Deficiencies (last 3 years)
Deficiencies (over 3 years)
10.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
84% worse than Montana average
Montana average: 5.8 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Deficiencies: 1
Date: Nov 19, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with timely reporting requirements for suspected abuse, neglect, or theft and the submission of investigation results to proper authorities.
Findings
The facility failed to submit investigation findings for an incident involving resident-to-resident interaction in a timely manner to the State Survey Agency, submitting findings one day late. The facility policy requires reporting incidents within 24 hours and submitting investigation findings within five days, excluding weekends and holidays.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and submit investigation results to proper authorities.
Report Facts
Residents sampled: 9
Residents involved in incident: 2
Days late: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member B interviewed regarding reporting requirements |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 28, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to provide prompt physician notification after a resident's fall, failure to timely report allegations of resident abuse, and failure to ensure a nursing home area was free from accident hazards.
Complaint Details
The complaint investigation was substantiated. The facility failed to notify the physician promptly after a resident's fall, delayed reporting of resident-to-resident abuse incidents to the State Survey Agency, and failed to prevent accidents leading to injury.
Findings
The facility failed to promptly notify the physician after a resident (#85) sustained a fall resulting in a fracture, causing delayed care and increased pain. The facility also failed to report allegations of resident-to-resident abuse within 24 hours for two residents (#99 and #129). Additionally, the facility did not ensure adequate supervision to prevent accidents, contributing to the resident's fall.
Deficiencies (3)
Failed to provide prompt physician notification for a resident who sustained a fall resulting in injury with pain and fracture.
Failed to timely report allegations of resident abuse to the State Survey Agency within 24 hours of an incident.
Failed to ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Report Facts
Residents sampled: 34
Residents sampled for Facility Reported Incidents: 5
Residents affected: 1
Residents affected: 2
Date of fall: Aug 9, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member O | Named in fall incident and failure to notify physician | |
| Staff member A | Interviewed regarding abuse reporting and physician notification | |
| Staff member B | Interviewed regarding fall protocol | |
| Staff member C | Interviewed regarding abuse reporting delay | |
| NF5 | Nurse | Attending nurse at emergency room for resident #85 |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Aug 28, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to nursing staff competencies, therapeutic diet provision, food safety, and sanitation in the facility.
Findings
The facility was found deficient in ensuring nursing staff competency in post-fall protocols, failure to provide prescribed thickened diets increasing aspiration risk, and multiple food safety violations including improper food storage, inadequate sanitation, and serving food at unsafe temperatures. Deficiencies were noted to pose minimal harm or potential for actual harm to residents.
Deficiencies (3)
Failure to ensure licensed nursing staff had the necessary knowledge and skillset on post-fall protocol and physician notification, resulting in delayed care for a resident who fell.
Failure to provide a thickened therapeutic diet as ordered for a resident, increasing risk of aspiration.
Failure to procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards, including unsanitary kitchen conditions, staff not wearing hair restraints, and serving food at unsafe temperatures.
Report Facts
Sampled residents: 34
Residents affected by fall protocol deficiency: 1
Residents affected by diet deficiency: 1
Residents affected by food safety deficiency: 4
Food temperatures observed: 110.9
Food temperatures observed: 116.2
Food temperatures observed: 114.3
Food temperatures observed: 110.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member O | Named in fall protocol deficiency for not notifying physician and incomplete incident reporting | |
| NF5 | Nurse | Attended resident #85 in emergency room and noted delayed care |
| Staff member D | Certified Nurse Assistant | Observed not properly thickening fluids and entering kitchen without hair covering |
| Staff member E | Provided information about thickened fluids and kitchen meetings | |
| Staff member F | Observed water pitcher inconsistency and food temperature checks | |
| Staff member M | Checked food temperatures on multiple resident trays | |
| Staff member P | Discussed undated condiment packages in kitchen | |
| Staff member K | Described meal delivery process and food heating practices | |
| Staff member N | Discussed kitchen hair covering policy and cleaning schedules | |
| Staff member L | Reported frequent reheating of food trays due to temperature issues |
Inspection Report
Routine
Deficiencies: 2
Date: Apr 3, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control protocols, specifically focusing on the use of personal protective equipment (PPE) and cleaning practices related to residents with infections such as COVID-19 and C-diff.
Findings
The facility failed to ensure staff wore appropriate PPE while caring for residents under special precautions and failed to educate and monitor staff on proper cleaning practices for residents positive for C-diff. These deficiencies increased the risk of infection transmission among residents.
Deficiencies (2)
Facility staff failed to wear appropriate PPE while caring for residents under special droplet/contact and contact precautions.
Facility failed to educate and monitor staff on cleaning practices for residents positive for C-diff.
