Inspection Reports for
Kenhodro Inc. dba Frontier Assisted Living
121 S 3rd Street, Livingston, MT, 59047
Back to Facility Profile12 Reports
Inspection Report — Sep 10, 2025
Renewal
Date: Sep 10, 2025
Visit Reason
The survey was conducted as a renewal inspection to assess compliance with Montana assisted living facility regulations.
Findings
The facility failed to maintain required reviews and training, including disaster plan exercises and staff orientation. Multiple deficiencies were found in resident assessments, medication storage, food service, and physical plant cleanliness.
Deficiencies (8)
37.106.322-2 Minimum standards for all health care fa: there was no evidence of a review or physical exercise of the disaster plan procedures since 2014.
37.106.2816-3 Assisted living facility staffing: staff files lacked evidence of orientation to the Residents Bill of Rights and job-specific duties.
37.106.2816-5 Assisted living facility staffing: staff files did not contain evidence of training in the abdominal thrust maneuver and basic first aid.
37.106.2821-6 Resident application and needs assessment procedure: resident files did not contain a resident needs assessment for 2024, with the last assessments dated 4/1/23 and 3/31/25.
37.106.2822-4 Resident service plan: category a: resident files lacked evidence that a copy of the resident service plan was given to the resident or legal representative, and signature lines were unsigned.
37.106.2846-1 Medications: storage and disposal: loose pills were found in the medication cart and overflow cabinet during the on-site inspection.
37.106.2860-1 Food service: uncovered ranch cups in the kitchen refrigerator were not labeled or dated.
37.106.2865-6 Physical plant: carpets throughout the facility needed vacuuming, stain removal, deep cleaning, and some replacement; multiple bathrooms required cleaning.
Report Facts
loose_pills:
Inspection Report — Jul 15, 2025
Complaint Investigation
Date: Jul 15, 2025
Visit Reason
The complaint inspection was conducted following concerns about medication administration and documentation at the facility.
Complaint Details
The cited finding involved missed medication doses for a resident and lack of documentation and practitioner notification regarding these missed doses.
Findings
The facility failed to properly document missed medication doses and did not notify the resident's practitioner of these missed doses as required.
Deficiencies (1)
37.106.2849-2 Medications: records and documentation: the facility did not document missed doses of multiple medications for a resident and failed to notify the practitioner of these missed doses.
Inspection Report — Dec 31, 2024
Complaint Investigation
Date: Dec 31, 2024
Visit Reason
The complaint inspection identified issues related to resident smoking and facility cleanliness.
Complaint Details
The complaint inspection cited issues with a resident smoking in their room and unsanitary conditions including stained bedding and feces on furniture.
Findings
Two deficiencies were found: a resident was observed smoking in their room despite ongoing issues, and the facility had cleanliness problems including stained bedding and feces on chairs in memory care rooms. The second deficiency is a repeat from previous surveys.
Deficiencies (2)
37.106.2839-4 Environmental control: a resident was observed smoking in their room despite ongoing issues with this behavior.
37.106.2865-6 Physical plant: common areas and resident rooms needed vacuuming, bedding was stained, and chairs in memory care had dry feces; this is a repeat deficiency.
Inspection Report — Oct 16, 2024
Renewal
Date: Oct 16, 2024
Visit Reason
The survey was conducted as a renewal inspection of the assisted living facility.
Findings
The facility had multiple deficiencies including incomplete staff training documentation, missing resident service plan copies, medication storage issues, lack of temperature logs, physical plant hazards, and missing fire drill documentation.
Deficiencies (10)
37.106.2816-3 Assisted living facility staffing: six direct care staff files lacked documentation of required dementia training, orientation to the Montana Resident Bill of Rights, and job-related duties.
37.106.2817-2 Employee files: several staff files did not contain documentation of ongoing training.
37.106.2822-4 Resident service plan: category A: all reviewed resident files lacked evidence that a copy of the service plan was given to the resident or legal representative.
37.106.2843-7 Personal care services: six direct care staff files lacked documentation of training related to prevention of pressure sores and skin maintenance.
37.106.2846-1 Medications: storage and disposal: surveyors found pre-portioned medications in an open cup not stored in pharmacy-dispensed containers.
37.106.2860-9 Food service: the facility did not have logs of food or medication fridge temperatures during the survey.
