21 Reports
Inspection Report — Apr 28, 2026
Renewal
Date: Apr 28, 2026
Visit Reason
The survey was conducted as a renewal inspection to assess compliance with Montana assisted living facility regulations.
Findings
The facility was found to have multiple deficiencies including admitting a resident with a jejunostomy tube not allowed in a Category A facility, inaccessible emergency call system, incomplete disaster plan reviews, inadequate staff background checks and training, and multiple issues with resident care plans and physical plant conditions.
Deficiencies (18)
50-5-226-2 Placement in assisted living facilities: the facility admitted and retained a resident with a jejunostomy tube, which is not permitted in a Category A assisted living facility.
37.106.302-2 Minimum standards of construction for a: the emergency call cord for a resident was blocked and inaccessible if the resident were collapsed on the floor.
37.106.322-3 Minimum standards for all health care fa: the facility lacks documented review of disaster plans with staff for 2025 and has not updated the disaster plan annually with a written off-site agreement.
37.106.2816-2 Assisted living facility staffing: staff background checks were incomplete or missing, including a disqualifying criminal background and failure to conduct out-of-state checks; this is a repeat deficiency and plan of correction was not followed.
37.106.2816-3 Assisted living facility staffing: employee files lacked documentation of orientation or training on medication administration and dementia care; this is a repeat deficiency and plan of correction was not followed.
37.106.2816-4 Assisted living facility staffing: staff files did not document review of each resident's service plan.
37.106.2816-5 Assisted living facility staffing: staff have not been trained in the abdominal thrust maneuver or basic first aid.
37.106.2821-6 Resident application and needs assessment procedure: a resident's needs assessment was not updated to reflect the placement of a jejunostomy tube and related medical changes.
37.106.2822-3 Resident service plan: category A: a resident's service plan was not updated to reflect the placement of a jejunostomy tube and associated care requirements.
37.106.2829-2 Resident file: incident reports lacked documentation of communication with providers or family, and two closed files failed to document discharge or death circumstances and required notices.
37.106.2835-2 Resident units: extension cords with multiple electronics were found in a resident's room, posing a safety hazard.
37.106.2836-1 Furnishings: five rooms had curtains without documentation confirming they are flame-resistant or made of non-combustible materials.
37.106.2860-9 Food service: the facility did not maintain monthly temperature logs for freezers and refrigerators.
37.106.2865-1 Physical plant: the facility has a persistent bed bug infestation despite ongoing pest control treatments, with treatment refusal in one resident's room.
37.106.2865-6 Physical plant: carpets and vinyl bathroom flooring in common areas and resident rooms were dirty, stained, and covered in debris, with additional damage to heater vents.
37.106.2865-11 Physical plant: shared bathrooms did not have single use paper towels available.
37.106.2866-8 Construction, building and fire codes: the facility could not provide documentation of fire drills for the current or previous years due to administrative transition.
37.106.2866-12 Construction, building and fire codes: the facility was unable to provide smoke detector battery and maintenance logs.
Inspection Report — May 1, 2025
Renewal
Date: May 1, 2025
Visit Reason
The survey was conducted as a renewal inspection of the assisted living facility.
Findings
Five deficiencies were identified related to administrator continuing education, staffing background checks, bathroom door hardware, environmental cleanliness, and fire code compliance.
Deficiencies (5)
37.106.2814-3 Administrator: the administrator only received 11.25 continuing education hours in 2024, which is insufficient.
37.106.2816-2 Assisted living facility staffing: one employee file lacked a criminal background check.
37.106.2838-4 Resident toilets and bathing: all resident bathroom doors are equipped with non-single motion locking doorknobs.
37.106.2839-1 Environmental control: resident rooms 9 and 11 need vacuuming, and room 10 is severely unclean with garbage and spilled cat food, creating a safety hazard.
37.106.2866-4 Construction, building and fire codes: the northeast side and downstairs exit doors have non-single motion locking doorknobs.
Inspection Report — Apr 30, 2024
Renewal
Date: Apr 30, 2024
Visit Reason
The facility underwent a renewal inspection as part of its regular licensing process.
Findings
Two deficiencies were identified: resident files lacked required documentation of significant events, and the carpet in resident rooms needed cleaning due to debris and dirt.
Deficiencies (2)
37.106.2829-2 Resident file: three resident files did not include required documentation of significant events as specified in (e)(i) and (e)(iii).
37.106.2839-1 Environmental control: the carpet in resident rooms 10 and 11 was dirty and had debris, requiring cleaning and vacuuming.
Inspection Report — May 10, 2023
Original Licensing
Date: May 10, 2023
Visit Reason
The survey was conducted as a provisional status inspection of the assisted living facility.
