Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ivy At Deer Lodge during CMS and state inspections, most recent first.
Mechanical lift transfer error resulted in a resident falling from the sling when staff did not hook it properly to the lift. The resident hit her head on the bed and floor, developed a head nodule, reported back pain and headaches afterward, and remained fearful and tense during later lift transfers.
Failure to Assess Psychosocial Harm After Lift Fall: A resident fell from a mechanical lift when the sling was not hooked correctly and later reported ongoing fear of transfers, fear of falling, and distrust of some staff. During a transfer observation, she showed visible anxiety and tension, but the chart contained no psychosocial assessments or social service notes after the incident, and an SW staff member stated no formal assessment for psychosocial harm or PTSD was completed.
Infection prevention and control failures were observed during meal service, laundry handling, and resident care. Staff entered the kitchen and served residents without proper hand hygiene between contacts, a laundry staff member removed PPE in the wrong order after handling dirty linens, and two staff members provided morning care to a resident with a wound and indwelling catheter without wearing protective gowns during high-contact care activities associated with EBP.
Failure to assess residents for self-administration of medications. Two residents were observed with oral meds left at the bedside, but staff could not produce a completed self-medication assessment for one resident and stated the other resident had neither an assessment nor a provider order. One resident was described as cognitively intact and taking multiple meds independently, while the other was found asleep with a medicine cup of pills on the bedside table and staff reported she often falls asleep before taking her meds.
Insulin pen not primed before insulin administration. During a med pass observation, an LPN prepared a resident’s insulin but stated nurses at the facility did not prime insulin pens before dialing the dose and was unsure of the policy. Other nursing staff stated priming was required, and the facility policy directed staff to prime the pen by dialing 2 units and confirming a drop of insulin appears at the needle tip.
Care Plan Not Updated for Lift Incident and Psychosocial Needs: A resident's comprehensive care plan was not revised after a mechanical lift incident and did not include interventions for her fear of falling again or her psychosocial needs. The resident said she was terrified, now double-checked lift straps during transfers, and had not been spoken to by social services or other facility staff about the incident. Staff were unaware of her fear and had not completed a psychosocial assessment.
The facility failed to provide adequate pressure ulcer care for three residents, leading to severe health consequences. One resident's wounds worsened due to inadequate assessment and treatment, resulting in severe sepsis and death. Another resident developed pressure ulcers on her heels, which were not properly offloaded or documented, leading to an inability to walk. A third resident experienced a decline in health following a hip fracture, with inadequate wound care resulting in surgical debridement and hospice care. The facility's lack of a comprehensive wound management system contributed to these deficiencies.
The facility failed to protect residents from neglect, particularly in wound care, resulting in Immediate Jeopardy deficiencies. A resident experienced worsening pressure ulcers, leading to hospitalization, while another was placed on hospice and passed away. The facility lacked a comprehensive wound management system, failing to identify, assess, document, and follow physician orders for wound care. Pain management was inadequate, leading to refusals of care and further deterioration of residents' conditions.
A resident with severe wounds experienced inadequate pain management, leading to refusals of care and worsening conditions. Despite changes in medication, pain control remained ineffective, with inconsistent documentation and assessments. The resident was eventually transferred to the hospital, where they passed away.
The facility failed to label and date food items in storage, maintain a clean kitchen environment, and ensure staff wore beard nets while serving food. Observations revealed unlabeled food in the refrigerator and freezer, unsanitary kitchen conditions, and a lack of awareness and resources for beard net use among staff.
Expired medical supplies, including needles and vacutainers, were found in the medication room, posing a risk to residents. A staff member responsible for checking these supplies admitted to missing the expired items, and the facility failed to provide relevant policies during the survey.
The facility failed to provide written notice of the reason for transfers to residents or their representatives, as required, for three residents transferred to the hospital due to acute changes in condition. Staff interviews revealed a lack of awareness about the transfer notification process, and no policy was provided to show it was operationalized. Additionally, the facility did not notify the State LTC Ombudsman about one resident's hospitalization.
