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F0725
F

Insufficient Staffing Leads to Inadequate Resident Care and Supervision

Hamilton, Montana Survey Completed on 11-18-2025

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 provide sufficient nursing staff on the Memory Care Unit to meet the needs of residents, resulting in inadequate monitoring, assistance with activities of daily living (ADLs), meal assistance, and abuse prevention. Multiple observations and staff interviews revealed that residents were left unsupervised, including those requiring one-to-one supervision due to disruptive behaviors. Staff reported being unable to complete all required tasks during their shifts, often skipping baths and showers due to time constraints and insufficient staffing. Residents were observed wearing the same clothing over consecutive days, appearing unkempt, and not receiving scheduled or needed bathing services. Further observations documented residents without appropriate assistance during meals, such as a resident eating with her fingers and pouring water onto her plate without staff intervention. Staff consistently reported that the lack of adequate staffing made it difficult to provide necessary care, particularly for bathing and supervision. The facility's own records confirmed that on several days, staffing levels were below what was identified as necessary in the facility assessment, directly impacting the quality of care provided to residents. Documentation and interviews indicated that the facility had identified staffing as an ongoing issue, particularly affecting the provision of ADL care and resident supervision. The lack of staff also affected the ability to provide activities and ensure resident safety, with staff expressing concerns about their inability to protect residents and complete essential care tasks. The deficiency was supported by observations, interviews, and record reviews, all indicating a pattern of insufficient staffing leading to unmet resident needs.

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