Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Faith Lutheran Home during CMS and state inspections, most recent first.
Failure to Timely Report Reportable Incidents: The facility did not submit multiple reportable incidents to the State Survey Agency within the required 24-hour timeframe. Incidents included resident-to-resident verbal altercations and aggressive behavior, such as derogatory statements, threats, and throwing cups at staff. An LPN/staff member stated she was the only person who knew how to use the online reporting portal, so incidents that occurred on weekends or holidays could be reported late.
CNA Training Lacked Dementia Care Education: The facility failed to provide CNAs with the required annual in-service training, including dementia management and abuse prevention-related education. Staff who worked in the memory care unit reported receiving only general orientation and no additional training on dementia care or managing resident behaviors, and the facility’s annual online and in-person training records did not show dementia-related topics.
The facility failed to document that two residents or their representatives were informed of the risks and benefits of psychotropic meds before treatment started. One resident received PRN alprazolam for anxiety, and another received PRN lorazepam related to anxiety and dialysis, but the EHRs did not show consent or notification documentation. An LPN/staff member stated the facility did not require signed risk/benefit consent for PRN psychotropic meds, and no documentation was produced when requested.
A resident had PRN alprazolam orders for anxiety that lacked an end or stop date and were not limited to 14 days. An LPN stated PRN psychotropic medication orders are limited to 14 days and that the alprazolam may have been missed during the medication regimen review.
A resident with DM and a weekly Trulicity injection was incorrectly coded on a Quarterly MDS as receiving insulin injections, based on a staff member’s misunderstanding of the MDS item. In a separate Comprehensive MDS, a Wander Guard alarm for another resident was incorrectly coded as a restraint and alarm used daily, even though it did not meet restraint criteria.
A licensed pharmacist failed to identify and report a resident’s PRN psychotropic medication during monthly drug regimen reviews. The resident had an active alprazolam order for anxiety, but the MRRs only addressed other medications and did not include monitoring or a GDR recommendation for the alprazolam. An F staff member stated he reviewed residents on psychotropics monthly but may have missed the medication.
Facility staff failed to maintain documentation of an employee’s COVID-19 vaccination status, including whether additional booster doses were received or refused. An interview showed the employee had only the initial 2 COVID-19 vaccinations and had not signed a declination for boosters, while another staff member was unaware of the requirement to educate employees and document referral information. The employee record contained only the 2 initial vaccine doses.
A resident arriving from out of town by ambulance was refused admission when staff found her family too intoxicated to complete paperwork. The resident left with her family without a safe discharge plan, and staff did not notify facility management at the time.
A staff member with limited MDS training failed to complete a required re-entry MDS for a resident readmitted from the hospital, resulting in missing assessment data. The staff member was also unaware of how to identify or correct MDS submission errors, leading to multiple reporting issues such as incorrect identifiers, duplicate and late assessments, and resident mismatches, as identified during survey review.
Surveyors found that the facility did not have a certified dietary manager on staff, as the interim manager's certification had expired three years prior and no documentation of advanced training was available. The interim manager was temporarily filling the role after coming out of retirement, and the facility had not yet hired a qualified replacement.
Surveyors found that kitchen and dietary storage areas were not maintained in a sanitary manner, with multiple food items unlabeled and undated, soiled equipment, improper storage of dented cans, and incomplete temperature logs. Staff with facial hair were observed preparing food without required beard or mustache covers, and cleaning schedules were not consistently followed.
A resident with a central IV catheter did not receive care in accordance with enhanced barrier precautions, as staff wore gloves but not gowns during personal care, despite care plan directives. The facility also lacked a current enhanced barrier precautions policy, had recently changed infection prevention staff multiple times, and had not consistently updated infection control and antibiotic stewardship policies.
The facility did not document required screening, education, or obtain signed consent or declination for influenza vaccination for four residents. Staff could not locate the necessary forms, and records lacked evidence of informed consent, contraindication screening, or education prior to vaccine administration, contrary to facility policy.
The facility did not ensure that grievance forms were readily available to residents, did not post the grievance official's contact information, and did not provide a way for residents to file grievances anonymously. A resident reported that anonymity was not possible, and staff confirmed that forms had to be requested and submitted directly to staff, with no secure receptacle for anonymous complaints.
