PRINTED: 01/11/2021

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB 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 ______________________

C
275132 B. WING _____________________________
12/14/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1305 E 7TH ST
WHITEFISH CARE AND REHABILITATION
WHITEFISH, MT 59937

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

F 000 INITIAL COMMENTS F 000

A Complaint survey was completed on 12/14/20.

Facility Reported Incidents were not investigated
during the survey.

The facility census on entrance was 53.

DEFICIENCIES CITED:

Deficient practices were cited for the Complaint

survey.

Deficient practices were cited for the complaint(s)

with Intake number(s): MT000048954 and
MT000049292.

DEFICIENCIES NOT CITED:

Refer to FORM CMS-2567; Event ID: QQMB11
for unsubstantiated findings.
Deficient practices were NOT cited for the
complaint(s) with Intake number(s):
MT000049779, MT000048666, MT000049218,
MT000049225.

Glossary

DON Director of Nursing

PRN As Needed
MAR Medication Administration Record
MG Milligrams
RN Registered Nurse
QA Quality Assurance
q Every
F 608 Reporting of Reasonable Suspicion of a Crime F 608 1/6/21
SS=D CFR(s): 483.12(b)(5)(i)-(iii)

§483.12(b) The facility must develop and

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Electronically Signed 01/07/2021

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.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 08MO11 Facility ID: MT275132 If continuation sheet Page 1 of 18
 PRINTED: 01/11/2021
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB 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 ______________________

C
275132 B. WING _____________________________
12/14/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1305 E 7TH ST
WHITEFISH CARE AND REHABILITATION
WHITEFISH, MT 59937

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

F 608 Continued From page 1 F 608

implement written policies and procedures that:

§483.12(b)(5) Ensure reporting of crimes

occurring in federally-funded long-term care
facilities in accordance with section 1150B of the
Act. The policies and procedures must include
but are not limited to the following elements.
(i) Annually notifying covered individuals, as
defined at section 1150B(a)(3) of the Act, of that
individual's obligation to comply with the following
reporting requirements.
(A) Each covered individual shall report to the
State Agency and one or more law enforcement
entities for the political subdivision in which the
facility is located any reasonable suspicion of a
crime against any individual who is a resident of,
or is receiving care from, the facility.
(B) Each covered individual shall report
immediately, but not later than 2 hours after
forming the suspicion, if the events that cause the
suspicion result in serious bodily injury, or not
later than 24 hours if the events that cause the
suspicion do not result in serious bodily injury.
(ii) Posting a conspicuous notice of employee
rights, as defined at section 1150B(d)(3) of the
Act.
(iii) Prohibiting and preventing retaliation, as
defined at section 1150B(d)(1) and (2) of the Act.
This REQUIREMENT is not met as evidenced
by:
Based on interview and record review, the facility PREPARATION AND EXECUTION OF
failed to report the suspicion of a crime of THIS RESPONSE AND PLAN OF
misappropriation of oxycodone to the State CORRECTION DOES NOT
Survey Agency, investigate thoroughly, and CONSTITUTE AN ADMISSION OR
develop policies and implement procedures to AGREEMENT
prevent a similar event from recurring. This had BY THE PROVIDER OF THE TRUTH OF
the potential to affect all residents with an THE FACTS ALLEGED OR
oxycodone medication order. Findings include: CONCLUSIONS SET FORTH IN THE
STATEMENT OF DEFICIENCIES. THE
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 08MO11 Facility ID: MT275132 If continuation sheet Page 2 of 18

