Montana Veterans Home N H

Based 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. Findings include: During an interview on 8/13/25 at 1:57 p.m., staff member L stated they received a report of an incident with resident #89 and resident #17, where resident #89 had no clothes on, and resident #17 was on top of resident #89 performing oral sex. This had occurred four months prior, and approximately three weeks ago, resident #17 went into resident #9's room, and staff found resident #9 in the bed.…

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 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. Findings include:During an interview on 8/13/25 at 11:37 a.m., staff member H stated there were many residents who participated in sexual activity who were unable to consent.A review of resident #17's care plan problem, goals, and interventions, all undated, showed the resident had a history of sexual behaviors that were exhibited towards other residents. There was no information for if he was a risk to other residents or himself. The goal was documented as the resident would have fewer episodes, but the goal did not show what episodes would be fewer or how this would be measured. The goal did not include information about the residents' safety. The interventions listed did not include any interventions related to protecting other residents from potential sexual abuse, or if the resident was able to consent to the sexual activities. During an interview on…

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 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. This required an ABN and NOMNC form were required to be filled out and given prior to the resident's discharge. Resident #9's, ABN form, showed, as of 5/22/24, the care being discontinued as Nursing Care, and 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 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. Findings include: During an interview on 6/21/23 at 7:40 a.m., staff member N stated, I already have the medications poured. We are allowed to pre-pour medications here, everything but narcotics During an interview and observation on 6/21/23 at 8:30 a.m., staff member N stated, she puts the resident's morning medications in a plastic medication cup, then places a paper medication cup on top of the medications with the resident's last name handwritten inside the paper cup. There were several cups in the top drawer of her cart arranged as she had described. Each cup had the resident's last name handwritten…

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 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. Findings include: During an interview on 6/21/23 at 7:40 a.m., Staff member N stated, I already have all the medications poured. We are allowed to pre-pour medications here, everything but narcotics. She asked the surveyor to return at 8:30 a.m. for the medication pass. During an interview and observation on 6/21/23 at 8:30 a.m., staff member N stated, she puts the resident's morning medications in a plastic medication cup, then places a paper medication cup on top of the medications with the residents last name handwritten inside the paper cup. There were several cups in the top drawer arranged as she had described. She stated this method helps her know to whom 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 protect residents from verbal and physical abuse, perpetuated by a staff member, for a resident with dementia, for 1 (#12) of 4 sampled residents. Findings include: Review of a Facility Reported Incident, dated 3/2/23, showed NF3 was observed by another staff member to flick resident #12 in the throat. He then wrote the words, You're being an asshole on the resident's white board and showed it to him. Resident #12 had dementia and was being combative with cares. Review of the facility investigation file, dated March 2023, showed the incident had been immediately reported, investigated, and the staff accused was suspended. NF3 no longer worked at the facility. Review of the facility's policy, titled: Abuse-Resident, with a revision date of 7/22/20, showed: - Abuse means the willful infliction of injury . verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents . regardless of their age, ability to comprehend . During an interview on…

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 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. Findings include: During an observation and interview on 6/19/23 at 3:53 p.m., resident #58 was sitting in his room, looking out the window. Resident #58 stated he prefers to stay in his room most of the time. Resident #58 stated he did not like to be around a lot of people; it made him nervous. A review of resident #58's admission diagnosis list, dated 3/8/23, showed: - Depression - PTSD During an interview on 6/21/23 at 1:20 p.m., Resident #58 stated, No one has ever talked to me about PTSD since I have been here. Resident #58 stated he does have some PTSD triggers, such as being around a lot of people makes him nervous; noises at night; and the news or current events can trigger his PTSD. Resident #58 was tearful as he discussed Vietnam and his PTSD triggers. A review of resident #58's…

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 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. Findings include: During an interview on 6/21/23 at 1:20 p.m., Resident #58 stated, No one has ever talked to me about PTSD since I have been here. Resident #58 stated during his time in Vietnam and Korea, he had taken 'heavy fire from the [NAME] Cong' and did not know if he was going to make it home alive or if he was ever going to see my family again. Resident #58 stated being around a lot of people; noises at night; and the news or current events can trigger his PTSD. Resident #58 stated at night he would sometimes be woken up by staff making loud noises, and this would cause a panic like reaction. During an interview on…

