Montana Mental Health Nursing Home

Inspectors wroteBased on interviews and record reviews, leadership staff failed to ensure residents were free from neglect of care and utilize or follow an effective system to identify, address, and correct concerns pertaining to staff member R's actions and failure to complete duties assigned when on shift and providing resident care, as to ensure residents were not neglected, and this failure affected 11 (#s 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, and 12) of 17 sampled residents. This failure continued over several months.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to have an effective and accurate system in place for the identification and correction of medication administration documentation omissions for physician-ordered medications. Due to this, it was unknown if the sampled residents received the physician-ordered medications, due to the lack of documentation, or what the reasoning was for the undocumented medication administrations, and it was unknown if a medication error occurred or if the residents had an outcome from an error, since the concerns were unaddressed. [...]

Inspectors wroteBased on observations, interviews, and record reviews, facility administrative staff failed to act timely and thoroughly to address concerns brought forth related to a staff member providing resident care and services, and to ensure neglect of care was not occurring, for 11 (1, 2, 3, 4, 5, 7, 8, 9, 10, 11, and 12); and administrative staff did not identify or act on concerns related to the medication administration policy, procedures, or system, and implement corrections, so concerns were ongoing, and this affected 12 (#s 1, 2, 3, 4, 5, 7, 8, 9, 11, 14, 16, 17) of 17 sampled residents.

Inspectors wroteBased on interview and record review, a staff member failed to provide necessary ADL care for a dependent resident when the staff member was directed to provide the necessary care, but the staff member left the shift and did not help the resident, and the resident was found with a soiled brief/chair, for 1 (#6) of 17 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify two areas of concern, which were contributing factors for a resident's severe weight loss of 11.86% over 3 months, which included the resident's increased sedation [sleeping through meals], and the resident had an ADL decline. The facility did not address the two contributing factors timely manner, in an attempt to intervene and prevent the severe loss, for 1 (#1) of 14 sampled residents.

Inspectors wroteBased on interview and record review, staff assigned to deliver mail to residents failed to do so for an extended period, and the mail was found piled in an employee's office, undelivered; and some mail was time-sensitive or confidential. This failure involved 9 (#s 6, 7, 8, 9, 10, 11, 12, 13, and 14) residents out of 14 sampled residents. It was also identified that staff did not assist residents with cognitive impairments with opening or understanding the mail. Findings Include:Review of the facility investigation notes for a Facility Reported Event, dated 1/10/25, which was related to undelivered mail, showed:-Residents 6, 7, 8, 9, 10, 11, 12, 13, and 14 had either personal mail, legal mail, or holiday packages sent to the faculty, which were undelivered between October 2024 and the beginning of January 2025. -Resident #6 was interviewed on 2/6/25 but unable to answer. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's physician, dietician, and representative in a timely manner of the resident's severe weight loss, for 1 (#1) of 14 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to address the timely completion or implementation of treatment wishes, specifically related to the Provider Orders for Life-Sustaining Treatment (POLST) forms, for 2 (#s 43, and 60); and failed to ensure advanced directives were in place for 1 (#37) of 29 sampled residents.

Inspectors wroteBased on interview and record review, facility staff failed to ensure an allegation of resident-to-resident abuse was reported to the State Survey Agency, within 24 hours after the allegation occurred, for 6 (#s 26, 37, 47, 53, 64, and 70) of 29 sampled residents.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure expired immunizations which were stored in 1 of 2 medication refrigerators in the treatment room were properly disposed of. The facility failed to monitor the treatment room and unit medication refrigerator and freezer temperatures. This failure created the potential for residents to experience negative effects related to the administration of expired Shingrix immunizations and negative effects related to inadequately monitored medication and immunization refrigerator and freezer temperatures.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the consistent practice of properly dating and labeling open foods, storing food, and monitoring food temperatures in unit refrigerators and freezers. This failure had the potential to lead to food borne illnesses and improper infection control practices for residents consuming food from the refrigerators and freezers on the Glacier and Firefly units.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident medical record documentation was dated appropriately, labeled with the resident's information, and completed in entirety, for 4 (#s 11, 43, 60, and 66) of 29 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to notify the guardian of a transfer to the emergency department, for 1 (#9) of 29 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to implement an effective discharge planning process for 1 (#67) of 1 sampled resident, who left the facility Against Medical Advice.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 (#43) of 29 sampled residents was administered oxygen at the rate the physician had prescribed, and ensure respiratory equipment was maintained in a manner of acceptable parameters.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a resident's right to privacy for 1 (#2) of 2 residents sampled for hoarding tendencies. This deficient practice caused the resident mental anguish and distrust of her caregivers.

