Inspection Reports for
Logan Health – Conrad – LTC
805 Sunset Blvd, Conrad, MT, 59425
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
17 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
193% worse than Montana average
Montana average: 5.8 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Routine
Deficiencies: 11
Date: Apr 24, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication management, food service, infection control, and documentation at Logan Health - Conrad.
Findings
The facility was found deficient in multiple areas including failure to provide appropriate hydration cups, incomplete PASARR documentation, delayed baseline care plans, inadequate shower frequency, improper medication regimen reviews, expired medications and food items, lack of qualified dietary manager, serving food at unsafe temperatures, improper food storage, incomplete POLST forms, and inadequate infection control practices including missing enhanced barrier precaution signage and improper masking and hand hygiene.
Deficiencies (11)
Failed to provide hydration in non-disposable cups causing distress to residents.
Failed to ensure a resident's diagnosed mental health condition was listed on PASARR.
Failed to implement a baseline care plan within 48 hours of admission.
Failed to ensure a resident was showered according to their preference.
Failed to ensure pharmacist identified and addressed excessive duration of PRN psychotropic medication.
Failed to remove expired items from medication room.
Failed to have a qualified Dietary Manager.
Failed to provide food at a safe and appetizing temperature.
Failed to store food in accordance with professional standards including disposal of expired food, temperature monitoring, and labeling.
Failed to ensure POLST forms were fully completed including provider signature and resident/representative signature.
Failed to post required enhanced barrier precaution signage and ensure staff adherence to infection control measures including masking and hand hygiene.
Report Facts
Residents sampled: 17
Residents affected: 2
Shower frequency: 12
Medication review months missed: 4
Expired items found: 6
Food temperature: 104
Food temperature: 206
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member D | Named in hydration cup and food service findings | |
| Staff member N | Director of Food Services | Named in hydration cup and food service findings, and food storage |
| Staff member L | Responsible for medication regimen reviews | |
| Staff member O | Dietary staff commenting on cup availability and food service | |
| Staff member R | Dietary staff commenting on cup availability | |
| Staff member H | Responsible for baseline care plans and POLST form oversight | |
| Staff member B | Commented on shower frequency and staff masking | |
| Staff member C | Staff member observed coughing without mask | |
| Staff member E | Observed not performing hand hygiene after removing contaminated PPE | |
| Staff member F | Commented on wound care and infection control signage | |
| Staff member G | Commented on food temperature challenges | |
| Staff member P | Commented on food temperature and enhanced barrier precautions | |
| Staff member Q | Responsible for checking medication room for expired medications |
Inspection Report
Routine
Deficiencies: 6
Date: Apr 25, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, incident investigations, care planning, supervision, safety, and food service quality at Logan Health - Conrad nursing home.
Findings
The facility was found deficient in supporting resident self-determination regarding bed arrangements, investigating and reporting incidents, revising care plans after falls, providing adequate supervision on the secure dementia unit, securing hazardous chemicals, ensuring wheelchair safety, and serving food at safe and appetizing temperatures.
Deficiencies (6)
Failed to support and assist two residents who wished to share a bed due to lack of staff assistance and unresolved maintenance requests.
Failed to thoroughly investigate and report findings following an incident of injury of unknown origin for one resident.
Failed to revise a resident care plan to show effective interventions following multiple falls with injury.
Failed to provide adequate supervision on a secure dementia unit, resulting in a resident ingesting odor eliminator and unsecured chemicals accessible to residents.
Failed to provide adequate supervision for fall prevention, resulting in a resident falling from a wheelchair without foot pedals.
Failed to ensure food and drink were palatable, attractive, and served at a safe and appetizing temperature for several residents.
