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)
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
Latest Citations in Montana
A resident was subjected to mental abuse when staff restricted her right to private in-room visitations, requiring all visits with certain individuals to occur only in common areas for staff convenience. This restriction was imposed without documented safety concerns, contradicted the resident's care plan preferences for socialization, and led to the resident experiencing ongoing feelings of isolation, frustration, and being watched.
A resident with a history of skin breakdown developed a worsening Stage III pressure ulcer due to inconsistent wound assessment, measurement, and dressing changes, with staff failing to follow physician orders and facility policy for documentation. Another resident with an indwelling catheter developed a wound on the foreskin after staff failed to provide consistent and proper perineal care, and the wound went undocumented and unrecognized by staff until observed during the survey.
Surveyors found that a common bathtub had not been cleaned for several months, with visible stains and sediment, and lacked signage indicating it was out of use. Staff confirmed the bathtub was not in use and believed monthly housekeeping audits were occurring, but no documentation of cleaning or audits was provided. Additionally, infection control policies, including water management and Legionella surveillance, had not been reviewed or updated annually as required.
A resident with severe cognitive impairment repeatedly accessed unmonitored elevators and was found on other floors or searching for exits, yet was not assessed as at risk for elopement and did not have interventions reflected in the care plan. Staff were unclear on elopement definitions, did not use the wander guard system, and failed to move the resident to a secure unit despite available beds, resulting in ongoing elopement hazards.
Insufficient nursing staff resulted in delayed wound care, inconsistent completion of ADLs, and prolonged call light response times. A resident's pressure ulcer worsened due to missed dressing changes and lack of wound monitoring, while other residents experienced delays in hygiene care and repositioning. Staff and residents reported frequent low staffing, with only one nurse and two CNAs at times for 34 rooms, directly impacting the quality and timeliness of care.
Two residents did not have comprehensive, person-centered care plans in place to address their specific needs. One resident's care plan lacked critical details for dialysis management, such as monitoring protocols and emergency contacts. Another resident with cognitive impairment and a history of elopement did not have interventions or risk identification documented in the care plan, despite repeated incidents and discussions about moving to a secure unit.
Surveyors found that several residents received oxygen therapy without provider orders specifying the delivery rate, and there was no consistent documentation or labeling of when oxygen tubing was last changed. Additionally, a nebulizer machine and mouthpiece were observed on the floor next to a trash can, with the mouthpiece touching the floor and covered with used tissues, indicating a lapse in infection control practices.
Three residents were admitted and began receiving care, including oxygen therapy and, in one case, urinary catheter care and extensive ADL assistance, but their baseline care plans did not include necessary problems, goals, or interventions for these needs. Staff interviews confirmed that baseline care plans were not always comprehensive, omitting key information required for effective and person-centered care.
The facility did not maintain complete medical records, as several residents lacked medical provider visit notes in both the EMR and paper charts, and a resident's POLST form was missing a required physician signature. Staff processes for handling provider notes were inconsistent, and the missing POLST signature was not identified during routine reviews.
Two residents receiving oxygen therapy did not have this intervention addressed in their care plans, and one resident with a recent aspiration event and documented swallowing difficulties lacked care plan interventions for aspiration risk. Staff confirmed these omissions, despite the needs being identified in MDS assessments.
Resident Subjected to Mental Abuse Through Restriction of Visitation Rights
Penalty
Summary
The facility failed to ensure a resident was free from mental abuse by depriving her of her rights to private visitations and by isolating her from social interactions for staff convenience. The resident was not allowed to have visitors in her room and was repeatedly told by staff to move her visits to the common area. This restriction was imposed despite the resident expressing that socialization was very important to her and that the limitation caused her to feel dull, bored, frustrated, and like a prisoner. The restriction had been in place for several months, and the resident agreed to it only to keep peace with the staff, not because she felt it was appropriate. Multiple staff interviews confirmed that the directive to limit the resident's in-room visitors originated from a specific staff member, who cited concerns about the resident discussing facility issues with others and encouraging complaints. There were no documented safety concerns or incidents that justified the restriction, and staff acknowledged that the resident's visitors, including a long-time friend and another resident's family member, were not involved in any inappropriate behavior. The facility did not provide the resident with written documentation or rationale for the visitation limitation, and the decision was not based on any documented behavioral or safety issues. The resident's care plan indicated a preference for socialization and maintaining her current level of social interaction, with a goal of avoiding complaints of isolation. However, the imposed visitation restrictions directly contradicted these care plan goals and the facility's own policies, which guarantee residents the right to private visits and to voice concerns without fear of punishment. The actions taken by staff resulted in the resident experiencing ongoing negative psychosocial effects, as evidenced by her own statements and corroborated by interviews with friends and staff.
