PRINTED: 11/02/2020

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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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

7/30/2020. Facility Reported Incidents were not
investigated during the survey.
DEFICIENCIES CITED:

Deficient practices were cited for the complaints

with Intake numbers: MT00047881,
MT00048107, MT00048538, MT00048534, and
MT00048555.

DEFICIENCIES NOT CITED:

Refer to FORM CMS-2567; Event ID: STYS11 for
unsubstantiated findings.
Deficient practices were NOT cited for the
complaint with Intake number: MT00048554.

Additionally, a COVID-19 Focused Infection

Control Survey was conducted by the State
Survey Agency on 7/30/2020. The facility was not
in compliance with 42 CFR §483.80 infection
control regulations and has not implemented the
CMS and Centers for Disease Control and
Prevention (CDC) recommended practices to
prepare for COVID-19.
The facility census on entrance was 95.

Glossary
CNA Certified Nursing Assistant
Liters Liters
LPM Liters Per Minute
PPE Personal Protective Equipment
% Percent
F 600 Free from Abuse and Neglect F 600 9/4/20
SS=E CFR(s): 483.12(a)(1)

§483.12 Freedom from Abuse, Neglect, and

Exploitation

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

Electronically Signed 08/24/2020

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: D88G11 Facility ID: MT275030 If continuation sheet Page 1 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 600 Continued From page 1 F 600

The resident has the right to be free from abuse,
neglect, misappropriation of resident property,
and exploitation as defined in this subpart. This
includes but is not limited to freedom from
corporal punishment, involuntary seclusion and
any physical or chemical restraint not required to
treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or

physical abuse, corporal punishment, or
involuntary seclusion;
This REQUIREMENT is not met as evidenced
by:
Based on interview and record review, the facility 1. How the corrective action will be
failed to prevent alleged abuse for 4 (#s 18, 19, accomplished to prevent abuse or
20, and 22) of 22 sampled and supplemental mistreatment of residents in facility:
residents. Findings include: Resident #18 still resides in the facility
and was put in cares in pairs per her care
During an interview on 7/28/20 at 9:43 a.m., staff plan effective 4/28/2020. Resident #19 no
member S stated resident #19 alerted her that longer resides in the facility. Resident #20
NF4 had been rough with resident #22 during no longer resides in the facility. Resident
cares. Staff member S explained NF4 was #22 no longer resides in the facility.
suspended immediately; he did not respond to 2. How the facility will identify other
the facility's phone calls and did not return to residents having the potential to be
work. Staff member S stated, "I founded that affected by the same alleged deficient
[particular] abuse allegation based on resident practice: On 8/24/2020 the Social
statements." Services Director/designee will interview
all resident in the facility and ask if they
During an interview on 7/28/20 at 1:02 p.m., staff have been abused or neglected in any
member A stated the facility was unable to way. On 7/28 and 7/29 all staff were
interview NF4 following the abuse allegation. Staff educated by the Social Services Director
member A explained that because staff were on abuse and neglect. Staff will continue
unable to get a statement from NF4, the abuse to be educated on abuse and neglect
allegation was substantiated. quarterly and all new hires will be
educated in new hire orientation.
Review of resident #18's statement, dated 2/9/20, 3. What measures will be put in place or
showed: "[NF4] is very rough with me. I told him what systematic changes you will make to
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 2 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 600 Continued From page 2 F 600

he was hurting my leg and he ignored me, and ensure that the deficient practice will not
[NF4] kept doing what he was doing." re-occur: The department heads in the
facility have been assigned a list of
Review of resident #19's statement, dated 2/9/20, residents to complete Guardian Angel
showed: "Approximately 3 weeks ago, I walked by rounds on 5 days a week. All department
[resident #22] in [her room]. She was make [sic] heads will be reeducated on Guardian
noises like she was hurt. I stood there in the Angel Rounds and timely reporting on
doorway and watched NF4 jerk the pillow out 8/24/20 by the Social Services manager.
from under her broken leg. Then [NF4] jerked the In this audit all residents will be asked by
pillow out from under her casted arm. He then department heads if they have any
turned around, saw me and said he needed concerns with their cares or unresolved
privacy for a 'Depends change,' and shut the issues. Staff performing Guardian Angel
door. [Resident #22] started shaking and was Rounds will report any allegations to
very agitated." Social Services or designee so that it may
be reported timely. Social Services will
Review of resident #20's statement, dated 2/9/20, interview each resident at their quarterly
showed: "[NF4] came in to help me go to the care plan meeting regarding their cares
bathroom; I wasn't moving fast enough so he and any concerns they may have
grabbed my pants and jerked them down really regarding abuse and neglect beginning
fast, and kind of rough." 8/24/20.
4. How the facility plans to monitor its
Review of NF4's personnel file showed a performance to ensure corrective actions
background check was completed upon hire, and are sustained. This plan must be
his CNA license was active until 11/30/21. NF4 implemented, and corrective action
had received education on abuse from the facility evaluated for its effectiveness. The POC
11/15/19. must be integrated into QA system:
Administrator/designee will perform audits
Review of the facility's Abuse and Neglect of 10 residents guardian angel room
In-Service, dated 2/7/20, showed: "Behaviors that rounds will be done beginning 8/28/2020
are physically abusive include: ...rough handling." weekly x 2 months, bi-weekly x 2 months,
The same document showed: "Verbal, sexual, and monthly x 2 months to ensure
physical, and mental abuse ....are strictly residents are free from abuse and neglect
prohibited." and continue to be free from abuse and
neglect. Administrator/designee will
perform audits of quarterly care plan
concerns regarding cares or abuse and
neglect will begin 8/24/2020 weekly x 2
months, bi-weekly x 2 months, monthly x
2 months to ensure all resident care plans
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 3 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 600 Continued From page 3 F 600

are updated according to their
preferences to ensure they are free from
abuse and neglect. Any concerns will be
addressed immediately and discussed
with the QAPI committee. Initial QAPI will
be held on 8/26/2020.
5. Date when corrective action will be
completed: Date of compliance 9/4/2020.
F 610 Investigate/Prevent/Correct Alleged Violation F 610 9/4/20
SS=E CFR(s): 483.12(c)(2)-(4)

§483.12(c) In response to allegations of abuse,

neglect, exploitation, or mistreatment, the facility
must:

§483.12(c)(2) Have evidence that all alleged

violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse,

neglect, exploitation, or mistreatment while the
investigation is in progress.

§483.12(c)(4) Report the results of all

investigations to the administrator or his or her
designated representative and to other officials in
accordance with State law, including to the State
Survey Agency, within 5 working days of the
incident, and if the alleged violation is verified
appropriate corrective action must be taken.
This REQUIREMENT is not met as evidenced
by:
Based on interview and record review, the facility 1. How the corrective action will be
failed to provide evidence that showed a thorough accomplished to prevent abuse or
investigation was completed following abuse mistreatment of residents in facility:
allegations against one employee for 4 (#s 18, Resident #18 still resides in the facility
19, 20, and 22) of 22 sampled and supplemental and was put in cares in pairs per her care
residents. Findings include: plan effective 4/28/2020. Resident #19 no
longer resides in the facility. Resident #20

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 4 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 610 Continued From page 4 F 610

During an interview on 7/28/20 at 9:43 a.m., staff no longer resides in the facility. Resident
member S stated that following the abuse #22 no longer resides in the facility.
allegation against NF4, residents were 2. How the facility will identify other
interviewed, but a full investigation did not occur residents having the potential to be
as NF4 terminated himself by not returning to affected by the same alleged deficient
work. Staff member S explained that if the facility practice: On 8/24/2020 the Social
had been able to interview NF4, she would have Services Director/designee will interview
interviewed other staff members as part of the all resident in the facility and ask if they
investigation. Additionally, staff member S stated have been abused or neglected in any
there was no reason to continue monitoring the way. On 7/28 and 7/29 all staff were
residents who gave statements or other residents educated by the Social Services Director
potentially at risk of abuse because NF4 did not on abuse and neglect. Staff will continue
return to the facility. Staff member S explained to be educated on abuse and neglect
the facility protected the residents by terminating quarterly and all new hires will be
NF4 and described the specific incident as educated in new hire orientation.
"isolated" to that staff member. 3. What measures will be put in place or
what systematic changes you will make to
During an interview on 7/28/20 at 1:02 p.m., staff ensure that the deficient practice will not
member A stated, "We couldn't get to the bottom re-occur: Social Services
of [the allegation involving NF4] without his Director/designee will report all allegations
statement, so there wasn't any more of an within the timeframe instituted within
investigation." regulation. All allegations will be reported
on and investigated immediately upon
Review of the facility's Abuse Investigation and notice 7 days a week. All department
Reporting policy, dated 10/20/16, showed the heads will be reeducated on guardian
following: angel room rounds on 8/20/2020. All
guardian angel rounds will be reviewed by
-"The Administrator will provide any supporting Social Services Director/designee to
documents relative to the alleged incident to the ensure timely reporting. Staff will be
person in charge of the investigation ...The re-educated on abuse policy and
Administrator will ensure that any further potential regulation by Social Services
abuse, neglect, exploitation or mistreatment is Director/designee at scheduled all staff
prevented." meetings quarterly. A mandatory all staff
meeting was held on 7/28/2020 and
-"The individual conducting the investigation will, 7/29/2020 to re-educate staff on abuse
as a minimum: interview staff members (on all reporting and policies. All new staff will be
shifts) who have had contact with the resident educated on abuse reporting and policies
during the period of the alleged incident; interview upon hire by SDC/designee.
the resident's roommate, family members, and 4. How the facility plans to monitor its
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 5 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 610 Continued From page 5 F 610

visitors; interview other residents to whom the performance to ensure corrective actions
accused employee provides care or services; and are sustained. This plan must be
review all events leading up to the alleged implemented, and corrective action
incident." evaluated for its effectiveness. The POC
must be integrated into QA system:
Review of the facility's documentation Administrator/designee will perform audits
surrounding the incident with NF4 showed of 10 residents guardian angel room
resident interviews were completed; however, no rounds will be done beginning 8/28/2020
interviews with staff, family members, or other weekly x 2 months, bi-weekly x 2 months,
residents, who may have been affected, were and monthly x 2 months to ensure
completed. residents are free from abuse and neglect
and continue to be free from abuse and
Refer to F0600 neglect. Administrator/designee will
perform audits of abuse and neglect
investigations for completion and
thoroughness of interviews/statements to
ensure proper investigations will begin
8/24/2020 weekly x 2 months, bi-weekly x
2 months, and monthly x 2 months. Any
concerns will be addressed immediately
and discussed with the QAPI committee.
Initial QAPI will be held on 8/26/2020.
5. Date of compliance: 9/4/20
F 657 Care Plan Timing and Revision F 657 9/4/20
SS=D CFR(s): 483.21(b)(2)(i)-(iii)