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
275132
NAME OF PROVIDER OR SUPPLIER
WHITEFISH CARE AND REHABILITATION
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
TAG
F 608 Continued From page 2
During an interview on 12/8/20 at 10:15 a.m.,
staff member A stated there was an instance of
drug diversion reported to the police, and a prior
DON handled the situation, as staff member A
was returning from another building at the time of
the discovery of the narcotic medication count
being off.
During an interview on 12/8/20 at 11:46 a.m., staff
member D stated nurses have access to the
"Cubex" machine which was utilized as an ekit.
To get narcotics out of the ekit, there needed to
be a code which two nurses had access to. Staff
member D stated narcotic reconciliation, or the
auditing of narcotics and PRN (as needed)
medications, was not something she was aware
of that needed to be done, other than to sign out
on the narcotics book.
During an interview on 12/9/20 at 2:42 p.m., staff
member A stated NF5 was no longer working at
the facility as of 7/30/20, after the narcotics count
was "off by a lot," and the three nurses working
during that time were drug tested. NF5 was found
to have oxycodone in her system from the drug
test, but claimed it was a prescription. Staff
member A stated he contacted the local police,
and contacted the nursing board after the police
told him to take that step, which would help their
investigation. Staff member A stated he did not
report the events to the State Survey Agency as
he was not aware he had to, because the police
took over the investigation. Staff member A stated
there was no way to tell which residents'
medications were taken, and none of the
residents had missed a medication that day. Staff
member A stated NF5 was a traveler (contracted
staff), and the agency was supposed to, and said
they had, completed a background check and
FORM CMS-2567(02-99) Previous Versions Obsolete
PRINTED: 01/11/2021
FORM APPROVED
OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
COMPLETED
A. BUILDING ______________________
C
B. WING _____________________________
12/14/2020
STREET ADDRESS, CITY, STATE, ZIP CODE
1305 E 7TH ST
WHITEFISH, MT 59937
ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG
DEFICIENCY)
F 608
PLAN OF CORRECTION IS PREPARED
AND/OR EXECUTED SOLELY
BECAUSE IT IS REQUIRED BY THE
PROVISIONS OF FEDERAL AND STATE
LAW. FOR THE PURPOSES OF ANY
ALLEGATION THAT THE FACILITY IS
NOT IN SUBSTANTIAL COMPLIANCE
WITH FEDERAL REQUIREMENTS
OF PARTICIPATION, THIS RESPONSE
AND PLAN OF CORRECTION
CONSTITUTES THE FACILITY'S
ALLEGATION OF COMPLIANCE IN
ACCORDANCE WITH SECTION 42
C.F.R. §488.18 AND SECTION 7317A OF
THE STATE OPERATIONS MANUAL.
1. No residents were named in the
alleged deficient practice.
2. The facility was provided an abuse
policy and investigation tools by the
contracted Clinical Consultants at the time
of the survey.
3. Beginning on 11/18/2020 the
contracted clinical consultants provided
education to the facility IDT on the
reporting requirements for abuse,
investigations of alleged abuse, and the
abuse policy. The policy includes hiring
practices and review of licensure and
background checks to be completed prior
to staff starting work. The facility
implemented a Master Signature Log for
clinical staff. Nurses were reeducated,
beginning on 1/5/2021, on the
requirement to complete a shift to shift
narcotic count at the end of each shift or
all narcotics and the need to report any
discrepancies to the DON or NHA
immediately. Any event that meets the
Event ID: 08MO11 Facility ID: MT275132 If continuation sheet Page 3 of 18
 PRINTED: 01/11/2021
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB 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 ______________________

C
275132 B. WING _____________________________
12/14/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1305 E 7TH ST
WHITEFISH CARE AND REHABILITATION
WHITEFISH, MT 59937

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

F 608 Continued From page 3 F 608

other pre-employment screening processes. criteria to be reported to the survey
Without these, the contracted staff member agency for a reasonable suspicion of a
would not be able to work at the facility. Staff crime will be reviewed in the daily stand
member A attempted to contact the police up meeting to ensure that an investigation
detective assigned to the narcotic theft case has been completed and that the event
during the survey, to obtain information on the was reported to the state survey agency.
case, and staff member A was given a number A weekly audit of narcotic count sheets
and case identification number, but no other will be conducted by the DON or designee
information was given due to the ongoing open for 1 month and then monthly for 2
criminal investigation status. additional months to ensure that nurses
are completing the shift to shift
During an interview on 12/10/20 at 2:10 p.m., reconciliation.
staff member G stated when doing the narcotics 4. The NHA or designee will provide a
count, the nurse at shift change was to count with report of state reportable events to the
the nurse who was leaving the shift. Staff QAPI committee monthly for 3 months for
member G stated one nurse was to have the review or until substantial compliance is
narcotic count book, and flip to each page as the determined by the committee. The DON
other nurse counted the medications in the cart, or designee will report the results of the
to make sure the information and medications narcotic count audits to the QAPI
matched, and then the nurses would sign at the committee monthly for 3 months for
back of the book. Staff member G stated the review or until substantial compliance is
facility was not having an issue recently with determined by the committee.
narcotic counts, and the responsibility of auditing
or reconciling narcotics has not been a duty given
to her.

Record review of facility reported incidents

showed the facility did not have documentation to
show administration self-reported the suspicion of
a crime for drug diversion to the State Survey
Agency.

Record review of the facility narcotic books

showed the pages used in the narcotic book, for
the narcotic shift change count, did not include
the signatures of the second nurse for the
verification of the narcotic counts for July and
August 2020. The days missing information and
concerns included:
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 08MO11 Facility ID: MT275132 If continuation sheet Page 4 of 18
 PRINTED: 01/11/2021
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB 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 ______________________

C
275132 B. WING _____________________________
12/14/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1305 E 7TH ST
WHITEFISH CARE AND REHABILITATION
WHITEFISH, MT 59937

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

F 608 Continued From page 4 F 608

-July 2020 - the 6th, 13, 21, 23, 26, 30, and 31st
-August 2020 - the 2nd, 4, 7 (2 times), 8, 9, 12,
13 (2 times), 17, and 19th (2 times)
-The facility did not have a master signature list
for nurses for the narcotics books
-None of the narcotic books included
documentation notes as to why there were
missing signatures and reasoning for missing
narcotics

Record review of facility policy, which was

provided for abuse, neglect, and
misappropriation, was the policy for Abuse
Investigations. The policy did not show criteria
specifying what the local authorities constituted
as a crime, which was to be reported, or the
required criteria for abuse prevention and policy
implementation.

