Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Montana Mental Health Nursing Home during CMS and state inspections, most recent first.
Leadership failed to identify and address a nurse's ongoing cognitive and performance issues, resulting in over 50 medication errors and missed care tasks for multiple residents. Despite repeated reports from staff about the nurse's confusion, slurred speech, and unresponsiveness, supervisors did not document or investigate these concerns, allowing neglect of care to continue for several months.
The facility did not have an effective system to identify or correct undocumented medication administrations, resulting in numerous missed doses and undocumented medication checks for multiple residents. Staff failed to document reasons for missed medications as required by policy, and pharmacy oversight did not address these ongoing issues, leaving medication errors unaddressed in the medical records.
Administrative staff did not act on repeated reports of an LPN exhibiting confusion, slurred speech, and other cognitive changes, nor did they investigate or document over 50 medication errors involving multiple residents. Ongoing issues with missed medication doses, patch checks, and removals were not identified or corrected, and facility policies for medication administration and error reporting were not consistently followed.
A staff member failed to provide necessary ADL care to a dependent resident who required full assistance, resulting in the resident being left in a soiled state with dried feces on their body, clothing, and wheelchair. The staff member did not follow instructions to change the resident and left the shift without completing the task, which was identified as neglect of care.
A resident did not receive enough food and fluids to maintain their health, as surveyors found that the facility did not meet the individual's nutritional and hydration needs.
A resident experienced a severe weight loss of 27 pounds over three months, but the physician, dietitian, and representative were not promptly notified. Documentation showed delays in communication, with the physician informed only during a routine visit and the dietitian and guardian notified days later. Staff interviews confirmed the delay in recognizing and reporting the weight loss.
The facility failed to report resident-to-resident abuse allegations to the State Survey Agency within 24 hours for six residents. Incidents were reported late despite procedures requiring timely reporting through the BOUNDS system. Interviews revealed that floor staff report incidents to nurses, who then alert an abuse team via a confidential app, but delays still occurred.
The facility failed to timely complete POLST forms for two residents and did not ensure an advanced directive was in place for another. Interviews revealed that only physicians could complete POLST forms, often delaying their completion. One resident's POLST was not completed for over thirty days, and another's took almost two months. Additionally, there was no documentation of an advanced directive discussion for a third resident.
The facility failed to dispose of expired Shingrix vaccines and did not consistently monitor medication refrigerator and freezer temperatures. Temperature logs were incomplete, and expired vaccines were found in the treatment room refrigerator. Staff interviews revealed inconsistencies in monitoring practices, with missing documentation for several dates, contrary to facility policy.
The facility failed to maintain proper food safety practices in the Firefly and Glacier unit kitchens, with missing documentation of refrigerator and freezer temperatures and unlabeled food found in the freezer. Night shift nurses were responsible for logging temperatures, but logs showed numerous missing entries, indicating a systemic issue with monitoring food storage conditions.
The facility failed to ensure complete and properly labeled medical records for several residents. POLST forms were incomplete, lacking signatures, dates, and phone numbers. An interdisciplinary progress note for a resident lacked identifying information, and another resident's medication administration records were not clearly labeled with the month or year. Staff interviews revealed that only physicians were allowed to complete POLST forms, leading to delays.
A facility failed to notify a resident's guardian of a transfer to the emergency department, as required by policy. The resident was admitted to the emergency department, but there was no documentation of guardian notification. Staff confirmed the guardian should have been informed, highlighting a lapse in communication and policy adherence.
A resident left a facility against medical advice due to a lack of effective discharge planning. The resident's court commitment expired without re-commitment, allowing voluntary status. Despite expressing a desire to leave, the facility did not prepare for discharge, assuming the resident was content. Upon leaving, the resident received a three-day medication supply without proper orders, and no follow-up care or accommodations were arranged.
A resident was not administered oxygen at the prescribed rate, and the facility failed to maintain respiratory equipment properly. The oxygen cannula was found on the floor, and the concentrator's filters were dirty. The facility's policy required monthly cleaning of the filters, but documentation showed this was not completed. Additionally, there was no record of oxygen monitoring or liter flow documentation for two months.
