PLAINS, MT - Federal inspectors documented multiple care deficiencies at Clark Fork Valley Nursing Home during a February 2025 inspection, including failures to investigate potential resident abuse, inaccurate medication assessments, and inadequate care planning for residents with complex medical needs.
Failure to Investigate Resident-to-Resident Altercations
Inspectors found the facility failed to properly investigate and report multiple instances of resident-to-resident incidents involving a resident with dementia. Medical records revealed documentation of aggressive and intrusive behavior by one resident toward others throughout 2024, yet the facility did not initiate formal abuse investigations or report these events to the State Survey Agency as required by federal regulations.
Progress notes from September 2024 through January 2025 contained references to resident-to-resident altercations, including entries stating one resident "hit and pulled hair" of another resident, and multiple instances where a resident "got into it" with other residents. Despite this documented pattern of concerning behavior, the facility's own records showed only four Facility Reported Incidents sent to the State Survey Agency in 2024, none of which involved the resident identified in these altercations.
When questioned about the documented incidents, a staff member indicated she would have investigated situations involving resident-to-resident altercations "for sure" if she had been aware of them. Another staff member revealed she had restricted one employee's access to write progress notes in the medical record in September 2024 after identifying concerning documentation, yet no formal investigation appeared to have been initiated at that time.
The facility's own policy on Abuse, Neglect & Exploitation clearly states that all alleged violations involving resident-to-resident incidents must be investigated, with results reported to administration and state officials within five working days. The failure to follow these protocols represents a breakdown in resident safety systems designed to protect vulnerable individuals.
Timely investigation of resident-to-resident incidents serves multiple critical purposes in nursing home care. First, it allows facilities to identify residents whose behaviors may indicate unmet medical needs, such as pain, infection, or medication side effects. Second, it protects potential victims from repeated exposure to harmful situations. Third, it ensures residents exhibiting aggressive behaviors receive appropriate evaluation and intervention rather than simply being separated from others.
When facilities fail to investigate these incidents, residents with dementia may not receive needed medical evaluation to determine underlying causes of behavioral changes. Urinary tract infections, medication interactions, uncontrolled pain, or worsening cognitive decline can all manifest as increased agitation or aggression. Without proper assessment, these treatable conditions may go unaddressed, leading to continued behavioral issues and potential harm to other residents.
Inaccurate Assessment Documentation
The inspection revealed systematic problems with the accuracy of required resident assessments. Three residents had assistive bed rails incorrectly classified as physical restraints on their Minimum Data Set (MDS) assessments, despite evidence these devices helped residents with mobility rather than restricting their movement.
During observations, residents demonstrated they used the narrow side rails to reposition themselves in bed and to assist with standing. One resident stated the side rail helped her get in and out of bed and did not restrict her movement. Another resident grabbed the side rail and stood up from the bed, explaining it helped him "stay more independent."
Despite this functional use, the facility's MDS coordinator marked these assistive devices as daily restraint use on quarterly and annual assessments completed in December 2024 and January 2025. The coordinator later acknowledged she believed she had to code the side rails as restraints, but was subsequently informed by nursing leadership this was incorrect.
Additionally, inspectors found a resident taking trazodone for insomnia had this medication omitted from the antidepressant category on their January 2025 MDS assessment. Trazodone, while commonly prescribed off-label for sleep, is classified as an antidepressant and should be documented as such in assessment records. The MDS coordinator confirmed the medication was not coded on the assessment.
Accurate MDS assessments form the foundation for appropriate care planning and resource allocation in nursing facilities. These federally mandated assessments capture detailed information about each resident's functional abilities, medical conditions, medications, and needs. When assessments contain inaccuracies, they can trigger inappropriate care protocols, affect quality measures used to evaluate facility performance, and lead to inadequate monitoring for medication side effects.
The misclassification of assistive devices as restraints can have multiple negative consequences. It may trigger unnecessary restraint reduction protocols, lead to removal of devices residents find helpful, and create inaccurate data about facility restraint use. Conversely, failing to document antidepressant medications means residents may not receive appropriate monitoring for side effects such as falls, sedation, or mood changes.
Incomplete Care Plans and Missing Documentation
Inspectors identified multiple instances where resident care plans failed to address significant medical conditions and resident preferences. One resident taking apixaban, a blood-thinning medication, had no documentation in their care plan addressing anticoagulant use or associated bleeding risks. During observation, this resident displayed easy bruising, a common side effect of anticoagulant therapy, yet staff found nothing in the care plan providing guidance about this high-risk medication.