Findings
The survey identified multiple deficiencies including inadequate cleaning and maintenance, missing documentation in employee and resident files, and safety issues such as missing smoke detectors and lack of thermometers in freezers.
Deficiencies (11)
37.106.320-7 Minimum standards for all health care facilities: a strong smell of urine was detected in a resident room where handheld urinals were only emptied once per shift.
37.106.2816-3 Assisted living facility staffing: employee files lacked documentation of orientation and training for some employees.
37.106.2817-2 Employee files: one employee file did not have an initialed or signed job description.
37.106.2822-1 Resident service plan: category A: a resident's service plan was not developed within 24 hours of admission.
37.106.2822-3 Resident service plan: category A: a resident's service plan was not reviewed and updated as required.
37.106.2829-2 Resident file: some residents did not have records of weight on admission or annual weights documented.
37.106.2838-4 Resident toilets and bathing: a resident bathroom was not equipped with a single motion doorknob.
37.106.2839-1 Environmental control: carpets in several resident rooms were dirty and needed cleaning.
37.106.2860-9 Food service: two stand-up freezers lacked thermometers.
37.106.2865-12 Physical plant: water temperatures recorded were 126.3°F in the main resident bathroom tub and 139.6°F in the kitchen sink.
37.106.2866-12 Construction, building and fire codes: several resident rooms were without smoke detectors at the time of the survey.
Report Facts
temperature: 126.3
temperature: 139.6
Inspection Report — Oct 18, 2022
Complaint Investigation
Date: Oct 18, 2022
Visit Reason
A complaint investigation was conducted following concerns about facility cleanliness and resident care.
Complaint Details
The complaint investigation cited deficiencies related to uncleanliness of resident rooms and bathrooms, improper laundry practices, and inadequate bedding maintenance.
Findings
The facility was found to have multiple environmental and laundry issues, including unclean resident rooms and bathrooms, full and overflowing garbage with soiled briefs, and beds with dirty linens not changed weekly. Many beds lacked moisture-proof mattress covers and pads.
Deficiencies (2)
37.106.2839-1 Environmental control: resident bedrooms and bathrooms were unclean with dirt, debris, full garbage containing soiled briefs, and urine and feces splattered on surfaces; urinals in rooms were full and not emptied.
37.106.2861-4 Laundry: many beds had dirty, stained linens not changed at least weekly, and most beds lacked moisture-proof mattress covers and mattress pads.
Inspection Report — May 12, 2022
Renewal
Date: May 12, 2022
Visit Reason
The facility underwent a renewal inspection to assess compliance with Montana assisted living standards.
Findings
Multiple deficiencies were found including issues with door locks not meeting safety standards, lack of documentation for disaster plans and employee orientation, missing resident assessments and service plans, medication order and administration documentation errors, oxygen use problems, pet vaccination documentation missing, and fire drill documentation deficiencies.
Deficiencies (19)
37.106.302-2 Minimum standards of construction for a: medication room, downstairs bathroom, and some resident room doors require a key or special knowledge to open if locked, violating life safety code. This is a repeat deficiency.
37.106.322-3 Minimum standards for all health care fa: no documentation of annual disaster plan review, no plans for acquiring additional supplies during disaster, and no written off-site evacuation agreement.
37.106.2816-3 Assisted living facility staffing: no documentation that employees reviewed policy and procedure manual, received orientation to services, or were oriented to Montana abuse prevention and resident rights acts. This is a repeat deficiency.
37.106.2816-4 Assisted living facility staffing: no documentation that staff were oriented to service plans.
37.106.2817-2 Employee files: majority of employee files lacked signed job descriptions and documentation of orientation and ongoing training including Heimlich and first aid. This is a repeat deficiency.
37.106.2817-3 Employee files: administrator file missing orientation and training documentation including Heimlich, first aid, abuse prevention, and resident rights acts.
37.106.2821-3 Resident application and needs assessmen: Resident #1 lacks an initial resident needs assessment. This is a repeat deficiency.
37.106.2822-1 Resident service plan: category a: Residents #1 and #2 lack service plans based on initial needs assessments. This is a repeat deficiency.
37.106.2836-1 Furnishings: facility cannot document flame-resistant or non-combustible window treatments; several rooms have cloth curtains and use blankets as window coverings. This is a repeat deficiency.
37.106.2839-4 Environmental control: resident #1 and #2’s shared room smells of recent cigarette smoke despite attempts to smoke outside. This is a repeat deficiency.
37.106.2847-1 Medications: practitioner orders: residents #1, #2, and #4 have no medication treatment orders to confirm prescribed orders are carried out. This is a repeat deficiency.