A resident who changed her code status to DNR with comfort care only did not have her care plan updated to reflect this decision, despite clear documentation from medical staff and her expressed wishes. The care plan lacked focus areas, goals, or interventions related to comfort care, even after the resident's condition and preferences were documented and discussed by staff.
A resident receiving regular hemodialysis treatments did not have a physician order for dialysis documented in the medical record, despite ongoing treatments and a care plan indicating dialysis history. The order was not entered until after the deficiency was identified.
The facility did not appoint a licensed Nursing Home Administrator for Montana after the interim Director of Nursing Services' contract negotiations fell through, leaving the position vacant since December 2024. Attempts to have staff share the roles of Nursing Home Administrator and Director of Nursing were unsuccessful due to the additional hours required, potentially affecting all residents.
The facility failed to employ a licensed administrator in Montana, affecting all residents and resulting in non-compliance. The Director of Nursing applied for a license but had not received it, and the facility had not advertised for the position. The Interim CEO confirmed the absence of a licensed administrator since December 2024. Despite multiple attempts by the Certification Bureau to contact the facility regarding the appointment, no response was received.
The facility failed to conduct monthly QAPI meetings and maintain the required committee members, as no meeting was held in February 2025 and a licensed administrator was not employed. This resulted in the QAPI committee lacking necessary staff participation, violating the plan of correction and CMS requirements.
A staff member conducted wound care on a resident in a public area, failing to ensure privacy. The procedure, including wound measurement and ointment application, was performed in the open television room in view of other residents. Interviews revealed that such procedures should not occur in public spaces, and the resident sometimes resists moving to a private room.
A resident with a history of falls did not have fall prevention interventions properly implemented. Despite a care plan update to include tread tape for improved traction, observations revealed the tape was not in place. The resident experienced multiple falls, and the care plan was not revised to address the root causes of these incidents, leading to a deficiency in care.
A resident with a history of falls experienced multiple incidents due to the facility's failure to implement and maintain fall prevention measures. Despite recommendations to use tread tape for improved traction and the need for assistance during transfers, these interventions were not consistently applied. The resident's care plan was not updated following each fall, leading to continued falls and injuries.
The facility failed to manage elopement and fall risks for two residents, leading to one resident leaving the facility unsupervised and another experiencing multiple falls with injuries. Despite indications of risk, proper assessments and care plan updates were not conducted, contributing to repeated incidents.
The facility failed to provide sufficient privacy for residents using shared bathrooms and during personal care. A resident reported a broken bathroom door replaced with a curtain, causing privacy concerns. Additionally, staff did not ensure privacy during personal care, and privacy curtains in four rooms had significant gaps.
The facility failed to provide and consistently document restorative nursing services for three residents, leading to missed opportunities for mobility improvement. Staff interviews and record reviews revealed inconsistencies in completing and documenting restorative exercises, with discrepancies in the electronic medical records and a lack of clear guidelines for staff.
The facility failed to provide food at a palatable temperature for three residents. Observations showed food sitting unattended on the steam table, with temperatures ranging from 112.9 to 125 degrees Fahrenheit. Residents reported that their food was often cold, and staff members were aware of these complaints.
The facility failed to timely update care plans for a resident who eloped multiple times and another who experienced repeated falls with injuries. Staff were unaware of required interventions, and care plans lacked accurate and effective fall prevention strategies.
The facility failed to monitor and control the temperature of personal resident room refrigerators, leading to unsafe food storage conditions for two residents. Observations revealed temperatures in the Danger Zone, and staff interviews indicated confusion and lack of knowledge about proper procedures.
Failure to Timely Report Reportable Incidents
Penalty
Summary
The facility failed to submit reportable incidents to the State Survey Agency within 24 hours for 7 of 17 sampled residents. The incidents involved resident-to-resident verbal altercations and aggressive behavior, including resident #25 making derogatory statements toward resident #13 and throwing cups of juice at staff, resident #29 having a verbal altercation with resident #25, resident #22 becoming verbally aggressive with resident #15 and threatening to hit resident #15 with a crossword book, and resident #14 becoming verbally aggressive toward resident #38 in the activities room. Several of these incidents were reported days after they occurred, including reports submitted 2, 3, 5, and 9 days later. During interviews, staff member C stated she was the only staff member who knew how to submit a reportable incident through the online reporting portal and that if an incident occurred on a weekend or holiday, it could be reported late because she was not in the facility. She also stated she did not know why some of the incidents were not submitted within 24 hours and that reports were completed when she returned to the facility. The facility policy titled Abuse Policies stated alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property are to be reported immediately, but not later than 24 hours when the events do not involve abuse and do not result in serious bodily injury.
