Clark Fork Valley Nursing Home
CLARK FORK VALLEY NURSING HOME in PLAINS, MT — inspection on February 13, 2025.
Found 4 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
F-F600 - Abuse for the events).
The documentation for the behaviors did not show staff sufficiently took action to protect other residents or provide ongoing behavioral assessments, or that interventions were identified, implemented, and monitored in an attempt to ease the resident's behaviors, stress, or anger toward others while protecting the others residing around the resident, to include:
- Effective Date: 07/03/2024 15:22 Type: Behavior Note, LATE ENTRY Note Text: this resident was in her wheel chair wondering the halls when she ran into another resident whom was walking in the day room. this resident what rolling fast and hit the other residents walker on the left side, hitting the walking residents fingers and almost knocking her over . staff said that this residents was intentionally trying to run over the walking resident . [sic]
- Effective Date: 07/03/2024 16:40 Type: Behavior Note, LATE ENTRY Note Text: this resident was trying to hit another resident [unidentified resident initials] with a recliner remote . when staff stepped in the resident did laugh, looked over to [unidentified resident initials] and said 'i almost gotchya'.
- Effective Date: 7/04/2024 09:35 Type: Behavior Note, LATE ENTRY Note Text: This resident was wondering in a wheelchair . this resident reached out and grabbed [unidentified resident initials] face.
This resident was able to get ahold of [unidentified resident initials] left eye brow and did create a open area above [unidentified resident initials] left eye brow . behavior was intentional, due to the fact that this resident was angry that [unidentified resident initials] was not letting her take the supplies and did yell at [unidentified resident initials].
- Effective Date: 07/10/2024 15:35 Type: Behavior Note, LATE ENTRY Note text: this resident . started to torment another resident [unidentified resident initials]. this resident entered into the dining room where the activity was taking place and intentionally found [unidentified resident initials], started to poke her aggressively on [resident initials] left shoulder and back. [Unidentified resident initials] asked her to stop because it was hurting and this resident laughed, continuing to poke . 5 minutes later this resident returned to the dining room, seeking out [unidentified resident initials]. this resident tried to take [unidentified resident initials] walker from her by grabbing the bars and dragging it away from [unidentified resident initials]. [Unidentified resident initials] asked this resident to give her walker back in order to use it for walking. staff had to step in . this resident began to swear and yell at staff . [sic]
- Effective Date: 07/10/2024 15:55 Type: Behavior Note, LATE ENTRY Note Text: . this resident then went over to the wall and started to take hanging pictures off the wall and tossed them on the ground. this resident also went to side tables and other dining tables where she would take anything that she could reach/grab or move and started to throw items on the ground while she made crying sounds .
275107
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 275107 B.
Wing 02/13/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Clark Fork Valley Nursing Home 10 Kruger Rd Plains, MT 59859
Review of the four Facility Reported Incidents, sent to the State Survey Agency, in 2024, showed no reports of resident to resident abuse allegations involving resident #19.
During an interview on 2/12/2025 at 4:13 p.m., staff member F said if she was aware of resident to resident altercations concerning abuse, she would have investigated the situation 'for sure.'
During an interview on 2/13/2025 at 8:50 a.m., staff member F said the notes in resident #20's EHR related to resident to resident altercations were written by staff member P.
Staff member F stated she had identified a progress note she was concerned about in September 2024 that was written by staff member P and restricted staff member P's access to write progress notes in the medical record.
A request was made for social service notes related to resident to resident incidents involving resident #19 and any notes from social service for potential victim follow-up. No documentation was received prior to the end of survey.
Review of the facility's policy, Abuse, Neglect & Exploitation of Elderly and Disabled, last approved 01/2025, showed:
Policy: [Facility Name] prohibits the mistreatment, neglect, and abuse of its patients and the misappropriation of patient's property.
Furthermore, the use of verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion is prohibited by [Facility Name] .
.Investigative Process:
1.
All alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of Patient or Resident property, shall be reported to the administration of the facility to include unit Manager, Chief Nursing Officer (CNO), and the Chief Executive Officer (CEO) and other officials in accordance with State law (including to the State survey and certification agency).
2.
All alleged violations involving resident to resident and resident to staff will be investigated.
3.
The facility will thoroughly investigate all alleged violations through established procedures .
275107
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 275107 B.
Wing 02/13/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Clark Fork Valley Nursing Home 10 Kruger Rd Plains, MT 59859
The facility failed to implement person-centered, individualized interventions, and staff were not successfully protecting others and being practice to prevent events before they occurred, for 1 (#19) of 17 sampled residents.
Findings include:
Review of resident #19's electronic health record showed the resident had a diagnosis of DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE, MODERATE, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY (F02.B0).
A record review of resident #19's nursing notes showed that from April 2024 to January 2025, she displayed the following behaviors, almost all directed toward other residents, and more were documented from April 2024 to July 2024:
Targeting others, pulling hair, seeking others out to [NAME] against them, attempting to bite staff, pinching a resident, pushing residents, taking the other resident's walkers, hitting other residents with her wheelchair, punching a resident, taking others' belongings, yelling, spitting, knocking pictures off walls and taking items off tables to throw them, caused a skin tear to a resident's eye area when she grabbed her, and almost knocked several residents over by running into them with her wheelchair.
A review of resident #19's Quarterly MDS, with an ARD of 4/19/24, showed:
- The resident was coded as being cognitively impaired, and she rarely understood others.
- She had minimal depression and scored a 2 on her depression assessment but displayed a poor appetite and short temper.
The resident took an antidepressant for 7 days of the 7-day assessment period but did not take an antipsychotic or anti-anxiety medication.
- Under section E, for behaviors, the resident was coded as disturbing others 1 to 3 days a week.
- #19 was independent with eating, but she was independent to max assist for mobility.
- The resident had as-needed pain medications but did not display nonverbal indicators of pain.
A review of resident #19's Annual MDS, with an ARD of 7/23/24, showed changes occurred with the resident, and:
275107
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 275107 B.
Wing 02/13/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Clark Fork Valley Nursing Home 10 Kruger Rd Plains, MT 59859
During an interview on 2/11/25 at 10:03 a.m., NF2 stated resident #24 did have a very traumatic life and had suffered a lot. NF2 stated he did not think anyone had every talked to her about her past experiences.
During an interview on 2/12/25 at 11:58 a.m., staff member L stated, If a patient or resident has any past trauma and it is known to us, we will go and speak with them, and set them up for resources, if they want. We do have a behavioral counselor on site we can refer to. We do a depression assessment on everyone. I am not sure if resident #24 was ever assessed for trauma, I am not sure if there is a trauma care plan in place.
Staff member L stated she was not sure if there was a trauma policy and did not know what it was if there was one.
Staff member L stated she could not find any Social Services notes on resident #24.
Staff member L stated, I will go down and talk with the resident, and all I can do is start from here.
Review of a facility document titled, Care within Long Term Care Unit, with a last approved date of 6/2023, showed:
.
Social Service function provides medically-related services to long term care residents, to allow them to attain or maintain the highest practicable level of physical, mental and, psychological well-being.
Such social services will be made available . [sic]
275107
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 275107 B.
Wing 02/13/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Clark Fork Valley Nursing Home 10 Kruger Rd Plains, MT 59859