Citations in Montana
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Montana.
Statistics for Montana (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Montana
A resident with severe protein calorie malnutrition and recent stroke experienced significant weight loss over one month. The resident was observed not receiving required assistance with eating, resulting in missed meals and visible difficulty during mealtimes. Documentation of required weekly weights was incomplete, and recommended dietary interventions were not implemented or monitored in a timely manner.
A resident did not receive appropriate care for existing pressure ulcers, and the facility failed to implement effective measures to prevent new ulcers from developing. Surveyors found that necessary interventions and monitoring were not consistently provided.
A deficiency was cited when a facility area was not kept free from accident hazards and supervision was inadequate to prevent accidents. The environment and oversight did not meet required standards to minimize accident risks.
A grievance box was placed on a counter and blocked by a trash can, making it inaccessible to residents using wheelchairs. Staff sometimes had to assist residents in submitting grievances, and a resident reported being unable to submit grievances anonymously due to the box's placement and design.
Multiple residents reported and were observed receiving meal trays late and at improper temperatures, with some expressing significant hunger while waiting. Staff interviews confirmed ongoing issues with timely meal delivery to resident rooms, attributed to kitchen delays, unclear meal schedules, and inconsistent staff performance.
Two residents with edema did not receive prescribed compression wraps or leg elevation as ordered by their physicians. Despite visible swelling and clear care plan directives, staff failed to apply the required interventions and inaccurately documented that treatments were provided. Staff interviews confirmed inconsistent application of the prescribed care.
A resident with a history of hip replacement complications fell during a transfer when left unsupported by a nurse. Staff did not promptly notify the physician as required by facility protocol, resulting in delayed treatment for a fracture and unmanaged pain. Documentation did not reflect timely physician notification, contrary to facility policy.
Staff cleaned a resident's room and disposed of personal items without the resident's presence or clear consent, despite the resident's history of homelessness and hoarding. The care plan did not specify how to involve the resident in decisions about his belongings, and there was no documentation of his agreement to the process. The resident was frustrated by the loss of his items, and the facility lacked a policy addressing room cleaning or hoarding.
Two residents were involved in a physical altercation where one reported being touched inappropriately by another. Although the incident was documented and communicated internally, the allegation was not reported to the State Survey Agency within the required 24-hour period, as required by facility policy. Staff interviews indicated a lack of awareness of the reporting requirement, and video evidence of the incident was no longer available for review.
Two residents did not receive respiratory care as ordered, including one who was observed multiple times without prescribed oxygen or with an empty tank and no oxygen warning sign posted, and another whose CPAP machine was unused, obsolete, and not maintained, despite staff documentation indicating regular use.
Failure to Provide Adequate Assistance and Monitoring for Resident with Severe Weight Loss
Penalty
Summary
A resident with a recent history of stroke and a new diagnosis of Severe Protein Calorie Malnutrition experienced a significant weight loss of 7.65% in one month. Observations revealed that the resident was left asleep with an untouched breakfast tray, which was later discarded without any attempt to assist or encourage intake. During lunch, the resident was seen struggling to eat independently, with food falling off the fork and visible frustration, yet no staff assistance was provided. The care plan indicated the resident required extensive assistance with eating, but this intervention was not implemented during observed meals. Record review showed the resident was to be weighed weekly, but a required weight was missing from documentation. Despite the physician's note identifying significant weight loss and recommending a Registered Dietitian consult and nutritional supplements, there was no evidence of dietary follow-up or intervention in the progress notes. Staff interviews confirmed the resident had not been included in weight loss monitoring until after the deficiency was identified, and dietary interventions were not updated in a timely manner.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents either did not receive necessary interventions for existing pressure ulcers or were not monitored and assessed adequately to prevent new pressure ulcers from forming.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Grievance Box Inaccessible to Wheelchair Users
Penalty
Summary
The facility failed to provide a wheelchair-accessible grievance box, preventing residents who use wheelchairs from independently or anonymously submitting grievances. During observation, the grievance box was found placed on top of a counter in the main lobby, with a trash can on the floor in front of it, creating a physical barrier. The box required the lid to be pulled down to deposit a form, further complicating access for those with limited mobility. Staff confirmed that they sometimes had to assist residents in wheelchairs to submit grievances, and a resident who relies solely on a wheelchair reported being unable to reach the box and therefore had to hand grievances directly to staff, compromising anonymity. The resident also expressed a desire for the box to be more accessible and discreet.
