Deficiencies (last 3 years)
Deficiencies (over 3 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% better than Montana average
Montana average: 5.8 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Deficiencies: 2
Date: Jan 30, 2025
Visit Reason
The inspection was conducted to assess compliance with care planning requirements, including trauma-informed care and catheterization care plans, for sampled residents in the facility.
Findings
The facility failed to include intermittent catheterization in a resident's care plan and did not create or implement a comprehensive trauma-informed care plan for a resident with PTSD, resulting in the resident becoming upset due to triggers related to his past war experiences.
Deficiencies (2)
Failed to include a resident's intermittent catheterization on the care plan.
Failed to create and implement a comprehensive person-centered care plan related to trauma informed care for a resident with PTSD.
Report Facts
Urine output: 650
Urine output: 750
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff members I, J, C, and D were interviewed regarding care planning and trauma-informed care but no full names were provided. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 8, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an alleged incident of verbal abuse involving a resident.
Complaint Details
The complaint investigation found that the facility did not report the verbal abuse allegation involving resident #1 within the required timeframe. The incident occurred on 11/30/2024 but was reported on 12/2/2024. Staff interviews confirmed the delay and the facility policy requires immediate reporting within two hours for abuse allegations involving serious bodily injury or within 24 hours for other allegations.
Findings
The facility failed to report an alleged verbal abuse incident involving resident #1 in a timely manner to the State Survey Agency, with the report being delayed by two days after the incident occurred. Interviews with staff confirmed the delay and lack of timely reporting as required by facility policy.
Deficiencies (1)
Failed to timely report an alleged incident of verbal abuse to the State Survey Agency as required.
Report Facts
Residents sampled: 5
Residents affected: 1
Date of incident: Nov 30, 2024
Date reported: Dec 2, 2024
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 3, 2024
Visit Reason
The inspection was conducted due to allegations of verbal and physical abuse of a resident by a caregiver, as well as failure to timely report suspected abuse to the State Survey Agency.
Complaint Details
The complaint was substantiated based on interviews and record review. The facility failed to protect resident #1 from abuse by staff member C and failed to report the abuse allegation to the State Survey Agency. Staff member C was terminated effective 5/30/24.
Findings
The facility failed to protect one resident from verbal and physical abuse by a caregiver, resulting in actual harm. Additionally, the facility failed to report the suspected abuse to the State Survey Agency in a timely manner. The caregiver involved was terminated from employment.
Deficiencies (2)
Failed to protect one resident from verbal and physical abuse by a caregiver.
Failed to timely report suspected abuse to the State Survey Agency.
Report Facts
Residents affected: 1
Date of incident: May 7, 2024
Date of staff termination: May 30, 2024
Date of survey completion: Jun 3, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member C | Caregiver who verbally and physically abused resident #1 and was terminated. | |
| Staff member A | Facility staff who conducted internal investigation and failed to report abuse to State Survey Agency. | |
| NF1 | Nurse who witnessed and described the abuse incident. | |
| NF2 | Author of ambulance report documenting abuse. | |
| Staff member D | Witnessed resident screaming during incident. |
Inspection Report
Deficiencies: 1
Date: Jan 31, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with submission requirements for Minimum Data Set (MDS) assessments, specifically Death in Facility and Discharge MDS assessments.
Findings
The facility failed to submit Death in Facility MDS assessments for 2 residents and Discharge MDS assessments for 2 residents out of 24 sampled. The assessments were significantly overdue, with delays ranging from 46 to 255 days. Staff responsible for completing the MDS assessments lacked adequate training and there was no alert system to track due dates.
Deficiencies (1)
Failure to submit Death in Facility MDS assessments for 2 residents and Discharge MDS assessments for 2 residents within required timeframes.
Report Facts
Days overdue: 255
Days overdue: 125
Days overdue: 68
Days overdue: 46
Sampled residents: 24
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 7, 2023
Visit Reason
The inspection was conducted due to complaints and concerns regarding fall management and care plan updates for residents with multiple falls and injuries, including an immediate jeopardy related to fall prevention and accident hazards.
Complaint Details
The complaint investigation revealed failures in fall prevention, care plan updates, and post-fall assessments. Immediate jeopardy was identified related to inadequate supervision and accident hazard prevention. Resident #9 suffered a fall with serious injuries and died six days later. The facility failed to update care plans and properly assess the resident after the fall.
Findings
The facility failed to ensure individualized fall care plans were updated for residents with recurrent falls and injuries, failed to thoroughly assess and document medical evaluations after falls, and failed to provide adequate supervision and accident prevention. One resident sustained major injuries and later died following a fall and inadequate post-fall care.
Deficiencies (3)
Failure to update individualized fall care plans for residents with multiple falls and injuries.
Failure to ensure nursing home area is free from accident hazards and provide adequate supervision to prevent accidents, resulting in immediate jeopardy.
Failure to thoroughly assess and document medical evaluations after a resident's fall, leading to increased risk of injury.
Report Facts
Falls: 5
Fall risk assessment effective date: Jan 30, 2023
Resident death date: Feb 17, 2023
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Feb 16, 2023
Visit Reason
The inspection was conducted due to complaints and allegations regarding failure to protect residents from abuse, failure to timely report suspected abuse, failure to investigate alleged sexual abuse, failure to provide timely notification of transfers, and failure to document bed hold agreements.
Complaint Details
The complaint involved allegations of sexual abuse by resident #33 against residents #25 and #28, failure to report the abuse to the State Survey Agency, failure to investigate the abuse, and failures related to transfer and bed hold notifications for residents #27 and #33.
Findings
The facility failed to protect residents from sexual abuse by a male resident entering female residents' rooms naked and touching one resident, failed to report the abuse to the State Survey Agency, failed to thoroughly investigate the abuse allegations, failed to provide timely transfer notices and bed hold documentation for residents transferred to hospitals, and failed to document rationale for extending PRN psychotropic medication orders beyond 14 days for two residents.
Deficiencies (6)
Failed to protect residents from sexual abuse by a naked male resident entering female residents' rooms and touching one resident.
Failed to timely report suspected sexual abuse to the State Survey Agency.
Failed to thoroughly investigate alleged sexual abuse by resident #33.
Failed to provide timely notification of transfer to resident or representative for two residents.
Failed to provide bed hold documentation to resident or representative for two residents.
Failed to document rationale for extending PRN psychotropic medication orders beyond 14 days for two residents.
Report Facts
Residents affected: 2
Residents affected: 3
Residents affected: 2
Residents affected: 2
PRN psychotropic medication orders: 2
Discharges with return anticipated: 4
PRN Lorazepam administrations: 8
PRN Lorazepam administrations: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member D | Provided detailed interviews about resident #33's inappropriate behaviors and incidents | |
| Staff member E | Interviewed regarding resident #33's awareness of inappropriate behavior | |
| NF1 | Telephone interview about the abuse incident involving resident #33 | |
| Staff member A | Discussed failure to report abuse, transfer notifications, and bed hold documentation | |
| Staff member B | Discussed PRN psychotropic medication orders and administration | |
| Staff member C | Discussed PRN medication reorder practices and physician orders |
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