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F0600
G

Resident Subjected to Mental Abuse Through Restriction of Visitation Rights

Great Falls, Montana Survey Completed on 05-20-2025

Penalty

Fine: $21,330
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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 ensure a resident was free from mental abuse by depriving her of her rights to private visitations and by isolating her from social interactions for staff convenience. The resident was not allowed to have visitors in her room and was repeatedly told by staff to move her visits to the common area. This restriction was imposed despite the resident expressing that socialization was very important to her and that the limitation caused her to feel dull, bored, frustrated, and like a prisoner. The restriction had been in place for several months, and the resident agreed to it only to keep peace with the staff, not because she felt it was appropriate. Multiple staff interviews confirmed that the directive to limit the resident's in-room visitors originated from a specific staff member, who cited concerns about the resident discussing facility issues with others and encouraging complaints. There were no documented safety concerns or incidents that justified the restriction, and staff acknowledged that the resident's visitors, including a long-time friend and another resident's family member, were not involved in any inappropriate behavior. The facility did not provide the resident with written documentation or rationale for the visitation limitation, and the decision was not based on any documented behavioral or safety issues. The resident's care plan indicated a preference for socialization and maintaining her current level of social interaction, with a goal of avoiding complaints of isolation. However, the imposed visitation restrictions directly contradicted these care plan goals and the facility's own policies, which guarantee residents the right to private visits and to voice concerns without fear of punishment. The actions taken by staff resulted in the resident experiencing ongoing negative psychosocial effects, as evidenced by her own statements and corroborated by interviews with friends and staff.

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