Anticoagulants require careful monitoring due to their potential for serious bleeding complications. Care plans for residents on these medications should include interventions to minimize fall risk, protocols for monitoring for signs of bleeding, and education for staff about the importance of reporting even minor injuries. The absence of such documentation leaves nursing staff without clear guidance about special precautions needed for residents on these medications.
Another resident who preferred sleeping in a recliner in the common area due to claustrophobia had no mention of this preference in their care plan. Multiple staff members confirmed the resident regularly slept in the common area rather than in her room, with one stating the resident "doesn't like being in her room because it makes her feel claustrophobic." The resident herself explained, "I have claustrophobia, and I hate being locked in my room."
Person-centered care requires documentation of individual preferences and accommodation of those preferences whenever safely possible. When care plans lack this information, staff members on different shifts may not understand a resident's routine, potentially leading to conflicts or distress when attempting to redirect residents to their rooms at night.
A third resident placed on comfort care in October 2024 had no revision to their care plan reflecting this significant change in treatment goals. The facility's nursing leadership acknowledged having no formal comfort care policy, instead relying on individualized conversations with residents and families. While individualization is important, the lack of documented care plan updates means staff may not have clear guidance about treatment priorities and symptom management approaches appropriate for comfort-focused care.
Weight Management and Nutritional Oversight
The facility failed to implement proper protocols when a resident experienced significant weight fluctuations. Records showed one resident's weight decreased from 190.2 pounds in November 2024 to 164.0 pounds in February 2025, representing a 13.77 percent loss over three months. Despite facility protocols requiring weekly re-weights for residents with 5 percent weight loss, no re-weights were documented during this period.
Staff provided conflicting explanations for the weight changes and lack of follow-up. One staff member attributed variations to edema and stated the resident's healthcare provider was not concerned about the weight. However, physician progress notes from November 2024 through February 2025 contained no documentation addressing weight loss, edema, or discussions about diuretic medications.
The facility's dietitian reported verbally expressing concerns about the need for re-weighing this resident to nursing leadership, but stated those concerns were not addressed. The dietitian indicated she would document recommendations for nursing to forward to the physician, but was uncertain whether that communication occurred.
Unintentional weight loss in nursing home residents can indicate multiple serious problems, including inadequate nutrition, difficulty eating, dental problems, medication side effects, infections, or progression of chronic diseases. A weight loss exceeding 10 percent over several months requires prompt medical evaluation to identify and address underlying causes.
Regular monitoring through re-weights allows early detection of continued decline and assessment of whether interventions are effective. The absence of this monitoring, combined with lack of physician documentation about the weight changes, suggests a breakdown in the communication systems meant to ensure residents' changing conditions receive appropriate medical attention.
Additional Issues Identified
Inspectors documented several other care deficiencies during the survey. The facility lacked a bladder retraining program for residents identified as good candidates for scheduled toileting or bladder retraining based on facility assessments. Two residents scoring as appropriate for bladder programs had no documented toileting schedules or retraining interventions, despite being capable of independent toilet use.
The facility failed to provide trauma-informed care for a resident with documented history of significant life trauma, including childhood abuse, domestic violence, and traumatic loss. Despite the resident frequently discussing these experiences with staff and expressing feelings of not being believed, no social services interventions were documented, and the resident had never been referred to available counseling services. The facility acknowledged having no policy or procedure for trauma-informed care.
Care plan development issues extended beyond those already mentioned. One resident's care plan was not revised to include focus, goals, or interventions related to comfort care even four months after a physician order was entered. Nursing leadership acknowledged the facility had no formal comfort care policy, instead relying on individualized approaches based on staff familiarity with residents.
The inspection findings point to systemic issues with care planning, assessment accuracy, investigation protocols, and interdisciplinary communication at the facility. These deficiencies were cited at the minimal harm level, indicating they had limited negative outcomes for residents but had the potential to cause more than minimal harm if left unaddressed.
Federal regulations require nursing facilities to maintain comprehensive, accurate assessments and care plans that address each resident's individual needs, preferences, and medical conditions. Facilities must investigate allegations of abuse and implement programs to maintain or restore residents' functional abilities. The violations identified at Clark Fork Valley Nursing Home represent failures across multiple areas of these fundamental care requirements.
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.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.