CNA Training Lacked Dementia Care Education
Penalty
Summary
The facility failed to provide 12 hours of annual in-service training for Certified Nursing Assistants, including dementia management education. During interviews, staff members who routinely worked in the memory care unit stated they had only received general orientation when hired and had not received additional training related to dementia care, resident behaviors, or how to manage residents with problematic behaviors. One staff member stated she had experience working with residents with dementia but had not received any additional dementia training since starting at the facility. Another staff member stated she had been employed since the beginning of 2025 and had not received any education or training related to dementia care or how to deal with resident behaviors, despite working in the memory care unit at least once every two weeks. A staff member also stated that annual training was required, but dementia care had not been part of the annual online training. Review of the facility's annual online training topic list did not show any topics related to dementia care or resident behaviors, and review of in-person CNA training over the past 12 months showed topics such as air mattress training, ambulating with a gait belt, CPR, C. difficile education, MDS Section GG Functional Abilities, and enhanced barrier precautions.
Failure to Document Psychotropic Medication Risk/Benefit Notification
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were informed of the risks and benefits associated with psychotropic medications before treatment began for 2 of 17 sampled residents. Resident #2 had physician orders for alprazolam 0.25 mg twice daily as needed for anxiety from 12/30/25 to 4/30/26, but the electronic health record reviewed between 5/18/26 and 5/21/26 did not show documentation that the resident or representative was made aware of the risks and benefits of this medication. Resident #3 had orders for lorazepam 0.5 mg three times daily as needed for anxiety from 12/30/25 to 1/2/26, then lorazepam 0.5 mg sent with the resident to dialysis for possible anxiety from 1/3/26 to 5/21/26, and lorazepam 0.5 mg once daily as needed after dialysis due to possible anxiety from 5/6/26 to 5/21/26; the EHR also did not show documentation that the resident or representative was informed of the risks and benefits of these psychotropic medications. During interview, staff member E stated the facility did not require signed risks and benefits consent documentation for residents taking as-needed psychotropic medications, and when surveyors requested the consent documentation for both residents, none was provided by the end of the survey.
PRN Psychotropic Medication Not Limited to 14 Days
Penalty
Summary
The facility failed to ensure that an as needed psychotropic medication was limited to 14 days unless a medical provider documented the rationale for continuing it, affecting resident #2. Review of the resident’s medication administration record from 1/1/26 through 4/30/26 showed an order for alprazolam 0.25 mg, two tablets twice daily as needed for anxiety. Review of the medication administration record from 5/1/26 through 5/19/26 showed a later order for alprazolam 0.5 mg, one tablet daily as needed for anxiety. Both alprazolam orders lacked an end or stop date and were not limited to 14 days. During an interview on 5/26/26 at 3:30 p.m., staff member F stated that as needed psychotropic medication orders were limited to 14 days and that the alprazolam may have been missed during the medication regimen review for resident #2.
MDS Coding Errors for Medication and Alarm Use
Penalty
Summary
The facility failed to accurately complete a Quarterly MDS assessment for a resident with Diabetes Mellitus who was prescribed Trulicity, a glucagon-like peptide-1 receptor agonist given once weekly by subcutaneous injection. In the resident’s Quarterly MDS with an ARD of 3/14/26, Section N was coded to show 1 day of insulin injections received in the last 7 days. During interview, the staff member responsible for the MDS stated she was new to the role, believed Trulicity was listed as an insulin, and entered the code because she assumed it was accurate. She stated she misunderstood the resident assessment instrument and that the error was hers. The facility also failed to accurately complete a Comprehensive MDS assessment for another resident. During interview, the same staff member stated she coded a Wander Guard alarm under Section P as a restraint, including restraints used in bed, restraints used in chair/out of bed, and alarms used daily, because she believed that if the alarm hindered independence it was also a restraint. The resident’s Comprehensive MDS with an ARD of 4/24/26 reflected those restraint and alarm entries, even though the Wander Guard alarm did not meet the criteria for a restraint because it could be easily removed and did not restrict normal access to the resident’s body. It was also not considered a position change alarm that would cause potential inhibition of movement.
