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
The facility did not maintain a designated full-time DON for an extended period, leaving the position vacant while DON responsibilities were informally divided among the IDT. Emails from the administrator showed that the previous DON had left and that a job posting was created, but there was no documentation that the DON’s duties were specifically reassigned to an RN or multiple RNs during the vacancy. A later email documented the start date of a new DON, confirming a gap of several weeks without a formally designated DON.
Multiple residents experienced abuse, neglect, and unaddressed complaints, including a resident who reported that another resident entered her room at night, held her down, attempted to get into bed with her, and yelled at her while she screamed for help without timely staff response, leaving her fearful of further harm. Another resident, dependent on staff for toileting and transfers and with depression and communication deficits, repeatedly expressed fear of her roommate’s loud, hostile behavior and felt staff did not listen to her concerns. Additional residents reported being left wet in bed, having pads added to briefs so CNAs would not have to change them as often, being turned by a single staff member despite a two-person assist requirement, having their heads hit against the wall during care, and being found in the morning soaked in urine from shoulders to shoes in the same clothes as the previous day. Several staff described routinely finding soaked beds, poor peri and oral care, and complaints about missed or improper care, while leadership reported being unaware of these issues and unable to locate related grievances, despite policies requiring immediate reporting and investigation of suspected abuse and neglect.
Two residents were involved in an alleged abuse incident in which one resident reported that a male resident entered her room at night, held her arms down, tried to get into bed with her, and ignored her prolonged calls for help, after having previously entered her room on other occasions. The resident described being very upset and fearful of further harm. Although facility policy required interviewing the alleged victim, alleged perpetrator, and witnesses, leadership acknowledged they did not initially complete staff or resident interviews and did not treat the event as abuse, even though a CNA later documented finding the male resident in another room, the call light on, the resident yelling for help, and water thrown around the room.
A resident with dementia, a trauma history, hallucinations, and longstanding behavioral symptoms such as wandering into other rooms, verbal and physical aggression, and disrobing experienced two separate sexual incidents with male residents. In one event, a male was found in the resident’s room with his hands down her pants while she verbally rejected him; in another, staff found a male without pants lying on top of the fully clothed resident on his bed while she yelled for him to get off. Staff interviews and records showed that, although non-pharmacologic interventions (snacks, showers, one-on-one, aroma therapy, warm towels) and multiple psychotropic medication changes were used, the facility did not develop or document a defined monitoring and supervision program specifying the level, duration, or methods of oversight to address the resident’s wandering, entry into other rooms, and sexually related interactions after these incidents, nor were the sexual encounters incorporated as identified triggers in the care plan.
The facility failed to report a resident-to-resident abuse incident to the State Survey Agency within the required 24-hour timeframe. Staff reported that incidents must be reported within 24 hours, with 2-hour reporting for serious bodily injury and investigation results due within 5 days, and the facility’s written policy reflected these requirements. However, an altercation between two residents was reported more than 24 hours after it occurred, contrary to the facility’s mandatory reporting policy and the timelines described by staff.
The facility failed to serve lunch at its scheduled times, with trays on one unit being delivered 36–47 minutes late on multiple days, despite a written schedule specifying earlier service. A resident on that unit experienced repeated delays, with a family member reporting that meals were often late and that the resident was not allowed to lie down until after lunch, causing frustration when lunch arrived significantly behind schedule and was then refused. Staff interviews confirmed that meals had been running late more frequently, citing short staffing in the kitchen, training of a new cook, and the time required to dish up and pass trays, in contrast to the facility’s policy requiring three daily meals without extensive time lapses.
Surveyors identified a failure to store food according to professional standards when they observed multiple open and prepared food items in the walk-in freezer and refrigerator without labels or dates, including an open bag of French fries, cut tomatoes and onion wrapped in cellophane, and a half-empty pan of red Jello. The dietary supervisor reported that staff are instructed to check received and expiration dates, label and date all open and cut items, and use a posted "Use by Date Guide" as a reminder, and facility policy requires labeling, dating, monitoring refrigerated foods, and keeping foods covered or in tight containers.
The facility failed to complete thorough investigations and implement incident-specific interventions following two reported events. In one case, a cognitively impaired resident in a wheelchair was taken outside through an alarmed door by a vendor, preventing the alarm from sounding, and staff were unaware the resident had left until notified by family; the subsequent review focused on door alarms and resident risk factors but did not address the vendor-assisted exit or lack of alarm activation as the root cause. In another case, a resident was found after shift change in urine-soaked clothing and a soiled brief, with the facility later unable to provide complete investigation documentation, interdisciplinary review notes, evidence of staff education, or proof that the resident’s provider and responsible party were notified, contrary to its abuse/neglect policy requiring complete written investigation records and reporting.
