Powder River Manor: POLST Form Incomplete - Broadus, MT
Federal inspectors visiting the facility on September 10, 2025, found that a POLST form for one resident, identified in inspection records as Resident 5, had been filled out selecting no CPR and selective treatment. The form was completed by the resident's responsible party, the person legally authorized to make medical decisions on the resident's behalf. But the responsible party had not signed it. The physician had not signed it. There was no date on the form, and no printed name for the provider.
Under Montana law, a POLST form requires the signature of a licensed physician, advanced practice registered nurse, or physician assistant, and the signature of the patient or their legal decision-maker. Without both, the document is not a valid medical order. What Powder River Manor had on file was a set of expressed wishes with no legal force behind them.
The stakes are not abstract. A POLST form exists precisely for emergencies, when there is no time to locate a family member or track down a doctor and ask what the patient would have wanted. Emergency personnel are supposed to be able to look at the form and know. An unsigned, undated form tells them nothing they can act on.
A staff member, identified in the inspection report only as Staff Member F, told inspectors that admission paperwork, including POLST forms, was reviewed with residents, responsible parties, and family members. She said some forms were sent home with residents or families to fill out before they moved in. She said she did not know why Resident 5's POLST had been left without the required signatures or a date.
That answer, given at 11:23 in the morning during an on-site interview, is the clearest summary of what went wrong. The form came back incomplete. No one caught it. It sat in the hard chart and the electronic medical record, looking like a completed document, functioning as nothing.
The facility's own advance directives policy describes a POLST as a portable medical order form that records a patient's treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency. The facility's separate guidance document for health care professionals states plainly that the provider signature and the patient or legal decision-maker signature are both required for the form to be valid.
Powder River Manor had written down the rules. It had not followed them.
Inspectors classified the violation as causing minimal harm or potential for actual harm, and noted that few residents were affected. The complaint inspection covered five sampled residents; the problem was found in one.
What that classification does not capture is the nature of the risk. Minimal harm is the finding when nothing bad has yet happened. Resident 5 selected no CPR. If Resident 5 had gone into cardiac arrest before this inspection, before anyone noticed the missing signatures, the form in the chart would have offered no protection. A paramedic or emergency room physician looking at an unsigned, undated document has no obligation to treat it as a binding order. The resident's expressed wish to forgo resuscitation could have been overridden, not out of malice, but because the paperwork that was supposed to make it enforceable was never actually completed.
The responsible party filled out the form. The facility accepted it. Weeks or months passed. No one went back to get the signatures that would have turned a piece of paper into a medical order.
Resident 5's wishes are on record. Whether they would have been honored in an emergency is a question the facility left open.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Powder River Manor from 2025-09-10 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
POWDER RIVER MANOR in BROADUS, MT was cited for violations during a health inspection on September 10, 2025.
The form was completed by the resident's responsible party, the person legally authorized to make medical decisions on the resident's behalf.
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.