37.106.2865-6 Physical plant: carpets were stained, frayed, and in need of replacement; broken flooring near the main entrance posed a trip hazard.
37.106.2865-12 Physical plant: the facility lacked water temperature logs for resident handwashing sinks and bathing areas.
37.106.2866-8 Construction, building and fire codes: the facility did not have documentation of two fire drills performed four months apart; the last documented drill was on 1/23/23.
37.106.2892-1 Direct care staff: category C: all direct care staff files lacked documentation of required training under 37.106.2892 (1)(a-h).
Inspection Report — Jul 24, 2024
Complaint Investigation
Date: Jul 24, 2024
Visit Reason
The survey was conducted following a complaint inspection.
Complaint Details
The cited findings involved unsanitary conditions in the facility including dirty carpets, bathrooms with odors and stains, and a kitchen freezer in need of cleaning.
Findings
The facility was found to have significant cleanliness issues including debris and stains on carpets and bathrooms, and a freezer in the kitchen that required cleaning due to spilled food and liquids.
Deficiencies (2)
37.106.320-4 Minimum standards for all health care fa: carpets were covered in debris and stains, bathrooms were extensively soiled with unflushed toilets, odors, and debris, and an unknown liquid puddle was observed near a toilet.
37.106.2865-6 Physical plant: the primary kitchen freezer needed cleaning due to spilled food, liquid, and food particles on the bottom shelf and an open bag of sweet potato fries spilled onto the shelf.
Inspection Report — Aug 9, 2023
Complaint Investigation
Date: Aug 9, 2023
Visit Reason
Complaint inspection conducted to investigate medication administration and documentation practices.
Complaint Details
The complaint inspection cited deficiencies related to medication documentation and administration practices involving PRN lorazepam.
Findings
Two deficiencies were found related to medication documentation and administration. Staff failed to document the effectiveness of PRN lorazepam, and unlicensed staff administered PRN lorazepam over 60 times without consulting a licensed health care professional.
Deficiencies (2)
37.106.2849-2 Medications: records and documentation: staff did not document in the Medication Administration Records whether PRN lorazepam was effective.
37.106.2885-3 Administration of medications: category: unlicensed staff administered PRN lorazepam over 60 times without consulting a licensed health care professional after assessment.
Report Facts
medication_administration_count: 94
unlicensed_administration_count: 60
Inspection Report — Aug 9, 2023
Renewal
Date: Aug 9, 2023
Visit Reason
The survey was a renewal inspection of the assisted living facility.
Findings
The facility had multiple deficiencies including lack of required practitioner orders for certain residents, poor housekeeping and sanitation, missing disaster plan documentation, incomplete employee background checks and training, inadequate staffing levels during night shifts, and unsafe physical plant conditions.
Deficiencies (21)
50-5-226-3 Placement in assisted living facilities: residents categorized as B and C did not have required written practitioner orders for admission or care.
37.106.320-2 Minimum standards for all health care facilities: many resident rooms were excessively dirty with debris, unwashed linens, and stains, and housekeeping services were frequently interrupted.
37.106.322-3 Minimum standards for all health care facilities: the facility lacked a written disaster plan, annual review documentation, and an annual written agreement for an off-site evacuation point.
37.106.2814-12 Administrator: 11 of 15 accident and incident reports lacked documentation of corrective actions to prevent recurrence.
37.106.2816-2 Assisted living facility staffing: employee files reviewed did not include background checks for some employees.
37.106.2816-5 Assisted living facility staffing: employee files lacked documentation of training in abdominal thrust maneuver and basic first aid.
37.106.2816-6 Assisted living facility staffing: staffing schedules showed multiple occasions with only one staff member on duty overnight, insufficient to meet resident needs and supervision requirements.
37.106.2831-1 Resident activities: no activities were observed being offered during the two-day survey.
37.106.2831-4 Resident activities: the facility did not have a posted group activity calendar.
37.106.2836-1 Furnishings: there was no documentation that window treatments in resident rooms were flame-resistant or non-combustible.
37.106.2843-7 Personal care services: direct care staff files lacked documentation of training on skin integrity maintenance and pressure sore prevention.
37.106.2846-2 Medications, storage and disposal: insulin was stored in a medication refrigerator without a thermometer to verify correct temperature.
37.106.2846-3 Medications, storage and disposal: medication cart was unsecured and open, and incident reports documented a resident consuming medications not prescribed to them.
