Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Glendive Medical Center N H during CMS and state inspections, most recent first.
Failure to Assess, Classify, and Monitor Pressure Ulcers: A resident with a tibial plateau fx was placed in a knee immobilizer and later developed multiple pressure-related wounds on the ankle, heel, and great toe. Staff did not consistently assess skin under the brace, did not accurately identify or stage the wounds, and the resident’s nutrition assessment and care plan did not fully reflect the pressure injuries or wound-related needs.
Dietary manager lacked required certification or related higher education. During a kitchen tour, no documentation of advanced training was posted, and a staff member stated he did not have the CDM certificate. Another staff member said he coordinated nourishment, assessed residents, and recommended diets and textures, but did not perform kitchen sanitation tours or monitor dietary requirements; the DON and administrator agreed the facility needed a certified dietary manager.
Kitchen sanitation, food labeling, and staff hygiene failures: Surveyors observed heavily soiled equipment, fans, prep areas, carts, floors, and spice storage, along with multiple open, unlabeled, or undated food items and improperly stored products such as dented cans, food on the floor, and an unlabeled cup on the oven. Chicken was held at 73 degrees in melted ice, freezer temp logs were missing, a sanitation bucket tested over 500 ppm, and staff were observed serving food without beard nets.
Two residents were involved in an incident where one reported unwanted touching by a roommate to a nurse, but the nurse did not escalate the allegation to administration. As a result, the abuse allegation was not reported to the State Survey Agency within the required 24-hour period, only coming to light after a resident representative contacted social services.
The facility did not ensure that two residents received social services support or psychosocial assessments following allegations of abuse, such as harsh treatment and rough handling during care. Medical records lacked documentation of follow-up or evaluation by social services, despite staff acknowledging that such actions and notes were required.
Care plan not timely updated for a resident with pressure ulcers. A resident developed an open area on the right ankle after a leg brace rubbed the skin, and later had additional wounds on the right heel and right great toe. The care plan did not include all of the wounds, did not identify the immobilizer use or discontinuation, did not note PT involvement, and key interventions such as Bunny Boots, a foot cradle, and a fortified diet were added after delays.
Blood Glucose Quality Control Checks Not Properly Monitored or Documented: Facility staff lacked the knowledge and skill set to properly monitor and document quality control checks for a blood glucose testing machine, and no system was in place to ensure the checks were completed as required. Staff could not locate documentation showing when control testing was done, and the facility policy required control solution testing when the meter was first received and at least weekly.
The facility failed to complete a timely Significant Change MDS after a resident sustained a tibial plateau fracture and became non-weight bearing. The resident's MDS showed a decline from partial to moderate assistance to substantial to maximum assistance with ADLs, and the MDS coordinator acknowledged the assessment reference date was not set on time.
The facility did not submit complete PBJ information to CMS for a quarter due to a missing job code (LPN2) in the file application. This resulted in the system failing to report hours worked by LPNs, despite timecards showing 24-hour coverage.
The facility failed to update care plans for several residents to include enhanced barrier precautions and other necessary interventions. A resident with a colostomy and urinary catheter, another with a urinary catheter, and a third on tube feeding did not have their care plans updated to reflect the need for enhanced barrier precautions. Additionally, a resident at risk for skin breakdown had a physician's order for a foot cradle that was not included in the care plan. Staff indicated that care plans were only updated quarterly, contributing to these deficiencies.
The facility failed to ensure timely medication regimen reviews by a registered pharmacist and that physicians addressed pharmacy recommendations promptly. For a resident, a six-week delay occurred in addressing a pharmacist's recommendation for a gradual dose reduction (GDR). Another resident experienced a ten-week delay in addressing medication change recommendations. Additionally, the facility lacked a comprehensive policy for monthly MRRs, contributing to these delays and inadequate documentation.
A facility failed to implement a comprehensive care plan for a resident with recurrent UTIs. Despite the resident's history and ongoing treatment with antibiotics, probiotics, and cranberry pills, the care plan lacked specific goals and interventions for UTI prevention. Staff interviews indicated care plans were updated quarterly, but real-time updates were being developed.
A facility failed to document the rationale for extending a PRN lorazepam order beyond 14 days for a resident. The resident, who had memory issues, had an active order for lorazepam for anxiety, despite responding well to non-pharmacological interventions. The staff member responsible for medication reviews was unaware of the regulation, and the medication review did not identify the issue. The facility's policy required prescriber documentation for extending PRN psychotropic medications, which was not followed.
