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F0584
D

Failure to Maintain Safe, Clean, and Repaired Resident Environment

Butte, Montana Survey Completed on 04-10-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a safe, clean, and comfortable environment for several residents, as evidenced by multiple areas of the building in need of repair and unaddressed housekeeping issues. Observations revealed that one resident's room had numerous holes in the wall near a grab bar, another had long vertical gouges above the bed, and a third had significant wall and baseboard damage. Residents expressed concern about the lack of timely repairs, and interviews with staff indicated that maintenance requests were not consistently entered into the facility's electronic system, resulting in delays. Staff members admitted to either forgetting to log repairs or preferring to verbally request them, leading to a lack of documentation and follow-through. Additionally, the facility failed to maintain cleanliness in at least one resident's room, where a thick brown substance was observed smeared on the commode seat, handrail, and toilet paper, along with a sticky substance on the floor and a full urinal left on the bedside table. Despite daily cleaning routines outlined in facility policy, these unsanitary conditions persisted over multiple days, and the resident confirmed that the bathroom had not been cleaned. Housekeeping staff acknowledged inconsistencies in cleaning due to staffing issues and unfamiliarity with the specific hall. Facility documents confirmed that daily cleaning and disinfection of toilets and handrails were required but not consistently performed.

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