Billings Rehabilitation And Nursing LLC

Based on observation, interview and record review, the facility failed to adhere to a resident's individualized plan of care regarding repositioning and elevation of the heels to prevent skin breakdown for 1 (#79) of 25 sampled residents. Findings include:During an observation and interview on 2/23/26 at 2:55 p.m., resident #79 was lying flat on her back with a pillow beneath her legs, but her heels and feet were still touching the bed. Resident #79 stated she was never repositioned by staff but would lie flat on her back very frequently. Resident #79 stated, They're (staff) supposed to not let my heels touch the bed, but stated the staff members would often forget to do this task.During an observation and interview on 2/24/26 at 2:12 p.m., resident #79 was lying on her back and had a pillow underneath her legs. Her heels were not elevated but were resting on the pillow's surface. Resident #79 stated she was dependent on staff for help and would rarely get out of bed for activities. During an observation on 2/25/26 at 2:28 p.m., resident #79 was lying on her back and had her heels…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to thoroughly investigate an unavoidable accident to the level necessary to ensure appropriate measures were implemented to prevent recurrences for 1 (#73) of 25 sampled residents. The resident spilled soup on himself, causing burn(s), but it was unclear (upon watching video footage) who the person was who provided the resident with the hot soup, and or what action was taken to investigate the incident further in an attempt to prevent future recurrences of this nature. The facility treated the resident's burn(s), which did heal. Findings include: During an interview on 2/24/26 at 10:20 a.m., staff member B stated resident #73 sustained a burn injury after spilling hot soup onto himself on 10/30/25. Staff member B stated NF3 reported he had reviewed the facility's video footage of the incident and observed a tall male visitor in street clothes handing resident #73 a container. Staff member B stated NF3 did not offer any additional information on the investigation, including whether there had been a review of video footage near…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop an individualized care plan reflecting a resident's past trauma, did not address his desire for sexual activities on the individualized care plan, or initiate behavior monitoring for potential sexual behaviors; and the facility did not identify the need for additional mental health trauma-based services timely for 1 (#73) of 25 sampled residents. This deficient practice increased the resident's risk of negative outcomes and or behaviors continuing to be unaddressed or unmonitored, which could affect 2 residents (#s 22 and 46). Findings include:During an interview on 2/24/26 at 5:05 p.m., staff member N stated she witnessed resident #73 assisting resident #46 with eating. She stated resident #73 had his hand on resident #46's thigh. She said she felt it was inappropriate and asked resident #73 to remove his hand. Staff member N stated she was not aware if resident #73 had a care plan or was to be monitored for any sexual behaviors.During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure medications to be administered matched the dose on the medication administration record for 2 (#s 14 and 51), and failed to ensure the medication, Voltaren gel, was measured appropriately for 1 (#14) of 25 sampled residents. This deficient practice resulted in a medication error rate of 10.34%. Findings include:1. During an interview and observation on 2/24/26 at 7:32 a.m., staff member I prepared the morning medications for resident #14. Staff member I stated the MAR and the medication bottle did not match for resident #14's glucosamine chondroitin. Staff member I stated the bottle was half empty and facility staff members had most likely been giving this medication in the past. The medication bottle showed Glucosamine Chondroitin Complex and had the following substances: Vitamin C 30 mg, Manganese 2.5 mg, Sodium 20 mg, Potassium 28 mg, Glucosamine Sulfate 250 mg, and Chondroitin Sulfate 200 mg. The MAR failed to show any other substances were ordered by the physician.Review of resident #14's EHR…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident's right to be free from physical restraints for 1 (#4) of 6 sampled residents, when the resident's stump was secured to the wheelchair with an elastic compression wrap that the resident could not release. There was no physician's order authorizing the use of the restraint, no assessment of the resident's need or risk for the restraint, and no monitoring for the restraint was documented. This deficient practice had the potential to cause an increased risk for impaired skin integrity, falls, and injury. Findings include:During an observation on 11/3/25 at 4:04 p.m., resident #4 was sitting in a wheelchair by the nursing station. Resident #4 had a left below-the-knee