The facility did not address concerns raised by the resident council, affecting all residents interested in the council's activities. Residents expressed frustration over unresolved issues like menu changes and lost laundry, which had been discussed for over a year. Staff indicated that concerns were forwarded to departments, but no follow-up occurred. Review of council minutes showed unresolved issues from February to September, with no evidence of action taken.
The facility failed to provide timely bed hold notices to two residents or their representatives during hospital transfers. Staff responsible for notifications were unaware of the requirement to inform residents or their representatives, leading to a lack of documentation and adherence to the facility's policy.
The facility failed to honor residents' rights to choose their attending physician, affecting three residents. A resident expressed dissatisfaction with being assigned to a specific physician, despite preferring another. Staff claimed VA residents were required to see the assigned physician, but the VA contract did not support this. All residents were automatically assigned to the same physician upon admission, contradicting the facility's policy on residents' rights.
The facility failed to maintain a clean and homelike environment for its residents. A resident was found in a room with a torn incontinence brief, exposed, and without proper clothing or bedding. The room had full urinals emitting a stale urine odor and a sticky floor, with flies present. The resident expressed dissatisfaction with clothing fit and cleanliness. Two other residents reported a fly infestation in the dining room, with flies landing on food and tables. A staff member admitted to not noticing the full urinals due to a busy day, indicating a lack of regular checks on residents' needs.
A resident's right to receive visitors without restriction was violated when hospice personnel were not allowed to visit without a staff member present. The staff member's presence was due to instructions from another staff member, who believed hospice personnel were negatively influencing the resident. Documentation practices were also questioned, as staff were directed to record specific observations not standard for other hospice residents.
A resident experiencing insomnia and anxiety did not receive Clonazepam as ordered by their primary care physician due to facility staff's concerns about medication interactions. Despite the physician's clarification, the order was not implemented, leading to ongoing sleep disturbances for the resident. The resident expressed dissatisfaction with the care, particularly with a staff member who discontinued medications ordered by their physician.
A facility failed to coordinate hospice services for a resident, as required by their agreement with the hospice agency. The hospice nurse reported that the facility had not held group care meetings and that a staff member was not administering medications ordered by the hospice physician. The resident's room was often dirty, and the resident was uncomfortable with facility staff listening to his conversations with hospice staff. The facility required hospice staff to be escorted during visits, which the resident disliked. A staff member expressed concerns about the resident's medication regimen and consulted a pharmacist and psychologist, who agreed to discontinue certain medications, contrary to the hospice physician's orders.
The facility failed to issue refunds within 30 days of discharge for two residents. One resident received a refund 53 days post-discharge, while another received it 41 days later. A staff member cited a change in finance companies as a reason for one delay. The facility's policy requires refunds within 30 days.
A newly hired CNA was left unsupervised before completing orientation, leading to neglect of incontinence care for five residents, increasing their risk of skin breakdown. The CNA lacked necessary skills and oversight, and staff interviews revealed concerns about his experience and inadequate training. The facility's schedule showed the CNA was left alone due to a trainer calling off, and his employment application lacked references.
The facility did not thoroughly investigate allegations of neglect, misappropriation, and abuse involving multiple residents. Incidents included a missing piece of art given to a staff member, neglect in resident care leading to unaddressed hygiene issues, and a resident being pushed onto a bed by a staff member. The facility failed to conduct necessary interviews and follow-up actions, increasing the risk of ongoing issues.
A new CNA was left to care for over 20 residents without proper training or assistance, resulting in neglect of care for several residents. The CNA was supposed to be in orientation, but the trainer was absent, and the CNA lacked basic skills. The facility's competency checklist was marked complete, but a note indicated the need for further orientation.
