Deficiencies per Year
16
12
8
4
0
Unclassified
Inspection Report
Complaint Investigation
Deficiencies: 2
Dec 19, 2025
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with minimum standards and fire safety regulations.
Findings
The facility failed to provide documented disaster reviews conducted with staff within the past year and had no recorded fire drills conducted during that time, indicating noncompliance with minimum standards and fire safety codes.
Complaint Details
The visit was complaint-related as indicated by the survey type 'Complaint Inspection'. No substantiation status is provided.
Deficiencies (2)
| Description |
|---|
| No records of documented disaster reviews conducted with staff within the past year. |
| No recorded fire drills conducted within the past year. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 18, 2025
Visit Reason
The inspection was conducted as a complaint investigation triggered by concerns related to medication administration at Bozeman Lodge.
Findings
The surveyors found that Resident #1 did not receive 11 doses of Morphine Sulfate ER 30 mg as scheduled between 5/25/25 and 5/29/25. The medication was documented as 'Drug Not Available' and the facility failed to notify the practitioner or find a solution for the missed doses.
Complaint Details
Complaint investigation related to missed medication doses for Resident #1; no substantiation status stated.
Deficiencies (1)
| Description |
|---|
| Resident #1 did not receive 11 doses of Morphine Sulfate ER 30 mg as scheduled; facility failed to notify practitioner or resolve medication unavailability. |
Report Facts
Missed medication doses: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Graham | Administrator | Named as facility administrator during complaint inspection |
| Noelle Markland | Survey Team Leader | Led the complaint inspection team |
Inspection Report
Complaint Investigation
Deficiencies: 13
Jun 18, 2024
Visit Reason
The inspection was conducted as a complaint investigation to assess allegations related to resident care, medication management, staffing, and facility conditions at Bozeman Lodge.
Findings
The investigation found multiple deficiencies including inadequate staff assistance to residents, medication delivery and administration failures, incomplete staff training, insufficient documentation, delayed staff response times, poor physical plant conditions, and lack of a current Registered Nurse. Numerous medication administration errors and documentation issues were observed, along with unsafe storage and handling of medications.
Complaint Details
The inspection was triggered by a complaint alleging inadequate resident care, medication errors, staffing shortages, and poor facility conditions. The complaint was substantiated by multiple findings including medication delivery failures, staffing inadequacies, and physical plant issues.
Deficiencies (13)
| Description |
|---|
| Resident unable to rely on staff for assistance to dining room and shower; strong urine odor and wet disposable briefs in unemptied trash can in room 334. |
| Medication management failures including delayed medication delivery to residents #5, #6, and #7. |
| Staff training incomplete for medication technicians. |
| Incident reports lacked documentation of administrator or designee review. |
| Over 1,000 staff response times to resident calls exceeded 10 minutes, with some delays over 90 minutes; insufficient night shift staffing. |
| Resident service plans not followed; resident #3's toenails unkempt and not wearing compression socks as required. |
| Incident reports lacked documentation of notification to legal representatives or physicians. |
| Medications pre-dispensed into portion cups not stored in pharmacy containers. |
| Resident #2's insulin administered without resident involvement in self-administration. |
| Multiple missed medication administrations and late medication administration documented for residents #5, #6, #7, #9, and #10 with no proper documentation or reporting. |
| Physical plant deficiencies including dirty and ripped carpet, damaged baseboards, holes in walls, and strong urine odor in resident rooms. |
| No current Registered Nurse employed at the facility. |
| Physician orders not transcribed or entered into MAR for two weeks. |
Report Facts
Staff response times over 10 minutes: 1018
Staff response times 21-30 minutes: 446
Staff response times 31-60 minutes: 234
Staff response times 61-90 minutes: 77
Staff response times over 90 minutes: 40
Missed medication administrations: 29
Missed medication administrations: 50
Missed medication administrations: 44
Missed medication administrations: 89
Staff on night shift: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ralph Scarano | Administrator | Named as administrator with no current Registered Nurse employed at facility. |
| Brett Christian | Survey Team Leader | Led the complaint inspection. |
Inspection Report
Renewal
Deficiencies: 1
Jan 2, 2019
Visit Reason
The inspection was conducted as a renewal inspection of the Bozeman Lodge facility license.
Findings
The review found that 5 of 6 resident files lacked documentation of a practitioner's annual order for residents to keep medication in their rooms and be responsible for taking it correctly. Staff interviews indicated about 30 residents keep their medication in their rooms without an annual practitioner order being obtained.
Deficiencies (1)
| Description |
|---|
| Lack of documentation of a practitioner's annual order for residents to keep medication in their rooms and be responsible for taking it correctly. |
Report Facts
Resident files reviewed: 6
Files lacking documentation: 5
Residents keeping medication in rooms: 30
Inspection Report
Renewal
Deficiencies: 1
Nov 6, 2013
Visit Reason
The inspection was conducted as a renewal inspection of the Bozeman Lodge facility to assess compliance with regulatory requirements.
Findings
The report identifies a core issue related to medications, specifically practitioner orders, indicating a deficiency in this area.
Deficiencies (1)
| Description |
|---|
| MEDICATIONS: PRACTITIONER ORDERS |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shelley Lowe | Survey Team Leader | Named as the survey team leader for the renewal inspection. |
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