, showed an alleged incident of verbal abuse occurred between staff member N and resident #1 on 4/14/25. This incident was not reported to the State Survey Agency within

the required two-hour time frame. Review of a facility reported incident, dated 7/13/25, showed an allegation of staff-to-resident abuse between staff member M and resident #1 on 7/12/25. This incident was not reported to the State Survey Agency within the required two-hour timeframe.During an interview on 9/10/25 at 10:05 a.m., staff member B stated she was notified of the incident on 7/13/25 at around 5:00 a.m. Staff member B stated she had notified staff member R, the building administrator at the time, but did not hear back from him until 9:00 a.m. Staff member B reported the incident after speaking with staff member R.During an interview on 9/10/25 at 10:25 a.m., staff member C stated that resident #1 will not always report an incident when it happened but would wait for a staff member she trusted to come on shift and then report the incident at that time. Staff member C stated that resident #1 had told staff member K about the incident, and staff member K reported it to staff member P. Staff member C stated she reported

the incident as soon as she found out about it and started an investigation. Staff member C stated staff member P should have notified the administrative staff right away.2. Review of a facility reported incident, dated 1/20/25, showed, resident #2's wedding ring was allegedly missing. The findings were not submitted to the State Survey Agency.Review of a facility reported incident, dated 1/26/25, showed an incident involving an allegation of resident-to-resident abuse for resident #s 5 and 10. The findings were not submitted to the State Survey Agency until 2/12/25, 13 business days later.During an interview on 9/10/25 at 11:11 a.m., staff member D stated there had been multiple administrators in the building over the last couple months. Staff member D stated there have been issues with reporting and investigating incidents and those staff members are no longer there. Staff member D stated new policies were put into place in April 2025.Review of a facility document titled, Abuse Policy, undated, showed: . Abuse Identification and Reporting1.The facility will ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin. are reported immediately, but no later than 2 hours, after

an allegation is made.Review of a facility document titled, Abuse, Neglect and Exploitation, dated 4/11/25, showed: . VII. Reporting/Response. 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (law enforcement when applicable) within specified timeframes: Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse. Not later than 24 hours if the events that cause the allegation do not involve abuse. [sic]

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Northern Pines Rehabilitation and Nursing

707 3rd St SE Cut Bank, MT 59427

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm

Investigation of Alleged Abuse, Neglect, and ExploitationA. An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur.B. Written procedures for investigations include:. 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who may have knowledge of the allegations;. 6.

Providing complete and thorough documentation of the investigation. [sic]

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Northern Pines Rehabilitation and Nursing

707 3rd St SE Cut Bank, MT 59427

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760

Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and record review, the facility failed to ensure nursing staff followed professional standards for medication administration before administering a controlled substance for 1 (#3) of 12 sampled residents. This deficient practice resulted in the administration of a controlled substance without a current physician's order on three separate days. Findings include:During an interview on 9/9/25 at 12:40 p.m., staff member E stated that each resident had their own supply of resident-specific narcotic medications in the medication cart. When there was a change to the order or the medication was discontinued, the card should be pulled from the medication cart and destroyed. Staff member E stated this ensured the resident no longer received the medication once the medication was discontinued. During an

interview on 9/9/25 at 12:51 p.m., staff member F stated that when a narcotic was discontinued, the medication card should be pulled from the locked narcotic box and destroyed by two nurses. Staff member F stated this was to help ensure the medication was not given after it was discontinued. During an interview

on 9/9/25 at 2:00 p.m., staff member B stated she did not know why the medication card for resident #3 was not removed from the medication cart when it was discontinued or why the nurse involved gave the medication after it was discontinued. Staff member B stated the medication should not have been given

after the discontinuation date. During an interview on 9/10/25 at 2:11 p.m., NF1 stated that a controlled substance should not be administered without a current physician's order, and when a narcotic was discontinued, the medication should have been removed from the medication cart and all of the pills destroyed with two nurses present. Record review of resident #3's physician orders, dated 2/18/25, showed, . LORazepam Oral Tablet 0.5 mg by mouth at bedtime related to ANXIETY DISORDER, UNSPECIFIED (F41.9) until 02/24/2025 23:59 (11:59 p.m.) administer 0.5mg po Q HS x 1 week then D/C. [sic] Review of resident #3's Medication Administration Record, dated 2/1/25 to 2/28/25, showed:- . LORazepam Oral Tablet 0.5 mg by mouth at bedtime related to ANXIETY DISORDER, UNSPECIFIED (F41.9) until 02/24/2025 23:59 (11:59 p.m.) administer 0.5mg po Q HS x 1 week then D/C. [sic]- The Medication Administration Record dated 2/1/25 to 2/28/25, showed the LORazepam was discontinued on 2/24/25.- The Medication Administration Record dated 2/1/25 to 2/28/25, showed there was no active physician's order for LORazepam after 2/24/25. Review of a facility provided Controlled Substance Log, dated 1/29/25, for resident #3 showed: - Lorazepam 0.5 mg was tracked on the Controlled Substance Log.- The medication was removed for administration on 2/25/25, 3/2/25, and 3/3/25, although the medication was discontinued

on 2/24/25. Review of a facility provided document titled, Misappropriation Report, dated 4/12/25 showed:The medication errors occurred on three separate days and were not identified by the facility until 4/12/25.

This was over a month after the medication errors occurred. the Controlled Substance Log reveals that three additional doses were documented as administered after the discontinuation date:February 25, 2025 @ 1900 (7:00 p.m.)March 2, 2025 @ 1900 (7:00 p.m.)March 3, 2025 @ 2000 (8:00 p.m.) [sic]Review of a facility provided training document titled Controlled Substance Expectations updated 4/15/25, showed:- .

When narcotics are discontinued/there is no longer an active order the DON/ADON needs to be alerted and the medication will be destroyed by 2 nurses.-- . It is unacceptable and a violation of the standard of practice to administer medications without an order.- . Rights of Medication Administration: .- . Right Documentation - .- . It is not acceptable to administer medications without a current order. [sic]Review of the facility policy titled, Medication Administration, adopted 12/19/16 showed:- . Medications must be administered in accordance with the orders. - . The individual administering the medication must verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. [sic]

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet