Blackfeet Care Center
BLACKFEET CARE CENTER in BROWNING, MT — inspection on March 26, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 3/26/26 at 11:48 a.m., staff member A stated the expectation for all investigations was for all staff on shift to be interviewed, residents to be interviewed, have social services and nursing staff monitor and assess the affected residents for a period of time to ensure there were no adverse effects from the incidents, and all information, assessments, and monitoring needed to be documented in the medical record.Review of a facility document titled Abuse Prevention Policy and Procedures, with a revision date of 10/2025, showed: . G.
Investigation.3.
Retrieve written statements. that are signed and dated along with titles.4.
The actual investigation will include:a.
Date, time, location;. e.
Interviews with all people involved;f.
Interview residents and/or family member(s).
Obtain signed statements regarding the incident, as well as their reaction, who was involved, and what they hope the outcome will be. [sic]
275133 03/26/2026
Blackfeet Care Center 728 S Government Sq Browning, MT 59417
Review of resident #36's nursing progress notes, dated 2/18/26 through 2/22/26, showed:- The resident was readmitted to the facility after hospitalization on 2/18/26.
The resident was on enhanced barrier precautions related to right-sided nephrostomy and colostomy.
There was yellow urine observed from the right-sided nephrostomy tube draining into the drainage bag.- On 2/20/26, there was blood observed from the right-sided nephrostomy tube draining into the resident's drainage bag.
There was no documentation that the provider was contacted regarding the blood in the urine- On 2/21/26, blood was observed from the right-sided nephrostomy tube draining into the drainage bag.
There was no documentation that the provider was contacted regarding the blood in the urine.- The resident's oxygen saturation was 85%.
Her oxygen was raised to 3L and her oxygen level only came up to 87%.
The resident had been weak and had not been eating.
She was unable to stay in a sitting position and would fall back or sideways on the bed.
The resident was transported to the local hospital via ambulance at 9:50 a.m.
The family was notified that the resident had been sent to the ER.- On 2/26/26, the following late entry was noted in resident #36's nurse's progress note, Communicated with physician regarding the resident's recent hospitalization for blood transfusion.
When the resident returned to the facility, the discharge summary was overlooked and the order to hold apixaban was not implemented. As a result, the resident continued receiving apixaban and was readmitted to the hospital and was administered a blood transfusion. [sic]Review of resident #36's nursing progress notes showed the resident had hematuria in her nephrostomy bag two days before transfer to the hospital on 2/22/26, without physician notifications made, and action taken to address it by the facility.
The facility did document in the medical record the blood in the resident's nephrostomy bag but failed to take measures to identify the cause or intervene for the resident's health and safety.