PLAINS, MT - Federal inspectors identified serious deficiencies at Clark Fork Valley Nursing Home during a February 2025 survey, including improper medication storage practices and infection control violations that put residents at risk of harm.
Medication Cart Left Unattended with Drugs Exposed
Inspectors documented a concerning incident involving unsecured medication administration that violated federal safety requirements. On February 11, 2025, surveyors observed a travel nurse leave the facility's medication cart unlocked and unattended in the activity/dining room area for approximately five minutes.
The medication cart contained prepared medications in two white paper cups on the top drawer when the nurse walked away from the area and down the main hallway. When questioned about the incident, the nurse stated, "I did not lock the cart because it was parked in the corner, and nobody should bother it," later acknowledging she should have secured the cart before leaving.
This violation represents a significant breach of medication security protocols. Unsecured medication carts create opportunities for medication errors, theft, or unauthorized access by residents or visitors. The presence of already-prepared medications in cups compounds the risk, as these could be confused, contaminated, or accidentally administered to the wrong resident.
Federal regulations require all medications to be stored in locked compartments to prevent unauthorized access. Proper medication cart security is fundamental to preventing medication errors, which can result in serious adverse drug events, hospitalizations, or death in vulnerable nursing home populations.
Expired Medications Found in Stock Supply
During the same inspection, surveyors discovered multiple expired medications in the facility's stock supply, indicating failures in the facility's medication monitoring system. The expired medications included:
- Senna Plus tablets for constipation management - Acetaminophen suppositories for pain and fever control - Glucagon injection (Gvoke Hypepen) for emergency treatment of severe low blood sugar
The presence of expired medications poses direct health risks to residents. Expired drugs may lose potency, rendering them ineffective for treating medical conditions. In some cases, degraded medications can become toxic or cause adverse reactions. The Glucagon injection is particularly concerning, as it serves as an emergency medication for diabetic residents experiencing severe hypoglycemia - a potentially life-threatening condition where treatment effectiveness is critical.
The facility's own policy required monthly monitoring of expiration dates across all medication storage areas, including medication carts, refrigerators, and locked cabinets. The policy also mandated that expired medications be documented and returned to the designated pharmacy for proper disposal.
Travel nurses and temporary staff may face challenges navigating unfamiliar medication management systems, highlighting the importance of comprehensive orientation and ongoing oversight of medication practices regardless of staff tenure.
Hand Hygiene Failures During Medication Administration
Inspectors identified improper hand hygiene practices during medication administration that could facilitate the spread of infections among residents. A travel nurse was observed dispensing medication to one resident, then immediately approaching another resident to take vital signs without performing hand hygiene between interactions.
The nurse stated confusion about proper hand hygiene timing, saying she had been instructed to clean her hands "after touching high-touch surfaces and between each resident." However, her understanding and implementation of these protocols proved inadequate during observed care activities.
Proper hand hygiene represents the single most effective measure for preventing healthcare-associated infections. Nursing home residents face elevated infection risks due to age-related immune system changes, chronic medical conditions, and frequent healthcare contact. The facility's own hand hygiene policy clearly required staff to clean hands before touching any patient, after touching any patient, and after contact with items in patient rooms.
Healthcare-associated infections in nursing homes can lead to serious complications, including pneumonia, urinary tract infections, and bloodstream infections. These infections contribute to increased hospitalizations, antibiotic resistance, and mortality among vulnerable elderly populations.
Contaminated Laundry Handling Violations
The facility also failed to follow proper infection control procedures when handling contaminated laundry materials. An inspector observed a housekeeping staff member placing a dirty mop head into the washing machine without wearing required personal protective equipment (PPE).
When questioned, the staff member acknowledged he should have worn gloves and other protective equipment, stating he had received education on infection control practices. This violation occurred despite the facility maintaining written policies requiring all personnel handling contaminated laundry to wear appropriate PPE.
Contaminated cleaning equipment can harbor dangerous pathogens, including antibiotic-resistant bacteria, viruses, and fungi. Direct contact with these materials without proper protection creates opportunities for infection transmission to other areas of the facility through cross-contamination.
Medical Context and Industry Standards
These violations collectively represent systemic breakdowns in fundamental nursing home safety protocols. Medication management errors contribute to an estimated 125,000 deaths annually in the United States, with nursing home residents facing particular vulnerability due to complex medication regimens and age-related physiological changes.
Infection control failures in long-term care facilities have received heightened attention following the COVID-19 pandemic, which disproportionately affected nursing home populations. The Centers for Disease Control and Prevention emphasizes that consistent application of infection prevention measures remains critical for protecting residents from both common healthcare-associated infections and emerging threats.
Federal nursing home regulations require facilities to maintain pharmaceutical services meeting professional standards, ensure proper medication storage and security, and implement comprehensive infection prevention and control programs. These requirements exist because nursing home residents depend entirely on facility staff for medication safety and infection protection.
Additional Issues Identified
The inspection also revealed inadequate trauma-informed care services, with one long-term resident reporting never receiving counseling or social work support despite experiencing significant past trauma. Staff members were uncertain about trauma assessment protocols and could not locate social services documentation for the affected resident.
The facility's social services department was found to lack clear processes for identifying and addressing residents' psychological trauma history, despite maintaining policies stating that medically-related social services should be available to help residents maintain their highest level of mental and psychological well-being.
These findings at Clark Fork Valley Nursing Home illustrate the complex care challenges facing nursing facilities and the critical importance of consistent adherence to safety protocols across all aspects of resident care.
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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