Kalispell Rehabilitation And Nursing Llc
KALISPELL REHABILITATION AND NURSING LLC in KALISPELL, MT — inspection on January 16, 2025.
Found 18 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
attendance sheet as being educated.
275025 01/16/2025
Kalispell Rehabilitation and Nursing LLC 171 Heritage Way Kalispell, MT 59901
Review of a Grievance Report Form, dated 3/1/24, showed: Why do we fill out grievances? Nothing changes.
Review of Grievance Report Form, dated 3/1/24, showed: Grievances not being addressed.
During an interview on 1/15/25 at 3:56 p.m., staff member C said he was the grievance officer and stated the administrator and director of nursing determine what gets elevated to a grievance as it related to missing items.
During an interview on 1/15/24 @ 4:21 p.m., Staff member A said social services handles the grievances, and the prior social worker was not very strong in her skillset.
Staff member A said the grievance log for August 2024 was missing.
During an interview on 1/15/24 at 4:21 p.m., staff member A stated missing items are elevated to a grievance if they were aware of them.
Staff member A stated when something doesn't get put on a grievance form they try to do a concern form for it, try to address the concern, and it doesn't always get in the grievance log.
During an interview on 1/16/25 at 9:13 a.m., NF5 stated resident #67 had discharged from the facility last week, and they were still missing an iPad, an apple watch, and clothing. NF5 stated she had requested resident #67's inventory sheet.
A review of resident #67's [Facility Name] Healthcare: Personal Belonging Inventory showed resident #67's iPad and apple watch were inventoried. A grievance was not resolved for the lost items.
Refer to F-F584 - Safe, Clean, Comfortable Environment for more details related to lost items, and greivances not initiated to address the lost items.
275025 01/16/2025
Kalispell Rehabilitation and Nursing LLC 171 Heritage Way Kalispell, MT 59901
Review of resident #62's PASARR Level I, dated 6/21/24 lacked the diagnosis of Post Traumatic Stress Disorder.
Review of resident #62's history and physical, dated 6/16/24 showed, .Social History .He does state he was in the special forces in the Korean war and Vietnam war, and at one point was a prisoner of war for 60 days, but escaped . [sic] Review of resident #62's MDS, with an ARD of 6/27/24, section I6100 showed the resident did not have a diagnosis of Post Traumatic Stress Disorder.
Review of resident #62's MDS, with an ARD of 9/22/24, section I6100 showed the resident did have a diagnosis of Post Traumatic Stress Disorder.
During an interview on 1/16/25 at 8:45 a.m., staff member C stated when the diagnosis of PTSD was added to the resident's diagnoses, a new PASRR Level 1 should have been completed.
The Level 1 would then show if a Level II was necessary.
A request was made for a Level II for resident #62's, and there was no information provided prior to the end of survey.
275025 01/16/2025
Kalispell Rehabilitation and Nursing LLC 171 Heritage Way Kalispell, MT 59901
A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .
275025 01/16/2025
Kalispell Rehabilitation and Nursing LLC 171 Heritage Way Kalispell, MT 59901
her room, and the resident's pants were observed inside out.
ADLs as needed; Focus: The resident has an ADL self-care performance deficit r/t Activity Intolerance, Parkinson's with Impaired balance, and impaired gait, and muscle stiffness .Interventions . DRESSING: The resident requires set-up with upper/lower body dressing . TOILET USE: The resident requires supervision of one staff for toileting
275025 01/16/2025
Kalispell Rehabilitation and Nursing LLC 171 Heritage Way Kalispell, MT 59901
palliative order for resident #29 was unclear and this doesn't make any sense.
palliative care policy.
275025 01/16/2025
Kalispell Rehabilitation and Nursing LLC 171 Heritage Way Kalispell, MT 59901
instead of a laying down position.
Upon observation, resident #28 had her pillow fluffed up around her
could be a choking hazard especially with her specialized diet: minced and moist.
275025 01/16/2025
Kalispell Rehabilitation and Nursing LLC 171 Heritage Way Kalispell, MT 59901
12/24/24, 12/29/24, 12/30/24, 1/3/25 and 1/11/25.
team's request sheet #4, which was provided to the facility. No policy or documentation was provided by the facility by the end of the survey.
275025 01/16/2025
Kalispell Rehabilitation and Nursing LLC 171 Heritage Way Kalispell, MT 59901
During an interview on 1/14/25 at 2:13 p.m., resident #10 stated he had pain everyday and all over. He stated staff were frequently very busy and he felt his pain was not managed effectively. He stated staff did not offer to rotate (reposition) him and he stated, I wouldn't refuse, if staff would offer to help him move in the bed. He stated, They're always understaffed and too busy.