Record review of the facility nursing license

verification information showed NF5 had her RN
license suspended by the state nursing board in
2016 for misappropriation of patient or other
property, was unable to practice safely by reason
of physical illness or impairment, narcotics
violation or other violation of drug statutes, and
diversion of a controlled substance. The sanction
was for misappropriating approximately 6,180
oxycodone and other medications from a
previous employer, said to be for personal use.
The RN license was reinstated in 2017.
F 658 Services Provided Meet Professional Standards F 658 1/6/21
SS=E CFR(s): 483.21(b)(3)(i)

§483.21(b)(3) Comprehensive Care Plans

The services provided or arranged by the facility,
as outlined by the comprehensive care plan,

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 08MO11 Facility ID: MT275132 If continuation sheet Page 5 of 18

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
275132
NAME OF PROVIDER OR SUPPLIER
WHITEFISH CARE AND REHABILITATION
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
TAG
F 658 Continued From page 5
must-
(i) Meet professional standards of quality.
This REQUIREMENT is not met as evidenced
by:
Based on observation, interview, and record
review, the facility failed to order, manage, and
provide PRN pain medications within the
accepted standards of practice for 3 (#s 2, 3, and
4) of 11 sampled residents. Findings include:
During an observation on 12/7/20 at 1:45 p.m.,
resident #4 requested and was given a prn
Percocet pain medication. Resident #4 had
self-propelled up to the nurse in a wheelchair,
smiling and showing no outward signs of pain or
distress.
During an interview on 12/8/20 at 11:46 a.m., staff
member D stated the pharmacy has a system in
place for ordering and retrieving medications from
the "Cubex" machine for the nurses, but was not
sure who did QA audits of the medication
reconciliation, as it had not fallen on her to do this
on her shifts.
During an interview on 12/8/20 at 12:45 p.m.,
NF3 stated there was "nothing in place," no
consistency, or direction from management for
nursing systems, such as medication
management, when she worked at the facility.
During an interview on 12/9/20 at 10:12 a.m.,
staff member B stated the facility was in the
process of fixing some of the facility systems,
including for medications. Staff member B stated
the facility's first psychotropic meeting had
occurred the day prior, and a lot of changes were
made to psychotropic medication orders. Staff
member B stated, for pain medications, concerns
FORM CMS-2567(02-99) Previous Versions Obsolete
PRINTED: 01/11/2021
FORM APPROVED
OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
COMPLETED
A. BUILDING ______________________
C
B. WING _____________________________
12/14/2020
STREET ADDRESS, CITY, STATE, ZIP CODE
1305 E 7TH ST
WHITEFISH, MT 59937
ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG
DEFICIENCY)
F 658
PREPARATION AND EXECUTION OF
THIS RESPONSE AND PLAN OF
CORRECTION DOES NOT
CONSTITUTE AN ADMISSION OR
AGREEMENT
BY THE PROVIDER OF THE TRUTH OF
THE FACTS ALLEGED OR
CONCLUSIONS SET FORTH IN THE
STATEMENT OF DEFICIENCIES. THE
PLAN OF CORRECTION IS PREPARED
AND/OR EXECUTED SOLELY
BECAUSE IT IS REQUIRED BY THE
PROVISIONS OF FEDERAL AND STATE
LAW. FOR THE PURPOSES OF ANY
ALLEGATION THAT THE FACILITY IS
NOT IN SUBSTANTIAL COMPLIANCE
WITH FEDERAL REQUIREMENTS
OF PARTICIPATION, THIS RESPONSE
AND PLAN OF CORRECTION
CONSTITUTES THE FACILITY'S
ALLEGATION OF COMPLIANCE IN
ACCORDANCE WITH SECTION 42
C.F.R. §488.18 AND SECTION 7317A OF
THE STATE OPERATIONS MANUAL.
1. Parameters for PRN narcotic orders
were put into place for resident #3 and #4
on 12/8/2020. Resident #2 no longer
resides in the facility.
2. Other PRN pain medication orders
were reviewed and updated to include
parameters that are based on giving when
pain is rated at a specific pain level.
3. Nurses were educated, beginning on
Event ID: 08MO11 Facility ID: MT275132 If continuation sheet Page 6 of 18
 PRINTED: 01/11/2021
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB 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 ______________________

