Deficiencies (last 3 years)
Deficiencies (over 3 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
3% worse than Montana average
Montana average: 5.8 deficiencies/year
Deficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 8
Date: Jun 19, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to psychotropic medication use, PASRR assessments, care planning, activities of daily living assistance, infection control, bed rail use, and medical waste management at Southwest Montana Veterans Home.
Findings
The facility was found deficient in multiple areas including improper use and documentation of psychotropic medications, incomplete PASRR Level II assessments, inadequate trauma-informed care planning, failure to provide consistent oral care, delayed treatment of urinary tract infection, lack of physician orders and consents for bed rails, failure to follow contact precautions for infection control, and improper storage of biohazardous waste.
Deficiencies (8)
Failed to ensure psychotropic medications were used to treat residents' specific, diagnosed, and documented conditions and failed to obtain signed GDRs for psychotropic medications.
Failed to ensure PASRR Level II was completed and mental health diagnoses were included on PASRR for some residents.
Failed to develop and implement a complete care plan addressing trauma informed care for a resident with PTSD.
Failed to ensure ADL oral care was offered and performed for a dependent resident.
Failed to ensure prompt treatment of a urinary tract infection resulting in delayed antibiotic administration.
Failed to obtain physician orders, informed consents, and signed statements of understanding for bed rail use for multiple residents.
Failed to ensure contact precautions were followed for a resident with a fungal infection, risking transmission.
Failed to properly store biohazardous waste in sealed, puncture-resistant containers preventing attraction of pests and contamination.
Report Facts
Residents sampled: 13
Residents affected by psychotropic medication deficiency: 3
Residents affected by PASRR deficiency: 3
Residents affected by care plan deficiency: 1
Residents affected by oral care deficiency: 1
Residents affected by UTI treatment deficiency: 1
Residents affected by bed rail deficiency: 5
Residents affected by infection control deficiency: 1
Residents affected by biohazard waste storage deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member M | Interviewed regarding resident #14's bipolar diagnosis and medication | |
| Staff member L | Interviewed regarding resident #14's medical history and bipolar diagnosis | |
| Staff member A | Interviewed regarding QAPI processes, PASRR resubmission, and bed rail consent issues | |
| Staff member I | Interviewed regarding medication administration and dose reduction reviews for resident #23 | |
| Staff member C | Interviewed regarding pharmacist monitoring of GDRs and infection control procedures | |
| Staff member E | Signed Consultant Pharmacist Recommendations document | |
| Staff member G | Interviewed regarding GDRs, bed rail use, and facility policies | |
| Staff member N | Interviewed regarding resident #30's oral care and dependency | |
| Staff member J | Interviewed regarding bed rail consent and infection control precautions | |
| Staff member K | Interviewed regarding bed rail consent process | |
| Staff member O | Observed not following contact precautions for resident #13 | |
| Staff member P | Observed not following contact precautions for resident #13 | |
| Staff member Q | Interviewed regarding biohazardous waste storage and disposal | |
| Staff member R | Interviewed and observed biohazardous waste storage | |
| Staff member S | Interviewed regarding disposal of biohazard bags | |
| Resident #32 | Resident | Interviewed extensively about PTSD symptoms and care needs |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 6, 2024
Visit Reason
The inspection was conducted due to concerns about the facility's process for allowing residents to leave the facility unattended, specifically related to resident #194's unsupervised exit and elopement risk.
Complaint Details
The visit was complaint-related due to resident #194 exiting the facility unattended without notifying staff, despite known wandering behaviors and elopement risk. The complaint was substantiated based on interviews, observations, and record reviews.
Findings
The facility failed to consistently evaluate and manage the check-out process for residents leaving the facility based on cognitive and physical levels, elopement risk, and wandering behavior, resulting in resident #194 exiting the facility unattended without notifying staff. Observations and interviews revealed unlocked doors and inconsistent supervision, increasing risk of accidents or harm.
Deficiencies (1)
Failed to have a consistent process, evaluation, and management of the check-out process for residents leaving the facility unattended based on cognitive level, physical level, elopement risk, and wandering behavior.