37.106.2849-3 Medications, records and documentation: medication administration records lacked a separate signature page linking staff names to initials.
37.106.2853-4 Oxygen use: eight portable oxygen tanks were unsecured and improperly stored in a resident room.
37.106.2861-4 Laundry: several residents had dirty, stained, and wet linens.
37.106.2865-6 Physical plant: the facility was unclean with stained carpets, sticky floors, water-damaged walls, stained furniture, and a broken medication room window.
37.106.2865-11 Physical plant: a shared bathroom lacked any towels, including single-use towels.
37.106.2865-13 Physical plant: laundry and utility rooms were unlocked and contained chemicals including bleach.
37.106.2866-5 Construction, building and fire codes: several doors including a resident's door and a fire exit door were stuck or blocked, impeding access.
37.106.2866-7 Construction, building and fire codes: the facility lacked a record of an annual fire inspection despite multiple attempts to obtain it.
Report Facts
resident_files_reviewed: 6
accident_incident_reports_reviewed: 15
employee_files_reviewed: 6
staffing_schedule_review_june_2023: 17
staffing_schedule_review_july_2023: 3
incident_reports_reviewed: 3
portable_oxygen_tanks_found: 8
Inspection Report — Oct 6, 2022
Renewal
Date: Oct 6, 2022
Visit Reason
The survey was a renewal inspection of the assisted living facility.
Findings
The facility had multiple deficiencies including an incomplete disaster plan, lack of annual policy reviews, no planned or posted resident activities, unsafe resident unit door locks, use of non-combustible window treatments, and missing fire drill documentation.
Deficiencies (7)
37.106.322-3 Minimum standards for all health care facilities: the disaster plan lacked provisions for additional blankets, water, or food when sheltering in place, had no annual staff review documentation, and no written off-site evacuation agreement.
37.106.330-1 Minimum standards for all health care facilities: the facility was unable to locate documentation of an annual review of all policies and procedures since 2016.
37.106.2831-1 Resident activities: there were currently no activities planned or performed for residents.
37.106.2831-4 Resident activities: there was no developed or posted monthly group activities calendar and no record of current or past three months' activities.
37.106.2835-2 Resident units: a shared room door locked from the outside with a key and the dead bolt did not unlock from the inside.
37.106.2836-1 Furnishings: the facility could not provide documentation that flame-resistant or non-combustible window treatments were used; standard cloth curtains were present in several areas.
37.106.2866-8 Construction, building and fire codes: the facility was unable to locate documentation of fire drills for 2021 and 2022.
Inspection Report — Jun 8, 2021
Complaint Investigation
Date: Jun 8, 2021
Visit Reason
Complaint inspection conducted to investigate issues related to resident safety and medication management.
Complaint Details
The complaint inspection cited deficiencies related to resident injuries linked to alcohol and marijuana use, inadequate medication documentation, and lack of policies addressing medical marijuana use.
Findings
The facility failed to protect residents by not addressing illegal drug use and lacking policies for medical marijuana use. Communication about marijuana use with practitioners was also inadequate.
Deficiencies (4)
37.106.2814-12 Administrator: incident reports lacked corrective actions to prevent injury recurrence and did not explain how the administrator plans to prevent future injuries related to resident alcohol and marijuana use.
37.106.2849-1 Medications, records and documentation: residents self-administering medication did not have medical marijuana documented on their medication lists.
37.106.2814-6 Administrator: the facility failed to address illegal marijuana use among residents and did not communicate this use with practitioners or provide education on risks.
37.106.2815-1 Written policies and procedures: the facility allowed medical marijuana use but lacked a policy for providing this service.
Inspection Report — Feb 2, 2021
Complaint Investigation
Date: Feb 2, 2021
Visit Reason
The complaint inspection was conducted due to concerns about facility cleanliness, medication administration, oxygen use, and laundry conditions.
Complaint Details
The complaint inspection cited deficiencies related to facility cleanliness, medication administration errors, unsecured oxygen tanks, cigarette smoking in a resident room, and poor laundry conditions.
Findings
The facility had multiple deficiencies including strong urine odor, dirty common areas and resident rooms, medication administration errors, unsecured oxygen tanks, cigarette smoking in a resident room, and stained linens on resident beds. Several deficiencies were repeats from prior complaint surveys.