A resident eloped from the facility without staff knowledge by exiting through an alarmed door that had been deactivated by a vendor. Following the incident, staff reported that the care plan would be updated after an IDT review, and facility documentation stated the plan would reflect a need for closer monitoring and supervision near exits. However, the actual care plan revision only included adding the resident to an elopement binder, providing education about not leaving without assistance, encouraging use of an enclosed patio, and general wandering/elopement interventions, without specifying closer supervision at exits. This failed to align with the facility’s own elopement policy requiring that risk-related interventions be incorporated into the care plan and communicated to staff.
A resident who required partial/moderate assistance with toileting hygiene and was frequently incontinent of bladder and bowel was found in bed with urine-soaked clothing and a soiled brief after a shift change. Day shift staff discovered the condition while beginning morning care and reported that the off-going night shift staff member, who had been responsible for the resident, did not communicate any need for incontinence care. The resident’s care plan required regular checks for incontinence and prompt peri-care, but this was not carried out, and the facility’s investigation identified a lapse in care by the night shift staff member.
Failure to Maintain a Designated Full-Time DON
Penalty
Summary
The facility failed to designate a full-time DON as required, leaving the position vacant for 37 days. During interviews, staff members B and C reported that the facility had been without a DON for a little over a month and that DON tasks were divided among the IDT during this period. An email from staff member A dated 9/8/25 showed an advertisement posting for the DON position and indicated that the IDT took over DON tasks after the previous DON left, but there was no documentation that the prior DON’s duties were specifically reassigned to an RN or multiple RNs. Another email from staff member A on 9/8/25 confirmed that the previous DON no longer worked at the facility, and a subsequent email dated 10/16/25 documented that staff member B started as the new DON on that date, confirming the facility was without a designated DON from 9/8/25 through 10/16/25. No residents or specific patient conditions were mentioned in the report, and the deficiency centers solely on the lack of a designated full-time DON and the absence of documented reassignment of DON responsibilities to an RN during the vacancy period.
Failure to Protect Residents From Abuse, Neglect, and Inadequate Response to Complaints
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from abuse and neglect, and to respond appropriately to allegations and signs of mistreatment. One resident reported that another resident entered her room at night, held her arms down, attempted to get into bed with her, and repeatedly yelled at her while she screamed for help and no staff responded for some time. She stated this resident had previously entered her room on two other occasions and used her toilet. She remained fearful that he might return and potentially harm or sexually assault her, and she believed his room had been moved away from hers, although their rooms remained side by side. Facility documentation from that night showed a CNA returned from break to find the alleged perpetrator in another resident’s room and the victim yelling for help with water all over the room, but facility leadership later could not locate resident interviews about the incident and were unaware of the victim’s ongoing fear and feelings of being unsafe. Another resident expressed fear and distress related to her roommate’s behavior and the environment in their shared room. She cried and begged staff not to take her back to her room, stating she was scared to go in because her roommate wanted everything her way, kept the TV very loud so she could not rest, became angry when she entered the room, and insisted her own needs be the priority. The resident stated she had reported these concerns to CNAs and nurses, but felt no one listened. During an observation when staff brought her to the room for toileting, the roommate yelled, “Now what?!” and became agitated with staff and the resident before growling and returning to bed. The resident’s care plan showed she was dependent for toileting, required a Hoyer lift for transfers, and had hearing impairment, expressive aphasia, and depression, indicating she relied heavily on staff to advocate for and address her concerns. A third resident reported being left wet at night with an additional pad placed in her brief so staff would not have to change her as often. She stated she was on antibiotics for a UTI and believed CNAs were not changing her during the night. She also reported that staff frequently attempted to turn her alone despite her care plan requiring two-person assistance and use of a sit-to-stand, causing pain and resulting in her head being hit against the wall repeatedly during brief changes. She described a night CNA answering her call light, saying she would return, but failing to come back, leaving her to wet herself and her bed, and then later yelling at her for wetting herself and adding a pad to her brief while stating she did not want to change her every two hours. Her care plan and MDS confirmed she required maximal assistance with toileting hygiene, care in pairs, and that she was on antibiotics for a UTI. Another resident was found by a staff member in the morning lying diagonally in bed with his feet dangling off the edge, soaked with urine from his shoes to his shoulders, with urine pooling in the bed and the bed saturated. He was still in the same clothing from the previous day. The staff member reported that earlier staff had tried to get him up but, after he refused, they left him in bed in that condition. The resident had severe cognitive impairment per his BIMS score, required maximal assistance for toileting, dressing, and walking, and was incontinent of bladder and bowel, indicating he was dependent on staff for continence care and repositioning. The staff member stated the resident did not resist care when she later attempted to get him up and clean. Multiple staff interviews described a pattern of neglected care, particularly on the night shift. One nurse reported frequent complaints about resident care being neglected, including improper transfers, residents’ heads being hit on the wall when only one staff member was used instead of two, soaked beds, use of pads in briefs to avoid changing them, unmet food preferences, and medications not given on time. She stated she re-educated CNA staff, many of whom were agency staff, but did not report these concerns to management. Other staff reported commonly finding residents in soaked beds, poor peri care, lack of oral care, and residents complaining about not receiving peri cream or timely brief changes. One staff member specifically noted that one resident was soaked and had inadequate peri care, resulting in red and inflamed skin folds around her pannus. Despite these repeated concerns, facility leadership reported they were unaware of the specific neglect issues for several residents and could not locate grievances or complaints related to them, even though staff stated they had reported issues to nurses or written grievances. Facility policies required immediate reporting, investigation, and protection related to suspected abuse and neglect, but the described events show failures to follow these policies and to protect residents from abuse, neglect, and psychosocial harm.
