Inspection Reports for Kenhodro Inc. dba Frontier Assisted Living
121 S 3rd Street, Livingston, MT, 59047
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
10.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
84% worse than Montana average
Montana average: 5.8 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Renewal
Deficiencies: 8
Date: Sep 10, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to assess compliance with licensing and regulatory standards.
Findings
The inspection identified multiple deficiencies including lack of disaster plan review since 2014, incomplete staff orientation and training records, missing resident needs assessments and service plan signatures, medication storage issues with loose pills, food service sanitation concerns, and physical plant maintenance needs such as carpet cleaning and bathroom sanitation.
Deficiencies (8)
No evidence of a review or physical exercise of the disaster plan procedures since 2014.
Staff #3 and #5's file did not contain evidence of orientation to the Residents Bill of Rights or orientation to job specific duties.
Staff #3 and #4 files did not contain evidence of receiving training in the use of the abdominal thrust maneuver and basic first aid.
Resident #4's file did not contain a resident needs assessment for 2024.
Resident #1-#5 files did not contain evidence that a copy of the resident service plan was given to the resident or resident's legal representative; signature lines were not signed or dated.
2 loose pills were observed in the bottom of the medication cart in the medication room; 1 loose pill was observed in the overflow cabinet.
Uncovered ranch cups in the kitchen refrigerator; condiment cups were not labeled or dated.
All carpets in the facility needed vacuuming, stain removal, deep cleaning, and some needed replacement; multiple bathrooms needed cleaning.
Report Facts
Facility License Number: 31532
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carissa Walsh | Administrator | Named as facility administrator |
| Laura Ashford | Survey Team Leader | Named as survey team leader |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 15, 2025
Visit Reason
The inspection was conducted as a complaint investigation to review allegations related to medication administration and documentation at the assisted living facility.
Complaint Details
Complaint inspection conducted; no substantiation status explicitly stated in the report.
Findings
The surveyors found that resident #1 did not receive multiple prescribed medication doses between 6/01/25 and 6/11/25, with staff documentation indicating medications were not sent or delivered by the pharmacy, and no documentation that the resident's practitioner was notified of the missed doses.
Deficiencies (1)
Resident #1 did not receive multiple prescribed medication doses as documented, and there was no notification to the practitioner of the missed doses.
Report Facts
Missed medication doses: 44
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 31, 2024
Visit Reason
The inspection was conducted as a complaint investigation following concerns raised about environmental control and physical plant conditions at the assisted living facility.
Complaint Details
This was a complaint inspection. The report does not explicitly state substantiation status.
Findings
The survey found ongoing issues with a resident smoking in their room and multiple areas of the facility needing cleaning, including stained bedding and chairs with dry feces in a memory care resident's room. These deficiencies were noted as repeat issues from previous surveys.
Deficiencies (2)
Resident observed smoking in their room despite ongoing issues.
Common areas and resident rooms in need of vacuuming; stained bedding; two chairs with dry feces in memory care room.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kayla Evans | Administrator | Named in relation to the smoking issue with a resident. |
| Brett Christian | Survey Team Leader | Led the complaint inspection. |
Inspection Report
Renewal
Deficiencies: 10
Date: Oct 16, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to assess compliance with licensing requirements and regulations.
Findings
The survey identified multiple deficiencies related to staff training, documentation, medication storage, food service logs, physical plant conditions, fire safety drills, and resident service plan documentation.
Deficiencies (10)
6/6 direct care staff files did not include documentation of two hours of dementia training upon hire or annually thereafter; missing documentation of orientation to Resident Bill of Rights and job duties in several staff files.
Staff files #1, #3, #4, and #7 did not contain documentation of ongoing training.
9/9 resident files did not contain evidence that a copy of the resident's service plan was given to the resident or legal representative.
6/6 direct care staff files did not include documentation of receiving training related to prevention of pressure sores and skin maintenance.
Unidentified cup with pre-portioned medications observed in medication cart; medications not stored in pharmacy-dispensed container.
Facility did not have logs of food or medication fridge temperatures present during survey.
Carpets covered in stains, fraying, need replacement; broken flooring near main entrance creating trip hazard.