Mechanical Lift Transfer Error Resulted in Resident Fall and Injury
Penalty
Summary
Facility staff failed to correctly position a mechanical lift sling during a transfer, resulting in resident #5 falling from the lift to the floor. A Facility Reported Event dated 2/18/25 stated the resident fell during a bed-to-wheelchair transfer because a staff member did not hook the sling properly to the lift. The resident was found on the floor lying flat on her back next to the bed and underneath the hoyer lift, and the resident stated that the account of events was accurate. Resident #5 reported that she hit her head on the metal part of the bed and had a large goose egg on her head, with pain rated at 5. Progress notes documented a small nodule on the right middle head, upper to mid back pain, and that the resident later reported pain greater than 5. A physician note recorded that the resident reported being dropped during a transfer and having nightly headaches and back pain since the event. During a later observation, staff assisted the resident with a mechanical lift transfer, and the resident appeared tense, held tightly to the lift bars, winced when the lift moved, and became quiet when the sling was removed.
Failure to Assess Psychosocial Harm After Lift Fall
Penalty
Summary
The facility failed to identify psychosocial harm after a resident experienced a traumatic mechanical lift transfer incident and failed to provide medically necessary social services for 1 of 14 sampled residents. Resident #5 reported that during a lift transfer, staff did not hook the sling correctly, she fell out of the sling, hit the bed and then the floor, and sustained a painful head injury with a goose egg on her head. She stated she remained scared of falling from the lift, nervous when the sling was pulled out from under her, and fearful when the CNA who dropped her was involved in her care. She also stated she did not trust some staff members and had a hard time with staff who did not listen to her. During observation, resident #5 showed signs of fear during a mechanical lift transfer, including gripping the lift bars tightly, wincing when the lift moved, and becoming quiet and tense when the sling was removed. Staff acknowledged that she had shown fear after the incident and that she had expressed fear of some staff members, especially the staff member involved in the fall. However, the medical record contained no psychosocial assessments after the lift fall and no social service notes after the incident. A staff member stated she did not complete a formal assessment for psychosocial harm or PTSD and did not realize the resident was afraid during transfers or scared of falling.
Infection Prevention and Control Failures During Meal Service, Laundry PPE Removal, and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure staff performed appropriate hand hygiene during meal service. During observations in the kitchen and dining area, one staff member entered the kitchen without performing hand hygiene and delivered a drink to a resident, another staff member served a drink while wearing gloves, returned to the kitchen touching the door, did not change gloves or perform hand hygiene, and continued preparing drinks for multiple residents, and a third staff member entered the dining area and kitchen without hand hygiene and assisted four residents with meal setup without cleaning hands between residents. Staff interviews reflected confusion about when hand hygiene was required during tray delivery and resident meal service, and one staff member stated hand sanitizer should be used between residents. Facility policy stated all staff must perform proper hand hygiene to prevent spread of infection, and the hand hygiene table stated hand hygiene should occur between resident contacts. The facility also failed to ensure laundry staff removed personal protective equipment appropriately after handling dirty laundry and linens. During an observation in the laundry area, a staff member demonstrated the process she normally used when handling and cleaning dirty laundry and removed her dirty gown before removing her dirty gloves after placing dirty laundry into the washing machine, contaminating her clothing. The staff member stated the process did not seem right to her but said it was how she had been shown when she started working at the facility. Another staff member stated she was aware of the process being used but did not address the failed practice. The facility policy on PPE stated that gloves should be removed first, followed by goggles or face shield and gown, with hand hygiene performed after removing the gown. The facility further failed to ensure staff performed resident care using PPE for Enhanced Barrier Precautions. During an observation, two staff members assisted a resident with getting up for the day; the resident had a wound and an indwelling catheter. One staff member disinfected the lift and sling while the other dressed the resident and changed the brief, and neither staff member wore a protective gown while providing this care. One staff member stated PPE would be used for direct catheter care or wound care, while another staff member stated staff should wear a protective gown and gloves for anyone on EBP and that residents with wounds or catheters would be on EBP. The facility's EBP document listed dressing, bathing, transferring, hygiene, changing linens, and changing briefs or assisting with toileting as high-contact resident care activities requiring EBP awareness before care.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that an assessment was completed to determine whether residents who wanted to self-administer medications were clinically appropriate to do so for 2 of 4 observed medication administration residents. For resident #43, staff observed him receiving multiple oral medications, including finasteride, lisinopril, meloxicam, omeprazole, oxybutynin chloride, torsemide, tamsulosin, gabapentin, glipizide, vitamin B12, and vitamin D3. Staff member C left all of the medications on the resident’s bedside table and reminded him to take them before leaving the room and closing the door. Although staff member C stated the resident was cognitively intact and had a self-administration assessment completed, staff member B later stated she was looking for such an assessment but had not found one and would need to perform one to ensure the resident was safe to self-administer his medications. For resident #8, staff observed her sleeping in bed with a medicine cup approximately half full of multiple pills and capsules on her bedside table. Staff member D stated the resident did not have a self-medication administration assessment or provider order and that staff usually checked on her three or four times to make sure she took her medications because she falls asleep a lot. Staff member D then went into the room and woke the resident to take her medications. The facility policy stated residents are offered the opportunity to self-administer medications during the routine assessment, and that the interdisciplinary team should consider cognitive status and the ability to correctly name medications and know what conditions they are taken for, with results recorded on a Medication Self-Administration Assessment Form in the medical record.
