Citations in Montana
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Montana.
Statistics for Montana (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Montana
Two residents were not adequately informed or educated when their incontinence products were changed to smaller, reusable liners. Both expressed frustration and increased accidents, and staff could not provide documentation of individualized education or explanations regarding the change.
A resident experienced an unwitnessed fall with injury, and the facility failed to submit the investigation findings to the State Survey Agency within the required five-day period. The staff member responsible for reporting was filling in for another and was not educated on the reporting requirements, resulting in a two-day delay.
The facility did not update the comprehensive care plans for two residents after changing their incontinence products from disposable to reusable liners. Both residents expressed dissatisfaction with the new products, reporting increased accidents, but their care plans were not revised to reflect the new interventions, education provided, or the residents' concerns.
A resident dependent on staff for toileting and hygiene activated her call light for over four hours without receiving needed assistance to change her brief. Multiple staff entered the room but did not provide care or turn off the call light, and communication breakdown at shift change contributed to the delay. The resident's family, unable to reach the facility, contacted local police for a welfare check.
Two residents did not have their baseline care plans completed within 48 hours of admission, resulting in unmet ADL needs. One resident was encouraged to ambulate without required assistive devices, and another was found in bed in soiled clothing without access to a shower. Staff confirmed that baseline care plans were incomplete and did not reflect the residents' ADL requirements.
Two residents did not receive necessary ADL assistance: one was encouraged by staff to ambulate without required mobility aids against therapy recommendations, and another was left in bed and wet into the afternoon because staff did not provide morning care, citing the resident's sleepiness after a rough night.
A resident with dementia repeatedly entered other residents' rooms, resulting in a physical altercation and ongoing aggressive behaviors, despite being on increased supervision and residing in a secured memory care unit. Staff documented multiple incidents of wandering, aggression, and mishandling of personal items, indicating that adequate supervision and necessary services were not consistently provided.
A resident with severe dementia and a history of falls was not provided with adequate supervision or individualized interventions to address her wandering and behavioral risks. Despite multiple injuries, including a compression fracture and a fractured hip, the care plan lacked specific strategies for fall prevention and behavioral management. Staff interviews and documentation revealed inconsistent monitoring, insufficient staffing, and a lack of effective interventions, resulting in repeated accidents and injuries.
A resident with severe dementia and a history of wandering and aggression was not provided with adequate supervision or individualized interventions, resulting in repeated incidents of entering other residents' rooms, altercations, falls, and injuries. Care plans were not tailored to the resident's needs, pain management was inconsistent, and required monitoring was not properly documented, leading to distress and harm for both the resident and others.
A resident with dementia who exhibited aggressive behaviors, wandering, frequent falls, pain, and elopement risk did not have a care plan with specific, person-centered interventions. The care plan relied on vague redirection strategies and lacked individualized pain management, fall prevention, and activity planning. Staff were unaware of the full extent of the resident's behaviors, and meaningful activities were not provided for residents in the memory care unit, resulting in inconsistent and unsafe care and unmet psychosocial needs.
Failure to Inform and Educate Residents on Incontinence Product Changes
Penalty
Summary
The facility failed to adequately inform and educate residents regarding a change in incontinence treatment and products. Two residents experienced a switch from their previous incontinence products to smaller, reusable liners without receiving a clear explanation or individualized education about the reasons for the change. One resident expressed frustration and sadness, noting increased accidents and dissatisfaction with the new products, while another questioned whether they could purchase their preferred products independently. Both residents reported that staff did not provide sufficient information about the change, and documentation confirming resident education was not available. Staff interviews revealed that the facility had discussed general information about skin breakdown and moisture management during a resident council meeting, but there was no evidence of individualized education or documentation provided to the affected residents. Review of care plans and physician orders indicated that residents had preferences for certain incontinence products, but the facility did not document any education or risk/benefit discussions related to the new products. The lack of communication and documentation led to resident frustration and a lack of understanding about their care changes.
