Kalispell Rehabilitation and Nursing LLC

In the surveyor’s words

From the most serious findings on record at Kalispell Rehabilitation and Nursing LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF726Aug 28, 2024

  Based on observation, interview, and record review, the facility licensed staff member failed to provide necessary services, medically neglecting a resident's care needs, after a significant medication error occurred due to the staff member failing to follow the facility procedures for medication administration, resulting in an Immediate Jeopardy level significant medication error, for 1 (#1) resident of 3 sampled residents for medication errors. The resident had a significant decline in health, was unresponsive, had to be given Narcan, and was sent to the ER and had a hospital stay due to the failures identified. […]

• Immediate jeopardy, isolatedF760Aug 28, 2024

  Based on interview and record review the facility failed to keep 2 (#s 1 and 3) residents free from significant medication errors, of 3 sampled residents for medication errors. This deficiency resulted in an Immediate Jeopardy level deficiency for 1 (#1) resident, and interventions included medication, emergency medical care, and hospitalization , and the deficiency had the potential to cause life threatening side effects for resident #3. Findings include: On [DATE] at 12:37 p.m., the facility Regional Director of Operations, Administrator, and Director of Nursing was notified an Immediate Jeopardy situation existed for 1 (#1) resident for F726 - Residents Free from Significant Medication Errors. An acceptable plan for the removal of immediacy was provided on [DATE] at 7:32 p.m. […]

• Actual harm, isolatedF686Mar 12, 2026

  Based on interview and record review, the facility failed to reposition and facilitate ambulation for 1 (#98) and this deficient practice resulted in the development of an avoidable Stage III pressure ulcer; and the facility failed to provide necessary positioning and repositioning for skin protection and the prevention of wound development, for 3 (#s 2, 71, and 73) of 38 sampled residents. Findings include:1. A review of resident #98's skin and wound care documentation showed the nursing staff identified a reddened area on the resident's coccyx due to pressure on 9/5/25. This reddened area then developed into a Stage III pressure ulcer. During the interview on 3/10/26 at 10:19 a.m., NF3 stated resident #98 had developed wounds while residing at the facility. […]

• Actual harm, isolatedF688Mar 12, 2026

  Based on observation, interview, and record review, the facility failed to frequently encourage and facilitate ambulation for 1 (#98) of 38 sampled residents, and this contributed to resident #98 losing mobility and becoming bed-bound and developing a Stage III pressure wound. Findings include:During an interview on 3/10/26 at 10:19 a.m., NF3 stated his father was not taken care of at the facility. NF3 stated his father ambulated independently with a walker prior to a fall at home and being admitted to the hospital. NF3 stated the plan for resident #98 was to go to the facility and gain strength in order to go to an assisted living facility. While resident #98 was at the facility, NF3 stated staff would not ambulate resident #98 because he was a high fall risk and sometimes combative. […]

• Actual harm, isolatedF690Mar 12, 2026

  Based on observation, interview, and record review, the facility failed to failed to ensure proper PPE was worn, clean technique was followed, a catheter bag was emptied timely, and catheter perineal care was completed correctly for an indwelling Foley catheter for 1 (#2), and the resident had multiple urinary tract infections in the prior year; and the facility failed to provide a physician ordered catheter change(s), failed to provide proper daily site assessments and a dressing change(s), and failed to empty the catheter drainage bag timely for a resident with a Suprapubic indwelling catheter, for 1 (#15). These deficient practices increased the risk of negative urinary outcomes for all residents receiving catheter services, out of 5 sampled residents for catheter use and care. […]