Clark Fork Valley Nursing Home

In the surveyor’s words

From the most serious findings on record at Clark Fork Valley Nursing Home, in the surveyor’s own words.

• Actual harm, isolatedF744Feb 13, 2025

  Based on interview and record review, the facility failed to address the aggressive and intrusive behavior of a resident with dementia toward others, and she was involved in many resident-to-resident abuse events. The resident's MDSs showed various declines occurred over the period of time, and the resident's mobility, pain, incontinence level, and mood/behaviors changed during the time many of the events were identified. The facility did not report the events as abuse or investigate the events fully (Refer to F609 and F610). The facility failed to assess the resident's individualized behaviors and antecedents to them, in a proactive attempt to prevent future events or alleviate the resident's anger/frustration. […]

• No harm, potential for more than minimal, widespreadF880Feb 13, 2025

  Based on observation, interview, and record review, the facility staff failed to complete proper hand hygiene during resident medication pass, and use proper PPE when transporting dirty housekeeping equipment, to the washing machine. This deficient practice had the potential to spread infection to all residents in the facility receiving care. Findings include: During an interview and observation on 2/11/25 at 8:29 a.m., staff member G was observed while dispensing medications to the facility residents. Staff member G stated she was confused as to the correct process for when to perform hand hygiene. She said she was told to perform hand hygiene after she touched all high touch surfaces and between each resident. […]

• No harm, potential for more than minimal, patternF600Feb 13, 2025

  Based on interview and record review, the facility failed to ensure residents were free from resident to resident abuse incidents, and failed to provide protection before or following each event to prevent further resident to resident abuse, by resident #19, who was the aggressor; and, the abuse resulted in injury for 1 (#10) of 17 sampled residents and affected many others. Findings include: Review of resident #19's, electronic medical record showed the following resident to resident altercations between #19 and other residents, and #19's various behaviors exhibited towards others: a. Effective Date: 06/22/2024 12:57 Type: Behavior Note, Note Text: (resident #19) is very unsafe in her wheelchair unattended. […]

• No harm, potential for more than minimal, patternF609Feb 13, 2025

  Based on interview and record review, the facility failed to report resident to resident abuse allegations to the State Survey Agency within the required reporting period, for 1 (#19) of 17 sampled residents. The events occurred over many months and involved different residents, without staff taking appropriate action for reporting the events. Findings include: Review of resident #19's EHR showed many resident to resident interactions, to include ones of abuse, in which the resident acted out on others, often in a purposeful manner or targeting residents. Refer to F600 Abuse, for detail related to the different resident to resident incidents of abuse not reported to the State Survey Agency. […]

• No harm, potential for more than minimal, patternF610Feb 13, 2025

  Based on interview and record review, the facility failed to recognize abuse and thoroughly investigate the potential for abuse; and failed to take appropriate action to prevent and protect other residents from further resident to resident abuse events which occurred repeatedly over a period of time, for 1 (#19) of 17 sampled residents, and the resident acted out aggressively towards others to include causing minor injuries. Findings include: Review of resident #19's EHR showed many resident to resident altercations. Refer to F600 and F609 related to the concerns of abuse initiated by resident #19. […]