Report Facts
Residents sampled: 17
Resident rooms with special droplet/contact precautions: 12
Resident rooms with enhanced barrier precautions: 8
Resident rooms with contact precautions: 3
Diagnosis date: 2025
Treatment duration: 10
Date placed on contact precautions: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff members D, O, G, P, F, N, and C mentioned in relation to PPE use, infection control practices, and cleaning procedures but no full names provided. |
Inspection Report
Routine
Census: 28
Deficiencies: 4
Date: Nov 21, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, facility cleanliness, accurate resident assessments, care plan updates, and medication management.
Findings
The facility was found to have deficiencies including failure to maintain clean resident rooms and hallways, incomplete and inaccurate resident assessments, delayed updates to care plans for pressure ulcers and behavioral issues, and improper management of psychotropic medication orders without proper consent or rationale.
Deficiencies (4)
Failed to provide clean resident rooms and hallways, with sticky substances and debris observed in multiple rooms.
Failed to complete accurate assessments for a resident involved in altercations, inaccurately depicting care needs.
Failed to update resident care plans timely for pressure ulcers and behavior interventions following altercations.
Failed to limit as needed anti-anxiety medication order to 14 days or provide rationale for continued use; lacked consent documentation.
Report Facts
Residents sampled: 28
Residents affected by cleanliness deficiency: 3
Residents sampled for assessment accuracy: 3
Residents sampled for care plan updates: 4
Residents affected by care plan deficiency: 3
Days Lorazepam initially ordered: 4
Days Lorazepam re-ordered: 14
Months Lorazepam re-ordered: 6
Times Lorazepam administered: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member F | Reported cleaning practices and observations of room cleanliness | |
| Staff member G | Reported on hall and room cleanliness and missed cleaning under beds | |
| Staff member S | Reported staffing shortages affecting cleaning and nursing staff workload | |
| Staff member E | Completed inaccurate vulnerable resident evaluation for resident #33 | |
| Staff member U | Described care plan update processes and monitoring | |
| NF1 | Reported no consent signed for tranquilizer use for resident #33 |
Inspection Report
Routine
Deficiencies: 9
Date: Aug 1, 2024
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements for Village Health & Rehabilitation nursing home.
Findings
The facility was found deficient in multiple areas including failure to implement baseline care plans timely for newly admitted residents, failure to develop care plans for PTSD, failure to update catheter care plans, failure to provide a safe environment resulting in a resident fall with injury, failure to manage catheter changes per physician orders, failure to ensure transportation for dialysis appointments, failure to provide behavioral health services, food safety violations in the kitchen, and lapses in infection prevention and control practices.
Deficiencies (9)
Failed to implement a baseline care plan within 48 hours for a newly admitted resident with subdural hematoma and stroke.
Failed to initiate a care plan for PTSD for a resident, resulting in lack of staff awareness and management of PTSD triggers.
Failed to update care plan related to catheter care for a resident, including scheduled and PRN catheter changes.
Failed to provide a safe environment leading to a resident fall and significant injury (hip fracture).
Failed to manage catheter changes as ordered, with multiple catheter changes in short periods and missing documentation of catheter flushes.
Failed to ensure transportation for a resident's dialysis appointment, resulting in missed treatment and hospitalization.
Failed to provide behavioral health services and mental health referrals for a resident with PTSD.
Failed to ensure kitchen staff wore beard coverings, failed to label and date food items, and failed to properly cool leftover chicken.
Failed to ensure nursing staff changed gloves and practiced hand hygiene during pericare and wound care, and failed to initiate enhanced barrier precautions for a resident with a PICC line.
Report Facts
Residents sampled: 36
Resident #138 baseline care plan delay: 5
Catheter changes for resident #107 in May 2024: 4
Catheter changes for resident #107 in June 2024: 3
Catheter changes for resident #107 in July 2024: 3
Date of inspection: Aug 1, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member J | Named in baseline care plan deficiency for resident #138 | |
| Staff member G | Named in PTSD care plan deficiency for resident #55 | |
| Staff member L | Named in catheter care deficiency for resident #107 | |
| Staff member B | Named in catheter care and transportation deficiencies | |
| Staff member H | Named in resident fall and injury deficiency | |
| Staff member E | Named in infection control deficiency for wound care | |
| Staff member F | Named in infection control deficiency for pericare and wound care | |
| Staff member C | Named in enhanced barrier precautions deficiency | |
| Staff member O | Named in food safety deficiency | |
| Staff member P | Named in food safety deficiency |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 20, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report and properly investigate an allegation of sexual abuse involving resident #16.
