FAITH LUTHERAN HOME
For profit - Limited Liability company
60 Beds
Independent
Data: November 2025
Trust Grade
53/100
#28 of 59 in MT
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Faith Lutheran Home in Wolf Point, Montana, has received a Trust Grade of C, indicating an average rating that places it in the middle of the pack among nursing homes. It ranks #28 out of 59 facilities in the state, which means it is in the top half, and is the only option in Roosevelt County. Unfortunately, the facility is experiencing a worsening trend, with issues increasing from 9 in 2024 to 11 in 2025. Staffing is a strong point here, with a perfect score of 5 out of 5 stars and a turnover rate of 49%, which is lower than the Montana average of 55%. However, the facility has incurred $22,825 in fines, which is concerning as it is higher than many other facilities, suggesting ongoing compliance issues. There have been some specific incidents of concern, such as a resident who fell multiple times after being identified as high risk for falls, including two falls that resulted in major injuries. Additionally, the facility failed to properly complete and transmit assessments for some residents, leading to potential inaccuracies in their care plans. Another issue involves the dietary manager not having the required certification, which could affect residents' nutritional care. Overall, while there are strengths in staffing, there are significant weaknesses that families should consider.
- Trust Score
- C
- In Montana
- #28/59
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 49% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $22,825 in fines. Lower than most Montana facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 71 minutes of Registered Nurse (RN) attention daily — more than 97% of Montana nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 24 deficiencies on record. Higher than average. Multiple issues found across inspections.
53/100
Top 47%
Needs review
9 → 11 violations
★★★☆☆
3.0
Overall Rating
★★★★★
5.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 9 issues
2025: 11 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
3-Star Overall Rating
Near Montana average (3.0)
Meets federal standards, typical of most facilities
Staff Turnover: 49%
Near Montana avg (46%)
Higher turnover may affect care consistency
Federal Fines: $22,825
Below median ($33,413)
Minor penalties assessed
The Ugly 24 deficiencies on record
1 actual harm
Apr 2025
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to develop, implement, and operationalize a facility policy and procedure for grievances, and insure grievance information was r...
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Based on observation, interview, and record review, the facility failed to develop, implement, and operationalize a facility policy and procedure for grievances, and insure grievance information was readily accessible, to include the name and contact information for the grievance official; failed to provide residents with readily available grievance forms, as noticed by at least 1, resident (#196), of 14 sampled; and failed to provide residents with the option to file grievances anonymously. Findings include:
During an interview on 4/23/25 at 2:00 p.m., resident #196 stated the resident council met monthly. Resident #196 stated the facility provided grievance forms, which were located near the nurse's station, but there was not a way to file a grievance anonymously. Resident #196 stated if a resident wanted to file a grievance, it was required to have the resident's name on the form, so the facility could address the grievance.
During an observation on 4/23/25 at 2:50 p.m., a walk-through of the facility's common areas was conducted. No grievance forms were found to be readily available to residents. No posting of the name and contact information of the grievance official was found, and no secure receptacle was identified to file an anonymous grievance.
During an interview on 4/23/25 at 4:30 p.m., staff member K stated grievance forms were located at the nurse's station, and a resident would need to ask a staff member for a grievance form. Staff member K stated social services also had grievance forms and could help a resident complete the form if assistance was needed. Staff member K stated residents would give the completed grievance form to a staff member, and the form would then be given to a supervisor or social services. Staff member K stated the facility did not have a way for residents to file a grievance anonymously or have a secure receptacle for residents who wanted to file grievances anonymously.
A review of the facility's policy titled, [Facility Name] Policy and Procedure February 2000 Filing Grievances/Complaints, dated November 2016, showed the following:
Policy Statement
Our facility assists patients/residents/clients, their representatives (sponsors), other interested family members, or advocates in filing grievances or complaints when such requests are made.
Policy Interpretation and Implementation
1. Any patient/resident/client, his or her representative (sponsor), family member, or appointed advocate may file a grievance or complaint concerning treatment, medical care, behavior of other patients, residents, staff members, theft of property, etc. without fear of threat or reprisal in any form.
2. Grievances and/or complaints may be submitted orally or in writing. Written complaints or grievances must be signed by the patient/resident/client or the person filing the grievance or complaint in behalf of the individual . [sic]
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to revise a resident care plan to address comfort care for 1 (#31) of 14 sampled residents. This failure placed the resident at risk for not r...
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Based on interview and record review, the facility failed to revise a resident care plan to address comfort care for 1 (#31) of 14 sampled residents. This failure placed the resident at risk for not receiving appropriate comfort care measures. Findings include:
During an interview on 4/23/25 at 7:30 a.m., staff member M stated resident #31 had a recent change in condition. Staff member M stated resident #31 decided at the time not to go to the hospital and instead requested comfort care. Staff member M stated resident #31 had recently changed her POLST to reflect comfort care only. Staff member M stated any treatment resident #31 may need would be provided at the facility.
During an interview on 4/23/25 at 1:05 p.m., staff member D stated she was responsible for updating the resident care plans. Staff member D stated she updated care plans as needed after the facility's daily morning meeting.
Review of resident #31's medical provider note, dated 3/5/25, showed resident #31 was seen by the medical provider for concerns related to not eating or drinking, since diagnosed with Influenza A, the week prior. Medical provider documentation showed:
Review of Systems
. Psych: Voices desire to hold any heroics in her care. Absolutely refuses any hospitalization or invasive treatments . States she is ready to go and has been for awhile. [Family member] is present in room for this discussion and agrees with [resident #31] to get comfort care only .
Assessment/Plan
. 2. Failure to thrive in adult Will change code status to DNR with comfort care only and no hospitalizations. Will update POLST form. Family in attendance at visit and in agreement to her decision.
Review of resident #31's POLST, dated 3/5/25, showed resident #31's code status was DNR with comfort care only.
Review of resident #31's dietician note, dated 3/11/25, showed resident #31 was recently treated for influenza A and pneumonia. The dietician's note also showed resident #31 reported she had no energy, a poor appetite, and had decided on comfort care only.
Review of resident #31's care plan, dated 3/26/25, failed to show a focus area, goals, or interventions which addressed the resident's needs specific to comfort care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facilty failed to ensure residents who received dialysis were provided services, consistent with professional standards of practice, to include physician orde...
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Based on interview and record review, the facilty failed to ensure residents who received dialysis were provided services, consistent with professional standards of practice, to include physician orders for the dialysis, for 1 (#22) of 14 sampled residents. The deficient practices placed the resident at risk for pre-dialysis and post-dialysis complications. Findings include:
During an interview on 4/22/25 at 8:29 a.m., resident #22 said she had been getting dialysis prior to her admission to the facility. Resident #22 said she goes to a dialysis center in another town on Monday, Wednesday, and Friday. Resident #22 said she left the facility at approximately 11:00 a.m., and the dialysis ran for three hours and fifteen minutes. Resident #22 said she returned to the facility at approximately 4:30 p.m. on dialysis days.
Review of resident #22's current physician orders, dated 4/22/25, showed the resident did not have a physician order for her dialysis treatment.
Review of resident #22's physician order received on 4/23/25, showed the physician ordered for hemodialysis. The physician dialysis order was dated 4/23/25.
Review of resident #22's initial care plan, dated 2/27/24, showed resident #22 started dialysis in August 2023. The medical record did not show a physician had ordered resident #22 to receive dialysis until 4/23/25.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure documentation for screening of medical contraindications, education, and signed consent or declination by the resident or their resp...
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Based on interview and record review, the facility failed to ensure documentation for screening of medical contraindications, education, and signed consent or declination by the resident or their responsible party for the influenza vaccination for 4 (#s 3, 7, 13, and 31) of 5 sampled residents. This increased the risk of residents not being informed of risks and benefits to the vaccination and verification of resident or responsible party authorization. Findings include:
During an interview on 4/23/25 at 3:10 p.m., staff member A stated staff member D looked and could not find influenza vaccine consents or declination forms for resident #s 3, 7, 13, and 31.
Review of a facility document titled, 2024-2025 flu vax, [sic] showed resident #s 3, 7, 13, and 31 received the influenza vaccination on 10/18/24.
Review of resident #s 3, 7, 13, and 31 vaccine records did not show a vaccine consent form provided, documented, or signed by the resident or responsible parties for the influenza vaccine. The records did not have documentation of screening for medical contraindications to the vaccine or education provided prior to administration of the vaccine explaining the risks and benefits of the influenza vaccination.
A request was made to the facility on 4/23/25 for influenza vaccine consent or declination forms for resident #s 3, 7, 13, and 31. No documentation was received by the end of the survey.