37.106.2849-1 Medications: records and documentation: medication administration records missing many staff signatures; Resident #3’s lisinopril was not signed out for 12 days though medication was dispensed. This is a repeat deficiency.
37.106.2849-2 Medications: records and documentation: MARs lack medication use reasons, documentation of missed/refused meds, many missing staff signatures, and no staff signature for MAR review. This is a repeat deficiency.
37.106.2849-4 Medications: records and documentation: no written doctor’s orders for residents #1, #2, or #4 indicating capability to keep medications at bedside. This is a repeat deficiency.
37.106.2853-3 Oxygen use: resident #6 had ongoing problems with oxygen administration; staff unaware how to properly connect oxygen.
37.106.2853-4 Oxygen use: resident #2 smokes halfway in her room while oxygen is present; resident #1 states oxygen is leftover from prior illness; no physician orders for oxygen for either resident. This is a repeat deficiency.
37.106.2859-1 Pets: facility has two dogs and one cat without documentation of vaccinations. This is a repeat deficiency.
37.106.2866-8 Construction, building and fire codes: no evidence of employee or resident fire drills conducted since 2020. This is a repeat deficiency.
37.106.2866-9 Construction, building and fire codes: no evidence that documentation of employee or resident fire drills was kept for 24 months.
Inspection Report — Feb 9, 2022
Complaint Investigation
Date: Feb 9, 2022
Visit Reason
Complaint inspection of At Home Assisted Living facility in Missoula, Montana.
Complaint Details
The complaint inspection found multiple deficiencies related to unsafe facility conditions, poor sanitation, inadequate resident activities, medication management issues, and food service problems.
Findings
Numerous deficiencies were found including unsafe locking mechanisms, unclean and unsanitary resident rooms, lack of planned activities, unsafe resident units, medication storage and documentation issues, food service problems, and physical plant maintenance concerns.
Deficiencies (22)
37.106.302-2 Minimum standards of construction for a: the lower-level basement door can be locked from the outside requiring residents to have a key to exit, violating life safety code.
37.106.320-4 Minimum standards for all health care fa: carpets throughout the facility and resident rooms are heavily stained and dirty with debris and food crumbs.
37.106.320-6 Minimum standards for all health care fa: resident rooms have strong odors of urine and feces due to staff not emptying commodes and poor sanitation.
37.106.2831-1 Resident activities: there are no planned activities and no indication residents are assessed for activity preferences on service plans.
37.106.2831-4 Resident activities: no activity calendar is posted and no previous months' calendars were provided.
37.106.2835-2 Resident units: extension cord taped loosely creating a tripping hazard and some resident room doors require special knowledge to open.
37.106.2839-1 Environmental control: most resident rooms and bathrooms are cluttered, unsanitary, and pose health risks due to garbage, mold, blood, feces, and urine.
37.106.2839-4 Environmental control: resident rooms have smoke odor, cigarette butts, old coffee, and rotting food clutter.
37.106.2846-3 Medications: storage and disposal: residents store medications in unlocked rooms and facility lacks secured medication storage.
37.106.2849-1 Medications: records and documentation: medication administration records are missing many staff signatures for administered medications.
37.106.2849-2 Medications: records and documentation: medication records lack reasons for use, prescriber contact info, documentation of missed/refused meds, and staff signatures for MAR review.
37.106.2849-3 Medications: records and documentation: no list of staff signatures indicating who monitors or assists with self-administration of medication.
37.106.2849-4 Medications: records and documentation: no annual written physician orders for self-medication administration for some residents.
37.106.2860-1 Food service: food items in refrigerators are loosely wrapped, removed from original packaging, and unlabeled.
37.106.2860-2 Food service: meals served are repetitive and unbalanced; staff lack cooking skills and meal times do not match menu.
37.106.2860-9 Food service: thermometers and temperature logs for kitchen fridges and freezers are missing.
37.106.2865-11 Physical plant: basement bathroom lacks a usable soap dispenser; it is broken and sitting on the countertop.
37.106.2865-13 Physical plant: chemicals found unlocked under kitchen sink and broom closet.
37.106.2865-15 Physical plant: trash is overflowing in resident rooms and bathrooms; residents make food in rooms with trash cans containing food items.
37.106.2865-2 Physical plant: outside building littered with cigarette butts and trash bags blocking doorway.
37.106.2865-6 Physical plant: carpets throughout building are stained and littered; kitchen floor sticky with water puddle; bathrooms not cleaned regularly with sticky residue on surfaces.
37.106.2861-4 Laundry: many beds have stained linens and mattresses, are untidy or unmade, and lack moisture-proof covers; residents must ask staff to clean linens and make beds.
