Glendive Medical Center: Assessment Delays After Fracture - MT
The resident fractured her tibial plateau on June 28, according to nursing notes from Glendive Medical Center Nursing Home. She was ordered to wear a knee immobilizer and remain non-weight bearing for two to three months.
Before the fracture, the woman needed only partial to moderate assistance with basic activities. She could mostly manage oral care, getting on and off the toilet, showering, removing footwear, personal hygiene, toilet transfers, moving from bed to chair, and standing up from a sitting position.
After the injury, everything changed.
By July 17, the resident required substantial to maximum assistance with these same tasks. Her functional decline was dramatic and obvious. Federal regulations require nursing homes to complete a "Significant Change" assessment within 14 days when residents experience major declines that could impact their physical and health status.
Staff member C, who had been completing minimum data assessments for about a year, missed the deadline entirely.
During a September 11 interview with inspectors, she acknowledged the failure. "Staff member C said the Significant Change minimum data set assessment reference date was not set on time, and the minimum data assessment was late," the inspection report states.
The staff member told inspectors she had been trying to educate herself through online training but hadn't completed all the required courses. She said she now understood the two-week requirement for setting assessment reference dates after significant changes.
The delayed assessment had the potential to impact the resident's care plan and services. These assessments determine Medicare reimbursement rates and help ensure residents receive appropriate levels of care and therapy.
The resident's case illustrates a broader problem with assessment compliance at the facility. When residents experience major declines, prompt reassessment is critical for adjusting care plans, therapy services, and safety precautions.
A non-displaced tibial plateau fracture typically requires months of restricted mobility and can significantly impact an elderly person's independence. The transition from partial assistance to maximum help with basic daily activities represents exactly the kind of substantial change that triggers federal assessment requirements.
The timing gap was significant. The resident's decline was evident by mid-July, yet staff failed to initiate the required assessment process. This left the facility operating with outdated information about the resident's needs and capabilities during a critical recovery period.
Staff member C's admission that she was still learning the assessment requirements through self-directed online training raises questions about the facility's training protocols. Federal regulations require nursing homes to ensure staff are competent in their assigned duties, including understanding assessment timelines and procedures.
The inspection found that few residents were affected by this particular deficiency, but the violation represents a systemic failure in the facility's assessment process. When staff responsible for critical evaluations lack complete training, residents throughout the facility face potential risks.
The resident's functional decline from the fracture was substantial and measurable. Moving from partial assistance to maximum help with toileting, transfers, and basic hygiene represents a significant change in care needs that directly impacts quality of life and safety.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm. However, delayed assessments can lead to inadequate care planning, inappropriate therapy services, and missed opportunities for interventions that could improve outcomes.
The case demonstrates how a single injury can cascade into broader care challenges for elderly residents. The woman went from managing most daily activities with minimal help to requiring substantial assistance with nearly everything, yet the facility's assessment system failed to capture and respond to this change promptly.
Staff member C's acknowledgment that she "now knows" the two-week requirement suggests the violation stemmed from inadequate training rather than willful neglect. Nevertheless, the impact on the resident was the same regardless of intent.
The delayed assessment occurred during a vulnerable period when the resident was adjusting to significant physical limitations and mobility restrictions. Proper assessment timing ensures care plans reflect current needs and capabilities, particularly important during recovery from fractures that affect independence and daily functioning.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Glendive Medical Center N H from 2025-09-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
GLENDIVE MEDICAL CENTER N H in GLENDIVE, MT was cited for violations during a health inspection on September 11, 2025.
The resident fractured her tibial plateau on June 28, according to nursing notes from Glendive Medical Center Nursing Home.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.