Insulin Pen Not Primed Before Administration
Penalty
Summary
The facility failed to ensure staff member C primed an insulin pen before administering insulin to resident #43 during a medication administration observation. During the observation, staff member C prepared the resident’s medication and insulin but stated that nurses at the facility did not prime insulin pens before dialing the insulin dose and that she was unsure of the facility’s policy and procedure for insulin pen priming. In interviews, staff member B stated the facility policy required insulin pens to be primed before dialing the dose, and staff member D stated nursing staff were required to prime the insulin pen prior to dialing the insulin dosage, adding that she primes the pen with 5 units of insulin. The facility policy titled Insulin Pen, implemented 1/2/25, stated that after attaching the pen needle, the insulin pen must be primed by dialing 2 units and pushing the plunger until at least one drop of insulin appears on the needle tip.
Care Plan Not Updated for Lift Incident and Psychosocial Needs
Penalty
Summary
The facility failed to revise a resident's comprehensive care plan after an incident involving a mechanical lift and failed to include psychosocial interventions for the resident. Resident #5 stated that she was afraid when she did not know or trust staff, that she now double-checked the straps on the lift every time she was transferred, and that social services and no one from the facility had talked to her about the incident. She also stated that she was terrified and upset about the experience. Staff member P stated that after an incident like this, she would usually talk to the resident and enter a progress note, but she was unaware that the resident was afraid of the lift or falling again and had not completed an assessment for psychosocial well-being. Staff member B stated that each department was responsible for its section of care planning and was unsure whether the care plan had been updated to reflect the interventions from the facility's investigation of the resident's fall from the lift. The resident's comprehensive care plan addressed the mechanical lift fall, but it did not show interventions for fear of falling again or for psychosocial needs.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for three residents, leading to severe health consequences. Resident #4 was admitted with multiple wounds, which worsened due to inadequate assessment, documentation, and treatment. The facility did not follow physician orders for wound care, and there was a lack of consistent documentation of the resident's response or refusals to care. The resident's condition deteriorated, resulting in severe sepsis and death shortly after being transferred to the hospital. Resident #2 developed pressure ulcers on her heels while in the facility, which were not properly offloaded or documented. The wounds increased in size and emitted a foul odor, yet there was inconsistency in the documentation of wound measurements and assessments. The resident reported that she was unable to walk due to the wounds, which she believed were acquired in the facility, although staff claimed they were hospital-acquired. Resident #3 experienced a decline in health following a hip fracture, leading to the development of pressure ulcers. The facility failed to provide timely and adequate wound care, resulting in the need for surgical debridement. Documentation of wound assessments and physician notifications was inconsistent, contributing to the resident's decision to enter hospice care. The lack of a comprehensive wound management system and oversight in the facility led to the worsening of residents' conditions and inadequate care.