Report Facts
: 16
: 3
: 15
: 10
: 8
: 7
: 10
Inspection Report — Jan 10, 2022
Complaint Investigation
Date: Jan 10, 2022
Visit Reason
The complaint inspection was conducted to investigate staffing and medication administration concerns at the facility.
Complaint Details
The complaint inspection cited deficiencies related to inadequate staffing coverage during night shifts and multiple medication administration and documentation errors for a resident.
Findings
Staffing schedules showed insufficient coverage on night shifts during weekends in December, leaving buildings without staff for up to three hours. Medication administration records for a resident revealed multiple documentation errors and missing blood sugar checks, indicating inadequate oversight.
Deficiencies (3)
37.106.2816-6 Assisted living facility staffing: night shift staffing was insufficient on weekends in December, resulting in periods with no staff coverage for one to three hours in one or both buildings.
37.106.2847-1 Medications, practitioner orders: multiple medication errors were found including undocumented topical cream application, incorrect timing of medications, and missing signatures for medication administration throughout December.
37.106.2849-2 Medications, records and documentation: medication administration documentation was missing for multiple medications and times in December, and blood sugar checks were inconsistently recorded, with many days lacking documentation.
Report Facts
dates_with_missing_staff_coverage: 19
blood_sugar_checks_missed: 12
Inspection Report — May 19, 2021
Complaint Investigation
Date: May 19, 2021
Visit Reason
The inspection was conducted following a complaint regarding staff conduct and resident safety concerns.
Complaint Details
The complaint involved concerns about staff conduct, including possession of a gun and drugs on shift, missing resident medication, and inadequate background checks.
Findings
The facility failed to properly complete background checks for multiple staff members, including one with convictions that contraindicate employment at an assisted living facility. There was also a missing medication reported and concerns about staff behavior on shift.
Deficiencies (1)
50-5-225-4 Assisted living facilities employee background checks: background checks were incomplete or improperly conducted for several staff, including one with multiple convictions and another with a conviction for elder exploitation, which contraindicates employment at an assisted living facility.
Inspection Report — Apr 30, 2021
Renewal
Date: Apr 30, 2021
Visit Reason
The survey was a renewal inspection of At Home Assisted Living facility.
Findings
The facility had multiple deficiencies including lack of documentation for disaster plan reviews, employee training, resident rights, medication management, and food service records. Several safety and housekeeping issues were observed such as unsecured oxygen tanks, malfunctioning emergency call systems, and unclean conditions.
Deficiencies (22)
37.106.322-3 Minimum standard for all health care facilities: disaster plan: there was no documentation of an annual disaster plan review with staff and no written agreement for an off-site evacuation point.
37.106.2816-3 Assisted living facility staffing: employee #2 had no documentation of orientation and training.
37.106.2817-2 Employee files: the administrator did not have a current, initialed job description.
37.106.2828-1 Resident rights: there was no documentation that resident #1 was provided a copy of the Montana Long-Term Care Residents' Bill of Rights.
37.106.2829-2 Resident file: resident #1 lacked a resident agreement, service plan, and admission weight record.
37.106.2831-4 Resident activities: no activity calendar was posted for April 2021 and no records of activities for the past three months were available.
37.106.2836-1 Furnishings: window treatments were not documented as flame-resistant; emergency call systems in most resident rooms did not activate and had loose wires and batteries needing replacement.
37.106.2838-7 Resident toilets and bathing: emergency call systems in all common use resident bathrooms did not activate and had disconnected wires and batteries needing replacement.
37.106.2839-1 Environmental control: the facility was unclean with garbage, food debris, tobacco, and stained walls throughout, including in resident rooms and common areas.
37.106.2846-3 Medications: storage and disposal: medication containers were observed unattended on a dining room table multiple times.
37.106.2849-1 Medications: records and documentation: multiple medications for residents #3, #4, and #5 were not signed out on the MARs with no documentation explaining the omissions.
37.106.2849-2 Medications: records and documentation: medication records for residents #3, #4, and #5 did not list the reason for use or the prescribing practitioner's telephone number.
37.106.2849-4 Medications: records and documentation: resident #2 kept medication in their room without documentation of a practitioner's annual order authorizing this or confirming responsibility for correct dosage and timing.
37.106.2853-4 Oxygen use: two portable oxygen tanks were found unsecured and improperly stored in a resident room.
37.106.2859-1 Pets: a resident's dog had no documentation of current vaccinations including rabies.
37.106.2860-3 Food service: there was no documentation of menus for food served in March and April 2021.
37.106.2860-9 Food service: no thermometer was present in freezer #2 and no temperature logs existed for refrigerators and freezers for March and April 2021.
