8 CMS Surveys
Inspection Report — Dec 10, 2025
Renewal
Date: Dec 10, 2025
Visit Reason
The survey was conducted as a renewal inspection of Eastern Montana Veterans Home.
Findings
The facility failed to conduct complete and accurate investigations of incidents involving resident altercations and staff verbal abuse. Additionally, inadequate supervision on the secure care unit contributed to resident altercations and a resident sustaining a hip fracture requiring hospitalization and surgery.
Deficiencies (2)
F 0610 Respond appropriately to all alleged violations: the facility failed to ensure complete investigations and accurate documentation of incidents involving resident altercations and staff verbal abuse, lacking interviews and interventions to prevent recurrence.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to provide sufficient supervision on the secure care unit, resulting in resident altercations and a resident sustaining a hip fracture requiring hospitalization and surgery.
Report Facts
Residents sampled for injuries/abuse: 6
Residents involved in supervision deficiency: 4
Residents involved in incident investigation deficiency: 3
Incident dates: 4
Inspection Report — Jun 19, 2025
Renewal
Date: Jun 19, 2025
Visit Reason
Routine renewal inspection of Eastern Montana Veterans Home to assess compliance with health and safety regulations.
Findings
The facility was cited for neglect of a resident resulting in actual harm, failure to prevent elopement of a resident with dementia, inadequate staff training on elopement policy, and deficiencies in infection prevention and control during an influenza outbreak affecting multiple residents.
Deficiencies (4)
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: the facility neglected a resident who was left unattended in bed for an extended period, resulting in pain, distress, skin tears, bruising, and pressure marks.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to prevent a resident with dementia from eloping through the front entrance, resulting in injury from a fall and lack of timely head counts after the alarm sounded.
F 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being: the facility failed to ensure nursing staff were adequately trained on the elopement policy, contributing to a resident eloping unattended.
F 0880 Provide and implement an infection prevention and control program: the facility failed to maintain a communicable disease surveillance system during an influenza outbreak, did not move infected residents appropriately, and lacked proper documentation and infection mapping.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 6
Residents affected: 2
Residents affected: 5
Residents affected: 9
Residents affected: 4
Elopement risk score: 6
Wander risk score: 10
Inspection Report — Feb 13, 2025
Renewal
Date: Feb 13, 2025
Visit Reason
The survey was a renewal inspection of Eastern Montana Veterans Home to assess compliance with licensing standards.
Findings
The facility had multiple deficiencies including incomplete POLST forms, unsanitary bathroom conditions, incomplete PASRR screenings, delayed care plan development, inadequate smoking safety measures, insufficient RN coverage, improper psychotropic medication orders, and food safety violations.
Deficiencies (9)
F 0578 Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive: the facility failed to ensure POLST forms were completed accurately with missing signature dates for 2 of 17 sampled residents.
F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely: the facility failed to provide a clean and sanitary environment with urine stains, strong odors, and a peeling hole in a resident's bathroom.
F 0645 PASARR screening for Mental disorders or Intellectual Disabilities: the facility failed to ensure PASRR Level One forms were completed and accurate for 3 of 17 sampled residents.
F 0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted: the facility failed to create a baseline care plan with pertinent condition specific information within 48 hours for 1 of 17 sampled residents.
F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: the facility failed to update resident care plans in a timely manner for 1 of 17 sampled residents despite significant weight loss.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to assess and monitor a resident's safety with smoking, failed to ensure the resident signed out when smoking, and did not adhere to the smoking policy for 1 of 17 sampled residents.
F 0727 Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis: the facility failed to have an RN working at least eight consecutive hours per day on multiple dates.
F 0758 Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited: the facility failed to ensure a PRN psychotropic medication was limited to 14 days for 1 of 17 sampled residents.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: the facility failed to ensure staff prepared food in a sanitary manner, maintain freezer equipment, and properly cover, label, and date food items, increasing risk of foodborne illness.
Report Facts
Residents sampled: 17
Residents affected by POLST deficiency: 2
Residents affected by PASARR deficiency: 3
Residents affected by baseline care plan deficiency: 1
Residents affected by care plan update deficiency: 1
Residents affected by smoking safety deficiency: 1
Dates without 8 consecutive RN hours: 6
PRN lorazepam doses in January 2025: 5
Weight loss in pounds: 12
Weight loss percentage: 8.39
Inspection Report — Oct 24, 2024
Renewal
Date: Oct 24, 2024
Visit Reason
The survey was a renewal inspection of Eastern Montana Veterans Home conducted on October 24, 2024.
Findings
The facility failed to honor a resident's dining preferences and subjected the resident to physical and psychosocial abuse by staff, resulting in injuries and emotional distress. Additionally, the facility failed to update a comprehensive care plan and provide grief support for another resident following the death of her husband.
Deficiencies (4)
F 0561 Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice: the facility failed to honor dining preferences for one resident who preferred to eat in her room but was forcibly taken to the dining room.
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: the facility failed to protect one resident from physical and psychosocial abuse by staff, resulting in bruises, emotional distress, and sleep difficulties.
F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: the facility failed to review and update a comprehensive care plan for one resident experiencing grief and sorrow after the death of her husband.
F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life: the facility failed to provide social services and grief support for one resident following the loss of her spouse.
