Inspection Report
Renewal
Deficiencies: 5
May 1, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the At Home Assisted Living facility to assess compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including inadequate administrator continuing education hours, missing criminal background check for an employee, issues with resident bathroom door locks, poor environmental control in resident rooms especially room 10 which poses a safety concern, and non-compliant exit door locking mechanisms.
Deficiencies (5)
| Description |
|---|
| Administrator only received 11.25 continuing education hours in 2024. |
| Employee #1 does not have a criminal background check. |
| All resident bathroom doors are equipped with non-single motion locking doorknobs. |
| Resident rooms 9 and 11 need vacuuming; room 10 is almost unlivable with carpet needing cleaning, garbage, used cups and bowls, dry cat food and litter spilled on the floor, posing a safety concern for emergency evacuation. |
| Northeast side and downstairs exit doors are equipped with non-single motion locking doorknobs. |
Report Facts
Continuing education hours: 11.25
Facility License Number: 13251
Inspection Report
Renewal
Deficiencies: 2
Apr 30, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the At Home Assisted Living facility to assess compliance with licensing requirements.
Findings
The inspection identified deficiencies including missing documentation in resident files regarding significant events and environmental control issues such as dirty carpets in resident rooms 10 and 11.
Deficiencies (2)
| Description |
|---|
| 3 resident files reviewed; all 3 did not include documentation of (e)(i) and (e)(iii) in their reports of significant events. |
| The carpet in resident rooms 10 and 11 need cleaning and vacuuming due to debris, dirt, and garbage on the floors. |
Report Facts
Resident files reviewed: 3
Resident files deficient: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laura Ashford | Survey Team Leader | Named as survey team leader for the renewal inspection |
Inspection Report
Deficiencies: 11
May 10, 2023
Visit Reason
Provisional status inspection conducted to evaluate compliance with assisted living facility regulations including staffing, resident service plans, environmental conditions, and safety standards.
Findings
Multiple deficiencies were identified including poor sanitation in resident rooms, incomplete employee training documentation, delayed resident service plan development, missing weight records, inadequate bathroom door hardware, unclean carpets, lack of thermometers in freezers, unsafe water temperatures, and missing smoke detectors in several resident rooms.
Deficiencies (11)
| Description |
|---|
| Strong smell of urine in resident room 11 with full handheld urinals not emptied frequently. |
| No documentation of orientation and training for employees #1 and #2. |
| Employee #3 lacks initialed or signed job descriptions. |
| Resident #1's service plan was not developed within 24 hours of admission. |
| Resident #4's service plan was last reviewed and updated over a year ago. |
| Residents #1 and #2 lack weight records on admission; Residents #3 and #4 lack annual weight records. |
| Resident bathroom labeled ‘B17’ lacks a single motion doorknob. |
| Carpets in resident rooms 4, 9, 11, and 12 are dirty and need cleaning. |
| No thermometers in two stand-up freezers known as 'bread' and 'meat' freezers. |
| Water temperature recorded at 126.3°F in main resident bathroom tub and 139.6°F in kitchen sink. |
| Resident rooms 1, 13, and 15 were without smoke detectors at the time of survey. |
Report Facts
Employee files reviewed: 4
Resident files reviewed: 6
Water temperature: 126.3
Water temperature: 139.6
Inspection Report
Complaint Investigation
Deficiencies: 2
Oct 18, 2022
Visit Reason
The inspection was conducted as a complaint investigation at At Home Assisted Living to assess reported concerns about facility cleanliness and resident care.
Findings
The inspection found multiple environmental control issues including unclean resident bedrooms and bathrooms, overflowing garbage with soiled briefs, urine and feces on bathroom surfaces, and unemptied urinals. Additionally, many beds had dirty, stained linens that were not changed weekly as reported by residents, and most beds lacked moisture-proof mattress covers and pads.
Complaint Details
The visit was triggered by a complaint inspection. Specific substantiation status is not stated.
Deficiencies (2)
| Description |
|---|
| Environmental control issues including unclean resident rooms and bathrooms, overflowing garbage with soiled briefs, and unemptied urinals. |
| Laundry deficiencies with dirty, stained linens not changed weekly and lack of moisture-proof mattress covers and pads. |
Inspection Report
Renewal
Deficiencies: 19
May 12, 2022
Visit Reason
The inspection was conducted as a renewal inspection of At Home Assisted Living facility to assess compliance with regulatory standards and licensing requirements.