§483.21(b) Comprehensive Care Plans

§483.21(b)(2) A comprehensive care plan must
be-
(i) Developed within 7 days after completion of
the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that
includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the
resident.
(C) A nurse aide with responsibility for the
resident.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 6 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 657 Continued From page 6 F 657

(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of
the resident and the resident's representative(s).
An explanation must be included in a resident's
medical record if the participation of the resident
and their resident representative is determined
not practicable for the development of the
resident's care plan.
(F) Other appropriate staff or professionals in
disciplines as determined by the resident's needs
or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary
team after each assessment, including both the
comprehensive and quarterly review
assessments.
This REQUIREMENT is not met as evidenced
by:
Based on observation, interview, and record 1. How the corrective action will be
review, the facility failed to revise and implement accomplished for those residents that
the care plan for oxygen for 3 (#s 2, 3, and 5) of 5 have been affected by the deficient
sampled residents. This failure had the potential practice: Resident #2 was assessed by
to affect any resident in the facility who required DON/Designee on 8/13/2020 and noted
oxygen. bilateral clear lung sounds, O2 saturation
at 97% on room air and no signs or
1. During an observation and interview on 7/28/20 symptoms of respiratory distress. O2
at 8:00 a.m., resident #2 was sitting in her room saturation monitoring every shift is in
eating breakfast. Resident #2 had her oxygen place, additionally residents care plan was
nasal cannula on and the concentrator was set to updated to reflect that oxygen is prn per
4L. Resident #2 stated she had no problems with MD order. Resident #3 was assessed by
her oxygen. She stated the staff put the oxygen DON/Designee 8/13/2020 and noted
on for her. bilateral clear lung sounds, O2 saturation
at 94% on 4L of oxygen via nasal cannula,
Review of resident #2's care plan with a revision and no signs or symptoms of respiratory
date 6/20/19, showed, "... I wear oxygen per distress. All direct care staff was educated
nasal cannula at 2-3 liters continuously,..." on monitoring adequate supply of oxygen
in the portable oxygen tank. Resident’s
Review of resident #5's Order Summary Report care plan was updated with the specific
for July 2020 did not show a physician's order for amount of oxygen and when to use the
oxygen. oxygen as per physician orders. Resident
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 7 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 657 Continued From page 7 F 657

#5 was assessed by the DON/Designee
There was no current revision date for oxygen on 8/13/2020 and noted bilateral clear
use on the care plan. lung sounds, O2 saturation at 92% on 3L
and no signs or symptoms of respiratory
2. During an observation on 7/27/20 at 1:45 p.m., distress. Review of clinical record on
resident #3 was in her room, sitting in her 8/13/2020 shows resident #5 has an order
wheelchair. Her oxygen cannula was in her nose for oxygen at 3L via nasal cannula while in
and the oxygen rate on the tank was set at 3L. bed since 3/4/2020. This order was
The oxygen tank was in the red, which meant it clarified with provider and order updated
required replacement. to 3L via nasal cannula continuously. Care
plan updated to reflect the current order.
During an observation on 7/27/20 at 3:25 p.m., 2. How the facility will identify other
resident #3 was sitting in the television room by residents having the potential to be
the nursing station. Resident #3 had her oxygen affected by the same deficient practice:
on, the tank remained in the red, showing it DON/Designee will review all residents on
needed to be replaced. 8/20/2020 with orders for oxygen and
ensure that a physician order is in place
During an observation on 7/28/20 at 12:20 p.m., and residents are receiving the correct
resident #3 was in her room sitting in her flow rate per physician order, and that the
wheelchair. Her oxygen nasal cannula was in her care plan reflects these orders
nose, the oxygen rate on the tank was set at 4L. accordingly.
The oxygen tank was in the red, showing it 3. What measures will be put in place or
needed to be replaced. what systemic changes you will make to
ensure that the deficient practice will not
During an observation on 7/28/20 at 1:55 p.m., re-occur: Beginning 8/24/2020
resident #3 was in her room sitting in her DON/Designee will review all residents
wheelchair. Her oxygen nasal cannula was in her with orders for oxygen administration
nose, the oxygen rate on the tank was set at 4L. quarterly in the quarterly care plan
The oxygen tank was in the red, showing it meeting to ensure accuracy of care plan
needed to be replaced. and needs are being met. DON/designee
will educate all nursing staff on 8/21/2020
During an observation on 7/29/20 at 8:00 a.m., on accessing the oxygen care plan to
resident #3 was lying in bed, waiting for her verify oxygen orders to ensure accuracy
breakfast. Resident #3 had her oxygen nasal of care plan and resident’s needs.
cannula on her face, hooked to the oxygen 4. How the facility plans to monitor its
concentrator, which was set at 2L. performance to ensure corrective actions
are sustained. This plan must be
During an interview on 7/28/20 at 2:00 p.m., staff implemented, and corrective action
member L stated resident #3 should have her evaluated for its effectiveness:
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 8 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 657 Continued From page 8 F 657

oxygen set at 4L. DON/designee will audit all oxygen orders
according to care plan beginning
During an interview on 7/29/20 at 8:05 a.m., staff 8/24/2020 to ensure accuracy. This audit
member CC stated resident #3 should have her will proceed as follows: weekly x 2
oxygen set at 4L. months, bi-weekly x 2 months, and
monthly x 2 months. DON/designee will
Review of resident #3's Order Summary Report then audit and select 6 residents to verify
and the Medication Review Report, dated 7/7/20, care plan accuracy to order to ensure
showed resident #3's oxygen was continuous to safety and accuracy. This audit will
keep oxygen saturations at or above 88%. Based proceed as follows: weekly x 2 months,
on interviews, the facility staff were not aware of bi-weekly x 2 months, monthly x 2
resident #3's current oxygen orders. months. Any concerns will be addressed
immediately and discussed with the QAPI
Review of resident #3's care plan showed the committee. Initial QAPI will be held on
oxygen interventions were last updated on 8/26/2020.
3/28/20 for the use of oxygen. The care plan did 5. Date of when corrective action will be
not specify the amount of oxygen to use, or when completed: 9/04/2020
the resident was to use the oxygen.

3. During an observation on 7/28/20 at 12:00

p.m., resident #5 was in her room, sitting in her
wheelchair, eating candy, and reading. Resident
#5 had an oxygen nasal cannula on, hooked up to
an oxygen concentrator, which was set at 2L.

During an interview on 7/28/20 at 8:05 a.m., staff

members CC and DD stated the staff could look
at the Kardex for information on how to assist
residents with their care, or they could ask
another staff member.

Review of resident #5's Order Summary Report

for July 2020 did not show a physician's order for
oxygen.

Review of resident #5's care plan, dated 12/2/18,

showed oxygen at 2L per nasal cannula at
bedtime.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 9 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 657 Continued From page 9 F 657

Review of resident #5's Kardex showed, oxygen
settings at 2L via nasal cannula at bedtime.
F 658 Services Provided Meet Professional Standards F 658 9/4/20
SS=D 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,
must-
(i) Meet professional standards of quality.
This REQUIREMENT is not met as evidenced
by:
Based on observation, interview, and record 1. How the corrective action will be
review, the facility failed to follow physician orders accomplished for those residents that
for oxygen for 2 (#s 2 and 3); and failed to obtain have been affected by the deficient
a physician order for oxygen for 1 (#5) of 5 practice: Resident #2 was assessed by
sampled residents. This failure had the potential DON/Designee on 8/13/2020 and noted
to affect any resident in the facility who required bilateral clear lung sounds, O2 saturation
oxygen. Findings include: at 97% on room air and no signs or
symptoms of respiratory distress. O2
1. During an observation and interview on 7/28/20 saturation monitoring every shift is in
at 8:00 a.m., resident #2 was sitting in her room, place, additionally residents care plan was
eating breakfast. Resident #2 had her oxygen updated to reflect that oxygen is prn per
nasal cannula on, and the concentrator was set to MD order. Resident #3 was assessed by
4L. Resident #2 stated she had no problems with DON/Designee 8/13/2020 and noted
her oxygen. She stated the staff put the oxygen bilateral clear lung sounds, O2 saturation
on for her. at 94% on 4L of oxygen via nasal cannula,
and no signs or symptoms of respiratory
Review of resident #2's Order Summary Report, distress. All direct care staff was educated
dated 7/28/20, did not show an order for oxygen on monitoring adequate supply of oxygen
use. in the portable oxygen tank. Resident’s
care plan was updated with the specific
The most current orders for resident #2 did not amount of oxygen and when to use the
include the use of oxygen. oxygen as per physician orders. Resident
#5 was assessed by the DON/Designee
2. During an observation on 7/27/20 at 1:45 p.m., on 8/13/2020 and noted bilateral clear
resident #3 was in her room, sitting in her lung sounds, O2 saturation at 92% on 3L
wheelchair. Her oxygen cannula was in her nose, and no signs or symptoms of respiratory

