Inspection Reports for
Logan Health – Conrad – LTC
805 Sunset Blvd, Conrad, MT, 59425
Back to Facility Profile7 CMS Surveys
Inspection Report — Apr 24, 2025
Renewal
Date: Apr 24, 2025
Visit Reason
The survey was a renewal inspection of Logan Health - Conrad to assess compliance with licensing requirements.
Findings
The facility had multiple deficiencies including failure to provide appropriate adaptive equipment for hydration cups, incomplete PASARR screening, delayed baseline care plans, inadequate shower frequency, medication regimen review lapses, expired medications and food items, lack of qualified dietary manager, food served at unsafe temperatures, improper food storage, incomplete POLST forms, and lapses in infection control practices.
Deficiencies (12)
F 0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights: the facility failed to provide hydration in non-disposable cups causing distress to residents who had difficulty using disposable cups.
F 0645 PASARR screening for Mental disorders or Intellectual Disabilities: the facility failed to ensure a resident's diagnosed bipolar disorder was listed on their PASARR, risking unaddressed mental health needs.
F 0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted: the facility failed to complete a baseline care plan within 48 hours for a new resident, delaying effective care.
F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: the facility failed to ensure a resident was showered according to their preference, with showers occurring about every nine days instead of twice weekly.
F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures: the pharmacist failed to identify and address an as needed psychotropic medication prescribed beyond the 14-day limit without documented re-evaluation.
F 0758 Implement gradual dose reductions and non-pharmacological interventions prior to initiating or continuing psychotropic medication; PRN orders for psychotropic medications are only used when necessary and limited: the facility failed to limit an as needed anti-anxiety medication order to 14 days or provide physician rationale for extension.
F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; all drugs and biologicals must be stored in locked compartments: the facility failed to remove expired medications and supplies from the medication room.
F 0801 Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician: the facility's Director of Food Services lacked current certifications required for the position.
F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature: the facility served food at unsafe temperatures below 135°F, risking foodborne illness and resident dissatisfaction.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: the facility failed to dispose of expired food in dry storage and walk-in cooler, did not track temperatures for a public area cooler, and failed to label and date food stored in freezers.
F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards: the facility failed to ensure POLST forms were fully completed with provider signatures and resident or representative signatures for two residents.
F 0880 Provide and implement an infection prevention and control program: the facility failed to post required enhanced barrier precaution signage for residents needing precautions, failed to ensure staff adhered to masking policies for a coughing staff member, and failed to ensure proper hand hygiene after handling contaminated laundry.
Report Facts
Residents sampled: 17
Shower frequency (days): 9
Expired baking soda boxes: 6
Expired yogurt containers: 3
Food temperature (°F): 104.4
Food temperature (°F): 117.5
Food temperature (°F): 119
Food temperature (°F): 120.8
Food temperature (°F): 121.4
Food temperature (°F): 121.5
Food temperature (°F): 123.3
Food temperature (°F): 123.6
Food temperature (°F): 126.2
Food temperature (°F): 126.6
Food temperature (°F): 127.9
Food temperature (°F): 128.2
Food temperature (°F): 188
Food temperature (°F): 197.7
Food temperature (°F): 204.4
Food temperature (°F): 206.9
Food temperature (°F): 194.4
Medication regimen reviews: 4
Inspection Report — Apr 25, 2024
Renewal
Date: Apr 25, 2024
Visit Reason
The survey was conducted as a renewal inspection of Logan Health - Conrad to assess compliance with health and safety regulations.
Findings
The facility was found deficient in multiple areas including failure to support resident self-determination, incomplete investigations of incidents, inadequate care plan revisions, unsafe environment with unsecured chemicals and inadequate supervision, fall prevention failures, and food service issues related to temperature and palatability.
Deficiencies (8)
F 0561 Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice: the facility failed to assist two residents who wished to share a bed due to lack of staff assistance and incomplete maintenance requests.
F 0610 Respond appropriately to all alleged violations: the facility failed to thoroughly investigate and report findings following an incident of injury of unknown origin for one resident, and did not submit findings within the required timeline.
F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: the facility failed to revise a resident care plan to show effective interventions following multiple falls with injury.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to provide adequate supervision on a secure dementia unit, resulting in a resident ingesting odor eliminator, unsecured chemicals accessible to residents, and inadequate supervision for fall prevention for two residents.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to maintain and update the SDS binder properly and failed to secure hazardous chemicals, exposing residents to potential harm.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to provide adequate fall prevention for a resident who ambulated without a walker and experienced multiple falls.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to ensure foot pedals were used on a resident's wheelchair, resulting in a fall and injury requiring stitches.
