Whitefish Care And Rehabilitation

F-F678 - Cardio Pulmonary Resuscitation, which included concerns with the lack of supplies and availability. Findings include:

During an observation and interview on [DATE REDACTED] at 11:55 a.m., staff member C showed the crash cart was located in the hallway by the medication room and the nurse's station on the 100 and 300 hallway. The crash cart was wedged in between a treatment cart and the wall and was not easily accessible. There was a light blue, tarp-like cloth covering the crash cart. Staff member C stated a secondary cart was in a utility room but not utilized because they could not access it. The crash cart in the utility room was in a back corner blocked

in by intravenous poles and wheelchairs. The crash cart was not covered. Staff member C stated she did not know when the crash carts were stocked or the equipment was tested .

a. During an interview on [DATE REDACTED] at 12:02 p.m., staff member D stated she was on shift when resident #1 had coded. Staff member D stated when the code was called staff had to run across the building to retrieve

the crash cart and it did not have the supplies needed. Staff member D stated no AED or Ambu bag was available on the crash cart (for the prior emergent situations). Staff member D said she did not know who was responsible for checking the crash carts.

During an interview on [DATE REDACTED] at 2:43 p.m., Staff member A stated, Ambu bags are now on the crash carts.

During an interview on [DATE REDACTED] at 7:08 p.m., an anonymous staff member stated respiratory supplies had been requested back in the middle of December, and said staff members A and K were notified of the need for more respiratory supplies, and they were not ordered until after [DATE REDACTED]. The anonymous staff member had to leave resident #1's room to search for an Ambu bag, one was found and the staff member returned to resident #1's room and took over the code . Staff members A and K were notified again about needed respiratory supplies.

During an interview on [DATE REDACTED] at 7:22 p.m., staff member E stated When I arrived in resident #1's room there was not an Ambu bag on the crash cart, I had to leave the code to go and find one. I had to look in multiple areas and had to run to a storage room located across the building from where resident #1's room was located. I was able to locate an Ambu bag and return to resident #1's room.

During an interview on [DATE REDACTED] at 9:50 a.m., staff member H stated I entered resident #1's room and . immediately started chest compressions and yelled for the crash cart. Staff member I came with the crash cart but there was no Ambu bags or barriers, so I could provide manual breathing safely . no one knew where the crash cart was and there were no Ambu bags or respiratory supplies available on the cart. Staff member H stated she didn't know who was responsible for checking or stocking the crash cart.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 24 275132 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 275132 B. Wing 01/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whitefish Care and Rehabilitation 1305 E 7th St Whitefish, MT 59937

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 0695 During an interview on [DATE REDACTED] at 10:10 a.m., staff member I stated she went to find the crash cart and called 911. Staff member I said, I called 911 at 8:25 a.m. When I was in resident #1's room during the code, there Level of Harm - Actual harm was no Ambu bag or barriers available so that manual respirations could be done safely. Staff member E had to leave the room to look for an Ambu bag. There was a complete delay in care from us. If we would Residents Affected - Few have had the needed supplies available, it may have helped save resident #1. Staff member I stated she didn't know who was responsible for checking or stocking the crash cart.

During an interview on [DATE REDACTED] at 10:30 a.m., staff member J stated he was the staff member who found resident #1 in his room not breathing. Staff member J stated he had called for the nurse, and she had run down to the room and had started chest compressions. Staff member J stated there was no barrier or Ambu bag available for staff to use, they had to try and locate one. Resident #1 expired at the facility.

b. [DATE REDACTED] at 11:54 a.m., a call was placed to staff member M. Staff member M was on duty when resident #3 coded. A voice message was left.

During an interview on [DATE REDACTED] at 1:10 a.m., staff member K stated the expectation of the facility was for all staff to know where to find supplies. Staff member K stated, I would expect night shift be checking the crash cart, but there is no documentation of crash cart checks or supplies. I would expect if a staff member used supplies off the crash cart that they replace what was used and restock the cart.

