Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gallatin Rest Home during CMS and state inspections, most recent first.
Opened food items were found in kitchen dry storage and refrigeration without open dates and, in some cases, not properly sealed. Surveyors observed partially used flour, spices, cereal, milk, frozen hamburger patties, Cream of Wheat, quick oats, garlic, and Caesar dressing stored without dating, while staff stated opened items should be dated for stock rotation and were unsure of storage timeframes. The facility policy required food items to be labeled, dated, and stored using FIFO.
A facility failed to protect residents from abuse and neglect involving agency staff and another resident. An agency worker physically grabbed and forced a resident into a seated position after yelling at him, a contract CNA was verbally abusive to one resident and refused care to another because of speech difficulty, and another agency employee repeatedly told a resident to shut up and used derogatory language despite the resident’s dementia-related behavioral needs. The report also described a resident-on-resident incident in which one resident threatened and struck another, leaving a bruise near the victim’s eye.
The facility failed to thoroughly investigate multiple abuse allegations involving residents and a contract CNA. Records did not show psychosocial follow-up, increased supervision, counseling, care plan revisions, or other documented measures after incidents involving resident-to-resident altercations, verbal abuse, neglect, and physical abuse. Staff also could not show that other residents were assessed for possible impact from the contract CNA's behavior.
A resident with moderate cognitive impairment and wandering/exit-seeking behaviors was placed on a wander guard alarm, but the record lacked a documented risk-benefit assessment and informed consent. Staff also failed to fully respond when a door alarm sounded, as the area outside the door was not checked for an exiting resident even though staff knew residents had used that door before and policy required a visual scan of the surroundings.
Staff failed to follow infection control practices during ostomy care and peri-care for a resident with an ostomy, including missed hand hygiene and improper glove use. During med pass for a resident with DM, staff did not disinfect the glucometer with the required EPA wipes and did not perform hand hygiene after glove removal. Staff also did not use the required gown and mask PPE during care for a resident on EBP who had a groin wound and suprapubic catheter, and staff interviews showed confusion about EBP requirements.
The facility failed to implement and maintain an effective behavioral health training program for all staff. Staff reported they had not received training on behavioral health services, suicide attempts, or suicidal ideations, and some did not know the protocol if a resident attempted suicide or voiced suicidal thoughts. After a resident’s ER discharge, verbal coaching was reportedly given about the resident’s safety plan, but the facility could not provide behavioral health training or in-service documentation when requested.
Failure to use and document CPAP/BiPAP therapy: A resident with OSA and a physician order for nightly BiPAP reported not using the machine because an electrical part was missing. Staff said missing parts should prompt removal from use, provider notification, and charting, but MAR entries were coded to "Other/See Progress Notes" and the progress notes contained no documentation about the CPAP/BiPAP use or the missing power cord.
A resident was observed in bed with two upper side rails raised, but the record lacked a bed rail safety assessment and informed consent from the resident’s representative. The chart included a physician order for the rails, and the resident had severe cognitive impairment with a BIMS score of 3. Staff stated the assessment and consent were not completed because the resident was receiving hospice services, and no supporting documentation or bed rail policy was provided by the end of the survey.
A resident with depression, anxiety, and suicidal thoughts did not receive timely behavioral health services after a provider ordered therapy. Staff reported the referral process lacked follow-up, paperwork was left on a desk, and the resident did not see counseling until weeks later. The resident also described prior suicide attempts, ongoing loneliness, and difficulty functioning when depressed.
The facility failed to address and document pharmacist-identified medication review irregularities for two residents. One resident had a recommendation for an AIMS assessment due to Seroquel use, but the record showed only one AIMS assessment completed. Another resident had a recommendation to clarify the mirtazapine diagnosis because it was being used for insomnia and duplicated zolpidem therapy, but the chart lacked documentation explaining why the indication was not changed or why the medication was continued for insomnia.
The facility failed to document staff education on the risks and benefits of the COVID-19 vaccine and failed to maintain COVID-19 vaccination status records for all staff. Staff stated they were not asking staff about COVID status because the vaccine was no longer mandatory, no education was being provided, and vaccination status was only tracked if self-reported. When surveyors requested records for one staff member, no documentation was provided before the survey ended.
