Faith Lutheran Home

F-F540 for more detail

on the individual regulatory areas noted.

On 1/28/25, staff member A sent an email to the Certification Bureau providing staff member B's contact information. An email was sent to staff member B on that day, which included the following, The SNF is required to have a licensed administrator per the SNF regulations. Our office has not received a confirmation or copy of the license for the new administrator. Please have the individual appointed forward a copy of the current active MT Nursing Home Administrator's license . No reply was received from staff member B.

Multiple other attempts were made (on 12/24/24, 12/27/24, 1/30/25, and 2/13/25) by the Certification Bureau to contact staff member B. These attempts included having staff member A relay the message to staff member B of the need for a return call related to the appointment of the Nursing Home Administrator. No return calls or emails were ever received from staff member B, who was reportedly providing facility oversight. The ongoing failure to employee a Montana licensed Nursing home Administrator prevented the facility from being in substantial compliance with Federal regulations.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 5 275073 Department of Health & Human Services Printed: 09/04/2025 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 275073 B. Wing 03/13/2025

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

Faith Lutheran Home 1000 6th Ave N Wolf Point, MT 59201

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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Level of Harm - Minimal harm or 48262 potential for actual harm Based on interview and record review, the facility failed to follow and uphold the plan of correction for the Residents Affected - Few survey dated 12/3/2024, as the QAPI committee did not meet monthly to identify ongoing issues and concerns related to the survey or faiclity, and ensure a licensed Administrator was present, which may negatively affect any resident. Findings include:

During an interview on 3/12/25 at 10:29 a.m., staff member A stated a quality assurance performance improvement meeting was not held in February 2025. Staff member A stated the meeting for February 2025 was not rescheduled. Staff member A stated the next meeting would be held the third week of March 2025.

Review of the Quality Assurance and Performance Improvement Committee Minutes, dated 12/23/24 and 1/22/25, showed no documentation the committee continued to meet monthly in February 2025.

Review of the facility's plan of correction, dated 1/6/25, showed:

. Audits will be presented to QAPI team monthly, for discussion of results and issues to maintain compliance. After 3 months, QAPI committee/IDT will determine the need for ongoing and frequency of the audit to ensure substantial compliance . [sic]

Interviews identified an administrator was not employed as of late December 2024. Due to this, the QAPI committee did not include the necessary staff, as required by the Centers for Medicare and Medicaid, to participate in the QAPI meetings.

Review of the Appendix PP, State Operations Manual, for

F-F585 - The management and oversight of the grievance process

F-F600 - Abuse, Neglect, and Misappropriation

5609 - Abuse Reporting

F-F727 - Director of Nursing/RN requirements, the Director of Nursing must be full-time. Having a full time DON fulfill the licensed Nursing Home Administrator position at the same time, would require that one person to work above and beyond full-time, in order to fulfill the Nursing Home Administrator requirements also. During this call, both staff stated they did not wish to work that many hours above their already full-time employment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 5 275073 Department of Health & Human Services Printed: 09/04/2025 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 275073 B. Wing 03/13/2025

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

Faith Lutheran Home 1000 6th Ave N Wolf Point, MT 59201

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 0837 Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing Level of Harm - Minimal harm or the facility. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48262 Residents Affected - Many Based on interview and record review, the facility's governing body failed to employ an administrator that was licensed in the State of Montana. This failure has affected all residents at the facility, due to the lack of

an Administrator, and the facility not being in substantial compliance due to this. Findings include:

During an interview on 3/10/25 at 2:20 p.m., staff member A stated she was the Director of Nursing and had applied to the State of Montana to become a licensed administrator. Staff member A stated the licensing board had recently requested her college transcripts to move forward with her application. Staff member A stated the facility did not have a current administrator, and the facility had not advertised for the open administrator position.

During an interview on 3/12/25 at 10:03 a.m., staff member B stated he was currently the Interim Chief Executive Officer. Staff member B stated in December of 2024 the interim Director of Nursing Services had planned to renew her contract and function in the administrator role, once her license was received from the State of Montana, but her contract negotiations fell through. Staff member B stated the Interim Director of Nursing Services' last day of employment for the facility was 12/27/24. As of 12/4/24, the facility has not employed a Montana licensed Nursing Home Administrator.

Review of the facility's Key Personnel Contact List, dated 3/10/25, did not include an Administrator name or contact information.

Review of the facility's policy titled, Big Book Info - Policies, last revised June 2023, showed:

. The facility has been administered in a manner that enables it to use its resources effectively and efficiently to assist each resident to attain or maintain his/her practicable mental, physical and psychosocial well-being.

This facility is licensed under all applicable State and Local laws.

The facility will operate and provide services in compliance with applicable Federal, State, and local regulations and codes and with accepted professional standards and principles.

The governing body appoints [NF4], a licensed State administrator, to be responsible for management of the facility.

FACILITY POLICIES:

[Facility Name] will have written administrative and resident care policies in the absence of the administrator,

the appointed designee is the DON .

Review of the State of Montana, Department of Labor and Industries online license verification, did not show

a temporary or permanent Nursing Home Administrator license for NF4, as of 12/31/22.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 5 275073 Department of Health & Human Services Printed: 09/04/2025 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 275073 B. Wing 03/13/2025

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

Faith Lutheran Home 1000 6th Ave N Wolf Point, MT 59201

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 0837 A request was made to the facility on [DATE REDACTED] for documented resources used for recruiting a new administrator. No documentation was received from the facility by the end of the survey. Level of Harm - Minimal harm or potential for actual harm A review of the Appendix PP, State Operations Manual, includes numerous regulations governing Skilled Nursing Facilities/Nursing Facilities. The Administrator is a position that is not only required by the federal Residents Affected - Many regulations, but included in many regulations related to processes for a facility. Refer to

F-F835 - Administration

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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 5 275073 Department of Health & Human Services Printed: 09/04/2025 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 275073 B. Wing 03/13/2025

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

Faith Lutheran Home 1000 6th Ave N Wolf Point, MT 59201

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 0540

F-F837 for the facility failing to employ a licensed Nursing Home Administrator.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 5 275073

F-F849 - Hospice Abuse Reporting/Handling potential for actual harm

F-F868, shows the facility must have the following positions participate in the QAPI Committee:

(i) The director of nursing services;

(ii) The Medical Director or his/her designee;

(iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and

(iv) The infection preventionist.

Refer to