37.106.2861-4 Laundry: many beds had stained linens and lacked moisture-proof mattress covers; linens were not changed twice weekly as required.
37.106.2862-1 Housekeeping: the kitchen garbage had no lid for the duration of the survey and no lid could be found.
37.106.2865-11 Physical plant: single use individual towels were not available in a shared bathroom labeled 'B4'.
37.106.2865-13 Physical plant: bleach and detergent were accessible to residents in the laundry room and not locked.
37.106.2866-8 Construction, building and fire codes: only one documented fire drill was conducted in 2020, on June 29.
Inspection Report — Apr 29, 2021
Complaint Investigation
Date: Apr 29, 2021
Visit Reason
The inspection was conducted in response to a complaint.
Complaint Details
The cited finding relates to environmental control issues that were previously addressed in the renewal inspection.
Findings
The complaint deficiencies were addressed in a prior renewal inspection. No new deficiencies were cited in this complaint inspection.
Deficiencies (1)
37.106.2839-1 Environmental control: complaint deficiencies were addressed in the renewal inspection #1285.
Inspection Report — Nov 4, 2020
Complaint Investigation
Date: Nov 4, 2020
Visit Reason
Complaint inspection conducted to investigate medication administration and employee background check compliance.
Complaint Details
The complaint inspection cited deficiencies related to missing medication administration documentation and inadequate employee background checks.
Findings
Two deficiencies were found: missing documentation of medication administration for multiple residents and lack of required background checks for employees hired after October 1, 2019.
Deficiencies (2)
37.106.2849-2 Medications: records and documentation: medication administration records for multiple residents were missing documentation of several prescribed medications given on November 1st and 2nd PM.
50-5-225-3 Assisted living facilities employee background checks: employee files for five employees lacked evidence of required background checks for those hired after October 1, 2019, and use of network search websites did not meet legal requirements.
Report Facts
date: Oct 1, 2019
count: 5
Inspection Report — Dec 6, 2019
Renewal
Date: Dec 6, 2019
Visit Reason
The survey was a renewal inspection of At Home Assisted Living facility.
Findings
The facility had multiple deficiencies including lack of proper policies, unsanitary conditions, medication errors, inoperable call lights, unsecured oxygen bottles, presence of weapons without policy, bed bug infestation, and failure to maintain clean linens and proper supervision.
Deficiencies (25)
37.106.2815-1 Written policies and procedures: the facility's policy and procedure manual pertained only to employees and not to the operation of the assisted living facility, and there was no policy regarding weapons despite residents having knives and handcuffs.
37.106.2822-1 Resident service plan: category A: several residents' service plans did not document smoking status, medication self-administration, or recent suicide attempts and lacked updated interventions.
37.106.2829-2 Resident file: a closed resident file did not indicate the disposition of personal possessions upon discharge.
37.106.2831-4 Resident activities: an activities calendar for daily or monthly activities was not posted at the time of survey.
37.106.2836-1 Furnishings: multiple call lights in resident rooms and bathrooms were inoperable, impairing resident safety.
37.106.2838-7 Resident toilets and bathing: call lights in bathrooms were inoperable or inaccessible, posing safety risks to residents.
37.106.2839-1 Environmental control: several resident rooms and bathrooms were unsanitary with soiled linens, overflowing trash, and unclean surfaces.
37.106.2846-3 Medications: storage and disposal: a resident kept medications unsecured in an unlocked drawer, and staff were unaware of this.
37.106.2846-4 Medications: storage and disposal: a resident's medication order was not documented in the file and medication lists were unreadable.
37.106.2849-1 Medications: records and documentation: multiple medication administration records had errors including missing signatures, undocumented refusals, and inconsistent dosing.
37.106.2853-4 Oxygen use: unsecured large oxygen bottles were stored in a resident's room.
37.106.2855-2 Infection control: unsanitary conditions included a milk jug with amber liquid likely urine and a full foley catheter bag with tubing on the floor.
37.106.2859-1 Pets: the facility had two dogs without documentation of current vaccinations including rabies.
37.106.2860-4 Food service: the current day or week's menu was not posted for resident viewing.
37.106.2861-4 Laundry: some resident rooms lacked sheets and had visibly soiled mattress pads.
37.106.2862-1 Housekeeping: the laundry room trash can was overflowing, lidless, and not enclosed.
37.106.2865-11 Physical plant: no towels were found in the downstairs bathroom next to room 14.
37.106.2865-12 Physical plant: hot water temperatures in some bathrooms were excessively high or low, and sinks drained extremely slowly.
37.106.2865-13 Physical plant: multiple bottles of cleaner were stored uncovered and unlocked in various locations including kitchen and basement.