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 10 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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

and the oxygen rate on the tank was set at 3L. distress. Review of clinical record on
The oxygen tank was in the red, which meant it 8/13/2020 shows resident #5 has an order
needed to be replaced. for oxygen at 3L via nasal cannula while in
bed since 3/4/2020. This order was
During an observation on 7/27/20 at 3:25 p.m., clarified with provider and order updated
resident #3 was sitting in the television room by to 3L via nasal cannula continuously. Care
the nursing station. Resident #3 had her oxygen plan updated to reflect the current order.
on, the tank remained in the red, showing it 2. How the facility will identify other
needed to be replaced. Staff member K obtained residents having the potential to be
her oxygen saturation at 90%. Staff member K affected by the same deficient practice:
stated the oxygen saturation was checked every DON/Designee will review all residents on
shift. Staff member K then asked another staff 8/20/2020 with orders for oxygen and
member to replace resident #3's oxygen tank. ensure that a physician order is in place
Staff member K provided the surveyor a form and residents are receiving the correct
titled, Oxygen & Equipment Order, dated 3/26/20. flow rate per physician order, and that the
The form showed resident #3 was to have oxygen care plan reflects these orders
at 4 LPM continuous via nasal cannula. accordingly.
3. What measures will be put in place or
During an observation on 7/28/20 at 12:20 p.m., what systemic changes you will make to
resident #3 was in her room, sitting in her ensure that the deficient practice will not
wheelchair. Her oxygen nasal cannula was in her re-occur: Beginning 8/24/2020
nose, the oxygen rate on the tank was set at 4L. DON/Designee will review each resident
The oxygen tank was in the red, showing it with orders for oxygen administration on
needed to be replaced. admission and quarterly care plan
meetings to ensure accuracy and needs
During an observation on 7/28/20 at 1:55 p.m., are being met. DON/designee will educate
resident #3 was in her room, sitting in her all nursing staff on 8/21/2020 on
wheelchair. Her oxygen nasal cannula was in her accessing the oxygen order on the eMAR
nose, the oxygen rate on the tank was set at 4L. to ensure accuracy of flow rate to the
The oxygen tank was in the red, showing it residents need and that there is adequate
needed to be replaced. supply of oxygen.
4. How the facility plans to monitor its
During an observation on 7/29/20 at 8:00 a.m., performance to ensure corrective actions
resident #3 was lying in bed, waiting for her are sustained. This plan must be
breakfast. Resident #3 had her oxygen nasal implemented, and corrective action
cannula on her face, hooked to the oxygen evaluated for its effectiveness:
concentrator which was set at 2L. DON/designee will audit all oxygen orders
beginning 8/24/2020 to ensure accuracy
During an interview on 7/28/20 at 2:00 p.m., staff weekly x 2 months, bi-weekly x 2 months,
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 11 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 11 F 658

member L stated resident #3 should have her and monthly x 2 months. DON/designee
oxygen set at 4l. Staff member L obtained a new will then use eMAR audit and select 6
oxygen tank to replace resident #3's empty tank. residents to verify eMAR matches
Staff member L checked resident #3's oxygen equipment and settings of oxygen to
saturation, which was 90%. ensure safety and accuracy weekly x 2
months, bi-weekly x 2 months, monthly x
During an interview on 7/29/20 at 8:00 a.m., staff 2 months. Any concerns will be addressed
members CC and DD stated most of the immediately and discussed with the QAPI
residents have their oxygen orders between 2 committee. Initial QAPI will be held on
and 4 liters. 8/26/2020.
5. Date of when corrective action will be
During an interview on 7/29/20 at 8:05 a.m., staff completed: 9/04/2020
member CC stated resident #3 should have her
oxygen set at 4L.

Review of resident #3's Order Summary Report

and the Medication Review Report, dated 7/7/20,
showed resident #3's oxygen was continuous to
keep oxygen saturations at or above 88%. Based
on interviews, the facility staff were not aware of
resident #3's current oxygen orders.

3. During an observation on 7/28/20 at 12:00

p.m., resident #5 was in her room, sitting in her
wheelchair, eating candy and reading. Resident
#5 had an oxygen nasal cannula on, hooked up to
an oxygen concentrator, which was set at 2L.

During an interview on 7/28/20 at 8:05 a.m., staff

members CC and DD stated the staff could look
at the Kardex for information on how to assist
residents with their care, or they could ask
another staff member.

Review of resident #5's Order Summary Report

for July 2020 did not show a physician's order for
oxygen.

Review of the facility policy titled, Oxygen

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 12 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 12 F 658

Administration, showed, "... 1. Verify that there is
a physician's order for this procedure. Review the
physician's order or facility protocol for oxygen
administration. 2. Review the resident's care plan
and assess for any special needs of the
resident..."
F 676 Activities Daily Living (ADLs)/Mntn Abilities F 676 9/4/20
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,

§483.24(b)(3) Elimination-toileting,

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 13 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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

§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, interview, and record 1. How the corrective action will be
review, the facility failed to provide the proper accomplished for those residents that
level of assistance; and failed to proivde an have been affected by the deficient
assistive device for meals for 1 (#10) of 21 practice: Resident #10’s necessity for
sampled and supplemental residents, which had adaptive equipment on her tray card for
the potential to affect all residents who required staff to catch before a meal is delivered.
assistance with meals and assisitve devices. 2. How the facility will identify other
Findings include: residents having the potential to be
affected by the same deficient practice:
During an observation on 7/29/20 at 8:05 a.m., Beginning 8/24/2020 the Registered
resident #10 was eating in her room, lying in bed, Dietitian will review care plans,
in the dark, with her bedside table over her bed, communication forms, and diet order for
and her breakfast tray on top of it. There was no all residents that require adaptive
red foam on her silverware handles. equipment. Beginning 8/24/2020 the
adaptive equipment tally report will be
During an observation on 7/29/20 at 8:07 a.m., printed out weekly for kitchen staff to
staff member W entered resident #10's dark review and posted in the kitchen. A new
room and offered her a bite of cereal. Staff report will be printed during the week if
member W did not turn on the light in resident there are adaptive equipment changes. All
#10's room. The silverware did not have red foam tray cards with adaptive equipment
on the handles for resident #10. required will be highlight for staff to easily
view and ensure the tray has the
During an observation on 7/29/20 at 8:09 a.m., necessary equipment.
staff member R entered resident #10's dark room 3. What measures will be put in place or
and opened the shades. what systemic changes you will make to
ensure that the deficient practice will not
During an observation on 7/29/20 at 1:18 p.m., re-occur: The Registered
resident #10's plate had silverware with red foam Dietitian/designee will be designated to
on the ends of both her fork and spoon. She had review the tray card versus contents on
consumed less than 25% of her meal. tray to provide accuracy before moving
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 14 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 14 F 676

tray into delivery cart. Beginning
During an interview on 7/28/20 at 12:45 p.m., 8/24/2020 all kitchen staff will be educated
staff member Y stated there was a on adaptive equipment and where to
communication form for resident #10 that locate the need for adaptive equipment on
addressed her level of assistance for meals. the tray card.
4. How the facility plans to monitor its
During an interview on 7/28/20 at 2:14 p.m., staff performance to ensure corrective actions
member V stated resident #10 often does not are sustained. This plan must be
have the endurance to eat with her dominant implemented, and corrective action
hand and resorts to using her utensil in her evaluated for its effectiveness: The
non-dominant hand to eat some of her meal. Staff registered dietitian/designee will perform
member V stated resident #10 needed more audits on 3 residents that require adaptive
supervision and assistance during her meals. equipment tray cards, care plans, and
communication forms weekly x 2 months,
During an interview on 7/29/20 at 8:12 a.m., staff bi-weekly x 2 months, and monthly x 2
member R stated, "I don't think [resident #10's] months. The Registered Dietitian/
silverware has any foam on them." She walked designee will monitor and audit mealtime
into resident #10's room and confirmed there was for 3 residents to ensure accuracy in the
no foam on the silverware. delivery of meals and adaptive equipment
weekly x 2 months, bi-weekly x 2 months,
During an interview on 7/29/20 at 8:54 a.m., staff and monthly x 2 months. Any concerns
member B stated staff was to encourage resident will be addressed immediately and
#10 to eat during her meals. Staff member B discussed with the QAPI committee. Initial
stated resident #10 did not use foam on her QAPI will be held on 8/26/2020.
silverware as an assistive device during meals. 5. Date of when corrective action will be
completed: 9/4/2020
During an interview on 7/29/20 at 10:29 a.m.,
staff member W stated she did not know if
resident #10 was supposed to use an assistive
device on her silverware. Staff member W stated
she would look at her book, on a computer, or
ask the nurse or dietician to find out whether a
resident needed an assistive device for meal
such as foam on the silverware.

Review of the facility's Communication Form for

resident #10, dated 7/24/20, showed, "Please
provide assistance at meals due to self-feeding
difficulty and weight loss." The form had boxes
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 15 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 15 F 676

checked for breakfast, lunch, and dinner.

Review of resident #10's Nutrition Care Plan,

dated 7/10/20, showed, "My oral intake improves
when nursing assists me with meals. To help
self-feeding, I receive red foam over my utensil
handles."
F 837 Governing Body F 837 9/4/20
SS=F CFR(s): 483.70(d)(1)(2)

§483.70(d) Governing body.