amputation that was tied to the left footrest of the wheelchair by a tan colored compression wrap. Resident #4 was pulling at the compression wrap and was unable to remove it. When resident #4 was asked if he could remove the compression wrap, he shook his head…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to complete a baseline care plan within the 48-hour required time frame, that included resident specific needs for activities of daily living for 1 (#3) of 6 sampled residents. This deficient practice had the potential to affect all new admissions into the facility. Findings include:During an observation and interview, on 11/4/25 at 1:41 p.m., resident #3 was standing at the nursing station. Resident #3 had on a red colored t-shirt and a pair of jeans. Resident #3's shirt had dried food debris on it, and the jeans had dried brown stains consistent with what appeared to be coffee. There were multiple spots noted on resident #3's jeans. Resident #3 stated he needed assistance at times with dressing and hygiene because of his wound. Resident #3 stated he had been wearing the same pair of jeans for multiple consecutive days.During an interview on 11/4/25 at 2:58 p.m., NF6 stated resident #3 had some forgetfulness and confusion at times and would…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record reviews, the facility failed to develop and implement a person-centered, comprehensive care plan that assessed the dental status for 1(#4) of 6 sampled residents. This deficient practice had the potential for resident needs to be unmet by staff. Findings include:During an observation on 11/3/25 at 4:04 p.m., resident #4 was sitting in a wheelchair by the nursing station. Resident #4 was noted to be lacking teeth.During an interview on 11/4/25 at 7:50 a.m., staff member G stated resident #4 had dentures and was seen at a dental clinic last week. Staff member G stated family had provided resident #4 with another pair of dentures because his had been lost.During an interview on 11/4/25 at 12:25 p.m., staff member M stated resident #4 had dentures and most mornings he already had them in place when staff member M arrived on shift. Staff member M stated if the dentures were already in resident #4's mouth oral care did not need to be done. Staff member M stated all staff have access to the resident care plan. Staff member M stated there was no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to revise a resident's care plan, based on the resident's refusal to wear a [NAME] brace, and the staff's application of a compression wrap to maintain stump positioning on the wheelchair leg rest, for 1 (#4) of 6 sampled residents. The care plan did not reflect the restraint assessment findings, risks, or resident preferences related to the refusals of the [NAME] brace. Findings include:During an observation on 11/3/25 at 4:04 p.m., resident #4 was sitting in a wheelchair by the nursing station. Resident #4 had a left below the knee amputation that was tied to the left footrest of the wheelchair with a tan colored compression wrap. Resident #4 was pulling at the compression wrap and was unable to remove it. When resident #4 was asked if he could remove the compression wrap, he shook his head no.During an interview on 11/4/25 at 7:50 a.m., staff member G stated staff tied resident #4's stump to the leg rest on the wheelchair because, His…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure grievances were resolved in a timely manner related to delayed meal service for 3 (#s 18, 51, and 62) of 28 sampled residents. The failure placed the residents at elevated nutritional, psychosocial, and medication management risk. Findings include:1. During an observation and interview on 8/11/25 at 1:56 p.m., resident #18 was observed eating lunch in his room. Resident #18 stated, All the meals have been very late; 2 or more hours sometimes. I have complained, but it doesn't change anything. They just say they don't have enough help in the kitchen.2. During an interview on 8/11/25 at 3:12 p.m., resident #51 stated the meals are late almost all of the time. Resident #51 stated the meal delays have been going on for months.3. During an interview on 8/12/25 at 10:08 a.m., resident #62 stated the meals have been late regardless of where they are served. Resident #62 stated he had complained, stating, Nothing has changed; our meals are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to provide timely notice to the State Long-Term Care Ombudsman of discharge/transfer for 3 (#s 79, 89 & 91) of 28 sampled residents. Findings include:1.During an interview on 8/12/25 at 11:50 a.m., NF1 stated she had not received any transfer or discharge notifications from the facility. During an interview on 8/14/25 at 8:30 a.m., Staff member D stated she was pretty new to this position. She started a year ago and had a quick orientation, and had not known the ombudsman notification was something she needed to do. Staff member D stated she received training from the regional nurse and will now be sending all the notifications of transfer and discharge on the first Wednesday of every month. Staff member D stated the facility now had a process for notification to the ombudsman for transfer and discharge. Review of resident #79's nursing progress notes, dated 6/5/25, showed the resident was transported to the Emergency Department for evaluation. The resident was admitted to the hospital and returned to the facility on 6/14/25.