Inspection Report Summary
The most recent inspection on July 17, 2025, identified deficiencies related to grievance policy implementation, care planning, medication administration errors, food safety, and infection control practices. Earlier inspections showed similar issues with care planning, medication management, dietary services, and timely abuse reporting, along with additional concerns about resident assessments, fall prevention, and psychotropic medication use. Complaint investigations substantiated delays in reporting incidents of resident abuse and neglect, as well as medication errors, but enforcement actions such as fines or license suspensions were not listed in the available reports. The main themes across inspections involved care planning, medication administration, dietary and infection control practices, and timely reporting of incidents. The pattern of findings suggests ongoing challenges with compliance, as deficiencies have persisted over multiple inspections without clear improvement.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
11.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
95% worse than Montana average
Montana average: 5.8 deficiencies/year
Deficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Jul 17, 2025
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including grievance policy implementation, comprehensive care planning, medication administration errors, food safety and sanitation, and infection prevention and control practices. Deficiencies included failure to provide anonymous grievance options, incomplete care plans for residents, medication errors exceeding 5%, expired food items in use, inadequate dish sanitization testing, and poor hand hygiene and barrier precaution adherence.
Deficiencies (6)
Failed to develop and implement a facility policy and procedure for written grievances to be submitted anonymously; failed to provide residents with readily available grievance forms; and failed to provide a resident with the option to submit written grievances anonymously.
Failed to develop and implement a comprehensive, person-centered care plan for a resident requiring oxygen therapy.
Failed to ensure resident-centered care plans were updated to include specific activity preferences and enhanced barrier precautions for residents with indwelling urinary catheters.
Medication error rate was 5.41%, exceeding the 5% threshold, including delayed insulin administration and incorrect documentation of medication given.
Failed to dispose of expired foods; failed to ensure dietary staff prepared and served food in a sanitary manner; and failed to properly test dish sanitization water.
Failed to ensure staff used appropriate hand hygiene after assisting residents and while preparing ready-to-eat foods; failed to ensure enhanced barrier precautions were followed for a resident with a urinary catheter.
Report Facts
Medication error rate: 5.41
Number of sampled residents: 25
Number of residents affected: 1
Number of residents affected: 1
Number of residents affected: 2
Number of residents affected: 1
Number of residents affected: 2
Number of residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member K | Named in grievance policy deficiency regarding availability of grievance forms and anonymous submission | |
| Staff member B | Named in oxygen therapy care plan deficiency and care plan updates | |
| Staff member O | Named in care plan deficiency related to activity preferences and care team meeting notes | |
| Staff member H | Named in care plan deficiency related to activity participation and hearing impairment | |
| Staff member C | Named in care plan deficiency related to enhanced barrier precautions for resident with urinary catheter | |
| Staff member N | Named in medication error deficiency and infection control observations | |
| Staff member J | Named in medication error deficiency related to incorrect documentation and timing | |
| Staff member E | Named in food safety deficiency and infection control observations | |
| Staff member G | Named in infection control deficiency related to hand hygiene and meal assistance | |
| Staff member P | Named in infection control deficiency related to lack of PPE use | |
| Staff member F | Named in infection control deficiency related to glove use during food preparation | |
| Staff member D | Named in infection control deficiency related to hand hygiene audits and education |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 17, 2025
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to timely report investigative findings and allegations of resident abuse to the State Survey Agency.
Complaint Details
The complaint investigation revealed delays in reporting incidents involving resident-to-resident verbal and physical abuse. The facility's policy requires notification within 24 hours and documentation within five business days, which was not met in these cases.
Findings
The facility failed to report investigative findings of a facility-reported incident in a timely manner for two residents and failed to report allegations of resident abuse within 24 hours for two other residents. This delay increased the risk of psychosocial harm to the residents involved.
Deficiencies (2)
Failed to report investigative findings of a facility-reported incident to the State Survey Agency in a timely manner for 2 residents (#23 and #72).
Failed to report allegations of resident abuse to the State Survey Agency within 24 hours of the incident for 2 residents (#24 and #95).
Report Facts
Residents sampled: 25
Days late reporting incident findings: 2
Days late reporting abuse allegation: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff members B and C interviewed regarding incident reporting responsibilities and delays |
Inspection Report
Routine
Census: 26
Deficiencies: 15
Date: Aug 15, 2024
Visit Reason
Routine inspection of St John's Lutheran Home to assess compliance with healthcare regulations including medication administration, abuse reporting, resident assessments, care planning, dietary services, infection control, and vaccination procedures.
