Polson Health & Rehabilitation Center

Based on interview and record review, the facility failed to ensure systems were in place to prevent multiple incidents of misappropriation of a residents' medication for 9 (#s 14, 15, 16, 18, 20, 23, 38, 48, and 52) of 25 sampled residents. Findings include:Review of the facility reported incident (for alleged misappropriation of residents' medication) which was reported to the State Survey Agency on 8/24/25 at 10:00 a.m., showed a staff member reported the possible diversion of residents' medication by staff member L. An investigation into the allegations was initiated and three nurses were suspended pending the results of the investigation. During an interview on 9/22/25 at 3:30 p.m., staff member A stated the incident of misappropriation of medications was reported to him by a CNA (certified nursing assistant). The unidentified CNA stated there were two nurses that had knowledge of the medication diversion. Staff member A stated during the investigation it was discovered two nurses had suspicion of misappropriation of medications but failed to report their suspicions to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure staff members M and N reported a reasonable suspicion of a crime, related to diversion of medication, in a timely manner to administrative personnel. Findings include: Review of the facility reported incident (for failure to report a reasonable suspicion of a crime), which was reported to the State Survey Agency on 8/25/25 at 1:30 p.m., showed staff members M and N potentially failed to report a concern of possible medication diversion to leadership personnel at the facility. An investigation was initiated, and the two nurses were suspended pending the results of the investigation. The investigation showed staff member N had a conversation with staff member M at the beginning of August 2025, related to suspicion of staff member L and signs of medication diversion, but had not reported those concerns to leadership. Staff member M had suspicions of medication diversion over the course of months, but failed to relay those concerns to staff member N, until early August 2025. During an interview on 9/22/25 at 3:30 p.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure the physician was notified of a weight gain greater than 3 pounds in 2 days or 5 pounds in a week for 1 (#22) of 25 sampled residents. Findings include: During an interview on 9/24/25 at 9:39 a.m., staff member C stated the physician was to be notified of a weight gain greater than three pounds in one day for resident #22. Staff member C stated shortness of breath was a sign of weight gain. Staff member C stated it was hard to tell what was causing the weight gain for resident #22.During an interview on 9/25/25 at 9:40 a.m., staff member C stated resident #22 had edema and weight gain. Staff member C stated she would need to look up the parameters for weight gain. Staff member C stated she was not aware of any shortness of breath in resident #22.During an interview on 9/25/25 at 9:50 a.m., staff member K stated resident #22 was to be weighed every day and she was to report the weight back to the nurse. Staff member K stated she was to report any changes to the nurse.During an observation and interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews, the facility failed to answer call lights timely, for 6 (#s 9, 17, 24, 36, 39, and 202) of 13 sampled residents. Findings include: 2. During an interview on 9/10/24 at 7:52 a.m., resident #202 stated during breakfast she can wait up to 30 minutes after pushing the call button. During an interview on 9/10/24 at 7:59 a.m., resident #39 stated the average call light wait time was an hour. He stated, One time it was three hours when I fell down a couple of months ago. During an interview on 9/9/24 at 3:10 p.m., resident #17 stated the average call light wait time was ten minutes. Resident #17 stated the longest he had waited for a call light to be answered was 45 minutes, in the evening. Resident #17 stated, In the evening, I can hear them messing around and talking down the hall. Resident #17 stated, One night I was having chest pains. They took a long time, and it (the chest pain) was gone by then (the time they came). During an interview and observation on 9/10/24 at 8:15 a.m., resident #24 reported she always waits longer in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to have the advance directive for 1 (#17) of 1 resident located in the Disaster Recovery Binder, easily accessible to staff during an emergency. Findings include: Review of resident #17's EHR showed: Advance Directives. Review of