Montana Veterans Home N H

Inspectors wroteBased on interview and record review, the facility failed to recognize and prevent sexual abuse and neglect, and identify the residents' ability to consent to sexual activity, for 9 (#s 9, 12, 17, 44, 61, 77, 78, 80, and 89) of 28 sampled residents. This deficient practice resulted in residents participating in sexual activities who were unable to make their own decisions, which increased the risk of sexual abuse and psychosocial harm for residents, and this was identified to be an Immediate Jeopardy situation; and, based on observation, interview, and record review, the facility failed to ensure a resident was free from physical abuse by a staff member, which resulted in a skin tear on the resident's left hand for 1 (#20) of 28 sampled residents. On [DATE] at 9:58 a.m., the Administrator and facility management team were notified that an Immediate Jeopardy existed in the area of F600. [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate allegations and resident actions of sexual abuse for 3 (#s 9, 17, and 89) out of 28 sampled residents. This deficient practice increased the risk of incidents occurring in the future for these residents, and others, and the residents were identified to be vulnerable and unable to consent to sexual activity. The facility staff did not identify the resident actions as potential abuse or protect them, and staff were aware of the resident actions but did not address the alleged potential abuse, reflecting the facility's abuse education program was not sufficient to ensure resident safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure the care plan contained a care area and interventions regarding sexual behaviors and interactions between residents, for 2 (#s 17 and 80) of 28 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to provide the required forms to residents who were ending skilled Medicare Part A services, to allow the resident or responsible party the opportunity to accept the discontinuation of coverage decision, appeal the decision, or agree to pay privately out of pocket, for ongoing services; and the facility failed to obtain the necessary signatures on these ABN and NOMNC forms, for 3 (#s 9, 11, and 113) of 3 sampled residents for the completion of the forms. This deficient practice may affect others ending skilled Medicare A services, due to the system failures identified with the handling of the forms. Findings Include: A. Review of resident #9's SNF Beneficiary Protection Notification Review form, was filled in showing the last covered day was 5/21/24 as a facility-initiated discharge from Medicare part A services. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label medications by only using the residents last name on medications removed from their original container and failed to properly store a narcotic during the practice of pre-pouring medications during the morning medication pass, for the residents on the 400 hall. This deficiency increased the risk of medication administration errors, and the potential for a narcotic medication to be mishandled.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to professional standards of care during medication administration pass and medications were pre-poured. This deficiency resulted #11 being handed the wrong cup of medications to take during morning med pass, and the medications were for resident#58. This practice had the potential to affect #58 or others residing on the 400-hall.

Inspectors wroteBased on interview and record review, the facility failed to protect residents from verbal and physical abuse, perpetuated by a staff member, for a resident with dementia, for 1 (#12) of 4 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a person-centered care plan to meet the resident's mental and psychosocial well-being for a resident with PTSD, and the resident voiced concerns related to triggers occurring, for 1 (#58) of 3 sampled residents.

Inspectors wroteBased on interview and record review, the facility staff failed to identify and address PTSD, provide trauma-informed care, and meet professional standards that accounted for the resident's experiences and preferences to manage and prevent or attempt to minimize PTSD triggers, for 1 (#58) of 3 sampled residents, and the triggers, especially at night or news, would cause him panic at times.

Inspectors wroteBased on interview and record review, the facility failed to provide completed beneficiary notices for 3 (#s 37, 41, and 48) of 3 sampled residents. This deficiency had the potential to affect any resident with discontinued Medicare part A services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish consent or develop a facility policy for continuous camera/video monitoring of residents, potentially violating a residents' right to privacy, for 2 (#s 23 and 47) of 2 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to act on an allegation of staff to resident abuse, and the resident had a mental illness and complained about a staff member's interactions with her on more than one occasion, and the resident considered it ongoing mental abuse; and, the facility failed to show why the allegation of abuse was not substantiated, for 1 (#29) of 6 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to report a resident allegation of mistreatment and potential mental abuse to the State Survey Agency for 1 (#29) of 6 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate two allegations of mistreatment and potential mental abuse, allowing the mistreatment and potential mental abuse to continue, for 1 (#29) of 6 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to manage oxygen therapy for 1 (#8) of 2 sampled residents, which could lead to an upper respiratory infection and exacerbation of respiratory symptoms due to low oxygen saturation for the resident(s).