Findings
The inspection identified multiple repeat deficiencies including issues with life safety code compliance, lack of documentation for disaster plan review, incomplete employee orientation and training records, missing resident needs assessments and service plans, medication administration record deficiencies, oxygen use concerns, and inadequate fire drill documentation.
Deficiencies (19)
| Description |
|---|
| Medication room and downstairs bathroom doors require a key or special knowledge to open if locked, violating NFPA 101 Life Safety Code. |
| No documentation of an annual disaster plan review with facility staff and no written agreement for an off-site evacuation point. |
| No documentation of employees reviewing policy and procedure manual, orientation to services, or relevant Montana elder abuse and resident rights acts. |
| No documentation that staff is orientated to service plans. |
| Majority of employee files lack signed job descriptions and documentation of orientation and ongoing training including Heimlich and first aid. |
| Administrator file missing orientation and training documentation including Heimlich, first aid, and relevant Montana elder abuse and resident rights acts. |
| Resident #1 lacks an initial resident needs assessment. |
| Residents #1 and #2 do not have service plans based on initial resident needs assessments. |
| Facility unable to provide documentation that flame-resistant or non-combustible window treatments were used; some residents use blankets as window coverings. |
| Resident #1 and #2’s shared room smells of recent cigarette smoke. |
| Residents #1, #2, and #4 have no medication treatment orders in files to confirm orders are carried out as prescribed. |
| Medication Administration Records missing many staff signatures; Resident #3’s lisinopril not signed out for 12 days though medication dispensed. |
| Medications on MARs lack reason for use, no documentation of missed/refused meds, many missing staff signatures, and no staff signature for MAR review date. |
| No written doctor’s orders indicating residents #1, #2, and #4 are capable and responsible to keep medications at bedside. |
| Resident #6 has ongoing problems with oxygen administration; staff unaware how to properly connect oxygen. |
| Resident #2 admits to smoking in room while oxygen is present; no physician orders for oxygen for residents #1 and #2. |
| Two dogs and one cat present; no documentation of vaccinations for pets. |
| No evidence of employee or resident fire drill conducted since 2020. |
| No documentation kept for 24 months of any employee or resident fire drill. |
Report Facts
Number of pets: 3
Days medication not signed out: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Noelle Markland | Survey Team Leader | Named as survey team leader for the renewal inspection |
| Staff #1 Administrator | Administrator | Mentioned in relation to lack of pet vaccination documentation |
Inspection Report
Complaint Investigation
Deficiencies: 23
Feb 9, 2022
Visit Reason
The inspection was conducted as a complaint investigation to assess multiple concerns regarding facility conditions, resident care, medication management, and environmental safety at At Home Assisted Living.
Findings
The inspection found numerous deficiencies including unsafe locking mechanisms, unclean and unsanitary resident rooms and common areas, lack of planned activities, medication storage and documentation issues, food service concerns, physical plant hazards, and inadequate laundry and housekeeping practices.
Complaint Details
The inspection was triggered by a complaint and focused on multiple issues including facility cleanliness, resident care, medication management, and safety hazards. The report does not explicitly state substantiation status.