Failure to Assess, Classify, and Monitor Pressure Ulcers
Penalty
Summary
Appropriate pressure ulcer care was not provided for a resident who developed multiple wounds after a right knee injury and subsequent immobilizer use. After the resident complained that her knee popped, an x-ray was negative, but she later fell and was diagnosed with a non-displaced tibial plateau fracture. A knee immobilizer was applied and the resident was to be non-weight bearing for two to three months. From the time the brace was applied through several weeks afterward, the record did not document that the resident’s skin was assessed under the immobilizer brace. The resident later developed pressure-related injury where the brace rubbed the right ankle and lower leg. Nursing notes described an open area on the outer Achilles/ankle with purple bruising and drainage, an abrasion with scab above the ankle, and a small abrasion to the inner right ankle. The brace was left off for comfort, but later notes showed the brace was again placed on the resident and the metal bar was pushing into an edematous area on the outer ankle. Subsequent documentation identified a lateral malleolus wound with tan slough, a right medial heel blister, and an open area on the right lateral heel, but the facility failed to identify, classify, and stage the wounds accurately in the nursing documentation. The resident’s nutrition and care planning also did not consistently reflect the wounds. A significant change nutrition assessment documented the resident’s skin as intact and did not include the ankle pressure ulcers or increased caloric, protein, or fluid needs for wound healing. Later nutrition meeting documentation identified only the blister on the right ankle and did not consider the heel wound. The care plan did not include treatment for the heel pressure ulcer, did not identify the use and discontinuation of the leg immobilizer, and did not identify that PT would assist with wound care. During a later observation, staff provided treatment to two open areas on the right lower leg, while a small red/brown wound on the tip of the right great toe was observed without treatment.
Dietary Manager Lacked Required Certification
Penalty
Summary
The facility failed to ensure the dietary manager completed a certification program approved by a national certifying body or had higher education in a related field. During the initial kitchen tour on 9/8/25 at 11:56 a.m., no documentation of advanced training for the dietary manager was posted. During an interview on 9/9/25 at 3:45 p.m., staff members A, G, and K were present, and staff member G stated he did not have the CDM certificate. During an interview on 9/10/25 at 8:50 a.m., staff members E and Q were present; staff member Q said he coordinates nourishment for the facility, assesses residents, and recommends diets and textures, but does not complete kitchen sanitation tours or go into the kitchen to monitor dietary requirements. Staff member E stated that staff member K is the kitchen manager's supervisor and that she and the administrator agreed the facility needs to have a certified dietary manager.
Kitchen sanitation, food labeling, and staff hygiene failures
Penalty
Summary
The facility failed to maintain clean and sanitary conditions in the kitchen and dietary storage areas and failed to ensure food was labeled and dated in the coolers. During the kitchen tour, surveyors observed soiled coffee machine nozzles, heavily soiled juice machine nozzles and plates, three fans coated with fuzzy brown material, food debris and sticky residue under mixers and on carts, greasy and dirty food prep and spice storage areas, and a dirty floor in the freezer. Multiple food items were found open, unlabeled, undated, or improperly stored, including soup base paste, yogurt, liquid eggs, spaghetti, linguini, spices, small tubs of food, glasses of liquid, bacon, cream cheese, chili sauce, black olives, melon, pineapple, fruited Jello, cake, mixed lettuce, pepperoni, mozzarella sticks, and chicken strips. Staff member M identified food that was not labeled or dated, removed dented cans, and stated the pizza sauce was outdated. A bucket of pickles was stored on the floor, bottled water was on the floor, and an unlabeled cup of white granular substance was sitting on top of the oven. Surveyors also observed food safety and sanitation issues during service and in equipment monitoring. Chicken held in a small container placed in melted ice measured 73 degrees, and staff member M stated it should be held at 40 degrees. The small freezer was missing documented temperatures for September 4th, 6th, and 7th, 2025. One sanitation bucket tested over 500 parts per million, while staff member M stated it should be 200-400 parts per million and that three buckets should be in use. The areas near the grill, soup tureen, and pizza oven were heavily soiled with greasy black buildup, the front panel from the grill to the floor was missing, cloth fabric covered in debris was lying over gas lines under the soup tureen, and the tile grout and floor under the steam table were dirty and greasy. During dining service, staff member N served food without a beard net, and staff members G, P, and O were observed in the food service area with beards and no beard nets.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report allegations of resident-to-resident abuse to the State Survey Agency within 24 hours as required. Specifically, a resident reported to a nurse that her roommate had engaged in unwanted touching of her thigh and groin area. This initial report was made by the resident to the nurse on 9/8/24, and the resident repeated her concerns an hour later. However, the nurse did not escalate the report to administration, resulting in a delay in notifying the appropriate authorities. The incident only came to the attention of facility administration when the resident's representative contacted social services several days later to request a room change due to the unwanted touching. Upon learning of the incident, the facility reported it to the State Survey Agency, but this was not within the required 24-hour timeframe from the initial event. The facility's own policy requires immediate reporting of such allegations, but this protocol was not followed due to the breakdown in communication between nursing staff and administration.