Failure to Address Staff Member's Declining Performance Led to Neglect of Resident Care
Penalty
Summary
Leadership staff failed to ensure residents were free from neglect by not identifying, addressing, or correcting concerns related to a staff member's performance over several months. Staff member R was responsible for more than 50 medication errors affecting 11 residents, including failures to administer medications, complete glucose checks, and perform skin checks as required by physician orders. Despite these errors, the facility reported that no harm was found for the residents, but the required care was not provided as ordered. Multiple staff members observed and reported significant changes in staff member R's behavior and cognitive status, such as confusion, slurred speech, slowed gait, weight loss, and periods of unresponsiveness. These concerns were communicated to supervisory staff, but were not documented, investigated, or escalated appropriately. Staff member D, after receiving reports, only briefly observed staff member R and did not take further action unless she personally identified an issue. Other staff, including staff members E and L, also noted missed medications and cognitive changes but did not report or document these concerns to higher management. The lack of an effective system to track, investigate, and respond to repeated reports of staff member R's declining performance and health resulted in ongoing neglect of care for multiple residents. The facility leadership did not ensure that concerns about staff member R's ability to safely perform her duties were properly managed, leading to a prolonged period during which residents did not consistently receive necessary medications, treatments, or monitoring as ordered.
Failure to Identify and Document Medication Administration Omissions
Penalty
Summary
The facility failed to maintain an effective and accurate system for identifying and correcting medication administration documentation omissions for physician-ordered medications. Multiple residents had numerous undocumented medication administrations, with no explanations or reasons recorded in the medication administration records (MARs) or nursing notes. The omissions included a wide range of medications, such as antipsychotics, insulin, pain medications, and supplements, and in some cases, checks for controlled substances like fentanyl patches were not documented. Facility policy required that such omissions be identified and addressed as medication errors, but this was not done. A review of the records for 14 out of 17 sampled residents revealed repeated instances of missed medication administrations and undocumented medication checks. For example, one resident had ten missed doses of various medications, another had 25 missed administrations, and another had 59 undocumented fentanyl patch checks. In all cases, there was no documentation to explain why the medications were not administered, and the medical records did not address the errors or any potential outcomes. Staff interviews confirmed that the process for identifying and documenting these omissions was not followed, and staff responsible for pharmacy services did not consider undocumented administrations as medication errors unless specifically reported or related to narcotics discrepancies. The contracted pharmacy also failed to identify or address these ongoing concerns. Staff interviews indicated a lack of clarity regarding who was responsible for reviewing MARs for missed doses or documentation holes. Facility policies clearly defined medication omissions as errors and required immediate documentation and follow-up, but these procedures were not implemented, resulting in unaddressed medication errors for a significant number of residents.
Failure to Address Staff Performance and Medication Administration Deficiencies
Penalty
Summary
Facility administrative staff failed to act in a timely and thorough manner to address concerns regarding a staff member responsible for resident care and services. Multiple staff members reported ongoing issues with this staff member, including confusion, slurred speech, calling people by the wrong name, weight loss, and wandering, over a period of three to four months. Despite these reports, administrative staff did not investigate, document, or escalate the concerns, nor did they ensure that the staff member was following facility policies. The staff member in question was involved in more than 50 medication errors, including failure to administer medications, improper glucose checks, and incomplete skin checks, affecting 11 residents. Concerns about the staff member's cognitive status and performance were not adequately addressed or documented by supervisors. Additionally, administrative staff did not identify or act on ongoing issues related to the facility's medication administration policy, procedures, or system. Medication administration records for 12 residents showed 138 missed medications, 59 missed fentanyl patch checks, and 17 missed lidocaine removals over a two-and-a-half-month period. Staff interviews revealed uncertainty about who was responsible for reviewing medication records for missed doses, and missed doses were only considered when medications were returned to the pharmacy without explanation. The facility's policies required immediate documentation of medication administration and errors, but these were not consistently followed. The deficiencies affected a significant number of residents, with ongoing medication errors and lack of proper oversight by administrative staff. The failure to investigate, document, and address staff performance and medication administration concerns resulted in continued issues with resident care and services. The administrative staff's inaction and lack of adherence to facility policies contributed to the persistence of these problems.
Failure to Provide Required ADL Care Resulting in Resident Neglect
Penalty
Summary
A staff member failed to provide necessary activities of daily living (ADL) care to a dependent resident who required full assistance for ambulation and brief changes. Despite being instructed by a nurse to change the resident's soiled brief, the staff member did not perform the task and left the shift. The resident was later found with dried feces up his back, on his clothing, in his wheelchair, and under the wheelchair cushion. Witness statements confirmed that the staff member did not spend sufficient time to properly change the resident and that the odor of soiling was noticeable to other staff in the area. The incident was reported as neglect of care, and it was determined to be an isolated event involving this particular resident and staff member, rather than a systemic issue. The staff member in question had a history of performance issues and was on administrative leave at the time of the investigation. Facility policies reviewed defined neglect as the failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress, and included toileting as a required ADL service.
