Inspection Reports for Kindred Transitional Care & Rehab – Park Place
MT, 59405
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
16.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
181% worse than Montana average
Montana average: 5.8 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Annual Inspection
Deficiencies: 5
Aug 6, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, fall prevention, elopement risk management, and infection prevention and control at Park Place Transitional Care and Rehabilitation.
Findings
The facility failed to ensure adequate supervision and safety measures to prevent resident elopements, including proper use of wander guards and secured doors. Additionally, staff were not consistently aware of or implementing individualized fall prevention interventions. The facility also failed to maintain proper storage and disposal of respiratory equipment, urinals, and recycling/trash in resident rooms.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure a resident with a history of elopements had a Wander guard in place and doors were secured. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure staff were aware of and employing appropriate fall interventions for residents with fall risks. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure proper storage of respiratory equipment in resident rooms. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure proper storage and emptying of full urinals. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure proper disposal of trash/recycling for residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents with high fall risk on 300-hall: 8
Residents with high fall risk on 400-hall: 38
Resident #3 falls in past four months: 4
Empty soda cans next to resident #4's bed: 9
Empty soda bottles next to resident #5's bed: 9
Empty soda cans next to resident #5's bed: 11
Inspection Report
Routine
Deficiencies: 8
Apr 24, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, safety, care, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to assist residents with obtaining proper clothing, failure to control odors in hallways, failure to provide timely vision care, inadequate pressure ulcer care, failure to assess and support self-catheterization, lack of behavioral health services, improper food storage and temperature monitoring, and lapses in infection prevention and control practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Level of Harm - Actual harm: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to assist a resident with obtaining clothing that fit and changing clothing regularly, affecting resident dignity. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide a homelike setting and control odors emanating on the 400B hallway affecting residents and visitors. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents received proper treatment and assistive devices to maintain optimal visual abilities. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to prevent development and progression of a pressure ulcer and to provide adequate wound care and pain management. | Level of Harm - Actual harm |
| Failed to assess and provide appropriate care for a resident with an indwelling catheter to support self-catheterization and independence. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide necessary behavioral health care and services for a resident showing signs of depression. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly store, label, date, and discard food items by use by date and failed to monitor refrigerator and freezer temperatures. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure safe and effective blood-draw practices by contracted staff, failed to implement appropriate transmission-based precautions, and failed to ensure proper hand hygiene related to glove use in the kitchen. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 39
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Use by date: 7
PHQ-9 score: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member W | Mentioned in relation to clothing assistance and PPE use | |
| Staff member Q | Responsible for scheduling eye appointments and mentioned in catheter care | |
| Staff member H | Mentioned in vision care and pressure ulcer care | |
| Staff member P | Mentioned in vision care and pressure ulcer care | |
| Staff member DD | Mentioned in clothing assistance | |
| Staff member NF4 | Mentioned in odor control deficiency | |
| Staff member NF3 | Mentioned in odor control deficiency | |
| Staff member EE | Mentioned in pressure ulcer care | |
| Staff member A | Mentioned in vision care | |
| Staff member L | Mentioned in catheter care | |
| Staff member M | Mentioned in catheter care | |
| Staff member N | Mentioned in catheter care | |
| Staff member O | Mentioned in catheter care | |
| Staff member B | Mentioned in catheter care and infection control | |
| Staff member T | Mentioned in behavioral health | |
| Staff member J | Mentioned in infection control and PPE use | |
| Staff member U | Mentioned in food safety and glove use | |
| Staff member AA | Mentioned in glove use in kitchen | |
| Staff member BB | Mentioned in glove use in kitchen | |
| NF1 | Contracted staff drawing blood | |
| NF2 | Contracted staff drawing blood | |
| Staff member R | Mentioned in blood draw observation | |
| Staff member CC | Mentioned in droplet precautions | |
| Staff member X | Mentioned in contact precautions |
Inspection Report
Complaint Investigation
Deficiencies: 2
Nov 6, 2024
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to identify residents' elopement risks, update care plans with appropriate interventions, and provide adequate supervision to prevent elopements.
Findings
The facility failed to identify and manage elopement risks for residents #16 and #23, did not update care plans timely after elopements, and failed to follow facility policy regarding resident monitoring and notification of legal representatives and physicians after elopement incidents.