37.106.2866-6 Construction, building and fire codes: a dining room window lacked an insect screen.
37.106.2814-6 Administrator: the administrator failed to supervise and protect residents, with issues including bed bug infestation, unsanitary conditions, medication errors, presence of weapons without policy, and inoperable call lights.
37.106.2904-1 Use of restraints, safety devices, assist: a resident was effectively restrained to her room due to bed bug isolation, which meets the definition of a restraint.
37.106.2866-3 Construction, building and fire codes: the facility was licensed for 20 beds but had a non-assisted living resident occupying a licensed bed without notification to the Department.
37.106.2843-7 Personal care services: direct care staff failed to provide clean and dry bed linens; 12 of 13 occupied rooms had unmade beds and two had soiled mattress pads without sheets.
37.106.2865-1 Physical plant: bed bugs were confirmed in multiple rooms and on the administrator's office door frame; pest control treatment was incomplete and unscheduled.
Report Facts
: 20
Inspection Report — Jul 24, 2019
Complaint Investigation
Date: Jul 24, 2019
Visit Reason
The complaint investigation focused on concerns about alcohol consumption by residents and staff during a facility event and medication administration practices.
Complaint Details
The complaint involved alcohol being purchased and consumed by residents and staff at a facility party, leading to intoxication and unsafe behavior, as well as concerns about medication administration practices during that time.
Findings
The administrator failed to protect residents' safety by purchasing alcohol for a party where staff intoxication occurred. Staff also performed medication assessments beyond their scope by withholding medications after the party.
Deficiencies (2)
37.106.2814-6 Administrator: the administrator failed to protect residents' safety and health by purchasing alcohol for a party where staff became intoxicated and disruptive.
37.106.2816-6 Assisted living facility staffing: staff performed medication assessments by withholding medications on the night of the party, which is beyond their scope of practice.
Inspection Report — Apr 25, 2019
Complaint Investigation
Date: Apr 25, 2019
Visit Reason
Complaint inspection conducted to investigate medication storage, practitioner orders, record keeping, oxygen use, and resident service plan compliance.
Complaint Details
The complaint inspection cited deficiencies related to medication storage, practitioner orders, medication records, oxygen use, and resident service plans.
Findings
Deficiencies were found in medication storage and documentation, practitioner orders, oxygen use, and resident service plans. Resident medications were unsecured and lacked proper orders and documentation, and service plans were inaccurate or missing updates.
Deficiencies (5)
37.106.2846-3 Medications: storage and disposal: medications were kept unsecured at the resident's bedside without a physician's order or self-administration assessment.
37.106.2847-1 Medications: practitioner orders: the resident did not have a current medication list signed by the practitioner nor signed orders for Ativan or Morphine.
37.106.2849-1 Medications: records and documentation: medication administration records were inaccurate and incomplete, missing reasons for use, routes, dosages, resident name, allergies, and proper PRN documentation.
37.106.2853-4 Oxygen use: a large oxygen bottle was unsecured in the resident's room.
37.106.2822-3 Resident service plan: category A: the resident's service plan was inaccurate, containing another resident's information and missing updates for hospice admission.
Inspection Report — Feb 12, 2019
Renewal
Date: Feb 12, 2019
Visit Reason
The survey was conducted as a renewal inspection of the assisted living facility.
Findings
Two deficiencies were found related to resident units and housekeeping. Resident rooms were not equipped with single motion door knobs, and the kitchen garbage lacked a lid throughout the survey.
Deficiencies (2)
37.106.2835-2 Resident units: resident rooms were not equipped with single motion door knobs.
37.106.2862-1 Housekeeping: the kitchen garbage had no lid for the duration of the survey and no lid was found by staff at the time of inspection.
Inspection Report — Dec 13, 2017
Complaint Investigation
Date: Dec 13, 2017
Visit Reason
The inspection was conducted following a complaint to assess medication administration practices.
Complaint Details
The cited findings involved medication administration errors, including administration of medications not yet scheduled and lack of documentation for missed doses.
Findings
The facility had repeated issues with medication administration records, including medications signed as given before their scheduled start dates and missing documentation for doses not given.
Deficiencies (1)
37.106.2847-1 Medications, practitioner orders: the facility's medication administration records showed medications signed as given before their scheduled start dates and missing documentation for doses not given. This is a repeat deficiency.
Inspection Report — Nov 20, 2017
Renewal
Date: Nov 20, 2017
Visit Reason
The survey was conducted as a renewal inspection of the assisted living facility.
Findings
Two deficiencies were identified related to medication administration records and resident files. Medication administration records showed missing signatures for medication administration, and resident files had incomplete resident agreements missing financial portions.