F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature: the facility failed to provide palatable food at an appetizing temperature for four residents, with food served cold, spicy, or not as ordered.
Report Facts
Residents sampled: 22
Falls recorded for resident #12: 4
Falls recorded for resident #15: 5
Temperature (°F): 100
Temperature (°F): 90
Incident date: 11.21
Incident report request date: 4.22
Incident report completion date: 4.24
Inspection Report — Apr 25, 2024
Renewal
Date: Apr 25, 2024
Visit Reason
The survey was a renewal inspection of Logan Health - Conrad nursing facility.
Findings
The facility had multiple deficiencies including failure to ensure resident dignity and privacy, inadequate assessment for medication self-administration, lack of support for resident self-determination, ineffective grievance process, incomplete incident investigations, failure to revise care plans after falls, inadequate hearing aid management, unsafe environment with unsecured chemicals and inadequate supervision, insufficient RN coverage, incomplete nurse staffing postings, food served at unsafe temperatures, improper food handling and storage, inaccurate staffing data submission, and inadequate infection control related to resident refrigerators.
Deficiencies (14)
F 0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights: staff failed to knock and announce themselves prior to entering resident rooms, violating residents' privacy and dignity.
F 0554 Allow residents to self-administer drugs if determined clinically appropriate: the facility failed to assess resident #31 for self-administration of medications despite evidence she self-administered eye drops.
F 0561 Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice: the facility failed to support spouses (#33 and #35) in sharing a bed due to lack of staff assistance and unresolved maintenance requests.
F 0585 Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances: the facility failed to provide grievance forms, investigate grievances, and maintain grievance documentation for multiple residents.
F 0610 Respond appropriately to all alleged violations: the facility failed to thoroughly investigate and report findings following an incident of injury of unknown origin for resident #11.
F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: the facility failed to revise resident #12's care plan to include effective interventions following multiple falls with injury.
F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason: the facility failed to ensure resident #6 had access to his hearing aids as directed in his care plan and EHR.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to provide adequate supervision on the secure dementia unit, resulting in resident #34 ingesting odor eliminator and unsecured chemicals accessible to residents; also failed to provide adequate supervision for fall prevention for residents #6 and #15.
F 0727 Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis: the facility failed to ensure RN coverage for eight consecutive hours on 10/29/23.
F 0732 Post nurse staffing information every day: the facility failed to post nurse staffing information at the beginning of each shift on multiple days.
F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature: the facility served food that was cold, overly spicy, and not at safe temperatures to multiple residents.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: the facility failed to store food off the floor, failed to ensure proper hand hygiene and thermometer cleaning, and failed to ensure staff wore beard covers properly during food service.
F 0851 Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data: the facility failed to submit accurate and complete direct care staffing information to CMS, inconsistent with actual staffing schedules.
F 0880 Provide and implement an infection prevention and control program: the facility failed to ensure resident #2's personal refrigerator was cleaned and maintained properly with dated and labeled food, risking foodborne illness.
Report Facts
Food filled boxes on freezer floor: 13
Milk crates on cooler floor: 1
Thermometer adjustments: 14
Falls: 5
Days without RN coverage 8 consecutive hours: 39
Days with licensed nurse staffing concerns: 66
Temperature of resident #33's eggs (°F): 100
Temperature of resident #33's potatoes (°F): 90
Inspection Report — Mar 7, 2024
Date: Mar 7, 2024
Visit Reason
The survey was conducted to assess compliance with health and safety regulations at Logan Health - Conrad.
Findings
The facility failed to ensure a dependent resident had access to a call light, did not update or revise a care plan timely for a wound, and failed to provide timely wound care and documentation. Additionally, the facility lacked procedures for wound care in the Extended Care setting.
Deficiencies (4)
F 0558 Reasonably accommodate the needs and preferences of each resident: a dependent resident did not have access to a call light within reach, causing frustration and disrespect.
F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: the facility failed to update and revise a care plan to include a wound and related interventions for over two months after the wound was noted.
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: the facility nursing staff failed to assess, document, and provide timely initial wound care, increasing the risk of wound deterioration.
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: the facility lacked procedures to address, assess, document, or perform wound care for wounds developed or occurring in the Extended Care Facility.
