Inspection Report
Complaint Investigation
Deficiencies: 2
Jun 11, 2025
Visit Reason
The inspection was conducted as a complaint investigation at Morning Star of Billings - ALF.
Findings
The surveyor found violations related to food service, including an unlabeled and uncovered tray of breakfast sausages and a tray of raw turkey leaking fluid on the refrigerator floor.
Complaint Details
The visit was triggered by a complaint, as indicated by the survey type 'Complaint Inspection'.
Deficiencies (2)
| Description |
|---|
| Tray of breakfast sausages in the main refrigerator was not labeled or covered. |
| Tray of raw turkey leaking fluid on the floor of the main refrigerator. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laura Ashford | Survey Team Leader | Named as the survey team leader conducting the complaint inspection. |
Inspection Report
Renewal
Deficiencies: 6
May 12, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the Morning Star of Billings assisted living facility to assess compliance with state regulations.
Findings
The inspection identified multiple deficiencies including lack of annual renewal orders for self-medication in resident files, missing first aid training documentation for direct care staff, lack of required certifications or training for certain employees, uncovered trash cans in laundry rooms, unlocked chemicals accessible in facility areas, and incomplete resident file documentation regarding disposition of personal possessions after death.
Deficiencies (6)
| Description |
|---|
| Two out of four resident files of residents responsible for self-medication lacked annual renewal orders from PCP. |
| Six out of six direct care staff files lacked documentation of first aid training; some employees lacked required certification or training per job descriptions. |
| No protective coverings found in laundry area. |
| Trash cans in laundry rooms were uncovered and without lids. |
| Chemicals were found unlocked and accessible in first floor laundry and exercise room. |
| One out of two closed resident files did not contain disposition of resident's personal possessions on death. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 12, 2017
Visit Reason
The inspection was conducted as a complaint investigation regarding allegations that a resident was not given prescribed medications as ordered.
Findings
The investigation substantiated that a resident did not receive prescribed medications (Citalopram and Potassium Chloride) for specified periods, with no incident reports generated or notifications made to family, practitioner, or RN. Additionally, staff failed to follow up on missed medications by notifying the administrator, indicating non-compliance with assigned tasks.
Complaint Details
The complaint was substantiated based on resident records and staff interviews confirming missed medications without proper reporting or notification.
Deficiencies (2)
| Description |
|---|
| Resident was not given prescribed Citalopram July 17-21, 2017 and Potassium Chloride July 23-31, 2017; no incident report generated; family and practitioner not notified; no communication to RN regarding missed medication. |
| Staff oriented to medication administration failed to follow up when resident was not receiving medication by notifying administrator or designated representative. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 8, 2016
Visit Reason
The inspection was conducted as a complaint investigation following a reported fall of Resident #1 and concerns about the facility's call system response times.
Findings
The investigation found that Resident #1's call light was on for 31 minutes around the time of his fall. Review of call system reports for 12/6/2016 and 12/7/2016 showed numerous call activations with many having response times of 5 minutes or more, including several with response times of 15 minutes or more. The facility does not have enough staff to meet the unscheduled needs of residents.
Complaint Details
Complaint investigation triggered by a fall incident involving Resident #1 and concerns about delayed response times to call system activations. The complaint was substantiated by findings of delayed responses.
Deficiencies (1)
| Description |
|---|
| Inadequate staffing to meet residents' unscheduled needs as evidenced by delayed response times to call system activations. |
Report Facts
Call system activations on 12/6/2016: 96
Activations with response time ≥ 5 minutes on 12/6/2016: 61
Activations with response time ≥ 15 minutes on 12/6/2016: 26
Call system activations on 12/7/2016: 104
Activations with response time ≥ 5 minutes on 12/7/2016: 67
Activations with response time ≥ 15 minutes on 12/7/2016: 37
Duration call light was on for Resident #1: 31
Inspection Report
Renewal
Deficiencies: 8
May 4, 2016
Visit Reason
The inspection was conducted as a renewal inspection of the Morning Star of Billings assisted living facility to assess compliance with licensing and regulatory requirements.
Findings
The inspection identified multiple deficiencies including lack of admission orders for Category C residents, insufficient documentation of corrective actions for incident reports, medication administration by unlicensed personnel, incomplete resident discharge documentation, inconsistent physician notification for missed medications, and inadequate medication administration policies not aligned with state regulations.
