Whitefish Care And Rehabilitation

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

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 submit an initial report within two hours to the State Survey Agency for a suspected resident to resident sexual abuse event, for 2 (#s 1 and 2) of 8 sampled residents. Findings include:A review of a facility reported incident, dated 8/24/25 at 1:30 a.m., showed resident #1 was found in resident #2's room by two staff members. Resident #2 was lying in his bed with his brief undone, and resident #1 had her hand on his penis. The reportable incident was received by

the State Survey Agency on 8/24/25 at 9:20 p.m., over 21 hours after the incident occurred. The report did not meet the required reporting timeline for abuse. During an interview on 9/9/25 at 9:58 a.m., staff member B stated she called the police sometime between 2:30 and 3:00 a.m. on 8/24/25. Staff member B further relayed that the incident was submitted to the State Survey Agency later that evening, on 8/24/25.During an

interview on 9/9/25 at 2:03 p.m., staff member A relayed that he thought serious bodily injury resulting from abuse had to be reported to the State Survey Agency within two hours, and if no injury resulted from the abuse, it was to be reported within 24 hours, which was not what the regulation requires.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

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

Facility ID:

If continuation sheet

Event ID:

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

09/09/2025

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 0610

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and record review, the facility failed to complete a thorough investigation and take necessary action to protect a resident from ongoing abuse for a resident-to-resident sexual incident, and

the facility failed to implement monitoring for the initiating resident, and failed to incorporate staff education for the prevention of abuse, for 2 (#s 1 and 2) of 8 sampled residents. Findings include:A review of a facility reported incident, dated 8/24/25, showed resident #1 was found in resident #2's room by two staff members. Resident # 2 was lying in his bed with his brief undone, and resident #1 had her hand on his penis. Resident #1 was redirected to her room, and both residents were assessed for injury.During an

interview on 9/9/25 at 9:58 a.m., staff member B stated she received a call early in the morning on 8/24/25, from the ADON at the facility, informing her of a resident-to-resident sexual incident between the two residents, #1 and #2. She stated she went to the facility to start an investigation.A review of the facility's investigation documents, dated 8/24/25 and 8/29/25, was lacking staff education for abuse prevention related to the two residents and for monitoring for sexual behaviors for resident #1.A review of a facility document/roster titled, In Service Training, dated 7/31/25, showed: abuse/neglect in the content of the training. This in-service training occurred three weeks prior to the incident with residents #1 and #2. There was no documentation for staff abuse training after the incident occurred for future prevention of abuse.During an interview on 9/9/25 at 2:03 p.m., Staff member B stated that the staff was charting behavior monitoring for resident #1 but did not know if sexual behaviors were identified and targeted for ongoing monitoring.A review of resident #1's care plan showed: BEHAVIORS: [Resident #1] has had some manifestations of her Bi-polar, she has been shouting out and wandering with the efforts to elope., with a date initiated of 8/7/2024 and a revision on 12/1/2024. No focus areas, goals, or interventions for sexual behaviors were noted on resident #1's care plan.

Residents Affected - Few

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

09/09/2025

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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Based on interview and record review, the facility failed to update a resident's care plan to include sexual behaviors towards others, which could be abuse, for 1(#1) of 8 sampled residents. Findings include:Based

on interview and record review, the facility failed to update a resident care plan to include sexual behaviors directed towards others which could be abuse, for 1 (#1) of # sampled residents. Findings include:A review of a facility reported incident, dated 8/24/25, showed resident #1 was found in resident #2's room by two staff member, and resident #2 had her hand on resident #1's genitals. A review of resident #1's current comprehensive care plan, accessed on 9/9/25, showed: Behaviors: [Resident #1] has had some manifestations of her Bi-polar, she has been shouting out and wandering with the efforts to elope., with a date Initiated of 08/07/2024 and a revision on 12/01/2024. Resident #1's care plan failed to show a focus area, goals, or interventions for sexual behaviors or potential sexual abuse towards others.During an

interview on 9/9/25 at 2:03 p.m., staff member B stated resident #1's sexual behaviors had not been added to her care plan. Staff member B further stated that resident #1's sexual behaviors should have been care planned.A review of a facility policy titled, Comprehensive Care Plans, with a revision date of 7/1/25, showed: PolicyIt is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, .A review of a facility policy titled, Care Plan Revisions Upon Status Change, with a revision date of 7/1/25, showed: PolicyThe purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change.Policy Explanation and Compliance Guidelines:1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change.

Event ID:

Facility ID:

If continuation sheet