Faith Lutheran Home

F-F812 - Food Procurement, Store/Prepare/Serve/Sanitary services for further detail.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 11 275073 Department of Health & Human Services Printed: 08/28/2025 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 04/23/2025

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 14005

Residents Affected - Many Based on observations, interviews, and record review, the facility failed to ensure sanitary conditions were maintained throughout the kitchen and the dietary storage areas; failed to ensure kitchen staff labeled and dated food in the coolers; and failed to maintain a clean kitchen environment. The deficient practices increased the risk for the development of foodborne illnesses and unsanitary conditions, for all residents who received food from the kitchen. Findings include:

During an observation of the kitchen, during the initial tour on 4/22/25 at 7:25 a.m., the following observations were made:

- One pitcher full of fluid was observed in the reach-in cooler. The pitcher was unlabeled and undated.

- One gallon of 2% milk, opened, and not dated.

- One quart of Half and Half, opened, and not dated.

- The inside of the microwave was splattered with food particles.

- The meat slicer had white and brown particles of debris on the cutting surface and base.

- Large containers of spices were opened, not dated.

- Cinnamon and cumin spice containers appeared soiled and were sticky to touch.

- Numerous cups of red jellied products were not labeled or dated in the walk-in cooler.

- A bowl containing a white fluffy substance was not labeled or dated in the walk-in cooler.

- A large metal pan containing a mixture of pasta and sliced meat was not labeled or dated in the walk-in cooler.

- A bag of seven chicken breasts were thawed in a metal pan on the top shelf of the walk-in cooler. The chicken breasts were dated 2/25/25.

During an observation and interview on 4/22/25 at 7:40 a.m., staff member F was observed with a mustache and beard. Staff member F was in the food preparation area and was not wearing a beard or mustache cover. Staff member F said he never worked with the food slicer, but he thought it got cleaned every time it was used.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 11 275073 Department of Health & Human Services Printed: 08/28/2025 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 04/23/2025

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 0812 During an observation and interview on 4/22/25 at 8:00 a.m., staff member E said dented cans are placed on

a special shelf and if dented, they are sent back for credit. During an observation, one can of pumpkin, one Level of Harm - Minimal harm or can of diced pears, and one can of tomato soup, all dented, were observed on the shelves where undented potential for actual harm storage cans were stored and taken by staff or use. Staff member E said the facility has a person that comes

in and does deep cleaning on Thursday and Friday every week. Staff member E said the cleaning must be Residents Affected - Many behind schedule due to the Easter holiday.

During an observation and interview on 4/22/25 at 12:30 p.m., staff member G was observed with a beard and mustache. Staff member G was in the food preparation area and was not wearing a mustache or beard cover. Staff member E said she knows the staff with beards should wear a bear cover. Staff member E asked staff member G to immediately put on a beard cover.

During an observation on 4/23/25 at 8:07 a.m., staff member F was observed in the kitchen without a beard or mustache cover.

Review of a facility temperature document, untitled, located on the reach-in refrigerator showed:

- Ten days in January 2025 with no temperatures documented,

- Five days in February 2025 with no temperatures documented, however temperatures were documented for February 29, 30 and 31,

- Four days in April 2025 with no temperatures documented.

Review of the facility document titled, DIETARY FRIDGE TEMPERATURE showed:

- Three days in April 2025 with no temperatures documented.

Review of facility document titled, DIETARY FREEZER TEMPERATURE log showed:

- Three days in January 2025 with no temperatures documented,

- Three days in April 2025 with no temperatures documented.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 11 275073 Department of Health & Human Services Printed: 08/28/2025 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 04/23/2025

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 14005 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure enhanced barrier precautions Residents Affected - Many were followed for 1 (#22) of 14 sampled residents; and failed to to maintain an adequate infection surveillance and antibiotic stewardship program and ensure policies and procedures were reviewed and revised annually for the Infection Prevention and Control Program. The deficient practices had the potential to increase the risk of infections within the facility. Findings include:

1. During an interview on 4/22/25 at 8:49 a.m., resident #22 said she had a central IV (intravenous) catheter for dialysis. Resident #22 said the nursing staff wore gloves, but never wore gowns when providing personal care.

During an observation and interview on 4/22/25 at 3:05 p.m., staff member H was observed assisting resident #22 prepare for a shower. Resident #22 had a central IV catheter in her upper right chest. The IV site was covered, but the ends of the tubing were not covered. Staff member H was wearing gloves while taping a piece of plastic over the IV insertion site and around the exposed IV catheter tubing. No gown was worn during the care observation. Staff member H said she had been trained on enhanced barrier precautions, but since the IV insertion site was covered, she said she did not need a gown. Gloves were available, but no other personal protective supplies were available in or near resident #22's room.

Review of resident #22's care plan, dated 4/23/25, showed an intervention directing the staff to use enhanced barrier precautions when caring for the central IV catheter.