Review of resident #10's EHR showed the following diagnoses: Spondylosis without myelopathy or radiculopathy, lumbar region; arthropathic psoriasis; polyneuropathy, spinal stenosis lumbar region with neurogenic claudication; wedge compression fracture of unspecified thoracic vertebra; other intervertebral disc degeneration, lumbar region. [sic] During an interview on 1/15/25 at 4:17 p.m., staff member A stated call light times were determined by resident satisfaction.
Review of a facility document, titled Call Light Audit, showed . 5 minute goal.
Never walk past a call light.
275025 01/16/2025
Kalispell Rehabilitation and Nursing LLC 171 Heritage Way Kalispell, MT 59901
Based on interview and record review, the facility failed to ensure a resident received services for the
During an interview on 1/13/25 at 4:14 p.m., resident #62 stated he was a Veteran; and, I saw a lot of combat in Korea and Vietnam. I have PTSD.
Review of resident #62's history and physical, dated 6/16/24 showed, .Social History . He does state that he was in the special forces in the Korean War in Vietnam war and at one point was a prisoner of war for 60 days but escaped[sic] During an interview on 1/15/25 at 8:14 a.m., resident #62 stated, I need to see a psychiatrist or a counselor for my PTSD.
Review of resident #62's list of diagnoses list showed the resident had a medical diagnosis of post-traumatic stress disorder.
During an interview on 1/16/25 at 8:45 a.m., staff member C stated resident #62 had not been referred for treatment related to the post traumatic stress disorder.
A request was made for documentation showing a referral was made for the treatment of resident #62's PTSD, but nothing was received prior to the end of survey.
275025 01/16/2025
Kalispell Rehabilitation and Nursing LLC 171 Heritage Way Kalispell, MT 59901
During an interview on 1/14/25 at 10:40 a.m., staff member G stated if the medication was not marked off in the MAR as given, it was a medication error, and there's no excuse.
During an interview on 1/16/25 at 8:02 a.m., staff member D stated if the medication was not checked off in the MAR, it wasn't given.
A review of a facility policy, titled, Administering Medications, with a revision date of December 2012, showed: Policy Statement Medications shall be administered in a safe and timely manner, and as prescribed.
Policy Interpretation and Implementation .
- Medications must be administered in accordance with the orders, including any required time frame
- If a drug is withheld, refused, or given at a time other than the scheduled time, the individual
- The individual administering the medication must document in the resident's MAR in the applicable
.
administering the medication shall document this information in the MAR accordingly.
section after giving each medication and before administering the next resident's medications
275025 01/16/2025
Kalispell Rehabilitation and Nursing LLC 171 Heritage Way Kalispell, MT 59901
Review of resident #5's EHR, accessed on 1/13/25, showed there was a physician's order for a dental referral dated 4/15/24.
Review of the resident's EHR failed to show any progress notes or followup referrals or treatment for the resident's identified dental concerns.
During an interview on 1/15/25 at 8:33 a.m., staff member B stated the facility had the referral in May (2024), but did not follow up, and they would make the appointment today (1/15/25).
- a.
During an interview on 1/13/25 at 4:37 p.m., resident #48 stated some of the foods (like chicken) were tough to eat, and she had a hard time eating them because her dentures did not fit properly.
Review of resident #48's EHR showed a 6.15% weight loss.
The resident's weight was 128.4 pounds on 11/4/24, and the weight went down to 120.5 pounds on 1/13/25. b.
During an interview on 1/14/25 at 2:50 p.m., resident #3 stated her dentures would slip, which made it hard for her to eat. c.
During an interview on 1/15/25 at 9:19 a.m., resident #6 stated her dentures did not fit properly so she did not wear them at all. d.
During an interview and observation on 1/15/25 at 8:33 a.m., resident #280 stated his dentures did not fit well which made it difficult to chew meats. Resident #280 had left two sausage links on his plate, and he stated he would not be able to chew them. Resident #280 stated he might not get enough protein for his renal diet.
A request was made for resident #3, #6, and #48's dental notes and appointments. No documentation was provided by the end of the survey.
275025 01/16/2025
Kalispell Rehabilitation and Nursing LLC 171 Heritage Way Kalispell, MT 59901
During three observations on 1/14/25 at 8:33 a.m., 8:37 a.m., and 8:41 a.m., whole grain toast was not observed on a resident's plate.
Review of the 1/14/25 breakfast menu showed: .