Complaint Details
The complaint investigation found substantiated failures related to elopement risk identification, care plan updates, resident supervision, and policy adherence for residents #16 and #23.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to identify a resident's elopement risk and update the care plan with interventions to prevent elopement for resident #16. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to identify a resident's elopement risk, implement effective interventions to prevent elopement, and failed to follow facility policy for residents #16 and #23. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled for elopement: 4
Elopement risk score: 11
Elopement duration: 7
Distance resident found from facility: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff members A, B, C, and D interviewed regarding resident #16's elopement and habits; no full names provided |
Inspection Report
Routine
Deficiencies: 4
Apr 25, 2024
Visit Reason
The inspection was conducted as a routine regulatory oversight visit to assess compliance with healthcare facility standards, including wound care, nutrition, medication management, and infection control.
Findings
The facility was found deficient in multiple areas including failure to continuously assess and document a worsening penile ulcer, failure to identify severe weight loss in a dialysis resident, medication errors causing omission of prescribed medications, and failure to use standard precautions during laundry handling, posing infection control risks.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Level of Harm - Actual harm: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to continuously assess and document a penile ulcer that was progressively worsening for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to identify a discrepancy in weight recordings which would have identified a severe 16% weight loss in two weeks for 1 dialysis resident. | Level of Harm - Actual harm |
| Failed to ensure a resident was free from a medication error omission, causing the resident to miss 15 days of two prescribed medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to use standard precautions while handling soiled laundry, resulting in potential for cross contamination. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Weight loss percentage: 16.27
Days medication missed: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member G | Interviewed regarding wound care difficulties with resident #40 | |
| Staff member B | Interviewed about resident #40's behavior affecting wound care | |
| Staff member M | Interviewed about weight monitoring and weight loss warning for resident #40 | |
| Staff member I | Observed weighing resident and noted scale malfunction | |
| Staff member A | Interviewed about scale calibration schedule | |
| Staff member F | Interviewed regarding medication omission for resident #244 | |
| Staff member K | Interviewed about lack of PPE use during laundry handling | |
| Staff member J | Suggested educating laundry staff on PPE use |
Inspection Report
Complaint Investigation
Deficiencies: 5
Mar 28, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to provide dignity and respect to a resident, failure to complete a thorough investigation including root cause analysis for a fall with injury, failure to complete an accurate MDS assessment, failure to implement a baseline care plan within 48 hours of admission, and failure to develop a comprehensive care plan.
Findings
The facility failed to provide dignity and respect to a resident who was sent to a physician's appointment soiled and uncleaned, failed to conduct a root cause analysis after a resident's fall resulting in a fractured hip, failed to complete an accurate MDS assessment regarding bowel and bladder incontinence, failed to implement a baseline care plan within 48 hours of admission, and failed to develop a comprehensive, person-centered care plan addressing the resident's needs.
Complaint Details
The complaint investigation was substantiated with findings that resident #1 was sent to a physician's appointment soiled and uncleaned, causing embarrassment and humiliation. A grievance was filed by staff member NF3. The facility staff denied the resident was soiled prior to the appointment, but the grievance was accepted as a case of an accident. Resident #1 had been incontinent 37 times during the review period.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide dignity and respect to resident #1 who was sent to a physician's appointment soiled with urine and dried stool. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete a thorough investigation including root cause analysis for a fall with injury for resident #9. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete an accurate MDS assessment in the area of bowel and bladder for resident #1. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement a baseline care plan within 48 hours of admission for resident #1. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement a comprehensive, person-centered care plan for resident #1. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Incontinence episodes: 37
Days after admission baseline care plan completed: 14
Sampled residents: 4
Sampled residents with fall incident: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| NF1 | Staff who cared for resident #1 during the follow-up appointment and reported the resident was soiled. | |
| NF3 | Staff who accompanied resident #1 to the appointment, filed a grievance, and reported the resident's incontinence issues. | |
| Staff member H | Received grievance from NF3 and interviewed facility staff regarding the incident. | |
| Staff member K | Reported resident #9 had a fall resulting in a fractured hip and was sent to the emergency room. | |
| Staff member A | Interviewed regarding fall of resident #9 but could not verbalize root cause analysis. | |
| Staff member B | Interviewed regarding fall of resident #9 but could not verbalize root cause analysis. | |
| Staff member I | Reported resident #1 was continent of bowel and bladder and provided information about admission and care planning. | |
| Staff member J | Reported limited knowledge about resident #1 and care plans; stated she would ask nurse if questions arise. | |
| Staff member D | Case manager | Currently doing all facility's MDS assessments; did not do resident #1's MDS. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Dec 4, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding neglect of care for a new admission resident whose condition deteriorated over a weekend.
