Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Southwest Montana Veterans Home during CMS and state inspections, most recent first.
The facility did not ensure that psychotropic medications were prescribed only for residents with clearly documented and diagnosed conditions, as two residents received antipsychotic medications for diagnoses not supported by their medical records. Additionally, a resident was maintained on multiple psychotropic medications without a physician-signed gradual dose reduction, despite pharmacist recommendations, and the required review process was not properly completed.
The facility did not ensure that PASRR documentation accurately reflected the mental health diagnoses of two residents receiving psychotropic medications for bipolar disorder, and failed to complete a required Level II PASRR for a resident newly diagnosed with Major Depressive Disorder. These omissions resulted in incomplete coordination of assessments and referrals for mental health services.
Several residents were found to have bed rails or similar devices in use without the required physician orders, informed consents, or signed statements of understanding. Staff interviews revealed confusion about terminology and inconsistent practices regarding documentation and assessment for bed rail use. Facility records and policies indicated requirements for consent and assessment, but these were not followed for the affected residents.
A resident with a history of PTSD and trauma from the Vietnam War did not have a care plan that specifically addressed his ongoing nightmares, unpleasant memories, and desire for isolation. The care plan only included general instructions about trauma triggers, lacking focused goals or interventions for his unique needs, despite the resident's continued psychological distress and avoidance of group activities.
A resident with cognitive and personal care needs did not consistently receive staff assistance with oral hygiene, as evidenced by persistent halitosis and staff observations of increased dependence, despite documentation indicating independence in oral care.
A resident with symptoms of a urinary tract infection had a positive urine culture, but antibiotic treatment was delayed for several days after results were available because the on-call provider could not access the results in the EHR or receive them by fax, resulting in the infection remaining untreated for a week.
A resident with a history of PTSD and significant trauma-related symptoms did not receive appropriate mental health treatment or trauma-informed interventions. The care plan lacked any focus or strategies for addressing PTSD, and the resident had not been referred to mental health professionals despite worsening symptoms.
Staff did not follow contact precautions for a resident with a physician order for Tinea Cruris, as staff members entered the room and assisted the resident without wearing required PPE such as gowns and gloves, despite posted signage and facility policy. Some staff were unaware of the reason for precautions or the correct procedures to follow.
Staff were unclear about proper disposal procedures for biohazardous waste, resulting in bags being left unboxed and stacked on the floor of a locked shed, with some boxes left open and the area emitting an unpleasant odor. The shed lacked a hand hygiene station, and staff reported inconsistent waste pickup and a shortage of boxes, leading to bags not always being secured or boxed nightly. These practices did not align with facility policy or CDC recommendations for medical waste storage.
A facility failed to respect a resident's right to self-determination by not allowing the POA to provide pureed food in squeeze packets, which followed the prescribed diet. Despite the food being appropriate and enjoyed by the resident, some staff refused it due to perceived dignity concerns. Interviews and observations showed the packaging was adult-focused, and several staff did not view it as a dignity issue, highlighting a deficiency in honoring the resident's preferences.
A facility failed to include a resident's bipolar disorder diagnosis in the admission PASARR assessment. The resident's PASARR only listed other medical conditions, despite later documentation in the MDS and psychiatric evaluations identifying bipolar disorder. The care plan also noted the risk for mood and behavior alterations related to bipolar disorder, and the resident was prescribed antipsychotic medication.
A facility failed to consistently manage the check-out process for residents, particularly those with cognitive impairments and a history of wandering. A resident left the facility without notifying staff, highlighting the lack of a reliable system to ensure supervision. Staff interviews and observations revealed inconsistencies in policy enforcement and unlocked doors, allowing unsupervised exits. The facility lacked a list of residents approved for self-check-out, complicating monitoring efforts.
