PLAINS, MT - Federal inspectors documented multiple instances where Clark Fork Valley Nursing Home failed to protect residents from harmful behaviors over a two-month period, with staff recording at least 15 separate incidents involving physical contact between residents without implementing adequate intervention strategies.
Pattern of Resident-to-Resident Incidents Documented
Between July and August 2024, facility staff documented a series of incidents involving one resident's repeated physical interactions with other residents. The events ranged from wheelchair collisions to grabbing, hitting, and pulling behaviors that created safety concerns throughout the facility.
On July 3, 2024, staff recorded that a resident in a wheelchair collided with another resident's walker, striking the walking resident's fingers and nearly causing her to fall. Later that same day, the same resident attempted to hit another resident with a recliner remote, and when staff intervened, reportedly laughed and said "I almost gotchya."
The following day brought a more serious incident when a resident grabbed another resident's face, specifically the left eyebrow area, creating an open wound above the eye. Staff documentation noted this occurred during a confrontation over supplies.
These incidents represent significant failures in behavioral management protocols. When a resident exhibits patterns of physical aggression toward others, facilities are required to conduct comprehensive behavioral assessments, identify triggering factors, and implement targeted interventions. The medical significance extends beyond immediate injuries - repeated exposure to aggressive behaviors can cause psychological distress, fear, anxiety, and reluctance to participate in social activities among affected residents.
The facility's documentation showed that staff recorded these events but did not demonstrate sufficient action to protect other residents or provide ongoing behavioral assessments. There was no evidence that interventions were systematically identified, implemented, and monitored to address the underlying causes of the resident's behaviors while simultaneously protecting others in the facility.
Escalation Without Adequate Response
The incidents continued to escalate throughout July. On July 10, 2024, staff documented that a resident "started to torment" another resident during an activity in the dining room, poking her aggressively on the left shoulder and back. When the affected resident asked her to stop because it was hurting, the aggressing resident reportedly laughed and continued. Five minutes later, the same resident returned to the dining room, attempted to take another resident's walker by grabbing and dragging it away, and when staff intervened, began swearing and yelling.
Later that same day, staff recorded that the resident removed hanging pictures from walls and threw them on the ground, then went to side tables and dining tables, grabbing and throwing items while making crying sounds.
From a clinical perspective, this pattern indicates significant unmet needs. When residents exhibit escalating aggressive behaviors combined with emotional distress, it typically signals underlying medical issues, environmental stressors, unaddressed pain, medication side effects, or progression of cognitive impairment. The combination of targeted aggression toward specific residents and generalized agitation suggests the resident was experiencing significant distress that required comprehensive evaluation.
Proper protocol requires facilities to convene interdisciplinary team meetings when behavioral patterns emerge, involving physicians, nursing staff, social services, activities personnel, and when appropriate, mental health professionals. The team should review medications, assess for underlying medical conditions, evaluate environmental factors, and develop individualized interventions that address root causes rather than simply documenting incidents as they occur.
Physical Contact Incidents Continue
The documented incidents persisted into August. On July 17, staff noted the resident was "running into other residents while in her wheelchair," then "swung at [a resident's] head and spit at her." Ten days later, the resident reached over and pinched another resident on her right arm multiple times before staff could separate them.
On July 31, the resident grabbed another resident's arm and attempted to pull her to the ground, prompting the affected resident to yell "Hey Stop, Ouch that hurt." Staff separated the residents and moved one to a safe location.
The pattern continued through early August with multiple incidents involving hitting residents with a recliner remote, grabbing residents' arms and attempting to pull them down, grabbing and pulling on residents' shirts, and hitting residents on their chests with fists. Staff documented incidents on August 2, August 3 (two separate events), August 15 (two separate events), and August 16.
The August 16 incident involved the resident pushing a laundry cart repeatedly into another resident while moving through the hallways.
These repeated physical contact incidents presented significant injury risks. Falls resulting from being pulled or pushed can cause fractures, particularly in elderly residents with osteoporosis. Hip fractures alone carry mortality rates of 20-30% within one year among nursing home residents. Repeated blunt force contact, even from objects like remote controls, can cause bruising, skin tears, and soft tissue injuries in residents with fragile skin and poor circulation.