Pharmacist Failed to Identify PRN Psychotropic Medication in Monthly Review
Penalty
Summary
The facility failed to ensure the licensed pharmacist completed a monthly drug regimen review that included the medical chart and identified irregularities for resident #2’s as needed psychotropic medication. Resident #2 had an active prescription for alprazolam 0.25 mg twice a day as needed for anxiety, written on 12/31/25, and the Medication Administration Record showed the medication was active from 1/1/26 through 5/21/26. Review of the resident’s Medication Regimen Reviews from 1/1/26 through 4/30/26 showed pharmacist recommendations about other medications, but no monitoring or recommendation related to alprazolam. During interview, staff member F stated he reviewed all residents taking psychotropic medication monthly, was not sure why resident #2’s alprazolam was not included in the review, and said he could have missed the medication when completing the medication reviews.
Missing COVID-19 Vaccination Documentation for Staff
Penalty
Summary
The facility failed to maintain documentation of the COVID-19 vaccination status for staff member E, including whether the vaccine was received or refused. During interviews, staff member C stated she was not aware the facility needed to offer employees education on where a COVID-19 booster vaccination could be obtained or document in the employee record that education and a referral had been provided. Staff member E stated she had received two COVID-19 vaccinations in 2021 but no additional vaccinations since, and she stated she did not sign a declination form for additional booster vaccinations. Review of staff member E’s vaccination record showed only the two initial COVID-19 vaccinations dated 1/6/21 and 2/3/21. The facility policy titled 7.91 SARS-2 Vaccine Program stated that HCP should receive education regarding the benefits of SARS-2 vaccination and that employees who elect not to get the vaccine should be requested to sign a declination statement.
Resident Discharged Without Safe Plan After Admission Refusal
Penalty
Summary
A resident was transported from out of town to the facility via contracted ambulance, with local family members meeting her upon arrival. Upon arrival, staff determined that the family members were too intoxicated to sign admission paperwork, and the staff present refused to accept the resident for admission. The resident subsequently left with her family, and staff did not contact the administrator or other management at the time of the incident. There was no safe discharge plan in place for the resident, who had previously been living with family before her hospitalization and did not have immediate medical concerns such as IV antibiotics or rehab orders.
Failure to Complete and Transmit MDS Assessments Timely and Accurately
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed, encoded, and transmitted within the required timeframe for one of fourteen sampled residents. Specifically, a staff member responsible for MDS assessments did not complete a re-entry MDS for a resident who was discharged to the hospital and subsequently readmitted. The staff member reported limited training, having only three days of MDS instruction, and was unaware of the process to correct or add a re-entry MDS. Review of the resident's records confirmed the absence of a required re-entry MDS following the resident's return from the hospital, and the next assessment completed was a quarterly assessment instead. Additionally, the same staff member, who was responsible for submitting the facility's MDS reports, indicated a lack of knowledge regarding the identification and correction of MDS submission errors. Facility records and quality reporting status reports revealed multiple errors, including incorrect Medicare Beneficiary Identifiers, duplicate assessments, late assessments, and resident mismatches. These issues resulted in inaccurate and missing MDS data, as identified during the annual recertification survey.
Lack of Certified Dietary Manager in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that the dietary manager had completed a certification program approved by a national certifying body or possessed higher education in a related field. During a kitchen observation, there was no documentation available to show advanced training for the dietary manager. Interviews revealed that the current interim dietary manager had come out of retirement to temporarily fill the position after the previous manager left, and her certified dietary manager certification had expired approximately three years prior. There was no certified dietary manager on staff at the time of the survey. These findings were based on direct observation, staff interviews, and record review.
