Deficiencies (last 3 years)
Deficiencies (over 3 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
3% worse than Montana average
Montana average: 5.8 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 5, 2025
Visit Reason
The inspection was conducted due to an allegation of theft reported by resident #34, involving missing money from her purse in her room.
Findings
The facility failed to fully investigate the theft allegation to ensure no other residents were affected. The investigation did not include interviewing potential witnesses or other residents, and the facility reimbursed resident #34 $100 without determining who took the money.
Complaint Details
The complaint involved resident #34 reporting several hundred dollars missing from her purse. The facility reimbursed $100 but did not complete a thorough investigation, did not interview potential witnesses or other residents, and reported the allegation to local police who doubted they would find the perpetrator.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to fully investigate an allegation of theft to ensure no other residents were affected. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 21
Residents affected: 1
Amount missing: 300
Amount reimbursed: 100
People in and out of room: 50
Date of initial report: 200408
Inspection Report
Routine
Deficiencies: 7
Jun 5, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, infection control, and facility operations at Gallatin Rest Home.
Findings
The facility was found deficient in multiple areas including failure to ensure informed consent for psychotropic medications, incomplete investigation of resident theft allegations, failure to update and revise resident care plans, inadequate pressure ulcer care, lack of root cause analysis and individualized fall prevention strategies, absence of dialysis care policies and monitoring, and deficient infection prevention practices including poor hand hygiene and unclean equipment.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Level of Harm - Actual harm: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure resident and representative were informed of risks and benefits of psychotropic medications prior to treatment for 1 of 21 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to fully investigate an allegation of theft to ensure no other residents were affected for 1 of 21 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to review and revise resident care plans for 3 of 21 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate pressure ulcer care and prevent new ulcers for 2 of 7 sampled residents with pressure ulcers. | Level of Harm - Actual harm |
| Failed to utilize a system for identifying root causes for falls and failed to develop individualized fall prevention strategies for 1 of 21 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to have policies, contract, and monitoring for dialysis care and transportation for 1 of 1 sampled resident requiring dialysis. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain proper hand hygiene during medication administration, failed to maintain cleanable surfaces on floor mats, failed to maintain clean respiratory equipment, and failed to properly store tube feeding supplies. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 21
Residents with pressure ulcers sampled: 7
Dialysis resident sampled: 1
Medication passes observed: 7
Residents affected by psychotropic medication consent deficiency: 1
Residents affected by theft investigation deficiency: 1
Residents affected by care plan revision deficiency: 3
Residents affected by pressure ulcer care deficiency: 2
Residents affected by fall prevention deficiency: 1
Residents affected by dialysis care deficiency: 1
Residents affected by infection control deficiency: 4
Pressure ulcer measurements: 13.5
Pressure ulcer measurements: 8.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member C | Responsible for obtaining psychotropic medication consent documentation; stated forms not consistently done if out of office | |
| Staff member B | Stated nurses should update care plans; acknowledged failure to revise care plans and lack of wound documentation | |
| Staff member D | Observed failing to perform hand hygiene during medication administration and handling | |
| Staff member E | Observed failing to perform hand hygiene and using unclean pill cutter during medication administration | |
| NF1 | Assessed resident #1's pressure wounds and described wound care needs | |
| NF5 | Stated resident #207 had dialysis transport arranged and dialysis monitoring done by dialysis center |
Inspection Report
Routine
Deficiencies: 2
Jul 2, 2024
Visit Reason
The inspection was conducted to assess compliance with regulations regarding meal service times and infection prevention and control measures at Gallatin Rest Home.
