Immanuel Skilled Care Center

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

non-ambulatory; cannot perform any form of self-ambulation nor assisted ambulation and Patient presents w/ mobility limitation restricting ability to participate in 1 or more ADLs.Examination/Functional Description: Resident was previously screened in May following report of forward falls from her wheelchair. At that time, her wheelchair cushion was found to be positioned backwards and was corrected. No further issues had been reported until a recent state visit, during which it was noted that staff had been using a seat belt with

the resident. Resident does not demonstrate a clinical need for a seat belt at this time. [sic]A request was made for consent for seatbelt use for resident #5 on 8/19/25 at 4:43 p.m. No documentation was provided prior to the end of survey.

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

08/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Immanuel Skilled Care Center

185 Crestline Ave Kalispell, MT 59901

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

was initiated at the time of event. Review of the facility reported findings, submitted on 6/18/25, showed the CNA had responded to resident #7's adamant request for a personal item. The CNA reported a gait belt was not used, and a review of the transfer status was conducted. The transfer card in resident #7's room did not specify a gait belt, and the status was updated to show gait belt for transfers. X-ray showed no findings.7. Review of a facility reported-incident, dated 7/9/25, showed an incident of an injury of unknown origin, where during a weekly skin assessment resident #5 was found bruising and swelling to right foot.

The provider was notified and x-ray requested. A podus boot was applied for comfort. Review of the facility reported findings, submitted on 7/21/25, showed resident #5 self-propelled in wheelchair, wore nonskid socks or soft slippers and rocked back and forth when in wheelchair. Staff interviewed the resident and found no findings of change in routine or increased pain. Resident #5 had the potential to run her toes over with her wheelchair secondary to the advanced dementia and soft footwear.During an interview on 8/19/25 at 1:30 p.m., staff member C stated incidents that are reported to the state agency need to be investigated and closed in five days. Staff member C stated there was a change a few months back where the investigation is to be completed in five working days, excluding holidays. Staff member C was shown the seven reportable incidents that were identified as being late when the findings were submitted. Staff member C the facility had struggled in the past with what was showing in in bounds, [the state report portal]. Staff member C stated there was difficulty with the findings being reported timely because there was more than one person involved with the reportable.During an interview on 8/19/25 at 1:35, staff member B stated reportables are reviewed in the morning meetings and sometimes the reportables do not get handed to IDT members in those meetings, and they get missed. Staff member B stated the facility had difficulty with timely reporting of findings of the investigations when the timing was changed a while back.During an interview on 8/19/25 at 4:37 p.m., staff member A stated it was hard to say why some reportables dating back to December of 2024 had findings of the investigation reported late. Staff member

A reported he did identify a trend of late submission of findings on 7/11/24 when he did a deep dive and audited all reportables to the state agency. Staff member A stated the identified findings were put on the QAPI board and a PIP was initiated.Review of facility QAPI minutes dated 7/17/25 showed, Our Facility reported incident have been late the last couple of months, we noted with the last QSO that the reporting period was changed to 5 business days. When reviewing the date in bounds we noted that the date was a day off being 6 business days, we will track the due date one day before Bounds in standup to beon time. 7/11/25 in audit of Reportables noted that there were two that had not been submitted on from 6/12/25, Social Services noted that they had wrote this and submitted, wondering if they had forgot to hit submit and got pulled away from computer, they will submit 7/11/2025. A PIP will be completed to monitor Reportables and tracked in QAPI for at least three months for sustainability. The benchmark will be 0 late Reportables. [sic]Review of the facility's, PIP for Facility Reported Incidents showed, FRI-Bounds will be looked at Daily

during the work weekend then reported in Stand up for date due-FRI will be closed at the latest one day

before the due date-Social Work and DON will work on completing FRI one day before their due date-Administrator and Social worker will go over FRI for the week every Friday [sic] Review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, showed, .9. Investigate and report any allegations within timeframes required by federal requirements.The corrective measures were implemented by the facility at the time of the identification of the late reporting.

No further late reports were noted after the corrective actions were implemented.

Event ID:

Facility ID:

If continuation sheet