Delayed and Improper Meal Service to Resident Rooms
Penalty
Summary
The facility failed to serve resident meal trays to rooms in a timely manner and according to posted mealtimes, resulting in multiple residents experiencing late and lukewarm meals. Observations and interviews revealed that residents who consistently ate in their rooms reported their food was often served thirty minutes late and was usually lukewarm. On several occasions, residents expressed significant hunger while waiting for their meals, with one resident rating their hunger as ten out of ten. Meals were observed being delivered after the designated end time for meal deliveries, and residents commented on the food being served late and not at the proper temperature. One resident expressed concern about the late meal affecting their ability to attend a scheduled appointment. Staff interviews confirmed that meal trays were often late getting to resident rooms, with some staff acknowledging that the facility could improve the timeliness of tray delivery. Staff attributed delays to food not coming out of the kitchen quickly enough and to the order in which halls were served. There were also reports of CNAs delaying food service due to inattentiveness. Meal delivery times were not clearly posted or communicated to residents, leading to confusion and unmet expectations regarding when meals would be served.
Failure to Follow Physician Orders for Edema Management
Penalty
Summary
The facility failed to follow physician orders for edema treatment for two residents with mobility issues. Observations revealed that both residents consistently exhibited swelling in their lower legs and feet, yet were not wearing the prescribed elastic bandages or compression stockings. Additionally, interventions such as leg elevation were not implemented as directed in their care plans. Despite these omissions, staff documented in the Treatment Administration Records that the interventions had been performed on the relevant dates. Interviews with staff confirmed that the prescribed treatments were not consistently applied, and some staff indicated that only certain nurses would perform these tasks. Review of the residents' care plans and treatment records showed clear orders for the use of compression wraps and leg elevation to manage edema. However, these interventions were not observed during multiple surveyor visits, and staff documentation did not accurately reflect the care provided. Weekly skin check assessments also failed to note the presence of edema, despite visible swelling. The lack of adherence to physician orders and inaccurate documentation contributed to the identified deficiency.
Failure to Promptly Notify Physician After Resident Fall Resulting in Injury
Penalty
Summary
A deficiency occurred when facility staff failed to promptly notify a physician after a resident experienced a fall that resulted in injury and pain. The resident, who had a history of complications following a right hip replacement, reported falling during a transfer when left unsupported by a nurse who went to seek assistance. Staff interviews confirmed that the established fall protocol required immediate notification of the physician and family, but the responsible staff member did not notify the on-call physician after the incident. Documentation in the resident's electronic health record did not show timely physician notification regarding the fall and the resident's increased pain. The delay in physician notification led to a delay in treatment, and the resident was later found to have sustained a fracture. Facility policy and the fall prevention program both required prompt notification of the physician and family following an accident resulting in injury. The lack of timely communication with the physician impacted the opportunity for the physician to provide directives on the resident's care, pain management, and injury assessment.