C
275132 B. WING _____________________________
12/14/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1305 E 7TH ST
WHITEFISH CARE AND REHABILITATION
WHITEFISH, MT 59937

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

F 658 Continued From page 6 F 658

were noticed during some chart reviews and 1/5/2021, on the importance of following
entered on the "pre-survey" document to work on. parameters for PRN orders and to
document the current reported pain level
During an interview and observation on 12/9/20 at at the time of administration. The DON or
11:20 a.m., staff member B showed the designee will review PRN usage weekly
"pre-survey" document with an example a for 3 months to ensure ongoing
resident where the prn pain medication order was compliance with parameters and notify the
adjusted to include assessing for alcohol MD of the need to review for potential
consumption before giving the pain medication. changes of pain regimens based on the
Pain medication was listed on the document, but MDs clinical assessment.
there was not a full PIP (performance 4. The DON or designee will report the
improvement plan) or goals set for the system results of the PRN usage audits to the
improvements, which would be reviewed and QAPI committee monthly for 3 months or
changed related to the prn usage of medications. until substantial compliance is determined
by the committee.
During an interview on 12/10/20 at 12:35 p.m.,
staff member M stated the pharmacy had controls
in place to prevent errors, and no issues with
medications while they were in the pharmacy
possession. Staff member M stated narcotics are
packaged separately and the pharmacy sent
enough for the order, and the system would flag
(warning) if it was reordered too soon by the
facility. Staff member M stated the pharmacy
does chart reviews monthly for the residents, but
PRN use and reviewing the MAR's were not a
part of the reviews, as it would not be feasible to
do.

During an interview on 12/10/20 at 2:10 p.m.,

staff member G stated, as a floor nurse she
follows physician orders, signs out, and gives
PRN medications. She stated residents would
ask for the prn medications as the residents know
what they are able to get, and when, so
completing the assessment was hard. Staff
member G stated for prn medication use, the
nurse could request an adjustment, but she was
unsure who reviewed or audited the MARs for
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 08MO11 Facility ID: MT275132 If continuation sheet Page 7 of 18
 PRINTED: 01/11/2021
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB 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 ______________________

C
275132 B. WING _____________________________
12/14/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1305 E 7TH ST
WHITEFISH CARE AND REHABILITATION
WHITEFISH, MT 59937

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

F 658 Continued From page 7 F 658

any changes or concerns.

a. Record review of resident #2's MAR for

November 2020 showed:

-"oxyCODONE HCl tablet 10MG Give 1 tablet by

mouth every 4 hours as needed for pain." Start
date of 11/06/20 and discontinue date 12/07/20.
The medication was administered 17 times with a
pain level of "0" (meaning no pain) recorded. The
medication was documented as given a total of
95 times.

-PRN Tylenol, Lidoderm Patch, and Biofreeze Gel

were not used.

Record review of resident #2's MAR for 12/1/20-

12/9/20 showed:

-"oxyCODONE HCl tablet 10MG Give 1 tablet by

mouth every 4 hours as needed for pain." Start
date of 11/06/20 and discontinue date 12/07/20.
The medication was given 29 times, 8 times with
a pain level of "0" (no pain) recorded.

-"oxyCODONE HCl tablet 10MG Give 1 tablet by

mouth every 4 hours as needed for pain rate at
7-10." Start date of 12/7/20. Given 7 times, 2
times with a pain level of "0," no pain.

-PRN Tylenol, Lidoderm patch, and Biofreeze gel

were not used.

b. Record review of resident #3s MAR for

October 2020:

-PRN oxyCODONE administered 10 times with a

pain level 0 recorded and administered a total of
111 times.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 08MO11 Facility ID: MT275132 If continuation sheet Page 8 of 18
 PRINTED: 01/11/2021
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB 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 ______________________

C
275132 B. WING _____________________________
12/14/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1305 E 7TH ST
WHITEFISH CARE AND REHABILITATION
WHITEFISH, MT 59937

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

F 658 Continued From page 8 F 658

-PRN medication of Tylenol was not used.

Record review of resident #3's MAR for

November 2020:

-PRN oxyCODONE administered 13 times with a

pain level documented at "0" (no pain) and given
a total of 119 times.

-PRN Tylenol was not used.

c. Record review of resident #4's MAR for

October 2020 showed:

-"Percocet Tablet 10-325 MG

(oxyCODONE-Acetaminophen) Give 1 tablet by
mouth every 4 hours as needed for pain" with a
start date of 10/8/20 and discontinue date of
12/4/20 was administered 15 times with pain level
of "0" (no pain) and a total of 135 times.

-PRN Ibuprofen not used.

-PRN Acetaminophen given two times, 1 of them

a pain level of "0" was recorded.

Record review of resident #4's MAR for

November 2020 showed:

-"oxyCODONE HCl tablet 5 MG give 2 tablet by

mouth every 4 hours as needed for pain
administer 1-2 tabs q 4 hours as needed" with a
start date of 11/6/20 given 21 times.