Findings
The facility failed to ensure meals were served with no more than 14 hours between dinner and breakfast, failed to provide nourishing bedtime snacks, and lacked documentation of resident group approval of mealtime hours. Additionally, the facility failed to implement and monitor measures to prevent Legionella growth in water systems and maintain cleanable surfaces on the ice/water dispenser.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide residents with meals with no more than 14 hours between the evening meal and breakfast; failed to provide a nourishing snack at bedtime; failed to document resident group approval of mealtime hours. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure implementation and monitoring of measures to prevent growth of Legionella or other opportunistic waterborne pathogens in the building's water systems; failed to maintain cleanable surfaces on ice/water dispenser machine. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 13
Residents affected: 7
Meal times gap: 15
Inspection Report
Complaint Investigation
Deficiencies: 2
Jun 8, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged verbal abuse by a staff member towards resident #33.
Findings
The facility failed to protect resident #33 from staff verbal abuse and failed to thoroughly investigate the alleged abuse. Staff member H verbally abused resident #33, leading to psychosocial harm, and the facility did not provide abuse education or training over the past year. Staff member H's contract was terminated, but documentation of a thorough investigation and resident interviews was lacking.
Complaint Details
The complaint involved resident #33 reporting verbal abuse by staff member H on 10/6/22. The abuse was substantiated, staff member H was terminated, but the facility failed to provide abuse education and did not document a thorough investigation or resident interviews.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to protect resident #33 from staff to resident verbal abuse causing psychosocial harm. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to thoroughly investigate an alleged abuse for resident #33, including lack of documentation of resident interviews. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 3
Residents affected: 4
Date of abuse incident: Oct 6, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member H | CNA | Named in verbal abuse incident and contract termination |
| Staff member B | Interviewed resident #33 and confirmed abuse, investigated and terminated staff member H | |
| Staff member I | Observed verbal abuse incident and assisted resident #33 | |
| Staff member A | Stated facility had not provided abuse education or training over the past year |
Inspection Report
Complaint Investigation
Deficiencies: 6
Jun 8, 2023
Visit Reason
The inspection was conducted due to complaints and allegations regarding staff to resident verbal abuse, failure to investigate alleged abuse thoroughly, maintenance issues leading to resident injury, improper food handling practices, lack of quality assurance activities, and inadequate infection control practices.
Findings
The facility failed to protect a resident from verbal abuse by staff, failed to thoroughly investigate abuse allegations, failed to maintain equipment leading to a resident fall and injury, failed to ensure proper food safety and staff attire, failed to conduct quality assurance performance improvement projects, and failed to enforce proper hand hygiene during meal service.
Complaint Details
The complaint involved verbal abuse by staff member H towards resident #33 on 10/6/22, which caused psychosocial harm. The facility failed to thoroughly investigate the abuse allegations, with no documentation of interviews for other residents on the same hall. Staff member H's contract was terminated following the incident.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Level of Harm - Actual harm: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to protect 1 resident from staff to resident verbal abuse causing psychosocial harm. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to thoroughly investigate an alleged abuse for 1 resident, risking unidentified additional abuse. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain scale equipment resulting in a fall with injury for 1 resident. | Level of Harm - Actual harm |
| Failed to ensure kitchen staff wore proper hair and beard coverings and label and date food items in the freezer. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to perform annual performance improvement projects and involve QAPI in abuse system issues. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure staff followed proper infection control hand hygiene practices when providing meal service. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 3
Residents affected: 4
Residents affected: 2
Number of sutures: 20
Residents affected: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member H | Named in verbal abuse incident and contract termination | |
| Staff member B | Interviewed regarding abuse incident and investigation | |
| Staff member A | Interviewed regarding abuse education, maintenance, QAPI, and infection control | |
| Staff member F | Interviewed regarding resident #28 fall and observed during meal tray delivery | |
| Staff member G | Interviewed regarding resident #28 fall | |
| Staff member E | Interviewed regarding maintenance of chair scale | |
| Staff member J | Observed and interviewed regarding improper hair and beard coverings | |
| Staff member K | Observed regarding improper hair and beard coverings | |
| Staff member M | Interviewed regarding staff attire policy and food labeling | |
| Staff member N | Observed and interviewed regarding hand hygiene during meal service | |
| Staff member C | Interviewed regarding hand hygiene expectations and education | |
| Staff member D | Mentioned as involved in revamping QAPI process |
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