Review of a facility document titled, [Facility Name] Influenza Policy and Procedure, last approved June 2023, showed:
. All residents and patients will be immunized against influenza as recommended by the Advisory Committee for Immunization Practices (ACIP). The vaccine will be provided to all residents . unless medically contraindicated, or the resident or responsible party refuses .
2. Obtain informed verbal consent before the immunization is administered and will be documented on the Resident's Vaccine Administration Record.
3. An informed verbal consent may be obtained by giving the resident, patient, or responsible party a copy of the current Vaccine Information Statement (VIS) and by providing an opportunity for their questions to be answered.
4. If the resident or patient or responsible party refuses an immunization, it should be documented in the permanent medical record. The resident or responsible party should be provided with an educations program and the immunization offered again .
5. The resident or patient will be screened for contraindications before each dose of vaccine is given. All contraindications will be recorded in the permanent record . [sic]
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure MDS assessments were completed, encoded, and transmitted, wi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure MDS assessments were completed, encoded, and transmitted, within the required timeframe, for 1 (#196) of 14 sampled residents, and failed to ensure the assigned staff member had the knowledge necessary to correct MDS transmission errors. The failures resulted in inaccurate and missing MDS data, which was identified during the annual recertification survey process. Findings include:
1. During an interview on [DATE] at 8:15 a.m., staff member D said she did not know how to correct or add a re-entry MDS when a resident returned from the hospital. Staff member D said resident #196 did not have a re-entry MDS and was now due for a quarterly assessment. Staff member D said she recently started completing MDS assessments and only had three days of MDS training at the facility.
Review of resident #196's nurse progress note, dated [DATE], showed resident #196 was discharged to the hospital on [DATE].
Review of resident #196's nurse progress note, dated [DATE], showed resident #196 was re-admitted to the facility on [DATE].
Review of a screen-shot of resident #196's MDS assessment list showed resident #196 was discharged from the facility on [DATE]. The assessment list showed the next MDS entered was for, . Nursing home: tracking (entry/expired). The assessment list did not show resident #196 as having a re-entry MDS completed.
2. During an interview on [DATE] at 1:05 p.m., staff member D stated she was responsible for submitting the facility's MDS reports. Staff member D stated she had been at the facility since [DATE], and had received approximately one week of MDS training from a previous employee. Staff member D stated she was unaware of any MDS submission errors and was also unaware of how to locate error messages or how to correct them.
Review of CMS report titled, CASPER Report 0004D Provider Full Profile, dated [DATE], showed no facility reporting for care-level resident characteristics.
Review of the facility-specific IQIES quality reporting status report, showed multiple errors, including incorrect Medicare Beneficiary Identifier, duplicate assessments, late assessments, and resident mismatches.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure the dietary manager completed a certification program approved by a national certifying body or had higher education i...
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Based on observation, interview, and record review, the facility failed to ensure the dietary manager completed a certification program approved by a national certifying body or had higher education in a related field. This had the potential to affect residents and their nutritional status, or meal safety for those who consumed food prepared and served by the facility. Findings include:
During an observation of the kitchen, on 4/22/25 at 7:50 a.m., no documentation of advanced training for the dietary manager was posted or readily available.
During an interview on 4/22/25 at 8:00 a.m., staff member E said she had come out of retirement a couple months ago when the dietary manager left. Staff member E said she would help the facility until they could advertise and find a new manager.
During an interview on 4/23/25 at 4:01 p.m., staff member A said the interim dietary manager came out of retirement to help the facility. Staff member A said staff member E's certified dietary manager certification expired about three years ago. Staff member A said there was no certified dietary manager on staff.
Concerns were identified related to the dietary department services. Refer to F812 - Food Procurement, Store/Prepare/Serve/Sanitary services for further detail.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations, interviews, and record review, the facility failed to ensure sanitary conditions were maintained throughout the kitchen and the dietary storage areas; failed to ensure kitchen s...
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Based on observations, interviews, and record review, the facility failed to ensure sanitary conditions were maintained throughout the kitchen and the dietary storage areas; failed to ensure kitchen staff labeled and dated food in the coolers; and failed to maintain a clean kitchen environment. The deficient practices increased the risk for the development of foodborne illnesses and unsanitary conditions, for all residents who received food from the kitchen. Findings include:
During an observation of the kitchen, during the initial tour on 4/22/25 at 7:25 a.m., the following observations were made:
- One pitcher full of fluid was observed in the reach-in cooler. The pitcher was unlabeled and undated.
- One gallon of 2% milk, opened, and not dated.
- One quart of Half and Half, opened, and not dated.
- The inside of the microwave was splattered with food particles.
- The meat slicer had white and brown particles of debris on the cutting surface and base.
- Large containers of spices were opened, not dated.
- Cinnamon and cumin spice containers appeared soiled and were sticky to touch.
- Numerous cups of red jellied products were not labeled or dated in the walk-in cooler.
- A bowl containing a white fluffy substance was not labeled or dated in the walk-in cooler.
- A large metal pan containing a mixture of pasta and sliced meat was not labeled or dated in the walk-in cooler.
- A bag of seven chicken breasts were thawed in a metal pan on the top shelf of the walk-in cooler. The chicken breasts were dated 2/25/25.
During an observation and interview on 4/22/25 at 7:40 a.m., staff member F was observed with a mustache and beard. Staff member F was in the food preparation area and was not wearing a beard or mustache cover. Staff member F said he never worked with the food slicer, but he thought it got cleaned every time it was used.
During an observation and interview on 4/22/25 at 8:00 a.m., staff member E said dented cans are placed on a special shelf and if dented, they are sent back for credit. During an observation, one can of pumpkin, one can of diced pears, and one can of tomato soup, all dented, were observed on the shelves where undented storage cans were stored and taken by staff or use. Staff member E said the facility has a person that comes in and does deep cleaning on Thursday and Friday every week. Staff member E said the cleaning must be behind schedule due to the Easter holiday.
During an observation and interview on 4/22/25 at 12:30 p.m., staff member G was observed with a beard and mustache. Staff member G was in the food preparation area and was not wearing a mustache or beard cover. Staff member E said she knows the staff with beards should wear a bear cover. Staff member E asked staff member G to immediately put on a beard cover.
During an observation on 4/23/25 at 8:07 a.m., staff member F was observed in the kitchen without a beard or mustache cover.
Review of a facility temperature document, untitled, located on the reach-in refrigerator showed:
- Ten days in January 2025 with no temperatures documented,
- Five days in February 2025 with no temperatures documented, however temperatures were documented for February 29, 30 and 31,
- Four days in April 2025 with no temperatures documented.
Review of the facility document titled, DIETARY FRIDGE TEMPERATURE showed:
- Three days in April 2025 with no temperatures documented.
Review of facility document titled, DIETARY FREEZER TEMPERATURE log showed:
- Three days in January 2025 with no temperatures documented,
- Three days in April 2025 with no temperatures documented.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure enhanced barrier precautions were followed for 1 (#22) of 14 sampled residents; and failed to to maintain an adequate ...
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Based on observation, interview, and record review, the facility failed to ensure enhanced barrier precautions were followed for 1 (#22) of 14 sampled residents; and failed to to maintain an adequate infection surveillance and antibiotic stewardship program and ensure policies and procedures were reviewed and revised annually for the Infection Prevention and Control Program. The deficient practices had the potential to increase the risk of infections within the facility. Findings include:
1. During an interview on 4/22/25 at 8:49 a.m., resident #22 said she had a central IV (intravenous) catheter for dialysis. Resident #22 said the nursing staff wore gloves, but never wore gowns when providing personal care.
During an observation and interview on 4/22/25 at 3:05 p.m., staff member H was observed assisting resident #22 prepare for a shower. Resident #22 had a central IV catheter in her upper right chest. The IV site was covered, but the ends of the tubing were not covered. Staff member H was wearing gloves while taping a piece of plastic over the IV insertion site and around the exposed IV catheter tubing. No gown was worn during the care observation. Staff member H said she had been trained on enhanced barrier precautions, but since the IV insertion site was covered, she said she did not need a gown. Gloves were available, but no other personal protective supplies were available in or near resident #22's room.
Review of resident #22's care plan, dated 4/23/25, showed an intervention directing the staff to use enhanced barrier precautions when caring for the central IV catheter.
2. During an interview on 4/23/25 at 8:07 a.m., staff member C stated the facility did not use McGeer criteria (infection surveillance tool) in the infection control program until about six months ago, which is about the time staff member C stated he started the position.
