Deficiencies (last 3 years)
Deficiencies (over 3 years)
20.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
257% worse than Montana average
Montana average: 5.8 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 6
Date: Mar 27, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to medication administration, resident safety, infection control, dietary practices, and use of equipment in the nursing facility.
Findings
The facility was found deficient in multiple areas including failure to ensure safe self-administration and administration of medications, improper use of lifts during resident transfers, failure to follow dietary sanitation protocols, and inadequate infection prevention practices during resident transfers. These deficiencies caused minimal harm or potential for harm to a few residents.
Deficiencies (6)
Failed to implement a system to ensure an interdisciplinary team was involved in determining if a resident was safe to self-administer medication and failed to secure as needed medication in a resident's room.
Failed to meet professional standards by not providing safe administration of a scheduled topical medication causing a resident a temporary burning sensation.
Failed to ensure staff followed appropriate protocols for safe transfer of residents using a Hoyer lift, with one staff member transferring alone.
Failed to provide pharmaceutical services to ensure safe administration of a scheduled topical medication causing a resident a temporary burning sensation.
Failed to ensure dietary staff wore hair coverings and beard nets while preparing resident meals, risking sanitation issues.
Failed to ensure enhanced barrier precaution practices were utilized by staff during high-contact resident care transfers, including failure to don gowns.
Report Facts
Residents sampled: 9
Residents affected: 1
Residents affected: 1
Medication administration time: 7.38
Medication application time: 23.3
Training dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member E | Completed medication self-administration assessment for resident #6 and denied dispensing Blu Emu cream | |
| Staff member K | Administered oral medication and placed topical cream on bedside table; failed to ensure safe medication administration | |
| Staff member J | Applied incorrect cream to resident #6 causing burning sensation; transferred resident #6 alone using Hoyer lift | |
| Staff member B | Provided education on lift protocols and infection prevention; stated facility requires two staff for lifts | |
| Staff member P | Provided training to staff member J on proper safety when using lifts | |
| Staff member I | Dietary staff observed not wearing hair covering or beard net while preparing food | |
| Staff member N | Transferred resident #5 without donning gown as required by enhanced barrier precautions | |
| Staff member L | Transferred resident #5 without donning gown as required by enhanced barrier precautions |
Inspection Report
Routine
Deficiencies: 2
Date: Nov 7, 2024
Visit Reason
The inspection was conducted to assess compliance with infection preventionist certification requirements and the implementation of policies and procedures for flu and pneumonia vaccinations.
Findings
The facility failed to ensure the Infection Preventionist had the necessary certification for oversight of the infection control program and failed to provide pneumococcal and Covid-19 vaccines for one resident despite documented consent.
Deficiencies (2)
Facility failed to ensure the Infection Preventionist had the necessary certification for oversight of the infection control program.
Facility failed to provide a pneumococcal and Covid-19 vaccine for 1 of 7 sampled residents for immunizations.
Report Facts
Residents sampled for immunizations: 7
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member D | Interviewed regarding infection preventionist certification and immunization documentation |
Inspection Report
Routine
Census: 36
Deficiencies: 16
Date: Nov 7, 2024
Visit Reason
The inspection was a routine survey of River Ridge Rehabilitation and Nursing LLC to assess compliance with regulatory requirements related to resident care, safety, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe, clean, and comfortable environment; failure to provide timely resident notifications for transfers and bed hold policies; incomplete and inaccurate resident assessments and care plans; inadequate staffing in dietary services; improper medication administration and storage; infection control lapses; and environmental cleanliness issues.
Deficiencies (16)
Failed to provide a safe, clean, and comfortable environment for resident #14, including presence of dried crusty brown substances and stains near the bed and on privacy curtains.
Failed to provide timely notification to residents and representatives before transfer or discharge for residents #18, 64, and 78.
Failed to notify residents or representatives in writing about bed hold policies upon transfer for residents #18, 64, and 78.
Failed to complete a comprehensive admission assessment within 14 days for resident #233.
Failed to accurately complete admission MDS assessment for resident #8's oral status.
Failed to implement a comprehensive care plan addressing dental, eating, dietary, and hearing needs for resident #8.
Failed to revise care plan to reflect mental health diagnosis of bipolar depression for resident #233.
Failed to employ a qualified activity professional to direct the activity program.
Failed to sufficiently and accurately document pressure ulcers for residents #11, 57, and 76.
Failed to ensure safe storage of chemicals in an unlocked housekeeping closet on Rosebud unit hallway.