§483.70(d)(1) The facility must have a governing
body, or designated persons functioning as a
governing body, that is legally responsible for
establishing and implementing policies regarding
the management and operation of the facility; and

§483.70(d)(2) The governing body appoints the

administrator who is-
(i) Licensed by the State, where licensing is
required;
(ii) Responsible for management of the facility;
and
(iii) Reports to and is accountable to the
governing body.
This REQUIREMENT is not met as evidenced
by:
Based on observation, interview, and record 1. How the corrective action will be
review, the facility's governing body failed to accomplished for those residents that
provide adequate building maintenance and have been affected by the deficient
repairs. This failure has the potential to affect all practice: All residents, visitors, and
residents, staff, and visitors of the facility. employees have potential to be affected
Findings include: by this deficient practice.
2. How the facility will identify other
During an observation on 07/27/20 at 12:30 p.m., residents having the potential to be
an internal and external inspection of the facility affected by the same deficient practice: A
was performed. Internally, several areas within complete walk through inspection was
the facility were observed to have sustained water completed on 7/29/2020 to identify all

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 16 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 837 Continued From page 16 F 837

damage. Externally, the facility's roof, soffits, and interior rooms that were affected by the
fascia were observed to be in extremely poor roof failing. These findings resulted in 5
condition, and severe water damage, possible rooms on the 400 and 500 hallways that
mold growth, and rodent infestation were noted. were directly affected by this deficient
practice. On 7/29/2020 all 5 residents
During an interview on 07/27/20 at 1:32 p.m., were given a letter and asked if they
staff member P stated he began working for the would like to switch rooms due to the roof,
facility in September of 2019. He stated the roof soffit and/or facia failing outside their
had been an ongoing issue and he has made room. All 5 residents declined and were
several repairs to it since beginning his put on “mold exposure” monitoring
employment. Staff member P stated he has been immediately on 7/30/2020. Mold tests and
securing quotes from multiple contractors to have air quality tests results came back clear
the roof, soffits, and all the fascia replaced. He on 8/14/2020. All residents were taken off
stated he cannot proceed with hiring a contractor monitoring on 8/17/2020. All soffits, fascia
until, "The powers that be approve it." was repaired and sealed on 8/4/2020. All
sprinkler heads on the 400 and 500 wings
During an interview on 07/27/20 at 2:13 p.m., were replaced and tested to ensure
staff member A stated he has worked at the proper functioning on 8/7/2020.
facility for two and a half years. He stated, "I've 3. What measures will be put in place or
been asking for a new roof since I started." He what systemic changes you will make to
stated staff member P had been securing quotes ensure that the deficient practice will not
to have the roof, soffits, and fascia replaced. He re-occur: A signed contract with
stated the facility also had quotes performed back Centimark was done 8/7/2020 for the
in 2018, but nothing was completed at that time. replacement of the roof. Beginning
Staff member A stated members from the 8/18/2020 prep work by contractors began
corporate office came out to observe the roof a for the entire replacement of the roof at
couple of months ago. He stated, "They know it's Park Place. The roof will be torn out and
bad", and there is money set aside for the repairs. completed in sections with the first section
Staff member A stated he anticipates having a starting on 8/24/2020. Total roof
new roof by the end of the year. replacement will take 60 days from start
date with projected end date of
During an interview on 07/28/20 at 10:27 a.m., 10/30/2020. At completion of roof the
resident #14 stated she had been a resident of maintenance director will complete
the facility for almost five years. She stated, "Are monthly evaluations as part of his
they finally going to fix that Eve? It's been like that preventive maintenance log to ensure the
since I've been in this room." Resident #14 stated roof, soffit, and fascia remain in good
she had asked to have the soffits and fascia standing.
repaired in the past. She stated the falling soffits 4. How the facility plans to monitor its
and fascia were restricting her outside view. performance to ensure corrective actions
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 17 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 837 Continued From page 17 F 837

are sustained. This plan must be
Record review of "Home Roof Project", prepared implemented, and corrective action
on 06/22/18 showed, "Many of the lower edges evaluated for its effectiveness:
have been fabricated to divert water into Maintenance Director/designee will
scuppers rather than allowing water to flow perform audits of the preventative
directly into a proper water collection system. In maintenance log will begin upon
the winter heavy ice damning has occurred due to completion of the roof. These audits will
this ...Excessive water and ice have deteriorated be done to ensure proper preventative
the membrane to the point where it is simply maintenance is being completed to
allowing water to pour through the mesh scrim prevent the roof from deteriorating and
sheet ...The damning of water here has caused that any issue that arise are
enough damage that the soffit, fascia, and communicated with the administrator and
trusses have begun to fall. Dirt stains show where contract to ensure issues are fixed per
ponding water occurs ...Drain inserts are rusted warranty. These audits will be done
and past the functioning life span ...Every single weekly x 2 weeks, bi-weekly x 2 weeks,
roof facet has multiple signs of water and and monthly x 2 weeks. Any concerns will
moisture damage ...Because of this massive be addressed immediately and discussed
amount of moisture in the roofing system all with the QAPI committee. Initial QAPI will
current roofing materials must be removed so be held on 8/26/2020.
that wood decking may be inspected, removed, 5. Date of when corrective action will be
and replaced if any rot or mold is found completed: 9/4/2020
...Recreation gazebo and Main Entrance walkway
roof are extremely deteriorated and pose
significant danger to anyone below as debris and
roofing materials have begun to be removed due
to the wind."

Record review of "Roof Assessment and

Proposed Solution", prepared on 06/05/20
showed, "The roof is failing and in need of
replacement ...The field of the roof has clearly
reached the end of its life cycle. Previous repairs
have been made and further attempts to repair
this roof are not recommended ...The details of
the roof are in poor condition and are currently
allowing for moisture to enter the roof system
...The insulation has become saturated in
identified areas. This moisture-laden material
needs to be removed and replaced immediately
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 18 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 837 Continued From page 18 F 837

to prevent further costly deterioration."

Record review of "Management Report",

prepared on 07/08/20 showed, "This roof is rated
an F. It has reached the end of its usefulness.
There are multiple areas where the membrane
has deteriorated to a point the inner layer of scrim
is showing through. There are areas of soffit and
fascia that are falling from the building."

On 07/28/20 at 12:36 p.m., the following email

was received from staff member EE, "I was
informed by our Administrator at [facility name],
[staff member A], that there have been questions
about the needed roof repairs at the facility. I
want to assure you that we understand the urgent
need for a solution and are meeting this week to
decide on a contractor. We received our final bid
last week on Thursday, and are meeting this
week to select a contractor to install a new roof
and replace all of the facility's fascia and soffit.
The funding for the roof replacement has already
been secured and we expect work to begin very
soon."

Refer to F0921 and F0925.

F 880 Infection Prevention & Control F 880 8/26/20
SS=F CFR(s): 483.80(a)(1)(2)(4)(e)(f)

§483.80 Infection Control

The facility must establish and maintain an
infection prevention and control program
designed to provide a safe, sanitary and
comfortable environment and to help prevent the
development and transmission of communicable
diseases and infections.

§483.80(a) Infection prevention and control

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 19 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 880 Continued From page 19 F 880

program.
The facility must establish an infection prevention
and control program (IPCP) that must include, at
a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying,

reporting, investigating, and controlling infections
and communicable diseases for all residents,
staff, volunteers, visitors, and other individuals
providing services under a contractual
arrangement based upon the facility assessment
conducted according to §483.70(e) and following
accepted national standards;

§483.80(a)(2) Written standards, policies, and

procedures for the program, which must include,
but are not limited to:
(i) A system of surveillance designed to identify
possible communicable diseases or
infections before they can spread to other
persons in the facility;
(ii) When and to whom possible incidents of
communicable disease or infections should be
reported;
(iii) Standard and transmission-based precautions
to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a
resident; including but not limited to:
(A) The type and duration of the isolation,
depending upon the infectious agent or organism
involved, and
(B) A requirement that the isolation should be the
least restrictive possible for the resident under the
circumstances.
(v) The circumstances under which the facility
must prohibit employees with a communicable
disease or infected skin lesions from direct
contact with residents or their food, if direct

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 20 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 880 Continued From page 20 F 880

contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed
by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents

identified under the facility's IPCP and the
corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and
transport linens so as to prevent the spread of
infection.

§483.80(f) Annual review.

The facility will conduct an annual review of its
IPCP and update their program, as necessary.
This REQUIREMENT is not met as evidenced
by:
Based on observations, interviews, and record F880 - DIRECTED PLAN OF
review, the facility staff failed to adhere to CORRECTION
infection control practices by not wearing face
masks appropriately; and failed to perform
appropriate hand hygiene while providing perineal 1. Criteria One - Corrective actions for
care for 1 (#1) of 14 sampled residents. These those residents affected by the deficient
failures had the potential to affect all residents in practice:
the facility. Findings include:
a. The Administrator and Director of
1. During an observation on 7/27/20 at 12:13 Nursing will develop a plan, and carry out
p.m., the surveyors entered the facility. Staff that plan, to assess all residents for signs
member C and staff member D were observed and symptoms of COVID-19 and
sitting in the front reception, not wearing their potential exposure, to determine if any
face masks. negative outcomes related to the lack of
use of facemasks or proper use of
During an observation on 7/27/20 at 12:13 p.m., facemasks, have occurred. The plan will
staff member U walked by the front reception include the identification of risk factors
area with her mask on, over her mouth and under presented by noncompliance of staff
her nose. Staff member U did not have her nose utilizing isolation precaution measures as
covered. instructed by the facility.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 21 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 880 Continued From page 21 F 880

During an observation on 7/27/20 at 1:19 p.m., For any residents identified to have
staff member D was observed in the front negative outcomes related to the lack of
reception area. She was not wearing a mask. Her use of facemasks or infection control
mask was observed sitting on the desk in front of precautions, the facility will immediately
her. (within that shift) implement interventions,
and if necessary, isolation precautions, for
During an interview on 7/27/20 at 1:22 p.m., staff that affected resident, and ensure direct
member D stated she was supposed to wear a care staff are educated on concerns
mask when she was within six feet of a resident identified.
of the facility. She stated, "When I am around
other staff, wearing a mask is at my own Nursing will document concerns identified
discretion." for any resident impacted by the deficient
practice, to include corrective actions or
During an observation on 7/27/20 at 2:00 p.m., interventions implemented, in the affected
staff members I and H were sitting at the desk on resident(s) medical record(s). All resident
the 600 hall. Staff member I was working on the assessments to be completed by 8/17/20.
computer. Staff member I had her mask under The Director of Nursing will maintain a
her chin not covering her mouth and nose. tracking sheet, to include followup actions
taken for any individual residents, for all
During an interview on 7/27/20 at 2:06 p.m., staff resident assessments completed and
member H stated staff were to wear masks at all ensure any concerns are addressed
times. timely.

