6 Reports
Inspection Report — Feb 6, 2025
Renewal
Date: Feb 6, 2025
Visit Reason
The facility underwent a routine renewal inspection to assess compliance with Montana assisted living standards.
Findings
Three deficiencies were identified related to staff not using clothes covers in laundry areas, incomplete resident file documentation, and non-functioning call systems in resident bathrooms.
Deficiencies (3)
37.106.331-1 Minimum standards for all health care facilities: staff handling laundry were not using clothes covers, and these were not present in laundry rooms.
37.106.2829-2 Resident file: closed resident charts lacked documentation of the date and circumstances of final transfer, discharge, or death, including notice to responsible parties and disposition of personal possessions.
37.106.2838-7 Resident toilets and bathing: call systems in resident bathrooms were not working due to dead batteries and failed to signal staff.
Inspection Report — Feb 2, 2023
Renewal
Date: Feb 2, 2023
Visit Reason
The facility underwent a renewal inspection as part of its regular licensing process.
Findings
Two deficiencies were found: the facility lacked a written agreement for an off-site evacuation point, and there was no record that residents or their legal representatives received copies of their service plans.
Deficiencies (2)
37.106.322-3 Minimum standards for all health care facilities: the facility does not have a written agreement for an off-site evacuation point.
37.106.2822-4 Resident service plan: category A: there is no record that residents or their legal representatives were given a copy of their service plan.
Inspection Report — Feb 27, 2019
Renewal
Date: Feb 27, 2019
Visit Reason
The survey was conducted as a renewal inspection of the facility.
Findings
The survey identified deficiencies in resident placement orders, service plan reviews, medication administration and documentation, housekeeping, and construction standards. Several residents lacked required physician orders and timely service plan updates, and multiple medications were not administered as prescribed.
Deficiencies (7)
50-5-226-3 Placement in assisted living facilities: two of three Category C residents did not have physician orders for Category C level of care.
37.106.2822-1 Resident service plan: Category A: five residents did not have evidence of a 60-day review of their service plans, though all were updated at 90 days.
37.106.2822-3 Resident service plan: Category A: residents admitted to hospice or transferred to memory care did not have timely reviews or updates to service plans and resident needs assessments at significant change.
37.106.2847-1 Medications, practitioner orders: multiple medications were not administered as prescribed, and the facility failed to notify practitioners of missed or refused medications; this is a repeat deficiency.
37.106.2849-2 Medications, records and documentation: three residents' MARs lacked required documentation elements.
37.106.2862-1 Housekeeping: all kitchen garbage cans lacked lids and no lids were found nearby.
37.106.302-2 Minimum standards of construction: resident bathroom doors did not have single motion doorknobs as required for egress.
Inspection Report — Sep 17, 2018
Complaint Investigation
Date: Sep 17, 2018
Visit Reason
The inspection was conducted following a complaint regarding medication administration and resident care.
Complaint Details
The complaint involved missed medication doses and failure to notify the practitioner, which resulted in resident hospitalization.
Findings
Three deficiencies were found related to medication orders and resident file documentation. Medications were not administered as ordered, and the facility failed to notify the practitioner or document safeguards after missed doses.
Deficiencies (3)
37.106.2847-2 Medications: practitioner orders: medication Entresto was not given on September 1, 2, and 3, and the licensed practical nurse failed to notify the practitioner, resulting in the resident's hospital admission.
37.106.2847-1 Medications: practitioner orders: medication was not given on September 1, 2, and 3 due to unavailability of the medication.
37.106.2829-2 Resident file: the facility did not file an incident report or document steps taken to protect the resident after missed doses of Entresto led to congestive heart failure and hospital transport.
Inspection Report — Jun 28, 2018
Complaint Investigation
Date: Jun 28, 2018
Visit Reason
The inspection was conducted following a complaint investigation.
Complaint Details
The complaint inspection cited deficiencies related to incident report documentation and medication administration records.
Findings
Deficiencies were found in documentation of corrective actions for incident reports, notification of family or practitioners regarding incidents, and documentation related to missed medications and practitioner notification.
Deficiencies (3)
37.106.2814-12 Administrator: three incident reports lacked documentation of appropriate corrective action to prevent reoccurrence.
37.106.2843-3 Personal care services: two of three incident reports did not indicate family or practitioner notification.
37.106.2847-1 Medications, practitioner orders: multiple missed medication administrations were not documented with reasons or practitioner notification.
Inspection Report — Feb 15, 2018
Renewal
Date: Feb 15, 2018
Visit Reason
The survey was conducted as a renewal inspection of the facility.
Findings
Three deficiencies were identified related to resident agreements, food service safety, and resident activities planning.
Deficiencies (3)
37.106.2823-1 Resident agreement: the agreements for two residents were signed after their admission dates.
37.106.2860-1 Food service: unlabeled and undated raw hamburger and poultry were stored improperly in the refrigerator with blood contamination.
37.106.2831-2 Resident activities: service plans did not identify the activity needs and interests of the residents.
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