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure resident meals were served timely for 5 (#s 4, 18, 20, 32, and 72) of 28 sampled and supplemental residents. This deficient practice led to frustration and distress over missing and/or being late to functions. Findings include:Review of the posted facility mealtimes showed: breakfast 7:30 a.m., lunch 11:30 a.m., and dinner 5:00 p.m.During an observation and interview on 8/11/25 at 2:15 p.m., resident #4 stated, Meals are always late, as you can see we just got lunch. A lunch tray was observed on the resident's table.During a resident council meeting surveyors were invited to on 8/12/25 at 3:03 p.m., the following interviews showed: Resident #72 stated, I have to rush to eat to make it to church on Sunday. I leave the room at 9:35 a.m. and need the tray before then for breakfast.Resident #18 stated he had gotten his evening medications before dinner the other night, the meal had been so late. Resident #32 stated lunch had been on time today and it was nice because she usually had to eat in a rush or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was supervised to prevent an elopement for 1 (#31) of 28 sampled residents. Resident #31 eloped from the facility without staff knowledge and was found by police in the park across the street from the facility. Findings include: Review of resident #31's reportable incident, dated 7/27/25, showed the resident had walked to the park across from the facility around 3:30 p.m. Staff were notified around 4:15 p.m., by local law enforcement, who stated the resident was seen at the park, and the resident fled when the law enforcement attempted to engage her. The incident report showed the facility administrator was notified at 4:23 p.m. and the resident was located at 4:31 p.m. The incident report showed the resident removed her wander guard, and exited through the main doors. During an interview on 8/14/25 at 9:00 a.m., staff member I stated resident #31 had a high BIMS (Brief Interview for Mental Status) of 13. Staff member I stated the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure staff performed proper suprapubic catheter care and maintenance for 1 (#35) of 28 sampled residents. This deficient practice resulted in an unidentified and untreated skin breakdown around the resident's suprapubic catheter. Findings include:During an interview and observation on 8/11/25 at 2:38 p.m., resident #35 stated the following regarding his suprapubic catheter: it would leak sometimes and the CNAs only clean around his catheter about every other brief change, he had frequent bladder infections, he had an open wound around his catheter that would get more red and gooey when the CNAs do not tape it to his leg, the staff rarely wear gowns when they clean around his catheter or change his briefs, and the CNAs usually clean his catheter tubing and around the insertion site with alcohol wipes. Resident #35's catheter was noted to not be secured to his leg to prevent pulling.During an interview and observation on 8/12/25 at 7:47 a.m., staff member J stated she was not clear what the actual orders were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to follow up on a re-weigh, document refusals, and implement interventions aimed at addressing a severe weight loss for 1 (#64) of 28 sampled residents. Findings include:Review of resident #64's documented weights showed:-1/3/25 163 lbs.,-2/1/25 162.4 lbs.,-3/11/25 163 lbs.,-4/5/25 163.4 lbs.,- May 2025 no weight documented or documented as refused on the treatment administration report or nursing progress notes.-6/1/25 146.6 lbs. This represented a 10.28% severe loss over two months.-July 2025 and August 2025 showed refusals in the resident's treatment administration record.There were no further documented weights.A request was made for resident #64's nutrition notes from February 2025 - current. Review of resident #64's weight change note, dated 6/5/25, showed, RD notes dramatic weight loss. Recommend re-weigh to confirm. There was no follow-up documentation related to the resident's re-weight or further dietary intervention.Review of resident #64's nursing progress note, dated 6/9/25, created 8/12/25, showed, late entry.