During an interview on 4/23/25 at 9:02 a.m., staff member D stated she started in her current position at the end of January this year. Staff member D stated she did not know what the facility was doing specifically with the antibiotic stewardship program prior to January 2025, she could not speak to what was or was not in place. Staff member D stated there was no current enhanced barrier precautions policy in place, only guidance for staff to follow. Staff member D stated the facility's corporate QAPI board needed to approve and sign off on the enhanced barrier precautions policy before it would be utilized.
During an interview on 4/23/25 at 12:43 p.m., staff member B stated she helped work on infection control items along with staff member D. Staff member B stated she started her role in September of 2024. Staff member B stated NF3 worked in the facility until the end of December of last year and oversaw the infection prevention program. Staff member B stated NF3 and herself reviewed the former antibiotic stewardship system in place. Staff member B stated she and NF3 decided it was not a complete program and started things over in September of last year. Staff member B stated the facility started using McGeer criteria in September of last year. Staff member B stated she was unaware if there was a break in services of the infection preventionist role between NF2's and NF3's employment.
Review of a facility document titled, Long Term Care Facility Component-Annual Facility Survey, showed, the facility reported for survey year 2025 a total of three times in the past year a new employee had to take over the infection preventionist role.
Review of a facility document titled, Monthly Infection Control Log (Line List), showed:
. Reporting Period Oct. 1 to Oct. 31, 2024 .
Types of infections .
- UTI no cath: 4 .
- URI: 1 .
- Eye: 3 .
- # New Cases colonized (not infected) with antibiotic resistant organisms: 8 .
1. Started McGeer Criteria
2. Started Ab Stewardship & [72 hour] stop Oct. 31 . [sic]
Review of the facility's Infection Prevention and Control Program policies showed the following:
- Infection Control - Antimicrobial Stewardship Policy and Procedure, Origination September 2024, last revised September 2024;
- Infection Control Antibiotic Stewardship- Review and Surveillance of Antibiotic Use and Outcomes, Origination September 2024, last revised September 2024;
- [Facility Name] Pneumoncoccal Immunization Policy and Procedure, [sic] last revised June 2023, next review due June 2024; and,
- [Facility Name] Influenza Policy and Procedure, last revised December 2017, next review June 2024.
Mar 2025
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to follow and uphold the plan of correction for the survey dated 12/3/2024, as the QAPI committee did not meet monthly to identify ongoing iss...
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Based on interview and record review, the facility failed to follow and uphold the plan of correction for the survey dated 12/3/2024, as the QAPI committee did not meet monthly to identify ongoing issues and concerns related to the survey or faiclity, and ensure a licensed Administrator was present, which may negatively affect any resident. Findings include:
During an interview on 3/12/25 at 10:29 a.m., staff member A stated a quality assurance performance improvement meeting was not held in February 2025. Staff member A stated the meeting for February 2025 was not rescheduled. Staff member A stated the next meeting would be held the third week of March 2025.
Review of the Quality Assurance and Performance Improvement Committee Minutes, dated 12/23/24 and 1/22/25, showed no documentation the committee continued to meet monthly in February 2025.
Review of the facility's plan of correction, dated 1/6/25, showed:
. Audits will be presented to QAPI team monthly, for discussion of results and issues to maintain compliance. After 3 months, QAPI committee/IDT will determine the need for ongoing and frequency of the audit to ensure substantial compliance . [sic]
Interviews identified an administrator was not employed as of late December 2024. Due to this, the QAPI committee did not include the necessary staff, as required by the Centers for Medicare and Medicaid, to participate in the QAPI meetings.
Review of the Appendix PP, State Operations Manual, for F868, shows the facility must have the following positions participate in the QAPI Committee:
(i) The director of nursing services;
(ii) The Medical Director or his/her designee;
(iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and
(iv) The infection preventionist.
Refer to F837 for the facility failing to employ a licensed Nursing Home Administrator.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0540
(Tag F0540)
Could have caused harm · This affected most or all residents
Guidance was provided by the Certification Bureau on 12/16/24 to member A and NF4 on the hourly requirements of the Nursing Home Administrator and Director of Nursing roles. At that time, they stated ...
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Guidance was provided by the Certification Bureau on 12/16/24 to member A and NF4 on the hourly requirements of the Nursing Home Administrator and Director of Nursing roles. At that time, they stated the facility was considering having the two of them share both required positions, or they would each fill one of the roles as both intended to attempt to obtain the current Montana Nursing Home Administrator license. The two employees stated staff member B and the governing body also mentioned having one person fulfill both Federally required positions. Per review of the Appendix PP, State Operations Manual, for F727 - Director of Nursing/RN requirements, the Director of Nursing must be full-time. Having a full time DON fulfill the licensed Nursing Home Administrator position at the same time, would require that one person to work above and beyond full-time, in order to fulfill the Nursing Home Administrator requirements also. During this call, both staff stated they did not wish to work that many hours above their already full-time employment.
Based on interview and record review, the facility failed to adhere to the participation requirements for long-term care facilities, related to the lack of appointing a licensed Nursing Home Administrator, who has an active license for Montana. This failure did not allow the facility to maintain compliance for the Requirements of Participation, and may negatively affect all residents at the facility. Findings include:
During an interview on 3/12/25 at 10:03 a.m., staff member B stated he was the current Interim Chief Executive Officer providing oversight for the facility. Staff member B stated in December of 2024 the interim Director of Nursing Services had planned to renew her contract and function in the administrator role, once her license was received from the State of Montana, but her contract negotiations fell through. Staff member B stated the Interim Director of Nursing Services' last day of employment for the facility was 12/27/24. The facility did not have a licensed Nursing Home Administrator for the State of Montana since that time.
A review of the State Operations Manual, Appendix PP, F540 Requirements for Participation shows:
2) Requirements. In addition to meeting the participation requirements for long-term care facilities set forth elsewhere in this subpart, a distinct part SNF or NF must meet all of the following requirements: .
(ii)The administrator of the SNF or NF reports to and is directly accountable to the management of the institution of which the SNF or NF is a distinct part.
The Appendix PP,includes numerous regulatory requirements which include direct involvement of the licensed Administrator, to include (not all inclusive):
F585 - The management and oversight of the grievance process
F600 - Abuse, Neglect, and Misappropriation
5609 - Abuse Reporting
F610 - Abuse Prevention
F835 - Administration
F844 - Disclosure Requirements
F849 - Hospice Abuse Reporting/Handling
F868 - Quality Assurance and Performance Improvement
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0837
(Tag F0837)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility's governing body failed to employ an administrator that was licensed in the State of Montana. This failure has affected all residents at the facility...
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Based on interview and record review, the facility's governing body failed to employ an administrator that was licensed in the State of Montana. This failure has affected all residents at the facility, due to the lack of an Administrator, and the facility not being in substantial compliance due to this. Findings include:
During an interview on 3/10/25 at 2:20 p.m., staff member A stated she was the Director of Nursing and had applied to the State of Montana to become a licensed administrator. Staff member A stated the licensing board had recently requested her college transcripts to move forward with her application. Staff member A stated the facility did not have a current administrator, and the facility had not advertised for the open administrator position.
During an interview on 3/12/25 at 10:03 a.m., staff member B stated he was currently the Interim Chief Executive Officer. Staff member B stated in December of 2024 the interim Director of Nursing Services had planned to renew her contract and function in the administrator role, once her license was received from the State of Montana, but her contract negotiations fell through. Staff member B stated the Interim Director of Nursing Services' last day of employment for the facility was 12/27/24. As of 12/4/24, the facility has not employed a Montana licensed Nursing Home Administrator.
Review of the facility's Key Personnel Contact List, dated 3/10/25, did not include an Administrator name or contact information.
Review of the facility's policy titled, Big Book Info - Policies, last revised June 2023, showed:
. The facility has been administered in a manner that enables it to use its resources effectively and efficiently to assist each resident to attain or maintain his/her practicable mental, physical and psychosocial well-being.
This facility is licensed under all applicable State and Local laws.
The facility will operate and provide services in compliance with applicable Federal, State, and local regulations and codes and with accepted professional standards and principles.
The governing body appoints [NF4], a licensed State administrator, to be responsible for management of the facility.
FACILITY POLICIES:
[Facility Name] will have written administrative and resident care policies in the absence of the administrator, the appointed designee is the DON .
Review of the State of Montana, Department of Labor and Industries online license verification, did not show a temporary or permanent Nursing Home Administrator license for NF4, as of 12/31/22.
A request was made to the facility on 3/11/25 for documented resources used for recruiting a new administrator. No documentation was received from the facility by the end of the survey.
A review of the Appendix PP, State Operations Manual, includes numerous regulations governing Skilled Nursing Facilities/Nursing Facilities. The Administrator is a position that is not only required by the federal regulations, but included in many regulations related to processes for a facility. Refer to F540 for more detail on the individual regulatory areas noted.
