Deficiencies per Year
8
6
4
2
0
Unclassified
Inspection Report
Renewal
Deficiencies: 4
Apr 6, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the Edgewood Billings Senior Living facility to assess compliance with licensing and regulatory standards.
Findings
The inspection identified several deficiencies including lack of documentation for flame-resistant treatment of curtains, absence of privacy curtains in double occupancy rooms, fire doors in the main dining hall that lock and require a key to unlock, a non-functioning laundry room vent with no fresh air supply, and confirmation of six category B residents in the facility.
Deficiencies (4)
| Description |
|---|
| Several resident units have curtains without documentation of non-combustible or flame-resistant treatment. |
| Four double occupancy rooms lack privacy curtains or screens upon resident request. |
| Main dining hall has four hallway fire doors that lock and do not unlock without a key, limiting egress options. |
| Laundry room vent was not working and there was no fresh air supply; a chemical smell was noted near the laundry area. |
Report Facts
Category B residents: 6
Number of double occupancy rooms without privacy curtains: 4
Number of hallway fire doors locking requiring key: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelsey Miller | Administrator | Named as facility administrator. |
| Noelle Markland | Survey Team Leader | Led the renewal inspection. |
| Staff #1 | Assistant Medical Director | Interviewed regarding resident certification and category B residents. |
Inspection Report
Renewal
Capacity: 18
Deficiencies: 4
Feb 23, 2018
Visit Reason
The inspection was a renewal inspection of the Edgewood Billings Senior Living facility to assess compliance with regulatory requirements.
Findings
The inspection identified deficiencies including lack of documentation for a resident's final transfer or discharge, emergency call system issues in bathrooms, inadequate laundry room ventilation, and loose grab bars in tub rooms.
Deficiencies (4)
| Description |
|---|
| No documentation of the date and circumstances of the resident's final transfer, discharge, or death, including notice to responsible parties and disposition of personal possessions. |
| One bathroom had no emergency call system and 11 bathrooms had call systems with pull cords not accessible to an individual collapsed on the floor. |
| Laundry room lacked adequate ventilation to prevent heat and odor build-up; room was very warm and smelled of urine. |
| Grab bars in tub rooms in Wing A and B were loose and not sufficiently anchored to sustain a concentrated 250-pound load. |
Report Facts
Rooms/bathrooms inspected: 18
Weight load: 250
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brinda Pluhar | Survey Team Leader | Leader of the renewal inspection team |
Inspection Report
Renewal
Deficiencies: 7
Mar 4, 2016
Visit Reason
The inspection was conducted as a renewal inspection of Edgewood Billings Senior Living, LLC to assess compliance with assisted living facility regulations.
Findings
Multiple deficiencies were identified including lack of practitioner orders for resident classification, missing documentation of staff orientation and training, incomplete resident medication and possession disposition records, non-flame resistant window treatments, missing reasons for medication use on MARs, and outdated health care plan reviews for most residents.
Deficiencies (7)
| Description |
|---|
| No practitioner’s written orders for admission to Category B and/or C classification for residents. |
| 4/4 employee files lacked documentation of orientation to Montana Elder and Persons with Developmental Disabilities Abuse Prevention Act. |
| 2/4 employee files did not contain documentation of training in first aid and Heimlich maneuver. |
| No indication in resident charts as to disposition of medications or personal possessions for discharged or expired residents. |
| No documentation that window treatments are flame resistant or non-combustible. |
| Medication Administration Records for residents #2 - #5 missing reason for use on all scheduled medications. |
| 10 out of 11 resident health care plans did not have current quarterly reviews. |
Report Facts
Resident files reviewed: 5
Employee files reviewed: 4
Closed resident files reviewed: 3
Resident Medication Administration Records reviewed: 5
Resident Health Care Plans reviewed: 11
Inspection Report
Complaint Investigation
Deficiencies: 4
Sep 24, 2014
Visit Reason
The inspection was conducted as a complaint investigation regarding the care and safety of resident #1, specifically related to self-harm ideations and the facility's response to these incidents.
Findings
The investigation found deficiencies in documentation of resident #1's admission and psychiatric history, lack of medication justification in the MAR, failure of staff to physically assess the resident during self-harm actions on 7-7-2014, and improper completion of incident reports by the administrator rather than the staff member with first-hand knowledge.
Complaint Details
Complaint investigation focused on resident #1's self-harm incidents and facility response; substantiation status not explicitly stated.
Deficiencies (4)
| Description |
|---|
| Documentation of resident #1 admission and stay at psychiatric unit incomplete; self-harm ideations documented but not adequately addressed. |
| Facility MAR review of resident #1 showed no reason for medication as required by rule. |
| No management team member or nursing staff physically assessed resident #1 during self-harm actions on 7-7-2014; interventions failed to meet resident's well-being and safety needs. |
| Incident report form was completed by facility administrator instead of staff member with first-hand knowledge as required by policy. |
Report Facts
Facility License Number: 12786
Response Due Date: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Don Kenny | Survey Team Leader | Named as survey team leader conducting the complaint inspection |
Inspection Report
Complaint Investigation
Deficiencies: 4
Nov 25, 2013
Visit Reason
The inspection was conducted as a complaint investigation regarding multiple aspects of resident #1's care that were allegedly not conducted properly during their stay at the facility.
Findings
The investigation found that resident #1 was admitted without a resident needs assessment, care plan, or assisted living agreement; there was no documentation of communication with the personal care physician; the resident was removed without prior notification and no discharge documentation was present; medication records were incomplete; and there were no physician orders for admission to a category C facility as required by state regulations.
Complaint Details
The visit was triggered by a complaint alleging improper care of resident #1, including lack of assessments, care planning, physician communication, discharge documentation, and medication record keeping.
Deficiencies (4)
| Description |
|---|
| No resident needs assessment conducted or updated, no care plan created or updated, and no assisted living agreement completed for resident #1. |
| No documentation that the facility or facility physician contacted the resident's personal care physician regarding care and medication management. |
| Resident #1 was removed without prior notification and no discharge documentation was found; medication records were incomplete and inconsistent. |
| No physician orders for resident #1’s admission to a category C facility as required by state regulations. |
Report Facts
Facility License Number: 12786
Inspection Report
Renewal
Deficiencies: 2
Sep 11, 2013
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility Edgewood Billings Senior Living, LLC.
Findings
Two core issues were identified related to placement in assisted living facilities and resident application and needs assessment.
Deficiencies (2)
| Description |
|---|
| Placement in assisted living facilities |
| Resident application and needs assessment |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Traci Clark | Survey Team Leader | Named as Survey Team Leader for the renewal inspection |
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