Findings
The facility had multiple deficiencies including failure to assess residents for safe self-administration of medications, delayed abuse reporting, inaccurate resident assessments, incomplete care plans, inadequate skin care documentation, insufficient fall prevention measures, failure to post nurse staffing, delayed medication administration, improper use of psychotropic medications, dietary service deficiencies including failure to follow therapeutic diets and maintain sanitary kitchen conditions, and failure to obtain signed consent for pneumococcal vaccination.
Deficiencies (15)
Failed to ensure residents were assessed for the ability to self-administer medications prior to leaving them unattended while taking medications.
Failed to timely report an allegation of resident neglect within 24 hours of the incident.
Failed to accurately complete the Quarterly resident assessment for one resident.
Failed to develop and implement a baseline care plan to address resident care needs within 48 hours of admission for two residents.
Failed to update comprehensive care plans for residents dealing with grief, frequent falls, and adjustment issues.
Failed to assess and document the condition of a resident's skin as part of preventative skin care.
Failed to sufficiently address repeated falls, identify root causes, evaluate interventions, and update care plans accordingly.
Failed to post daily nurse staffing information in the four cottages housing residents.
Failed to help obtain mental health services for a resident dealing with grief and loss of spouse.
Failed to provide medications in a timely manner; insulin was administered three hours late without physician notification.
Failed to ensure as needed psychotropic medications were limited to 14 days or had documented rationale for extended use.
Dietary department failed to provide nourishing, palatable, well-balanced diets meeting residents' daily nutritional and special dietary needs.
Failed to provide food accommodating resident allergies, intolerances, and preferences; failed to follow menus and serve planned meals or appropriate substitutes.
Failed to maintain sanitary conditions in kitchens including dirty floors, vents, refrigerators, cabinets, unlabeled and expired food items, and improper glove use by staff.
Failed to obtain signed consent for pneumococcal vaccination for a resident unable to consent.
Report Facts
Residents sampled: 26
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 26
Residents affected: 1
Residents affected: 2
Residents affected: 13
Residents affected: 5
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member B | Interviewed regarding abuse reporting, care planning, fall prevention, medication policies, and vaccination consent | |
| Staff member C | Interviewed and observed regarding medication administration and fall prevention | |
| Staff member D | Interviewed regarding resident care and skin condition | |
| Staff member F | Interviewed regarding fall prevention strategies | |
| Staff member G | Interviewed regarding grief counseling and mental health services | |
| Staff member I | Interviewed regarding care plan updates and resident assessments | |
| Staff member L | Observed and interviewed regarding medication administration | |
| Staff member M | Interviewed regarding baseline care plan process | |
| Staff member N | Observed and interviewed regarding dietary service and kitchen sanitation | |
| Staff member O | Interviewed regarding dietary service and kitchen sanitation | |
| Staff member P | Observed and interviewed regarding dietary service and kitchen sanitation | |
| Staff member Q | Interviewed regarding kitchen sanitation | |
| Staff member R | Observed and interviewed regarding dietary service and infection control | |
| Staff member T | Interviewed regarding kitchen ventilation cleaning | |
| Staff member U | Interviewed regarding kitchen ventilation cleaning | |
| Staff member E | Observed not wearing mask during outbreak | |
| Staff member A | Interviewed regarding dietary staffing and kitchen cleaning |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 15, 2024
Visit Reason
The inspection was conducted due to allegations of resident neglect and failure to provide timely medication administration.
Complaint Details
The complaint involved an allegation of resident neglect by a staff member towards resident #77. The allegation was reported late, beyond the required 24-hour timeframe. The staff member making the allegation was reportedly disgruntled and had been employed for only three days.
Findings
The facility failed to report an allegation of resident neglect within 24 hours as required and failed to provide timely administration of insulin to a resident, resulting in delayed medication delivery without physician notification.
Deficiencies (2)
Failed to timely report an allegation of resident neglect within 24 hours.
Failed to provide medications in a timely manner; insulin was administered three hours late without physician notification.
Report Facts
Residents sampled: 26
Residents affected: 1
Residents affected: 1
Time delay: 3
Blood sugar reading: 112
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff members J and K were involved in reporting the neglect allegation via email. | ||
| Staff member B interviewed regarding the delay in reporting the neglect allegation. | ||
| Staff member L observed administering insulin late to resident #41. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 23, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a medication error involving an incorrect dose of an antiepileptic medication administered to a resident for 27 days.
Complaint Details
The complaint investigation found the medication nurse asked a pharmacy technician, not a pharmacist, to clarify the order, leading to the error. The error was discovered on 1/23/24 by a hospice nurse. The investigation was completed on 2/8/24, and corrective actions were taken including revised nursing and pharmacy processes and pharmacist sign-off on medication errors.