Late Submission of Facility Reported Incident Findings
Penalty
Summary
The facility failed to submit the findings of a Facility Reported Incident involving a resident who suffered an unwitnessed fall with injury to the State Survey Agency within the required five-day deadline. The findings were submitted two days late. Staff interviews revealed that the staff member responsible for submitting the findings was filling in for another staff member who was out of state at the time of the incident. The substitute staff member acknowledged missing the deadline and submitted the findings as soon as she realized the requirement. Additionally, it was confirmed that no education had been provided to the substitute staff member regarding the reporting requirements related to this event. Facility policy requires the administrator to report the results of the investigation to government agencies within five working days of the incident.
Failure to Update Care Plans After Changes in Incontinence Products
Penalty
Summary
The facility failed to update the comprehensive care plans for two residents following changes in their incontinence care interventions. Both residents reported dissatisfaction with the new reusable liners provided, stating that these products were less effective and resulted in more frequent accidents. One resident indicated that they were no longer participating in care planning discussions, despite having previously done so. Staff confirmed that care plans should reflect all incontinence products tried and any changes made, but the documentation did not include the recent switch to reusable liners or the residents' feedback regarding their effectiveness. Record reviews showed that the care plans for both residents had not been revised to include updated interventions, education provided about the risks and benefits of the new incontinence products, or the facility's decision to change the products. The care plans only referenced previous interventions and did not document the residents' current experiences or the facility's recent changes in incontinence management. This lack of timely and accurate care plan updates failed to address the residents' needs and preferences as expressed during interviews.
Failure to Respond Timely to Resident Call Light for Dependent Personal Care
Penalty
Summary
Staff failed to respond in a timely manner to a resident who required assistance with activities of daily living, specifically with changing briefs due to urinary and bowel incontinence. The resident activated her call light, which remained on for over four hours, and multiple staff members entered her room but did not provide the needed personal care or turn off the call light. The resident ultimately contacted a family member for help, who, after being unable to reach the facility, called the local police to conduct a welfare check. Interviews with staff revealed that shift change communication was lacking, as incoming staff were not informed of the resident's need for assistance. Staff prioritized other residents based on perceived urgency and did not follow through with the resident's request, despite being aware of her call light. Documentation showed that staff were instructed to leave call lights on until all resident needs were met, but this led to confusion and further delay in care. The resident was dependent on staff for toileting and hygiene, as indicated by her care plan and assessment, and had a history of urinary and bowel incontinence. Despite being checked on earlier in the day, her needs were not met during the evening shift, resulting in an extended period without necessary personal care. Facility records confirmed the prolonged call light response time and the lack of timely assistance provided to the resident.
Failure to Complete Baseline Care Plans for ADL Needs Within 48 Hours of Admission
Penalty
Summary
The facility failed to ensure that baseline care plans were completed within 48 hours of admission to address the activities of daily living (ADL) needs for two residents. One resident reported being instructed by staff to ambulate without a walker or gait belt, despite not being cleared by therapy for such activity. The baseline care plan for this resident did not include necessary ADL care needs such as walking, toileting, transfers, bathing, or eating. Staff interviews confirmed that the resident should have used assistive devices per therapy evaluation, but this information was not communicated or documented in the baseline care plan. Another resident was found by a family member to be in bed, dressed in day clothes, soaked in urine, and unable to access a shower room. The baseline care plan for this resident also lacked documentation of ADL care needs, including walking, toileting, transfers, and bathing. Staff confirmed that the baseline care plans for both residents were incomplete and that the admitting nurse did not complete them at the time of admission.