Findings
The facility staff neglected to properly assess, monitor, and document care for a newly admitted resident with a respiratory infection, resulting in missed medication doses and delayed transcription of physician orders. The resident was transferred to the hospital and passed away. The facility terminated two staff members involved but did not report the incident as neglect.
Complaint Details
The complaint investigation found that the facility neglected a new admission resident by failing to assess and monitor the resident properly, resulting in missed medications and deterioration. The facility terminated two staff members but did not report the incident as neglect. The facility also failed to timely report the neglect incident to proper authorities.
Severity Breakdown
Level of Harm - Actual harm: 1
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to protect residents from neglect, including inadequate assessment and monitoring of a new admission resident, improper medication administration, and incomplete documentation. | Level of Harm - Actual harm |
| Failure to timely report suspected abuse, neglect, or theft and report investigation results to proper authorities. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide doctor's orders for the resident's immediate care at the time of admission, resulting in missed medications due to incomplete and inaccurate transcription of physician admission orders. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Days resident was at facility: 4
Date of resident's hospital transfer: Oct 24, 2023
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 25, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to identify signs and symptoms of infection in a resident, which led to septic shock, hospitalization, surgery, and additional amputation.
Findings
The facility failed to follow physician orders for staple removal, delayed hospital transfer despite worsening infection signs, and inadequately managed a resident's infected amputation site, resulting in actual harm including septic shock and further leg amputation.
Complaint Details
The complaint investigation revealed that the facility failed to identify infection signs in resident #1, delayed hospital transfer despite family requests, improperly removed surgical staples without surgeon consultation, and the resident suffered septic shock and additional leg amputation.
Severity Breakdown
Level of Harm - Actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals, leading to septic shock and additional amputation. | Level of Harm - Actual harm |
Report Facts
Deficiencies cited: 1
Staple removal date: Sep 22, 2023
CT scan abscess size: 6
CT scan abscess width: 3.3
CT scan abscess depth: 1.2
Infectious Disease Consult abscess size: 5.5
Infectious Disease Consult abscess width: 1
Leg amputation revision length: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| NF1 | Nursing Facility Staff | Interviewed regarding resident #1's condition and facility's response |
| NF2 | Nursing Facility Staff | Interviewed regarding resident #1's condition and family concerns |
| NF3 | Nursing Facility Staff | Interviewed regarding staple removal and resident #1's worsening condition |
| NF4 | Surgeon | Interviewed regarding resident #1's surgical care and staple removal |
| Staff member D | Nursing Staff | Interviewed regarding resident #1's wound assessment and staple removal |
| Staff member C | Nursing Staff | Interviewed regarding wound care and staple removal |
| Staff members A and B | Nursing Staff | Interviewed regarding resident #1's change in mentation and wound condition |
Inspection Report
Routine
Deficiencies: 18
Apr 27, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations at Park Place Transitional Care and Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to identify and notify physicians of abnormal vital signs, delayed reimbursement, failure to provide timely transfer and bed-hold notices, inadequate pressure ulcer assessment and care, failure to identify significant changes in resident condition, incomplete care plans, unsafe resident practices, inadequate respiratory and dialysis care, insufficient staffing and training, and failure to maintain an effective infection prevention and water management program.