Two residents experienced the development and worsening of Stage II and Stage III pressure ulcers due to inconsistent wound care, lack of regular repositioning, incomplete documentation, and failure to use prescribed preventive devices. Staff did not consistently follow care plans or perform required interventions, resulting in chronic pressure injuries.
The facility did not update care plans for three residents after significant changes in their care needs, including removal of a urinary catheter, multiple unwitnessed falls, and resolution of a UTI. Care plans continued to reflect outdated information and lacked documentation of new interventions, with staff unable to explain the omissions.
Surveyors observed multiple failures in infection prevention, including staff not performing hand hygiene before and after medication administration, not changing gloves between clean and dirty tasks, and not cleaning medication equipment. Unsanitary storage of tube feeding supplies, unclean respiratory equipment, and non-cleanable floor mats were also noted. Staff lacked documented hand hygiene education, and there was no policy for cleaning suction equipment.
A resident was administered multiple psychotropic medications, including Seroquel, olanzapine, and sertraline, for conditions such as sleeplessness, agitation, and mild dementia with psychotic disturbance, without documented evidence that the risks and benefits were explained to the resident or their representative. Staff interviews confirmed inconsistent completion of consent forms, and no documentation was available for review during the survey.
A resident with multiple unwitnessed falls did not have root causes identified or individualized fall prevention strategies implemented. Staff reported needing more training in root cause analysis, and care plans only included general interventions rather than those tailored to the specific circumstances of the falls.
A resident requiring dialysis did not have appropriate facility policies, physician orders, or monitoring in place for dialysis care and transportation. Staff were unaware of communication protocols with the dialysis center, and the facility lacked a contract with the dialysis provider. Documentation of pre- and post-dialysis monitoring was absent, and the only record was a care plan entry and ambulance transport form.
A resident with mobility and speech difficulties reported several hundred dollars missing from her purse. The facility partially reimbursed her and notified law enforcement, but did not interview potential witnesses, other residents, or investigate further to determine if others were affected or if there was a trend of missing items.
The facility failed to provide meals within a 14-hour window between dinner and breakfast and did not offer bedtime snacks to residents. Observations showed a 15-hour gap between meals, and residents reported not being offered snacks, although they were available at the nurses' station. Staff confirmed snacks were not routinely offered, and there was no documentation of resident approval for mealtime hours.
The facility did not implement and monitor measures to prevent Legionella growth in water systems. An ice/water dispenser was found dirty and uncleanable. Staff interviews revealed a lack of documentation and implementation of the water management plan, despite having a binder for it. The facility's plan required documentation and monitoring, which was not effectively done.
Opened Food Items Were Not Labeled or Properly Stored
Penalty
Summary
The facility failed to ensure opened food products were labeled with the date opened and failed to properly store opened food products after opening. During observations of the kitchen dry storage and cold storage areas, surveyors found an open, unsealed 25-pound bag of flour with about one quarter of the contents remaining and no open date, several partially used bulk spice containers with no open dates, a rolled-closed bag of dry oat cereal stored on a preparation shelf with no open date, and three opened gallons of milk in the refrigerator with no open dates. Surveyors also observed an open box of frozen hamburger patties in an unsealed manufacturer's plastic bag exposing the patties to air, with no open date. On a later observation, surveyors found one open box of Cream of Wheat stored on a preparation shelf with about one fourth of the contents remaining and no open date, one open container of quick oats with no open date, and refrigerated containers labeled Garlic and Caesar Dressing with remaining product and no open dates. During interview, staff stated opened food products should be labeled with the date opened to ensure proper stock rotation and prevent use of outdated food products, and one staff member stated spices could be stored after opening for about a year while another was unsure how long opened dry cereals would be kept. The facility policy required all food items to be appropriately labeled and dated and stored using FIFO inventory management.