Deficiencies (2)
37.106.2847-1 Medications, practitioner orders: medication administration records were missing signatures for medication given in November 2017, including missing administrations on specific dates.
37.106.2829-2 Resident file: resident files for several residents had incomplete agreements, missing financial portions or other parts of the agreement.
Inspection Report — Jan 18, 2017
Complaint Investigation
Date: Jan 18, 2017
Visit Reason
Complaint inspection of At Home Assisted Living facility to assess compliance with licensing standards.
Complaint Details
The complaint inspection identified deficiencies related to unsafe environmental conditions, inadequate staff training and documentation, incomplete resident care planning and activities, medication management issues, and facility maintenance problems.
Findings
Multiple deficiencies were found including unsafe use of space heaters, improper laundry handling, incomplete staff orientation and training, inadequate resident service plans and activities, unsanitary environmental conditions, medication administration and documentation errors, lack of pet vaccination records, facility maintenance issues, and absence of a contracted RN for this Category B facility.
Deficiencies (26)
37.106.302-2 Minimum standards of construction: general requirements: space heaters were improperly placed on personal refrigerators and dressers in resident rooms, creating safety hazards.
37.106.331-1 Minimum standard for all health care facilities: laundry and bedding: laundry was folded and sorted on a community couch without protective coverings, and no designated area or protective measures were present in the laundry room.
37.106.2814-11 Administrator: review of 16 staff files showed 9 lacked orientation documentation and 6 had incomplete orientation records.
37.106.2814-12 Administrator: incident reports were signed as reviewed by the administrator but lacked consistent documentation of corrective actions to prevent recurrence.
37.106.2815-1 Written policies and procedures: policies for Category B residents, advanced directives, activities, pet vaccinations, and medication disposal were missing or not followed, and staff training on policies was lacking.
37.106.2816-3 Assisted living facility staffing: review of 16 staff files revealed multiple missing required documents and incomplete records.
37.106.2816-5 Assisted living facility staffing: 15 of 16 staff files were missing required documentation.
37.106.2817-2 Employee files: 8 of 16 staff files were missing required documents and 15 of 16 were missing others, indicating incomplete employee records.
37.106.2821-4 Resident application and needs assessment: resident needs assessments were incomplete, blank, or dated after move-in dates for several residents.
37.106.2822-1 Resident service plan: category A: residents #11 and #12 did not have service plans.
37.106.2822-3 Resident service plan: category A: 16 of 18 resident service plans were not updated in over a year, and some residents lacked annual reviews.
37.106.2831-1 Resident activities: no activities calendar was posted and no activities were conducted; only a few service plans addressed resident interests.
37.106.2831-2 Resident activities: no activities calendar was posted and no activities were conducted; only a few service plans addressed resident interests.
37.106.2831-3 Resident activities: no activities calendar was posted and no activities were conducted; only a few service plans addressed resident interests.
37.106.2831-4 Resident activities: no activities calendar was posted and no activities were conducted; only a few service plans addressed resident interests.
37.106.2839-1 Environmental control: facility was unclean with visible garbage, tobacco, and dirt; bathrooms and resident rooms had unsanitary conditions including rotted flooring and urine odors.
37.106.2843-3 Personal care services: incident reports showed inconsistent notification of residents' practitioners or representatives.
37.106.2843-3 Personal care services: incident reports showed inconsistent notification of residents' practitioners or representatives.
37.106.2846-2 Medications: storage and disposal: residents' insulin and refrigerated medications were stored improperly next to food items without barriers.
37.106.2847-1 Medications: practitioner orders: multiple medications were not signed out as administered on various dates, and there was no indication practitioners were notified of refusals or missed doses.
37.106.2849-2 Medications: records and documentation: resident medication files lacked diagnoses for multiple prescribed medications.
37.106.2859-1 Pets: two cats resided in the facility without records of current vaccinations.
37.106.2865-6 Physical plant: multiple interior surfaces needed repair including water-damaged ceilings, rotted bathroom flooring, non-working laundry dryer, open ceiling holes leaking water, and leaking bathroom faucets.
37.106.2866-7 Construction, building and fire codes: last facility fire inspection was conducted over a year prior, on 8/23/2015.
37.106.2866-8 Construction, building and fire codes: only one facility fire drill was documented, dated 2/11/2016.
37.106.2872-2 Requirements for category B facilities: the facility did not have a registered nurse employed or contracted as required.
Report Facts
staff_files_reviewed: 16
resident_service_plans_reviewed: 18
resident_service_plans_not_updated: 16
resident_service_plans_addressing_interest: 6
cats_in_facility: 2
last_fire_inspection_year: 2015
last_fire_drill_date: Feb 11, 2016
Inspection Report — Jan 13, 2016
Complaint Investigation
Date: Jan 13, 2016
Visit Reason
The facility was inspected following a complaint related to failure to notify the department of sexual abuse incidents and concerns about resident safety and care.