Failure to Ensure Proper Use and Review of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that psychotropic medications were used only for residents with specific, diagnosed, and documented conditions. In two cases, residents were prescribed antipsychotic medications (Quetiapine Fumarate and Risperdal) for diagnoses such as bipolar disorder, but review of their medical records and histories did not confirm the presence of these diagnoses. Staff interviews revealed uncertainty about the residents' diagnoses, and facility records, including histories and physicals, did not support the documented indications for the medications. Consent forms and medication orders listed diagnoses that were not substantiated in the residents' medical histories at the time of review. Additionally, the facility failed to obtain a physician-signed gradual dose reduction (GDR) for five psychotropic medications prescribed to another resident. Although the consultant pharmacist made recommendations for GDR, there was no evidence of physician review or signature on the relevant documentation. Staff interviews indicated that nurses were not involved in reviewing medications for possible dose reductions, and the process for obtaining physician approval for GDRs was not consistently followed, as evidenced by incomplete and unsigned forms.
Failure to Complete and Update PASRR for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure proper coordination and completion of the Pre-Admission Screening and Resident Review (PASRR) process for several residents with mental health diagnoses. For one resident, the PASRR Level I did not include a diagnosis of bipolar disorder, despite the resident receiving Quetiapine Fumarate for bipolar depression. Similarly, another resident's PASRR omitted a bipolar disorder diagnosis, even though the resident was prescribed Risperdal for this condition. In both cases, the PASRR documentation did not accurately reflect the residents' mental health conditions for which they were receiving psychotropic medications. Additionally, a third resident was diagnosed with Major Depressive Disorder after the initial Level I PASRR was completed, but a required Level II PASRR was not conducted following the new diagnosis. Although staff reported contacting the relevant entity and being told that a Level II PASRR was not needed, this communication was not documented, and the facility did not resubmit a Level I PASRR as required after the new mental health diagnosis was made.
Failure to Obtain Orders and Consents for Bed Rail Use
Penalty
Summary
The facility failed to obtain required physician orders, informed consents, and signed statements of understanding for the use of bed rails for five of thirteen sampled residents. Observations revealed that bed rails or similar devices were present on both sides of the beds for these residents, yet their electronic medical records did not contain the necessary documentation authorizing their use. Care plans referenced the use of bed canes, assist rails, or quarter rails to aid in bed mobility, repositioning, or transfers, but there was no evidence of proper assessment, consent, or physician order for these devices. Interviews with staff indicated confusion regarding the terminology and processes for bed rail use. Some staff members acknowledged that both physician orders and consents were required, while others were uncertain about the need for consents. Staff also reported inconsistent practices, such as sometimes obtaining paper consents or entering orders after assessments, but not consistently ensuring all required documentation was completed. There was also a lack of clarity among staff about the distinction between bed rails and bed canes, with some believing that consents were not needed for bed canes, despite their functional similarity to bed rails. A review of facility documents showed that there was a form intended for side rail utilization assessment and a policy requiring consent after presenting risks and benefits, but these were not consistently implemented. No additional documentation for physician orders, consents, or statements of understanding was provided for the affected residents during the survey. The lack of a standardized process and consistent terminology contributed to the failure to comply with requirements for the safe and authorized use of bed rails.
Failure to Develop Comprehensive Trauma-Informed Care Plan
Penalty
Summary
The facility failed to ensure that an updated and comprehensive care plan addressing trauma-informed care was in place for one resident with a history of significant trauma related to the Vietnam War. The resident experienced ongoing nightmares and unpleasant memories, and preferred isolation due to distress caused by discussions about the war. Review of the care plan revealed only general instructions regarding trauma triggers, such as noise reduction and maintaining routines, without specific focus, goals, or interventions tailored to the resident's PTSD or experiences as a prisoner of war. Interviews confirmed the resident's ongoing psychological distress and avoidance of social interaction due to his trauma history. The facility's documentation indicated that the interdisciplinary team is responsible for developing individualized care plans, but in this case, the care plan lacked detailed, measurable actions to address the resident's specific trauma-related needs.