Deficiencies (8)
| Description |
|---|
| Facility lacks admission orders for Category C classification on residents #1 to #5 despite physician orders for secured unit. |
| Incident reports are reviewed by the administrator but lack documentation of corrective actions to prevent recurrence. |
| Medication administration observed being performed by a PCA on the memory care unit, which is not compliant with state requirements. |
| Resident #17 and #18 discharge files lack documentation of discharge and disposition of personal property and medications. |
| Medication Administration Records show missed medications without consistent documentation of physician notification. |
| Medication administration policies require Licensed Healthcare Professionals for administering medications, but facility uses unapproved QMAP personnel for this role. |
| Health Care Plans for Category C residents lack goals for each problem listed. |
| Parameters for PRN medication administration allow med techs to administer medications without required nursing assessments or documentation of resident request or nurse approval. |
Report Facts
Facility License Number: 31466
Response Due Date: May 14, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stacie Kautzman | Administrator | Named in relation to incident report review and facility administration |
| Tara Wooten | Survey Team Leader | Led the renewal inspection |
Inspection Report
Complaint Investigation
Deficiencies: 3
Dec 3, 2015
Visit Reason
The inspection was conducted as a complaint investigation following concerns related to resident care and facility conditions at Morning Star of Billings - ALF.
Findings
The inspection identified issues including an inaccessible call system for residents, lack of documentation regarding a resident pulling out his urinary catheter, and incomplete medication administration records lacking reasons for use.
Complaint Details
Complaint investigation triggered by concerns about resident care, including a resident pulling out his Foley catheter and medication documentation issues. The complaint was substantiated by findings during the inspection.
Deficiencies (3)
| Description |
|---|
| The call system, throughout the facility, is not accessible to a resident on the floor. |
| No documentation in resident file or in Daily Log notes that resident #1 had pulled his urinary catheter out on 10/25/2015. |
| Reason for use was not indicated for all medications on all resident Medication Administration Records (MARs). |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stacie Kautzman | Administrator | Named as facility administrator during the inspection. |
| Tara Wooten | Survey Team Leader | Led the complaint inspection. |
| Staff #1 | Director of Nursing | Interviewed regarding resident #1's care and documentation. |
| Staff #2 | Care Manager | Interviewed regarding resident #1's care and documentation. |
Inspection Report
Renewal
Deficiencies: 4
Mar 26, 2015
Visit Reason
The inspection was conducted as a renewal inspection of the Morning Star of Billings assisted living facility to assess compliance with regulatory standards.
Findings
The inspection identified deficiencies including the lack of a comprehensive preventive maintenance master plan and schedule, incomplete resident service plans lacking specific activity needs, physical plant issues such as significant floor damage and an inoperable dryer, and outdated fire inspection documentation from 2013.
Deficiencies (4)
| Description |
|---|
| No master plan for preventive maintenance with no schedule to document all preventative maintenance; facility’s maintenance plan is incomplete. |
| Service Plan did not contain identification of the activity needs and interest of residents; contained canned statements. |
| Approximately 25 significant scratches on dining room floor and 4 sections of vinyl floor removed; dryer in laundry room inoperable due to loud screech. |
| Last documented fire inspection was in 2013, as confirmed by administrator and surveyor. |
Report Facts
Number of significant scratches: 25
Number of vinyl floor sections removed: 4
Year of last fire inspection: 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stacie Kautzman | Administrator | Named as facility administrator during the survey |
| Harry Dziak | Survey Team Leader | Named as survey team leader conducting the renewal inspection |
Inspection Report
Renewal
Deficiencies: 3
Apr 17, 2014
Visit Reason
The inspection was conducted as a renewal inspection of the Morning Star of Billings assisted living facility to assess compliance with regulatory requirements.
Findings
The inspection identified inconsistencies in the use of resident needs assessments, emergency pull cords tied around grab bars making them unavailable, and discrepancies in medication responsibility documentation for residents.
Deficiencies (3)
| Description |
|---|
| Inconsistent use and incomplete content of resident needs assessments, including undated forms and lack of categorization. |
| Emergency pull cords in three of five resident bathrooms were tied around grab bars and unavailable to individuals on the floor. |
| Discrepancies between service plans and physician orders regarding responsibility for residents' medications. |
Report Facts
Resident bathrooms inspected: 5
Resident bathrooms with tied emergency pull cords: 3
Percentage of facility produced RNAs lacking categorization: 50
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