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure staff followed proper infection control practices related to hand hygiene and proper use of PPE during suprapubic catheter care for 1 (#35) of 28 sampled residents. Findings include:During an observation and interview on 8/12/25 at 7:47 a.m., staff member J entered resident #35's room without performing hand hygiene and then went back out of the room, after having touched items in the room, to perform hand hygiene. Staff member J performed suprapubic catheter care for resident #35 without wearing a gown. During an interview on 8/12/25 at 8:07 a.m., staff member O said she did not know why there was an EBP sign was on resident #35's door. Staff member O looked in resident # 35's care plan and stated, oh it's for his suprapubic catheter. During an interview on 8/12/25 at 8:10 a.m., staff member J stated she usually performed hand hygiene before entering a resident's room. Staff member J stated, the sign (EBP sign on resident #35's door) means that you put a gown on before doing cath care or any cares, I…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to prevent and protect 4 residents (#s 7, 8, 11, and 13) from abuse, and failed to sufficiently monitor #8 when grabbing or intruding on the space of other residents. Resident #8's behavior preempted altercations with #13 when he tried to push or remove #8 from his room. Both resident #8 and #13 sustained injuries in the altercations or when falling during the fighting. The 4 residents identified were out of 6 sampled residents reviewed for resident to resident altercations. Findings include: a. Review of an incident reported to the State Survey Agency, dated 6/2/25 at 3:30 p.m., showed resident #8 approached resident #7 in a common area located near the nursing station. Resident #8 grabbed resident #7 by the back of his shirt, pulled him up and out of his (resident #7's) wheelchair, which resulted in both residents falling to the ground. The report showed resident #7 was not exhibiting any behaviors to provoke the physical interaction. The two residents were separated, and resident #8 was placed on enhanced monitoring for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure medications were given on time, no more than one hour before or one hour after the administration time, for 4 (#s 4, 15, 16, and 19); and failed to give the right medication to the right resident for 2 (#s 15 and 16) of 4 residents sampled for appropriate medication administration. Findings include: 1. During an interview on 6/18/25 at 8:55 a.m., resident #19 stated she has gotten her evening medications late several times. Resident #19 stated the late medications usually happened on weekends and night shift. Review of resident #10's Medication Admin Audit Report, dated 6/15/25, 6/16/25, and 6/17/25, showed the following times the medications were scheduled, and then the documented times they were actually administered: - 6/14/25 at midnight, buprenorphine-narcan 2-0.5 mg given at 1:45 a.m., - 6/14/25 at 6:00 p.m., lidocaine external patch given at 9:00 p.m., - 6/14/25 at 7:00 p.m., Cymbalta 60 mg given at 9:10 p.m., - 6/14/25 at 7:00 p.m., insulin aspart 3 units given at 9:13 p.m., - 6/15/25 at midnight,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to maintain an accurate and complete medical record for 3 (#s 7, 8, and 13) of 21 sampled residents. Findings include: 1. Review of a Facility-Reported Incident, dated 6/2/25 at 3:30 p.m., and submitted to the State Survey Agency reporting portal, showed an altercation which involved resident #7 and resident #8. The report showed resident #8 approached resident #7 from behind and pulled him up and out of his wheelchair, causing both resident #7 and the wheelchair to tip over and fall to the floor. The report showed resident #7, . was not engaging in any distress [sic] behaviors at the time, but was saying 'help' calmly and repetitively, a known behavioral baseline. Review of resident #7's nursing progress notes, dated 6/2/25, failed to show the incident described above. The resident's medical record progress notes failed to show documentation of an assessment of resident #7's physical and psychosocial condition after the incident. Review of resident #8's nursing progress notes, dated 6/2/25, failed to show the incident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure a resident was free from neglect, when leaving a resident on the toilet without a call light within reach, for 40 minutes, for 1 (#14); and neglected to ensure dignity was upheld for a resident while being transported to the shower for 1 (#52) who felt humiliated, of 29 sampled residents. This deficient practice caused emotional distress for resident #14 and #52; and increased the risk of skin break down or a fall to occur for resident #14. Findings include: 1. Review of a Facility Reported Incident, dated 12/12/24, reflected resident #14 was left on the toilet by a CNA, who believed another CNA would be getting her off the toilet, on 12/10/24. Resident #14 was found crying in her room, stating a CNA left her on the toilet. During an interview on 2/24/25 at 3:01 p.m., resident #14 stated she was scared during the night the staff left her on the toilet. Resident #14 stated she could not reach the call light and had to get herself out of the bathroom. Review of resident #14's progress