Neglect in Wound Care and Pain Management
Penalty
Summary
The facility failed to protect residents from neglect, particularly in the area of wound care, resulting in Immediate Jeopardy deficiencies for three residents. Resident #2 experienced a worsening of pressure ulcers from Stage II to Unstageable within ten days, leading to hospitalization due to foul odor, increased assistance with activities of daily living (ADLs), and edema. Resident #3's pressure ulcers worsened, leading to a hospital stay with sepsis, and eventually, the resident was placed on hospice and passed away. Resident #4 was admitted with skin tears and pressure injuries, which worsened over time, leading to hospitalization and death due to sepsis. The facility lacked a comprehensive wound management system, failing to identify, assess, document, and follow physician orders for wound care. This neglect resulted in the worsening of residents' conditions, as seen in Resident #4, who refused care due to pain and was not on a routine pain medication regimen. The facility also failed to document wound measurements and assessments consistently, contributing to the deterioration of residents' wounds. Staff interviews revealed that residents were in significant pain, refused care, and were not adequately repositioned or treated for their wounds. Additionally, the facility failed to manage pain effectively, leading to refusals of wound care and further deterioration of residents' conditions. Resident #4's pain was not adequately addressed, resulting in refusals of care and worsening wounds. The facility's documentation was inconsistent, with gaps in wound care orders and a lack of comprehensive assessments. These deficiencies highlight the facility's failure to provide necessary care and interventions to prevent the worsening of residents' conditions, ultimately leading to severe outcomes, including hospitalization and death.
Inadequate Pain Management for Resident with Severe Wounds
Penalty
Summary
The facility failed to provide adequate pain management for a resident with severe pain during pressure ulcer dressing changes and repositioning. The resident consistently reported that the pain regimen was ineffective, leading to refusals of care and worsening skin conditions. Despite multiple changes in pain medication, there was no consistent documentation of the effectiveness of these interventions, and the resident's pain ratings remained high. Interviews with staff revealed that the resident had severe wounds upon admission and experienced significant pain, which led to refusals of care. Staff noted that the resident's condition declined, and the wounds became infected, making it difficult to reposition the resident. Although changes were made to the pain regimen, the resident continued to report ineffective pain control, and there was a lack of consistent premedication before wound care. The facility's documentation showed inconsistencies in pain assessments and follow-up on pain medication effectiveness. The resident's care plan included administering analgesics and monitoring for side effects, but there was no documentation of physician orders for pain medications after a certain date. The facility's policy on pain management emphasized recognizing and managing pain, but the resident's pain was not adequately controlled, leading to a transfer to the hospital where the resident passed away.
Deficiencies in Food Safety and Kitchen Sanitation
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items in the refrigerator and freezer, as observed during an initial kitchen tour. Undated and unlabeled items included sliced cheese, unknown liquids, mixed vegetables, diced rhubarb, pepperoni, and blueberries. Staff member J confirmed that all food stored should be labeled and dated, as per the facility's policy on food safety requirements. This policy mandates that refrigerated foods be labeled, dated, and monitored to ensure they are used by their use-by date or appropriately discarded. Additionally, the facility did not maintain a clean and sanitary kitchen environment. Observations revealed dirt, grease, grime, trash, and food particles on the floor, particularly in corners and along walls. Staff member I acknowledged the absence of cleaning logs and stated that the dietary department was responsible for kitchen cleaning. Furthermore, staff member I was observed serving food without a beard net, contrary to the facility's policy requiring hair restraints to prevent food contamination. Staff member I was unaware of the requirement and noted the absence of beard nets for use.
Expired Medical Supplies Found in Medication Room
Penalty
Summary
The facility failed to remove and dispose of expired medical supplies in the medication room, which increased the risk of expired supplies being used for residents. During an observation, several expired items were found, including needles, vacutainers, syringes, and a collection swab, with expiration dates ranging from August 2023 to September 2024. A staff member responsible for checking expired medications and supplies admitted to having recently checked the room but missed the expired items. Additionally, the facility did not provide the requested Medication and Medical Supply Storage and Destruction policies during the survey.