Report Facts
Residents sampled: 22
Residents affected: 2
Incident date: Nov 21, 2023
Bruise size: 60
Falls dates: 4
Falls dates: 5
Fall injury stitches: 4
Food temperature: 100
Food temperature: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member B | Placed maintenance request for wider/longer bed; involved in SDS binder maintenance | |
| Staff member E | Notified about bed issue; involved in SDS binder maintenance and chemical safety education | |
| Staff member A | Responsible for reporting and submitting findings for facility reported events; unable to locate incident report | |
| Staff member J | Reported resident #12 falls and lack of care plan updates | |
| Staff member G | Responsible for updating and revising resident care plans | |
| Staff member N | Reported ingestion of odor eliminator by resident #34 and chemical safety concerns | |
| Staff member M | Witnessed resident #34 with odor eliminator; involved in incident reporting | |
| Staff member K | Notified staff of incident with resident #34; involved in SDS binder maintenance | |
| Staff member F | Involved in SDS binder maintenance and chemical labeling | |
| Staff member R | Expressed concerns about working alone on secure care unit | |
| Staff member U | Reported falls including resident #6 fall from wheelchair | |
| Staff member I | Reported on resident #6 wheelchair use and foot pedal absence | |
| Staff member P | Observed resident #6 wheelchair without foot pedals | |
| Staff member Y | Explained foot pedal removal from resident #6 wheelchair | |
| Staff member K | Brought breakfast to resident #33; involved in incident reporting | |
| NF7 | Expressed upset about lack of foot pedals on wheelchair for resident #6 |
Inspection Report
Routine
Deficiencies: 14
Date: Apr 25, 2024
Visit Reason
The inspection was a routine regulatory survey to assess compliance with healthcare facility regulations, including resident rights, medication administration, safety, grievance processes, staffing, food service, and infection control.
Findings
The facility was found deficient in multiple areas including failure to respect resident privacy, inadequate assessment for medication self-administration, failure to support resident self-determination, poor grievance process management, incomplete incident investigations, failure to revise care plans after falls, inadequate hearing aid management, insufficient supervision on secure dementia unit, lack of RN coverage for required hours, failure to post nurse staffing daily, food served at unsafe temperatures, improper food storage and hygiene practices, inaccurate staffing data submission, and inadequate infection prevention related to resident refrigerators.
Deficiencies (14)
Failure to provide dignity and respect by not knocking before entering resident rooms.
Failure to assess resident for self-administration of medications.
Failure to support resident self-determination by not assisting spouses to share bed space.
Failure to ensure access to grievance process and maintain grievance documentation.
Failure to thoroughly investigate and report findings of injury of unknown origin.
Failure to revise resident care plan following multiple falls with injury.
Failure to ensure resident had access to hearing aids for communication.
Failure to provide adequate supervision on secure dementia unit, resulting in ingestion of odor eliminator and fall risks.
Failure to ensure registered nurse on duty at least eight consecutive hours daily.
Failure to post nurse staffing information daily at shift start.
Failure to provide palatable food at safe and appetizing temperatures.
Failure to store food off the floor, wear beard covers properly, clean thermometers before use, and follow hand hygiene when serving food.
Failure to electronically submit accurate and complete direct care staffing information to CMS.
Failure to implement infection prevention program adequately related to resident refrigerators, including lack of labeling, dating, and disposal of expired food.
Report Facts
Residents sampled: 22
Falls for resident #12: 4
Days without RN coverage for 8 consecutive hours: 39
Days with licensed nurse staffing concerns: 66
Food boxes on freezer floor: 13
Thermometer adjustments by staff member X: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member M | Named in findings related to failure to knock before entering rooms and odor eliminator ingestion incident | |
| Staff member B | Named in findings related to grievance process and RN scheduling | |
| Staff member O | Named in medication self-administration observation | |
| Staff member L | Named in failure to knock before entering resident room | |
| Staff member A | Named in grievance process and incident reporting | |
| Staff member J | Named in care plan revision deficiency | |
| Staff member G | Named in care plan revision deficiency | |
| Staff member N | Named in odor eliminator ingestion and chemical storage findings | |
| Staff member K | Named in odor eliminator incident and food service temperature findings | |
| Staff member X | Named in food service hygiene deficiency | |
| Staff member U | Named in grievance process and fall incident | |
| Staff member I | Named in hearing aid and fall incident | |
| Staff member Y | Named in wheelchair fall incident | |
| Staff member V | Named in grievance process and food quality findings | |
| Staff member E | Named in chemical safety and SDS binder maintenance | |
| Staff member F | Named in chemical safety and SDS binder maintenance |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Mar 7, 2024
Visit Reason
The inspection was conducted due to complaints regarding the care of resident #105, specifically related to access to call lights and wound care management.
