Montana Mental Health NH: Pharmacy Failures - MT
The November 4 incident at Montana Mental Health Nursing Home triggered a neglect investigation after the next shift discovered the resident covered in waste that had hardened on his clothing and equipment.
Staff member G received explicit instructions from a nurse to change resident #6's brief because he had soiled himself. Instead of completing the task, the worker left her shift without providing the necessary care.
When the second shift arrived, they found resident #6 in deplorable conditions. Dried feces covered his back, stained his clothing, filled his wheelchair, and had worked its way under the wheelchair cushion.
The facility immediately reported the incident as neglect of care. Staff member G was placed on administrative leave pending investigation.
Staff member U, who was working that day, described the disturbing scene to inspectors. The smell of soiled waste was noticeable throughout the area, alerting other workers to the resident's condition.
"Staff in the area could smell that resident #6 had soiled himself," staff member U told inspectors during a November 17 interview.
Staff member U witnessed the nurse's direct instruction to staff member G to change the resident's brief. But instead of completing the task, staff member G claimed to handle it and returned in under five minutes.
The timeline made no sense. Resident #6 required full assistance for ambulation and brief changes due to his condition. Such care could not possibly be completed in five minutes or less.
"This could not have been done in five minutes or less," staff member U explained to inspectors, describing the extensive assistance the resident needed.
Federal inspectors attempted to reach staff member G multiple times on November 17. They called at 7:35 a.m. and again at 10:40 a.m., but could not leave messages because the worker had never set up voicemail.
Staff member A from the facility's Human Resources department confirmed their own unsuccessful attempts to contact the worker. Despite being required to remain available between 8:00 a.m. and 5:00 p.m. during administrative leave, staff member G provided no response to multiple contact attempts.
This marked the third time since September that staff member G had been placed on administrative leave for performance issues. The pattern of problems had not gone unnoticed by colleagues.
"Some staff complained staff member G was lazy and did not complete her duties," staff member A told inspectors.
The facility's own policies clearly defined the care standards that were violated. Their Activities of Daily Living policy, revised in March, explicitly requires staff to provide toileting assistance as part of basic care services.
More significantly, the facility's abuse and neglect policy defines neglect as "the failure of the facility, its employees, or service provider to provide goods and services to a resident necessary to avoid physical harm, pain mental anguish or emotional distress."
The November 4 incident represented a clear violation of both policies. A vulnerable resident who depended entirely on staff for basic hygiene care was abandoned in his own waste for hours.
The inspection report classified this as an isolated incident specific to one resident rather than a systemic care failure. However, the worker's history of performance problems and previous administrative leaves suggests a pattern of inadequate care.
Federal inspectors determined the violation caused minimal harm or potential for actual harm, but the human dignity implications were severe. The resident endured hours sitting in dried waste that had spread across his body and equipment.
The facility reported the incident through proper channels, demonstrating awareness of their reporting obligations. But the underlying question remains how a worker with multiple performance issues continued to provide direct resident care.
Staff member G's repeated placement on administrative leave since September indicates ongoing problems with job performance. The November 4 neglect incident represented an escalation from general performance concerns to direct abandonment of a vulnerable resident.
The inspection occurred two weeks after the incident, suggesting the complaint that triggered the survey came from within the facility or from concerned family members who learned of the neglect.
Montana Mental Health Nursing Home serves residents with complex mental health needs who often require extensive assistance with basic activities of daily living. The facility's specialized population makes proper toileting assistance even more critical for resident dignity and health.
The dried feces found on the resident's back and wheelchair equipment indicated he had been sitting in waste for an extended period. The condition of the waste suggested hours had passed between the initial soiling and discovery by the next shift.
Other staff members' ability to smell the soiled condition throughout the area demonstrates how obvious the resident's need for care had become. Yet staff member G chose to ignore both the nurse's direct instruction and the resident's evident distress.
The worker's failure to set up voicemail during administrative leave further demonstrated a pattern of avoiding accountability. Despite being required to remain available during business hours, staff member G made no effort to facilitate communication with supervisors or investigators.
Federal inspectors classified the deficiency under regulations requiring facilities to provide care and assistance for activities of daily living. The violation specifically cited the facility's failure to ensure necessary ADL care when a staff member was directed to provide it but instead abandoned the resident.
The incident report filed by the facility acknowledged this as neglect of care, not a simple oversight or system failure. This classification carries serious implications for both the individual worker and the facility's oversight responsibilities.
Resident #6 remains at the facility, presumably receiving proper care from other staff members. But the November 4 incident left him sitting in his own waste for hours, a violation of basic human dignity that no nursing home resident should endure.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Montana Mental Health Nursing Home from 2025-11-19 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
MONTANA MENTAL HEALTH NURSING HOME in LEWISTOWN, MT was cited for violations during a health inspection on November 19, 2025.
Staff member G received explicit instructions from a nurse to change resident #6's brief because he had soiled himself.
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.