Deficiencies (23)
| Description |
|---|
| Lower-level basement door can be locked from outside requiring a key for egress, violating Life Safety Code. |
| Carpets throughout facility and resident rooms are heavily stained and dirty with debris and food crumbs. |
| Resident #12's room has strong urine smell; commode not emptied causing odor in hallway. |
| No planned activities or assessment of resident activity preferences on service plan. |
| No activity calendar posted; no previous months' calendars provided. |
| Extension cord taped loosely creating tripping hazard; some resident room doors not single motion. |
| 15 of 16 occupied rooms found unclean with clutter, garbage, moldy food, and unsanitary conditions posing health risks. |
| Resident #11's room foul smelling with unemptied bedside commode and stained carpet. |
| Resident #1 smoking marijuana in room; smoke and clutter present including rotting food and cigarette butts. |
| Residents #1 and #7 store medications unsecured in rooms with open/unlocked doors. |
| Medication Administration Records missing many staff signatures and lack documentation of missed/refused meds. |
| Medications on MARs lack reason for use and prescriber contact info; no staff signing MAR reviews. |
| No list of staff signatures indicating who monitors or assists with self-medication. |
| No annual written physician orders for self-medication for Residents #1 and #7. |
| Food items in refrigerator loosely wrapped, removed from original packaging, and unlabeled. |
| Resident complaint that meals often consist of hot dogs or corn dogs; meals not balanced; menu discrepancies noted. |
| No thermometers or temperature logs found for kitchen fridges and freezers. |
| Lower-level basement bathroom lacks usable soap dispenser. |
| Chemicals found unlocked under kitchen sink and broom closet. |
| 15 of 16 resident rooms and 3 bathrooms have overflowing trash; residents make food in rooms with trash containing food items. |
| Outside building littered with cigarette butts and trash bags left at doorway. |
| Carpets throughout building stained and littered; kitchen floor sticky with water puddle; bathrooms unclean with sticky residue on surfaces. |
| Many beds have stained linens and mattresses; beds untidy or unmade; lack of moisture-proof mattress covers and pads. |
Report Facts
Resident rooms inspected: 16
Bathrooms inspected: 3
Medication bottles: 10
Medication packages in fridge: 7
Days hot dogs/corn dogs served: 8
Inspection Report
Complaint Investigation
Deficiencies: 3
Jan 10, 2022
Visit Reason
The inspection was conducted as a complaint investigation to review staffing adequacy and medication administration practices at At Home Assisted Living.
Findings
The inspection found insufficient staffing coverage during night shifts on weekends and multiple medication administration errors and documentation deficiencies for Resident #1, including missed medication administrations and incomplete blood sugar monitoring.
Complaint Details
The visit was complaint-related, focusing on staffing and medication administration issues. Substantiation status is not explicitly stated.
Deficiencies (3)
| Description |
|---|
| Insufficient staffing on night shifts during weekends resulting in periods with no staff coverage. |
| Multiple medication administration errors for Resident #1, including missed documentation and incorrect timing. |
| Missing medication administration documentation and incomplete blood sugar monitoring records for Resident #1. |
Report Facts
Dates with no staff coverage: 19
Medication administration errors: Multiple errors documented in Resident #1's medication administration record for December 2021.
Blood sugar checks missed: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tara Wooten | Survey Team Leader | Named as the survey team leader conducting the complaint inspection. |
Inspection Report
Complaint Investigation
Deficiencies: 3
May 19, 2021
Visit Reason
The inspection was conducted as a complaint investigation triggered by concerns related to employee background checks and potential resident safety issues at At Home Assisted Living.
Findings
The investigation found multiple issues with employee background checks, including an employee terminated for bringing a gun and pills into the facility, incomplete or incorrect background checks for other staff, and a staff member with a conviction for elder exploitation, which is prohibited by Montana State Law.
Complaint Details
The complaint investigation was substantiated by findings of improper background checks and employment of a staff member with a disqualifying criminal conviction. The Administrator reported suspected dependent adult/elder abuse related to Staff #1.
Deficiencies (3)
| Description |
|---|
| Staff #1 was terminated after being seen with a gun and pills on security footage; background check was incorrectly conducted and did not reveal multiple criminal convictions. |
| Staff #2's employee file contained an incomplete background check with missing report pages. |
| Staff #3 had a February 2020 conviction for elder exploitation, which contraindicates employment at an assisted living facility under Montana law. |
Report Facts
Medication missing: 1
Dates: 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tara Wooten | Survey Team Leader | Named as the survey team leader conducting the complaint inspection. |
| Administrator | Administrator reported findings and completed the report of suspected dependent adult/elder abuse. |
Inspection Report
Renewal
Deficiencies: 22
Apr 30, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the At Home Assisted Living facility to assess compliance with state regulations and licensing requirements.
Findings
The inspection identified multiple deficiencies including lack of documentation for disaster plan review, incomplete employee training records, missing resident agreements and service plans, unclean facility conditions, malfunctioning emergency call systems, medication storage and documentation issues, unsecured oxygen tanks, missing pet vaccination records, and inadequate food service documentation.