Failure to Provide Required ADL Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide appropriate assistance with activities of daily living (ADLs) for two dependent residents. One resident reported that a staff member instructed her to walk without her walker or gait belt over a weekend, despite not being cleared by therapy to do so. Staff interviews confirmed that the resident should have used a gait belt and four-wheeled walker for transfers and walking, as indicated by her therapy evaluation. The staff member who encouraged the resident to walk without these aids stated he was told during shift report that she did not need them. Another resident was found by family members wet and still in bed at 12:30 p.m., indicating that necessary ADL care had not been provided that morning. Staff documentation and interviews revealed that the resident was very sleepy and not waking up, and the staff member on duty allowed her to sleep, having been informed during shift report that the resident had a rough night. The staff member later expressed regret for not being more proactive in waking and toileting the resident.
Failure to Prevent Resident with Dementia from Entering Other Residents' Rooms
Penalty
Summary
The facility failed to provide necessary services and supervision to a resident diagnosed with dementia who repeatedly entered other residents' rooms, resulting in a physical altercation and minor injuries to another resident. Despite being known to wander and having a history of confusion regarding his own room, the resident continued to access other residents' rooms even after being placed on 1-to-1 observation, then fifteen-minute checks, and eventually residing in a secured memory care unit. Staff interviews and nursing progress notes documented multiple incidents where the resident was redirected after entering other rooms, displaying aggressive behavior, and taking or mishandling other residents' personal items. The facility's policy required appropriate treatment and services for residents with dementia to ensure their highest practicable well-being. However, documentation showed that the resident continued to wander into other rooms and engage in disruptive and aggressive behaviors, including taking items and attempting to dispose of them inappropriately, despite interventions. The facility did not consistently ensure adequate supervision to prevent these incidents, placing both the resident and others at risk for further altercations.
Failure to Provide Adequate Supervision and Fall Prevention for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and monitoring for a resident with a significant history of falls and cognitive impairment. The resident, who resided in the memory care unit and had severe dementia, was known to wander frequently and had altercations with other residents. Despite being identified as a high fall risk with previous injuries, the care plan did not include sufficient or specific interventions to address her safety needs, wandering behavior, or fall prevention. The care plan goals were unrealistic given her cognitive status, and interventions lacked detail regarding her pain management, mobility limitations, and behavioral triggers. Multiple incidents were documented where the resident sustained injuries, including a compression fracture and a fractured hip requiring surgery. These injuries resulted from both witnessed and unwitnessed falls, as well as altercations with other residents. Progress notes and staff interviews revealed that supervision was inconsistent, and staff were often unaware of the resident's whereabouts. There was a lack of documentation regarding the direct causes of falls, the effectiveness of interventions, and whether appropriate supervision was in place at the time of each incident. Staff reported being too busy to provide adequate oversight, and 1:1 observation, when implemented, was not maintained as a long-term intervention. The facility's policies required systematic monitoring and management of residents at risk for elopement or unsafe wandering, but these were not effectively implemented for this resident. The care plan did not address specific needs such as toileting schedules, safe wandering paths, or individualized behavioral interventions. Staff interviews confirmed that interventions were limited to redirection, and additional measures such as visual cues or environmental modifications were not consistently used. The lack of adequate supervision and failure to implement effective, individualized interventions directly contributed to the resident's repeated falls and injuries.