During an interview on [DATE REDACTED] at 3:00 p.m., staff member B stated, My expectation for supplies is that they are available, and staff know where to find them at . That should be part of the floor training staff get during orientation.

During an interview on [DATE REDACTED] at 11:24 a.m., staff member M stated she had been called down to resident #3's room and found resident #3 was not breathing and had no pulse. Staff member M stated she had to use her own respiratory barrier she carried in her pocket because one was not available. Staff member M said there was no Ambu bag available to use. Staff member M stated she had continued to provide CPR until EMS arrived and took over.

A review of the Facility Assessment, dated [DATE REDACTED], failed to show information related to Respiratory Care and Services. The assessment did not include:

- The type of care, services, or contracted services, provided to residents for Respiratory Therapy Services and a Pulmonary Program.

- Changes in staffing as a result of adding a Pulmonary Program.

- Equipment needed for residents who participated in the Pulmonary Program.

- No staff training or competencies addressing the Pulmonary Program.

- The medical supplies section did not address CPAP, BIPAP, or emergency respiratory supplies, such as Ambu bags.

A review of a facility document titled, Emergency Crash Cart, undated, showed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 24 275132 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 275132 B. Wing 01/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whitefish Care and Rehabilitation 1305 E 7th St Whitefish, MT 59937

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 0695 It is the policy of this facility to ensure that the facility will maintain at least one emergency crash cart per nursing care floor with additional carts added as deemed necessary in the case of the need for basic life Level of Harm - Actual harm support.

Residents Affected - Few The purpose of this policy is to ensure that all supplies critical to basic life support are readily available on

the emergency cart .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 24 275132 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 275132 B. Wing 01/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whitefish Care and Rehabilitation 1305 E 7th St Whitefish, MT 59937

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 47752 potential for actual harm Based on interview and record review, the facility failed to properly administer medications with Residents Affected - Some 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. Findings include:

1.Review of resident #18's physician's orders dated 1/1/25, showed:

Midodrine HCL oral tablet 2.5 Mg

Give 2.5 mg by mouth three times a-day for hold if systolic >120, diastolic >60 related to ORTHOSTATIC HYPERTENSION. Notify provider for held medications. [sic]

A review of resident #18's medication administration record, dated January 2025, showed Midodrine HCL 2.5 mg was given 20 times, on the following dates, while blood pressure measurements were outside of ordered parameters.

- 1/1/25 at 6:00 a.m., with a blood pressure of 121/80, and 2:00 p.m., with a blood pressure of 142/67,

- 1/2/25 at 6:00 a.m., with a blood pressure of 127/71, and at 2:00 p.m., with a blood pressure of 140/63,

- 1/3/25 at 2:00 p.m., with a blood pressure of 126/67,

- 1/14/25 at 2:00 p.m., with a blood pressure of 138/72, and at 8:00 p.m., with a blood pressure of 140/81,

- 1/15/25 at 8:00 a.m., with a blood pressure of 135/80, at 2:00 p.m., with a blood pressure of 126/70, and at 8:00 p.m., with a blood pressure of 144/80,

- 1/16/25 at 8:00 a.m., with a blood pressure of 135/79, at 2:00 p.m., with a blood pressure of 126/74, and at 8:00 p.m., with a blood pressure of 148/82,

- 1/17/25 at 2:00 p.m., with a blood pressure of 125/67, and at 8:00 p.m., with a blood pressure of 135/69,

- 1/18/25 at 2:00 p.m., with a blood pressure of 133/78,

- 1/20/25 at 8:00 a.m., with a blood pressure of 133/75, and at 8:00 p.m., with a blood pressure of 120/71, and

- 1/21/25 at 8:00 a.m., with a blood pressure of 128/68, and 2:00 p.m., with a blood pressure of 129/64.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 24 275132 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 275132 B. Wing 01/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whitefish Care and Rehabilitation 1305 E 7th St Whitefish, MT 59937

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 2. Review of resident #23's physician's orders dated 12/31/24, showed:

Level of Harm - Minimal harm or Midodrine HCL oral tablet 5 MG potential for actual harm Give 2 tablets by mouth three times a day for Hypotension hold if systolic >120, diastolic >60. [sic] Residents Affected - Some

A review of resident #23's medication administration record, dated January 2025, showed:

Midodrine HCL 5 mg was given 13 times, on the following dates, while blood pressure measurements were outside of ordered parameters.