Deficiencies (22)
| Description |
|---|
| No documentation of an annual review with facility staff for disaster plan and no written agreement for an off-site evacuation point. |
| Employee #2 lacks documentation of orientation and training. |
| Employee #1, administrator, does not have a current, initialed job description. |
| Resident #1 not provided with a copy of the Montana Long-Term Care Residents' Bill of Rights. |
| Resident #1 lacks resident agreement, service plan, and record of admission weight. |
| No activity calendar posted for April 2021 and no record of activities for past three months. |
| No documentation that window treatments are flame-resistant; emergency call system in most resident rooms does not activate; call stations run on batteries, some needing replacement. |
| Emergency call system in all common use resident bathrooms does not activate; call stations run on batteries, some needing replacement. |
| Facility found to be unclean with garbage, food debris, stained walls, overflowing garbage cans, and water damage in ceiling; multiple resident rooms dirty with various items on floors and dressers. |
| Medication container with insulin pens and inhaler found unattended on dining room table twice during inspection. |
| Multiple medications for residents #3, #4, and #5 not signed out on various dates; no documentation explaining missing signatures. |
| Medications for residents #3, #4, and #5 do not list reason for use or prescribing practitioner's telephone number. |
| Resident #2 keeps medication in room and is responsible for dosage without documentation of practitioner's annual order. |
| Two portable oxygen tanks found unsecured in a resident room. |
| Resident in room 10 has a dog with no documentation of current vaccinations including rabies. |
| No documentation of menus for food served in March and April 2021. |
| No thermometer in freezer #2 and no temperature logs for refrigerators and freezers for March and April 2021. |
| Many beds observed with stained linens; linens not changed twice weekly as required; most beds lack moisture-proof mattress covers and pads. |
| No lid on kitchen garbage during survey and no lid found by staff. |
| Single use individual towels not available in shared bathroom labeled 'B4'. |
| Bleach and detergent accessible to residents in laundry room and not locked. |
| Only one documented fire drill for 2020 conducted on 6/29/2020. |
Report Facts
Employee files reviewed: 3
Resident files reviewed: 4
Medication Administration Records reviewed: 12
Fire drills documented: 1
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 29, 2021
Visit Reason
The inspection was conducted as a complaint investigation to address reported deficiencies related to environmental control at At Home Assisted Living.
Findings
The complaint deficiencies related to environmental control were noted but are stated to have been addressed in a subsequent Renewal Inspection #1285.
Complaint Details
Complaint deficiencies related to environmental control were investigated and noted to be addressed in a later renewal inspection.
Deficiencies (1)
| Description |
|---|
| Environmental control deficiency related to complaint investigation |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brett Christian | Survey Team Leader | Named as the survey team leader conducting the complaint inspection. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 29, 2021
Visit Reason
The inspection was conducted as a complaint investigation to address reported deficiencies related to environmental control at At Home Assisted Living.
Findings
The complaint deficiencies related to environmental control were noted and are stated to have been addressed in a subsequent Renewal Inspection #1285.
Complaint Details
Complaint deficiencies were identified and noted to be addressed in a later renewal inspection.
Deficiencies (1)
| Description |
|---|
| Environmental control deficiency related to complaint investigation |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brett Christian | Survey Team Leader | Named as the survey team leader for the complaint inspection. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Nov 4, 2020
Visit Reason
The inspection was conducted as a complaint investigation to review medication administration records and employee background checks at At Home Assisted Living.
Findings
The inspection found multiple instances of missing documentation for medications administered to residents and lack of required background checks for employees hired after October 1, 2019.
Complaint Details
Complaint inspection triggered by concerns regarding medication administration documentation and employee background checks; substantiation status not stated.
Deficiencies (2)
| Description |
|---|
| Missing documentation of medications given to residents on November 1st and 2nd PM medication administration records. |
| Employee files for employees #1-5 lacked evidence of required background checks for hires after October 1, 2019. |
Inspection Report
Renewal
Capacity: 20
Deficiencies: 22
Dec 6, 2019
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with licensing requirements and facility operations.
Findings
The facility was found to have multiple deficiencies including lack of appropriate policies and procedures, unsanitary conditions, medication administration errors, presence of weapons without policy, bed bug infestation, inoperable call lights, and inadequate supervision by the administrator.