Failure to Provide Adequate Food and Fluids
Penalty
Summary
The facility failed to provide sufficient food and fluids to maintain a resident's health. This deficiency was identified by surveyors based on observations and records indicating that the nutritional and hydration needs of at least one resident were not adequately met. The lack of appropriate provision of food and fluids resulted in a failure to support the resident's overall health status.
Failure to Timely Notify Physician, Dietitian, and Representative of Severe Weight Loss
Penalty
Summary
The facility failed to notify a resident's physician, dietitian, and representative in a timely manner after the resident experienced a severe weight loss. The resident lost 27 pounds, representing an 11.86% decrease in body weight over a three-month period, with a 20-pound loss occurring in less than two months. Documentation in the medical record did not show immediate notification to the physician, dietitian, or the resident's representative regarding this significant change. Nursing progress notes indicated that the medical physician was only notified of the weight loss during a routine 90-day visit, and the dietitian was consulted several days later. The resident's guardian was informed after the fact, and attempts to reach the family were not immediately successful. Staff interviews confirmed that awareness of the weight loss occurred only in the days leading up to the notification, and there was a delay in obtaining a reweigh when a significant weight difference was first noted.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report allegations of resident-to-resident abuse to the State Survey Agency within the required 24-hour timeframe for six residents. Specific incidents included an allegation involving two residents that occurred on July 6, 2024, but was not reported until July 8, 2024. Another incident involving two different residents occurred on July 22, 2024, and was reported on July 24, 2024. Additionally, an incident on September 12, 2024, involving two more residents was not reported until September 16, 2024. These delays in reporting were identified during interviews and record reviews conducted by surveyors. Interviews with facility staff revealed that floor staff are responsible for reporting incidents to the nurse on duty, who then fills out a report. The facility has an abuse team that oversees investigations, and the nurse on duty is expected to alert the team via a confidential texting application. The team designates an individual to investigate and submit the report through the facility's online reporting system, BOUNDS. Despite these procedures, the facility's document titled "Abuse, Misappropriations, and/or Neglect of Residents" mandates that the administrator and quality coordinator input the alleged abuse report into the BOUNDS system within 24 hours, which was not adhered to in these cases.
Failure to Timely Complete POLST and Advanced Directives
Penalty
Summary
The facility failed to address the timely completion or implementation of treatment wishes for residents, specifically related to the Provider Orders for Life-Sustaining Treatment (POLST) forms. Resident #43's POLST was not completed for over thirty days after admission, despite the resident recalling being asked about her code status. Similarly, resident #60's POLST form was not completed until almost two months after admission, which did not align with the facility's policy. Interviews with staff members revealed that physicians were the only ones allowed to complete POLST forms, and it was common for physicians to not see residents for two to three weeks after admission, resulting in residents being considered full code unless treatment wishes were documented. Additionally, the facility failed to ensure advanced directives were in place for resident #37. The medical record for resident #37 showed no advanced directive was filled out, and there was no documentation of a discussion regarding her wishes. The facility did not provide information about an advanced directive or a refusal for resident #37 before the end of the survey. Staff interviews indicated that the resident's provider would discuss advanced directives during the initial visit, which was expected within the first thirty days after admission. The facility conducted monthly audits to ensure POLST forms were present and properly filled out, but these deficiencies indicate a lapse in the timely completion and documentation of residents' treatment wishes.
Expired Immunizations and Inadequate Temperature Monitoring
Penalty
Summary
The facility failed to ensure proper disposal of expired immunizations and did not adequately monitor the temperatures of medication refrigerators and freezers. During a record review, it was found that temperature logs for the treatment room immunization freezer and refrigerator were incomplete for several dates. An observation revealed expired Shingrix vaccines in the treatment room refrigerator, which were not disposed of as per protocol. Staff member L mentioned that expired immunizations are typically returned to the pharmacy by staff member K, who frequently visits the treatment room. However, the expired vaccines were still present, indicating a lapse in the process. Interviews with staff members L and K revealed inconsistencies in the monitoring of refrigerator temperatures. Staff member K stated that she checks the treatment room fridge daily when present, while night shift nurses are responsible for checking temperatures on weekends or holidays. However, documentation showed missing temperature logs for several dates. The facility's policy requires daily temperature checks and logging by designated personnel, but this was not consistently followed, leading to potential risks associated with improper storage conditions for medications and immunizations.
