Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Northern Montana Care Center during CMS and state inspections, most recent first.
The facility failed to document required transfer/discharge information for two residents and did not notify the Ombudsman’s office of all resident transfers/discharges. Staff said nurses completed LOA/bed-hold forms but did not chart the LOA or transfer in the EHR, and no follow-up documentation was done unless the resident returned. One resident remained in a hospital after transfer with no documentation of an indefinite transfer or bed hold, while another resident had a trial home LOA and discharge without the required discharge documentation.
Failure to Complete Death in Facility MDS: A resident died in the facility, but the EMR did not show a required Tracking (Death Record) MDS after death. Staff confirmed the death in facility MDS had not been completed and stated it was missed; the discharge MDS was 118 days late. The facility policy required the RAI-based assessments to be completed for all residents.
A resident's POA consented to an influenza vaccine on admission, but staff later found no documentation in the EHR showing the vaccine was actually administered. An LPN and another staff member confirmed the consent was in paper files, yet the resident's record still lacked evidence that the flu shot was given.
A resident with confusion and wandering behaviors was observed entering multiple other residents' rooms, including while one was sleeping, and touching personal items. Staff relied on a wanderguard for safety and did not consistently intervene, despite one resident expressing discomfort due to PTSD and concerns about theft and infection control.
A resident with multiple medical and cognitive conditions was observed using a seatbelt as a physical restraint in a motorized wheelchair without a physician's order, signed consent, or required assessment documented in the EHR. Staff were unaware of the need for these steps, and facility policy requiring such documentation and assessment was not followed.
A resident with a diagnosis of PTSD did not have a completed PASARR screening on file. Staff were unable to provide the required documentation when requested, explaining that the paperwork was likely lost during a transfer to another entity responsible for filing.
Two residents with behavioral issues and trauma histories did not have their care plans updated to reflect their current needs. One resident exhibited verbal outbursts and aggression, while another had a diagnosis of PTSD, but neither care plan included problems, goals, or interventions addressing these concerns. Staff reported providing interventions, but these were not documented in the care plans.
Staff member G failed to follow proper infection control practices by not sanitizing hands before and after glove changes during medication administration for three residents. Despite acknowledging the importance of hand hygiene, staff member G missed sanitization steps, as confirmed by interviews and the facility's hand hygiene policy.
A facility failed to ensure dignity and respect for a resident with dementia during incontinence care when two CNAs shaved the resident's pubic area without consulting a nurse or obtaining consent. The incident caused significant distress to the resident's family, who had previously requested female caregivers for the resident.
Failure to Document Transfers, LOA, and Discharge Information
Penalty
Summary
The facility failed to document required information for resident transfers and discharges for 2 sampled residents and failed to inform the Ombudsman’s office of all resident transfers and discharges. Staff stated that when a resident went on LOA or transferred to another facility, the floor nurse completed a transfer and/or bed-hold form and faxed it to admissions, but the nursing staff did not document the LOA or transfer in the medical record. Staff also stated that once residents were placed on hold, nursing did not follow up unless the resident returned, and no documentation or assessment would be completed for a resident returning from LOA unless the resident reported a problem. For one resident, the record showed admission to the facility, transfer to the emergency department, then transfer to another hospital where the resident remained. The chart did not contain documentation of an indefinite transfer or bed hold, or a recapitulation of stay after 30 days out of the facility. The census showed the resident entered LOA with a hospital notation and later had a room/bed change. Staff stated the resident had a bed hold because the resident was not admitted to another nursing home and had not discharged home, and that the bed hold was continued because the facility had rooms available for a return. For the other resident, the record showed the resident was placed on LOA for a trial stay at home and then returned from LOA and discharged the same day. Progress notes reflected communication from the POA and family about the trial home stay and discharge timing, but the notes did not include the required information for discharge from the facility. Staff stated the resident was private pay and did not have a qualifying Medicare A stay, and that the facility charted by exception and did not document for LOA or bed hold. The Ombudsman’s office was also not routinely notified of resident transfers or discharges unless the discharge was involuntary.
Failure to Complete Death in Facility MDS
Penalty
Summary
The facility failed to complete a Discharge Minimum Data Set (MDS) Assessment for a resident who died in the facility. Review of the discharge summary showed the resident passed peacefully with family by her side. The electronic medical record showed a Tracking MDS had been completed and a Comprehensive MDS had been completed, but it did not show that a Tracking (Death Record) MDS was completed after the resident’s death. During observation and interview, staff member G reviewed the resident’s MDS records and stated the resident passed away in the facility and that a death in facility MDS had not been completed. Staff member G said the MDS submissions were typically sent every Thursday after the IDT review meeting and stated, “I just missed this one, and I don’t know why.” The Death in Facility Discharge MDS was documented as 118 days late. The facility’s MDS policy stated the Resident Care Coordinator/designee shall complete assessments of all residents using the RAI format.
Failure to Administer Consented Influenza Vaccine
Penalty
Summary
The facility failed to administer an influenza vaccine for resident #12, even though the resident's POA consented to the vaccine on the vaccination consent/declination form signed on 10/31/25. During interview, staff members A and C stated that resident #12 did not have documentation of receiving the influenza vaccine that was consented to on admission, and staff member A said the consent was found in the paper completed filings but the resident's medical record did not show actual administration of the vaccine. Review of resident #12's EHR on 7/16/26 also did not show administration of the influenza vaccine on admission, and the facility had no evidence that the vaccine was provided to the resident.