Deficiencies (22)
| Description |
|---|
| Facility policy and procedure manual was incomplete and resident had thrown away the manual; no policy on weapons despite presence of knives and a sword in resident rooms. |
| Resident service plans did not reflect current resident conditions such as smoking status and recent suicide attempt. |
| Resident file did not indicate disposition of personal possessions upon discharge. |
| No activities calendar posted for residents at time of survey. |
| Multiple call lights in resident rooms and bathrooms were inoperable. |
| Unsanitary conditions observed in multiple resident rooms and bathrooms including soiled mattresses, overflowing trash, and unclean surfaces. |
| Resident medications stored unsecured in rooms; medication administration records had multiple errors and missing documentation. |
| Unsecured oxygen bottles present in resident room. |
| Infection control issues including urine-filled containers and full Foley catheter bags on floor. |
| Facility had two dogs without documentation of current vaccinations. |
| No menu posted for resident viewing. |
| Beds in multiple rooms lacked clean linens and had soiled mattress pads. |
| Laundry room trash can overflowing and not enclosed. |
| No towels found in downstairs bathroom. |
| Hot water temperature in some bathrooms was excessively high or low with slow draining sinks. |
| Cleaning products stored improperly and in unlocked areas. |
| Dining room window lacked insect screen. |
| Administrator failed to adequately supervise facility operations including pest control, cleanliness, medication administration, and weapon policies. |
| Resident was restrained by being confined to room due to bed bug infestation, constituting an unauthorized restraint. |
| Facility licensed for 20 beds; a non-assisted living resident was found residing in a licensed bed without notification to the Department. |
| Direct care staff failed to provide clean and dry bed linens to residents. |
| Bed bug infestation present in multiple rooms with inadequate treatment schedule and maintenance policies. |
Report Facts
Licensed beds: 20
Knives counted: 5
Oxygen bottles: 7
Resident rooms observed: 13
Beds unmade: 12
Beds with soiled mattress pads: 2
Inspection Report
Complaint Investigation
Deficiencies: 2
Jul 24, 2019
Visit Reason
The inspection was conducted as a complaint investigation triggered by concerns related to alcohol consumption at a facility event and staff conduct.
Findings
The administrator purchased alcohol for a resident and staff party, which led to safety and health concerns including intoxicated staff behavior. Staff also withheld medications from residents who consumed alcohol, which was outside their scope of practice.
Complaint Details
Complaint investigation regarding alcohol use at a facility party on July 4, 2019, including staff intoxication and medication withholding.
Deficiencies (2)
| Description |
|---|
| Administrator failed to protect the safety and physical, mental and emotional health of residents by purchasing alcohol for resident and staff consumption at a party. |
| Staff performed assessment by withholding medications which is out of their scope of practice on the night of the party. |
Report Facts
Facility License Number: 13251
Date of party: Jul 4, 2019
Number of staff interviewed: 8
Number of residents interviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Egebjerg | Survey Team Leader | Named as survey team leader conducting the complaint inspection |
Inspection Report
Complaint Investigation
Deficiencies: 5
Apr 25, 2019
Visit Reason
The inspection was conducted as a complaint investigation to review medication storage, practitioner orders, medication records, oxygen use, and resident service plans at At Home Assisted Living.
Findings
Multiple deficiencies were found related to medication storage and disposal, lack of proper practitioner orders, inaccurate medication administration records, unsecured oxygen use, and incomplete or incorrect resident service plans, particularly for resident number one.
Complaint Details
The inspection was triggered by a complaint and focused on medication management and resident care issues for resident number one.
Deficiencies (5)
| Description |
|---|
| Medication is not locked and resident does not have an MD order or self-administration assessment for medications kept at bedside. |
| Resident does not have a current medication list signed by practitioner and lacks signed MD orders for Ativan or Morphine. |
| Medication Administration Records (MARs) are inaccurate and incomplete, missing reasons for use, routes, dosages, resident's last name, allergies, and proper PRN documentation. |
| Large bottle of oxygen was unsecured in resident's room. |
| Resident service plan was incorrect, belonging to another resident, and missing updates to reflect hospice admittance. |
Report Facts
Facility License Number: 13251
Survey Date: Apr 25, 2019
Inspection Report
Renewal
Deficiencies: 2
Feb 12, 2019
Visit Reason
The inspection was conducted as a renewal inspection of the At Home Assisted Living facility to assess compliance with licensing requirements.
Findings
Two deficiencies were identified: resident rooms #1 and #2 lacked single motion door knobs, and the kitchen garbage did not have a lid during the inspection.