Failure to Maintain Sanitary Kitchen and Food Storage Conditions
Penalty
Summary
Surveyors observed multiple failures to maintain sanitary conditions in the kitchen and dietary storage areas. Food items in the coolers, such as a pitcher of fluid, a gallon of milk, a quart of Half and Half, red jellied products, a bowl of white fluffy substance, and a pan of pasta with sliced meat, were found unlabeled and undated. Large containers of spices were opened and not dated, with some containers appearing soiled and sticky. The inside of the microwave was splattered with food particles, and the meat slicer had visible debris. Dented cans were found stored with undented cans, contrary to staff statements about their handling. Additionally, a bag of chicken breasts thawed in the walk-in cooler was dated from a previous month. Staff members with facial hair were observed in the food preparation area without wearing required beard or mustache covers on multiple occasions. Temperature logs for refrigerators and freezers were incomplete, with several days missing documentation and some dates recorded incorrectly. Staff interviews confirmed lapses in cleaning schedules and knowledge of required practices, contributing to the unsanitary conditions observed throughout the kitchen and storage areas.
Failure to Implement Enhanced Barrier Precautions and Maintain Infection Control Program
Penalty
Summary
The facility failed to ensure that enhanced barrier precautions were properly implemented for a resident with a central IV catheter used for dialysis. During personal care, staff wore gloves but did not use gowns as required, despite the resident's care plan specifying enhanced barrier precautions for the central IV catheter. Observations confirmed that staff did not wear gowns while handling the resident's IV site, and only gloves were available in the resident's room. Staff indicated they believed gowns were unnecessary if the IV insertion site was covered, and there was a lack of accessible personal protective equipment beyond gloves. Additionally, the facility did not maintain an adequate infection surveillance and antibiotic stewardship program. The infection control program had only recently begun using the McGeer criteria, and there was no current enhanced barrier precautions policy in place, only informal guidance. Multiple staff changes in the infection preventionist role occurred over the past year, and some infection control policies had not been reviewed or updated annually as required. Documentation showed gaps in the implementation and oversight of infection prevention and control measures, including incomplete antibiotic stewardship and outdated policies.
Failure to Document Consent and Screening for Influenza Vaccination
Penalty
Summary
The facility failed to ensure proper documentation and procedures were followed for influenza vaccination for four of five sampled residents. Specifically, there was no evidence in the medical records of these residents that screening for medical contraindications was performed, education regarding the risks and benefits of the vaccine was provided, or that informed consent or declination was obtained and documented prior to vaccine administration. Staff interviews confirmed that consent or declination forms could not be located for these residents, despite records showing that the influenza vaccine had been administered. A review of the facility's influenza policy indicated that informed consent, provision of the Vaccine Information Statement (VIS), screening for contraindications, and documentation of refusals or contraindications are required steps prior to vaccination. However, for the residents in question, these steps were not documented as completed. The facility was unable to provide the requested documentation during the survey, resulting in a deficiency related to the administration and documentation of influenza vaccinations.
Failure to Provide Accessible and Anonymous Grievance Process
Penalty
Summary
The facility failed to develop, implement, and operationalize a comprehensive grievance policy and procedure, as well as ensure that grievance information was readily accessible to residents. During interviews and observations, it was found that grievance forms were not readily available in common areas, and there was no posting of the name or contact information for the grievance official. Additionally, there was no secure receptacle for residents to file grievances anonymously. Staff confirmed that residents needed to request grievance forms from staff at the nurse's station or social services, and completed forms were to be handed to staff, with no option for anonymous submission. A review of the facility's grievance policy revealed that written grievances were required to be signed by the resident or the person filing on their behalf, and did not provide for anonymous submissions. A resident reported that while grievance forms were available near the nurse's station, anonymity was not an option, as the facility required the resident's name on the form to address the grievance. These findings demonstrate that the facility did not provide residents with the ability to file grievances anonymously, nor did it make grievance forms and information about the grievance official readily accessible.
Failure to Update Care Plan for Comfort Care Status
Penalty
Summary
The facility failed to revise the care plan for a resident who had recently changed her code status to DNR with comfort care only. Despite clear documentation from the medical provider and dietician, as well as the resident's updated POLST and expressed wishes for comfort care, the care plan dated several weeks after these changes did not include any focus area, goals, or interventions specific to comfort care. Staff interviews confirmed that the resident had declined hospitalization and invasive treatments, opting instead for comfort care, and that the care plan updates were the responsibility of a specific staff member following daily meetings. Medical records showed the resident had been diagnosed with Influenza A and pneumonia, was experiencing poor appetite and low energy, and had made a clear decision, with family present, to receive only comfort care. However, the care plan was not updated to reflect these significant changes in the resident's condition and care preferences, as required by facility policy and regulatory standards.