During an interview on 7/27/20 at 2:13 p.m., staff The Administrator will meet with the
member A stated, "All staff, at all times, in all director of nursing daily, and monitor the
areas of the facility must wear masks." He stated, completion and tracking of the resident
"Business office staff are included. Everyone assessments and actions taken for
must wear a mask." affected residents, and ensure follow up
tasks are carried out as necessary.
During an interview on 7/27/20 at 2:45 p.m., staff
member R stated that the staff have been trained b. For resident #1, the Director of Nursing
to wear a mask at all times covering their nose or Designated RN will assess resident's
and mouth. health status or outcomes related to the
lack of proper glove use and handwashing
During an observation on 7/28/2020 at 2:06 p.m., during ADL care, to ensure no negative
staff member C was observed sitting at a desk in outcomes have occurred from the
the front reception area. His face mask was deficient practice. If outcomes are, or are
observed hanging from his right ear and not not, identified, the resident's medical
covering his face. record will reflect the completion and
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 22 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 880 Continued From page 22 F 880

outcome of the assessment, to include
During an observation and interview on 7/27/20 any interventions potentially implemented.
at 12:32 p.m., staff member U was sitting on a This will be completed by 8/17/20.
chair at the end of hall with her mask under her
nose. Staff member U stated residents and staff c. Education will be provided to the
were to wear their masks in all areas of the Administrator, Director of Nursing,
building. Staff member U stated her mask was Infection Preventionist, and all
supposed to cover her face fully. Department Heads, by a designated
nursing member of the parent company,
During an interview on 7/28/20 at 8:00 a.m., staff on the proper use, expectations, safety,
member T stated the housekeeping staff are to and monitoring of use of facemasks by
wear their mask at all times and to cover their 8/17/20. Documentation of education will
nose and mouth. She stated if the house keeping be maintained and provided for
staff do not wear the mask properly, they would compliance. After the education is
receive corrective action. provided, the Administrator and Director of
Nursing will educate all unit managers,
Review of the facility "April 2020 All Staff Infection Preventionist, or nursing
Agenda", showed infection control, including supervisors on the use of, monitoring, and
Covid-19, listed on the agenda. requirements for use and wearing
facemasks for resident/staff protection
Review of the documentation for a facility staff related to COVID-19. This is to be
meeting titled, "May 2020 All Staff Agenda", completed by 8/20/20. For those not in
showed ... Reiteration of PPE or isolation; and attendance for the education, this will be
continuation for wearing a mask during work provided prior to their next scheduled
hours.... shift, or they will not be allowed to work,
and documented for compliance.
2. During an observation on 7/27/20 at 12:23
p.m., the kitchen was inspected. Staff member E 2. Criteria Two - Identification of others
was observed standing near the cooler with a potentially at risk:
resident food tray. He did not have a mask on.
All residents are at risk for this deficient
During an observation on 7/27/20 at 12:27 p.m., practice. All residents will be assessed for
staff member F was observed standing in the potential COVID-19 exposure, as shown
kitchen, serving and preparing resident room above in Criteria One, which is to be
trays for lunch. He was observed wearing a completed by 8/17/20.
yellow surgical mask over his mouth; his nostrils
were uncovered. 3. Criteria Three - Systematic changes to
correct the deficient practice:
During an interview on 7/27/20 at 12:28 p.m.,
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 23 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 880 Continued From page 23 F 880

staff member G stated he was the Dietary a. Education will be provided to all staff, to
Manager and responsible for overall operations include contract staff working at the
and staff in the kitchen. He stated, "Kitchen staff facility, on the proper use of facemasks
must wear masks at all times, especially while and ensuring facemasks are utilized prior
serving food." Staff member G explained staff are to entrance and while working in the
supposed to make sure that the masks cover facility. Education will be completed by the
their mouth and nostrils. He stated, "I'm Director of Nursing, Administrator, and/or
constantly telling everyone to cover their nose." Infection Preventionist by 8/21/20.
Documentation of education topics, date
Record review of facility training, "New COVID-19 provided, and names of staff in
Policies for Dietary Staff" on 07/28/20 showed, attendance, will be maintained by the
"Masks must always be worn in kitchen and Director of Nursing and Administrator, to
during meal/snack delivery." ensure all staff are educated timely. Any
3. During an observation on 7/28/20 at 12:55 staff member not receiving education by
p.m., staff members L and M provided pericare to 8/21/20 will be required to receive
resident #1 after an incontinent bowel episode. education prior to their next shift, or they
Staff member L gathered wipes, a clean brief, will not be allowed to work.
moisture barrier cream, and put her gloves on.
Staff member M washed her hands and put her b. Education will be provided to all direct
gloves on. Staff member L raised the bed with the care givers on the proper use of
controller, pulled the covers back, and removed handwashing during the provision of ADL
the pillows from under resident #1. Both staff care, by the Director of Nursing or nursing
members explained the procedure to resident #1. management designee, by 8/21/20.
Staff members L and M assisted resident #1 to Documentation of education topics, date
roll over onto her right side. Staff member M held provided, and names of staff in
onto resident #1 while staff member L tucked the attendance, will be maintained by the
soiled brief and incontinent pad under resident Director of Nursing and Administrator, to
#1's side, and provided perineal care. Staff ensure all staff are educated timely. Any
member L obtained a clean incontinent pad from staff member not receiving education by
resident #1's wheel chair and placed it under her. 8/21/20 will be required to receive
Staff member L obtained the clean incontinent education prior to their next shift, or they
brief and placed it under resident #1, and then will not be allowed to work.
applied moisture barrier cream to resident #1's
buttocks. c. The Administrator, Director of Nursing,
Infection Preventionist, will develop a plan
Staff members L and M assisted resident #1 to to monitor and audit all staff during all
roll over onto her back. Staff members L and M shifts, and in all departments, for the
removed the soiled brief and incontinent pad. proper use of facemasks related to
Staff member M held onto the soiled products COVID-19. Monitoring should occur (at a
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 24 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 880 Continued From page 24 F 880

with one hand, while staff member L continued to minimum) daily, on all shifts, all units, and
provide perineal care. Staff member L opened the all departments. Any concerns identified
drawer of the night stand, obtained more wipes, will be addressed immediately (that shift)
and provided more perineal care for resident #1. by the facility. Documentation of
Staff member L secured the clean brief. Staff monitoring will be maintained for
member M then placed the soiled products in the compliance. If monitoring is delegated, the
garbage, removed her gloves, and washed her Administrator, Director of Nursing, and
hands. Staff member L removed her gloves, Infection Preventionist will also monitor
gathered the garbage, and placed a new garbage independently for the proper use of
bag in the garbage can. Staff member L and M facemasks for the prevention of infection,
then repositioned resident #1 in her bed, gave her and document the monitoring, which
the call light, obtained the garbage, and left the should be measurable and show concerns
room. are addressed timely. All monitoring
should occur (at a minimum) daily, on all
During an interview on 7/29/20 at 8:05 a.m., staff shifts, all units, and all departments.
members CC and DD stated when providing Auditing will be passed to the QAPI
perineal care, staff should wash your hands, put committee each month for review and
gloves on, remove soiled gloves, wash your discussion of actions taken and concerns
hands, put new gloves on, and then finish cares. or trends identified, by the Director of
To summarize, soiled gloves should be changed Nursing.
in between "dirty" and "clean" tasks.
4. Criteria Four - Monitoring to ensure
Review of the facility's policy titled, Infection deficient practice is corrected and
Control Guidelines for All Nursing Procedures, sustained:
revised 8/2012, showed:
a. The QAPI committee will meet and
"Employees must wash their hands for ten to review monitoring/auditing, education, and
fifteen seconds using antimicrobial or concerns related to this deficient practice
non-antimicrobial soap and water under the and plan of correction, to determine if the
following conditions: before and after direct facility has met the requirements of the
contact with residents; when hands are visibly plan, no later than 8/25/20.
dirty or soiled with blood or other body fluids; after
contact with body fluids; after removing gloves ... b. The QAPI committee will review and
In most situations, the preferred method of hand track the progress or concerns related to
hygiene is with an alcohol-based hand rub. If this deficient practice weekly for one
hands are not visibly soiled, use an alcohol-based month, bi-weekly for two months, then
hand rub ... before and after direct contact with monthly for two months, for a minimun of
residents ... before moving from a contaminated 6 months. If the COVID-19 directives
body site to a clean body site during resident care change related to mask use, based on the
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 25 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 880 Continued From page 25 F 880

.... after removing gloves." State of Montana/CMS, CDC
guidelines/laws, the facility will modify
their plan and follow-up, as necessary, but
QAPI will continue to monitor and discuss
infection prevention efforts related to the
prevention efforts of COVID-19 for the 6
month period. Actions taken by the QAPI
committee will be documented for
compliance and for sustaining
compliance.