Abuse, verbal abuse, and neglect involving agency staff and one resident-on-resident assault
Penalty
Summary
The facility failed to ensure a resident was free from physical abuse by agency staff when NF2 was observed grabbing resident #27 by the arm and directing the resident into a seated position. Staff member N reported that NF2 was trying to prevent resident #27 from standing, yelled at the resident to sit down, grabbed the resident by the arm, forced the resident into a seated position, and did not let go. Staff member N also reported that NF2 made a hand gesture as if reaching for an imaginary handgun. The facility investigation substantiated the allegation of abuse, and records showed prior concerns had been raised about NF2's behavior, including lack of motivation, attitude, insubordination, and prior resident-care concerns communicated with the travel agency. The facility also failed to ensure residents were free from verbal abuse by agency staff and from neglect of care. A contract CNA was reported to have been verbally abusive to resident #39 and refused to provide care to resident #13 because resident #13's speech was difficult to understand. The facility investigated and determined verbal abuse had occurred. Resident #39 stated she remembered an incident with a CNA being verbally abusive, while resident #13 did not remember the issue. The report also noted the facility failed to ensure the staff member had the necessary training, oversight, and skills to address resident care needs and prevent abuse. In another incident, two staff members reported that agency employee NF3 entered resident #60's room and repeatedly told her to shut up, told her she had a severe migraine, and told her to grow up, act like an adult, and stop yelling. The facility verified the allegation and removed NF3 from duty. Resident #60 had a diagnosis of unspecified dementia with behavioral disturbance, and her care plan called for calm approaches, explanation before care, and time to adjust. The report also described an incident in which resident #46 threatened resident #59 with statements about smacking and punching him, and staff later found a resolving bruise near resident #59's right eye; resident #59 stated he had been hit by resident #46.
Incomplete Abuse Investigations and Missing Resident Follow-Up
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse for 7 of 8 residents sampled for abuse, and the investigations did not document ongoing actions taken for resident well-being, resident-specific interventions, care plan revisions, or other measures to prevent recurrence. For residents #37 and #55, a facility-reported incident showed the two residents were involved in a physical altercation without injuries; staff separated them and completed initial assessments, and resident #55 was later transferred to another facility. However, resident #37 stated that no one followed up with him and no one told him to stay away from resident #55. The record review for residents #27, #37, and #55 did not show increased supervision, emotional support, counseling, psychosocial follow-up, monitoring of interactions or behavioral changes, or care plan revisions after the incidents. For resident #27, a contract staff member was observed grabbing the resident by the arm and directing the resident into a seated position. The facility substantiated abuse and terminated the agency staff member, but there was no evidence of psychosocial monitoring, care planning, or revision of care after the event. For residents #13 and #39, the facility determined a contract CNA was verbally abusive to resident #39 and neglectful with resident #13, and the CNA's contract was terminated, but the report did not show that the facility attempted to determine whether other residents were affected by the CNA's behavior. For residents #46 and #59, resident #46 threatened to smack and punch resident #59, and later resident #59 was found with a resolving bruise near the right eye and stated he had been hit by resident #46; resident #46 was moved to another hall and counseled, but staff could not describe what was done to ensure no other residents were affected by the CNA's behavior.
Wander Guard Consent and Door Alarm Response Failures
Penalty
Summary
The facility failed to assess the risks and benefits of using a wander guard alarm and failed to obtain informed consent for one resident who had wandering and exit-seeking behaviors. The resident had a BIMS score of 8, indicating moderate cognitive impairment, and the MDS coded wandering as present with significant risk of entering a potentially dangerous place and intruding on others' privacy or activities. A physician order dated 5/17/26 directed use of a wander guard alarm related to exit-seeking behavior, and the record showed an elopement assessment identifying the resident as at risk for elopement, but there was no documentation of a risk-benefit evaluation or informed consent from the resident's representative. Staff members stated they were not familiar with a wander guard alarm risk-benefit assessment or consent process, and the facility policy required identification of risks and use of alarms only when benefits outweighed risks. The facility also failed to ensure staff checked the outside of a door when its alarm sounded. During observation, an alarm at door 8 activated, and a staff member looked down the hallway and went to the nurse's station but did not check the door or outside area to see whether a resident had exited. Staff later stated that when a door alarm went off, they were supposed to check whether a resident was outside and safe, and another staff member said the door should be visually inspected, including the outside area, because residents had gone through that door before. The facility policy for door alarm activations directed staff to scan the immediate surroundings, hallways, and parking lots through windows or open doors to check for any exiting resident.