Lack of Physician Order for Ongoing Dialysis Services
Penalty
Summary
The facility failed to ensure that a resident who required dialysis services had a current physician order for dialysis, as required by professional standards of practice. The resident, who had been receiving dialysis since August 2023 and continued to attend treatments at an off-site dialysis center three times a week, did not have a physician order for dialysis documented in her medical record at the time of review. The absence of a physician order was confirmed during a review of the resident's current orders, which showed no such order until one was entered on 4/23/25, despite the resident's ongoing dialysis treatments. The initial care plan also indicated the resident's dialysis history, but there was no evidence of a physician order for dialysis until well after the resident's admission and ongoing treatments.
Lack of Licensed Nursing Home Administrator
Penalty
Summary
The facility failed to comply with the participation requirements for long-term care facilities by not appointing a licensed Nursing Home Administrator with an active license for the State of Montana. This deficiency arose after the interim Director of Nursing Services, who was expected to renew her contract and assume the administrator role, did not proceed with the contract due to failed negotiations. Her last day of employment was on December 27, 2024, leaving the facility without a licensed Nursing Home Administrator since that time. The report highlights that the facility considered having the interim Chief Executive Officer and another staff member share the roles of Nursing Home Administrator and Director of Nursing, or each filling one of the roles. However, both staff members expressed their unwillingness to work the additional hours required to fulfill both roles simultaneously. The State Operations Manual, Appendix PP, specifies that the Director of Nursing must be full-time, and fulfilling both roles would necessitate working beyond full-time hours. This lack of a licensed administrator may negatively affect all residents at the facility.
Failure to Employ Licensed Administrator
Penalty
Summary
The facility's governing body failed to employ a licensed administrator in the State of Montana, affecting all residents due to the lack of an administrator and resulting in the facility not being in substantial compliance. Staff member A, the Director of Nursing, applied for a license but had not yet received it, and the facility had not advertised for the open administrator position. Staff member B, the Interim Chief Executive Officer, confirmed that the facility had been without a licensed administrator since December 2024, following the departure of the interim Director of Nursing Services, whose contract negotiations fell through. The facility's policy requires a licensed state administrator to manage the facility, but no such individual was listed in the facility's Key Personnel Contact List. The State of Montana's online license verification did not show a license for the appointed administrator. Despite multiple attempts by the Certification Bureau to contact staff member B regarding the appointment of a licensed administrator, no response was received. This ongoing failure to employ a licensed Nursing Home Administrator prevented the facility from complying with federal regulations.
Failure to Conduct Monthly QAPI Meetings and Maintain Required Committee Members
Penalty
Summary
The facility failed to adhere to its plan of correction following a survey conducted on December 3, 2024. Specifically, the Quality Assurance and Performance Improvement (QAPI) committee did not meet monthly as required, with no meeting held in February 2025. This lapse was confirmed during an interview with a staff member who stated that the February meeting was not rescheduled, and the next meeting was planned for the third week of March 2025. A review of the QAPI Committee Minutes from December 2024 and January 2025 showed no documentation of a meeting in February 2025. Additionally, the facility did not have a licensed Nursing Home Administrator employed as of late December 2024, which resulted in the QAPI committee lacking the necessary staff participation as mandated by the Centers for Medicare and Medicaid Services. The facility's plan of correction, dated January 6, 2025, required audits to be presented to the QAPI team monthly to maintain compliance. However, the absence of an administrator meant the committee did not include the required positions, such as the director of nursing services, the medical director or designee, at least three other staff members including an administrator or individual in a leadership role, and the infection preventionist, as outlined in the State Operations Manual, Appendix PP, for F868.