Failure to Provide Transfer Notifications and Ombudsman Notification
Penalty
Summary
The facility failed to provide written notice of the reason for facility-initiated transfers to residents or their representatives, as required. This deficiency was identified for three residents who were transferred to the hospital due to acute changes in their conditions. The medical records for these residents did not contain the necessary written notifications. Interviews with staff revealed a lack of awareness regarding the process for issuing transfer notices, and no policy or procedure was provided to demonstrate that the process was operationalized. Specifically, staff members were unclear about who was responsible for completing immediate transfer notifications, and there was no physical form provided to residents or their representatives before transfers. Additionally, the facility failed to notify the Office of the State Long-Term Care Ombudsman about the hospitalization of one of the residents. Staff interviews indicated that notifications to the Ombudsman were sent monthly, but there was no evidence of transfer discharge information being received for the month in question. The absence of a transfer notification policy and the lack of written notifications for the sampled residents highlight the facility's failure to comply with regulatory requirements for resident transfers.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to provide evidence of acknowledging and resolving concerns raised by the resident council, affecting all residents interested in the council's activities. Interviews with residents revealed dissatisfaction with the facility's response to repeated concerns about the menu and lost laundry, which had been brought up in resident council meetings for over a year. Residents expressed frustration that their input seemed to be ignored, with one resident noting that attending council meetings felt like "talking to the wind." Staff interviews indicated that concerns from the resident council were discussed in daily meetings and forwarded to the appropriate departments, but there was no follow-up or resolution. The dietary manager had attempted to contact the corporate office regarding menu changes but received no response. A staff member mentioned a follow-up form for resident concerns, but no documentation was found. Review of resident council minutes showed unresolved issues from February to September 2024, with no evidence of action taken. The facility's policy required acting upon council concerns, but no tracking documentation was provided.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide the required bed hold notice to residents or their representatives in a timely manner during hospital transfers. Specifically, two residents were transferred to the hospital multiple times, and in each instance, the bed hold notifications were signed by a staff member but not by the residents or their representatives. There was no documentation in the medical records to indicate that the residents or their representatives were notified of the bed hold policy as required. Interviews with staff revealed a lack of understanding and communication regarding the responsibility for completing and providing bed hold notifications. Staff member H, who was responsible for completing the notifications, stated that she was unaware that the notification should be provided to the resident or their representative and believed it was only for billing or medical record purposes. Additionally, staff member G was not aware of any specific form associated with bed hold notifications. The facility's policy required written notice of the bed hold policy to be provided at the time of transfer or within 24 hours in emergency situations, but this was not adhered to in the cases reviewed.
Failure to Honor Residents' Right to Choose Physician
Penalty
Summary
The facility failed to honor the residents' right to choose their attending physician, affecting three sampled residents. Resident #2 expressed dissatisfaction with being assigned to staff member C as his physician, despite his preference for NF1. Staff member C claimed that as a VA resident, Resident #2 was required to see her, although the VA contract did not support this claim. Staff members D and B confirmed that all residents were automatically assigned to staff member C upon admission, regardless of their preferences. Resident #3 and Resident #4 also reported not being given a choice of physician upon admission, with Resident #4 unaware of his right to choose. Staff members A, F, and G acknowledged that residents were routinely switched to staff member C as their primary care physician, despite the facility's policy stating residents have the right to choose their medical service providers. Staff member F noted that in her years of employment, no resident had chosen a physician outside the facility's employed providers. The facility's practice of assigning staff member C as the primary care physician for all residents, including VA residents, contradicted the documented resident rights, leading to the deficiency.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment for three residents, with observations indicating significant deficiencies in cleanliness and resident care. Resident #2 was found in his room wearing a torn incontinence brief, exposing his left hip and glute, and was not covered with any clothing or bedding. The room contained two urinals filled with urine, emitting a stale urine odor, and the floor was sticky. Resident #2 reported that staff would only empty the urinals upon request and expressed dissatisfaction with the fit of his clothing, which he claimed had not been comfortable since his admission. Flies were observed in the room, and the resident mentioned that the floor was often dirty, but he refrained from complaining due to the staff's busyness. Interviews with visitors confirmed the room's unclean state and the resident's lack of proper clothing. Additionally, residents #3 and #4 reported a fly infestation in the dining room, with flies landing on food, tables, and walls. Resident #4 was observed using a fly swatter to kill flies in the hallway, expressing disgust at the number of flies in the dining area. Staff member D, assigned to resident #2, admitted to not noticing the full urinals due to a busy day and stated that CNAs were responsible for regular rounds to check on residents' needs. These observations and interviews highlight the facility's failure to maintain a clean and comfortable environment for its residents, affecting their quality of life and dignity.