On 1/28/25, staff member A sent an email to the Certification Bureau providing staff member B's contact information. An email was sent to staff member B on that day, which included the following, The SNF is required to have a licensed administrator per the SNF regulations. Our office has not received a confirmation or copy of the license for the new administrator. Please have the individual appointed forward a copy of the current active MT Nursing Home Administrator's license . No reply was received from staff member B.
Multiple other attempts were made (on 12/24/24, 12/27/24, 1/30/25, and 2/13/25) by the Certification Bureau to contact staff member B. These attempts included having staff member A relay the message to staff member B of the need for a return call related to the appointment of the Nursing Home Administrator. No return calls or emails were ever received from staff member B, who was reportedly providing facility oversight. The ongoing failure to employee a Montana licensed Nursing home Administrator prevented the facility from being in substantial compliance with Federal regulations.
Dec 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to ensure privacy during wound measurement and ointment application, for 1 (#25) of 9 sampled residents. Findings include:
During an observation...
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Based on observation and interview, the facility failed to ensure privacy during wound measurement and ointment application, for 1 (#25) of 9 sampled residents. Findings include:
During an observation on 12/3/24 at 1:30 p.m., resident #25 was seated in a recliner, in the open television room, on the dementia unit. Staff member G did not ask the resident #25 to go to his room but asked if it was alright to do his treatment at that time and place. Resident #25 was in full view of two other male residents. Staff member G pulled the pant legs up and removed resident #25's socks from both legs. Staff member G laid on the floor and used a piece of white paper and traced around the wound on the back of resident #25's heel/lower leg area. Staff member #25 stood up and got a medication cup containing a white colored ointment. Staff member G applied the white ointment to resident #25's legs. After resident #25's socks were reapplied, and the pant legs were pulled back down, staff member G said she did not want to waste the ointment. Staff member G then applied the same ointment to resident #25's bilateral forearms.
During an interview on 12/3/24 at 2:10 p.m., staff member C said she would not expect a nurse to complete wound care in the dining room and not in front of other residents.
During an interview on 12/3/24 at 5:00 p.m. staff member G said the times for wound care should be changed as resident #25 does not always cooperate with going to his room to receive the treatment in privacy.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure a resident with individualized care needs, related to falls and prevention of falls, had identified fall interventions...
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Based on observation, interview, and record review, the facility failed to ensure a resident with individualized care needs, related to falls and prevention of falls, had identified fall interventions implemented and in place, so care was provided care in a manner to promote the well-being and prevent further falls, for 1 (#51) of 9 sampled residents. Findings include:
Review of the facility, undated, fall tracking log, provided by staff member C, showed resident #51 had two falls in October 2024 and two falls in November 2024.
Review of #51's nursing notes, dated 10/7/24, showed a request was sent to maintenance to place tread tape on the floor in front of the toilet in #51's bathroom. The nursing progress note showed the fall care plan was updated accordingly on 10/7/24.
During review of resident #51's care plan, it was found the only intervention to correlate with the 10/7/24 update was for dycem (non-skip material) to be placed on the resident's wheelchair seat. There was no 10/7/24 update to add tread tapes to the floor in the resident bathroom.
Review of resident #51's care plan problems showed resident #51 had potential for falls related to weakness, poor balance and history of falls. Resident #51's care plan, updated on 10/14/24, showed an intervention for tread tape to be placed in front of the toilet, and next to the bed, for improved traction while transferring.
Review of #51's nursing notes, dated 11/15/24 showed resident #51 fell while transferring in the bathroom. Resident #51 was attempting to get off the toilet and to his wheelchair. The resident fell to the floor. Review of the care plan following this fall, showed resident #51 did not have any changes made to his care plan for the fall on 11/15/24, to address the root causes of the fall.
Review of #51's nursing notes, dated 11/17/24 showed, resident #51 was found on the floor near his bed. Following this fall, there was no interventions added to the care plan to prevent further falls or address the root cause(s) of the fall.
During an observation on 12/3/24 at 4:10 p.m., it was found resident #51 did not have the care plan interventions from 10/14/24 implemented. There was no tread tape in front of the resident's toilet and no tread tape in front of the bed.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure a resident with individualized care needs, related to falls and prevention of falls, had identified fall interventions...
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Based on observation, interview, and record review, the facility failed to ensure a resident with individualized care needs, related to falls and prevention of falls, had identified fall interventions implemented and in place, so care was provided care in a manner to promote the well-being and prevent further falls, for 1 (#51) of 9 sampled residents. Findings include:
Review of the facility, undated, fall tracking log, provided by staff member C, showed resident #51 had two falls in October 2024 and two falls in November 2024.
Review of resident #51's care plan dated 8/27/24, showed resident #51's toileting transfer needs instructed the staff to provide assistance of one to two people. The care plan also showed, If you assist (name) with transfers, he expects you to do all the work, actually increasing his risk for falling as he has the expectation you are there to do it all and he needs to do nothing . So, staff do not assist and (resident) does all the work, and his safety is maintained.
Review of resident #51's nursing notes, dated 10/1/24, showed the resident was having more incontinent episodes, and the staff would need to check on him every two hours.
Review of #51's nursing note's dated 10/6/24, showed resident #51 was alone in the bathroom and fell while attempting to transfer from the toilet to the wheelchair. The note showed, the resident slipped and fell on the floor.
Review of a fall review investigation for #51, dated 10/7/24, showed the interdisciplinary team reviewed and determined the root cause of the fall. This investigation identified the resident had said the bathroom floor was slick. The fall investigation team recommendation looking into using tread tape for the floor in the bathroom.
Review of #51's nursing notes, dated 10/7/24, showed a request was sent to maintenance to place tread tape on the floor in front of the toilet in #51's bathroom. The nurses progress note showed the fall care plan was updated accordingly on 10/7/24. This intervention was not implemented as identified, per review of the care plan.
Review of resident #51's nursing note, dated 10/13/24, showed resident #51 slipped and fell off the edge of his wheelchair seat. The note also showed the resident was transferring himself from his wheelchair to his bed and he slipped. The nurses note showed resident #51 had gripper socks on but tread tape was not documented as a preventative measure.
Review of resident #51's fall incident report and post fall evaluation form, dated 10/13/24, showed the interdisciplinary team reviewed the fall on 10/14/24. The interdisciplinary team note showed, attempt to place tread tape in front of bed.
Review of resident #51's care plan problems showed resident #51 had potential for falls related to weakness, poor balance and history of falls. Resident #51's care plan, updated on 10/14/24, showed an intervention for tread tape to be placed in front of the toilet, and next to the bed, for improved traction while transferring.
Review of resident #51's nursing notes, dated 11/15/24 showed resident #51 fell while transferring in the bathroom. Resident #51 was attempting to get off the toilet and to his wheelchair. The resident fell to the floor. Review of the care plan following this fall, showed resident #51 did not have any updates made to his care plan for fall prevention.
Review of resident #51's nursing notes, dated 11/17/24 showed, resident #51 was found on the floor near his bed. The nurse's note showed, . it appears as though res. was attempting to transfer from his w/c to his bad and slipped out of his w/c. Resident #51 did not tell the staff how the fall occurred, but said he did not hit his head and that he did not hurt anything. Resident #53 sustained three skin tears during this fall. The nursing notes showed the resident did not hit his head or get any injuries. The facility failed to update the care plan following this fall to prevent further falls and injuries.
During an observation on 12/3/24 at 4:10 p.m., resident #51 did not have tread tape in front of the toilet and did not have tread tape in front of the bed.
May 2024
6 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an interview on 5/7/24 at 9:20 a.m., Staff member C reported that resident #50 scored high risk for falls on admission...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an interview on 5/7/24 at 9:20 a.m., Staff member C reported that resident #50 scored high risk for falls on admission to the facility on 5/18/23. Staff member C stated, These (falls) occurred before I came here, so I don't know anything about them.
During an interview on 5/8/24 at 10:12 am, staff member A stated that all nursing and CNA staff received fall, abuse, and dementia training annually through an online platform.
Review of the Care Area Assessment, completed on 5/24/23, showed resident #50 triggered for Cognitive Loss/Dementia and Falls.
Closed record review showed resident #50 was admitted on [DATE] after a fall with major injury at home and fell four additional times in the facility between 5/18/23 and 7/13/23, including two with major injuries.