Report Facts
Residents sampled: 17
Residents affected: 1
Distance resident traveled: 0.3
Medications administered: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member F | Interviewed regarding resident check-out process and door locking | |
| Staff member G | Interviewed regarding resident notification when leaving building | |
| Staff member E | Interviewed regarding resident safety concerns and staffing challenges | |
| Staff member A | Interviewed regarding list of residents allowed to self-check-out |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 6, 2024
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to honor residents' rights related to food preferences, mental health diagnosis documentation, and safety supervision for residents leaving the facility.
Complaint Details
The complaint investigation involved three residents: #15 regarding food preference and dignity issues; #21 regarding missing mental health diagnosis in PASARR; and #194 regarding unsafe unsupervised exits from the facility. The findings were substantiated with interviews, observations, and record reviews.
Findings
The facility failed to allow a resident's POA to provide food preferences consistent with physician orders, failed to include a mental health diagnosis in a resident's admission PASARR assessment, and lacked a consistent process to supervise residents leaving the facility, increasing risk of accidents.
Deficiencies (3)
Failed to allow the POA and decision-maker of resident #15 to make food preference requests that followed physician orders, dietary preferences, and swallowing precautions.
Failed to ensure a mental health diagnosis was included in resident #21's admission PASARR assessment.
Failed to have a consistent process, evaluation, and management of the check-out process for residents leaving the facility, increasing risk of accidents or harm for resident #194 and others.
Report Facts
Residents sampled: 17
Residents affected: 1
Distance: 0.3
Medication doses: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NF1 | Family member who brought in extra food for resident #15 and reported staff refusal to allow food packets | |
| Staff member B | Interviewed regarding resident #15's diet and use of squeeze packages | |
| Staff member D | Interviewed regarding resident #15's nutrition and use of squeeze packages | |
| Staff member E | Interviewed regarding resident #15's nutrition and safety concerns in cottages | |
| Staff member C | Interviewed regarding resident #21's mental health diagnosis and PASARR | |
| Staff member F | Interviewed regarding resident #194's exit from facility and door security | |
| Staff member G | Interviewed regarding resident supervision and permission to leave building | |
| Staff member A | Interviewed regarding lack of list of residents allowed to self-check-out |
Inspection Report
Routine
Deficiencies: 6
Date: May 11, 2023
Visit Reason
The inspection was conducted to assess compliance with care planning, activity programming, pain management, pharmaceutical services, psychotropic medication use, and food storage policies at Southwest Montana Veterans Home.
Findings
The facility failed to update individualized care plans for several residents, implement resident-centered activity programs, effectively manage pain for a resident, ensure timely pharmaceutical services due to medication order delays, document acceptable indications for antipsychotic medication use, and assist a resident in safely storing food brought into the facility.
Deficiencies (6)
Facility staff failed to update individualized care plans to show current focus areas, goals, and interventions for 4 of 12 sampled residents.
Facility staff failed to implement a resident-centered activity program incorporating individualized interests for 2 of 9 sampled residents.
Facility staff failed to effectively identify, treat, and reassess pain management for 1 of 9 residents.
Facility staff failed to sufficiently address a resident's pain for four days due to medication order wet signature and pharmacy delays.
Facility failed to ensure an acceptable diagnosis and indication for the use of an antipsychotic medication were documented for 1 of 5 sampled residents.
Facility staff failed to assist a resident in safely storing food brought into the facility and failed to ensure safe food handling practices.
Report Facts
Residents sampled for care plan deficiencies: 12
Residents sampled for activity program deficiencies: 9
Residents sampled for pain management deficiencies: 9
Residents sampled for antipsychotic medication review: 5
Resident #30 falls without injury: 17
Medication order start date: 2023
Medication dose increases: 2
Tramadol order start date: 2023
Tramadol doses given: 0
Refrigerator temperature: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member K | Named in pain management failure for resident #8 | |
| Staff member A | Named in pain management failure and pharmaceutical services delay for resident #8 | |
| Staff member G | Named in pharmaceutical services delay for resident #8 | |
| Staff member H | Named in activity program deficiencies | |
| Staff member L | Named in food storage and activity program deficiencies | |
| Staff member P | Named in antipsychotic medication use deficiency |
Viewing
Loading inspection reports...