Severity Breakdown
Level of Harm - Actual harm: 3
Level of Harm - Minimal harm or potential for actual harm: 14
Deficiencies (18)
| Description | Severity |
|---|---|
| Failed to identify, follow up, and notify the physician of out-of-range vital signs for resident #195 upon admission. | Level of Harm - Actual harm |
| Failed to send reimbursement check within the required 30-day window for resident #185. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide timely notification of transfer and bed-hold policy to resident #187 and family. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to identify pressure ulcers upon admission for resident #74. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to identify significant change in ADL status, hearing, and weight loss for resident #26. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement a person-centered baseline care plan within 48 hours for resident #194. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement a comprehensive care plan addressing resident #75's use of cooking supplies and food storage in his room. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to revise care plan to include hearing device use for resident #26. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to identify, prevent, and treat pressure ulcers leading to development of Stage IV ulcers requiring hospitalization for resident #4, and multiple pressure ulcers for residents #98 and #194. | Level of Harm - Actual harm |
| Failed to ensure resident #66 complied with non-smoking policy, resulting in smoking on facility property and potential burn risk. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain safe environment related to use of emersion heater and multiple power strips in resident #75's room. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate respiratory care including timely replacement of CPAP supplies and oxygen tubing for residents #5, #75, #191, and #194. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide safe and appropriate dialysis care including post dialysis monitoring for resident #9. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide sufficient nursing staff with appropriate annual competencies and skills for wound care and MDS assessment accuracy for residents #4, #26, #74, #78, and #194. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide a registered nurse on duty for at least 8 consecutive hours a day, seven days a week. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement gradual dose reductions and limit PRN psychotropic medication use for residents #26, #68, and #75. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain a water management program to minimize growth and spread of waterborne pathogens. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure nurse aides had required annual training and competencies including dementia care and abuse prevention. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Days late for reimbursement check: 87
Days late after insurance payment: 54
Number of calls made for reimbursement: 12
Weight loss: 17
Pressure ulcer sizes: 2
Pressure ulcer sizes: 3
Nurse to resident ratio: 29
PRN Ativan administrations: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Involved in reimbursement issue for resident #185 and smoking incident with resident #66 | |
| Staff member B | Involved in staffing concerns and training deficiencies | |
| Staff member C | Involved in CPAP mask cleaning and respiratory care | |
| Staff member D | Performed wound care and involved in MDS coding for resident #74 | |
| Staff member E | Noted missed significant change MDS for resident #26 | |
| Staff member F | Provided wound care and described pressure ulcer care for resident #4 | |
| Staff member G | Unable to complete dressing change for resident #4 due to lack of supplies | |
| Staff member H | Described pressure ulcer care for resident #4 | |
| Staff member I | Involved in staffing concerns and training deficiencies | |
| Staff member J | Involved in reimbursement issue, respiratory care, and wound care | |
| Staff member M | Provided restorative dining services and involved in hearing device care | |
| Staff member N | Unaware of resident #75's cooking supplies and safety risks | |
| Staff member O | Infection preventionist and involved in water management and pressure ulcer care | |
| NF2 | Unaware of transfer and bed-hold notices for resident #187 | |
| NF3 | Made multiple calls regarding reimbursement for resident #185 | |
| NF5 | Aware of resident #26's Ativan prescription | |
| NF6 | Reported resident #194's pain and bed sores | |
| Staff member P | Involved in reimbursement issue and GDR completion |
Inspection Report
Deficiencies: 3
Apr 27, 2023
Visit Reason
The inspection was conducted to assess compliance with Medicaid/Medicare reimbursement procedures, resident transfer notification requirements, and bed-hold policy notifications for residents at Park Place Transitional Care and Rehabilitation.
Findings
The facility failed to send a reimbursement check within the required 30-day window for one resident, failed to provide timely notification of transfer to the resident and family for another resident, and failed to notify the resident or family in writing about the bed-hold policy for a transferred resident. These deficiencies were identified through interviews and record reviews.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to send a reimbursement check to one resident within the 30-day required window. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide timely notification to the resident, representative, and ombudsman before transfer or discharge. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify the resident or representative in writing about the bed-hold policy when transferring a resident. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Days late for reimbursement check: 87
Days late after insurance payment: 54
Number of calls made regarding reimbursement: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Interviewed regarding reimbursement issues and took over task to ensure reimbursement check was received | |
| NF3 | Resident representative who made multiple calls regarding reimbursement and received the reimbursement check | |
| NF2 | Interviewed regarding lack of knowledge about transfer notification and bed hold policy | |
| Staff member I | Interviewed regarding lack of notification letters and re-education efforts | |
| NF4 | Contacted regarding reimbursement check sent to incorrect address |
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