resident #12's EHR showed: For Advance Directives and Code Status, see Disaster Recovery binder at nursing station. During an observation on 9/11/24 at 9:55 a.m., resident #17's POLST was not located in the disaster recovery book. During an interview and observation, on 9/11/24 at 9:58 a.m., staff member I stated, I do not see it (#17's POLST in the Disaster Recovery Binder). It would be in the B section. Staff member I stated they (staff) would have to look on Point Click Care (electronic health record) in the uploaded documents, when they explained would staff would find a resident's POLST if it was missing from the Disaster Recovery Binder. During an interview on 9/11/24 at 1:45 p.m., staff member A stated, It (#17's POLST) should have been in the book (Disaster Recovery Binder).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a resident's care plan accurately showed the resident's current non-use of interventions for a wheelchair cushion, and for bedside rails, for 1 (#37) of 13 sampled residents. Findings include: During an observation on 9/9/24 at 4:04 p.m., resident #37 was hunched over, sleeping in his wheelchair, with a thin pillow under him and his right leg on the bed. The bed was flat and had no siderails or bar attachments. During an observation and interview on 9/11/24 at 11:20 a.m., resident #37 was sitting on a pillow in his wheelchair. His bed was flat, in a low position, with no bed rails, no pillow, he had one shoe on. Resident #37 did not know what a siderail was and said he never had one, he would just stand up from his wheelchair. During an observation and interview on 9/11/24 at 9:47 a.m., staff member E stated, resident #37 never slept in his bed, only in his wheelchair, because he said the bed and recliner were uncomfortable. Staff member E went into resident #37's room and asked to see his wheelchair.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide sufficient interventions for 1 (#40) of 2 residents who had severe weight loss. Resident #40 was self-limiting her intake which contributed to the weight loss. This resident had the diagnoses: Borderline Personality Disorder, Generalized Anxiety Disorder, Major Depressive Disorder, Epilepsy, Other Drug Induced Secondary Parkinsonism, as shown in resident #40's EHR and was not consulted with psychiatry. Findings include: Review of resident #40's EHR showed resident #40 weighed 172.4 pounds on 6/4/2024, and she weighed 151.0 pounds on 9/3/2024. This was a 12.41% severe weight loss. Review of a facility provided document, Nutrition/Dietary Note, dated 9/12/24, showed: Resident shows 12.9% loss over 3 months, weight hx shows resident weight of 172.4# on 6/4/24 and weight of 145.1# on 7/9. Between these weight recordings resident was discharged from facility due in part to mental health concerns and weight on 7/9 . [sic] Review of resident #40's EHR showed the following weights: - 3/4/24 weighed 177.6…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to follow physician orders to change oxygen tubing for 1 (#34) of 3 sampled residents. This increased the potential for respiratory infection and medical decline. Findings include: During an observation on 9/9/24 at 3:46 p.m., resident #34's oxygen tubing on the portable tank was dated with a piece of tape dated 8/11/24. The tubing on the concentrator being used by resident #34, at that time, was also dated 8/11/24. A review of resident #34's physician's order, dated 3/23/24, showed, O2 tubing to be changed Q2 weeks and prn. During an interview on 9/11/24 at 9:58 a.m., staff member E stated the treatment book has the changes scheduled for the night shift. She stated, It gets charted in TAR when changed. Sometimes the nurse will change it or sometimes the nurse may delegate the task to a CNA. During an observation on 9/11/24 at 10:30 a.m., the tape on the oxygen tubing for resident #34 still read 8/11/24, for both the concentrator, and the portable tank. During an interview on 9/12/24 at 8:40 a.m., staff member…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to have and maintain a sanitary kitchen, staff failed to follow hygienic practices, and failed to take and record temperatures for food storage and for food during meal service. These deficient practices had the potential to affect all residents consuming food from the facility kitchen. Findings include: A. Sanitary Kitchen During an observation of the facility kitchen on 5/18/24 at 11:53 a.m., multiple areas of concern for cleanliness showed: - A large window located above the meal serving line and clean dishes was opened several inches and had a buildup of grey and brown dust on it. - A