Inspectors wroteBased on interview and record review, the facility failed to investigate and protect other vulnerable residents from potential financial exploitation after 1 (#1), of 3 sampled residents, was approached by a staff member to become a financial payee.

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards related to a resident's hoarding behavior and interventions, for 1 (#2) of 2 residents sampled for hoarding tendencies. This deficient practice resulted in a resident's mental anguish including crying, distrust of staff, and fear of leaving her room. During an interview on 4/9/24 at 9:20 a.m., resident #2 stated staff had gone into her room when she was out of the facility and cleaned it out. She stated she was missing items like a Starbucks cup, a card from her sister, and a small pencil she liked to write with. Resident #2 stated these things were not on the ground or creating any type of tripping hazard. Resident #2 stated she was bothered because she had trusted staff and had been taken by surprise. [...]

Inspectors wroteBased on interview and record review the facility failed to update and revise care plans for 2 (#'s 13 and 43) of 21 sampled residents. This deficient practice did not show updated problems or interventions that would give staff the correct information to properly care for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safeguard a resident from recurring aspiration pneumonia for 1 (#43) of 21 sampled residents. The resident was admitted to the hospital on three occasions for aspiration pneumonia.

Inspectors wroteBased on interview and record review, the facility failed to follow a dietician's recommendation for a resident with severe weight loss for 1 (#28) of 1 resident sampled for weight loss.

Inspectors wroteBased on observation, interview, and record review the facility failed to educate and complete skill competencies for staff in the areas of feeding and aspiration for 1 (#43) of 21 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure missing resident dentures were reported to the IDT and investigated/replaced for 1 (#28) of 1 sampled resident.

Inspectors wroteBased on interview and record review, the facility failed to provide a pneumovax vaccination for 1 (#64); and failed to have a signed declination in the medical record for 1 (#13) of 21 sampled residents. This deficient practice had the potential to cause an increased risk of infection during pneumonia and influenza season.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement effective fall interventions and provide adequate supervision or devices for a resident who had significant fall history and risk factors for more falls. This failure resulted in head lacerations and a hospitalization for 1(#14); failed to implement interventions to reduce risk for falls for 1(#5) of 7 sampled residents, and this increased the risk of injury for both of the residents identified.

Inspectors wroteBased on interview and record review, the facility failed to have a system in place to notify the resident and the resident's representative, in writing, of transfers to the hospital for 4 (#s 1, 14, 31, and 41) of 4 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff had a COVID-19 vaccine, or an exemption or delay for the vaccine, prior to providing care, for 1 (staff member K) of 7 sampled staff members. This deficiency had the potential to increase the incidence of COVID-19 amongst residents and staff in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure direct care staff implemented care planned interventions related to fall prevention for 2 (#s 5 and 14) of 7 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise and implement effective interventions for a resident with declining ambulation ability. This failure resulted in injury to 1 (#14) of 1 sampled resident. During an observation and interview on 8/15/22 at 3:59 p.m., resident #14 was noted to have a healed wound in the middle of her forehead, near the scalp line. The resident stated she got the wound on her head when she fell. During an observation and interview on 8/16/22 at 2:43 p.m., resident #14 stated, I fell out of bed (this morning), I was trying to get up. Resident #14 had a new bandage and bruising above the left eye. During an interview on 8/16/22 at 3:55 p.m., staff member P stated resident #14 was walking around frequently and was involved in activities around three months ago, and had experienced a large decline recently. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to identify and provide necessary care for a skin rash for 1 (#45) of 1 sampled resident.

Inspectors wroteBased on interview and record review, the facility failed to directly monitor and document the intake of meals for 1 resident (#1) of 3 sampled residents healing from a fracture.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing personnel had the knowledge necessary for providing resident care regarding fall prevention and care plan interventions, after orientation for 1 (#5) of 7 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of floor stock expired medications. This deficient practice had the potential to affect all residents who utilized the facility's medication floor stock.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during toileting, and the handling of food for 1 (#8) of 17 sampled residents.