Failure to Provide Consistent Oral Care Assistance
Penalty
Summary
A deficiency was identified when a resident who was dependent on staff for activities of daily living, including oral care, did not consistently receive assistance with oral hygiene. Observations and interviews revealed that the resident had noticeable halitosis during interactions, and staff acknowledged the resident's increased dependence, including needing help with dressing. Despite this, electronic health records documented the resident as independent in oral hygiene for 26 out of the past 30 days. The resident's medical record included diagnoses of a need for assistance with personal care and a cognitive communication deficit, indicating a requirement for staff support that was not consistently provided.
Delayed Treatment of Urinary Tract Infection Due to Lapse in Result Communication
Penalty
Summary
A resident experienced an elevated temperature and was suspected of having a urinary tract infection, prompting a provider to order a complete blood count and urine culture. The urine culture, finalized two days later, confirmed an infection and identified antibiotics to which the bacteria was sensitive. Despite these results, the resident was not started on antibiotic therapy until five days after the culture results were available and one week after the onset of symptoms. The delay occurred because the on-call provider was unable to access the results in the electronic health record system or receive them by fax, resulting in the infection going untreated for an extended period.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
A resident with a medical diagnosis of post-traumatic stress disorder (PTSD) was not provided with appropriate treatment and services to support his highest practicable mental well-being. The resident, a former prisoner of war, reported frequent nightmares, distressing memories, and avoidance of activities that reminded him of past trauma. He also described a history of violent dreams that affected his relationship with his wife, who no longer felt safe staying overnight with him. Despite these ongoing symptoms and an increase in the frequency of distress as indicated by recent trauma assessments, the resident had never been referred to or seen by a psychiatrist or psychologist for his PTSD. Review of the resident's care plan revealed that there was no focus, goal, or interventions addressing PTSD or trauma, nor were there strategies for staff to identify triggers or assist the resident if triggered. Previous trauma assessments showed a recent increase in the severity of symptoms, but this was not reflected in the care planning. The facility's own policy on trauma-informed care requires services that address the needs of trauma survivors, but this was not implemented for the resident in question.
Failure to Follow Contact Precautions for Resident with Fungal Infection
Penalty
Summary
Staff failed to follow contact precautions for a resident with a physician order for contact precautions due to Tinea Cruris, a contagious fungal infection. During observations, one staff member transferred the resident from a wheelchair to a recliner without wearing a gown or gloves, despite signage on the resident's door indicating Enhanced Barrier Precautions and Contact Precautions. The staff member also entered the resident's bathroom, touched the door handle, and handled the resident's water container without appropriate personal protective equipment (PPE). Upon leaving the room, the staff member performed hand hygiene but had already touched personal items and surfaces without PPE. Another staff member entered the resident's room to assist with lunch without donning a gown or gloves and expressed uncertainty about the reason for the contact precautions. Interviews with additional staff revealed a lack of awareness regarding the proper precautions required for the resident, although one staff member clarified that the resident was on contact precautions due to a fungal infection on his arms and was supposed to wear sleeves at all times. Review of facility policy confirmed the requirement for contact precautions for residents with infections transmissible by direct or indirect contact.
Improper Storage and Handling of Biohazardous Waste
Penalty
Summary
The facility failed to ensure proper storage and handling of biohazardous waste, as observed during multiple staff interviews and direct inspection of the waste storage area. Staff members were unclear about the correct disposal procedures for red biohazard bags, and it was noted that some biohazardous waste bags were not stored in boxes and were instead stacked on the floor of a locked shed. Additionally, some biohazard boxes were left open and not full, and the shed had an unpleasant odor upon opening. The shed did not have a designated area for staff to perform hand hygiene after handling biohazardous waste, and the storage area was observed to be full, with boxes placed toward the front of the shed. Staff also reported uncertainty regarding the frequency of waste pickup and admitted that biohazardous waste was not always secured or boxed nightly, with some bags left on the ground due to a shortage of boxes. Review of facility policies and CDC recommendations indicated that medical waste should be stored in labeled, leak-proof, puncture-resistant containers, kept covered, and protected from animals and pests. The facility's own policies required that medical waste be securely sealed, stored in rigid and leak-resistant containers, and kept covered at all times. However, these procedures were not consistently followed, as evidenced by the improper storage and handling practices observed and described by staff.