Facility did not have water temperature logs for resident handwashing sinks and bathing areas.
Facility lacked documentation of two fire drills performed four months apart; last documented drill was 1/23/23.
6/6 direct care staff files did not include documentation of required training as per 37.106.2892 (1)(a-h).
Report Facts
Direct care staff files missing dementia training: 6
Resident files missing service plan copy: 9
Staff files missing ongoing training documentation: 4
Direct care staff files missing pressure sore training: 6
Direct care staff files missing required training: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kayla Evans | Administrator | Named as facility administrator in report header |
| Laura Ashford | Survey Team Leader | Named as survey team leader conducting the renewal inspection |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 24, 2024
Visit Reason
The inspection was conducted as a complaint investigation to assess the facility's compliance with health care and physical plant standards.
Complaint Details
The inspection was triggered by a complaint and conducted as a complaint inspection.
Findings
The surveyor observed significant cleanliness issues including debris and stains on carpets, unflushed toilets with bodily waste stains, trash not emptied, and odors of human waste in bathrooms. Additionally, the primary freezer in the kitchen was found to be dirty with spilled food and liquids.
Deficiencies (2)
Carpets covered in debris, food particles, and stains; bathrooms needing extensive cleaning with unflushed toilets and odors of human waste; trash cans not emptied.
Primary freezer in the kitchen needing cleaning with spilled food, liquid, and food particles on the bottom shelf.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kayla Evans | Administrator | Named as facility administrator during the inspection. |
| Laura Ashford | Survey Team Leader | Led the complaint inspection survey. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 9, 2023
Visit Reason
The inspection was conducted as a complaint investigation regarding medication administration and documentation practices at Kenhodro Inc. dba Frontier Assisted Living.
Complaint Details
The visit was triggered by a complaint related to medication administration and documentation. The complaint was substantiated by findings of improper documentation and unauthorized medication administration.
Findings
The inspection found that staff failed to document the effectiveness of PRN lorazepam medication in the Medication Administration Records and that unlicensed staff administered PRN lorazepam over 60 times without consulting a licensed healthcare professional.
Deficiencies (2)
Staff is not documenting in the Medication Administration Records (MARs) if the medication is effective or not for Resident #1 receiving PRN lorazepam.
Unlicensed staff administered PRN lorazepam over 60 times without consulting a licensed health care professional after assessment of need.
Report Facts
Times PRN Lorazepam given: 94
Times unlicensed staff administered medication: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Noelle Markland | Survey Team Leader | Named as Survey Team Leader for the complaint inspection. |
| Shaylee Taylor | Administrator | Named as Administrator of the facility. |
Inspection Report
Renewal
Deficiencies: 21
Date: Aug 9, 2023
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with licensing and regulatory standards for the assisted living facility.
Findings
The facility was found to have multiple deficiencies including lack of required practitioner orders for certain residents, poor housekeeping and cleanliness, inadequate disaster planning, insufficient staff training and background checks, unsafe medication storage and administration practices, unsecured oxygen tanks, and physical plant issues such as blocked exits and lack of fire inspection documentation.
Deficiencies (21)
Residents #12, #14, and #15 do not have practitioner's written orders for admission or care as required for category B or C residents.
Resident rooms #1 through #7 were excessively dirty with debris, unwashed linens, urine and BM stains, and sticky floors; housekeeping services are inconsistently provided.
Facility has not developed a written disaster plan or conducted annual documented review with staff; no annual written agreement for off-site evacuation point.
11 of 15 accident and incident reports lacked documentation of corrective actions to prevent recurrence.
Employees #2 through #4 do not have background checks.
Employees #2 through #6 lack documentation of training in abdominal thrust maneuver and basic first aid.
Staffing schedules for June and July 2023 show multiple shifts with only one staff member overnight, insufficient to meet resident needs and supervision requirements.
No observed resident activities during the two-day survey.
No group activity calendar posted in the facility.
No documentation that window treatments in resident rooms are flame-resistant or non-combustible.
Employees #2 through #6 lack training documentation related to skin integrity and pressure sore prevention.