Privacy Breach During Wound Care Procedure
Penalty
Summary
The facility failed to ensure privacy during a medical procedure for a resident in the dementia unit. During an observation, a staff member conducted wound measurement and ointment application on a resident seated in a recliner in the open television room, in full view of two other male residents. The staff member did not ask the resident to move to a private area but instead proceeded with the treatment in the common area. The staff member traced the wound on the resident's heel/lower leg area using a piece of paper and applied ointment to the resident's legs and forearms. Interviews with other staff members indicated that wound care should not be performed in public areas and that the resident sometimes does not cooperate with moving to a private room for treatment.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that a resident with individualized care needs related to falls had appropriate interventions implemented and maintained. The resident, who had a history of falls and was identified as having potential for falls due to weakness and poor balance, experienced multiple falls in October and November 2024. Despite a nursing note on 10/7/24 indicating a request for tread tape to be placed in the resident's bathroom, the care plan was not updated to reflect this intervention until 10/14/24. However, during an observation on 12/3/24, it was found that the tread tape was not in place as per the care plan update. Following falls on 11/15/24 and 11/17/24, the resident's care plan was not revised to address the root causes of these incidents. The lack of timely updates and implementation of the care plan interventions contributed to the resident's continued risk of falls. The facility's failure to ensure that the care plan was accurately updated and interventions were implemented as planned resulted in a deficiency in providing care that promotes the resident's well-being and prevents further falls.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement and maintain fall prevention interventions for a resident with a history of falls and specific care needs. The resident experienced multiple falls in October and November 2024, despite having a care plan that required assistance during transfers and the use of tread tape for improved traction. The care plan was not consistently updated following each fall, and the recommended interventions, such as the placement of tread tape in the bathroom and near the bed, were not implemented. The resident's care plan initially instructed staff to provide assistance during transfers, but it also noted that the resident expected staff to do all the work, which increased the risk of falls. Despite this, the resident was left alone during transfers, leading to falls. The facility's failure to update the care plan and implement the recommended interventions, such as tread tape, contributed to the resident's continued falls and injuries, including skin tears.
Deficiencies in Elopement and Fall Risk Management
Penalty
Summary
The facility failed to identify and manage the elopement risk for a resident, leading to an incident where the resident left the facility unsupervised. Despite previous indications of the resident's desire to leave, such as requests to visit a friend and an attempt to exit the facility, no elopement assessment was conducted. The resident, with a fluctuating BIMS score indicating moderately impaired cognition, managed to leave the facility undetected and was found hours later in a field, suffering from hypothermia and abrasions. The facility's response included applying a wander guard and conducting visual checks, but there were delays in transferring the resident to a more secure unit, and monitoring of the wander guard was not documented until weeks later. The facility also failed to implement and update fall prevention interventions for another resident, who was identified as high risk for falls upon admission. This resident experienced multiple falls, including two with major injuries, without adequate modifications to their care plan. Although some interventions were noted, such as assisting with transfers and keeping a bathroom light on, these were not consistently documented in the care plan. After a significant fall resulting in hospitalization, no new interventions were added to the care plan upon the resident's return. The lack of effective and timely interventions for both elopement and fall risks highlights deficiencies in the facility's ability to prevent accidents and ensure resident safety. The failure to conduct proper assessments, document interventions, and update care plans contributed to repeated incidents and injuries for the residents involved.
Privacy Deficiencies in Shared Bathrooms and During Personal Care
Penalty
Summary
The facility failed to provide sufficient privacy for residents using shared bathrooms and during personal care. Resident #17 reported that the shared bathroom with a neighboring resident had a broken sliding pocket door, which had been replaced with a curtain. This situation had persisted for over a year, causing privacy concerns as the neighboring resident, who had severe cognitive impairment, would often pull the curtain open without knocking. Staff interviews revealed that no maintenance order had been placed for the broken door, and some staff believed the door was unfixable, while others stated it could be repaired by ordering new tracks. Additionally, the facility failed to ensure privacy during personal care for resident #23, as staff member M did not pull the privacy curtain around the bed or close the door while providing care. The resident's roommate was present during this time. Observations also showed that privacy curtains in four rooms had significant gaps, ranging from 32 to 50.5 inches, which compromised visual privacy. Staff interviews indicated that housekeeping was responsible for the curtains, and agency staff were unaware of whom to report the issue to.