Facility Fails to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor the resident's right to self-determination and communication by not allowing the Power of Attorney (POA) and decision-maker of a resident to make food preference requests that aligned with the physician's orders, dietary preferences, and swallowing precautions. The issue arose when the POA, identified as NF1, brought in pureed food in squeeze packets for the resident, which followed the prescribed diet. Despite the food being appropriate for the resident's dietary needs, some staff members refused to allow NF1 to provide these packets, citing concerns about dignity due to the packaging's appearance. However, the packaging was adult-focused, and several staff members did not view it as a dignity issue, noting that the resident enjoyed the food and it posed no choking risk. Interviews with staff members revealed differing opinions on the matter, with some staff not considering the squeeze packets as a dignity issue and acknowledging the resident's enjoyment and nutritional benefit from them. The resident's care plan indicated that the family was aware not to provide food in plastic pouches, yet the staff's actions contradicted the resident's right to self-determination and the POA's requests. Observations confirmed the presence of these food packets in the resident's room, and the packaging was deemed appropriate for adults, lacking any childlike colors. The facility's failure to accommodate the POA's requests and the resident's preferences led to the deficiency noted in the report.
Failure to Include Mental Health Diagnosis in PASARR
Penalty
Summary
The facility failed to include a mental health diagnosis in a resident's admission PASARR assessment. During an interview, a staff member acknowledged that the resident's diagnosis of bipolar disorder was not listed on the History and Physical (H&P) submitted for the PASARR at the time of admission in 2021. The PASARR, dated October 26, 2021, only listed chronic obstructive pulmonary disease, post-traumatic stress disorder, and dependence on supplemental oxygen as diagnoses. However, the resident's Quarterly MDS, with an Assessment Reference Date (ARD) of January 13, 2024, identified the resident as having a psychiatric illness: bipolar. Additionally, a psychiatric provider's initial evaluation from February 8, 2023, noted a background of Bipolar Unspecified. The resident's care plan, initiated on April 4, 2024, also indicated a risk for alterations in mood and behavior related to bipolar disorder, and the resident was prescribed antipsychotic medication.
Inadequate Supervision and Check-Out Process for Residents
Penalty
Summary
The facility failed to implement a consistent process for managing the check-out procedure for residents, particularly those with cognitive impairments and a history of wandering or elopement. This deficiency was highlighted by an incident involving a resident who left the facility on a scooter without notifying staff, despite having a documented history of wandering and cognitive impairment. The resident returned without incident, but the event underscored the lack of a reliable system to ensure residents at risk of elopement are adequately supervised when exiting the facility. Interviews with staff revealed inconsistencies in the enforcement of the sign-out policy, with some staff members indicating that residents do not always inform them when leaving. Observations showed that doors to certain cottages were unlocked, allowing residents to exit freely without supervision. Additionally, the facility did not maintain a list of residents approved to self-check-out, further complicating the ability to monitor and manage residents' movements effectively. The resident involved in the incident was on multiple medications, including narcotics, which could have impacted their decision-making abilities, yet there was no specific protocol in place to address such risks.
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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 Butte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crest Nursing Home | 3.1 mi | ★★★★★ | 9 | 0 |
| Continental Care And Rehabilitation | 3.3 mi | ★★★★★ | 1 | 0 |
| Copper Ridge Health And Rehabilitation Center | 3.3 mi | ★★★★★ | 17 | 0 |
| Community Nursing Home Of Anaconda | 24 mi | ★★★★★ | 17 | 0 |
| Ivy At Deer Lodge | 32.2 mi | ★★★★★ | 10 | 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 July 2026) and official state health department websites.