Deficiencies (2)
| Description |
|---|
| Resident rooms #1 and #2 are not equipped with single motion door knobs. |
| There was no lid on the kitchen garbage for the duration of the survey and no lid could be found by staff at the time of inspection. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 13, 2017
Visit Reason
The inspection was conducted as a complaint investigation based on concerns related to medication administration practices at the facility.
Findings
The review of Medication Administration Records (MARs) for residents #1 through #5 revealed that resident #1 had medications signed out as given that were not scheduled to start until 2019 and were not on the premises. Resident #5 had three consecutive days of Atorvastatin not signed out as given with no documentation explaining the omission. This deficiency was noted as a repeat issue.
Complaint Details
The visit was triggered by a complaint regarding medication administration errors, specifically involving incorrect documentation and administration timing.
Deficiencies (1)
| Description |
|---|
| Medication Administration Records showed medications given before scheduled start dates and missing documentation for doses not given. |
Report Facts
Response Due Days: 10
Residents Reviewed: 5
Days of Medication Not Signed Out: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Egebjerg | Survey Team Leader | Named as the survey team leader conducting the complaint inspection. |
Inspection Report
Renewal
Deficiencies: 2
Nov 20, 2017
Visit Reason
The inspection was conducted as a renewal inspection of the At Home Assisted Living facility to assess compliance with licensing requirements.
Findings
The inspection found medication administration records with missing signatures for doses given in November 2017 and incomplete resident agreements missing financial portions for several residents.
Deficiencies (2)
| Description |
|---|
| Medication Administration Records (MARs) for Residents #1 - #5 showed missing signatures for medication doses given in November 2017, including specific missing administrations on November 9, 13, and 19 for Resident #3. |
| Resident files for Residents #1, #2, and #4 had incomplete resident agreements, with missing financial portions or other parts of the agreement. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Egebjerg | Survey Team Leader | Named as the survey team leader conducting the renewal inspection. |
Inspection Report
Complaint Investigation
Deficiencies: 17
Jan 18, 2017
Visit Reason
The inspection was conducted as a complaint investigation at At Home Assisted Living to assess compliance with regulatory standards and address specific concerns raised.
Findings
The inspection revealed multiple deficiencies including unsafe use of space heaters, improper laundry handling, incomplete staff orientation and missing documentation, inadequate policies, unclean facility conditions, medication administration and documentation errors, lack of resident service plans and activities, and physical plant issues such as water damage and rotting floors.
Complaint Details
The inspection was triggered by a complaint and focused on multiple areas of noncompliance including safety, staffing, medication management, and facility conditions.
Deficiencies (17)
| Description |
|---|
| Resident #18 had a space heater placed unsafely on top of a personal refrigerator on a small dresser; Resident #12 also had a space heater in her room. |
| Laundry was folded and sorted on a community couch without proper hygiene measures; no designated area for sorting or folding laundry in the basement laundry room. |
| 9 of 16 staff files lacked documentation of orientation; 6 of 15 staff files had incomplete orientation. |
| Incident reports signed by Administrator lacked consistent documentation of corrective actions to prevent recurrence. |
| Facility policies did not meet standards for Category B residents; missing policies on advanced directives, activities, and medication disposal; no evidence of staff training on policies. |
| Staff files missing multiple required documents and information. |
| Resident Needs Assessments were incomplete, blank, or not updated timely for several residents. |
| Resident Service Plans missing for some residents and many not updated for over a year. |
| No activities calendar posted; no activities conducted; only 6 resident service plans addressed interests; Administrator reported lack of time and owner refusal to hire activity staff. |
| Facility was unclean with visible garbage, tobacco products, dirty bathrooms, and urine odors; no working vacuum; hazardous conditions noted in common areas and resident rooms. |
| Inconsistent notification of residents’ practitioners or representatives in incident reports. |
| Medications improperly stored next to food condiments without barriers; multiple medication administration record (MAR) errors including missed signatures, incorrect dosing frequency, and lack of practitioner notification for refused or missed medications. |
| Medication records lacked diagnoses for many prescribed medications for multiple residents. |
| Two cats resided in the facility without vaccination records. |
| Multiple physical plant issues including water damage to ceiling in Resident #18’s room, rotted flooring in bathrooms, non-functioning laundry dryer, open ceiling hole above washer/dryer leaking water, and leaking bathroom tub faucet. |
| Only one fire drill documented since 2015; last fire inspection conducted in 2015. |
| Facility lacked a registered nurse (RN) on staff or contract as required for Category B facilities. |
Report Facts
Staff files reviewed: 16
Residents with missing or incomplete service plans: 18
Cats residing in facility: 2
Fire drills documented: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tara Wooten | Survey Team Leader | Led the complaint inspection |
| Staff #16 | Administrator | Named in findings related to incident report reviews, activities, medication administration, and staffing |
Inspection Report
Complaint Investigation
Deficiencies: 12
Jan 13, 2016
Visit Reason
The inspection was conducted as a complaint investigation regarding failure to notify the department of sexual abuse incidents occurring between August and September 2015 at the facility.