Violation of Resident's Right to Unrestricted Visitation
Penalty
Summary
The facility failed to honor a resident's right to receive visitors of their choosing without restriction, as evidenced by the experiences of a resident receiving hospice care. On two separate occasions, hospice personnel were not allowed to visit the resident without a facility staff member present. During these visits, the staff member insisted on remaining in the room, even during personal care activities such as a bed bath, which compromised the resident's privacy. The staff member's presence was reportedly due to instructions from another staff member, who believed that hospice personnel were influencing the resident negatively. The facility's documentation practices were also called into question, as staff were instructed to document specific observations about the resident's condition, such as cleanliness and lack of complaints, which were not standard for other residents on hospice care. This documentation was reportedly directed by a staff member who was unavailable for interview during the survey. The facility's own resident rights document states that residents have the right to privacy and to meet with visitors privately, which was not upheld in this case.
Failure to Administer Prescribed Medication for Insomnia and Anxiety
Penalty
Summary
The facility failed to administer medications according to the physician's order for a resident experiencing insomnia and anxiety. The resident had requested to restart Clonazepam, which was ordered by their primary care physician, NF1. However, the facility staff, including staff member C, did not implement the order, citing concerns about the combination of benzodiazepines and opioids, and instead sought clarification from the physician. Despite NF1's clarification and intention for the resident to receive the medication, the order was not executed, and the resident continued to experience sleep disturbances. The resident expressed dissatisfaction with the care provided, particularly with staff member C, who they did not want as their physician. The resident reported that staff member C repeatedly discontinued medications ordered by NF1, contributing to their ongoing insomnia and anxiety. The resident's electronic medical record showed an order for Clonazepam, but the medication administration record lacked an entry for it, indicating a failure to follow through with the physician's orders. Interviews with facility staff revealed a lack of communication and coordination regarding the resident's medication management. Staff member C was aware of the physician's order but chose to delay its implementation, pending further review by a pharmacist. This decision was made without consulting NF1, who had already clarified the order. The facility's failure to administer the prescribed medication resulted in the resident's continued insomnia and anxiety, highlighting a deficiency in meeting professional standards for medication administration.
Failure to Coordinate Hospice Services
Penalty
Summary
The facility failed to provide hospice services in coordination with the hospice management and staff as per the hospice agreement for a resident. The hospice nurse, NF2, reported that the facility had not conducted a group care meeting in months, and staff member C was not administering medications ordered by the hospice physician, NF1. The resident's room was often found dirty, with full urinals in the garbage can. The resident expressed a desire to change physicians, which the facility did not allow, and was uncomfortable with facility staff listening to his conversations with hospice staff. NF2 and NF3, another hospice nurse, noted that the facility required hospice staff to be escorted by facility staff during visits, which the resident disliked. Staff member C expressed concerns about the resident being on opioids and benzodiazepines simultaneously and had consulted a pharmacist and psychologist, who agreed to discontinue these medications. NF1, the hospice physician, was unaware of why staff member C was altering his orders and emphasized the need for compassion in the resident's care. The facility's agreement with the hospice agency stipulated that hospice care should be authorized by hospice and delivered according to the hospice plan of care, which was not being adhered to in this case.