Failed to follow physician orders for feeding tube medication administration, failed enhanced barrier precautions, and failed to measure and record total fluid volume for residents #3 and #20 with PEG tubes.
Failed to provide sufficient dietary staffing resulting in late and cold meals.
Failed to store food properly by not labeling and dating food in walk-in cooler and nutrition room refrigerators; failed to maintain cleanliness and monitor refrigerator/freezer temperatures on Rosebud Hall.
Failed to provide pneumococcal and COVID-19 vaccines for resident #74 despite consent.
Failed to timely fix maintenance issues in resident rooms for residents #17 and #44; medication room sink was unsanitary and in disrepair.
Failed to follow infection prevention and control practices including hand hygiene, mask use, equipment sanitization, enhanced barrier precautions, dietary infection control, and environmental cleanliness.
Report Facts
Residents sampled: 36
Residents affected by environment deficiency: 1
Residents affected by transfer notification deficiency: 3
Residents affected by bed hold notice deficiency: 3
Days late for MDS assessment: 76
Missed wound care sessions: 6
Census on specific dates: 69
Census on specific date: 76
Medication water flush volume observed: 185
Medication water flush volume ordered: 150
Weight loss: 16
Temperature log days out of range: 31
Temperature log days out of range: 30
Temperature log days out of range: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member Q | Observed and interviewed regarding environment cleanliness issues near resident #14's bed | |
| Staff member U | Interviewed about housekeeping duties and cleaning schedules | |
| Staff member L | Interviewed about medication labeling and storage practices | |
| Staff member H | Observed and interviewed regarding PEG tube medication administration for resident #3 | |
| Staff member N | Observed and interviewed regarding PEG tube medication administration and infection control | |
| Staff member S | Dietary staff interviewed about staffing shortages and infection control | |
| Staff member E | Interviewed regarding dental services and resident #17's dental needs | |
| Staff member D | Interviewed regarding MDS assessments, care plans, infection control audits | |
| Staff member B | Interviewed regarding Director of Nursing duties and charge nurse role | |
| Staff member C | Interviewed regarding wound care documentation and refrigerator cleaning | |
| Staff member A | Interviewed regarding infection control concerns and maintenance requests | |
| Staff member G | Interviewed regarding maintenance requests and workload | |
| Staff member T | Interviewed regarding medication room sink condition |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Aug 1, 2024
Visit Reason
The inspection was conducted based on complaints alleging failure to refund timely at discharge, failure to resolve grievances promptly, neglect of residents, failure to report abuse and neglect timely, and inadequate supervision of residents with leave privileges.
Complaint Details
The complaint investigation was substantiated with findings that the facility failed in multiple areas including timely refunds, grievance handling, resident neglect, abuse reporting, and supervision of residents with leave privileges.
Findings
The facility failed to refund a resident representative within 30 days of discharge, failed to act promptly on grievances and protect residents from neglect, failed to report neglect and abuse allegations timely to the State Survey Agency, and failed to ensure adequate supervision of residents with leave privileges, resulting in actual harm to some residents and potential harm to others.
Deficiencies (5)
Failed to refund a resident representative within 30 days of discharge.
Failed to act promptly to resolve grievances, provide anonymous grievance filing, protect residents from potential abuse, and conduct thorough investigations for multiple residents.
Failed to keep residents free from neglect, contributing to skin breakdown, psychosocial harm, and pain for residents #1 and #15.
Failed to timely report suspected abuse, neglect, or theft and failed to report investigation results to proper authorities within required timeframes.
Failed to ensure residents were appropriately assessed for independent outside privileges and failed to ensure residents were inside the facility at night, resulting in a resident eloping on a motorized scooter.
Report Facts
Residents sampled: 17
Residents affected by grievance failures: 6
Residents affected by neglect: 2
Residents affected by abuse reporting failures: 3
Residents affected by supervision failure: 1
Call light durations: 93
Time resident #15 left in feces-filled brief: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Administrator | Reported not filing neglect reports timely and was new to reporting neglect |
| NF2 | Resident representative reporting grievances and poor care for resident #1 | |
| NF4 | Nurse who reported neglect and poor care for resident #15 | |
| Staff member F | CNA | Named in neglect and abuse allegations for refusing to change resident #15's brief and rough care |
| Staff member C | Reported resident #15's grievance to administrator immediately | |
| Staff member E | Reported grievances about staff member F and poor call light response | |
| Staff member G | Reported missing grievances and resident council concerns | |
| Staff member J | Reported grievances to administrator and unaware of resident #13 elopement | |
| Staff member O | Reported administrator did not follow proper reporting protocol |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Apr 25, 2024
Visit Reason
The inspection was conducted based on a complaint regarding failure to provide necessary care and services to a dependent resident, as well as concerns about restorative nursing services and nurse staffing postings.