- 1/3/25 at 8:00 a.m., with a blood pressure of 131/72,

- 1/5/25 at 8:00 a.m., with a blood pressure of 124/70,

- 1/7/25 at 8:00 a.m., with a blood pressure of 127/72, and at 8:00 p.m., with a blood pressure of 122/75,

- 1/10/25 at 8:00 p.m., with a blood pressure of 137/95,

- 1/13/25 at 8:00 a.m., with a blood pressure of 128/74, and at 2:00 p.m., with a blood pressure of 125/100,

- 1/14/25 at 8:00 a.m., with a blood pressure of 130/90, and 2:00 p.m., with a blood pressure of 121/96,

- 1/15/25 at 8:00 a.m., with a blood pressure of 121/76, and 8:00 p.m., with a blood pressure of 122/70,

- 1/16/25 at 8:00 p.m., with a blood pressure of 144/86, and

- 1/20/25 at 8:00 a.m., with a blood pressure of 121/68.

3. A review of resident #24's physician's orders dated 12/28/24 showed:

Atenolol oral tablet 50 mg. Give 50 mg by mouth in the evening for essential hypertension. Hold if BP <100/60 or HR <60.

A review of resident #24's medication administration record, dated January 2025, showed:

Atenolol 50 mg was given 15 times, on the following dates, with no documentation of blood pressure or pulse

before administration.

- 1/1/25,

- 1/2/25,

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 24 275132 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 275132 B. Wing 01/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whitefish Care and Rehabilitation 1305 E 7th St Whitefish, MT 59937

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 - 1/4/25,

Level of Harm - Minimal harm or - 1/5/25, potential for actual harm - 1/7/25, Residents Affected - Some - 1/12/25,

- 1/13/25,

- 1/14/25,

- 1/15/25,

- 1/16/25,

- 1/17/25,

- 1/18/25,

- 1/19/25,

- 1/20/25; and

- 1/21/25.

During an interview on 1/21/25 at 4:32 p.m., staff member H stated blood pressure and pulses should be taken right before administration of a medication when parameters are on the physician's orders. Staff member H said the blood pressure and pulse need to be as accurate as possible before administering the medications. Staff member H could not recall resident #24's blood pressure or pulse but had administered

the ordered dose of atenolol.

During an interview on 1/22/25 at 12:20 p.m., staff member D stated when a medication has ordered parameters the blood pressure and pulse should be done just prior to when the medication is scheduled to be administered. Staff member D stated it is part of the five rights of medication administration.

During an interview on 1/22/25 at 12:25 p.m., staff member U stated if a medication was ordered with a set of parameters, the blood pressure or pulse needed to be done before giving the medication.

During an interview on 1/22/25 at 12:50 p.m., staff member Y stated vital signs should be done prior to administering medication if there were parameters on the orders. Staff member Y said, You never give a medication with parameters if the vital signs are not recent.

A review of a facility document titled, Medication administration, undated, showed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 24 275132 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 275132 B. Wing 01/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whitefish Care and Rehabilitation 1305 E 7th St Whitefish, MT 59937

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 Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to Level of Harm - Minimal harm or prevent contamination or infection. potential for actual harm . 10. Ensure the six rights of administration are followed: Residents Affected - Some a. Right resident

b. Right drug

c. Right dosage

d. Right route

e. Right time

f. Right documentation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 24 275132 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 275132 B. Wing 01/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whitefish Care and Rehabilitation 1305 E 7th St Whitefish, MT 59937

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 0838 Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Level of Harm - Minimal harm or potential for actual harm 47752

Residents Affected - Many Based 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. Findings include:

Review of the Facility Assessment, dated 1/7/25, failed to show any information related to Respiratory Care and Services or the addition of a Pulmonary Program. The assessment did not include:

- The type of care, services, or contracted services provided to the resident in the area of Respiratory Therapy Services and a Pulmonary Program.