Insulin stored in medication room refrigerator without thermometer to verify correct temperature.
Resident #14 consumed medication not prescribed to them; medication cart is an open food serving cart and does not lock.
Medication Administration Records lack a separate signature page linking staff names to initials.
Eight portable oxygen tanks found unsecured in resident room #9.
Residents #1, #9, #10, and #11 have dirty stained linens; Resident #9’s bedding was wet through two cloth chuck pads.
Facility is unclean in multiple areas including heavily stained carpeted dining room, sticky floors, water-damaged walls, stained recliner cushions, and broken medication room window glass.
Residents #12 and #13 share a room and bathroom lacking any towels including single-use towels.
Downstairs and upstairs laundry areas and upstairs utility room are unlocked and contain chemicals including bleach.
Exit to patio near main dining room blocked; Resident #5’s door sticks and is difficult to open; top floor fire exit door stuck and could not be opened.
Facility lacks record of an annual fire inspection despite multiple surveyor attempts to obtain it.
Report Facts
Resident files reviewed: 6
Employee files reviewed: 6
Accident and incident reports reviewed: 15
Incident reports for Resident #14: 3
Portable oxygen tanks found unsecured: 8
Staffing schedule occurrences with only one staff overnight: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shaylee Taylor | Administrator | Named as facility administrator |
| Noelle Markland | Survey Team Leader | Named as survey team leader |
| Staff #1 | Housekeeper | Interviewed regarding housekeeping services and staffing |
Inspection Report
Renewal
Deficiencies: 7
Date: Oct 6, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to assess compliance with regulatory standards.
Findings
The inspection identified multiple deficiencies including an incomplete disaster plan lacking provisions for additional supplies and annual staff review, missing annual review documentation of policies and procedures since 2016, absence of planned or performed resident activities and activity calendars, a shared room door with a dead bolt lock that cannot be unlocked from inside, lack of documentation for flame-resistant window treatments, and missing documentation of fire drills for 2021 and 2022.
Deficiencies (7)
Disaster Plan did not include acquisition of additional blankets, water or food when sheltering in place; no documentation of annual Disaster Plan review with staff; no written agreement for off-site evacuation point.
Facility unable to locate documentation of annual review of all policies and procedures since 2016.
No activities planned or performed for residents.
No developed or posted monthly group activities calendar; no record of current or past three months' activities.
Shared room door for Resident #2 and #3 had a dead bolt lock that locked from outside with a key and did not unlock from inside.
Facility unable to provide documentation that flame-resistant or non-combustible window treatments were used; standard cloth curtains present.
Facility unable to locate documentation of 2021 and 2022 fire drills.
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jun 8, 2021
Visit Reason
The inspection was conducted as a complaint investigation to review incidents involving resident injuries and concerns related to medication administration and marijuana use at the facility.
Complaint Details
Complaint inspection focused on incidents involving resident injuries related to marijuana use and medication documentation; no substantiation status explicitly stated.
Findings
The facility failed to document corrective actions to prevent injury reoccurrence, did not list medical marijuana on residents' medication records, and allowed illegal marijuana use without proper policies or communication with practitioners. The administrator and facility failed to protect residents' health and safety by not addressing illegal drug use.
Deficiencies (4)
Incident report for resident #2 lacked corrective action to prevent injury reoccurrence; resident #3's report did not indicate how to prevent reoccurrence despite alcohol and marijuana use contributing to falls.
Resident #1 and #4 did not have medical marijuana listed on their medication records despite self-administering it.
Staff interviews revealed knowledge of residents sharing marijuana resulting in injury; no communication with practitioners or education on risks was provided.
Facility allows medical marijuana use but lacks a written policy on providing this service.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Linda Egebjerg | Survey Team Leader | Named as survey team leader conducting the complaint inspection. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Feb 2, 2021
Visit Reason
The inspection was conducted as a complaint investigation following concerns raised about facility conditions and medication administration.
Complaint Details
The visit was triggered by a complaint. Repeat deficiencies were noted from complaint surveys conducted on 11/04/2020 and 10/30/2018 & 11/04/2020. Issues included environmental cleanliness, oxygen use, and medication administration.