note, dated 12/11/24, reflected…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service. This deficient practice had the potential to affect all residents receiving food from the kitchen. Findings include: During an observation and interview on 2/24/25 at 1:17 p.m., the following items were found in the kitchen storage: Open Worcestershire sauce: expired 9/30/24 Open Pancake/waffle mix- no date Open Chili Powder: expired 10/13/24 Open Parsley Flakes: no date Open Montreal Steak Seasoning: no date Open Pepperoni: no dates Blueberries: no date Opened Tortilla Shells: no date Opened Dry Yeast: no date Opened Mango preserves: no date Pineapple: use by date 2/20 Open Tuscan [NAME] Dressing: expired 12/20 Open Fat Free Italian dressing: expired 11/14 Open Thousand Island Dressing: expired 10/27 Open one-gallon balsamic Vinegar: no date Open bottle of molasses with brown crusty cap: no date Open Panco breading: no date Open bag of sugar: no date and sitting open…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to complete maintenance services necessary to maintain a clean, safe, and sanitary environment for 3 (#s 28, 29, and 72) of 29 sampled residents. Two residents, #s 28 and 29, were aware and not happy about the concerns identified in their rooms. Findings include: 1. During an observation and interview on 2/25/25 at 9:40 a.m., resident #28 was resting in her bed, with her face against the wall, on her left side. Resident #28's wall had an approximately four inch wide by 12-inch-long tear in the sheetrock. The powdered sheetrock was exposed, and there appeared to be digging marks in the sheetrock. Resident #28 stated, That wall's a mess, they need to do something about it. In the bathroom, the paint was peeled away around the toilet, leaving an uncleanable surface. 2. During an observation and interview on 2/25/25 at 8:27 p.m., resident #72 was in bed sleeping. A hole in the white floor linoleum approximately 12 inches long by five inches wide was noted on the floor of the bathroom, to the left of the toilet. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to cover catheter bags for 2 (#s 2 and 24) of 29 sampled residents, and staff were aware the covers should be utilized for resident dignity, and one resident was not ok with the bag being uncovered. Findings include: 1. During an observation on 2/25/25 at 11:13 a.m., resident #2's catheter bag was attached to the bed and not covered with yellow urine in the bag. During an observation and interview on 2/25/25 at 11:24 a.m., resident #2 was in her room with the curtain pulled. Resident #2's catheter bag was hanging from the bed and not covered, with urine in the bag. When asked about her catheter bag, resident #2 stated, I just figured that was how the bag was supposed to be, I didn't know there was another option. 2. During an observation and interview on 2/24/25 at 2:30 p.m., resident #24 was in bed resting, her door was open, and the catheter bag was exposed, with urine in the bag. The catheter bag was hanging from her bed. Resident #24 stated she was not okay with her catheter bag being exposed. During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to supervise the self-administration of insulin for 1 (#29) of 29 sampled residents. This deficient practice increased the risk of a negative outcome if the resident in the event the medication and monitoring were not handled properly by the resident. Findings include: During an interview on 2/24/25 at 7:53 a.m., resident #29 stated he gave his own insulin and monitored his own blood glucose levels. When asked if the nurses watched him administer his insulin, resident #29 stated, No, I do it myself and have for years. During an observation and interview on 2/26/25 at 8:05 a.m., resident #29 demonstrated how his continuous glucose monitoring system worked with the arm sensor he wore and the app on his mobile phone. Resident #29 stated, I tell the nurses what my blood glucose was when asked by the nurses. During an interview on 2/26/25 at 8:52 a.m., staff member G stated resident #29 should have had a self-administration of medication assessment, but was not sure where to find it. Staff member G stated she did not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to complete a thorough investigation for an event with a staff member accepting money from a resident, in exchange for craft items, for 1 (#41) and failed to identify missing items for 2 (#s 37 and 280) of 29 sampled residents. Residents #37 and #280 were frustrated and concerned about the missing items, and resident #41 was upset and worried about a staff member accepting money from a resident. Findings include: 1. During an observation and interview on 2/24/25 at 4:05 p.m., resident #41 was in her room; her room was full of crafts and puzzles she had completed or was working on. Resident #41 stated, I'm worried about saying anything; I'm afraid of retaliation. I have had some issues with a staff member, and she still works on my hall. I have told the previous administration