5. Criteria Five - Date of

Correction/Compliance: 8/26/2020
F 921 Safe/Functional/Sanitary/Comfortable Environ F 921 9/4/20
SS=F CFR(s): 483.90(i)

§483.90(i) Other Environmental Conditions

The facility must provide a safe, functional,
sanitary, and comfortable environment for
residents, staff and the public.
This REQUIREMENT is not met as evidenced
by:
Based on observation and interview, the facility 1. How the corrective action will be
failed to: accomplished for those residents that
have been affected by the deficient
a) maintain access to portable fire extinguishers practice:
in accordance with NFPA 10 Standard for
Portable Fire Extinguishers, 2010 Edition, Section 1- On 7-28-2020, the dining room table
6.1.3.3.1.; was moved away from the portable fire
b) ensure accessibility to a manual fire alarm pull extinguisher by the maintenance
station in accordance with NFPA 101, 2012 department, no longer blocking access.
Edition, Section 9.6.2.7.; 2- On 7-28-2020, the garbage can was
c) maintain the electrical system in accordance moved away from the K extinguisher in
with NFPA 70 National Electric Code, 2011 the kitchen by the dietary manager, no
Edition, Article 110-12(B).; longer blocking access. The various items
d) ensure fire/smoke barrier doors located in the obstructing access to the manual pull
fire/smoke partitions were maintained per NFPA station on the back wall and the manual
101-2012, Section 8.4.3.4 and NFPA 80 Standard pull station for the kitchen hood were

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 26 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 921 Continued From page 26 F 921

for Fire Doors and Other Opening Protectives, moved allowing easy access to the
2010 Edition, Section 6.3.1.7.1.; stations.
e) ensure an exit sign was located above an exit 3- The cabinet at the 400 nurse station is
door in accordance with NFPA 101, 2012 edition, a built-in cabinet. The maintenance
section 7.10.1.9.; director removed the decorative items
f) ensure proper sprinkler maintenance in from the top of the cabinet, on 8-20-2020.
accordance with NFPA 101-2012 and NFPA 4- The maintenance department
25-2011, Sections 5.2 and 5.2.1.1.1, 5.3.2.1, and installed a smoke seal along the 200 wing
table 5.1.1.2.; smoke doors, creating a gap less than
g) keep the means of egress open to full and 1/8”, on 8-21-2020.
instant use in accordance with NFPA 101, 2012 5- On 8-21-2020, the maintenance
Edition, Sections 7.1.10.1 and 19.2.3.4(5).; director installed an exit sign at the 200
h) provide a safe, functional, sanitary, and wing emergency exit door, readily visible
comfortable environment for residents, staff and in the direction of exit access.
the public; and 6- At the time of inspection, the 200 wing
i) maintain oxygen cylinders per NFPA 99-2012, was going through a remodel. The
Section 11.6.2.3. penetrations around the sprinkler piping
on the 200 wing were sealed with fire stop
These deficiencies affect all smoke prior to the 7-27-2020 inspection. On 8-20
compartments of the facility. Findings include: -2020, the maintenance department
installed the missing escutcheon rings on
1. During an observation on 7/27/20 at 12:20 the 200 wing for aesthetics.
p.m., the main dining room was inspected. A 7- On 7-29-2020, the maintenance
dining table was observed, approximately four department trimmed the overgrown
feet in length, placed up against the wall, and shrubs growing over the sidewalks around
blocking access to the portable fire extinguisher the perimeter of the building which were
in the room. blocking the means of egress to the public
way.
2. During an observation on 7/27/20 at 12:23 8- The maintenance department
p.m., the kitchen was inspected. The K tank in repaired the soffit and fascia outside room
the room was blocked from easy access by a 424 on 7-31-2020.
large garbage can being stored in front of it. The 9- The maintenance department cleaned
manual fire pull station on the back wall and the area around the missing soffit and
manual pull station for the kitchen hood were both repaired the soffit outside room 429 on 7-
obstructed by various items being stored in front 31-2020.
of them. 10- The maintenance department
repaired the soffit and fascia outside room
3. During an observation on 7/27/20 at 1:13 p.m., 423 on 7-31-2020.
the 400-wing nursing station was inspected. A 11- The maintenance department
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 27 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 921 Continued From page 27 F 921

large side table with decorative items was re-secured the soffits to the building
observed, placed directly in front of two electrical outside room 418 and 419 on 8-3-2020.
panels on the wall. 12- The maintenance department
repaired the exterior corner area of 400
4. During an observation on 7/27/20 at 1:25 p.m. and 500 on 8-3-2020.
the 200-wing smoke doors were inspected. The 13- The maintenance department
doors were closed and a gap greater than ½" was repaired the soffit outside the 500 wing
observed in the bottom portion of the door. sitting room on 8-3-2020.
14- The holes and gaps in the soffits
5. During an observation on 7/27/20 at 1:27 p.m., outside rooms 517, 516, 510, 509, 505
the 200-wing emergency exit door was inspected. and 504 were patched by the
The door was missing illuminated exit signage maintenance department on 8-20-2020.
directing all persons in the area to the means of 15- The maintenance department
egress. repaired the soffit and fascia outside room
503 on 8-3-2020.
6. During an observation on 7/27/20 at 1:28 p.m., 16- The maintenance department cleaned
the 200-wing was inspected. Several sprinkler the area and repaired the soffit outside
heads throughout the hall were observed, missing rooms 412 and 413 on 7-31-2020.
their escutcheon rings. 17- The maintenance department patched
the holes in the soffits and re-secured the
7. During an observation on 7/28/20 at 8:08 a.m., soffits to the building outside the main
the exterior of the facility was inspected. Several dining room and rooms 403 and 406, on 8
large overgrown shrubs were observed growing -20-2020.
over the sidewalks around the perimeter of the 18- The 6 water stained ceiling tiles were
building, blocking the means of egress to the replaced on 8-21-2020 by the
public way. maintenance department. The roof deck
above the ceiling tiles in the conference
8. During an observation on 7/28/20 at 8:57 a.m., room was discolored but not structurally
a walk around of the exterior of the facility was compromised.
conducted. Outside of resident room 424, the 19- The seven water stained ceiling tiles
soffits and fascia were observed tearing away in the dining room were replaced on 8-21-
from the roof. Severe water damage was present. 2020 by the maintenance department.
20- The water stains on the exterior wall
9. During an observation on 7/28/20 at 8:59 a.m., in the dining room were cleaned by the
a walk around of the exterior of the facility was maintenance department on 8-21-2020.
conducted. Outside of resident room 429, a large 21- The insulation was positioned back in
portion of the soffit was observed missing from place and the area was cleaned by the
the exterior of the facility. Several areas were maintenance department on 7-30-2020, in
noted with severe water damage and possible the 500 sitting room across from room
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 28 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 921 Continued From page 28 F 921

mold growth. Rodent feces were present. 521. The soffit outside the 500 wing sitting
room was repaired by the maintenance
During an interview on 7/28/20 at 9:00 a.m., staff department on 8-3-2020.
member P stated the opening was, "About my 22- The insulation was replaced and the
height, I'm just over six feet tall." area was cleaned by the maintenance
department on 7-31-2020, in room 413,
10. During an observation on 7/28/20 at 9:02 above the drop ceiling on the exterior wall.
a.m., a walk around of the exterior of the facility The soffit outside room 413 was repaired
was conducted. Outside of resident room 423, by the maintenance department on 7-31-
the fascia was observed missing from the exterior 2020.
of the facility and the soffit was tearing away from 23- On 7-30-2020, the maintenance
the building. Severe water damage was present. director removed the growing vegetation
from the areas observed on 7-28-2020.
11. During an observation on 7/28/20 at 9:05 No standing water was noted on 7-30-
a.m., a walk around of the exterior of the facility 2020.
was conducted. Outside of resident rooms 418 24- The burnt out bulbs in the six ceiling
and 419, the soffits were observed tearing away mounted light fixtures were replaced on 8-
from the building. 20-2020, by the maintenance department.
25- The burnt out bulbs in the four ceiling
12. During an observation on 7/28/20 at 9:08 mounted light fixtures were replaced by
a.m., a walk around of the exterior of the facility the maintenance department, on 8-20-
was conducted. At the exterior corner of the 400 2020.
and 500 wings, the fascia was observed missing. 26- The oxygen contractor removed the
Wet wood was exposed, and severe water twenty-four oxygen e-tanks which were
damage was present. sitting on a cart outside of the front office
sitting area.
13. During an observation on 7/28/20 at 9:09 27- The maintenance department cleaned
a.m., a walk around of the exterior of the facility the dust and debris from the two sprinkler
was conducted. A large piece of soffit was heads in the front exterior entrance, on 8-
observed, approximately five feet in length, lying 20-2020.
on the ground. The soffit had fallen from the 28- At 3:45pm, on 7-29-2020, after an
exterior of the building. Severe water damage exterior inspection of the facility and an
was present. interior inspection of the sitting room
across from 521 and room 413 was
During an interview on 7/28/20 at 9:10 a.m., staff conducted in conjunction with the City of
member P stated he was not aware that the soffit Great Falls Fire Captain and the City of
had fallen. He stated, "It must have fallen recently Great Falls Building Official, the facility
because it's still on the ground." Staff member P implemented our 24 hour fire watch
stated the exposed area of the building was, "At procedure. On 7-30-2020, the
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 29 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 921 Continued From page 29 F 921

least five feet long." maintenance department positioned the
piece of insulation back into place in the
14. During an observation on 7/28/20 at 9:12 sitting room across from 521. On 8-3-
a.m., a walk around of the exterior of the facility 2020, the maintenance department
was conducted. The exterior of the building repaired the soffit outsider the sitting area
outside of resident rooms 517, 516, 510, 509, across from 521. On 7-31-2020, the
505, and 504 we observed. Several holes and maintenance department replaced the
gaps were noted in the soffits and water damage insulation and repaired the soffit outside
was present. room 413. On 7-31-2020, GFFS started
replacing sprinkler heads on the 400 and
15. During an observation on 7/28/20 at 9:21 500 wings, completing the replacement on
a.m., a walk around of the exterior of the facility 8-3-2020. GFFS conducted a flow test on
was conducted. The exterior of the building the automatic fire sprinkler system on 8-3-
outside of resident room 503 was observed. The 2020 to ensure proper operation of the
soffits and fascia were tearing away from the system. On 8-5-2020, Northern Industrial
building and drooping greater than two feet. Hygiene conducted visual inspections, air
Severe water damage was present. sampling and lift tests in the sitting room
across from 521 and in room 413, also air
16. During an observation on 7/28/20 at 9:24 sampling on the 400 and 500 wings. On 8
a.m., a walk around of the exterior of the facility -7-2020, the maintenance director was
was conducted. Outside of resident rooms 413 verbally informed the results of the
and 412, a large portion of the soffit, samples as being ok with no elevated
approximately six feet in length, was observed spore count levels. On 8-14-2020, the
missing. The missing soffit was observed maintenance director received the written
propped against the exterior of the building on report from Northern Industrial Hygiene,
another wing. Severe water damage and rodent confirming the results.
feces were observed.