Failure to Respect Resident's Personal Belongings During Room Cleaning
Penalty
Summary
Facility staff failed to respect a resident's personal belongings during a room cleaning, disposing of items without the resident's presence or awareness. The resident, who had a documented history of homelessness and hoarding, kept various personal items in his room, including painted rocks, a handmade plant, and papers, none of which posed a safety hazard at the time of observation. Staff cleaned the room while the resident was absent, removed items from display, and discarded stored food, citing routine housekeeping and the need to prevent hoarding. The resident expressed frustration and distress upon discovering his items were missing or displaced, indicating he was not informed or consulted about the cleaning or the disposal of his belongings. Review of the resident's care plan showed interventions related to his history of hoarding and the need to maintain a safe environment, but did not specify how staff should ensure the resident was comfortable with the cleaning process or aware of what was being discarded. Staff interviews revealed that while the resident had previously consented to staff cleaning his room, there was no documentation or clear communication regarding which items could be removed or discarded. Additionally, the facility lacked a specific policy on hoarding or room cleaning for safety concerns, and there was no evidence of a documented agreement or contract outlining the resident's preferences or consent for the disposal of his personal items.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to the State Survey Agency within the required 24-hour timeframe. Specifically, two residents were involved in a physical altercation in which one resident reported that another had touched his groin. The incident was initially reported by the resident to nursing staff on the evening it occurred, and this was documented in the nursing progress notes. The staff communicated the incident internally to social services and the DON, but the allegation was not reported to the State Survey Agency until several days later. Staff interviews revealed a lack of awareness regarding the reporting requirement and confusion about the need to report when the resident later denied the incident occurred. Facility policy requires immediate reporting of suspected abuse, including sexual abuse, to the State Survey Agency and other authorities within specified timeframes. Despite this, the initial allegation was not reported as required, and the facility's video surveillance of the incident was no longer available for review at the time of the survey. The deficiency was identified through interviews, record review, and examination of facility policy, which clearly outlines the obligation to report such incidents promptly.
Failure to Follow Physician Orders for Oxygen and CPAP Administration
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents by not following physician orders for oxygen and CPAP administration. One resident, who had an order for continuous oxygen at 2 L per minute via nasal cannula, was repeatedly observed without oxygen or with an empty oxygen tank attached to her wheelchair. The resident's room lacked the required oxygen warning sign, and multiple empty oxygen tanks were present. Documentation indicated that oxygen was administered only 92% of the time, despite the order for continuous use. Another resident, who had an order for nightly CPAP use for obstructive sleep apnea, had not used the CPAP machine for an extended period. The CPAP equipment was found buried, dusty, missing a power cable, and without a current biomedical inspection date. Despite this, staff documentation reflected that the CPAP was applied most nights, which was inconsistent with the resident's statements and the observed condition of the equipment. The order for CPAP was eventually removed, but the order to clean the facemask remained.
Some of the Latest Corrective Actions taken by Facilities in Montana
Facility corrective actions were not detailed in the provided information for these citations.
Failure to Prevent and Document Progression of Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to prevent, assess, and document the progression of a Stage 4 pressure ulcer for a resident. The resident was readmitted to the facility without a sacral pressure ulcer, but by September 2023, a pressure ulcer of the sacral region was diagnosed. The wound care progress note from November 2023 indicated that the pressure ulcer had been present for nine weeks and was classified as Stage IV. There were no weekly skin or wound assessments until late September 2023, and no assessments were conducted in October or November 2023. Consistent weekly assessments only began after the initiation of a Wound Care Performance Improvement Plan (PIP) in December 2023. Interviews with staff revealed that new management identified wound care as a significant concern and initiated a PIP to address the issue. Contributing factors to the skin concerns included a lack of pressure-reducing mattresses and pads, poor layering of linen and plastic pads under residents, and inadequate wound documentation. The facility's QAPI team implemented immediate interventions, including the use of pressure reduction mattresses and pads, changing to cloth bedding protectors, weekly graphing of wounds, and a consistent wound care protocol. These actions were part of a broader effort to improve wound care processes and reduce the incidence of pressure ulcers among residents.
Removal Plan
- Pressure reduction mattresses and pads
- Change from plastic to cloth bedding protectors for better air flow to skin
- Graphing of wounds
- Wound care protocol for consistency of wound care/nutritional interventions
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