about this issue, and nothing was done. Staff member U brought in some craft stuff for me to look through. I thought she brought it in for me to use. I picked out what I wanted and then offered to pay a little bit. Staff member U said,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to report an abuse allegation to the State Survey Agency within the required timeframe for 1 resident (#14); and failed to report their investigative findings to the State Survey Agency in a timely manner for 1 resident (#52), of 29 sampled residents. Findings include: 1. Review of a Facility Reported Incident, dated 12/12/24, reflected resident #14 was left on the toilet by a CNA who believed another CNA would be getting her off the toilet on 12/10/24. Resident #14 was found crying in her room stating a CNA left her on the toilet at 7:30 p.m. The alleged neglect initial report was not submitted to the State Survey Agency until 12/12/24 at 9:55 p.m. Review of the Facility Reported Incident final report, submitted 12/19/24, reflected a staff member was terminated due to the failure to report the incident to the facility abuse coordinator. 2. Review of a Facility Reported Incident, dated 12/30/24, showed resident #52 was transported by staff from his room, to the hall's shower room, naked and not covered. Review of the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure a complete investigation of a facility reported incident was completed, and failed to maintain and provide thorough investigation of the findings for 1 resident (#52) of 29 sampled residents. Findings include: Review of a Facility Reported Incident, dated 12/30/24, showed resident #52 was transported by staff from his room, to the hall's shower room, naked and not covered. The findings, submitted 1/8/25, showed one staff member was terminated for the event and the facility provided a final written warning to the other staff member involved. During an interview on 2/25/25 at 2:04 p.m., staff member B stated there was no facility reported incident documentation left by the previous administrator and stated the typical process is more accurate. An initial request was made to the facility for documentation of the facility's investigation notes for #52's reportable event on 12/30/24. The facility provided the following: - two written statements from staff members who learned of the incident from resident #52 while…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to accurately assess the dental needs of a resident on the comprehensive MDS assessment for 1 (#29) of 29 sampled residents. This deficient practice increased the risk to cause dental related complications due to lack of accurate assessment. Findings include: During an interview on 2/25/25 at 7:53 a.m., resident #29 stated he lost his dentures seven years ago, and was not offered help to get new dentures. During an observation on 2/25/25 at 12:23 p.m., resident #29 was observed being unable to chew a piece of broccoli and took it out of his mouth because he could not chew it. Resident #29 stated he has difficulty eating overcooked meat and undercooked vegetables without dentures. During an interview on 2/26/25 at 3:23 p.m., staff member M stated resident #29 was screened during admission for his dental needs, and most recently six weeks ago, which showed no dental issues, and stated, no indications or difficulties. Staff member M stated the MDS admission process was a team effort; nurses did a head-to-toe…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a baseline care plan, to include pertinent information to safely address resident care needs, within 48 hours of admission, for 2 (#75 and #282) of 29 sampled residents. Findings include: 1. Review of resident #75's electronic medical record showed resident #75 was admitted to the facility on [DATE]. Resident #75's baseline care plan showed a completion date of 12/14/24. During an interview on 2/26/25 at 3:00 p.m., staff member D reported nursing staff was responsible for completing the baseline care plan. Staff member D stated the care plans were updated as necessary during quarterly care plan meetings. During an interview on 2/26/25 at 4:06 p.m., staff member B reported nursing staff were responsible for initiating baseline care plans, and care plan updates were completed at IDT meetings and resident care conferences. Staff member B stated resident #75's baseline care plan was completed late, and she did not know…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement a comprehensive care plan to include dialysis for 1 (#72); and, failed to include a resident's dental and respiratory needs on the comprehensive assessment, for 1 (#29) of 29 sampled residents. This deficient practice caused staff to not complete cares required post dialysis for resident #72 resulting in a risk for harm related to post-dialyzed complications, and increased the risk for resident #29 having respiratory issues and difficulty with eating. Findings include: During an observation on 2/24/25 at 