During an interview on 7/28/20 at 9:25 a.m., staff

member P stated he observed the rodent feces
surrounding the opening in the exterior of the 2. How the facility will identify other
building. He stated, "Surprisingly, there's been no residents having the potential to be
complaints of rodents." affected by the same deficient practice:

17. During an observation on 7/28/20 at 9:26 1. On 8-20-2020, the maintenance

a.m., a walk around of the exterior of the facility director conducted an audit of the facility
was conducted. The exterior of the building portable fire extinguishers to ensure easy
outside of the main dining room and resident access in accordance with NFPA 10
rooms 403 and 406 were observed. Holes in the Standard for Portable Fire Extinguishers,
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 30 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 921 Continued From page 30 F 921

soffits were noted, as well as several areas where 2010 Edition, Section 6.1.3.3.1.
the soffits and fascia were tearing away from the 2. On 8-20-2020, the maintenance
exterior of the building. Water damage was director conducted an audit of the facility
present. manual fire alarm pull stations to ensure
accessibility in accordance with NFPA
18. During an observation on 7/28/20 at 9:58 101, 2012 Edition, Section 9.6.2.7.
a.m., a walk around of the interior of the facility 3. On 8-20-2020, the maintenance
was conducted. Inside the conference room, six director conducted an audit of the facility
ceiling tiles were observed with water damage. electrical panels to ensure access in
Above the ceiling tiles, water damage to the roof accordance with NFPA 70 National
deck was observed. Electric Code, 2011 Edition.
4. The maintenance department will
During an interview on 7/28/20 at 9:59 a.m., staff conduct an audit of facility fire/smoke
member P stated the water damage to the ceiling barrier doors located in the fire/smoke
tiles was a result of one of the roof leaks the partitions on or before 8-26-2020 to
facility had sustained. He stated, "I patched it in ensure they are properly maintained with
early March." a gap not more than 1/8” per NFPA 101-
2012, Section 8.4.3.4 and NFPA 80
19. During an observation on 7/28/20 at 10:01 Standard for Fire Doors and Other
a.m., a walk around of the interior of the facility Opening Protectives, 2010 Edition,
was conducted. Inside the dining room, seven Section 6.3.1.7.1.
ceiling tiles were observed with water damage. 5. The maintenance director conducted
an audit of the facility emergency exit
During an interview on 7/28/20 at 10:02 a.m., doors on 8-20-2020, to ensure an exit
staff member P stated the water damage was sign is present in accordance with NFPA
sustained in early March during the same time 101, 2012 edition, section 7.10.1.9.
that the conference room ceiling sustained water 6. The maintenance department will
damage. conduct an audit of the facility sprinkler
escutcheon rings on or before 8-26-2020,
20. During an observation on 7/28/20 at 10:02 to ensure proper maintenance of
a.m., a walk around of the interior of the facility escutcheon rings in accordance with
was conducted. The exterior wall in the dining NFPA 101-2012.
room was observed, covered with streaks of 7. On 8-20-2020, the maintenance
brown water stains. department conducted an audit of the
facilities means of egress to ensure they
During an interview on 7/28/20 at 10:03 a.m., were open to full and instant use in
staff member P stated the water stains were a accordance with NFPA 101, 2012 Edition,
result of constant patching of the facility's gutter Sections 7.1.10.1 and 19.2.3.4(5).
system. He stated he had tried to wash the stains 8. On 8-4-2020, the maintenance
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 31 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 921 Continued From page 31 F 921

off the wall several times, but they keep coming director conducted an exterior audit of the
back and won't scrub off. facilities soffits and fascia to ensure they
were in place and holes were sealed.
21. During an observation on 7/28/20 at 10:04 9. On 7-30-2020, the maintenance
a.m., a walk around of the interior of the facility director conducted an external audit of the
was conducted. The storage area, across from facilities fascia and soffits to identify any
resident room 521 was inspected. A ceiling tile areas where the insulation was missing
was removed near the exterior wall. The soffit creating exposure from the outside
was missing on the exterior of the building, elements to the inside.
exposing the interior of the building, and the wet 10. The maintenance department will
sprinkler piping to external elements. Rodent conduct an audit of the facilities ceiling
feces and severe water damage were observed. tiles and walls on or before 8-26-2020, to
identify any tiles and/or walls which may
22. During an observation on 7/28/20 at 10:32 be damaged or stained due to water from
a.m., a walk around of the interior of the facility roof leaks.
was conducted. Resident room 413 was 11. On 7-30-2020, the maintenance
inspected. A ceiling tile was removed near the director conducted an audit of the facilities
exterior wall. The soffit was missing on the roof to identify areas of standing water or
exterior of the building, exposing the interior of growing vegetation.
the building, and the wet sprinkler piping to 12. On or before 8-26-2020, the
external elements. Rodent feces and severe maintenance department will conduct an
water damage were observed. audit of the facility lighting to ensure
ceiling mounted light fixtures are properly
23. During an observation on 7/28/20 at 12:49 lit.
p.m., the roof was inspected. Standing water was 13. On 8-20-2020, the maintenance
observed in addition to growing vegetation. director conducted an audit of the facility
to ensure there were no unapproved
During an interview on 7/28/20 at 12:50 p.m., areas where portable oxygen tanks were
staff member P stated the roof at the facility not being supervised or attended to by
needed to be replaced. He stated he has any staff members.
received several bids; however, he was waiting 14. On or before 8-26-2020, the
for permission to proceed with the work from the maintenance department will conduct an
corporate office. Staff member P stated the roof audit of the facility sprinkler heads and
was flat and holds water after rainstorms. sprinkler piping to ensure they are free
from debris or any foreign materials.
24. During an observation on 7/29/20 at 10:16 3. What measures will be put in place or
am, the 500 wing was inspected. Six of the what systemic changes you will make to
thirteen ceiling mounted light fixtures were ensure that the deficient practice will not
observed with burnt out bulbs. re-occur
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 32 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 921 Continued From page 32 F 921

25. During an observation on 7/29/20 at 10:30 1. The Maintenance Director or qualified

a.m., the 400 wing was inspected. Four of the six designee will re-educate facility staff on
ceiling mounted light fixtures were observed with properly maintaining easy access to
burnt out bulbs. facility fire extinguishers per NFPA 10,
2010 Edition Section 6.1.3.3.1. The
26. During an observation on 7/29/20 at 11:10 Maintenance Director or qualified
a.m., twenty-four portable oxygen e-tanks were designee will educate newly hired staff on
observed sitting on a cart outside of the front properly maintaining easy access to
office reception area. The oxygen tanks were not facility fire extinguishers, during the new
being supervised or attended to by any staff hire orientation process.
members. The e-tanks were again observed 2. The Maintenance Director or qualified
unaccompanied at 1:10 p.m.. designee will re-educate facility staff on
properly maintaining manual fire alarm
During an interview on 7/29/20 at 1:11 p.m., staff pull stations to ensure accessibility in
member C stated that he was not sure why the accordance with NFPA 101, 2012 Edition,
e-tanks were being stored in front of the reception Section 9.6.2.7. The Maintenance Director
area, however he believed that the oxygen or qualified designee will educate newly
contractor was on-site and was going to be hired staff on properly maintaining manual
putting them away. fire alarm pull stations to ensure
accessibility, during the new hire
27. During an observation on 7/29/20 at 1:13 orientation process.
p.m., the front exterior entrance was inspected. 3. The Maintenance Director or qualified
Two sprinkler heads were observed, loaded with designee will re-educate the facility staff
dust and debris. on having sufficient working space around
electrical panels in accordance with NFPA
28. On 7/29/20 at 2:00 p.m., an interior and 70 National Electric Code, 2011 Edition.
exterior inspection of the facility was conducted in The Maintenance Director or qualified
conjunction with the City of Great Falls Fire designee will educate newly hired staff on
Captain and the City of Great Falls Building properly maintaining sufficient working
Official. All above noted deficiencies were space around electrical panels, during the
inspected during this time. new hire orientation process.
4. The Maintenance Director will
During an interview on 7/29/20 at 2:08 p.m., the re-educate the maintenance department
City of Great Falls Fire Captain stated his on ensuring fire/smoke barrier doors
department was not responsible for enforcing located in the fire/smoke partitions are
building code requirements. He observed the properly maintained with a gap not more
above deficiencies noted deficiencies and stated than 1/8” per NFPA 101-2012.
that his two primary concerns were: 5. The Maintenance Director will
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 33 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 921 Continued From page 33 F 921