Complaint Details
The complaint involved a staff member refusing to assist resident #19 with getting out of bed and retrieving the call light, and stretching the resident's urinary catheter tubing causing discomfort. The staff member resigned voluntarily and did not return to work. Resident #19 was dependent on assistance for activities of daily living and cognitively intact but passed away before the survey.
Findings
The facility failed to provide necessary care to a dependent resident, resulting in minimal harm. Additionally, the facility did not ensure consistent provision of restorative nursing services due to staffing shortages and lack of backup plans. The facility also failed to post required nurse staffing information daily, missing many days and failing to update census changes.
Deficiencies (4)
Failed to provide care and assistance to perform activities of daily living for a dependent resident who was unable.
Failed to ensure residents with limited range of motion or mobility received restorative services necessary to maintain their highest level of functioning.
Failed to provide enough nursing staff every day to meet the needs of every resident and have a licensed nurse in charge on each shift.
Failed to post nurse staffing information every day as required, including changes in staffing or census.
Report Facts
Residents sampled: 19
Residents sampled for restorative services: 4
Restorative services frequency: 3
Admissions: 74
Missing daily staff postings: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| staff B | Investigated allegation of failure to assist resident #19 and reported staff member resigned | |
| staff member D | Interviewed regarding restorative services and resident assistance | |
| staff member H | Interviewed regarding restorative services and staffing challenges | |
| staff member E | Interviewed regarding restorative services and EHR tasks | |
| staff member F | Interviewed regarding restorative services and charting | |
| staff member C | Responsible for nursing oversight and staffing postings |
Inspection Report
Deficiencies: 2
Date: Oct 26, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including notification of significant weight loss and provision of routine bathing for dependent residents.
Findings
The facility failed to notify a resident representative of a significant weight loss for one resident and failed to provide routine bathing for dependent residents for four sampled residents. Documentation and interviews revealed gaps in communication and care provision.
Deficiencies (2)
Failed to notify a resident representative of a significant weight loss for resident #303.
Failed to provide routine bathing for dependent residents #2, 6, 27, and 44.
Report Facts
Residents sampled: 23
Residents affected by weight loss notification deficiency: 1
Residents affected by bathing deficiency: 4
Weight loss percentage: 8.32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NF3 | Interviewed staff member who was unaware of resident #303's weight loss notification |
Inspection Report
Routine
Deficiencies: 16
Date: Oct 26, 2023
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements for River Ridge Rehabilitation and Nursing LLC.
Findings
The facility was found deficient in multiple areas including failure to formulate advanced directives, failure to notify resident representatives of significant weight loss, failure to maintain resident privacy, failure to report suspected abuse, failure to complete timely Significant Change MDS, failure to develop baseline care plans within 48 hours, failure to follow care plan interventions, failure to meet professional standards in medication administration, failure to provide routine bathing, failure to prevent pressure ulcers, failure to monitor severe weight loss, failure to follow physician orders for tube feeding, failure to have RN coverage for 8 hours daily, failure to post nurse staffing information daily, failure to maintain sanitary food preparation conditions, and failure to implement infection prevention and control practices.
Deficiencies (16)
Failed to formulate an advanced directive for 1 of 23 sampled residents.
Failed to notify a resident representative of significant weight loss for 1 of 23 sampled residents.
Failed to provide privacy by leaving window blinds open during perineal care for 1 of 23 sampled residents.
Failed to report and investigate suspected abuse related to bruising for 1 of 1 sampled residents.
Failed to complete a Significant Change MDS within 14 days for 1 of 1 sampled resident receiving hospice services.
Failed to develop and implement a baseline care plan within 48 hours of admission for 2 of 23 sampled residents.
Failed to follow care plan interventions to protect a resident's room from being entered by others for 1 of 1 sampled residents.
Failed to follow physician's order to hold insulin for blood glucose less than 100 mg/dL for 1 of 23 sampled residents.
Failed to provide routine bathing for dependent residents for 4 of 23 sampled residents.
Failed to prevent development of an unstageable pressure injury for 1 of 2 sampled residents with wounds.