Findings
Multiple deficiencies were found including failure to notify authorities of sexual abuse incidents, lack of intervention to protect a resident from staff misconduct, inadequate staff training on abuse prevention, inconsistent resident needs assessments, inaccurate service plans, no planned activities program, facility safety issues such as lack of single action doorknobs and privacy curtains, inaccessible bathroom call systems, medication record deficiencies, and lack of oxygen use signage.
Complaint Details
The complaint investigation was substantiated by findings of failure to notify the department of sexual abuse incidents and multiple other regulatory violations related to resident safety, staff training, and documentation.
Deficiencies (12)
| Description |
|---|
| Failure to notify the department of sexual abuse incidents occurring August-September 2015. |
| No intervention to protect Resident #1 from inappropriate sexual behaviors by Staff #2. |
| No documentation that staff are oriented and trained to Montana Elder and Persons with Developmental Disabilities Abuse Prevention Act. |
| Resident Needs Assessments not consistently completed prior to admission for Residents #2 and #3; Resident #4's RNA document was blank. |
| Service Plans do not accurately reflect residents' needs and full services provided. |
| No indication that family/guardians are notified of incidents; facility policy conflicts with Montana Administrative Rule. |
| No planned Activities program; wall calendar documenting activities was empty. |
| Resident rooms and bathroom doors lack single action doorknobs. |
| Semi-private rooms lack privacy curtains or screens. |
| Bathroom call system not accessible to individuals on the floor; no time-framed plan for installation of new call system; repeat deficiency from prior renewal survey. |
| Medication Administration Records lack reason for use on all medications and lack signature page for self-administration assistance. |
| Two residents use oxygen in rooms without posted signs. |
Report Facts
Number of Service Plans reviewed: 25
Residents with no RNA present: 2
Residents using oxygen: 2
Resident rooms lacking single action doorknobs: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tara Wooten | Survey Team Leader | Conducted the complaint inspection and left business card with Administrator. |
| Tara Popp | Surveyor | Visited facility on November 13, 2015, offered assistance and left business card. |
| Staff #1 | Administrator | Interviewed regarding failure to notify department and other issues. |
Inspection Report
Renewal
Deficiencies: 10
Oct 16, 2015
Visit Reason
The inspection was conducted as a renewal inspection of At Home Assisted Living facility to assess compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including outdated policies and procedures, lack of activity calendars, inaccessible call system in bathrooms, unvaccinated pets, missing food service records and temperature logs, housekeeping issues, physical plant cleanliness concerns, missing smoke detector maintenance logs, and absence of a registered nurse on staff.
Deficiencies (10)
| Description |
|---|
| Policy and Procedure manual lacked evidence of reviews and contained outdated contact information. |
| Facility did not have an activity calendar for daily or past three months' scheduled activities. |
| Call button in resident bathroom was not accessible to an individual collapsed on the floor and could only be silenced at the kitchen panel. |
| Facility had two cats without current vaccination records. |
| Daily menu posted but staff unable to produce records of past menus. |
| Two kitchen freezers lacked thermometers and no current temperature logs for freezers and refrigerators. |
| Trash cans in laundry room and kitchen were uncovered and improperly located. |
| Sink in front bathroom filled to the top with water while running water for less than one minute; bathtub had black substance; fly paper with dead flies hung over hospice resident; overall facility cleanliness was poor. |
| Smoke detector belonging in upstairs hall was found on office desk; maintenance log for battery changes was missing. |
| Facility did not employ or contract with a registered nurse. |
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