-"Percocet Tablet 10-325 MG

(oxyCODONE-Acetaminophen) Give 1 tablet by
mouth every 4 hours as needed for pain" with a
start date of 10/8/20 and discontinue date of
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 08MO11 Facility ID: MT275132 If continuation sheet Page 9 of 18
 PRINTED: 01/11/2021
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB 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 ______________________

C
275132 B. WING _____________________________
12/14/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1305 E 7TH ST
WHITEFISH CARE AND REHABILITATION
WHITEFISH, MT 59937

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

F 658 Continued From page 9 F 658

12/4/20 was administered 125 times with 18
being reported with a pain level of "0," no pain.

-PRN Acetaminophen was given twice.

-PRN Ibuprofen was given once with pain level of

"0" documented.

Record review of resident #4's MAR for

12/1/20-12/7/20 showed:

-"Percocet Tablet 10-325 MG

(oxyCODONE-Acetaminophen) Give 1 tablet by
mouth every 4 hours as needed for pain" with a
start date of 10/8/20 and discontinue date of
12/4/20 administered 18 times, 11 of the times
with a pain level 0 recorded.

-"Percocet Tablet 10-325 MG

(oxyCODONE-Acetaminophen) Give 1 tablet by
mouth every 4 hours as needed for pain please
assess resident for use of alcohol before
administering medication. Resident not to have
pain medication if intoxicated" with a start date of
12/4/20. Administered 12 times with 7 having a
pain level 0 recorded.

-"oxyCODONE HCl tablet 5 MG give 2 tablets by

mouth every 4 hours as needed for pain
administer 1-2 tabs q 4 hours as needed" with a
start date of 11/6/20 given two times.

-PRN Ibuprofen and Acetaminophen were not

used.

Record review of the facility policy Pain

Management and Assessment showed, "Pain
management interventions shall reflect the
sources, type, and severity of pain." Under the
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 08MO11 Facility ID: MT275132 If continuation sheet Page 10 of 18
 PRINTED: 01/11/2021
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB 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 ______________________

C
275132 B. WING _____________________________
12/14/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1305 E 7TH ST
WHITEFISH CARE AND REHABILITATION
WHITEFISH, MT 59937

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

F 658 Continued From page 10 F 658

heading, Monitoring and Modifying Approaches
showed, "If pain is not adequately controlled, the
multidisciplinary team, including the physician,
shall reconsider approaches and make
adjustments as indicated. If pain symptoms have
resolved or there is no longer an indication for
pain medication, the multidisciplinary team and
physician shall try to discontinue or taper
analgesic medications to the extent possible."
F 676 Activities Daily Living (ADLs)/Mntn Abilities F 676 1/6/21
SS=D CFR(s): 483.24(a)(1)(b)(1)-(5)(i)-(iii)

§483.24(a) Based on the comprehensive

assessment of a resident and consistent with the
resident's needs and choices, the facility must
provide the necessary care and services to
ensure that a resident's abilities in activities of
daily living do not diminish unless circumstances
of the individual's clinical condition demonstrate
that such diminution was unavoidable. This
includes the facility ensuring that:

§483.24(a)(1) A resident is given the appropriate

treatment and services to maintain or improve his
or her ability to carry out the activities of daily
living, including those specified in paragraph (b)
of this section ...

§483.24(b) Activities of daily living.

The facility must provide care and services in
accordance with paragraph (a) for the following
activities of daily living:

§483.24(b)(1) Hygiene -bathing, dressing,

grooming, and oral care,

§483.24(b)(2) Mobility-transfer and ambulation,

including walking,

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 08MO11 Facility ID: MT275132 If continuation sheet Page 11 of 18
 PRINTED: 01/11/2021
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB 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 ______________________

C
275132 B. WING _____________________________
12/14/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1305 E 7TH ST
WHITEFISH CARE AND REHABILITATION
WHITEFISH, MT 59937