Infection Control Failures During Ostomy Care, Glucometer Use, and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow infection control practices during ostomy care and peri-care for a resident with an ostomy bag. During observation, staff entered the room and donned gloves without performing hand hygiene, changed gloves and put on a gown without hand hygiene, and later donned new gloves again without cleaning hands after removing dirty gloves. The staff member emptied the resident’s ostomy bag into a trash bag, cleaned the bag, and then washed hands before continuing care. While providing body care, the staff member cleaned the resident’s body with a warm, soapy washcloth and wiped from the top of the groove of the buttocks toward the vaginal area. The staff member later stated she did not perform hand hygiene as required, and another staff member stated staff were expected to sanitize or wash hands upon entering a resident’s room and before donning gloves and after taking them off. During medication administration for a resident with diabetes, staff did not disinfect the resident’s glucometer before use and did not use EPA wipes to disinfect it after use. The resident’s individual glucometers were stored together in the same white basket in the medication cart, touching each other. After removing gloves, staff did not perform proper hand hygiene before preparing the resident’s medication. The staff member stated that alcohol did the same thing as the required disinfectant, and another staff member stated the orange top EPA wipes were supposed to be used to clean residents’ glucometers, not green top wipes. Enhanced barrier precautions were not followed for a resident with a wound in the right groin and a suprapubic catheter. A gown sticker on the resident’s name plate indicated enhanced barrier precautions, but staff changing the wound dressing and staff assisting the resident with dressing and morning care were not wearing isolation gowns or masks during the care. Staff interviews showed uncertainty about what enhanced barrier precautions required, and several staff stated they did not remember receiving education on the topic. A staff member who said training had been provided also stated he did not monitor adherence to enhanced barrier precautions to determine whether additional education was needed.
Behavioral Health Training Not Implemented
Penalty
Summary
The facility failed to implement and maintain an effective behavioral health training program for all staff, as required by the facility assessment. During interviews, staff members reported they had not received behavioral health training and did not know the protocol for a resident who attempted suicide or voiced suicidal ideations. One staff member stated they were not aware of any education regarding suicide attempts or ideations, and another stated they had not received any education or training at the facility. After resident #14 was discharged from the emergency room, staff member B stated verbal education and verbal coaching were provided to staff regarding the resident’s safety plan. A request for behavioral health training and in-service documentation was made, but the facility could not provide the requested documentation by the end of the survey.
Failure to Use and Document CPAP/BiPAP Therapy
Penalty
Summary
The facility failed to follow professional standards of practice when it did not use a resident’s CPAP/BiPAP equipment, did not notify the resident’s provider, and did not document the reason for the non-use of the therapy for 1 of 15 sampled residents. The resident had a diagnosis of obstructive sleep apnea and a physician order dated 2/2/26 for BiPAP each evening. During interview, the resident stated she was not using her CPAP/BiPAP machine because an electrical part was missing and she could not say how long the machine had been unusable. A staff member stated that when working evening shifts, it was her responsibility to apply the resident’s CPAP mask at bedtime, and that if parts were missing she would remove the equipment from use, notify the provider, and document the circumstances in the resident’s chart. Review of the MAR showed multiple charted entries for CPAP/BiPAP use coded as “Other/See Progress Notes,” but the nursing progress notes for the reviewed periods did not contain any notes related to the resident’s CPAP/BiPAP use. A request for documentation related to the missing power cord for the resident’s CPAP machine produced no documentation by the end of the survey.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to assess the safety and appropriateness of bed rail use and failed to obtain informed consent for the use of two upper side rails for resident #49. During an observation on 6/16/26 at 8:12 a.m., resident #49 was seen in bed with two upper side rails raised. The resident’s electronic health record included a physician order dated 7/22/25 for "Bed Rail - 2 upper rails for safety and repositioning." The resident’s quarterly MDS assessment with an ARD of 4/16/26 showed severe cognitive impairment with a BIMS score of 3. During interviews, staff member A stated the facility did not complete a bed rail safety assessment or obtain informed consent because the resident was receiving hospice services. Staff member B stated the facility should have documentation supporting bed rail use, including a safety assessment and informed consent from the resident or representative. Review of the record did not show documentation evaluating the risks and benefits of bed rail use or informed consent from the resident’s representative. Staff member A also stated the facility did not have any policies pertaining to bed rails because they do not use them. A request for supporting documentation, including a bed rail safety assessment, informed consent, and facility policies, was made on 6/16/26, and no documentation was provided by the end of the survey.
