Inspection Reports for
Eastern Montana Veterans Home

The complaint investigation found substantiated issues including incomplete investigations of incidents between residents and staff, lack of thorough documentation, and inadequate supervision on the secure care unit leading to resident injuries and altercations.

The facility failed to conduct complete and accurate investigations of incidents involving resident altercations and staff verbal abuse, and failed to provide adequate supervision on a secure care unit, resulting in resident injuries including a hip fracture requiring hospitalization and surgery.

The complaint investigation substantiated neglect and abuse of residents, failure to prevent elopement, inadequate staff training on elopement policy, and infection control deficiencies during an influenza outbreak. Specific incidents included a resident left unattended and neglected causing injury, a resident eloping and sustaining a head laceration, staff not following elopement protocols, and failure to isolate or move residents during the influenza outbreak.

The facility was found to have neglected a resident resulting in actual harm, failed to prevent a resident with dementia from eloping and sustaining injury, did not ensure nursing staff were adequately trained on elopement policy, and failed to maintain an effective infection prevention and control program during an influenza outbreak affecting multiple residents.

The facility was found deficient in multiple areas including incomplete POLST forms, unsanitary bathroom conditions, incomplete PASRR screenings, failure to create baseline care plans timely, inadequate care plan updates, unsafe smoking practices, insufficient RN coverage, improper psychotropic medication orders, and food safety violations in dietary services.

The complaint investigation substantiated that resident #7 was physically and psychosocially abused by multiple staff members on 8/22/24, resulting in bruises and emotional distress. The facility suspended the involved staff and reported the abuse to the State Survey Agency but failed to address root causes or prevent recurrence. Resident #7's preference to eat in her room was not honored. Resident #8's care plan was not updated to address grief after her husband's death, and social services were not adequately provided.

The facility failed to honor resident #7's preference to eat meals in her room, forcibly transferring her to the dining room, resulting in physical and psychosocial abuse causing bruises, emotional distress, and fear. The facility also failed to update the comprehensive care plan for resident #8 to address grief and provide social services following the death of her husband.

The investigation was complaint-driven, focusing on incidents involving resident #2's willful abuse of resident #1 and resident #3's elopement behavior and wanderguard use. The complaint was substantiated with findings of failure to address abuse and inadequate management of elopement risks.

The facility failed to identify and address willful abuse by a resident with dementia who attacked another resident, and failed to properly assess and manage a confused resident with elopement behaviors, including not obtaining a physician's order for a wanderguard and not using least restrictive interventions. Additionally, the facility's abuse education for staff was inadequate to ensure proper identification and management of abuse incidents.

The investigation was complaint-driven, focusing on allegations of delayed reporting of abuse and misappropriation, inadequate abuse investigations, and insufficient behavioral health care and services. The report documents substantiated failures in timely reporting and preventive actions.

The facility failed to report allegations of abuse and misappropriation of resident property to the State Survey Agency within 24 hours for 2 of 3 sampled residents. Abuse investigations did not show sufficient actions to prevent future resident-to-resident abuse events for 5 sampled residents on the secured dementia unit. Additionally, staff failed to implement behavioral interventions and provide activities to redirect residents displaying behavioral concerns for 3 of 4 sampled residents.

The facility was found deficient in multiple areas including failure to notify physicians of significant resident condition changes, delayed reporting of abuse allegations, inadequate abuse investigations, inaccurate resident assessments and care plans, failure to maintain adequate nutritional interventions for residents with severe weight loss, insufficient behavioral health interventions and activities, and failure to enforce COVID-19 source control measures for vaccine exempt staff.