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

F 676 Continued From page 11 F 676

§483.24(b)(3) Elimination-toileting,

§483.24(b)(4) Dining-eating, including meals and

snacks,

§483.24(b)(5) Communication, including

(i) Speech,
(ii) Language,
(iii) Other functional communication systems.
This REQUIREMENT is not met as evidenced
by:
Based on observation, record review, and PREPARATION AND EXECUTION OF
interview, the facility failed to provide restorative THIS RESPONSE AND PLAN OF
services to maintain activities of daily living for CORRECTION DOES NOT
eating, transfers, and mobility for 1 (#3) of 11 CONSTITUTE AN ADMISSION OR
sampled residents. Findings include: AGREEMENT
BY THE PROVIDER OF THE TRUTH OF
During an observation and interview on 12/8/20 at THE FACTS ALLEGED OR
12:23 p.m., resident #3 stated, "We don't have CONCLUSIONS SET FORTH IN THE
any restorative here. Only if they have time, which STATEMENT OF DEFICIENCIES. THE
is never. That is why I am this way." Resident #3 PLAN OF CORRECTION IS PREPARED
raised her arms, showing her contracted hands, AND/OR EXECUTED SOLELY
which were propped open with molded braces. BECAUSE IT IS REQUIRED BY THE
Resident #3 said she had a physician's order for PROVISIONS OF FEDERAL AND STATE
ROM (range of motion), daily. "It never happens." LAW. FOR THE PURPOSES OF ANY
"I love when my legs can be stretched out. I get ALLEGATION THAT THE FACILITY IS
spasms in my legs." NOT IN SUBSTANTIAL COMPLIANCE
WITH FEDERAL REQUIREMENTS
Review of resident #3's documented restorative OF PARTICIPATION, THIS RESPONSE
cares for 12/1/20 through 12/8/20 showed the AND PLAN OF CORRECTION
resident received restorative cares every shift for CONSTITUTES THE FACILITY'S
passive range of motion to the bilateral lower ALLEGATION OF COMPLIANCE IN
extremities on 12/1/20 and 12/7/20, and passive ACCORDANCE WITH SECTION 42
ROM for the bilateral upper extremities on C.F.R. §488.18 AND SECTION 7317A OF
12/1/20 and 12/7/20. THE STATE OPERATIONS MANUAL.

Review of 11/1/20-11/30/20 documented cares 1. Resident #3 is currently being seen by

showed resident #3 was to receive stretching and outpatient therapy. The facility will
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 08MO11 Facility ID: MT275132 If continuation sheet Page 12 of 18
 PRINTED: 01/11/2021
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB 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 ______________________

C
275132 B. WING _____________________________
12/14/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1305 E 7TH ST
WHITEFISH CARE AND REHABILITATION
WHITEFISH, MT 59937

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

F 676 Continued From page 12 F 676

ROM each day. Resident #3 received the care collaborate with the outpatient clinic to
11/1, 11/3-14, 11/17, 11/19-26, and 11/30/20. develop an appropriate plan of treatment
and any recommendations by the
Review of resident #3's documented restorative outpatient clinic for a restorative nursing
cares for 10/1/20-10/31/20 showed the resident program.
was to receive stretching and ROM each day. 2. Other residents that require
Resident #3 received cares on 10/1/20 and then assistance with ADL’s or have the
10/7010/31. potential for a decline in ADLs will be
screened by the therapy department to
Review of resident #3's care plan, initially dated develop an individualized and appropriate
11/17/18, with a revision on 5/8/20, showed restorative nursing program.
resident #3 was to receive restorative passive, 3. The Director of Therapy and the DON
active, and assisted range of motion with CNA were educated by the contracted clinical
(certified nursing assistant) assist, related to the consultants on the process for identifying
loss of range of motion in functional deterioration and assessing residents who have had a
with muscle weakness and paraplegia. decline or would benefit from a restorative
Restorative Nursing program to be used for program on 12/21/2020. The process
passive range of motion for stretching with includes nursing referrals to therapy for a
straight leg raise, heel slides, knee flex, ankle decline, routine screening by therapy,
dorsi, hip internal/external rotation, abduction, therapy recommendations for programs,
adduction, QD (four times daily) as tolerated. care planning, competencies for nursing
staff and documentation. The DON or
Review of the facility policy, Activities of Daily designee and the Director of therapy will
Living (ADL) Supporting, revised 3/2018, showed meet weekly for 1 month and then
the residents will be provided with care, treatment monthly to review active restorative
and services as appropriate to maintain or referrals and programs to ensure the
improve their ability to carry out ADLs so ADLs do system is in place. The DON or designee
not diminish. Appropriate care and services were will audit documentation of any restorative
to be provided for residents, including support programs weekly for 3 months to ensure
and assistance. that programs are being followed.
4. The results of the audits will be
Review of the facility policy, Restorative Nursing reported to the QAPI committee by the
Services, revised 7/2017, showed the services DON or designee monthly for 3 months or
consist of nursing interventions to help promote until substantial compliance is determined
optimal safety and independence. Resident would by the committee.
receive restorative nursing care as needed.

During a meeting on 12/9/20 at 10:03 a.m., staff

member B stated, "Restorative is nonexistent,
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 08MO11 Facility ID: MT275132 If continuation sheet Page 13 of 18
 PRINTED: 01/11/2021
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB 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 ______________________

C
275132 B. WING _____________________________
12/14/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1305 E 7TH ST
WHITEFISH CARE AND REHABILITATION
WHITEFISH, MT 59937

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

F 676 Continued From page 13 F 676

really, at this time." "Therapies are picking up as
they can. But that is if the resident has a
physician's order and their insurance covers."