Delayed Behavioral Health Referral Follow-Through
Penalty
Summary
The facility failed to obtain necessary behavioral health services for a resident with depression, anxiety, and a history of suicidal behavior. The resident stated she had previously attempted suicide by hanging herself with her call light and reported that the call light had been removed, leaving only a short cord protruding from the wall. She also described significant personal losses, including the death of her husband and son, and said loneliness and depression were ongoing concerns. She reported seeing a psychiatrist, an outside counselor, and a nurse practitioner for medications. Staff interviews showed there was no clear follow-up process for mental health referrals and that referrals were not consistently tracked or delivered. One staff member stated she was responsible for coordinating mental health referrals but did not have a follow-up process and that there was no facility policy or procedure for following up on mental health referrals. She stated the resident’s referral paperwork was stacked on her desk and that a referral placed in March was missed until later. Another staff member stated she was not aware of an order for in-house counseling dated 3/20/26 and that the resident did not see a counselor or psychiatrist until after the emergency room visit for suicidal ideation. Record review showed a provider order dated 3/20/26 for referral to therapy for depression and anxiety, and a provider note documented that the resident had sadness related to a family event, stress and conflict with her roommate, and intermittent suicidal thoughts without a plan. The note also stated the facility had reached out to the counselor who came to the building, but the referral had not yet gone through. The resident’s first counseling appointment did not occur until 5/27/26, more than ten weeks after the referral order. Staff also reported the resident voiced suicidal ideation on 5/13/26, was sent to the emergency room, and was discharged the same day with a safety plan.
Failure to Address Pharmacist Medication Review Irregularities
Penalty
Summary
The facility failed to ensure that all irregularities identified by the pharmacist during the monthly medication regimen review were addressed and documented in the residents’ medical records for 2 of 15 sampled residents. For one resident, the February 2026 consulting report noted that an AIMS assessment was needed due to Seroquel use, but the electronic health record showed only one AIMS assessment completed during the review period, with no other assessments documented. For another resident, the February 2026 consulting report stated that the diagnosis for mirtazapine should be clarified because it was being used for insomnia, an off-label indication, and because of duplication of therapy with zolpidem; the resident also had a diagnosis of anxiety that may have been more appropriate. The resident’s order for mirtazapine remained active for unspecified insomnia, and nursing progress notes and a physician progress note did not document a rationale for not changing the indication or for continuing the medication for insomnia. During interview, staff member B stated she managed the medication regimen review process and acknowledged she did not have documentation showing the nursing recommendations were completed or why they were not completed, and the facility policy required the pharmacist to document identified irregularities.
Missing COVID-19 Vaccine Education and Staff Vaccination Documentation
Penalty
Summary
The facility failed to maintain documentation of staff education on the risks and benefits associated with the COVID-19 vaccine and failed to document the COVID-19 vaccination status for all staff members. During an interview, staff member A stated that staff were not asked about their COVID status because the vaccine was no longer mandatory and that no education was provided to staff regarding COVID vaccines. During another interview, staff member G stated the facility was not tracking COVID-19 status documentation unless it was self-reported by staff. When surveyors requested the COVID-19 vaccination status, consent or declination, education, and administration records for staff member K, no documentation was provided before the end of the survey.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development and worsening of pressure ulcers for two residents. One resident was observed with a wound dressing on her right heel but had an open area on her coccyx without a dressing during morning care. Staff applied only a moisture barrier cream and a new incontinence brief, and the resident expressed pain when moved. Nursing progress notes indicated a history of bruising and the development of a pressure ulcer on the coccyx, which progressed to an unstageable ulcer and later a Stage III ulcer with maceration. The wound nurse was reportedly seeing the resident weekly, but dressing changes were otherwise performed by staff. Another resident was repeatedly observed lying on his back in bed with the head of the bed elevated, and his head tilted forward to the left side, with a neck pillow/collar not in use as care planned. Observations over multiple days showed the resident remained in the same position for extended periods, and staff interviews confirmed that turning and repositioning were not consistently performed every two hours as required. The resident had a history of pressure injuries and maceration on his ear and neck due to positioning and moisture, and current assessments revealed multiple pressure wounds on the buttocks, including Stage I and Stage II ulcers. The care plan specified the use of a soft cervical collar-type pillow and routine repositioning, but these interventions were not consistently implemented. Documentation and wound tracking for both residents showed ongoing issues with pressure ulcer management, including incomplete wound documentation, inconsistent use of preventive devices, and lack of adherence to turning and repositioning protocols. These failures contributed to the development and chronicity of Stage II and Stage III pressure ulcers in both residents, as evidenced by direct observation, staff interviews, and record review.