Review of a facility document titled, Resident Fall Incident Report and Post Fall Investigation, completed on 6/16/23, and reviewed by IDT on 6/20/23, showed resident #50 sustained an unwitnessed fall with major injury on 6/16/23 at 7:00 a.m. The document showed the care plan was reviewed on 6/16/23, and showed the following additional fall interventions were implemented at that time:
- 1.Get her up and toilet her at start of shift to make sure she does not try to get out of bed by herself. [sic]
- 2. Keep bathroom light on her room for better visibility. [sic]
The document listed the following information under the heading, Contributing Factors/Action Plan to prevent another injury:
- Resident got out of bed by herself and tried to walk. Too weak to remain standing .
Resident #50's care plan did not show new fall interventions as per the document above. One fall intervention was added to the care plan in June 2023 was on 6/20/23, as follows:
- Assist with transfers (2 person preferred). Resident does not reliably bear weight and needs a [NAME] lift for transfers (ability varies). [sic]
Review of facility document titled, Resident Fall Incident Report and Post Fall Investigation, completed on 7/13/23, and reviewed by IDT on 7/18/23, showed resident #50 sustained an unwitnessed fall with major injury on 7/13/23 at 8:00 p.m. The document did not show the care plan was reviewed, and no new care plan interventions were listed. The IDT note stated that the resident was transferred to the hospital on 7/14/23. Resident #50 returned to the facility on 7/19/23. No new fall interventions were added to the care plan in July 2023 or August 2023.
The document listed the following information under the heading, Contributing Factors/Action Plan to prevent another injury:
- Confused. Monitor more closely. [Physician Name] notified orders rec. were to monitor res. clinically t/o night. [sic]
The facility failed to implement effective and measurable fall prevention interventions, which had the potential to contribute to resident #50's repeated falls and injuries.
Based on interview and record review, the facility failed to identify a resident's elopement risk or implement interventions following an elopement for 1 (#31) of 4 residents sampled for elopement, and failed to implement, monitor, and modify fall interventions to prevent multiple falls for 1 (#50) of 6 residents sampled for falls. Findings include:
1. During an interview on 5/8/24 at 12:33 p.m., staff member A stated resident #31 had made some requests to leave the facility to visit his friend. Staff member A stated approximately two or three weeks prior to his elopement, resident #31 had gone to the door to leave, but staff stopped him from exiting. Staff member A stated no elopement assessment had been done, prior to his elopement and he was not identified as an elopement risk. The resident did not have a history of eloping and had been at the facility an extended period of time.
Review of resident #31's interdisciplinary progress notes on 11/8/23, at 3:07 a.m., showed resident #31 was not in his room. The staff searched the facility and surrounding grounds from 3:00 a.m., until 3:45 a.m. After the initial search, the police, administration, and IT (information technology) were notified. At the time of the elopement, resident #31's BIMS was a 10; moderately impaired cognition. Review of resident #31's last five MDS assessments showed he had a fluctuating BIMS score, and the scores ranged from 9-14. A score of 9 is moderately impaired, and a score of 14 is intact cognition.
Review of resident #31's interdisciplinary progress notes on 11/8/23 showed information technology watched the facility video and identified resident #31 leaving the facility at 12:26 a.m., through the front door of the facility. Using this new information, resident #31 was found at 7:00 a.m., in a field six blocks southwest of the facility. Resident #31 was exposed for 6 1/2 hours and transported to the hospital by an ambulance.
Review of resident #31's emergency department report, on 11/8/23 at 7:14 a.m., showed resident #31 was hypothermic upon arrival. Resident #31 also had abrasions to his knees. Resident #31 was returned to the facility on [DATE] at 4:04 p.m.
During an interview on 5/8/24 at 12:33 p.m., staff member A stated following the elopement a wander guard was applied to his wrist and every one-hour visual checks were done.
Review of resident #31's interdisciplinary progress notes on 11/10/24 at 6:51 p.m., showed resident #31 walked out of the 200 wing west door and then re-entered via the activity room door. No changes to the care plan was noted after this elopement attempt.
Review of resident #31's interdisciplinary notes on 12/1/23 at 2:39 p.m., Resident walked out of room to the activity door and alarm sounded. The maintenance workers there returned resident to the floor and a CNA assisted the resident further to help back into bed.
Review of the 12/1/23 through 12/31/23 treatment records showed the staff began monitoring the placement of the wanderguard on 12/24/23. There was no documentation of the monitoring of placement or the function prior to those dates.
Review of resident #31's interdisciplinary progress notes on 12/26/23 at 3:07 p.m., showed a delay in transferring resident #31 to the locked memory care unit.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an interview on 5/7/24 at 10:25 a.m., staff member G reported personalized fall prevention strategies would be located...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an interview on 5/7/24 at 10:25 a.m., staff member G reported personalized fall prevention strategies would be located on each resident's care plan. Staff member G reported care plan changes and updates were, usually updated by (staff member A, B, or C) I think.
During an interview on 5/7/24 at 12:18 p.m., staff member B stated fall risk was assessed on admission for every resident, and if needed, the fall risk would be included in the care plan as a problem category.
During an interview on 5/7/24 at 4:15 p.m., staff member C reported care plan interventions would be updated in the care plan if there was a new indication or event, including a new fall or injury. Staff member C stated, We have fall meetings to go over every fall. Fall meetings were held weekly until recently, and now are held Monday through Friday.
Review of resident #50's progress notes showed resident #50 was admitted on [DATE] after a fall with major injuries at home. Resident #50 was identified on the facility's admission assessment to be at high risk for falls.
Review of resident #50's progress notes for the period of 5/18/23 through 8/22/23 showed he had four falls between 5/21/23 and 7/13/23, which included fractures. Refer to F689 Accidents and Hazards for resident #50's fall information.
Review of resident #50's initial care plan identified fall risk under the heading Problems/Strengths as follows:
Potential for Falls related to cognitive impairment and weakness and it is possible fractures are pathological in nature. Strengths: Was admitted to (Facility Name) recovering from (left) hip and wrist. 6/16/23 - Had fall with nondisplaced (fracture) to pelvis; fell 7/13/23 and fractured (right) hip and wrist. [sic]
Review of resident #50's care plan, with a revision date of 8/23/23, showed a total of two active fall interventions listed between 5/18/23 and 8/22/23, although resident #50 had four falls including two falls with major injuries during the same period. The fall interventions listed on the care plan were as follows:
- 5/21/23: Anticipate her needs as able, for she may not be able to make her needs known.
-6/20/23: Assist with transfers (2 person preferred). Resident does not reliably bear weight and needs a [NAME] lift for transfers (ability varies). [sic]
Review of a facility document titled, Falls Prevention and Management, showed the following information:
GOALS
- . 3. Document all measures used to prevent falls . ,
POLICY
- . 2. Staff will enter interventions in the care plan appropriate for all resident's level of risk . [sic]
Based on interview and record review, the facility failed to update a resident care plan in a timely manner for elopement for 1 (#31) of 5 residents sampled for elopement, and failed to revise a resident care plan to show effective fall risk interventions following repeated falls with injury for 1 (#50) of 6 residents sampled for falls. Findings include:
1. Review of resident #31's care plan showed the following updates:
- 11/21/23, Redirect when wandering .,
- 1/31/24, Room was moved to memory care unit locked unit for safety s/t elopement x 2. [sic]
- 5/1/24, Hourly visual wellness checks to ensure safety.
Review of resident #31's interdisciplinary progress notes showed resident #31 eloped from the facility on 11/8/23, 11/10/23, and 12/1/23. A wander guard was placed on resident #31's wrist on 11/8/23. The care plan was not updated to reflect the elopements until 1/31/24. Review of resident #31's interdisciplinary notes showed he was moved to the memory care unit on 12/26/23, not 1/31/24 as noted in the care plan.
During an interview on 5/8/24 at 11:00 a.m., staff member L stated she was not aware they were supposed to do hourly visual wellness checks.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0813
(Tag F0813)
Could have caused harm · This affected 1 resident
Based on observations, interview, and record review, the facility failed to monitor and control the temperature of the personal resident room refrigerators, and ensure food safety with the use of them...
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Based on observations, interview, and record review, the facility failed to monitor and control the temperature of the personal resident room refrigerators, and ensure food safety with the use of them, per the facility policy, for 2 (#12 and #17) of 3 sampled residents with refrigerators. Findings include:
1. During an observation and interview on 5/8/24 at 10:28 a.m., the temperature of the refrigerator in resident #12's room was 55 degrees Fahrenheit. Resident #12's refrigerator had seven cartons of milk present. Resident #12 stated the facility managed the refrigerator temperatures and cleanliness. Staff member I stated she was unsure of what a safe refrigerator temperature should be.
2. During an observation on 5/7/24 at 8:50 a.m., resident #17's personal refrigerator was at a temperature of 50 degrees Fahrenheit and in the Danger Zone as indicated on the thermometer located inside the refrigerator. Resident #17 stated the facility provided cleaning and temperature monitoring and maintenance of the refrigerator.