51111

2. During an interview on 4/23/25 at 8:07 a.m., staff member C stated the facility did not use McGeer criteria (infection surveillance tool) in the infection control program until about six months ago, which is about the time staff member C stated he started the position.

During an interview on 4/23/25 at 9:02 a.m., staff member D stated she started in her current position at the end of January this year. Staff member D stated she did not know what the facility was doing specifically with

the antibiotic stewardship program prior to January 2025, she could not speak to what was or was not in place. Staff member D stated there was no current enhanced barrier precautions policy in place, only guidance for staff to follow. Staff member D stated the facility's corporate QAPI board needed to approve and sign off on the enhanced barrier precautions policy before it would be utilized.

During an interview on 4/23/25 at 12:43 p.m., staff member B stated she helped work on infection control items along with staff member D. Staff member B stated she started her role in September of 2024. Staff member B stated NF3 worked in the facility until the end of December of last year and oversaw the infection prevention program. Staff member B stated NF3 and herself reviewed the former antibiotic stewardship system in place. Staff member B stated she and NF3 decided it was not a complete program and started things over in September of last year. Staff member B stated the facility started using McGeer criteria in September of last year. Staff member B stated she was unaware if there was a break in services of the infection preventionist role between NF2's and NF3's employment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 11 275073 Department of Health & Human Services Printed: 08/28/2025 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 04/23/2025

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 0880 Review of a facility document titled, Long Term Care Facility Component-Annual Facility Survey, showed, the facility reported for survey year 2025 a total of three times in the past year a new employee had to take over Level of Harm - Minimal harm or the infection preventionist role. potential for actual harm

Review of a facility document titled, Monthly Infection Control Log (Line List), showed: Residents Affected - Many . Reporting Period Oct. 1 to Oct. 31, 2024 .

Types of infections .

- UTI no cath: 4 .

- URI: 1 .

- Eye: 3 .

- # New Cases colonized (not infected) with antibiotic resistant organisms: 8 .

1. Started McGeer Criteria

2. Started Ab Stewardship & [72 hour] stop Oct. 31 . [sic]

Review of the facility's Infection Prevention and Control Program policies showed the following:

- Infection Control - Antimicrobial Stewardship Policy and Procedure, Origination September 2024, last revised September 2024;

- Infection Control Antibiotic Stewardship- Review and Surveillance of Antibiotic Use and Outcomes, Origination September 2024, last revised September 2024;

- [Facility Name] Pneumoncoccal Immunization Policy and Procedure, [sic] last revised June 2023, next

review due June 2024; and,

- [Facility Name] Influenza Policy and Procedure, last revised December 2017, next review June 2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 11 275073 Department of Health & Human Services Printed: 08/28/2025 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 04/23/2025

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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51111 potential for actual harm Based on interview and record review, the facility failed to ensure documentation for screening of medical Residents Affected - Some contraindications, education, and signed consent or declination by the resident or their responsible party for

the influenza vaccination for 4 (#s 3, 7, 13, and 31) of 5 sampled residents. This increased the risk of residents not being informed of risks and benefits to the vaccination and verification of resident or responsible party authorization. Findings include:

During an interview on 4/23/25 at 3:10 p.m., staff member A stated staff member D looked and could not find influenza vaccine consents or declination forms for resident #s 3, 7, 13, and 31.

Review of a facility document titled, 2024-2025 flu vax, [sic] showed resident #s 3, 7, 13, and 31 received the influenza vaccination on 10/18/24.

Review of resident #s 3, 7, 13, and 31 vaccine records did not show a vaccine consent form provided, documented, or signed by the resident or responsible parties for the influenza vaccine. The records did not have documentation of screening for medical contraindications to the vaccine or education provided prior to administration of the vaccine explaining the risks and benefits of the influenza vaccination.

A request was made to the facility on [DATE REDACTED] for influenza vaccine consent or declination forms for resident #s 3, 7, 13, and 31. No documentation was received by the end of the survey.

Review of a facility document titled, [Facility Name] Influenza Policy and Procedure, last approved June 2023, showed:

. All residents and patients will be immunized against influenza as recommended by the Advisory Committee for Immunization Practices (ACIP). The vaccine will be provided to all residents . unless medically contraindicated, or the resident or responsible party refuses .

2. Obtain informed verbal consent before the immunization is administered and will be documented on the Resident's Vaccine Administration Record.

3. An informed verbal consent may be obtained by giving the resident, patient, or responsible party a copy of

the current Vaccine Information Statement (VIS) and by providing an opportunity for their questions to be answered.

4. If the resident or patient or responsible party refuses an immunization, it should be documented in the permanent medical record. The resident or responsible party should be provided with an educations program and the immunization offered again .

5. The resident or patient will be screened for contraindications before each dose of vaccine is given. All contraindications will be recorded in the permanent record . [sic]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 11 275073