Failed to monitor and follow interventions for severe weight loss for 1 of 1 sampled residents.
Failed to follow physician's order for continuous tube feeding administration, failed to label feeding bags, and failed to document intake for 1 of 23 sampled residents.
Failed to have an RN scheduled for eight hours per day.
Failed to post daily nurse staffing information.
Failed to prepare food in sanitary conditions, including dirty kitchen equipment and floors.
Failed to keep a foley catheter and tubing from dragging on the floor and failed to follow infection control standards during bed linen changes.
Report Facts
Weight loss percentage: 15.9
Weight loss percentage: 8.32
Bathing frequency: 1
Bathing frequency: 1
Insulin units administered: 7
Tube feeding rate: 58
Free water rate: 18
Tube feeding duration: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member B | Mentioned in multiple interviews related to care plan responsibility, abuse reporting, and infection control. | |
| Staff member C | Mentioned in multiple interviews related to advanced directives, care planning, and infection control. | |
| Staff member F | Mentioned in interviews related to baseline care plan responsibility and resident care. | |
| Staff member K | Mentioned in interviews and observations related to insulin administration and tube feeding. | |
| Staff member L | Mentioned in interviews related to tube feeding documentation and labeling. | |
| Staff member I | Mentioned in infection control observations and interviews. | |
| Staff member J | Mentioned in infection control observations and interviews. | |
| Staff member M | Mentioned in interview related to kitchen cleaning schedule. | |
| Resident #205 | Resident interviewed regarding advanced directives and care plan. | |
| Resident #6 | Resident interviewed regarding abuse, bathing, weight loss, and room privacy. | |
| Resident #19 | Resident observed and discussed regarding tube feeding. | |
| Resident #24 | Resident observed regarding foley catheter care. |
Inspection Report
Routine
Deficiencies: 11
Date: Jan 5, 2023
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements for River Ridge Rehabilitation and Nursing LLC.
Findings
The facility was found deficient in multiple areas including failure to notify resident representatives of health changes, inadequate restraint monitoring, delayed reporting of abuse investigations, incomplete investigation documentation, failure to invite resident representatives to care plan meetings, inadequate personal hygiene and bathing care, failure to maintain skin integrity resulting in pressure ulcers, failure to provide restorative range of motion services, medication administration errors, failure to implement transmission-based precautions, and lack of a designated qualified infection preventionist.
Deficiencies (11)
Facility staff failed to notify a resident's representative of changes in a resident's health, including positive COVID-19 status and severe weight loss.
Facility failed to perform ongoing monitoring and documentation of the continued need for a physical restraint for a resident.
Facility failed to ensure findings of a reportable incident were submitted to the State Survey Agency within five days.
Facility failed to provide investigation documentation for a resident-to-resident altercation.
Facility staff failed to invite a resident representative to care plan meetings.
Facility staff failed to provide showers or baths and personal hygiene care to multiple residents as required.
Facility failed to maintain skin integrity resulting in a Stage II pressure ulcer and failed to assess, document, and provide timely wound care for pressure ulcers.
Facility failed to provide restorative range of motion services as per care plan for a resident with decreased range of motion.
Facility staff failed to follow physician orders for medication changes and failed to update sliding scale insulin orders, resulting in incorrect medication administration.
Facility failed to implement transmission-based precautions for a resident with C-Diff and Norovirus.
Facility failed to designate a qualified infection preventionist meeting regulatory requirements.
Report Facts
Weight loss: 27.2
Shower frequency: 7
Shower frequency: 8
Shower frequency: 5
Shower frequency: 3
Bath frequency: 3
Restorative ROM sessions: 13
Missed dressing changes: 27
Medication dosage error duration: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NF3 | Named in findings related to failure to notify resident representative and medication error. | |
| Staff member F | Discussed medication error, shower aide hiring, and late reporting of abuse findings. | |
| Staff member C | Discussed restraint assessments and restorative program oversight. | |
| Staff member A | Discussed missing investigation documentation and order entry procedures. | |
| Staff member E | Discussed pressure ulcer care and wound care training. | |
| Staff member D | Discussed wound care training and pressure ulcer staging. | |
| Staff member G | Discussed care plan meeting invitations. | |
| Staff member J | Discussed resident shower refusals. | |
| Staff member L | Discussed wound care order errors and corrections. | |
| NF2 | Discussed pressure ulcer development. | |
| Staff member B | Discussed infection control and transmission-based precautions. |
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