During an interview on 5/7/24 at 2:46 p.m., staff member G stated he was unsure, but thought the night staff managed the temperature of the personal refrigerators.
During an interview on 5/7/24 at 4:57 p.m., staff member B stated housekeeping managed the temperature and cleanliness for the personal refrigerators in the residents' rooms.
During an interview on 5/8/24 at 9:17 a.m., staff member I stated her supervisor usually managed the personal refrigerators. However, due to an illness, the supervisor was out of the office this week, so staff member I was expected to check the temperatures of the residents' personal refrigerators.
During an observation and interview on 5/8/24 at 10:17 a.m., the refrigerator #17's room did not have a thermometer in it. Resident #17 stated the thermometer was gone because staff member I had taken it out of the refrigerator as staff member I thought the thermometer was broken.
Policy: This facility does not provide a refrigerator in a resident's room. However, it is the policy of this facility to ensure safe and sanitary use of any resident-owned refrigerators .
- 1. Dormitory-sized refrigerators are allowed in a resident's room under the following conditions:
- a. The refrigerator is inspected by maintenance personnel and deemed safe prior to use and upon routine inspections.
- b. The refrigerator maintains proper temperature .
. 2. Environmental Services staff shall record refrigerator temperatures weekly on a temperature log.
- a. A thermometer shall remain in the refrigerator. It shall be calibrated prior to use and periodically thereafter.
- b. Temperatures will be at or below 41 degrees F .
According to the U.S. Department of Agriculture, the Danger Zone is considered to be the temperature range from 40 to 140 degrees Fahrenheit where bacteria can grow very quickly (U.S. Department of Agriculture, 2020).
During an interview on 5/8/24 at 10:40 a.m., staff member I asked, What should the temperature be under?
Review of facility policy titled, Resident Refrigerators, dated 5/2018, showed:
- . 1. Dormitory-sized refrigerators are allowed in a resident's room under the following conditions:
. b. The refrigerator maintains proper temperature .
- . 2. Environmental Services staff shall record refrigerator temperatures weekly on a temperature log .
. b. Temperatures will be at or below 41 degrees F .
Reference
A temperature of 40 °F should be maintained in the refrigerator. In contrast to freezer storage, perishable foods will gradually spoil in the refrigerator. Spoilage bacteria will make themselves known in a variety of ways. The food may develop an uncharacteristic odor, color and/or become sticky or slimy. Molds may also grow and become visible. Bacteria capable of causing foodborne illness either don't grow or grow very slowly at refrigerator temperatures. An appliance thermometer should always be used to verify that the temperature of the unit is correct.
U.S. Department of Agriculture. (2020, October 19). How Temperatures Affect Food. Retrieved from Food Safety and Inspection Service: https://www.fsis.usda.gov/food-safety/safe-food-handling-and-preparation/food-safety-basics/how-temperatures-affect-food#5
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide sufficient privacy between residents with a shared bathroom d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide sufficient privacy between residents with a shared bathroom due to the use of a curtain for 1 (#17) and failed to provide privacy during cares for 1 (#23) of 2 residents sampled for privacy concerns, and failed to ensure the privacy curtains could be closed adequately to provide visual privacy for residents in four rooms, 304, 305, 306, and 308. Findings include:
1. During an interview and observation on 5/7/24 at 8:50 a.m., resident #17 stated she shared a bathroom with the resident in a neighboring room. The shared bathroom had a sliding pocket door entry from each of the resident's rooms. Resident #17 stated the neighboring resident's door was unable to be closed as it would get stuck. A curtain was used in place of the door. Resident #17 stated the door had been broken for over a year. Resident #17 stated she felt this was a privacy concern for her as the neighboring resident was often confused, and she would pull the curtain open without knocking or asking for permission to enter when resident #17 was using the restroom. Resident #17 stated, It bothers me that the lady next door . will never knock. As shown on the MDS, the neighboring resident had a BIMS of 7; severe cognitive impairment.
During an interview on 5/8/24 at 7:45 a.m., staff member F stated no maintenance order had been placed for the broken door in the neighboring resident's room. Staff member F stated he had never been shown or told about the broken door in the neighboring resident's room.
During an interview on 5/8/24 at 7:54 a.m., staff member A stated the door had been like that for five or six years and the tracks were ruined. Staff member A stated she thought this door was unable to be fixed.
During an interview on 5/8/24 at 8:00 a.m., staff member F stated this would make him feel uncomfortable if this was his living situation. Staff member F stated this door could be fixed as he could order new tracks.
2. During an observation on 4/7/24 at 8:47 a.m., staff member M was providing personal care for resident #23. Staff member M failed to pull the privacy curtain around resident #23's bed and failed to close the door. Resident #23's roommate was present during the care.
During an interview on 5/8/24 at 8:15 a.m., staff member F stated housekeeping took care of the curtains, and he did not have anything to do with them. When the privacy curtains were closed, a gap was observed between the wall and the edge of the curtain. The arrangement of the rooms would allow for the residents in the bed to observe the care being provided to the other resident.
- room [ROOM NUMBER] privacy curtain had an open gap of 37.5 inches.
- room [ROOM NUMBER] privacy curtain had an open gap of 42.5 inches.
- room [ROOM NUMBER] privacy curtain had an open gap of 50.5 inches.
- room [ROOM NUMBER] privacy curtain had an open gap of 32 inches.
During an interview on 5/8/24 at 8:20 a.m., staff member L stated she was aware the curtains did not close, but as an agency staff, she did not know who to tell about the problem.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During an interview on 5/7/24 at 10:05 a.m., resident #46 stated she would like to walk more and she had noticed she had beco...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During an interview on 5/7/24 at 10:05 a.m., resident #46 stated she would like to walk more and she had noticed she had become weak. Resident #46 stated, I wish I got a bit more mobility.
During an interview on 5/7/24 at 4:14 p.m., staff member G stated he was expected to provide restorative cares or ROM once per shift based on the Care Plan Intervention Task. Staff member G stated a task had not been completed and was due if it had a red outline around the box [the intervention].
Review of resident #46's electronic medical record showed resident #46 had an order for ROM dated 2/14/24, that read, Ambulate to tolerance w/gaitbelt and wheelchair TID. [sic] However, the CNA restorative task showed it was to be completed twice daily.
Based on observation, interview, and record review, the facility failed to provide and consistently document restorative nursing services intended to improve or maintain mobility for 3 (#s 13, 31, and 46) of 9 residents sampled for restorative services. Findings include:
1. During an observation and attempted interview on 5/7/24 at 10:02 a.m., resident #13 was observed in a specialized wheelchair. Mild muscular spasticity and contractures of extremities were observed. Resident #13 was unable to speak due to his diagnosis of receptive and expressive aphasia secondary to cerebral palsy.
During an interview on 5/7/24 at 10:17 a.m., staff member G stated restorative exercises were completed for the residents as much as possible. Staff member G stated the CNAs were not always good at completing the documentation in the electronic medical record, but they try.
During an interview on 5/7/24 at 10:44 a.m., staff member O stated if the CNA reported a resident had missed their restorative services for the day, they would pass the information on to the next shift nurse or the DON.
During an interview on 5/7/24 at 12:20 p.m., staff member C stated the restorative services were no longer located in the restorative binder as stated in the restorative policy, but were now listed under CNA tasks in the electronic medical record. Staff member C stated the policy needed to be updated.
During an interview with staff members A and C on 5/8/24 at 9:53 a.m., staff member A demonstrated the restorative task component of the electronic health record system. Staff member A stated if the task was highlighted in red, then it had not been completed. If it was green, it had been completed for the shift. If a task was not completed, the CNAs would let a nurse know. Staff members A and C both stated they were unsure what a yellow highlight on the restorative task would indicate or how the process would work for nurses to follow-up on incomplete CNA tasks.
During an interview with staff members A and C on 5/8/24 at 11:55 a.m., Staff member C stated she did not know what Y-1 or N-1 meant on the restorative flow sheet, other than the resident did or did not receive the services. Staff member A reported she did not think there was a way to identify the details of the treatments in the system.
Review of resident #13's electronic medical record on 5/8/24, showed a physician's order for restorative services starting on 11/21/22, which remained on the active orders. The order stated PROM (passive range of motion) to B (bilateral) UE/LE (upper extremity/lower extremity) QD (every day).
Review of resident #13's restorative flow sheet for the period 3/1/24 through 5/1/24 showed the completion of services were indicated with Y-1 or N-1 on the respective shift. There was no legend to define Y-1 and N-1 included on the flow sheet. There were no treatment details including, length of treatment time, number of repetitions, pain, limitations with treatment, or if the resident was unavailable or refused. There was a minimum of 7 missed opportunities for restorative services, on 3/7/23, 3/14/23, 3/15/23, 3/28/23, 4/16/23, 4/17/23, and 5/1/23. Confirmation of additional missed opportunities was not possible without a legend for N-1.