Whole grain toast During an observation on 1/15/25 at 12:37 p.m., the following foods were served for lunch: - Potato soup - Ham and cheese on a croissant - Watermelon - Cupcake Review of the 1/15/25 Lunch Menu showed: Garden vegetable soup Classic beef stroganoff Lemon buttered broccoli Baked roll Raspberry jello salad The menu items posed were not what was served that day.
275025 01/16/2025
Kalispell Rehabilitation and Nursing LLC 171 Heritage Way Kalispell, MT 59901
the time.
the food, and the residents told staff member J the food was jail food.
275025 01/16/2025
Kalispell Rehabilitation and Nursing LLC 171 Heritage Way Kalispell, MT 59901
During an interview on 1/15/25 at 10:45 a.m., staff member D stated she had tested all close contact residents the day prior (1/14/25) but had forgotten to put a progress note in the resident record's, and had just now completed them.
Staff member D stated everyone had tested negative.
Review of the facility policy, Water-borne Contaminants, dated 12/16/19, showed, Approaches to controlling waterborne microorganisms (i.e., water system decontamination) will be consistent with current Centers for Disease Control and Prevention . recommendations or state and local health department requirements . designee is responsible to identify the facility's risk for water-borne contaminants . and to implement appropriate prevention measures .
During an interview on 1/16/25 at 10:48 a.m., staff member E stated the facility did not have any procedures or systems in place for waterborne microorganisms.
275025 01/16/2025
Kalispell Rehabilitation and Nursing LLC 171 Heritage Way Kalispell, MT 59901
Review of resident #62's history and physical, dated 6/16/24 showed, .Social History .He does state he was in the special forces in the Korean war and Vietnam war, and at one point was a prisoner of war for 60 days, but escaped . [sic]
Review of resident #62's MDS, with an ARD of 6/27/24, section I6100 showed the resident did not have a diagnosis of Post Traumatic Stress Disorder.
Review of resident #62's MDS, with an ARD of 9/22/24, section I6100 showed the resident did have a diagnosis of Post Traumatic Stress Disorder.
During an interview on 1/16/25 at 8:45 a.m., staff member C stated when the diagnosis of PTSD was added to the resident's diagnoses, a new PASRR Level 1 should have been completed.
The Level 1 would then show if a Level II was necessary.
A request was made for a Level II for resident #62's, and there was no information provided prior to the end of survey.
275025
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 275025 B.
Wing 01/16/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Kalispell Rehabilitation and Nursing LLC 171 Heritage Way Kalispell, MT 59901
During an observation and interview on 1/15/25 at 1:05 p.m. staff member Q stated they worked with activities to return clothes that had piled up monthly.
Staff member Q stated the label maker was currently in activities because of the influx of Christmas clothing.
Staff member Q stated clothes were labeled with the label maker, written on with a Sharpie, or they requested family to label the clothing.
During an interview on 1/15/25 at 3:56 p.m., staff member C stated, I literally spend one third of my time looking for missing items.
During an interview on 1/15/24 at 4:21 p.m., staff member A stated missing items are elevated to a grievance if they were aware of them.
Staff member A stated when something doesn't get put on a grievance form they try to do a concern form for it, try to address the concern, and it doesn't always get in the grievance log.
When asked about the current process for safeguarding personal items staff member A stated it is an expectation to complete an inventory of the resident's personal items and they try to complete an inventory listing on admission.
Staff member A stated resident inventory is an area the facility could improve on.
During an interview on 1/16/25 at 8:13 a.m., staff member J stated there were missing items all the time, more so clothing.
Staff member J said the residents never had clothes, their closets were empty, and we never had anything to dress them in.
When asked what happens if missing items were reported to her, she stated she goes to laundry or asks staff member I.
During an interview on 1/16/25 at 8:30 a.m., staff member Q stated yes, we do have missing clothing, it definitely does happen.
Staff member Q stated there was a no name cart or the clothing goes to the lost and found, and then it is gone through every once in a while.
Staff member Q stated he believed there was also a lost and found area in c hall, because we had so many missing items.
During an interview on 1/16/25 at 8:34 a.m., staff member R said there was a lot of missing clothing in the memory care unit, there were a lot of moving parts, and things can get lost quickly.
When asked if there was a policy or procedure that was followed for missing items, staff member R stated she had not seen a policy
During an interview on 1/16/25 at 9:13 a.m., NF5 stated resident #67 has discharged from the facility, and they were still missing an iPad, an apple watch, and clothing. NF5 stated she had requested resident #67's inventory sheet.
275025
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 275025 B.
Wing 01/16/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Kalispell Rehabilitation and Nursing LLC 171 Heritage Way Kalispell, MT 59901
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.