Failure to Prevent Resident Wandering and Unwanted Room Entry
Penalty
Summary
The facility failed to prevent a resident with confusion and wandering behaviors from entering the rooms of other residents, resulting in multiple instances of unwanted intrusions. One resident, who has a history of PTSD, reported feeling uncomfortable and stated that the wandering resident would sometimes steal items from his room. Staff instructed this resident to secure his belongings to prevent theft. Observations confirmed that the wandering resident entered the rooms of four other residents, including while one was sleeping, and touched personal items such as shoes, chairs, and wheelchair leg rests. Staff interviews revealed that the resident was able to move freely throughout the facility, with staff relying on a wanderguard system for safety. Staff did not express concern about the resident entering rooms, except in the case of the resident with PTSD who had voiced discomfort. It was acknowledged by staff that the wandering resident had previously gone through another resident's closet and that there could be infection control concerns due to the frequent room entries. Facility policy requires interventions to reduce unwanted intrusions, but these were not implemented in this case.
Failure to Obtain Physician Order and Consent for Physical Restraint
Penalty
Summary
A deficiency occurred when a resident was observed using a seatbelt in a motorized wheelchair without a physician's order or signed consent documented in the electronic health record (EHR). The seatbelt, which functioned as a physical restraint to prevent falls, was applied without the required assessment or documentation. Staff interviews revealed a lack of awareness that a physician's order and consent were necessary for the use of a seatbelt as a restraint, and that a physical therapy assessment had not been completed for this intervention. The resident involved had multiple complex medical diagnoses, including bipolar I disorder, intellectual disability, developmental delay, PTSD, hypertension, insomnia, prediabetes, traumatic brain injury, aggressive behavior, and a history of a sacral pressure ulcer. The resident was dependent for mobility, had upper and lower extremity deficits, and was unable to complete a mental status interview. The facility's own policy required a signed order and assessment for any restraint use, which was not followed in this case.
Failure to Complete PASARR for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a PASARR (Preadmission Screening and Resident Review) was completed for one resident diagnosed with PTSD. During an interview, the resident reported having PTSD from the war, and a review of the electronic health record confirmed this diagnosis. When surveyors requested the resident's Level I and Level II PASARR documentation, staff members were unable to provide it, stating that the paperwork must have been lost during a transfer to another entity responsible for filing most of their documents. As a result, the required PASARR screening was not completed or available for this resident.
Failure to Update Care Plans for Behavioral and Trauma Needs
Penalty
Summary
The facility failed to update and individualize care plans for two residents regarding their behavioral issues and trauma history. For one resident, electronic health records documented an incident where the resident exhibited verbal outbursts and aggressive language towards another resident and staff, but the care plan, last reviewed over two months prior, did not address these behaviors with any problem statements, goals, or interventions. For the second resident, who had a diagnosis of PTSD, the care plan did not include any problems, goals, or nonpharmacological interventions related to PTSD, despite this being a known diagnosis. Interviews with staff confirmed that behavioral interventions and trauma-informed care were being provided to these residents on a daily basis, but these actions were not reflected in the residents' care plans. The lack of documentation and care plan updates meant that the individualized needs and preferences of these residents were not formally recognized or communicated in their care plans, despite ongoing behavioral incidents and known trauma histories.
Infection Control Deficiency in Hand Hygiene Practices
Penalty
Summary
Staff member G failed to adhere to proper infection control practices during medication administration for three residents. Observations revealed that staff member G did not perform hand sanitization after doffing gloves or before donning new gloves while administering eye drops and performing blood glucose monitoring for a resident. Additionally, staff member G did not sanitize her hands before donning gloves for blood glucose monitoring for two other residents. Interviews with staff members G and C confirmed the expectation that hand sanitization should occur before and after each glove change and resident contact. The facility's hand hygiene policy, last revised in April 2024, supports this practice by stating that an alcohol-based hand sanitizer should be used before direct patient contact and after removing gloves. Despite this, staff member G acknowledged missing hand sanitization during her medication pass.
Failure to Ensure Dignity and Respect for Resident During Incontinence Care
Penalty
Summary
The facility failed to ensure dignity and respect for the privacy of medical information for one resident. The incident involved two CNAs who shaved the pubic area of a resident with dementia during incontinence care without consulting a nurse or obtaining consent. The resident's family member, who had previously requested female caregivers for the resident, was not informed until after the incident occurred. The incident was discovered when the family member noticed bruising on the resident's arm and inquired about it. During the visit, the family member was informed by staff about the shaving incident, which led to significant distress and concern. The family member expressed that the resident would not have consented to such an action and was upset with the facility's handling of the situation. Interviews with staff revealed that the CNAs believed they were helping the resident by shaving her to clean her more effectively. However, they did not follow proper protocol by consulting the charge nurse or obtaining consent. The facility administration did not suspend the involved staff members immediately, considering it a care issue rather than a reportable incident. The incident was later reported to the State Survey Agency and the police department, and an investigation was initiated.
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What surveyors actually found near you
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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 Havre
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sweet Memorial Nursing Home | 20.5 mi | ★★★★★ | 17 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.