Failure to Fully Investigate Resident-on-Resident Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to fully investigate an allegation of abuse between two residents and to follow its own abuse investigation policy. One resident reported that on the night of 12/28/25, another resident entered her room, held her arms above her head and down, attempted to get into bed with her, and repeatedly yelled, “You know who I am.” She stated she screamed for help for quite some time and no one came. She described trying to defend herself by hitting the other resident, throwing water at him, and wishing she could have used her cane, which was across the room. She also reported that the same resident had previously entered her room on two other occasions and used her toilet before leaving. The resident stated she was scared, upset, and fearful that the other resident would return at night and potentially harm or sexually assault her, and she was not aware that his room remained next door to hers. The facility’s written policy on abuse investigations, updated 10/22, required identification and interviews of involved persons, including the alleged victim, alleged perpetrator, witnesses, and others with knowledge of the allegations. However, during interviews, facility leadership acknowledged they did not initially have staff or resident interviews for the facility-reported incident involving the two residents. They later located some staff statements, including one from a CNA who documented returning from lunch to find the alleged perpetrator in another resident’s room, the alleged victim’s call light on, and the alleged victim yelling for help, very upset, and reporting that a man had tried to get into bed with her, that she had hit him, yelled for help, and thrown water at him, with water observed all over the room. Staff further stated they did not consider the incident to be abuse at the time, which contributed to the residents’ rooms remaining next to each other and to the lack of a complete investigation consistent with facility policy.
Failure to Implement Adequate Supervision and Monitoring After Resident Sexual Incidents
Penalty
Summary
The deficiency involves the facility’s failure to identify and implement necessary and beneficial supervision and monitoring interventions for a cognitively impaired resident with a history of trauma and significant behavioral symptoms, including wandering into other residents’ rooms and sexually related interactions with male residents. Interviews with multiple staff members confirmed that the resident frequently wandered the halls, entered other residents’ rooms, displayed verbal and physical aggression, yelled, ran on the unit, and sometimes removed her clothing or kept her hands in her pants. Staff were aware that the resident had a trauma history, including being locked in her room by a family member prior to admission, and that she had auditory and visual hallucinations, paranoia, and worsening behaviors around menstruation. Despite this, the care plan and behavior documentation did not clearly link her behaviors to the sexual interactions with male residents or identify new contributing factors after those events. The record shows two separate sexual incidents involving the resident and male residents. In the first incident, documented in the nursing notes, a male resident was found in the resident’s room with his hands down the front of her pants while she stated, "I don't like you." The male was redirected, and the provider adjusted medications, but documentation only stated that staff were to monitor the resident for increasing behaviors without specifying how long, what level of monitoring, or how staff were to keep her safe. In the second incident, staff heard the resident yelling "help me" and "get off" and found her fully clothed, lying crossways on a bed in a male resident’s room, with the male resident on top of her without pants and making thrusting movements. Staff separated the residents and returned her to her room, and again documentation only referenced closer monitoring without defining duration, intensity, or specific safety measures. Behavior review notes from several months showed persistent and escalating behaviors: wandering, pacing, entering other residents’ rooms, refusing redirection, yelling, crying, verbal hallucinations, paranoia, refusing medications and care, physical and verbal aggression toward staff, slamming and banging on doors, furniture, and walls, and attempts to pull her pants down in common areas. After the sexual incidents, new behaviors such as having her hands in her pants and attempting to remove clothing in public areas appeared, along with increased agitation, refusal of meals and medications, and statements that people were trying to kill or be mean to her. The behavior review identified triggers such as incontinence, reportable events, shingles, dental pain, clothing preferences, and phone calls with family, and listed non-pharmacologic interventions like snacks, one-on-one time, walking with staff, back rubs, aroma therapy, warm towels, and use of different