Failure to Provide Adequate Supervision and Individualized Dementia Care
Penalty
Summary
A resident with severe dementia, poor safety awareness, and a history of aggressive behaviors and wandering was admitted to the memory care unit. The resident exhibited continuous wandering, entered other residents' rooms, displayed aggression, and had multiple falls, some resulting in significant injuries such as a hip fracture and a compression fracture. Despite being identified as high risk for elopement and falls, the resident was not consistently provided with individualized interventions or adequate supervision to address her specific behavioral and safety needs. Documentation showed that staff were often unaware of her whereabouts, and interventions such as 1:1 observation were implemented only temporarily and not maintained, even though staff reported these measures were effective in ensuring safety. The care plans developed for the resident were not sufficiently individualized or tailored to her needs. Goals set for the resident, such as developing coping skills for cognitive decline, were unrealistic given her severe cognitive impairment. Interventions lacked specificity, and there was no clear plan for managing her pain, which may have contributed to her behaviors. The care plan also failed to identify patterns in her wandering or provide detailed strategies to prevent her from entering other residents' rooms. Staff interviews revealed a lack of consistent use of visual cues or other non-pharmacological interventions, and staff expressed concerns about insufficient staffing and supervision. Additionally, the facility failed to consistently administer pain medications as ordered, which was noted by the provider as a concern and may have contributed to the resident's ongoing agitation and behavioral issues. Monitoring tools, such as 15-minute checks, were not completed as required, and documentation was often incomplete or inaccurate. The lack of adequate supervision and oversight resulted in repeated incidents where the resident intruded into other residents' rooms, leading to altercations and injuries, and caused distress and fear among other residents. The facility's actions and inactions did not meet the resident's behavioral, safety, and cognitive needs as required.
Failure to Develop Person-Centered Care Plan and Provide Individualized Dementia Interventions
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with dementia who exhibited aggressive behaviors, wandering, frequent falls, pain, and was at risk for elopement. The care plan lacked specific dementia-related interventions and relied primarily on nonspecific redirection strategies. Staff interviews revealed that key team members were unaware of the full extent of the resident's behaviors, such as constant wandering, and therefore did not include appropriate interventions in the care plan. The care plan did not provide measurable or detailed actions for staff to follow, and interventions were often generic or unrealistic given the resident's cognitive status. Record reviews showed that the care plan did not address the resident's pain management needs, as interventions for pain in the right knee were missing, and pain goals were not individualized or specific to the resident's condition. The plan for cognitive decline included unrealistic goals, such as developing coping skills, despite severe cognitive impairment. Interventions for falls, elopement, and aggressive behaviors were vague, lacked specificity, and did not reflect the resident's actual patterns or needs. For example, the falls care plan did not address the resident's weakness, confusion, or poor safety awareness, and did not specify which items should be kept within reach or how to anticipate the resident's needs. Additionally, the facility failed to provide meaningful activities for residents in the memory care unit, as reported by both family and staff interviews. The care plan for elopement risk referenced offering preferred activities, but none were listed, and interventions were generic and not tailored to the resident. The lack of individualized, person-centered interventions and activities resulted in staff lacking clear guidance to effectively meet the resident's needs, leading to inconsistent and potentially unsafe care, as well as unmet psychosocial needs for multiple residents.
Some of the Latest Corrective Actions taken by Facilities in Montana
Facility corrective actions were not detailed in the provided information for these citations.
Failure to Prevent and Document Progression of Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to prevent, assess, and document the progression of a Stage 4 pressure ulcer for a resident. The resident was readmitted to the facility without a sacral pressure ulcer, but by September 2023, a pressure ulcer of the sacral region was diagnosed. The wound care progress note from November 2023 indicated that the pressure ulcer had been present for nine weeks and was classified as Stage IV. There were no weekly skin or wound assessments until late September 2023, and no assessments were conducted in October or November 2023. Consistent weekly assessments only began after the initiation of a Wound Care Performance Improvement Plan (PIP) in December 2023. Interviews with staff revealed that new management identified wound care as a significant concern and initiated a PIP to address the issue. Contributing factors to the skin concerns included a lack of pressure-reducing mattresses and pads, poor layering of linen and plastic pads under residents, and inadequate wound documentation. The facility's QAPI team implemented immediate interventions, including the use of pressure reduction mattresses and pads, changing to cloth bedding protectors, weekly graphing of wounds, and a consistent wound care protocol. These actions were part of a broader effort to improve wound care processes and reduce the incidence of pressure ulcers among residents.
Removal Plan
- Pressure reduction mattresses and pads
- Change from plastic to cloth bedding protectors for better air flow to skin
- Graphing of wounds
- Wound care protocol for consistency of wound care/nutritional interventions
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