standing black fan, not in current use, had the blades and wire cage covered in grey and brown dust. - The ceiling air vents, ceiling, and the wall over the cooking area were covered in grey and black dust buildup. - The refrigerator labeled, Kitchen's Fridge had chocolate syrup splashed over the top shelf wall and door. The bottom two drawers had an orange congealed substance in them. - An unopened, thickened apple juice was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an injury of unknown origin to the State Survey Agency for 1 (#9) in the required timeframe; and failed to report incident findings to the State Survey Agency within the five-day required time frame, for 5 (#s 1, 5, 8, 10, and 11) of 11 sampled residents. Findings include: 1. Review of a facility reported incident, occurring on 4/8/24, showed resident #9 went to another facility for a follow up MRI, as the resident had previous back issues, and a T11 (thoracic) fracture was found. The facility was not sure if the fracture was old or new. The facility reported this fracture as an injury of unknown origin, to the State Survey Agency, on 4/10/24, two days after the facility was notified of the results. Review of resident #9's nursing progress note, dated 4/8/24 at 3:24 p.m., showed staff member J wrote a note showing, Resident went to [Hospital Name] for MRI. Report stated that she has a new T11 fx (fracture towards the bottom of the thoracic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to create baseline care plans with the necessary information to safely address the resident's needs, within the 48-hour timeline, for 4 (#s 2, 3, 6, and 8) of 8 sampled residents. Findings include: 1. During an interview on 11/6/23 at 11:33 a.m., NF1 stated resident #6 was transferred to the facility from the hospital, and NF1 did not recall talking about the resident's baseline care plan. During an interview on 11/6/23 at 3:01 p.m., staff member A stated the facility did not have a baseline care plan for resident #6 and her admission on [DATE]. Review of resident #6's EMR showed the resident was admitted on [DATE] and discharged on 10/13/23. The resident's care plan showed interventions were initiated after the resident was discharged , on 10/17/23. 2. During an interview on 11/6/23 at 1:25 p.m., NF2 stated her goals for resident #8 included improving hygiene and the resident's nutrition status. During an interview on 11/6/23 at 1:58 p.m., staff member D…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a resident was safe to self-administer medications, before leaving the medications at bedside, causing an increased risk for medications not being taken as the physician prescribed, for 1 (#15) of 5 sampled residents for self-administration of medications. Findings include: During an observation and interview on 8/28/23 at 3:22 p.m., resident #15 was lying in bed. There was a clear medication cup with medications, a bottle of nasal spray, and two tubes of cream on the bedside table. Resident #15 stated he had just come back from dialysis. During an interview on 8/29/23 at 1:46 p.m., staff member E stated she had left the medications on resident #15's bedside table, the previous day, for resident #15 to take. Staff member E stated resident #15 had medication which needed to be taken with food, so she left the medications on the bedside table, and left the room. Staff member E stated she knew the proper assessments and consents had not been completed for resident #15 to self-administer his medications,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure a PRN (as needed) psychotropic medication prescription had a rationale for continuation, and stop date, for 1 (#33) of 5 sampled residents taking psychotropic medications. Findings include: During an interview on 8/30/23 at 12:35 p.m., staff member B stated she talked to NF2 about the need for a stop date for resident #33's PRN trazodone, but NF2 did not want to add a stop date, as he wanted the resident to always have the option to have the medication. Staff member B stated there was going to be a meeting about the stop date issue during resident #33's next medication review. During an interview on 8/30/23 at 12:43 p.m., resident #33 stated she had been sleeping well and had not used the PRN trazodone that often. During an interview on 8/30/23 at 1:09 p.m., staff member A stated the facility had a back-up provider that could sign off on monthly pharmacy medication recommendations if NF2 was unavailable. Review of resident #33's MAR showed a physician order for, traZODone HCl Oral Tablet (Trazodone HCl) Give 25 mg…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.