Complaint Details
The complaint investigation found that the facility did not report the sexual abuse allegation within two hours, delayed interviewing the resident and other residents, did not send the resident for hospital evaluation, and failed to notify the resident's physician. The investigation revealed changes in the alleged perpetrator during the process and inadequate removal of staff from resident care.
Findings
The facility failed to report the sexual abuse allegation within the required two-hour timeframe, delayed the start of the investigation, did not send the resident for a sexual abuse assessment, and failed to notify the resident's physician. The alleged perpetrators were suspended, but one was not immediately removed from providing care to other residents.
Deficiencies (2)
Failed to timely report an allegation of sexual abuse within the required two-hour timeframe to the State Survey Agency and local law enforcement.
Failed to immediately start investigating an allegation of sexual abuse by a staff member.
Report Facts
Residents affected: 1
Investigation duration: 5
Date of allegation report: Apr 2, 2023
Date of report submission: Apr 3, 2023
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jul 20, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations of sexual abuse and other regulatory compliance concerns at Village Health & Rehabilitation.
Complaint Details
The complaint investigation involved allegations of sexual abuse of resident #16. The facility failed to report the abuse allegation within two hours, delayed investigation and interviews, and did not send the resident for hospital evaluation. The investigation revealed changes in the alleged perpetrator and suspensions of involved staff.
Findings
The facility failed to timely report and investigate an allegation of sexual abuse, inaccurately coded Minimum Data Set (MDS) assessments for several residents, and committed a significant medication error that posed a risk of bleeding for a resident.
Deficiencies (4)
Failed to report an allegation of sexual abuse within the required two-hour timeframe to the State Survey Agency and local law enforcement for resident #16.
Failed to immediately start investigating an allegation of sexual abuse by a staff member for resident #16, including delayed interviews and lack of hospital assessment.
Failed to accurately code the MDS for 3 residents (#16, 26, and 75), including incorrect antibiotic use, catheter status, and anticoagulant medication coding.
Failed to protect resident #22 from a significant medication error involving administration of incorrect blood thinner medications, increasing risk of bleeding.
Report Facts
Deficiencies cited: 4
Medication error details: 40
Medication error details: 20
Medication prescribed: 15
Residents sampled: 8
Residents with MDS coding errors: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member B | Interviewed regarding sexual abuse allegation reporting and medication error incident. | |
| Staff member C | Interviewed regarding MDS completion and coding errors. | |
| Staff member E | Interviewed about risks of blood thinner medication errors. | |
| Staff member F | Interviewed about nurse training on medication administration. | |
| Staff member G | Involved in medication error by mixing up medications for resident #22 and roommate. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Mar 14, 2023
Visit Reason
The inspection was conducted due to complaints involving allegations of verbal and physical abuse by a family member towards a resident, failure to report suspected abuse, inadequate investigation of staff to resident abuse allegations, and failure to prevent an elopement.
Complaint Details
The complaint investigation involved allegations of verbal and physical abuse by a family member towards resident #1, failure to report the abuse incident to the State Survey Agency, inadequate investigation of a staff to resident abuse allegation involving resident #7 and staff member E, and failure to prevent an elopement by resident #6. The abuse allegations were not substantiated for staff member E, but the facility failed in reporting and investigation procedures. The resident #6 elopement was confirmed with no injuries.
Findings
The facility failed to prevent further verbal and physical abuse by a resident's family member, failed to report suspected abuse to the State Survey Agency, did not thoroughly investigate a staff to resident abuse allegation, and failed to prevent an elopement of a high-risk resident. The deficiencies were associated with minimal harm or potential for actual harm affecting a few residents.
Deficiencies (4)
Failed to prevent further verbal and physical abuse by a family member towards a resident.
Failed to report an incident of suspected verbal and physical abuse to the State Survey Agency.
Failed to thoroughly investigate a staff to resident abuse allegation and document the investigation thoroughly.
Failed to prevent an elopement of a high-risk resident.
Report Facts
Residents sampled: 7
Incident date: Oct 18, 2022
Incident date: Sep 3, 2022
Incident date: Jul 10, 2022
Elopement risk score: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff members B, C, A, and D are mentioned in relation to interviews and investigations but no full names provided. | ||
| Staff member E is the CNA accused in the staff to resident abuse allegation; no full name provided. | ||
| Director of Nursing (DON) | DON involved in addressing family member abuse incident and follow-up. | |
| Assistant Director of Nursing (ADON) | ADON involved in addressing family member abuse incident. |
Inspection Report
Deficiencies: 0
Date: Mar 14, 2023
Visit Reason
The inspection was conducted as a regulatory survey of the nursing home facility Village Health & Rehabilitation.
Findings
No health deficiencies were found during the inspection.
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