Complaint Details
The complaint involved failure to notify the department of sexual abuse incidents and concerns about resident safety and care, which resulted in multiple deficiencies related to reporting, resident protection, staffing training, resident assessments, service plans, activities, physical environment, and medication documentation.
Findings
The facility failed to notify the department of sexual abuse incidents and did not protect a resident from repeated inappropriate sexual behavior by staff. Resident assessments and service plans were incomplete or inaccurate, and the facility lacked a planned activities program. Several physical environment issues and medication documentation deficiencies were also noted.
Deficiencies (15)
52-3-811-1 Reports: the facility failed to notify the department of sexual abuse incidents that occurred during August and September 2015, and the administrator's reported contact was to an outdated phone number.
37.106.2814-6 Administrator: multiple incident reports documented inappropriate sexual behavior by staff toward a resident, but no intervention was initiated to protect the resident and guardians were not contacted.
37.106.2816-3 Assisted living facility staffing: there is no documentation that staff are oriented and trained to the Montana Elder and Persons with Developmental Disabilities Abuse Prevention Act.
37.106.2821-3 Resident application and needs assessment: resident needs assessments were not consistently completed prior to admission, with some residents having no assessment or blank documents.
37.106.2822-1 Resident service plan: category A: service plans did not accurately reflect residents' needs or the full services provided, often listing only medication management or limited services.
37.106.2829-2 Resident file: incident reports lacked indication that family or guardians were notified of incidents, conflicting with facility policy and Montana administrative rules.
37.106.2831-1 Resident activities: the facility had no planned activities program, and the wall calendar used to document activities was blank at the time of survey.
37.106.2831-2 Resident activities: the facility had no planned activities program, and no activities were documented on the wall calendar.
37.106.2831-4 Resident activities: the facility had no planned activities program, and no activities were documented on the wall calendar.
37.106.2835-2 Resident units: several resident rooms and bathroom doors did not have single action doorknobs as required.
37.106.2836-1 Furnishings: semi-private rooms lacked privacy curtains or screens to provide privacy for occupants.
37.106.2838-7 Resident toilets and bathing: bathroom call systems were not accessible to individuals on the floor, and there was no documented plan or timeframe for installation of a new call system; this was a repeat deficiency.
37.106.2849-2 Medications: records and documentation: medication administration records lacked documented reasons for use on all medications and had no signature page for self-administration assistance.
37.106.2849-3 Medications: records and documentation: medication administration records lacked documented reasons for use on all medications and had no signature page for self-administration assistance.
37.106.2853-4 Oxygen use: two residents used oxygen in their rooms but had no signs posted on the doors as required.
Report Facts
date: 2015-08-01 to 2015-09-30
count: 25
count: 9
count: 5
count: 6
count: 5
count: 2
date: Oct 16, 2015
Inspection Report — Oct 16, 2015
Renewal
Date: Oct 16, 2015
Visit Reason
The survey was a routine renewal inspection of the assisted living facility.
Findings
The facility lacked current policies and procedures reviews, did not maintain activity calendars, and had accessibility issues with the call system. There were concerns about pet vaccinations, food service records, housekeeping, physical plant cleanliness, fire safety equipment, and staffing requirements.
Deficiencies (10)
37.106.2815-1 Written policies and procedures: the policy and procedure manual lacked evidence of reviews and contained outdated contact information.
37.106.2831-4 Resident activities: the facility did not have an activity calendar for daily activities or for the past three months.
37.106.2838-7 Resident toilets and bathing: the bathroom call button was inaccessible to an individual who had collapsed and could only be silenced at the main call panel in the kitchen.
37.106.2859-1 Pets: the facility had two cats without current vaccination records.
37.106.2860-3 Food service: daily menus were posted but staff could not produce records of past menus.
37.106.2860-9 Food service: two kitchen freezers lacked thermometers and there were no current temperature logs for freezers and refrigerators.
37.106.2862-1 Housekeeping: trash cans in the laundry room and kitchen were uncovered, with the kitchen trash can full and located in a walkway.
37.106.2865-6 Physical plant: the facility was not clean with issues including a sink filled with water, black substance in a bathtub, dead flies on fly paper in a common area, and a hospice resident resting nearby.
37.106.2866-12 Construction, building and fire codes: a smoke detector was found on a desk instead of installed, and maintenance logs for battery changes were missing.
37.106.2872-2 Requirements for category B facilities: the facility did not employ or contract with a registered nurse as required.
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