Failure to Provide and Document Restorative Nursing Services
Penalty
Summary
The facility failed to provide and consistently document restorative nursing services intended to improve or maintain mobility for three residents. Resident #13, who has receptive and expressive aphasia secondary to cerebral palsy, was observed in a specialized wheelchair with mild muscular spasticity and contractures. Staff interviews revealed inconsistencies in completing and documenting restorative exercises, with missed opportunities for services on multiple dates. The electronic medical record showed a physician's order for daily passive range of motion exercises, but the restorative flow sheet lacked detailed treatment information and a legend to define completion indicators, making it difficult to confirm the extent of missed services. Resident #31, who was discontinued from outpatient occupational therapy, was supposed to continue specific exercises four times per week. However, staff interviews indicated that no restorative exercises were being provided, and there were no guides or directions for staff on the memory care unit. Resident #46 expressed a desire to walk more and noted increased weakness. Despite having an order for range of motion exercises, the electronic medical record showed discrepancies in the frequency of the tasks to be completed. Staff interviews confirmed that restorative care tasks were not consistently completed or documented.
Failure to Provide Food at Palatable Temperature
Penalty
Summary
The facility failed to provide food at a palatable temperature for three of the sampled residents. During an observation, it was noted that food had been sitting unattended on the steam table with lids on, and the temperature of the chicken was recorded at 123.9 degrees Fahrenheit. Additionally, there were no insulated plate bases under the plates, and the food temperatures ranged from 112.9 to 125 degrees Fahrenheit. Staff members acknowledged that the plates were usually warmed before food was placed on them, but this procedure was not followed consistently. Residents reported that their food was often cold, and staff members were aware of these complaints. Interviews with residents revealed consistent dissatisfaction with the temperature of their food. One resident mentioned that the vegetables were consistently cold, and another stated that the hot food was lukewarm. Staff members confirmed that they were aware of the residents' complaints about cold food. The observations and interviews indicate a failure in maintaining food at a palatable temperature, affecting the quality of care provided to the residents.
Failure to Update Care Plans for Elopement and Fall Risk
Penalty
Summary
The facility failed to update a resident care plan in a timely manner for elopement and failed to revise a resident care plan to show effective fall risk interventions following repeated falls with injury. Resident #31 eloped from the facility on three occasions, and although a wander guard was placed on the resident's wrist after the first elopement, the care plan was not updated to reflect these incidents until nearly three months later. Additionally, the care plan inaccurately noted the date the resident was moved to the memory care unit. Staff were also unaware of the requirement for hourly visual wellness checks, indicating a lack of communication and proper documentation. Resident #50, identified as high risk for falls upon admission, experienced four falls, including two with major injuries, within a three-month period. Despite these incidents, the resident's care plan only listed two active fall interventions during this time. Interviews with staff revealed that fall risk assessments and care plan updates were not consistently or promptly conducted, and fall prevention strategies were not adequately documented or implemented. This lack of timely and effective care plan updates contributed to the resident's repeated falls and injuries.
Failure to Monitor and Control Refrigerator Temperatures
Penalty
Summary
The facility failed to monitor and control the temperature of personal resident room refrigerators, leading to unsafe food storage conditions for two residents. During observations, the refrigerator in one resident's room was found to be at 55 degrees Fahrenheit, containing seven cartons of milk. The resident stated that the facility managed the refrigerator temperatures and cleanliness, but a staff member was unsure of the safe temperature range. Another resident's refrigerator was observed at 50 degrees Fahrenheit, which is within the Danger Zone for bacterial growth. The resident also stated that the facility was responsible for cleaning and temperature monitoring. Multiple staff members provided conflicting information about who was responsible for managing the refrigerator temperatures, indicating a lack of clear protocol and accountability. The facility's policy requires that dormitory-sized refrigerators in resident rooms maintain a temperature at or below 41 degrees Fahrenheit and that Environmental Services staff record these temperatures weekly. However, the policy was not followed, as evidenced by the unsafe temperatures observed and the absence of a thermometer in one of the refrigerators. Staff interviews revealed confusion and lack of knowledge about the proper procedures for monitoring and maintaining refrigerator temperatures, further contributing to the deficiency in ensuring food safety for the residents.
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What surveyors actually found near you
We read the citations issued around you in the last 12 months — including the immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wolf Point
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valley View Home | 29.1 mi | ★★★★★ | 21 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.