- Changes in staffing as a result of adding Pulmonary Program.

- Equipment needed for residents who participated in the Pulmonary Program.

- No staff training or competencies addressing the Pulmonary Program.

- The medical supplies section did not address CPAP, BIPAP, or any emergency respiratory supplies, such as Ambu bags.

During an interview on 1/15/25 at 2:10 p.m., staff member A stated the facility had the Pulmonary Program for about a year. Staff member A, the administrator, stated she was unsure why the facility assessment did not include the Pulmonary Program, and staff member A was in the Administrator position when the program was implemented.

During an interview on 1/15/25 at 3:00 p.m., staff member B stated, The respiratory program was implemented about a year ago, and this last summer we started recruiting for respiratory therapists. The respiratory therapists have only been in the building for a few months. The therapists are able to give more one-on-one respiratory attention to the residents, this helps take some pressure off of the nursing staff. We are constantly evolving this program. We use this program to help decrease the risk of infection, re-hospitalization , and help speed up recovery time by improving stamina. We help the residents be more independent. If you can breathe better, you can ambulate better, and this helps residents get home quicker. Staff member B stated she was not involved in the facility assessment, and it was a building process.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 24 275132 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 275132 B. Wing 01/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whitefish Care and Rehabilitation 1305 E 7th St Whitefish, MT 59937

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 47752 potential for actual harm Based on observation, interview, and record review, the facility staff failed to adhere to standards of infection Residents Affected - Some 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. Findings include:

During an observation on 1/22/25 at 8:42 a.m., staff member P was walking down the hallway heading back to the medication cart. Staff member P was carrying a clear plastic medication cup, and a small plastic cup of water. Staff member P set the two cups onto the medication cart and started touching the computer located

on top of the medication cart. Staff member P locked the medication cart, picked up the two plastic cups, walked into resident #16's room, and administered the medications to resident #16. No hand hygiene was performed prior to entering or exiting resident #16's room, and the staff member touched unclean surfaces prior to entering the room.

During an observation on 1/22/25 at 8:52 a.m., staff member S knocked on resident #20's door, grabbed the door knob, and went into the room. No hand hygiene was performed prior to entering resident #20's room. Staff member S picked up resident #20's breakfast tray, left the room, walked down the hall to a large metal meal cart, opened the door, and placed the tray inside the cart. No hand hygiene was performed after placing the breakfast tray in the metal cart. Staff member S walked down the hall to resident #17's room, knocked on the door, grabbed the door knob, and went into resident #17's room. No hand hygiene was completed prior to entering or exiting resident #17's room.

During an interview on 1/22/25 at 8:56 a.m., staff member S stated, I usually wash my hands, we are supposed to wash hands or use sanitizer. Staff member S stated she could not recall the last time she had any infection prevention or hand hygiene training.

During an observation and interview on 1/22/25 at 8:58 a.m., staff member P was standing at the medication cart. Staff member P opened the drawer on the medication cart, picked up resident #18's medication cards, and dispensed them into a clear, plastic, medication cup. Staff member P picked up the plastic medication cup, walked to resident #18's door, knocked on the door, and entered the room. Resident #18 had gloves, isolation gowns, face shields, and masks in a clear plastic container outside the door to the room, and a sign posted outside of the door which notified staff of the need for enhanced barrier precautions. No hand hygiene was completed prior to entering #18's room. Staff member P touched resident #18's bedside table and touched his hand. Staff member P handed the medication cup to resident #18, and he took the medications. Staff member P left resident #18's room, walked back to the medication cart, and touched the computer. No hand hygiene was completed after exiting resident #18's room. Staff member P stated she was not aware resident #18 was on enhanced barrier precautions and had not received any infection prevention education or training by the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 24 275132 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 275132 B. Wing 01/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whitefish Care and Rehabilitation 1305 E 7th St Whitefish, MT 59937