Deficiencies (6)
37.106.320-6 Minimum standards for all health care facilities: physical plant and equipment maintenance: a strong smell of urine was noted in a resident's room.
37.106.2839-1 Environmental control: the facility's entryways, hallways, common areas, staircases, and several resident rooms were dirty with debris, dirt, and garbage. This is a repeat deficiency from a prior complaint survey.
37.106.2849-1 Medications: records and documentation: medication administration records showed discrepancies in medication schedules and missing documentation for medication administration.
37.106.2849-2 Medications: records and documentation: multiple residents had medications not given as prescribed with no documentation of reasons or physician notification, including blood thinners and psychiatric medications.
37.106.2853-4 Oxygen use: portable oxygen tanks were unsecured and cigarette smoking was occurring in a resident room. This is a repeat deficiency from prior complaint surveys.
37.106.2861-4 Laundry: multiple resident beds had stained linens and many beds lacked moisture-proof mattress covers and pads.
Report Facts
date: 11/04/2020
date: 10/30/2018
date_range: 12/04-27/2021
date_range: 12/8-9 & 12-16/2021
date_range: 12/4-9/2021
date: 1/21 & 23/2021
date_range: 1/18, 19, & 23/2021
date: 1/5/2021
Inspection Report — Nov 4, 2020
Complaint Investigation
Date: Nov 4, 2020
Visit Reason
Complaint inspection conducted to investigate reported issues at the facility.
Complaint Details
The complaint inspection cited issues with facility cleanliness, oxygen use safety, and accessibility obstructions.
Findings
The facility had multiple deficiencies including unsecured memory care unit keypads, unsanitary conditions throughout the building and kitchen, oxygen use safety violations, and obstructed accessibility due to cardboard boxes in hallways. A repeat deficiency was noted regarding oxygen use signage and smoking near oxygen.
Deficiencies (4)
37.106.316-2 Minimum standards for all HCFs: secured care unit within a licensed long-term HCF: no codes were posted on the egress side of each keypad located on the memory care unit.
37.106.2839-1 Environmental control: multiple areas including entryways, kitchen, hallways, and resident rooms were dirty with debris and stains, the kitchen and storage areas showed a general lack of cleanliness with spills, sticky substances, and uncovered garbage containers.
37.106.2853-4 Oxygen use: a strong cigarette smoke odor was detected near oxygen use in a resident's room and no conspicuous 'No Smoking, Oxygen in Use' sign was posted. This is a repeat deficiency from a prior complaint survey.
37.106.2866-5 Construction, building and fire codes: cardboard boxes were observed near the kitchen hallway restricting accessibility of wheelchairs and walkers.
Inspection Report — May 7, 2019
Renewal
Date: May 7, 2019
Visit Reason
The survey was a renewal inspection of the assisted living facility.
Findings
Deficiencies were found in resident placement certification, administrator documentation of corrective actions, staff orientation, resident assessments, medication practitioner notifications, medication records, and facility housekeeping and ventilation.
Deficiencies (9)
50-5-226-3 Placement in assisted living facilities: two Category C residents did not have certification by a licensed health care professional indicating their needs could be met and no significant change in status requiring higher care.
37.106.2814-12 Administrator: resident incident reports lacked documentation of appropriate corrective actions to prevent reoccurrence.
37.106.2816-3 Assisted living facility staffing: staff files lacked evidence of orientation to the Montana Elder and Persons with Developmental Disabilities Abuse Prevention Act including MCA 52-3-801.
37.106.2821-4 Resident application and needs assessment: annual or quarterly assessments used a different form missing required items including level of assistance with ADLs and did not provide a level of care.
37.106.2847-1 Medications, practitioner orders: the facility did not consistently notify practitioners of missed or refused medications for multiple residents.
37.106.2849-2 Medications, records and documentation: medication administration documentation was missing for multiple residents on May 6, 2019.
37.106.2849-3 Medications, records and documentation: the memory care unit MAR book lacked a signature page and the rest of the facility's MAR book had outdated signatures.
37.106.2861-2 Laundry: the basement laundry room lacked mechanical ventilation and had a window screen needing replacement; the upstairs laundry lacked working ventilation and the ceiling fan was inoperable.
37.106.2862-1 Housekeeping: the upstairs laundry room had two uncovered garbage cans at the time of survey.
Report Facts
date: May 6, 2019
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