Report Facts
Residents sampled: 13
Bruises: 3
Care plan revision date: Aug 21, 2024
Resident #7 MDS assessment date: Jul 14, 2024
Resident #7 care plan revision date: Sep 20, 2024
Resident #8 spouse death month: 202409
Inspection Report — Jan 31, 2024
Renewal
Date: Jan 31, 2024
Visit Reason
Routine renewal inspection of the Eastern Montana Veterans Home.
Findings
No health deficiencies were found during this inspection.
Inspection Report — Oct 11, 2023
Renewal
Date: Oct 11, 2023
Visit Reason
The survey was conducted to assess compliance with regulations related to resident care, abuse prevention, and staff education at Eastern Montana Veterans Home.
Findings
The facility failed to identify and address willful abusive behavior by a resident with dementia and did not properly assess or manage a confused resident's elopement risk, including failure to obtain a physician's order for a wanderguard. Additionally, staff education on dementia care and abuse identification was inadequate for administrative staff.
Deficiencies (3)
F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia: the facility failed to identify and address willful abusive behavior by a resident with dementia who attacked another resident, and failed to ensure a confused resident with elopement behaviors was assessed and managed safely, including inappropriate use of a wanderguard.
F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia: the facility failed to obtain a physician's order for the use of a wanderguard, did not complete a wandering assessment, and did not use the least restrictive intervention for a resident who repeatedly removed the wanderguard causing increased agitation.
F 0943 Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation: the facility's abuse education was inadequate to ensure administrative staff had necessary knowledge to identify willful abuse and manage such events for future prevention.
Report Facts
Residents sampled: 5
Residents affected: 2
Residents affected: 1
Inspection Report — Feb 15, 2023
Renewal
Date: Feb 15, 2023
Visit Reason
The survey was a renewal inspection of Eastern Montana Veterans Home conducted on February 15, 2023.
Findings
The facility was cited for multiple deficiencies including failure to notify physicians of significant resident condition changes, delayed reporting of abuse allegations, inadequate abuse investigations, inaccurate resident assessments, failure to update care plans for severe weight loss and fall prevention, ineffective nutritional interventions, insufficient staff competencies in weight monitoring, lack of behavioral health interventions, failure to ensure dietitian communication, and inadequate enforcement of COVID-19 source control for vaccine exempt staff.
Deficiencies (10)
F 0580 Immediately tell the resident, the resident's doctor, and a family member of situations that affect the resident: the facility failed to notify a resident's physician of a significant change in condition including severe weight loss.
F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: the facility failed to report allegations of abuse and misappropriation of resident property to the State Survey Agency within 24 hours for two residents.
F 0610 Respond appropriately to all alleged violations: the facility's abuse investigations failed to show sufficient actions taken to prevent future reoccurrences of resident to resident abuse events for residents on the secured dementia unit.
F 0641 Ensure each resident receives an accurate assessment: the facility failed to ensure resident MDS data was coded accurately for three residents, including mis-coding medications and failure to identify hospice status.
F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: the facility failed to update a care plan to show a resident's severe weight loss and fall prevention interventions.
F 0692 Provide enough food/fluids to maintain a resident's health: the facility failed to maintain an effective system for tracking resident weights, identifying weight loss, and implementing nutritional interventions for two residents with significant and severe weight loss.
F 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being: the facility failed to obtain a follow-up weight to confirm or refute an inconsistent documented 21 pound weight loss in a 14-day period for one resident.
F 0740 Ensure each resident must receive and the facility must provide necessary behavioral health care and services: the facility failed to offer and attempt to use interventions identified on individualized care plans or provide activities to redirect residents displaying behavioral concerns.
F 0801 Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician: the facility failed to ensure the dietitian and dietary manager accurately assessed and communicated the nutritional needs of a resident with severe weight loss.
F 0880 Provide and implement an infection prevention and control program: the facility failed to implement and enforce appropriate Covid-19 source control for vaccine exempt staff who were not wearing masks as required.
Report Facts
Weight loss (%): 15.13
Weight loss (pounds): 11
Weight loss (pounds): 18
Weight loss (pounds): 20
Weight loss (%): 7.33
Weight loss (pounds): 11
Weight loss (%): 10.62
Weight loss (pounds): 21
Behavioral incidents: 27
Inspection Report — Feb 15, 2023
Date: Feb 15, 2023
Visit Reason
The survey was conducted to assess compliance with regulations related to abuse reporting, abuse investigations, and behavioral health care services.
Findings
The facility failed to timely report allegations of abuse and misappropriation of resident property within 24 hours. Abuse investigations did not show sufficient actions to prevent future resident-to-resident abuse. Staff also failed to implement behavioral interventions and provide activities to residents with behavioral concerns on the secure care unit.
Deficiencies (3)
F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: 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.
F 0610 Respond appropriately to all alleged violations: the facility's abuse investigations failed to show sufficient actions to prevent future resident-to-resident abuse events for 5 sampled residents on the secured dementia unit with cognitive deficits.
F 0740 Ensure each resident must receive and the facility must provide necessary behavioral health care and services: staff failed to offer or use interventions from individualized care plans and did not provide activities to redirect residents displaying behavioral concerns for 3 of 4 sampled residents on the secure care unit.
Report Facts
Behavioral incidents: 27
Residents affected: 3
Residents affected: 5
Residents affected: 2
Residents affected: 4
Residents affected: 3
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