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 0880 During an observation and interview on 1/22/25 at 9:10 a.m., staff member R opened a large metal cart and picked up a breakfast tray, shut the door on the cart, and walked into resident #19's room. Staff member R Level of Harm - Minimal harm or placed the breakfast tray down on a table, opened drinks, and set up the breakfast tray. Staff member R potential for actual harm stated resident #19 required assistance with eating. No hand hygiene was performed prior to entering the resident's room or before starting to set up the meal tray. Staff member R stated hand hygiene should have Residents Affected - Some been done prior to picking up the breakfast tray out of the cart and again prior to setting up the breakfast tray. Staff member R stated she could not remember the last time she had been educated on infection prevention or hand hygiene.

During an observation and interview on 1/22/25 at 12:20 p.m., resident # 25 was lying in bed, dressed in a hospital gown. Resident #25 is hooked up to a pump which delivered continuous tube feeding though a gastrostomy tube, and there was a catheter bag attached to the side of the bed. There was no signage or personal protective equipment inside or outside of resident #25's room. Staff member D stated, I thought he (resident #25) should have been on enhanced barrier precautions; he has a suprapubic catheter and the tube feeding. I was never trained or educated on the facility's infection control policies or procedures.

During an interview on 12:25 p.m., staff member U stated resident #25 should have been placed on enhanced barrier precautions, but there was no sign or personal protective equipment for resident #25. Staff member U stated she did not know who to talk to about infection prevention and had not received any training or education on the facility's infection prevention policies and procedures.

During an interview on 1/22/25 at 2:00 p.m., and 2:35 p.m., Staff member B stated the previous Infection Preventionist had resigned at the end of November 2024, and there had not been anyone officially doing infection prevention, until 1/21/25. Staff member B stated, Every time I am here, I look at all the residents with enhanced barrier precautions and make sure everything is set up correctly, the signage is up, and the supplies are all there.

Review of a facility document titled, In service Training, Infection control, Hand washing, dated, 10/24/24, showed, staff member R and T attended and signed the in-service sheet.

Review of a facility document titled, Hand Hygiene, with a revision date, 9/18/24, showed:

Policy:

All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.

. 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice .

3. Implementation of Enhanced Barrier Precautions

a. Make gowns and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 24 275132 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 275132 B. Wing 01/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whitefish Care and Rehabilitation 1305 E 7th St Whitefish, MT 59937

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 0880 . e. The Infection Preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education. Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 24 275132 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 275132 B. Wing 01/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whitefish Care and Rehabilitation 1305 E 7th St Whitefish, MT 59937

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 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47752 potential for actual harm Based on interview and record review, the facility failed to ensure there was an affective training program for Residents Affected - Many 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. Findings include:

During an interview on [DATE REDACTED] at 1:09 p.m., staff member D stated she was contracted staff employee. Staff member D stated she had not been educated to where extra supplies were kept or how to get supplies ordered. Staff member D stated, I was told that if supplies were needed to write it down. I was not shown where supplies were kept or where the order page was when I started here.

During an interview on [DATE REDACTED] at 7:08 p.m., an anonymous staff member stated no training was received on supplies or ordering supplies. The staff member stated a verbal notification was given to staff member A and staff member K about needing more supplies. The staff member stated they did not know there was a place to write down needed supplies.

During an interview on [DATE REDACTED] at 7:22 p.m., staff member E stated she was involved in an emergency situation, but there was not an Ambu bag on the crash cart. Staff member E stated, I had to leave the room to try and find an Ambu bag, and stated she had to go to three different areas to find one, and there was not just one place for supplies. Staff member E stated she was never educated or trained on supplies or how to order supplies.