2. Review of resident #31's physicians order, dated 5/31/22, showed resident #31 was discontinued from outpatient occupational therapy. The orders showed the resident was to continue the [NAME] Voice Treatment (LSVT) exercises with contact guard assistance and gait belt four times per week.
Review of resident #31's care plan showed resident #31 was to do the Restorative nursing exercises: LSVT-big exercises 4X/week independently in (resident's) room; Ask him and document when completed; prompt him and remind him to do . [sic]
During an interview on 4/8/24 at 9:20 a.m., staff member N stated she had been at the facility about six months. Staff member N stated she had not provided restorative nursing for resident #31. Staff member N stated resident #31 will sometimes walk, but the steps taken are weak and his feet cross over each other. Staff member N stated she mostly feeds resident #31 his meals and may take him to some activities. Staff member N stated there are no restorative exercise programs being offered to resident #31.
During an interview on 4/8/24 at 11:00 a.m., staff member L stated she does not complete any restorative exercises with resident #31. Staff member L stated she is unaware of any formal program. Staff member L stated there are no guides or directions for the staff on restorative exercises on the memory care unit. Staff member L stated she would not know where to document restorative exercises. Staff member L stated she has not helped resident #31 with any exercise program. Staff member L stated resident #31's legs are weak.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, interviews, and record review the facility failed to provide food at a palatable temperature for 3 (#s 4, 20, and 46) of 21 sampled residents. The failure had the ability to affe...
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Based on observation, interviews, and record review the facility failed to provide food at a palatable temperature for 3 (#s 4, 20, and 46) of 21 sampled residents. The failure had the ability to affect all residents who eat food from the kitchen in the facility. Findings include:
During an observation and interview on 5/6/24 at 4:44 p.m., the food had been sitting unattended on the steam table with the lids on, and staff member E had just entered the kitchen after running food to another facility. Staff member E was asked to take the temperature of the food on the steam table. The temperature of the chicken in the steam table at that time was 123.9 degrees Fahrenheit.
During an observation on 5/6/24 at 4:59 p.m., there were no insulated plate bases located under the plates that the food was served on.
During an observation and interview on 5/6/24 at 5:02 p.m., six trays had been prepared with food to be shortly served in the dining room. The plates had insulated dome covers on the top of the plates, but did not have warmers on the bottom of the plates. Staff member D was asked to take the temperature of these foods. At the lowest temperature, the carrots were 112.9 degrees Fahrenheit, and the highest temperature was 125 degrees Fahrenheit. Staff member D said to staff member E, .the temps are dropping on the vegetables.
During an interview and observation on 5/6/24 at 5:07 p.m., staff member D stated the plates were usually warmed before food was placed on them. Staff member D showed a plate warmer that was located in front of the steam table.
During an interview on 5/6/24 at 5:31 p.m., staff member E was asked if the plate he was about to put food on was warm to the touch. Staff member E grabbed the plate and stated, No.
During an interview on 5/7/24 at 9:14 a.m., resident #20 stated, No one warms up the veggies - they are consistently cold. Someone there doesn't know how to use the microwave!
During an interview on 5/7/24 at 10:05 a.m., resident #46 stated the hot food is lukewarm.
During an interview on 5/7/24 at 2:56 p.m., staff member H stated she was aware of resident complaints about cold food.
During an interview on 5/8/24 at 11:00 a.m., resident #4 stated, No, it's just a little bit warm (when he was asked if the food was hot).
May 2023
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
2. During an interview on 5/21/23 at 10:34 a.m., NF2 stated resident #13 was recently transferred to the hospital with a hip injury, and the facility contacted her by phone to report the transfer. NF2...
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2. During an interview on 5/21/23 at 10:34 a.m., NF2 stated resident #13 was recently transferred to the hospital with a hip injury, and the facility contacted her by phone to report the transfer. NF2 stated she never received anything in writing from the facility, regarding the reason for the transfer.
Review of resident #13's EHR, accessed on 5/21/23, failed to show documentation of the Notice of Transfer/Discharge documentation which occurred on 4/5/23.
During an interview on 5/23/23 at 7:55 a.m., staff member A stated the facility did not have a Notice of Transfer/Discharge document for resident #13 and a verbal notice, by phone, was given to resident #13's family at the time of the transfer.
A request for the written notice of transfer for resident #13 was made on 5/21/23. No documentation was received prior to the end of the survey.
Review of the facility's policy titled, Leaves/Hospitalization, not dated, showed, Before a resident is transferred, the facility will notify the resident, and if known, a family member or legal representative . This notice shall be in a language and manner they understand.shall be in writing and shall include the reason to transfer.
Based on interview and record review, the facility failed to ensure the resident and the resident's representative received written notice of the reason for a transfer for 2 (#s 7 and 13) of 2 sampled residents. Findings include:
1. During an attempted interview on 5/21/23 at 7:38 a.m., resident #7 was lying on her bed with her eyes closed. Resident #7 did not rouse to her name spoken in a normal voice. The resident was left undisturbed. The resident was unavailable for interview as she was sleeping when additional interviews were attempted, several times between 5/21/23 and 5/23/23.
Review of resident #7's EHR, accessed on 5/21/23, showed the resident sustained three falls in January of 2023, having occurred on 1/1/23, 1/21/23, and 1/30/23. After complaining of hip pain following the fall on 1/30/23, resident #7 was transferred to the emergency department for an evaluation. Resident #7 returned to the facility on 2/1/23 with diagnoses of a pelvic fracture and a urinary tract infection.
During an interview on 5/21/23 at 3:45 p.m., staff member A stated the facility documented the resident's family was notified of resident #7's transfer to the emergency department on 1/30/23. Staff member A stated the facility had a policy regarding the written transfer notice. But, when the transfer was emergent, the form did not get done. Staff member A stated they did not have a process for ensuring the written notice of transfer was provided as soon as practicable, after the transfer was completed.
A request for the written notice of transfer for resident #7 was made on 5/21/23. No documentation was received prior to the end of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to develop and implement a comprehensive, resident-centered care plan based on the comprehensive assessment for 3 (#s 7, 20, and 35) of 6 samp...
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Based on interview and record review, the facility failed to develop and implement a comprehensive, resident-centered care plan based on the comprehensive assessment for 3 (#s 7, 20, and 35) of 6 sampled residents. Findings include:
1. Review of resident #35's face sheet, received on 5/22/23 at 11:30 a.m., showed an admission date of 9/15/22. Resident #35's diagnoses included, but were not limited to, Other Sleep Disorders and Major Depressive Disorder, recurrent, unspecified.
Review of resident #35's admission MDS, with an ARD of 9/20/22, showed the care area of psychotropic drug use was identified.
Review of resident #35's current (May 2023) physician orders, showed:
- Doxepin 10 mg (milligram) capsule, to be taken by mouth, at bedtime, for Sleep Disorder, started on 9/15/22, and
- Sertraline 50 mg tablet, to be taken by mouth, one time a day, for Major Depressive Disorder.
Review of resident #35's care plan, as of 5/22/23 at 11:00 a.m., did not show any focus areas, goals, or interventions for a sleep disorder or depression, including any monitoring for side effects of the medications prescribed.
During an interview on 5/22/23 at 10:53 a.m., staff member E stated care plans were based on the MDS assessment. She stated if the resident was on an antidepressant and medication for insomnia, those areas should be identified in the care plan, with goals and interventions.
During an interview on 5/23/23 at 7:24 a.m., staff member F stated she had access to the care plans, in a book kept on the unit. She stated the care plan book was updated to reflect changes made to the resident's plan of care. Staff member F stated if areas were not identified on the care plan, she would not know what to monitor for the resident or how to help them.
2. Review of resident #20's EHR, accessed on 5/22/23, showed the resident had recurrent cellulitis and edema on her lower extremities. Resident #20 received several different antibiotics as treatment.
Review of resident #20's care plan, dated from 12/1/22 through 5/23/23, failed to show a focus area related to the resident's cellulitis and antibiotic treatment.
During an interview on 5/23/23 at 7:45 a.m., staff member C stated she was responsible for updating care plans based on the MDS assessments completed. Staff member C stated if there were changes to the care plan between the completion of the MDS assessments, the nursing staff would need to notify her so the changes could be made to the care plan. Staff member C stated the floor nurses did not generally make changes to the care plan. Staff member C stated she did not know why resident #20's care plan did not show a focus area and interventions related to the resident's cellulitis diagnosis.