During a meeting on 12/10/20 at 11:38 a.m., staff

member N stated physical therapy was working
with residents having a physician's order for
therapy, but the department did not do restorative
care, "That is nursing's department." If the
resident's insurance covered therapies, then the
therapy department worked with the resident.
When the resident would plateau at the "nursing
home level," maximum level, the resident was
discharged from therapy services.
F 684 Quality of Care F 684 1/6/21
SS=G CFR(s): 483.25

§ 483.25 Quality of care

Quality of care is a fundamental principle that
applies to all treatment and care provided to
facility residents. Based on the comprehensive
assessment of a resident, the facility must ensure
that residents receive treatment and care in
accordance with professional standards of
practice, the comprehensive person-centered
care plan, and the residents' choices.
This REQUIREMENT is not met as evidenced
by:
Based on interview, and record review, the PREPARATION AND EXECUTION OF
facility nursing staff failed to ensure an x-ray was THIS RESPONSE AND PLAN OF
performed in a timely manner, using the CORRECTION DOES NOT
emergency room at the hospital, and the CONSTITUTE AN ADMISSION OR
physician orders provided the next morning, for 1 AGREEMENT
(#3) of 11 sampled residents. Findings include: BY THE PROVIDER OF THE TRUTH OF
THE FACTS ALLEGED OR
During an interview on 12/8/20 at 12:23 p.m., CONCLUSIONS SET FORTH IN THE
resident #3 stated she caught her foot in the STATEMENT OF DEFICIENCIES. THE
wheelchair and fell to the floor, while transferring. PLAN OF CORRECTION IS PREPARED

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 08MO11 Facility ID: MT275132 If continuation sheet Page 14 of 18

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
275132
NAME OF PROVIDER OR SUPPLIER
WHITEFISH CARE AND REHABILITATION
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
TAG
F 684 Continued From page 14
Only one CNA was assisting. The CNA was
unable to stop resident #3 from falling out of her
chair to the floor. Resident #3 stated she had
terrible pain in her left ankle right after the
accident happened. Resident #3 said the facility
did not have x-rays taken in a timely manner.
Resident #3 said it took five days to get an x-ray
taken of her ankle. Through the x-rays, resident
#3 found out she broke her left ankle.
Review of resident #3's care plan, with a revision
date of 5/8/20, showed, "Transfers: Provide me
with total assist of 2 for transfers using a hoyer
lift."
Review of a nurse progress note, dated 9/10/20,
showed an evaluation was completed on 9/10/20
earlier at 2:27 p.m., that day. The evaluation
showed, "Scale: Intake: Output: Resident
complains of pain. Pain Description: Pain: 8
(hurts whole lot). Reports that pain is constant.
Cool compress applied. Relaxation techniques
encouraged. Distraction techniques utilized.
Resident position changed. Non-medication
interventions did not provide relief. PRN
medication provided..."
Review of a Neurologic Focused Evaluation dated
9/10/20 at 5:25 p.m. showed resident #3
complained of pain, at a pain level of an 8 out of
10, with 10 being the worst pain at 4:00 p.m.
Resident #3 was medicated for pain.
Review of a Pain Evaluation for resident #3, with
an effective date of 9/10/20 at 5:25 p.m. showed
resident #3 had an onset of sharp pain, "radiating
from the distal medial tibia," of the left ankle.
Resident #3 verbally stated frequent significant
pain, rated at 8 (hurts a whole lot), with an
FORM CMS-2567(02-99) Previous Versions Obsolete
PRINTED: 01/11/2021
FORM APPROVED
OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
COMPLETED
A. BUILDING ______________________
C
B. WING _____________________________
12/14/2020
STREET ADDRESS, CITY, STATE, ZIP CODE
1305 E 7TH ST
WHITEFISH, MT 59937
ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG
DEFICIENCY)
F 684
AND/OR EXECUTED SOLELY
BECAUSE IT IS REQUIRED BY THE
PROVISIONS OF FEDERAL AND STATE
LAW. FOR THE PURPOSES OF ANY
ALLEGATION THAT THE FACILITY IS
NOT IN SUBSTANTIAL COMPLIANCE
WITH FEDERAL REQUIREMENTS
OF PARTICIPATION, THIS RESPONSE
AND PLAN OF CORRECTION
CONSTITUTES THE FACILITY'S
ALLEGATION OF COMPLIANCE IN
ACCORDANCE WITH SECTION 42
C.F.R. §488.18 AND SECTION 7317A OF
THE STATE OPERATIONS MANUAL.
1. Resident #3 has had no change in
level of function from prior to the fracture
and condition is stable.
2. Other residents who reside in the
facility who have x rays ordered have the
potential to be affected by the alleged
deficient practice.
3. Nurses were educated, beginning on
1/5/2021,on the need to notify the MD and
DON if x ray services are not available in
a timely manner and document any new
orders or treatment plans. The DON or
designee will review orders daily for new
orders for x rays and audit that results are
received timely to ensure there is not a
delay in treatment. The audits will occur
daily for 1 month and then weekly for 2
additional months
4. The results of the audits will be
reported to the QAPI committee monthly
for 3 months or until substantial
compliance is determined by the
committee.
Event ID: 08MO11 Facility ID: MT275132 If continuation sheet Page 15 of 18
 PRINTED: 01/11/2021
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB 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 ______________________