Systemic Failure in Behavioral Management
The inspection revealed that while staff diligently documented each incident, the facility failed to implement the systematic behavioral interventions required by federal regulations. There was no evidence of comprehensive behavioral assessments analyzing patterns, triggers, and potential underlying causes. The documentation did not show that the interdisciplinary team developed and implemented specific interventions targeting the resident's behaviors while protecting others in the facility.
Effective behavioral management in long-term care requires a multi-faceted approach. Staff should identify patterns in when and where behaviors occur, what happens immediately before incidents, and which residents are repeatedly targeted. This analysis guides intervention development. If behaviors occur during specific activities, the care plan might include one-on-one supervision during those times. If certain residents appear to trigger reactions, seating arrangements and activity scheduling can be adjusted. If behaviors stem from unmet needs, addressing pain, boredom, overstimulation, or other factors becomes the priority.
The facility also failed to demonstrate adequate protection measures for other residents. When one resident poses ongoing risks to others, facilities must implement immediate safeguards while longer-term interventions are developed. This might include enhanced supervision, environmental modifications, activity schedule adjustments, or temporary room assignment changes to create physical separation while addressing underlying causes.
Social Services Assessment Deficiency
Inspectors identified an additional concern regarding medically-related social services. During a February 10, 2025 interview, one resident described experiencing "many traumatic experiences" throughout her life, stating "My horrible life started when I was a child." The resident went on to describe multiple traumatic events from her past.
Federal regulations require nursing homes to provide medically-related social services to help each resident achieve the highest possible quality of life. When residents disclose significant trauma histories or demonstrate signs of psychological distress, social services staff should conduct comprehensive psychosocial assessments, provide supportive counseling, facilitate connections to mental health professionals when appropriate, and develop care plan interventions addressing emotional and social well-being.
The inspection found the facility failed to provide adequate social services for this resident, creating potential negative impacts on her mental well-being. Unaddressed trauma can manifest as depression, anxiety, social withdrawal, or difficulty adjusting to nursing home life. Social services interventions help residents process difficult emotions, develop coping strategies, maintain meaningful connections, and achieve better quality of life despite past hardships.
Additional Issues Identified
Beyond the primary behavioral management and social services concerns, the inspection narrative indicated the facility's documentation practices revealed gaps in care planning and intervention implementation. The repeated use of "late entry" designations in behavior notes suggests potential delays in documenting incidents, which can impact the timeliness of clinical responses and care plan modifications.
The inspection findings represent violations of federal participation requirements for skilled nursing facilities. The Centers for Medicare & Medicaid Services requires nursing homes to ensure each resident receives appropriate treatment and services to maintain the highest practicable physical, mental, and psychosocial well-being. This includes protecting residents from abuse, which federal regulations define to include willful infliction of injury or unreasonable confinement, as well as failure to prevent resident-to-resident altercations when the facility has knowledge of patterns.
Regulatory Standards and Expectations
Federal nursing home regulations establish clear expectations for behavioral management. Facilities must assess each resident's behavioral health needs upon admission and regularly thereafter. When behavioral issues emerge, comprehensive assessments should identify contributing factors including medical conditions, medications, environmental triggers, and unmet needs. Care plans must include specific, individualized interventions targeting identified causes, with regular monitoring and modification based on effectiveness.
Staff training requirements mandate that nursing home employees receive education in behavioral management techniques, de-escalation strategies, and person-centered approaches to challenging behaviors. Facilities should maintain adequate staffing levels to implement behavioral interventions safely and consistently.
The regulatory framework also requires facilities to create environments that minimize factors contributing to behavioral disturbances, including noise levels, lighting, activity programming appropriate to residents' interests and cognitive levels, and physical layouts that reduce confusion and promote safety.
When incidents occur despite preventive efforts, facilities must respond immediately to protect all residents involved, document thoroughly, analyze contributing factors, and adjust care plans accordingly. Patterns of repeated incidents without evidence of systematic intervention development and implementation constitute regulatory violations.
Clark Fork Valley Nursing Home's inspection occurred on February 13, 2025, as part of routine federal oversight of Medicare and Medicaid-certified nursing facilities. The facility is located at 10 Kruger Road in Plains, Montana.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Clark Fork Valley Nursing Home from 2025-02-13 including all violations, facility responses, and corrective action plans.
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