Failure to Review and Revise Resident Care Plans After Changes in Condition
Penalty
Summary
The facility failed to review and revise care plans for three residents following significant changes in their conditions or care needs. For one resident, the care plan continued to document the presence of an indwelling urinary catheter and related interventions, despite physician orders for catheter removal and multiple observations confirming the absence of a catheter. Staff interviews confirmed that the care plan was not updated to reflect the resident's current status. Another resident experienced multiple unwitnessed falls over several months, with nursing progress notes lacking documentation of contributing factors or any new interventions implemented after each fall. The care plan did not reflect all falls or show updates with new interventions following these incidents. A third resident's care plan failed to indicate the resolution of a urinary tract infection after completion of antibiotic therapy, despite physician orders and medication administration records confirming treatment. In each case, staff were unable to explain why care plans were not revised to reflect current conditions and interventions.
Infection Control Deficiencies in Hand Hygiene, Equipment Cleaning, and Environmental Sanitation
Penalty
Summary
Multiple instances of improper hand hygiene were observed during medication administration for several residents. Staff members failed to perform hand hygiene before entering resident rooms, before and after gloving, and between dirty and clean tasks. In one case, a staff member prepared and administered medications, handled food items, and used a pill cutter without cleaning it or performing hand hygiene at any point. Another staff member applied topical medications and performed personal care tasks without changing gloves or performing hand hygiene between tasks, and then proceeded to prepare medications for another resident without washing hands. Additionally, a staff member washed hands only after leaving the unit and did not perform hand hygiene between contaminated and clean activities. Environmental cleanliness and equipment maintenance were also found lacking. Observations revealed that tube feeding supplies were stored in unsanitary conditions, with bottles showing signs of spoilage and residue present on cupboard surfaces. A suction machine used for a resident had a canister filled with old, crusted liquid, indicating it had not been cleaned after use. Floor mats used for residents were found to be cracked, dirty, and not cleanable, with staff acknowledging the issue but stating it had not been addressed as a priority. A review of facility policies showed that while there was a hand hygiene policy in place, staff education files lacked documentation of hand hygiene training. Furthermore, the facility did not have a policy specific to the maintenance and cleaning of intermittent suction equipment. These deficiencies were identified through direct observation, staff interviews, and record reviews, and were found to have the potential to increase the risk of infection for all residents receiving care.
Failure to Obtain and Document Psychotropic Medication Consent
Penalty
Summary
The facility failed to ensure that a resident and the resident's representative were informed of the risks and benefits associated with the use of psychotropic medications prior to the initiation of treatment. Observation showed the resident ambulating slowly with a walker and requiring staff direction. Review of the resident's physician orders revealed administration of Seroquel, olanzapine, and sertraline for conditions including sleeplessness, agitation, and mild dementia with psychotic disturbance. Examination of the electronic health record did not show documentation that the risks and benefits of these medications were discussed with or provided to the resident or their representative. Staff confirmed that the process for obtaining consent with documented risks and benefits was inconsistent, particularly when the responsible staff member was unavailable, and no consent documents were provided for review during the survey period.
Failure to Identify Root Causes and Individualize Fall Prevention Strategies
Penalty
Summary
The facility failed to utilize a system for identifying root causes for falls and did not develop or implement individualized fall prevention strategies for a resident with a history of multiple unwitnessed falls. Observations showed the resident ambulating with a walker and requiring verbal cues to locate her room. Nursing progress notes documented several unwitnessed falls, but did not include any analysis of contributing factors or possible causes for these incidents. Review of the resident's electronic health record also failed to show documentation of root cause identification for the falls. Interviews revealed that staff felt they needed further training in root cause analysis and struggled to understand the process. The resident's care plans, while noting fall risk and listing general interventions such as assistance with ambulation, call light availability, and therapy referrals, did not include interventions tailored to the specific causes of the resident's falls. The facility's fall prevention policy outlined general risk protocols but did not ensure that individualized interventions were developed based on root cause analysis for residents who experienced falls.