staff. However, the care plan and behavior documentation did not incorporate the sexual encounters as triggers, did not identify prior sexual abuse as a trauma factor, and did not specify any enhanced supervision or monitoring level to protect the resident from further harm related to her wandering and sexually related interactions. The care plan for cognitive loss/dementia and psychosocial well-being included general interventions such as providing consistent caregivers, encouraging expression of feelings, and assisting the resident to avoid trauma triggers, with trauma history listed as car accidents, fires, heart attacks, deaths in the family, and the murder of an aunt. There was no mention of sexual trauma or the recent sexual incidents as part of her trauma profile. Behavioral symptom interventions, many of which were not initiated until after the period of escalating behaviors, focused on pain assessment, use of different staff, aroma therapy, warm towels, and recognition that menstruation worsened behaviors. Medication reviews showed multiple antipsychotic and psychotropic adjustments, including Abilify, Seroquel at various doses, Haloperidol, and PRN Ativan, with documentation that Seroquel changes had little to no effect on her behaviors. Despite ongoing documentation of high-risk behaviors and two documented sexual encounters with male residents, the facility did not develop or document a clear, individualized monitoring and supervision program specifying the level, duration, and methods of oversight needed to maintain the resident’s safety in relation to her wandering and sexual encounters.
Failure to Timely Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report an incident of suspected abuse within 24 hours as required by its policy and staff-stated procedures. During interviews, staff members B and C stated that incidents must be reported within 24 hours and that investigations begin as soon as a reportable event is known, with annual abuse training and additional in-services on abuse and reporting timelines. Staff member A stated that the administrator, DON, and Social Services are responsible for obtaining statements from staff and residents, and confirmed that the time frames for reporting to the State Survey Agency are 2 hours for incidents involving serious bodily injury and 24 hours for incidents without serious bodily injury, with investigation findings due within 5 days. Record review showed that an incident of resident-to-resident abuse involving an altercation between residents #8 and #10, which occurred on 8/16/25, was not reported to the State Survey Agency until 8/18/25, exceeding the 24-hour reporting requirement. Review of the facility’s policy titled “Mandatory Reporting for Montana Nursing Facilities” confirmed that resident-to-resident abuse must be reported within 24 hours of discovery, that there is a 2-hour reporting requirement for crimes resulting in serious bodily injury, and that investigation results must be sent to the state agency within 5 working days of receipt of the abuse report. Despite these established policies and staff awareness of the required timelines, the facility did not submit the abuse incident involving residents #8 and #10 within the mandated 24-hour period from the date of the incident.
Late Meal Service and Resident Frustration Due to Delayed Lunch Trays
Penalty
Summary
The deficiency involves the facility’s failure to provide meals at the scheduled times established by its own meal schedule, resulting in resident frustration. The facility’s posted meal schedule indicated that lunch trays for Birch Hall residents were to be delivered at 12:20 p.m. However, observations on two separate days showed that lunch trays were passed significantly later than scheduled: at 12:56 p.m. on one day (36 minutes late) and at 1:07 p.m. on another day (47 minutes late). On one of these days, the last lunch tray to Birch Hall was still being delivered at 1:14 p.m. Staff interviews confirmed that meals were sometimes late, that residents often sat waiting in the dining room for extended periods, and that meals had been served late more frequently recently. One resident, identified as resident #31, was directly affected by these delays. On one day, the resident’s lunch tray was delivered to his room at 12:56 p.m., and a family member (NF1) reported that lunch meals were often served late and that “you get used to it over time.” On another day, NF1 approached staff to ask where the lunch meal was, stating that the resident wanted to lie down but had been told he could not do so until after lunch, and that he was not happy lunch was so late. When the tray was finally delivered at 1:07 p.m., the resident expressed dissatisfaction with the meal, and NF1 returned the tray and ordered an alternative. Staff interviews attributed the late meals to factors such as training a new cook, being short two kitchen staff members, and the time it took staff to dish up and pass the meals, despite a facility policy stating that residents would receive at least three meals daily without extensive time lapses between meals.
