F0600

E

Failure to Protect Residents From Abuse, Neglect, and Inadequate Response to Complaints

Laurel, Montana Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect multiple residents from abuse and neglect, and to respond appropriately to allegations and signs of mistreatment. One resident reported that another resident entered her room at night, held her arms down, attempted to get into bed with her, and repeatedly yelled at her while she screamed for help and no staff responded for some time. She stated this resident had previously entered her room on two other occasions and used her toilet. She remained fearful that he might return and potentially harm or sexually assault her, and she believed his room had been moved away from hers, although their rooms remained side by side. Facility documentation from that night showed a CNA returned from break to find the alleged perpetrator in another resident’s room and the victim yelling for help with water all over the room, but facility leadership later could not locate resident interviews about the incident and were unaware of the victim’s ongoing fear and feelings of being unsafe.

Another resident expressed fear and distress related to her roommate’s behavior and the environment in their shared room. She cried and begged staff not to take her back to her room, stating she was scared to go in because her roommate wanted everything her way, kept the TV very loud so she could not rest, became angry when she entered the room, and insisted her own needs be the priority. The resident stated she had reported these concerns to CNAs and nurses, but felt no one listened. During an observation when staff brought her to the room for toileting, the roommate yelled, “Now what?!” and became agitated with staff and the resident before growling and returning to bed. The resident’s care plan showed she was dependent for toileting, required a Hoyer lift for transfers, and had hearing impairment, expressive aphasia, and depression, indicating she relied heavily on staff to advocate for and address her concerns.

A third resident reported being left wet at night with an additional pad placed in her brief so staff would not have to change her as often. She stated she was on antibiotics for a UTI and believed CNAs were not changing her during the night. She also reported that staff frequently attempted to turn her alone despite her care plan requiring two-person assistance and use of a sit-to-stand, causing pain and resulting in her head being hit against the wall repeatedly during brief changes. She described a night CNA answering her call light, saying she would return, but failing to come back, leaving her to wet herself and her bed, and then later yelling at her for wetting herself and adding a pad to her brief while stating she did not want to change her every two hours. Her care plan and MDS confirmed she required maximal assistance with toileting hygiene, care in pairs, and that she was on antibiotics for a UTI.

Another resident was found by a staff member in the morning lying diagonally in bed with his feet dangling off the edge, soaked with urine from his shoes to his shoulders, with urine pooling in the bed and the bed saturated. He was still in the same clothing from the previous day. The staff member reported that earlier staff had tried to get him up but, after he refused, they left him in bed in that condition. The resident had severe cognitive impairment per his BIMS score, required maximal assistance for toileting, dressing, and walking, and was incontinent of bladder and bowel, indicating he was dependent on staff for continence care and repositioning. The staff member stated the resident did not resist care when she later attempted to get him up and clean.

Multiple staff interviews described a pattern of neglected care, particularly on the night shift. One nurse reported frequent complaints about resident care being neglected, including improper transfers, residents’ heads being hit on the wall when only one staff member was used instead of two, soaked beds, use of pads in briefs to avoid changing them, unmet food preferences, and medications not given on time. She stated she re-educated CNA staff, many of whom were agency staff, but did not report these concerns to management. Other staff reported commonly finding residents in soaked beds, poor peri care, lack of oral care, and residents complaining about not receiving peri cream or timely brief changes. One staff member specifically noted that one resident was soaked and had inadequate peri care, resulting in red and inflamed skin folds around her pannus. Despite these repeated concerns, facility leadership reported they were unaware of the specific neglect issues for several residents and could not locate grievances or complaints related to them, even though staff stated they had reported issues to nurses or written grievances. Facility policies required immediate reporting, investigation, and protection related to suspected abuse and neglect, but the described events show failures to follow these policies and to protect residents from abuse, neglect, and psychosocial harm.