Inspection Reports for
Southwest Montana Veteran’s Home

F0605 Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function: the facility failed to ensure psychotropic medications were used to treat residents' specific, diagnosed, and documented conditions, and failed to obtain signed gradual dose reductions for five psychotropic medications for one resident.

F0644 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed: the facility failed to ensure a PASRR Level II was completed for one resident and failed to include mental health diagnoses on PASRRs for two residents receiving psychotropic medication.

F0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured: the facility failed to ensure an updated care plan addressing trauma informed care for one resident with PTSD.

F0677 Provide care and assistance to perform activities of daily living for any resident who is unable: the facility failed to ensure oral care was consistently offered and performed for one dependent resident, resulting in noticeable halitosis.

F0690 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 ensure prompt treatment of a urinary tract infection for one resident, delaying antibiotics for five days after culture results.

F0700 Try different approaches before using a bed rail. If a bed rail is needed, the facility must assess a resident for safety risk, review risks and benefits, get informed consent, and correctly install and maintain the bed rail: the facility failed to obtain physician orders, informed consents, or signed statements of understanding for bed rails used by five residents.

F0742 Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder: the facility failed to ensure one resident with PTSD received appropriate treatment and services to attain highest practicable mental well-being, lacking focused care plan interventions.

F0880 Provide and implement an infection prevention and control program: the facility failed to ensure contact precautions were followed for one resident with a contagious fungal infection, resulting in staff not wearing required personal protective equipment.

F0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public: the facility failed to ensure biohazardous waste was stored properly in sealed, puncture-resistant containers protected from pests, with some bags improperly stacked and exposed in a shed.

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to have a consistent process to evaluate and manage residents leaving the building, including those with wandering behaviors and cognitive impairments, and doors were left unlocked allowing residents to exit unsupervised.

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 allow the resident's decision-maker to provide food in squeeze packets that met physician orders and dietary preferences, restricting the resident's dignity and nutrition.

F 0644 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed: the facility failed to include a mental health diagnosis of bipolar disorder in a resident's admission PASARR assessment.

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to have a consistent process and supervision for residents leaving the facility, allowing a cognitively impaired resident with elopement risk to exit unattended without signing out.

F 0657 Develop the complete care plan within 7 days of the comprehensive assessment: the facility failed to update individualized care plans to show current focus areas, goals, and interventions for 4 of 12 sampled residents, including hearing aids, scooter use, activity preferences, and dietary needs.

F 0679 Provide activities to meet all resident's needs: the facility failed to implement a resident-centered activity program incorporating individualized interests and cultural preferences for 2 of 9 sampled residents.

F 0697 Provide safe, appropriate pain management for a resident who requires such services: the facility failed to effectively identify, treat, and reassess pain for 1 of 9 residents, resulting in delayed medication administration due to wet signature and pharmacy issues.

F 0755 Provide pharmaceutical services to meet the needs of each resident: the facility failed to sufficiently address a resident's pain for four days due to medication order delays requiring wet signatures and pharmacy delays.

F 0758 Implement gradual dose reductions and non-pharmacological interventions prior to initiating or continuing psychotropic medication: the facility failed to ensure an acceptable diagnosis and indication for antipsychotic medication use for 1 of 5 sampled residents, with dose increases lacking documented rationale.

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors: the facility failed to assist a resident in safely storing food in a personal refrigerator and failed to ensure safe food handling practices for 1 of 9 sampled residents.