3:01 p.m., staff member I stated resident #72 went to dialysis on Mondays, Wednesdays, and Fridays. During an observation and interview on 2/25/25 at 12:07 p.m., resident #72 stated staff do not take her vitals, assess her dialysis site, or check on her when she returned from dialysis. Resident #72 showed the surveyor her access site. Review of resident #72's EHR, dated 2/25/25, reflected no dialysis assessments had been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to thoroughly complete an elopement evaluation for a resident who was an elopement risk, and had attempted to elope. The resident was oriented to person only, upon admission, for 1 (#282) of 29 sampled residents. This deficient practice caused resident #282's responsible party to worry about his safety. Findings include: During an interview on 2/26/25 at 3:45 p.m., NF3 stated staff did not notify her of the use of a wander guard device for resident #282 following his attempt to leave the facility on 2/17/25. NF3 stated she had been to the facility to visit resident #282, and he stated, Look at this stupid thing on me. NF3 stated she asked resident #282 what happened, and why the device was on him. NF3 stated resident #282 replied to her that he tried to leave to go home. NF3 stated she is worried about him and does not feel staff were doing enough to supervise resident #282, based on his medical condition. NF3 stated she was concerned he was crying a lot when she went to visit him, and stated, How can he have already had two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to change oxygen tubing as ordered for 1 (#29) of 29 sampled residents. This deficient practice had the potential to increase the risk of respiratory infections. Findings include: During an observation on 2/24/25 at 3:28 p.m., on 2/25/25 at 7:53 a.m., and on 2/26/25 at 8:09 a.m., resident #29's oxygen tubing, connected to his CPAP, was dated 11/3/24 on a piece of tape wrapped around the tubing closest to the machine. During an interview during the 2/26/25 observation, resident #29 stated he had been using a CPAP machine at night for a long time, and he owned it. Resident #29 stated no one checked his CPAP machine or the oxygen tubing, and it, . has never been changed before. During an interview on 2/26/25 at 8:54 a.m., staff member F stated CNAs and Nurses were in charge of changing oxygen tubing, but mostly she did it. Staff member F stated oxygen tubing should be changed every 30 days. Staff member F stated she did not know the process for keeping track of oxygen tubing changes, and staff used to write the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pre and post assessment care for a resident receiving dialysis for 1 (#72) of 3 sampled residents receiving dialysis. This deficient practice caused staff to not complete cares required post dialysis for resident #72 resulting in a potential for harm, including hypotension, renal failure, and infection at the access site. Findings include: During an observation on 2/24/25 at 3:01 p.m., resident #72 was not in her room. Staff member I stated resident #72 was at dialysis. Staff member I stated resident #72 went to dialysis on Mondays, Wednesdays, and Fridays. During an observation and interview on 2/25/25 at 12:07 p.m., resident #72 was in her room, in bed. Resident #72 stated staff do not take her vitals when she returned from dialysis, did not assess her access site, and the nurse did not come in to check on her when she returned from dialysis. Resident #72 showed the surveyor her access site. Review of resident #72's EHR, dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure scheduled subcutaneous medications were administered by staff licensed to administer the medications, for 1 (#3) of 29 sampled residents. Findings include: During an interview on 2/26/25 at 3:00 p.m., staff member D stated the facility had two full time certified medication aide II's who were utilized for medication administration to residents. Staff member D stated the medication aides are allowed to administer prefilled scheduled subcutaneous medications. Staff member D then referenced the Montana Code Annotated 2023 and stated, It appears the medication aide II is only allowed to administer prelabeled, pre-drawn insulin subcutaneously. Staff member D stated, Moving forward, all non-insulin subcutaneous injections will be administered by licensed nursing staff. During an interview on 2/26/25 at 4:08 p.m., staff member V stated she had administered resident #3's scheduled subcutaneous medications over the past six months. Staff member V stated because the medications were prefilled, and the injection was given…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to meet the resident's oral health needs for 1 (#29) of 29 sampled residents. This deficient practice had the potential to cause the resident to choke on their food. Findings include: During an interview on 2/25/25 at 7:53 a.m., resident #29 stated he had not had dentures during his entire residency at the facility, and