Findings
Multiple deficiencies were found including strong urine odor in a resident's room, dirty common areas and resident rooms, medication administration record discrepancies with missed doses and lack of documentation, unsecured oxygen tanks, cigarette smoking in a resident room, and stained linens with inadequate mattress protection. Several deficiencies were noted as repeat from prior complaint surveys.
Deficiencies (5)
Strong smell of urine noted in resident #7's room, room 36.
Entryways, hallways, common areas, staircases, and several resident rooms were dirty with debris, dirt, and garbage; repeat deficiency from prior complaint survey.
Medication Administration Record (MAR) discrepancies including missed doses without documentation or physician notification for residents #7, #8, #9, and #10.
Three portable oxygen tanks observed unsecured and improperly stored; cigarette smoking confirmed in resident #1's room; repeat deficiency.
Multiple resident beds with stained linens and many beds without moisture-proof mattress covers and mattress pads.
Report Facts
Facility License Number: 31532
Response Due Date: Feb 12, 2021
Medication missed documentation dates: 12
Oxygen tanks observed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tara Wooten | Survey Team Leader | Named as survey team leader conducting the complaint inspection |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Nov 4, 2020
Visit Reason
The inspection was conducted as a complaint investigation to address concerns related to facility conditions and compliance with regulations.
Complaint Details
The visit was triggered by a complaint and the survey type is explicitly stated as Complaint Inspection. The repeat deficiency related to oxygen use was noted from a prior complaint survey conducted on 10/30/2018.
Findings
The inspection found multiple deficiencies including lack of posted keypad codes on the memory care unit, poor environmental cleanliness throughout the facility including soiled resident areas and kitchen, a repeat deficiency related to oxygen use with cigarette smoke odor and missing no smoking signs, and fire code violations due to obstructive cardboard boxes in hallways.
Deficiencies (4)
No codes posted on the egress side of each keypad located on the memory care unit.
Facility areas including entryways, kitchen, hallways, common areas, and resident rooms were dirty with debris and stains; kitchen and storage areas showed general lack of cleanliness with spills, dried substances, and uncovered garbage containers.
Strong cigarette smoke odor detected near resident room with oxygen use; no conspicuous 'No Smoking, Oxygen in Use' sign posted. This is a repeat deficiency from a prior complaint survey.
Cardboard boxes observed near kitchen hallway restricting accessibility for wheelchairs and walkers.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brett Christian | Survey Team Leader | Named as the survey team leader conducting the complaint inspection. |
Inspection Report
Renewal
Deficiencies: 9
Date: May 7, 2019
Visit Reason
The inspection was conducted as a renewal inspection of Kenhodro Inc. dba Frontier Assisted Living to assess compliance with licensing requirements and regulations.
Findings
The inspection identified multiple deficiencies including lack of certification for Category C residents, inadequate documentation of corrective actions for incidents, incomplete staff orientation on abuse prevention, inconsistent medication notification to practitioners, missing medication administration documentation, outdated medication record signatures, and ventilation and housekeeping issues in laundry areas.
Deficiencies (9)
Category C residents did not have certification by a licensed health care professional indicating needs can be met and no significant change requiring higher level of care.
Resident Observation Assessment Reports (ROAR) lacked documentation of appropriate corrective action to avoid reoccurrence.
Staff files lacked evidence of orientation to the Montana Elder and Persons with Developmental Disabilities Abuse Prevention Act as required.
Annual or quarterly resident needs assessments did not include required items and did not provide a level of care for residents.
Facility did not consistently notify resident practitioners of missed or refused medications.
Medication Administration Records were missing documentation for multiple residents on May 6, 2019.
Memory care unit MAR book lacked a signature page and the rest of the facility's MAR book signatures were outdated.
Laundry room in basement lacked mechanical ventilation, window screen needed replacement, and upstairs laundry ventilation was not working.
Laundry room upstairs had two uncovered garbage cans at the time of survey.
Report Facts
Resident files reviewed: 5
Staff files reviewed: 2
Residents with missing medication documentation: 11
Garbage cans uncovered: 2
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