Failure to Consistently Assess, Document, and Provide Wound and Perineal Care
Penalty
Summary
The facility failed to consistently assess, measure, and monitor a resident's pressure ulcer, and did not ensure wound dressings were provided as ordered by the physician. One resident with a history of Addison's disease and susceptibility to skin breakdown developed a Stage III pressure ulcer on the back of her right upper thigh after readmission from the hospital. The resident reported that staff did not listen to her instructions on wound dressing application, resulting in dressings that frequently rolled up and came off. She also stated that dressing changes were not performed consistently, and wound care was not always provided as scheduled. Observations confirmed the presence of a worsening wound, and record reviews showed a lack of consistent wound assessment, measurement, and documentation between physician visits, despite facility policy requiring regular monitoring and documentation. Staff interviews revealed that wound care and assessments were primarily performed by a wound care nurse who visited weekly, but measurements were not always taken at each dressing change, and sometimes the nurse did not return to complete wound care if the resident was unavailable. Other nursing staff were expected to perform dressing changes as ordered, but documentation was inconsistent or missing for multiple dates. The resident's wound progressed from improving to worsening over a period of several weeks, as documented by the Wound Clinic physician, with a significant increase in wound size. Facility records and task histories confirmed that dressing changes and wound assessments were not completed or documented as required by physician orders and facility policy. Additionally, the facility failed to ensure proper perineal care for another resident with an indwelling catheter, resulting in the development of a wound on the foreskin. The resident reported inconsistent perineal care and that staff often failed to properly clean the area, especially under the foreskin. Staff were unaware of the wound until it was observed during the survey, and there was no prior documentation or notification regarding the wound. The lack of proper perineal care and failure to identify and document the wound contributed to the resident's condition.
Inadequate Infection Control Program and Equipment Cleaning
Penalty
Summary
The facility failed to maintain an adequate infection prevention and control program, as evidenced by improper cleaning and maintenance of resident-care equipment and lack of annual review of infection control policies. During an observation, a common bathtub in the North hallway was found with long streaks of dark, rust-colored stains and dried brown sediment around the drain. The bathtub lacked signage or a cover to indicate it was out of use. A staff member reported that the bathtub had not been cleaned in five or six months and confirmed it was not being used by residents, with only the toilet and sink in use in that bathroom. The staff member also believed that housekeeping audits were being conducted monthly by another staff member. Review of facility policies revealed that the cleaning and disinfection policy for resident-care equipment was last updated in April 2025, and both the Water Management Program Policy and Legionella Surveillance Policy had not been reviewed or revised since April 2020. The facility assessment indicated that routine maintenance and cleaning schedules existed for most equipment, with non-routine maintenance conducted as needed. However, when documentation was requested for cleaning or deep cleaning of the North hallway tub and for housekeeping audits from June 2024 to the present, no records were provided by the end of the survey.
Failure to Identify and Address Elopement Risk for Cognitively Impaired Resident
Penalty
Summary
The facility failed to timely identify and address elopement risks for a resident with severe cognitive impairment. The resident, who had a BIMS score of 7 indicating severe cognitive deficits, was not assessed as being at risk for elopement in the most current available assessment, and no updated elopement assessment was provided during the survey. Despite repeated incidents where the resident accessed elevators and was found on other floors or searching for exits, the care plan did not reflect the resident's wandering or elopement risk, nor did it provide staff with guidance on managing these behaviors. Multiple nursing notes documented the resident's repeated attempts to use the elevator and leave the unit, including instances where the resident was found on different floors and continued to seek exits for extended periods. Staff attempted to redirect the resident without success, and discussions occurred about moving the resident to a secure unit. However, there was no documented follow-up or implementation of this intervention, even though secure unit beds were available in the facility. Staff interviews revealed a lack of awareness and understanding regarding the classification of elopement events, with some staff considering the incidents as AWOL rather than elopement, despite the resident's cognitive impairment. Additionally, the facility's wander guard system was not utilized for this resident, and staff were unsure how it functioned on the unit. The facility had unmonitored elevators and exits, further contributing to the ongoing elopement hazard for the resident.
Insufficient Staffing Leads to Delayed Care and Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in several care deficiencies. One resident with a pressure ulcer on her right upper leg reported that her dressing was not changed consistently, particularly during the day when staff stated they did not have time. Medical record review confirmed that the wound was not assessed, measured, or monitored for nearly a month, and a Wound Clinic note documented that the pressure injury worsened during this period. Staff interviews corroborated that dressing changes were not completed as ordered and that wound care documentation was lacking. Other residents experienced unmet needs related to activities of daily living (ADLs) and long call light response times. One resident was often left in her room in the dark during breakfast, missing opportunities for socialization and encouragement to eat. Another resident reported waiting an hour and a half to be changed and stated that basic hygiene tasks such as face washing and hair brushing were inconsistently performed. Observations confirmed that at times, no CNAs were present on the floor, and staff reported that the unit was frequently staffed with only one nurse and two CNAs for 34 rooms, with some residents requiring two-person assistance for transfers. Multiple residents and staff expressed concerns about low staffing levels, with reports of call lights going unanswered for extended periods and residents feeling reluctant to request assistance. Staff described being floated to other buildings and feeling short-staffed more than half the time. The call light system was also reported to be down, preventing the facility from providing call light response data. These staffing shortages directly contributed to delays in care, incomplete ADLs, and inadequate repositioning for residents at risk of skin breakdown.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in unmet care needs. For one resident with multiple diagnoses including congestive heart failure, diabetes, and pulmonary fibrosis, the care plan did not include essential details related to dialysis care. Missing elements included the dialysis center's contact information, specifics on monitoring pre- and post-dialysis vitals, transportation arrangements, the type and location of dialysis, which arm to use for blood pressure, emergency contacts for dialysis-related issues, and monitoring for complications such as infection or hypotension at the access site. Another resident with cognitive impairment, ataxia, and a history of traumatic brain injury experienced repeated elopement incidents. The care plan did not identify the resident's elopement risk or outline interventions to prevent further incidents, nor did it include person-centered activities or diversions tailored to the resident's interests or dementia progression. Despite multiple documented elopements and discussions about transferring the resident to a secure unit, the care plan was not updated to reflect these risks or interventions.