Complaint Details
The investigation was complaint-driven based on multiple complaints involving resident #105, including issues with call light access and wound care. Family and nursing staff expressed frustration over lack of communication and inadequate care.
Findings
The facility failed to ensure resident #105 had access to a call light, causing frustration and disrespect. Additionally, the facility failed to update and revise the care plan timely, assess, document, and provide appropriate wound care for a wound on resident #105's left lower extremity, resulting in increased risk of wound deterioration. Communication with family and nursing staff was inadequate.
Deficiencies (4)
Failed to ensure a dependent resident had access to a call light, causing frustration and disrespect.
Failed to update and revise a care plan to show a wound and associated interventions for resident #105.
Failed to assess, document, and provide initial wound care in a timely manner for resident #105, increasing risk of wound deterioration.
Facility policy lacked procedures to address, assess, document, or perform wound care in the Extended Care Facility for wounds developed during residency.
Report Facts
Residents sampled: 5
Resident affected: 1
Days wound care delayed: 49
Days until wound assessment documented: 78
Date of wound noted: Nov 1, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member G | Stated residents are supposed to have their call lights within reach | |
| Staff member H | Stated resident #105 requires two people to assist and call light should have been given prior to staff leaving the room | |
| NF2 | Reported resident #105 had a wound since November 2023 and expressed frustration about lack of information | |
| NF3 | Noticed wound on resident #105 and reported lack of communication and delayed reporting | |
| NF1 | Reported multiple complaints involving resident #105 and staff inactivity | |
| Staff member F | Stated nursing staff and care plan team responsible for updating care plans |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 12, 2023
Visit Reason
The inspection was conducted due to an allegation of verbal abuse by a facility staff member towards a resident, reported on August 5, 2023.
Complaint Details
The complaint was substantiated. The staff member was suspended pending investigation, and the facility conducted interviews and abuse education. The facility reported the abuse as required by CMS.
Findings
The investigation confirmed that a staff member verbally abused a resident using profanity and inappropriate language, resulting in minimal harm or potential for actual harm. The staff member was suspended pending investigation, and abuse education and follow-up meetings were conducted.
Deficiencies (1)
Facility staff member verbally abused and failed to regard the need for care when requested for a resident.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Apr 27, 2023
Visit Reason
The inspection was conducted due to complaints regarding verbal abuse by staff towards residents and failure to properly investigate and educate staff following abuse allegations, as well as concerns about fall prevention and supervision.
Complaint Details
The complaint investigation revealed verbal abuse incidents involving staff members towards residents #9 and #46. The facility did not properly investigate or educate staff after the incidents. Staff reported a hostile environment and lack of administrative response. Additionally, a fall incident involving resident #9 was reviewed, showing inadequate supervision and follow-up interventions.
Findings
The facility failed to protect residents from verbal abuse by staff and did not thoroughly investigate or educate staff following abuse allegations for two residents. Additionally, the facility failed to anticipate the needs of a resident resulting in a fall with injury and inadequate follow-up interventions to prevent future falls.
Deficiencies (3)
Failed to protect residents from verbal abuse by staff for 2 of 3 sampled residents.
Failed to thoroughly investigate and educate staff following verbal abuse allegations for 2 of 3 sampled residents.
Failed to ensure nursing home area was free from accident hazards and provide adequate supervision to prevent accidents, resulting in a fall with injury for 1 of 4 sampled residents.