C
275132 B. WING _____________________________
12/14/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1305 E 7TH ST
WHITEFISH CARE AND REHABILITATION
WHITEFISH, MT 59937

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

F 684 Continued From page 15 F 684

acceptable rate at 5. Routine medication and
PRN (as needed) were given for the pain. After
time elapsed, from implementation of the
medication, the writer documented, "nothing
relieves all pain."

Review of the physician's verbal order, dated

9/10/20 at 8:29 p.m., showed resident #3 was to
have a "foot/ankle x-ray one time only for possible
foot trauma for 1 Day."

Review of resident #3's progress notes, dated

9/10/2020 at 10:05 p.m. showed: "During a
wheelchair-to-bed transfer, res attempted to
readjust her positioning causing her to slide to the
floor. The CNA present was able to help her land
gently and placed her in a safe position on the
floor. The CNA then reached out for help to
properly maneuver the manlift and place her back
in bed. After the incident, the resident began to
feel a sharp pain in her L ankle. Ice was applied.
The ankle was visually inspected. [Resident #3's
provider] requested an X-ray to be taken on
9/11/2020..."

Review of the physician's verbal order, dated

9/12/20 at 8:51 a.m., showed resident #3 was to
have two x-ray views of the left ankle.

Review of resident #3's progress note, dated

9/12/2020 at 10:58 a.m. showed resident #3 was
complaining of pain to her left ankle. Resident #3
was unable to touch or move the area without
yelling in pain. Resident #3 told the writer that her
left ankle had hurt since her fall on Thursday
(9/10/20). The provider was notified, and an order
was obtained for the mobile x-ray to come to the
facility and x-ray the left ankle. The mobile
imaging was contacted and stated the ability to do
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 08MO11 Facility ID: MT275132 If continuation sheet Page 16 of 18
 PRINTED: 01/11/2021
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB 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 ______________________

C
275132 B. WING _____________________________
12/14/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1305 E 7TH ST
WHITEFISH CARE AND REHABILITATION
WHITEFISH, MT 59937

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

F 684 Continued From page 16 F 684

the x-ray the next day.

Review of the physician progress note, dated

9/15/20 showed resident #3 had a tibia fracture
as a result of her fall on 9/10/20. The physician
said to the fracture of the tibia with immobilization
for 6 weeks with a boot and then re-image.

During an interview on 12/9/20 at 10:03 a.m.,

staff member A stated the reason for delay in
x-ray services for resident #3 was due to the local
critical access hospital would not accept resident
#3 because she had Covid-19. The local mobile
x-ray company said they wouldn't come into the
building due to COVID-19 in the facility.

During an interview on 12/9/20 at 10:35 a.m.,

staff member N stated the mobile x-ray service
would not come into the facility when an order
was placed 9/10/20. The facility contacted the
provider who gave another order. The mobile
x-ray company returned, completing the x-ray in
the dining room of the facility.

Review of all resident #3's records showed no

contact physically or verbally with the local critical
access hospital, the local mobile x-ray services,
or the local hospital in the town located
approximately 15 miles away from the facility to
get an x-ray completed for a physician order for
resident #3. The x-rays were completed 9/15/20,
five days after the resident fell out of her
wheelchair.

Review of resident #3's care plan on falls had

been revised on 11/29/20 to include, providing
verbal cues for proper pacing and energy
conservation techniques during care so resident
does not overcorrect during assistance. There
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 08MO11 Facility ID: MT275132 If continuation sheet Page 17 of 18
 PRINTED: 01/11/2021
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB 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 ______________________

C
275132 B. WING _____________________________
12/14/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1305 E 7TH ST
WHITEFISH CARE AND REHABILITATION
WHITEFISH, MT 59937

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)

F 684 Continued From page 17 F 684

were no updates for the broken ankle which
occured during the fall on 9/10/20.

During an interview on 12/9/20 at 11:32 a.m., staff

member B stated the facility now updates all
residents' care plans following a fall. There is a
risk management interdisciplinary team which
now reviews falls.

During an interview on 12/10/20 at 11:18 a.m.,

staff member A agreed there was a delay in
receiving an x-ray for resident #3's left ankle,
after her fall on 9/10/20.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 08MO11 Facility ID: MT275132 If continuation sheet Page 18 of 18