Failure to Maintain Proper Food Safety Practices
Penalty
Summary
The facility failed to ensure proper food safety practices in the Firefly and Glacier unit kitchens, as observed during a survey. Specifically, there was a lack of consistent documentation of refrigerator and freezer temperatures, with missing entries on multiple dates across several months. This failure to record temperatures was noted in logs for both units, indicating a systemic issue with monitoring food storage conditions. Additionally, during observations, a Styrofoam bowl with food was found in the Firefly unit freezer, unlabeled and undated, which is against the facility's policy for food storage. Interviews with staff members revealed that the responsibility for checking and logging refrigerator and freezer temperatures fell to the night shift nurses. However, the logs showed numerous instances of missing documentation, suggesting that this task was not consistently performed. The facility's policy requires that temperatures be checked and logged daily by designated personnel, and that all refrigerated food be labeled, dated, and monitored. The lack of adherence to these protocols could potentially lead to foodborne illnesses and improper infection control practices for residents consuming food from these units.
Incomplete and Unlabeled Medical Records
Penalty
Summary
The facility failed to ensure that resident medical record documentation was complete and properly labeled for four of the sampled residents. Specifically, the POLST forms for residents were found to be incomplete, lacking necessary information such as the preparer's signature, date, and phone numbers. For instance, resident #11's POLST form was missing the preparer's information and date, while resident #43's form lacked the signature and phone numbers. Additionally, resident #60's form did not include the medical provider's phone number. Interviews with staff members revealed that only physicians were allowed to complete the POLST forms, and there was a delay in completion until the physician or nurse practitioner made their initial visit. Furthermore, resident #66's interdisciplinary progress note lacked identifying information, making it unclear which resident the note pertained to. Additionally, resident #43's medication administration records were provided in two sets, both lacking clear labeling of the month or year, making it difficult to determine the dates of the records. Staff member B was unable to identify the month for the medication administration records, indicating a lack of proper documentation and organization within the facility's record-keeping practices.
Failure to Notify Guardian of Emergency Department Transfer
Penalty
Summary
The facility failed to notify the guardian of a resident's transfer to the emergency department, which constitutes a deficiency in communication and adherence to policy. The resident was admitted to the emergency department at 9:49 p.m. on 10/20/24, but there was no documentation in the medical record indicating that the guardian was informed of this transfer. Interviews conducted on 10/23/24 revealed that the guardian was not notified, and staff acknowledged that the guardian should have been informed according to the facility's policy. The policy, revised on 2/6/2023, mandates that family or guardians be contacted in coordination with nursing services when significant events occur, such as a change in the resident's condition.
Failure in Discharge Planning for Resident Leaving Against Medical Advice
Penalty
Summary
The facility failed to implement an effective discharge planning process for a resident who left the facility against medical advice. The resident was initially required to stay at the facility due to a court commitment for a minimum of 90 days. However, the court commitment expired, and a re-commitment was not filed in time, allowing the resident to be in the facility on a voluntary basis. Despite multiple indications from the resident expressing a desire to leave, including exit-seeking behavior and a preference to be in a place where smoking was allowed, the facility did not initiate discharge planning. Staff members assumed the resident was content at the facility and did not take steps to prepare for a potential discharge. When the resident eventually left against medical advice, the facility did not have a proper discharge plan in place. The resident was given a three-day supply of medications, but there were no physician orders for this in the medical record. Additionally, there were no arrangements made for a follow-up appointment, ensuring the resident had a wheelchair, or ensuring the resident had enough medication until a new prescription could be obtained. The lack of discharge planning was attributed to assumptions made by staff about the resident's satisfaction with the facility and unresolved financial issues related to the resident's co-ownership of a house.
Oxygen Administration and Equipment Maintenance Deficiency
Penalty
Summary
The facility failed to administer oxygen to a resident at the rate prescribed by the physician and did not maintain respiratory equipment according to acceptable standards. During an observation, a resident was found using oxygen via a nasal cannula connected to an oxygen concentrator, with the cannula lying on the floor and the nose pieces in direct contact with the floor. The oxygen concentrator was set at two and one-half liters per minute, despite the physician's order allowing up to five liters per minute. The resident was unaware of the need to clean the filter on the concentrator, which was found to have a fine layer of gray particles and a heavy layer of particles and hair-like substances. The facility's policy required the air inlet filter on the concentrator to be washed and rinsed in warm soapy water at least monthly and as needed. However, the certified nurse assistant documentation flow sheets showed that the oxygen filter cleaning scheduled for a specific date had not been completed. Additionally, the resident's monthly medication administration records and treatment records lacked documentation of oxygen monitoring results or the oxygen liter flow for two months. Staff interviews revealed that the night shift was responsible for cleaning the filters monthly, and the company renting the concentrators performed quarterly maintenance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lewistown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valle Vista Rehabilitation And Nursing Llc | 0.6 mi | ★★★★★ | 10 | 0 |
| Central Montana Nursing & Rehabilitation Center | 1 mi | — | 0 | 0 |
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