Failure to Establish and Implement Dialysis Care Policies and Monitoring
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care and services for a resident requiring dialysis. There were no facility policies in place for dialysis care and management, dialysis transportation, or communication with the dialysis center. The facility also lacked a contract with the dialysis provider. Staff interviews revealed that the resident's electronic chart did not contain dialysis orders, schedules, or monitoring instructions, and staff were unaware of any communication or monitoring protocols related to the resident's dialysis care. The only documentation available was a care plan entry noting dialysis and a form for ambulance transport, with no evidence of pre- or post-dialysis monitoring by facility staff. The resident, who had a dialysis port and required regular treatments, reported that transportation was arranged prior to admission and that he did not receive meals from the facility for dialysis days. Staff confirmed that dialysis assessments and weights were performed at the dialysis center, but no information was sent back to the facility. Review of the resident's records showed only an admission weight and no ongoing monitoring or physician orders related to dialysis. The facility was unable to provide requested documentation for dialysis monitoring, relevant policies, or a contract with the dialysis provider during the survey.
Failure to Fully Investigate Resident Theft Allegation
Penalty
Summary
The facility failed to fully investigate an allegation of theft involving a resident who reported several hundred dollars missing from her purse. The resident, who had difficulty with mobility and speech, stated that she informed facility management of the missing money and was partially reimbursed, but was not told if the perpetrator was identified. Staff interviews revealed that the theft was reported to administration, and local law enforcement was notified. However, the facility did not conduct interviews with potential witnesses or other residents who may have been affected, nor did they attempt to determine if there was a pattern of missing items. The investigation was limited to the initial report, and no further steps were taken to identify the responsible party or assess the impact on other residents. Documentation showed inconsistencies in the reported amount stolen, with staff noting the resident initially reported $200 missing, later stating $300. The resident's purse was typically left unzipped due to her physical limitations, and staff acknowledged that many individuals could have accessed her room during the relevant period. Despite these factors, the facility's response was limited to partial reimbursement and advising the resident's family to provide a lockbox, without a comprehensive investigation or review of other possible victims.
Failure to Provide Timely Meals and Snacks
Penalty
Summary
The facility failed to adhere to the requirement of providing meals with no more than 14 hours between the evening meal and breakfast, as well as offering a nourishing snack at bedtime. Observations revealed that breakfast was served at 8:20 a.m., resulting in a 15-hour gap from the dinner served at 5:00 p.m. the previous evening. Several residents, including those who were blind or had mobility issues, reported not being offered snacks at bedtime, although snacks were available at the nurses' station. Staff interviews confirmed that snacks were not routinely offered, and there was a misunderstanding about the requirement to maintain a 14-hour gap between meals. Additionally, the facility did not document resident group approval of the mealtime hours, which is necessary to ensure that meal schedules align with residents' needs and preferences. Staff members indicated that residents had previously been asked about mealtime changes, but no documentation was available to support this claim. The lack of proactive snack offering and the extended gap between dinner and breakfast had the potential to affect all residents receiving meals from the dining service.
Failure to Implement Water Management Plan
Penalty
Summary
The facility failed to implement and monitor measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building's water systems. During an observation, the ice/water dispenser on the rehabilitation unit was found to be dirty, with a black film, white mineral deposits, and rust on the tray and bottom wall of the dispensing area, rendering the tray uncleanable. Interviews with staff members revealed a lack of documentation and implementation of the water management plan. Staff member H admitted to not documenting flushes or cleaning of ice machines, while staff member B acknowledged having a water management plan binder but admitted it was not fully implemented. The facility's Risk Management Plan for Legionella Control indicated that documentation should be housed in the maintenance department and monitored through infection control surveillance, but this was not being done effectively.
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Illustrative
What surveyors actually found near you
We read the 25 citations issued within 25 miles in the last 12 months — 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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bozeman
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Livingston Health & Rehabilitation Center | 23.3 mi | ★★★★★ | 25 | 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 October 2026) and official state health department websites.