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 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. Findings include: A. Review of resident #48's, SNF Beneficiary Protection Notification Review form, was filled in showing the last covered day was 4/22/22 as a facility-initiated discharge from Medicare part A services. This required an ABN form and NOMNC form to be filled out and given prior to the discharge. Resident #48's, ABN form, showed, as of 4/23/22, the care being discontinued as, Nursing Care, and the reason for stopping Medicare Part A was, Skilled Care not required at this time. No estimated cost for continued services was filled out. The three options for accepting, appealing, or paying out of pocket were not selected; no additional information was provided, and no representative signature, date, or documentation of notification was completed. Resident #48's NOMNC showed, staff member M made a note on 4/22/22 that she called…

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 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. Findings include: A. During an observation on 7/7/22 at 9:18 a.m., resident #47 was visualized sitting in the recliner in his room via a camera monitor that was placed at the nurses' station. During an interview on 7/7/22 at 9:46 a.m., staff member K stated staff will turn off the cameras during care. She was not sure about any consents for the residents to be continuously monitored by camera/video. Review of resident #47's medical record showed consents signed by his POA for psychotropic medications and position change alarms. There was no consent for video monitoring. B. During an interview on 7/7/22 at 10:20 a.m., staff member J stated the video monitors were interventions for fall prevention. Staff member J stated they did not have the requested facility policy for the monitors or visual monitoring in resident…

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 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. Findings include: 1. Review of a facility reported incident reported to the State Survey Agency, dated 6/15/21, showed resident #29 reported to the MD that NF2 would not give her a requested PRN medication for pain, which should be given with food. The report showed, The RN may have misunderstood whether the resident had eaten or not. Resident #29 stated staff member NF2 was curt and sarcastic with her on a regular basis. The resident reported feeling mentally abused. The findings of the investigation showed, It seems no abuse occurred. Staff member NF2 will return to work. RN supervisor will work with staff member on customer service and approach with resident #29 in the future.…

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 a resident allegation of mistreatment and potential mental abuse to the State Survey Agency for 1 (#29) of 6 sampled residents. Findings include: Review of a hand-written allegation of mistreatment/mental abuse, dated 7/12/21, by resident #29, showed the resident stated staff member NF2 continues to treate her with absolutley no respect, and she did not deserve that kind of treatement. It was having a negative impact on her life, by her feeling 'not good.' Review of a Facility Reported Incident, dated 6/15/21, showed resident #29 voiced a similar allegation with no documented resolution for the resident. During an interview on 7/7/22 at 12:30 p.m., staff member A stated the 7/12/21 allegation did not rise to the level of abuse, and was just a resident grievance, and so it was not reported to the State Survey Agency.

Based 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. Findings include: 1. Review of the Facility Reported Incident, dated 6/15/21, showed resident #29 reported to her physician that NF2 refused to give her a PRN pain medication. She also stated he was curt and sarcastic when interacting with her. The report showed the allegation of potential mental abuse was not substantiated, but did not include the information the facility used to reach their conclusion. No documentation was provided regarding resident #29's psychosocial status or further monitoring of NF2 for the protection of the resident. 2. Review of a second allegation, on a facility Grievance/Complaint form, dated 7/12/21, showed resident #29 stated she continued to be treated with disrespect at all times from NF2, and that she did not need that treatment in her life. Review of the response from the facility was a typed conversation…

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 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). Findings include: During an observation on 7/5/22 at 3:56 p.m., inside the smoking door area, there was one oxygen canister with a mask hung on a nail touching the wall with no cover. The portable oxygen canister the mask was connected to, was low on oxygen, and still running with a buildup of white condensation on it. Another portable oxygen canister had a cannula, with an orange tinge to it, and no cover, slung over the railing, touching the bottom of the wall along the floor. During an observation on 7/5/22 at 4:04 p.m., resident #8 let himself in the smoking door. The resident then put on the oxygen mask that was running and touching the wall, without sanitizing his hands, and continued to go to his room. No staff checked his oxygen levels. Resident #8 had a slow, shuffling pace, and on observation he had a…

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.