Delayed Refunds for Discharged Residents
Penalty
Summary
The facility failed to refund residents or their representatives within 30 days of discharge, as required. For two sampled residents, refunds were delayed beyond the stipulated timeframe. Resident #1 was discharged on January 25, 2024, but the refund of $2,000 was issued 53 days later, on March 18, 2024. Similarly, Resident #2 was discharged on March 21, 2024, and the refund of $2,655 was issued 41 days later, on May 1, 2024. Staff member A acknowledged the delays, attributing the late refund for Resident #2 to a change in finance companies during the processing period. The facility's policy mandates that refunds be processed within 30 days, which was not adhered to in these cases.
Neglect Due to Inadequate Training and Supervision of New CNA
Penalty
Summary
The facility experienced a system breakdown when a newly hired CNA was left alone before completing the orientation period, lacking necessary competencies, skills, and supervisory oversight. This resulted in neglect of incontinence care for five residents, increasing their risk of skin breakdown. The incident was reported on 5/9/24, revealing that six residents were found with dried bowel movements or urine, or wet beds, implicating staff member E in failing to provide necessary peri care. Staff member E did not complete rounds with oncoming staff and was subsequently terminated without being asked for a statement. Interviews with staff members revealed concerns about staff member E's lack of experience and inadequate training. Staff member C noted that staff member E did not possess the knowledge expected of a veteran CNA and had concerns about his employment history. Staff member F was unaware that staff member E was a trainee and noted the absence of management during the shift. Staff member G observed that staff member E appeared busy but was not performing resident checks and changes. The facility's schedule indicated that staff member E was supposed to be in orientation with a trainer who called off, leaving him to work alone. Additionally, staff member E's employment application lacked references, and his competency checklist was incomplete, with a note indicating a need for further orientation.
Failure to Investigate Allegations of Neglect and Abuse
Penalty
Summary
The facility failed to thoroughly investigate several allegations of neglect, misappropriation of property, and abuse involving multiple residents. In one incident, a resident reported a missing piece of art, which was later found to have been given to a staff member. Although a police report was filed, the facility did not conduct resident interviews or further investigate the matter internally. In another incident, a necklace was reported stolen from the same resident's room, but the facility did not follow up with additional information as requested by the police. In a separate incident, six residents were found with dried bowel movements or urine, indicating neglect in their care. The implicated staff member did not complete rounds and was no longer employed, but the facility failed to conduct skin checks or interview other residents to assess the extent of neglect. Additionally, a resident reported being pushed onto a bed by a staff member and restricted from leaving the room, yet the facility did not interview other residents who received care from the accused employee. These failures to investigate thoroughly increased the risk of ongoing neglect, abuse, or misappropriation for residents.
Inadequate Training Leads to Resident Neglect
Penalty
Summary
The facility failed to provide necessary staff training and ensure competency for a new employee, leading to neglect of care for five residents. A facility-reported incident revealed that six residents were not changed during the night, resulting in dried bowel movements or urine, or wet beds in the morning. Staff member E was identified as the individual who neglected care and failed to complete peri care for these residents. The incident report indicated that staff member E did not complete rounds with the oncoming staff and was subsequently terminated from employment. Interviews with staff members revealed that staff member E was left alone to care for 23-24 patients without proper training or assistance, as the assigned trainer called off. Staff member E expressed feeling overwhelmed and exhausted, leading to incomplete rounds. Other staff members noted that staff member E lacked basic skills expected of a veteran CNA and did not receive adequate training. The facility's schedule confirmed that staff member E was supposed to be in orientation, but the trainer was absent. Additionally, the Nurse Aide Skill Competency Checklist for staff member E was marked as completed, but a note indicated the need for further orientation and corrections.
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 17 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 Deer Lodge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Community Nursing Home Of Anaconda | 21.4 mi | ★★★★★ | 17 | 0 |
| Copper Ridge Health And Rehabilitation Center | 29.8 mi | ★★★★★ | 17 | 0 |
| Continental Care And Rehabilitation | 29.8 mi | ★★★★★ | 1 | 0 |
| Crest Nursing Home | 30 mi | ★★★★★ | 9 | 0 |
| Southwest Montana Veterans Home | 32.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.