3. Review of resident #7's medication list from the EHR, accessed on 5/22/23, showed the resident was receiving the antidepressants citalopram and trazadone for depression.
Review of resident #7's care plan, accessed on 5/21/22, failed to show a focus area related to the use of antidepressants, monitoring for side effects, or interventions related to the resident's depression diagnosis.
Review of resident #7's care plan, accessed on 5/22/23, showed the focus area of potential drug-related complications associated with the use of citalopram and trazadone for depression had been added on 5/22/23. The care plan also showed the addition of interventions related to monitoring and documentation of side effects and behaviors associated with depression and the use of antidepressants. The interventions were also dated 5/22/23.
During an interview on 5/23/23 at 7:45 a.m., staff member C stated she had been working at the facility for approximately six months. Staff member C stated she was still trying to get the care plans organized and updated. Staff member C stated she had not been able to update resident #7's care plan yet. Staff member C stated if a resident was receiving psychotropic medications, their care plan should have included monitoring and documentation of side effects and behaviors.
Review of the facility policy titled, Resident Care Planning, last approved 9/22, showed:
- .The resident care plan includes at least the following items:
- 1. Identification of care needs based on initial written and continuing comprehensive assessment of the resident's needs.
- .4. Care to be given, objectives to be accomplished and the professional discipline responsible for each element of care.
- 5. Measurable and time-limited objectives (goals).
- 6. Reviewing, evaluating and updating of the resident care plan as necessary, but at least quarterly.
- The plan of care of resident will be implemented according to the methods indicated and each resident's care will be based on this plan. [sic]
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
2. Review of resident #15's Quarterly MDS, with an ARD of 3/29/23, showed the resident had functional limitations in range of motion, with impairment to both sides of his body, upper and lower extremi...
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2. Review of resident #15's Quarterly MDS, with an ARD of 3/29/23, showed the resident had functional limitations in range of motion, with impairment to both sides of his body, upper and lower extremities, and was dependent on staff for actitivites of daily living.
Review of resident #15's restorative treatment records, dated between 1/1/23 and 5/21/23, showed the resident had a total of 141 opportunities to receive passive range of motion. Documentation showed the resident received passive range of motion 40 times during the same timeframe.
During an interview on 5/22/23 at 10:33 a.m., staff member H stated restorative care for residents was completed by the CNAs assigned to the resident during their shift, and were documented in the restorative book at the nurse's station. Staff member H said she was not sure if staff had gotten used to documenting in the restorative book because it was previously done through the resident's electronic medical record.
During an interview on 5/22/23 at 12:03 p.m., staff member G stated sometimes the restorative care was not documented because the book was not always at the nurse's station, and stated, Out of site out of mind.
Review of the facility's policy titled, Rehabilitative Nursing Services Policies, [sic] not dated, showed a Rehabilitative Nursing Aide (RNA) was available to administer exercises and gait assistance, to meet the needs of the residents.
Based on observation, interview, and record review, the facility failed to provide and consistently document restorative nursing services intended to improve or maintain mobility for 2 (#s 12 and 15) of 4 sampled residents. The deficient practice had the potential to delay discharge to home for resident #12. Findings include:
1. During an observation and interview on 5/21/23 at 8:58 a.m., resident #12 stated she had been receiving physical therapy services until approximately December of 2022. Resident #12 stated she wanted to get strong enough to be able to go home. The resident stated she practiced standing while alone in her room. Resident #12 stated the facility did not want her to do this activity alone, but did not provide supervision so she could perform the activity consistently. Resident #12 stated she was able to stand, unassisted, for approximately one minute at a time, and did as many repititions as she could. The resident was able to lift both lower legs off the floor, but was not able to fully extend at her knees.
During an interview on 5/22/23 at 1:39 p.m., staff member B stated she did not know why the staff were not documenting restorative services, including refusals, consistently.
During an interview on 5/23/23 at 7:19 a.m., staff member G stated if there is not an extra CNA scheduled to complete restorative services, the CNAs were supposed to complete the restorative tasks for the residents assigned to them. Staff member G stated after completing the ordered services, the CNAs were supposed to document the task in the book at the nurse's station. Staff member G stated in the old EHR system, restorative services were documented in the computer, not on paper, and a lot of people forgot to document in the book.
During an interview on 5/23/23 at 7:26 a.m., staff member F stated the CNAs documented restorative services in the book when the exercises were completed.
During an interview on 5/23/23 at 7:35 a.m., staff member H stated all of the CNAs were responsible for doing restorative services during their shift. Staff member H stated the CNAs were supposed to document the services in the book, not in the computer. Staff member H stated she did not think anyone was used to documenting in the book, and it is was missed because the CNA's were not used to the change yet.
Review of resident #12's Quarterly MDS, with an ARD of 5/3/23, showed the resident was unsteady when transitioning from sitting to standing, and required assistance. Ambulation did not occur during the observation period.
Review of resident #12's nursing rehabilitation order, dated 11/21/22, showed the resident was supposed to ambulate in the hall with a two-wheeled walker, and followed with a wheelchair daily.
Review of resident #12's treatment records, dated from 11/22/22 through 5/19/23, showed the resident had a total of 179 opportunities to ambulate during the six month period. The documentation showed the resident was assisted with ambulation 35 times, and refused to ambulate three times.
Review of resident #12's nursing progress note, dated 5/9/23, showed the resident expressed a wish to walk more. The note showed the staff would offer to walk with resident #12 in the evening, as was her preference.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to annually review the Infection Prevention Program and revise as necessary. Findings include:
During an interview on 5/22/23 at 1:39 p.m., st...
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Based on interview and record review, the facility failed to annually review the Infection Prevention Program and revise as necessary. Findings include:
During an interview on 5/22/23 at 1:39 p.m., staff member B stated she was responsible for infection prevention activities in the facility. Staff member B stated the policies associated with infection prevention were stored in an electronic system which alerted staff when a policy was up for review. Staff member B stated the policies were set for review every two years as the facility was affiliated with a critical access hospital which required policy review every two years. Staff member B stated she was not aware of the annual review requirement of the Infection Prevention Program and policies. Staff member B stated some of the facility's policies had not been reviewed within the previous 12 months.
Review of the facility's Infection Prevention Program policies showed the following:
- Infection Control Program policy, last review dated 2/22, next review due 2/23,
- Surveillance policy, last revision dated 2/22, next review due 2/23,
- Antibiotic Stewardship policy, last review dated 2/21, next review due 2/22,
- Antibiotic Stewardship - Orders for Antibiotics policy, last review dated 2/21, next review due 2/22,
- Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes policy, last review dated 2/21, next review due 2/22,
- Antibiotic Stewardship - Staff and Clinician Training and Roles, last review dated 2/21, next review due 2/22,
- CMS Omnibus COVID-19 Health Care Staff Vaccination policy, last revision dated 4/22, next review due 4/23, and
- Influenza Vaccine Program, last revision dated 4/22, next review due 4/23.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • 24 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $22,825 in fines. Higher than 94% of Montana facilities, suggesting repeated compliance issues.
- • Grade C (53/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 53/100. Visit in person and ask pointed questions.
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About This Facility
What is Faith Lutheran Home's CMS Rating?
CMS assigns FAITH LUTHERAN HOME an overall rating of 3 out of 5 stars, which is considered average nationally. Within Montana, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Faith Lutheran Home Staffed?
CMS rates FAITH LUTHERAN HOME's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 49%, compared to the Montana average of 46%.
What Have Inspectors Found at Faith Lutheran Home?
State health inspectors documented 24 deficiencies at FAITH LUTHERAN HOME during 2023 to 2025. These included: 1 that caused actual resident harm and 23 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Faith Lutheran Home?
FAITH LUTHERAN HOME is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 60 certified beds and approximately 42 residents (about 70% occupancy), it is a smaller facility located in WOLF POINT, Montana.
How Does Faith Lutheran Home Compare to Other Montana Nursing Homes?
Compared to the 100 nursing homes in Montana, FAITH LUTHERAN HOME's overall rating (3 stars) is above the state average of 3.0, staff turnover (49%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Faith Lutheran Home?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Faith Lutheran Home Safe?
Based on CMS inspection data, FAITH LUTHERAN HOME has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Montana. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Faith Lutheran Home Stick Around?
FAITH LUTHERAN HOME has a staff turnover rate of 49%, which is about average for Montana nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Faith Lutheran Home Ever Fined?
FAITH LUTHERAN HOME has been fined $22,825 across 1 penalty action. This is below the Montana average of $33,307. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Faith Lutheran Home on Any Federal Watch List?
FAITH LUTHERAN HOME is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.