a) The wet sprinkler system being compromised re-educate the maintenance department
due to the internal wet sprinkler piping being on ensuring an exit sign is present at
exposed to external elements; emergency exit doors in accordance with
b) The two unprotected areas with the large NFPA 101, 2012 edition, section 7.10.1.9.
openings in the ceiling, which expose the inside 6. The Maintenance Director will
of the facility to the outside. re-educate the maintenance department
He stated in the event that there was to be a fire on ensuring proper maintenance of
within the facility, oxygen from the outside would escutcheon rings in accordance with
fuel the fire. NFPA 101-2012.
7. The Maintenance Director will
During an interview on 7/29/20 at 2:50 p.m., the re-educate the maintenance department
City of Great Falls Building Official stated the on the facilities means of egress, ensuring
facility was, "Very cheaply built." He stated the they are open to full and instant use in
building was both habitable and structurally accordance with NFPA 101, 2012 Edition,
sound; however, the extent of the water damage Sections 7.1.10.1 and 19.2.3.4(5).
was a serious concern and there was possible 8. The Maintenance Director will
mold growth present. He stated, "The building is re-educate the maintenance department
compromised", and failure to repair the identified on the facilities soffits and fascia to
issues would result in the building getting worse. ensure they are in place and holes are
He acknowledged the presence of rodent feces sealed.
inside the facility and stated his department was 9. The Maintenance Director will
not responsible for enforcing maintenance and re-educate the maintenance department
repair deficiencies. on identifying and repairing/replacing
stained and/or damaged ceiling tiles
throughout the facility.
10. The Maintenance Director will
re-educate the maintenance department
on ensuring there is no standing water or
growing vegetation, on the roof.
11. The Maintenance Director will
re-educate the maintenance department
on identifying and replacing any burnt out
bulbs in ceiling mounted light fixtures
when first seen. The Maintenance
Director will re-educate the facility staff on
notifying the maintenance department on
burnt out lights, using the Tels work order
system.
12. The Maintenance Director or qualified
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 34 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 921 Continued From page 34 F 921

designee will re-educate facility staff and
the oxygen contractor the need to have
portable oxygen tanks supervised or
attended to when in the hall. The
Maintenance Director or qualified
designee will educate newly hired staff on
the need to have portable oxygen tanks
supervised or attended to when in the hall,
during the new hire orientation process.
13. The Maintenance Director re-educate
the maintenance staff on ensuring
sprinkler heads are free from any foreign
debris, items and/or materials per NFPA
101, 2012 Edition and NFPA 25, 2011
Edition.

4. How the facility plans to monitor its

performance to ensure corrective actions
are sustained. This plan must be
implemented, and corrective action
evaluated for its effectiveness:
1. The maintenance department will
conduct audits of the facility extinguishers
weekly times four weeks and then
monthly for two months, to ensure
extinguishers are properly maintained with
easy access. The Maintenance Director
will present audit findings to the monthly
Performance Improvement Committee for
review and evaluation of the plans
effectiveness and sustainability.
2. The maintenance department will
conduct audits of the manual fire alarm
pull stations weekly times four weeks and
then monthly for two months, to ensure
manual pull stations are properly
maintained with easy access. The
Maintenance Director will present audit
findings to the monthly Performance
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 35 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 921 Continued From page 35 F 921

Improvement Committee for review and
evaluation of the plans effectiveness and
sustainability.
3. The maintenance department will
conduct audits of the facility electrical
panels weekly times four weeks and then
monthly for two months, to ensure
sufficient working space around them per
NFPA 70 NEC, 2011 Edition. A summary
of the audits will be presented to the
monthly Performance Improvement
Committee for evaluation of the plans
effectiveness and sustainability.
4. The maintenance department will
conduct audits of the facility fire/smoke
doors located in the fire/smoke partitions
weekly times four weeks and then
monthly thereafter, ensuring fire/smoke
barrier doors are properly maintained with
a gap not more than 1/8” per NFPA 101-
2012. A summary of the audits will be
presented to the monthly Performance
Improvement Committee for evaluation of
the plans effectiveness and sustainability.
5. The maintenance department will
conduct audits of the facility emergency
exit doors weekly times four weeks and
then monthly for two months, ensuring an
exit sign is present in accordance with
NFPA 101, 2012 edition, section 7.10.1.9.
A summary of the audits will be presented
to the monthly Performance Improvement
Committee for evaluation of the plans
effectiveness and sustainability.
6. The maintenance department will
conduct audits of the facility escutcheon
rings weekly times four weeks and then
monthly thereafter, ensuring proper
maintenance of escutcheon rings in
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 36 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 921 Continued From page 36 F 921

accordance with NFPA 101-2012. A
summary of the audits will be presented to
the monthly Performance Improvement
Committee for evaluation of the plans
effectiveness and sustainability.
7. The maintenance department will
conduct audits of the facility means of
egress weekly times four weeks and then
monthly thereafter, ensuring they are
open to full and instant use in accordance
with NFPA 101, 2012 Edition, Sections
7.1.10.1 and 19.2.3.4(5). A summary of
the audits will be presented to the monthly
Performance Improvement Committee for
evaluation of the plans effectiveness and
sustainability.
8. The maintenance department will
conduct audits of the facilities soffits and
fascia weekly times four weeks and then
monthly thereafter, ensuring they are in
place and holes are sealed. A summary of
the audits will be presented to the monthly
Performance Improvement Committee for
evaluation of the plans effectiveness and
sustainability.
9. The maintenance director will conduct
10% sample audits of the facilities exterior
wall insulation weekly times four weeks
and then monthly times two weeks,
ensuring the insulation is in place. A
summary of the audits will be presented to
the monthly Performance Improvement
Committee for evaluation of the plans
effectiveness and sustainability.
10. The maintenance department will
conduct audits of the facilities ceiling tiles
and walls weekly times four weeks and
then monthly thereafter, ensuring no water
damage is present. A summary of the
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 37 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 921 Continued From page 37 F 921

audits will be presented to the monthly
Performance Improvement Committee for
evaluation of the plans effectiveness and
sustainability.
11. The maintenance director will conduct
audits of the facilities roof weekly times
four weeks and then monthly thereafter,
ensuring no standing water and/or
vegetation growth. A summary of the
audits will be presented to the monthly
Performance Improvement Committee for
evaluation of the plans effectiveness and
sustainability.
12. The maintenance director will conduct
audits of the facilities ceiling mounted light
fixtures times four weeks and then
monthly thereafter, ensuring the fixtures
are properly lit. A summary of the audits
will be presented to the monthly
Performance Improvement Committee for
evaluation of the plans effectiveness and
sustainability.
13. The maintenance director will conduct
audits of the facility weekly times four
weeks and then monthly times two
months, ensuring there are no
unapproved areas where portable oxygen
tanks are stored were not being
supervised or attended to by any staff
members. A summary of the audits will be
presented to the monthly Performance
Improvement Committee for evaluation of
the plans effectiveness and sustainability.
14. The maintenance department will
conduct audits of the facility sprinkler
heads weekly times four weeks and then
monthly times two months, to ensure
sprinkler heads are free from debris or
any foreign material. The Maintenance
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 38 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 921 Continued From page 38 F 921

Director will present audit findings and
completed sprinkler maintenance reports,
from outside contractor, to the monthly
Performance Improvement Committee for
review and evaluation of the plans
effectiveness and sustainability.

5. Date of when corrective action will be

completed: 9-4-2020
F 925 Maintains Effective Pest Control Program F 925 9/4/20
SS=E CFR(s): 483.90(i)(4)

§483.90(i)(4) Maintain an effective pest control

program so that the facility is free of pests and
rodents.
This REQUIREMENT is not met as evidenced
by:
Based on observation and interview, the facility 1. How the corrective action will be
failed to maintain an adequate pest control accomplished for those residents that
program to prevent rodents from entering the have been affected by the deficient
facility. This deficient practice had the potential to practice:
affect all residents residing in the 400 and 500 The insulation was positioned back in
wings of the facility. Findings include: place and the area was cleaned by the
maintenance department on 7-30-2020, in
During an observation on 7/28/20 at 10:04 a.m., the 500 sitting room across from room
the sitting room, across the hall from resident 521. The soffit outside the 500 wing sitting
room 521, was inspected. A ceiling tile was room was repaired by the maintenance
removed from the ceiling, and an opening in the department on 8-3-2020.
exterior wall of the facility was observed. Rodent The insulation was replaced and the area
feces were observed on several of the ceiling was cleaned by the maintenance
tiles. department on 7-31-2020, in room 413,
above the drop ceiling on the exterior wall.
During an observation on 7/28/20 at 10:32 a.m., The soffit outside room 413 was repaired
resident room 413 was inspected. A ceiling tile by the maintenance department on
was removed from the ceiling and an opening in 7-31-2020. On 7-31-2020 Orkin verified
the exterior wall of the facility was observed. no rodents were nesting above the ceiling
Rodent feces were observed on several of the on the 400 or 500 wings.
ceiling tiles.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 39 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 925 Continued From page 39 F 925

2. How the facility will identify other
During an interview on 7/28/20 at 10:34 a.m., residents having the potential to be
staff member P stated he was not aware that the affected by the same deficient practice:
exterior of the facility was open to the interior. He On 7-30-2020, the maintenance director
stated he could see the rodent feces present in conducted an external audit of the
the area. facilities fascia and soffits to identify any
areas where the insulation was missing
Refer to 0921, creating exposure from the outside
Safe/Functional/Sanitary/Comfortable elements to the inside giving the
Environment, for additional information. opportunity for pest or rodents to enter the
facility.
3. What measures will be put in place or
what systemic changes you will make to
ensure that the deficient practice will not
re-occur
The Maintenance Director will re-educate
the maintenance department on the
facilities soffits and fascia to ensure they
are in place and holes are sealed and
insulation is in place to prevent pests
and/or rodents access to the facility.
4. How the facility plans to monitor its
performance to ensure corrective actions
are sustained. This plan must be
implemented, and corrective action
evaluated for its effectiveness:
The maintenance director will conduct 10
sample audits of the facilities exterior wall
insulation weekly times four weeks and
then monthly times two weeks, ensuring
the insulation is in place. The
maintenance director will review the
monthly pest control service reports from
Orkin for any issues or concerns. A
summary of the audits and summary of
the monthly service report will be
presented to the monthly Performance
Improvement Committee for evaluation of
the plans effectiveness and sustainability.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 40 of 41
 PRINTED: 11/02/2020
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
275030 B. WING _____________________________
07/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1500 32ND ST S
PARK PLACE TRANSITIONAL CARE AND REHABILITATION
GREAT FALLS, MT 59405

(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 925 Continued From page 40 F 925

5. Date of when corrective action will be

completed: 9-4-2020

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D88G11 Facility ID: MT275030 If continuation sheet Page 41 of 41