Report Facts
Residents sampled: 3
Residents affected: 2
Residents sampled for fall: 4
Fall incident date: Aug 17, 2022
Days after incident for follow-up report: 23
Days after incident for education report: 33
Inspection Report
Complaint Investigation
Deficiencies: 12
Date: Apr 27, 2023
Visit Reason
The inspection was conducted based on complaints regarding verbal abuse by staff, inadequate investigation and education following abuse allegations, staffing shortages, failure to revise care plans, medication errors, and infection control issues at Logan Health - Conrad nursing home.
Complaint Details
The complaint investigation focused on allegations of verbal abuse by staff members towards residents, inadequate investigation and education following abuse allegations, staffing shortages especially in the secured unit, failure to revise care plans and document catheter care, medication errors including a significant medication error, lack of infection control systems, and insufficient behavioral health training for staff.
Findings
The facility failed to protect residents from verbal abuse, did not thoroughly investigate abuse allegations, had inadequate staffing especially in the secured unit, failed to revise care plans for catheter use, had medication errors including a significant medication error, lacked proper infection control tracking, and failed to provide behavioral health training to staff.
Deficiencies (12)
Failed to protect residents from verbal abuse by staff for 2 of 3 sampled residents.
Failed to thoroughly investigate and educate staff following verbal abuse allegations for 2 of 3 sampled residents.
Failed to revise a resident care plan to show interventions related to new diagnosis and catheter use for 1 sampled resident.
Failed to anticipate needs resulting in a fall with injury for 1 of 4 sampled residents.
Failed to enter provider orders and chart catheter care for 1 sampled resident.
Failed to provide adequate staffing, especially in the secured unit, affecting many residents.
Failed to ensure staff identified low oxygen saturation and provide adequate oxygen therapy for 1 of 4 sampled residents; failed to assess ongoing edema for 1 sampled resident.
Failed to maintain registered nurse coverage for at least 8 consecutive hours a day, 7 days a week.
Failed to limit PRN anti-anxiety medication order to 14 days or provide rationale for continued use for 1 of 6 sampled residents.
Failed to protect a resident from a significant medication error involving administration of phenobarbital instead of oxycodone.
Failed to institute a system for identifying, tracking, and controlling infections for residents and staff.
Failed to provide behavioral health training to all staff consistent with facility assessment.
Report Facts
Residents affected by verbal abuse: 2
Residents sampled: 3
Residents affected by care plan deficiency: 1
Residents affected by fall: 1
Residents affected by catheter care deficiency: 1
Residents affected by staffing deficiency: 2
Reported incidents in secured unit: 21
Reported incidents during night shift: 15
Days without RN coverage: 8
PRN psychotropic medication duration limit: 14
Medication error date: 1
Staff behavioral health training absence: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member F | Heard verbal abuse incident and reported it; involved in abuse investigation | |
| Staff member G | Alleged verbal abuser in incident with resident #46 | |
| Staff member P | Alleged verbal abuser in incident with resident #9 | |
| Staff member B | Interviewed about abuse investigation and staffing issues | |
| Staff member A | Involved in abuse investigation and follow-up | |
| Staff member M | Witnessed verbal abuse and reported staffing shortages | |
| Staff member I | Reported staffing shortages and hostile environment | |
| Staff member Q | Reported staffing shortages and resident wandering | |
| Staff member L | Reported staffing shortages and monitoring difficulties | |
| Staff member C | Spoke to witness of verbal abuse; involved in abuse follow-up | |
| Staff member D | Nurse | Involved in oxygen therapy incident with resident #35 |
| Staff member E | Nurse | Administered incorrect medication to resident #38 |
| Staff member J | Provided information about psychotropic medication policies and medication error risks | |
| Staff member O | Infection control staff; reported lack of infection tracking system | |
| Staff member K | Reported lack of behavioral health training | |
| Staff member H | Reported lack of behavioral health training |
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