Findings
The facility failed to follow the proper process for entering and confirming medication orders, resulting in an incorrect dose of Depakote being administered to one resident for 27 days. The error was identified by a hospice nurse and was linked to miscommunication between pharmacy staff and nursing, with corrective actions implemented to prevent recurrence.
Deficiencies (1)
Failed to ensure the process for entering and confirming medication orders was followed, resulting in an incorrect dose being administered for 27 days for one resident.
Report Facts
Days incorrect dose administered: 27
Date error identified: Jan 23, 2024
Date error corrected: Jan 24, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NF1 | Interviewed regarding resident #1's medication and error circumstances | |
| Staff member A | Identified the medication error on 1/23/24 | |
| Staff member B | Confirmed correction of medication order on 1/24/24 | |
| Staff member C | Documented adjustments in the EHR related to medication change | |
| Staff member D | Contacted pharmacy to clarify titration dosing on the order |
Inspection Report
Routine
Deficiencies: 7
Date: Aug 3, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, pressure ulcer care, respiratory care, psychotropic medication use, and food safety at St John's Lutheran Home.
Findings
The facility was found deficient in multiple areas including failure to honor resident preferences for caregivers, incomplete care plans for residents with dementia and behavioral issues, inadequate pressure ulcer care, lack of appropriate respiratory equipment for a resident, failure to implement nonpharmacological interventions prior to psychotropic medication use, medication order errors, and failure to maintain safe refrigerator temperatures in the kitchen.
Deficiencies (7)
Failed to address a resident's preference for female caregivers for personal cares.
Failed to develop and implement a comprehensive resident-centered care plan for a resident with dementia with behaviors and failed to identify, document, and utilize behavioral interventions for a resident prescribed antipsychotic medication.
Failed to perform a skin assessment on a resident's sacrum for two weeks, resulting in evolution of a pressure ulcer.
Failed to provide durable medical equipment (BiPAP) necessary to prevent adverse sleep events for a resident.
Failed to attempt, document, or care plan nonpharmacological interventions prior to initiation of antipsychotic medication for a resident's disruptive behaviors and agitation.
Failed to ensure a physician's antibiotic order contained all necessary elements, resulting in resident receiving extra doses.
Failed to consistently monitor and maintain refrigerated food temperatures at safe levels, causing elevated risk for foodborne illness.
Report Facts
Residents sampled: 6
Residents sampled: 3
Days with elevated refrigerator temperatures: 4
Days with elevated refrigerator temperatures: 5
Consecutive days with 50°F refrigerator temperature: 3
Days without AM temperature reading: 10
Days without AM temperature reading: 11
Extra antibiotic doses given: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member D | Interviewed regarding resident #1's vocal behaviors and care | |
| Staff member C | Interviewed regarding resident #1's preferences and behaviors | |
| Staff member G | Interviewed regarding nonpharmacological interventions for resident #24 | |
| Staff member H | Interviewed regarding wound care documentation for resident #34 | |
| Staff member B | Interviewed regarding admission assessments and respiratory equipment for resident #142 | |
| Staff member E | Interviewed regarding behaviors of resident #24 | |
| Staff member I | Interviewed regarding medication order and administration for resident #59 | |
| Staff member K | Interviewed regarding refrigerator temperature monitoring | |
| Staff member L | Interviewed regarding refrigerator temperature monitoring | |
| Staff member M | Interviewed regarding refrigerator temperature monitoring regulations | |
| Staff member A | Interviewed regarding refrigerator maintenance and monitoring |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 3, 2023
Visit Reason
The inspection was conducted following a complaint related to the facility's failure to attempt, document, or care plan nonpharmacological interventions prior to initiating antipsychotic medication for a resident exhibiting disruptive behaviors and agitation.
Complaint Details
The complaint investigation focused on resident #24's increased disruptive behaviors and agitation, including an incident on 2/20/23 where the resident kicked another resident. The investigation found no documented nonpharmacological interventions prior to the initiation of Seroquel antipsychotic medication. The complaint was substantiated by observations, interviews, and record reviews.
Findings
The facility failed to implement or document nonpharmacological interventions for resident #24's disruptive behaviors before starting antipsychotic medication. Observations, interviews, and record reviews confirmed increased agitation and behaviors without documented attempts at alternative interventions prior to medication initiation.
Deficiencies (1)
Failure to attempt, document, or care plan nonpharmacological interventions prior to initiating antipsychotic medication for resident #24.
Report Facts
Residents Affected: 1
Medication dosage: 12.5
Dates of behavior notes: Behavior notes dated between 1/27/23 and 3/31/23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member E interviewed regarding resident #24's behaviors and interventions | ||
| Staff member G interviewed regarding nonpharmacological interventions prior to medication |
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