staff had never asked him if he would like to get new ones. Resident #29 said it was sometimes hard to eat food. During an observation and interview on 2/25/25 at 12:23 p.m., resident #29 took a piece of broccoli out of his mouth, because he could not chew it. Resident #29 stated he had difficulty eating overcooked meat and undercooked vegetables without dentures. During an interview on 2/26/25 at 8:36 a.m., staff member F stated she was very familiar with resident #29. Staff member F stated resident #29 did not have dentures, and assumed he did not want them, I never thought to ask. Staff member F stated the ADON would set up the dental appointment if resident #29 wanted dentures. During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide food that accommodated a resident's intolerances and preferences for 1 (#29) of 29 sampled residents. This deficient practice caused resident #29 to feel frustrated at his preferences not being met. Findings include: During an observation on 2/24/25 at 3:28 p.m., an untouched food tray was on resident #29's bed while resident #29 was out of the facility for dialysis. During an observation and interview on 2/25/25 at 7:53 a.m., resident #29 picked up a banana off his breakfast tray and set it aside. Resident #29 appeared frustrated, and stated he was often given bananas with his breakfast even though he was on dialysis and did not want them. Resident #29 stated his breakfast was sometimes late on dialysis days, and he does not get to eat breakfast. Resident #29 stated, The lunches they used to give me were spoiled by the time I could eat them at dialysis. During an observation and interview on 2/26/25 at 8:20 a.m., resident #29 was wheeling down E hall with cranberry juice, and stated, They forget my…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, a facility staff member failed to communicate the location of a resident, when the resident was dropped off for an appointment at the dialysis center and left in the bathroom unattended, and the resident was cognitivey impaired, and elopement risk, and unable to assist himself out of dangerous situations. The resident later located in the bathroom and missed his dialysis appointment, for 1 (#1) of 7 sampled residents transported by facility staff for offsite medical appointments. Findings include: Review of a Facility Reported Incident, sent to the State Survey Agency for resident #1, dated 11/1/24, showed on 11/1/24, at 6:30 a.m., Resident #1 was transported by the facility's transportation driver to a scheduled dialysis appointment. Upon arriving at the dialysis center, the resident urgently requested to use the bathroom. The driver rang the doorbell three times to gain access and was eventually buzzed in by a medical staff. Once inside, the driver assisted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to provided pain medication as ordered to relieve chronic pain, this failure caused the resident to voice pain, for 1 (#69) of 3 sampled residents. Findings include: A review of a Facility Reported Incident, dated 8/6/24, showed an allegation of neglect concerning pain medication administration. The report showed NF2 failed to medicate one resident for pain (#69) on 8/6/24. The facility's investigation showed NF2 reported she had forgotten to give the medication. Review of resident #69's MAR, dated August of 2024, showed the following order, HYDROcodone-Acetaminophen Oral Tablet 7.5 - 325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth five times a day related to OTHER CHRONIC PAIN (G89.29) Hold if sedated or SBP <90. Order Date- 7/26/2024 1131 (11:31 a.m.) [sic] The resident's MAR showed the 1:00 a.m. hydrocodone-acetaminophen dose on 8/6/24 was held. The 5:00 a.m. dose of hydrocodone-acetaminophen on 8/6/24 was not administered as scheduled. Review of resident #69's progress notes, dated 8/6/24, failed to show the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to report to the State Survey Agency a facility reported event involving a resident who was denied reentry after discharging against medical advice from an acute hospital for 1 (#1) in the required timeframe; and failed to report incident findings to the State Survey Agency within the five-day required time frame for 11 (#s 2, 3, 5, 6, 8, 9, 10, 11, 12, 13, and 14) of 14 sampled residents. Findings include: 1. Review of resident #1's electronic medical record nursing progress note, dated 5/23/24 at 6:12 a.m., showed staff member D stated, Received call from [Hospital Name] 2400 (12:00 a.m.) showing this resident had left hospital AMA and was heading back to facility in a cab. Called administration to ask what to do. ADON attempted to call administrator and DON, then came to facility. Resident is outside in the cab, and when we had not heard back from administration told cab driver to take him back to the ER. Cab left with resident inside. Later a girl rang the doorbell and stated there is an old man sitting on the bench, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.