Failure to Label and Date Open and Prepared Food Items in Dietary Storage
Penalty
Summary
Surveyors found that the facility failed to store food in a sanitary manner in the dietary department. During an observation of the walk-in coolers, an open bag of French fries was found in the freezer with no label or date. In the refrigerator, two halves of a tomato wrapped in cellophane, half of an onion wrapped in cellophane, and a large pan of half-empty red Jello were also observed without any labels or dates. These items were not labeled or dated as required by facility policy. In an interview, the dietary staff member responsible for directing dietary staff stated that she instructs staff to check the received date and expiration date when they open an item and to place a label and date on any open items and anything cut and wrapped in cellophane. She reported that she continues to remind staff to label open items and indicated that a "Use by Date Guide" was posted on the outside of the refrigerator door as a reminder of the rules for dating open items. Review of the facility’s Food Safety Requirements policy confirmed that food is to be stored in accordance with professional standards, including labeling, dating, and monitoring refrigerated food such as leftovers so it is used by its use-by date or discarded, and keeping foods covered or in tight containers.
Incomplete Incident Investigations and Lack of Incident-Specific Interventions
Penalty
Summary
The deficiency involves the facility’s failure to conduct comprehensive investigations and implement appropriate, incident-specific interventions following two separate facility-reported events. In the first event, a resident with moderate cognitive impairment (BIMS score of 11) exited the building in a wheelchair through an alarmed entrance door that had been opened by a non-employee vendor, which prevented the door alarm from triggering. Staff were unaware the resident had left the building and only became aware when a family member reported the resident was outside; video surveillance later showed the resident was outside unsupervised for an estimated 15 minutes. The facility’s investigation and documentation identified the resident’s impaired memory, confusion, and desire to smoke as risk factors and focused on staff response to door alarms, but did not accurately identify or address the root cause that the resident was assisted out by a vendor and that no alarm had sounded. In the second event, a resident was found in bed with urine-soaked clothing and a soiled brief by oncoming staff after shift change, following care responsibility by a night-shift CNA. The incident was reported up the chain of command, but the facility was unable to produce documentation showing that the resident’s responsible party or provider had been notified, nor could it provide risk management or event forms with detailed information about the incident. The facility’s written findings referenced interviews with other residents on the hallway, review of security camera footage, the CNA’s resignation, and an interdisciplinary team conclusion that there had been a lapse in care and that the incident was isolated. However, there was no complete and thorough documentation of the investigation, interdisciplinary team notes, event review, staff education, or evidence of required notifications, despite facility policy requiring comprehensive written procedures and documentation for investigations and reporting of alleged abuse, neglect, and exploitation.
Failure to Revise Care Plan After Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan to reflect current care needs following an elopement. A facility-reported incident submitted to the State Survey Agency documented that resident #67 eloped from the facility without staff knowledge, exiting through an alarmed door that had been deactivated by a facility vendor. Staff interviews indicated that care plans were expected to be updated by nurses or designated staff after such events and on an as-needed basis. The facility’s incident investigation stated that the resident’s care plan was updated to reflect a need for closer monitoring and supervision when approaching facility exits. However, review of resident #67’s care plan entry dated 9/27/25 showed only that the resident was added to an elopement binder, educated not to leave the facility without assistance, and instructed to use an enclosed patio to enjoy the outdoors, along with general interventions such as engaging the resident in purposeful activity, identifying triggers for wandering or eloping, and providing calm, reassuring care. The care plan did not specify the need for closer supervision and monitoring when the resident approached facility exits, as identified in the incident investigation. This omission occurred despite a facility policy on elopements and wandering residents that required interventions to increase staff awareness of a resident’s risk and to minimize associated hazards to be added to the resident’s care plan and communicated to appropriate staff.
Failure to Provide Timely Incontinence and ADL Assistance
Penalty
Summary
Staff failed to respond timely to a resident’s need for assistance with activities of daily living, specifically incontinence care. A facility-reported incident documented that on 6/5/25 at 8:40 a.m., a staff member found resident #99 lying in bed in urine-soaked clothing and a soiled brief. This was discovered by day shift staff members O and L after they completed shift change report with NF3, the night shift staff member responsible for the resident’s care. During interview, staff member L stated that NF3 did not report that the resident needed his brief and clothes changed and that it was not normal routine to leave a resident in a soiled brief or clothing. Resident #99’s MDS, with a quarterly assessment reference date of 5/14/25, showed he required partial/moderate assistance for lower body dressing and toileting hygiene and was frequently incontinent of bladder and bowel. His comprehensive care plan, initiated 3/24/25 for an ADL self-care performance deficit, included an intervention for staff to check him regularly for incontinence episodes and provide prompt peri-care after such episodes. The facility’s interdisciplinary team investigation identified a lapse in care by NF3 related to this incident, during which the resident remained in soiled clothing and a soiled brief without timely incontinence care.
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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