Whitefish Care and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Whitefish Care and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Jan 23, 2025

  Based on observation, interview, and record review, the facility failed to ensure nursing staff had the necessary skills and training for CPR for 2 (#s 1 and 3) of 26 sampled residents. Resident #s 1 and 3 expired in the facility. The facility failed to ensure a process was in place for identifying and tracking staff CPR certifications. The facility failed to obtain the supplies necessary, and ensure they were in stock and on the crash cart, for staff to perform high-quality CPR during emergent situations, which affected 2 (#s 1 and 3). […]

• Actual harm, widespreadF880Apr 13, 2022

  Based on interview and record review, the facility failed to protect residents from the transmission of COVID-19 during an outbreak, and 34 residents were found to be positive for COVID-19, to include (#s 3, 4, 5, 7, 8, 9, 12, 17, 21, 22, 23, 27, 28, 37, 38, 39, 42, 45, 47, 48, 50, 51, 52, 56, 61, 62, 63, 65, 72, 75, 77, 177, 228, 229, and 230) of 49 sampled residents; failed to ensure the Infection Prevention and Control policies and procedures were based on current national standards and reviewed at least annually; failed to ensure staff were consistently screened for symptoms of COVID-19 prior to the beginning of each shift worked; and failed to implement a surveillance plan which included ongoing analysis of data and corrective action in response to identified concerns. […]

• Actual harm, isolatedF690Mar 12, 2026

  Based on observation, interview, and record review, the facility failed to ensure there was a clinical indication for a resident's long-term use of a Foley catheter; failed to follow up timely on a physician's PRN order for changing the catheter for over four months1 in an attempt to prevent infections or complications; failed to establish a voiding pattern; and failed to ensure a comprehensive individualized care plan was developed for the resident's long term catheter use, to include goals and interventions for the monitoring and care of the catheter, for 1 (#37) of 3 residents sampled for catheter use and care. Findings include:During an observation and interview on 3/10/26 at 9:51 a.m., resident #37 had a Foley catheter bag attached to the underside of his wheelchair. […]

• Actual harm, isolatedF692Oct 22, 2025

  Based on interview and record review, the facility nursing staff failed to obtain weekly weights and failed to recognize a resident's severe weight loss for 1 (#3) of 4 sampled residents; and failed to ensure residents were monitored and tracked for maintenance of proper hydration status for 3 (#s 1, 3, and 4) of 4 sampled residents. This deficient practice contributed to resident #3's decline in weight and for the development of dehydration, requiring hospitalization for residents #1, 3, and 4. Findings include: 1. Review of resident #3's hospitalist history and physical, for the admission date of 10/3/25, showed: . […]

• Actual harm, isolatedF726Oct 22, 2025

  Based on interview and record review, the facility failed to ensure nursing staff were competent in assessing, monitoring, and recognizing clinical changes for a resident with an ongoing clinical decline for 1 (#3) of 4 sampled residents. This deficient practice resulted in the resident developing an altered mental status, dehydration, and acute renal failure which resulted in a hospitalization. Findings include: Review of resident #3's Emergency Department Note, dated 10/3/25, showed: .XXX[AGE] year-old female from a care facility presented to the ED [Emergency Department] with four days of recurrent vomiting, hypotension (systolic in the 60s-78 mmHg [millimeters of mercury]), and altered mental status. On arrival she was minimally responsive and found to be hypoxic . […]