Report Facts
Sampled residents: 5
Days wound not documented in care plan: 66
Days wound orders delayed: 49
Days wound assessment delayed: 78
Inspection Report — Oct 12, 2023
Date: Oct 12, 2023
Visit Reason
The survey was conducted to assess compliance with regulations related to resident abuse and care.
Findings
A facility staff member verbally abused a resident by using profanity and refusing care when requested. The facility promptly investigated, suspended the staff member, provided abuse education, and reported the incident as required.
Deficiencies (1)
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: a staff member verbally abused a resident by using profanity and refusing care when requested, which was confirmed by investigation and witness statements.
Inspection Report — Apr 27, 2023
Date: Apr 27, 2023
Visit Reason
The survey was conducted to assess compliance with regulations regarding resident abuse prevention, investigation, and fall management.
Findings
The facility failed to protect residents from verbal abuse by staff and did not thoroughly investigate or educate staff following abuse allegations. Additionally, the facility failed to prevent a resident fall by not adequately anticipating resident needs or reassessing interventions.
Deficiencies (6)
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: the facility failed to protect residents from verbal abuse by staff toward two residents, including threats and inappropriate language.
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: staff member P was verbally gruff and verbally abused a resident, and no effective administrative response occurred despite reports.
F 0610 Respond appropriately to all alleged violations: the facility failed to thoroughly investigate and educate staff following verbal abuse allegations involving two residents, with delayed and incomplete investigations and lack of education for involved staff.
F 0610 Respond appropriately to all alleged violations: staff member P was verbally gruff and verbally abusive toward a resident, and the facility failed to provide education or timely corrective action after the incident.
F 0610 Respond appropriately to all alleged violations: the facility's policy failed to include interviewing additional staff not involved in abuse incidents to identify other residents affected.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to anticipate the needs of a resident who fell and sustained injuries, and failed to reassess or implement effective interventions to prevent future falls.
Report Facts
Residents sampled: 3
Residents affected: 2
Residents affected: 1
Incident date: Aug 17, 2022
Incident date: Sep 11, 2022
Incident date: Sep 21, 2022
Education date: Aug 9, 2022
Education date: Oct 14, 2022
Inspection Report — Apr 27, 2023
Renewal
Date: Apr 27, 2023
Visit Reason
The survey was conducted to assess compliance with state and federal regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including staff verbal abuse, inadequate investigation of abuse allegations, failure to update care plans, insufficient staffing, medication errors, and lack of infection control and behavioral health training.
Deficiencies (14)
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: staff verbally abused residents #9 and #46, including threats and inappropriate language.
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: staff member P was verbally gruff and verbally abused resident #9 without subsequent education or intervention.
F 0610 Respond appropriately to all alleged violations: the facility failed to thoroughly investigate and educate staff following verbal abuse allegations involving residents #9 and #46, with incomplete investigations and delayed follow-up.
F 0610 Respond appropriately to all alleged violations: the facility's abuse investigation policy failed to include interviewing additional staff not involved in incidents to identify other affected residents.
F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: the facility failed to revise resident #41's care plan to include interventions related to neurogenic bladder and catheter use.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to anticipate needs for resident #9, resulting in a fall with injury and no new interventions to prevent future falls.
F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections: the facility failed to enter provider orders and chart catheter care for resident #41.
F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift: the facility failed to provide adequate staffing, especially in the secured unit, resulting in inadequate supervision, resident wandering, and staff fear of retaliation.
F 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being: staff failed to identify and respond to resident #35's severely low oxygen saturation and failed to assess and address ongoing edema for resident #23.
F 0727 Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis: the facility failed to maintain RN coverage for at least eight consecutive hours a day on multiple dates.
F 0758 Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited: the facility failed to limit PRN Lorazepam orders to 14 days or provide rationale for continued use for resident #24.
F 0760 Ensure that residents are free from significant medication errors: resident #38 was given phenobarbital instead of oxycodone due to staff error, risking serious central nervous system effects.
F 0880 Provide and implement an infection prevention and control program: the facility failed to institute a system for identifying, tracking, and controlling infections for residents and staff, lacking infection mapping and lab result tracking.
F 0949 Provide behavior health training consistent with the requirements and as determined by a facility assessment: the facility failed to provide behavioral health training to all staff, including training on PTSD and trauma informed care.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 4
Residents affected: 6
Residents affected: 15
Reported incidents: 21
Days without RN coverage: 8
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