Failure to Provide Social Services Follow-Up After Alleged Abuse
Penalty
Summary
The facility failed to provide medically-related social services to assist two residents with emotional and psychosocial support following allegations of abuse. For one resident, after an incident where a staff member spoke harshly to her, there were no progress notes or social service documentation in the medical record from the date of the incident through several weeks later. Additionally, the resident exhibited behaviors such as frequent skin picking that resulted in open areas, but there was no evidence that social services assessed or addressed the potential psychosocial causes or connection to the alleged abuse. In a separate incident, another resident was reportedly handled roughly during a transfer. There were no progress notes or social service documentation indicating follow-up with the resident after the allegation. Staff interviews confirmed that social services follow-up and documentation should have occurred, including psychosocial assessments and notes in the medical record to reflect the residents' status after the events, but these were not completed.
Care Plan Not Timely Updated for Resident With Pressure Ulcers
Penalty
Summary
The facility failed to update the comprehensive care plan within 7 days of the comprehensive assessment and failed to have it prepared, reviewed, and revised by a team of health professionals for a resident who developed avoidable pressure ulcers. Resident #6 developed an open area on the outer Achilles area of the right ankle with purple bruising related to pressure after the brace on the right leg rubbed the skin, as documented in a nurse’s note on 7/19/25. Staff member C stated she updated care plans when needed and reviewed them quarterly, but she was not sure how the wounds on the resident’s ankle caused by the immobilizer were missed. The care plan dated 8/1/25 identified an open area below the right ankle and added Bunny Boots 13 days after the pressure ulcers developed, but it did not include the right heel pressure ulcer or the wound to the right great toe. The care plan was updated on 8/14/25 when the nutrition at risk team determined a fortified diet would be appropriate for wound healing, and the foot cradle was not added until 8/12/25 after the resident developed a wound on the right great toe. The care plan also failed to identify that Physical Therapy would assist with treatment and care of the pressure ulcers and did not identify the leg immobilizer as being used or when it was discontinued. During observation on 9/11/25, staff member F provided pressure ulcer treatment to two open areas on the resident’s right lower leg, and a small red/brown wound was observed on the tip of the right great toe.
Blood Glucose Quality Control Checks Not Properly Monitored or Documented
Penalty
Summary
The facility staff failed to have the necessary knowledge and skill set related to the proper monitoring and documentation of quality control checks for a blood glucose testing machine, and a system was not in place for the checks. During interviews, staff member F stated that a blood glucose control solution test was completed daily, but not on her shift, and she did not know where to find documentation showing that a controlled test had been completed on the glucose monitoring system. Staff member B stated the blood glucose monitoring system was new and she was not sure whether the controlled test was completed weekly or monthly, and she could not find documentation showing when control testing was completed for the glucose monitoring system. On 9/11/25, staff member B confirmed the facility did not have a system in place to ensure quality control checks were being completed and documented as required by facility policy and manufacturer guidelines. Staff member B stated the facility had implemented a blood glucose quality control testing log as of 9/11/25. A request was made for blood glucose quality control documentation, but no documentation was received by the end of the survey. The facility policy for the real-time blood glucose monitoring system stated that a control solution test should be done when the meter is first received and at least once a week, among other specified times.
Late Significant Change MDS Assessment After Major Functional Decline
Penalty
Summary
The facility failed to complete a Significant Change MDS assessment within 14 days after it identified a major decline in resident #6's condition. On 6/28/25, a nursing note documented that resident #6 was diagnosed with a non-displaced tibial plateau fracture and was to wear a knee immobilizer and remain non-weight bearing for two to three months. A review of the resident's MDS with an assessment reference date of 5/8/25 showed the resident needed partial to moderate assistance with oral care, toileting, showering, removing footwear, personal hygiene, toilet transfer, transfer from bed to chair, and moving from sitting to standing. A later MDS with an assessment reference date of 7/17/25 showed the resident had declined and now needed substantial to maximum assistance with those activities. During interview, staff member C stated she had been completing MDS assessments for about one year, had not completed all of her training, and acknowledged that the Significant Change MDS assessment reference date was not set on time and the assessment was late.