During an interview on [DATE REDACTED] at 9:50 a.m., staff member H stated she had never been offered any education or training for CPR in the two years she was employed by the facility. Staff member H stated she had not been provided any education or training on the crash cart. Staff member H stated, I have no idea what supplies are supposed to be on it (the crash cart), or who is responsible for checking it. No one even really knew where the crash cart was. We did not even know where Ambu bags were stored, no one ever told us.

During an interview on [DATE REDACTED] at 10:25 a.m., staff member Q stated she was not CPR certified, and was not offered any training. Staff member Q stated the first time she was offered any CPR training was on [DATE REDACTED]. Staff member Q stated she was not sure who was responsible for supplies or stocking the crash cart.

During an interview on [DATE REDACTED] at 10:55 a.m., staff member A stated there was not a designated person to stock supplies. Staff member A stated, Staff members just go to the supply closet and get what they need, there is not just one person responsible for stocking supplies, but staff member L orders the supplies for the building.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 24 275132 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 275132 B. Wing 01/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whitefish Care and Rehabilitation 1305 E 7th St Whitefish, MT 59937

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 0940 During an interview on [DATE REDACTED] at 1:10 p.m., staff member K stated the expectation was all staff know where to find supplies and where the crash cart was located. Staff member K stated there was no documentation of Level of Harm - Minimal harm or supplies needed for the crash cart or who checks the crash cart. Staff member K stated she expected if a potential for actual harm staff member used supplies off the crash cart, then that staff member would restock it.

Residents Affected - Many During an interview on [DATE REDACTED] at 3:00 p.m., staff member B stated, My expectation for supplies is that they are available, and staff know where to find them at. Staff should know where supplies are located, it should be part of the floor training they (staff) get during orientation. The crash cart should be fully stocked with supplies at all times in case of an emergency, if not, what is the purpose of having a crash cart. Staff member B stated she was not sure how the facility ensured staff were trained or certified in CPR.

A request for the staff training policy was made on [DATE REDACTED] at 11:00 a.m. Staff member A stated they did not have a policy but would provide what information was in the employee handbook.

Review of a facility document from the employee handbook, undated, showed:

Orientation and Training

. Your orientation should prepare you to perform your essential duties.

. Occasionally, your supervisor or Administrator will call upon you to attend in-service programs to strengthen your skill and knowledge in a particular area.

. The meeting, coarse, or lecture is related to your current job. Participation in our training programs is a condition of continuing employment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 24 275132 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 275132 B. Wing 01/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Whitefish Care and Rehabilitation 1305 E 7th St Whitefish, MT 59937

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 0945 Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Level of Harm - Minimal harm or potential for actual harm 47752

Residents Affected - Many Based 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. Findings include:

During an interview on 1/22/25 at 8:58 a.m., staff member P stated she had just started working at the facility. Staff member P stated she was not provided any education on infection prevention or hand hygiene policies and procedures, and she was just doing what I know. Staff member P stated she was not aware of who the Infection Preventionist was.

During an interview on 1/22/25 at 12:20 p.m., staff member D stated she was contracted staff and had been working in the facility for over one month, and she had not been provided any education on infection prevention or hand hygiene policies and procedures. Staff member D stated she was not aware who the Infection Preventionist was.

During an interview on 1/22/25 at 12:25 p.m., staff member U stated she had just started working in the facility not long ago. Staff member U stated she had not been trained on infection control or hand hygiene policies and procedures. Staff member U stated she did not know who the Infection preventionist was.

During an interview on 1/22/25 at 1:50 a.m., staff member A stated there had not been an Infection Preventionist since the end of November 2024.

During an interview on 1/22/25 at 2:00 p.m. and 2:35 p.m., staff member B stated the last Infection Preventionist resigned, and staff member Z started as the facility's Infection Preventionist on 1/21/25. Staff member B stated no one was officially employed as the Infection Preventionist.

Review of a facility document titled, Infection Prevention and Control Program, undated, showed:

. 16 Staff Education

a. All staff shall receive training, relevant to their specific roles and responsibilities, regarding the facility's infection prevention and control program, including policies and procedures related to their job function.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 24 275132