Deficient Respiratory Care: Incomplete Oxygen Orders, Poor Tubing Documentation, and Infection Control Lapses
Penalty
Summary
The facility failed to ensure that oxygen therapy orders for several residents included a specific rate of oxygen delivery. Observations revealed that multiple residents were receiving oxygen via nasal cannula, but their provider orders only specified to maintain oxygen saturation above a certain percentage, without indicating the exact flow rate. In some cases, contradictory orders were present, and staff interviews confirmed that orders often lacked a defined rate, especially when transferred from hospital records. This omission was noted for four residents, with staff acknowledging the issue and attributing it to the electronic medical record systems used. Additionally, the facility did not maintain proper documentation or labeling to indicate when oxygen tubing was last changed for several residents. During observations, none of the oxygen tubing in use had visible dates or labels showing the last change, despite facility policy requiring weekly changes and documentation. Staff interviews revealed uncertainty about where or if tubing changes were documented, and it was noted that a recent staffing mix-up may have contributed to the lack of labeling. A whiteboard in the nurse's lounge outlined the process, but this was not consistently followed in practice. Furthermore, infection control practices were not adhered to regarding respiratory equipment. One resident's nebulizer machine and mouthpiece were observed on the carpeted floor next to a trash receptacle, with the mouthpiece touching the floor and covered with used tissues. Staff confirmed that this did not meet infection control standards and acknowledged that the resident was unlikely to have placed the equipment there independently. The resident had a current order for nebulized albuterol four times daily, indicating frequent use of the equipment.
Failure to Include Essential Needs in Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans that included the minimum necessary instructions to provide effective and person-centered care for three of seventeen sampled residents. Specifically, observations revealed that multiple residents were receiving oxygen therapy, but their baseline care plans did not address problems, goals, or interventions related to oxygen use. One resident, who also had a urinary catheter due to urinary retention and required extensive assistance with activities of daily living (ADLs) because of a cancer diagnosis, did not have these needs reflected in the baseline care plan. Interviews with staff confirmed that baseline care plans were initiated at admission but did not consistently include all required information for continuity of care. Staff acknowledged that areas such as ADLs, pain, urinary issues, falls, psychotropic medications, and oxygen therapy should be included, but these were sometimes omitted. Additionally, staff noted that some aspects of the computer system used for care plan entry needed to be addressed to ensure thorough completion of baseline care plans.
Incomplete Medical Records and Missing POLST Signature
Penalty
Summary
The facility failed to maintain complete and accessible medical records for several residents, specifically lacking medical provider visit notes in both the electronic medical record (EMR) and paper charts. For four residents, there were no medical provider visit notes available in the EMR or in the paper charts at the nurse's desk, despite the residents having been admitted months prior. The process for handling provider notes involved receiving them via facsimile, review by the charge nurse, and subsequent scanning into the EMR, with the original faxed copy placed in the paper chart. However, the most recent notes had not been scanned, and in some cases, no notes were found in either record system. Staff confirmed that a nurse was present during provider visits but did not document the visit in the EMR, and the facility was in the process of changing to direct provider entry into the EMR. Additionally, the facility failed to ensure that a resident's Provider Orders for Life-Sustaining Treatment (POLST) form was properly completed, as one resident's POLST lacked a required physician signature. The unsigned POLST had been carried over from a previous facility and was not identified as incomplete during the admission or care planning process. Facility policy required that advance directives be copied and placed on the chart upon admission and reviewed periodically, but this process did not identify the missing signature.
Failure to Include Oxygen Therapy and Aspiration Risk in Care Plans
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan addressing all identified needs for two residents who were receiving oxygen therapy and for one resident with an increased risk of aspiration following a recent hospitalization for aspiration and respiratory failure. Observations confirmed that both residents were receiving oxygen via nasal cannula, and interviews with staff and residents revealed inconsistencies in the monitoring and supervision of meals, particularly for the resident with a history of aspiration. Documentation review showed that the Minimum Data Set (MDS) assessments for both residents indicated the use of oxygen therapy, and for one resident, documented swallowing difficulties and a history of aspiration. Despite these documented needs, the comprehensive care plans for both residents did not include problems, goals, or interventions related to oxygen therapy. Additionally, the care plan for the resident with a history of aspiration did not address the increased risk for aspiration or swallowing difficulties. Staff interviews confirmed that these care areas should have been included in the care plans, as identified by the MDS assessments.
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