Incomplete PBJ Submission Due to Missing Job Code
Penalty
Summary
The facility failed to submit complete and accurate Payroll Based Journal (PBJ) information to the Centers for Medicare and Medicaid Services (CMS) for the second quarter of the fiscal year 2024. The deficiency was identified when the PBJ Staffing Data Report indicated a failure to have licensed nursing coverage 24 hours each day. Upon review of the facility's timecards for specific dates within the quarter, it was confirmed that licensed nursing staff were present 24 hours each day. However, during an interview, a staff member revealed that a job code (LPN2) was missing from the file application, which led to the system not recognizing and reporting the hours worked by employees with this job code when the information was electronically transferred to the PBJ.
Failure to Update Resident Care Plans with Enhanced Barrier Precautions
Penalty
Summary
The facility failed to update care plans for four residents when changes in their care occurred. Resident #137, who had rectal cancer resulting in a colostomy and urinary retention necessitating a urinary catheter, was observed with an ostomy appliance and a urinary drainage bag. The care plan did not reflect the need for enhanced barrier precautions due to these conditions. Similarly, Resident #24, who had a urinary catheter, was not noted to be on enhanced barrier precautions in her care plan. Resident #14, who was on tube feeding, also had a care plan that failed to indicate the use of enhanced barrier precautions, despite the presence of a ladybug sticker indicating such precautions were necessary. Additionally, Resident #13, who was at risk for impaired skin integrity, had a physician's order for a foot cradle to prevent breakdown on the tops of her toes. However, this intervention was not included in the resident's care plan. Staff interviews revealed that care plans were only updated quarterly, which contributed to the failure to reflect current care needs. The facility's policy on Enhanced Barrier Precautions indicated that such precautions were necessary for residents with wounds or indwelling medical devices, yet this was not consistently documented in the care plans.
Failure to Conduct Timely Medication Regimen Reviews and Address Recommendations
Penalty
Summary
The facility failed to ensure that a registered pharmacist performed monthly medication regimen reviews (MRR) for residents, and that physicians addressed pharmacy recommendations and irregularities in a timely manner. Specifically, for one resident, the pharmacist recommended a gradual dose reduction (GDR) for certain medications, but the physician did not address these recommendations for six weeks. Additionally, there was no documentation indicating that a physician or pharmacist was present during the GDR discussion. Another resident's MRR showed recommendations for medication changes that were not addressed for ten weeks, and there was a lack of documentation of the pharmacist's presence during discussions. Furthermore, the facility did not maintain a comprehensive policy and procedure for monthly MRRs, which should have included documentation requirements and time frames for addressing identified irregularities. This lack of policy contributed to delays in addressing medication recommendations and irregularities, as evidenced by the absence of an MRR within 30 days of admission for another resident. The facility's policy also failed to outline steps for resolving disagreements between the pharmacist's recommendations and the attending provider's orders, as well as procedures for residents with an anticipated length of stay of less than 30 days.
Failure to Implement Comprehensive Care Plan for UTI Prevention
Penalty
Summary
The facility failed to implement a comprehensive, resident-centered care plan for a resident with a history of recurrent urinary tract infections (UTIs). The resident, who required assistance with toileting and perineal care, had been on antibiotics for UTIs and was also started on probiotics and cranberry pills for prevention. Despite these interventions, the resident's care plan did not include a focus area, goals, or interventions specifically related to the prevention of UTIs. This oversight was identified during a review of the resident's care plan dated late July 2024. Interviews with staff members revealed that care plans were typically updated on a quarterly basis, and the resident was due for her first quarterly care conference in late July 2024. However, the facility was in the process of developing a system for more real-time updates to care plans. The lack of a comprehensive care plan addressing the resident's recurrent UTIs was a deficiency noted by surveyors, as it failed to meet the resident's specific health needs.
Failure to Document Rationale for Extended Use of PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that orders for as-needed psychotropic medications did not exceed 14 days without documented rationale from the provider for one of the sampled residents. During an observation, a resident was seen walking with a walker and expressed memory issues. The resident had an active order for lorazepam 0.5 mg every four hours as needed for anxiety, which had been in place since early July and was still active by the end of the month. Interviews with staff revealed that the resident responded well to non-pharmacological interventions such as redirection and distraction techniques when anxious. The staff member responsible for medication regimen reviews was new to the role and unaware of the regulations regarding the duration of as-needed psychotropic medication orders. The medication regimen review conducted after the survey began did not identify the issue of the prolonged as-needed order. Additionally, the resident's electronic health record lacked documentation from a medical provider justifying the continued use of lorazepam beyond the 14-day limit. The facility's policy on psychotropic drug use required prescriber documentation for extending as-needed psychotropic medications beyond 14 days, which was not adhered to in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 2 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Glendive
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eastern Montana Veterans Home | 0.9 mi | ★★★★★ | 2 | 0 |
| Wibaux County Nursing Home | 25.8 mi | ★★★★★ | 14 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Glendive Medical Center N H.
100% money-back within 48 hours.
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.