Montana Veterans Home N H
MONTANA VETERANS HOME N H in COLUMBIA FALLS, MT — inspection on August 19, 2025.
Found 4 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
Review of resident #77 chart showed a BIMS of 11 (moderate cognitive impairment), dated [DATE].
- Facility Reported Incident
Review of a Facility-Reported Incident, for resident #20, submitted to the State Survey Agency, on [DATE], showed the facility reported a staff member squeezed a resident’s hand and caused a skin tear while trying to retrieve Tylenol from the resident’s hand.
The resident had a history of caching medications and was to only take medication while in the presence of a nurse.
The report showed the staff member was immediately removed from caring for the resident.
Review of resident #20's investigative file, dated [DATE], showed the facility reported staff member R came in to assist staff member S with retrieving medications from resident #20, who was refusing to take them, and he had a history of caching medications.
During this time, staff member R held resident #20’s hand very tightly to get him to release the Tylenol.
This caused a skin tear to resident #20’s left hand. Resident #20 then refused treatment to the wound.
The investigative file showed that staff members R and S were immediately removed from caring for resident #20.
During an observation and interview on [DATE] at 9:05 a.m., resident #20 had bruising and a large yellow scab raised on his left hand. Resident #20 stated, “I don’t care what happened to them (staff members R and S) as long as they don’t take care of me anymore… I am happy with the outcome. …” The investigative file for resident #20, dated [DATE], showed staff members R and S were immediately suspended pending the completion of the investigation.
The file also showed staff members R and S were both terminated.
The file also showed staff and residents were interviewed, and no other concerns were identified. Resident #20’s care plan was updated.
The facility provided abuse training to all staff on [DATE].
Review of a facility policy titled Abuse-Resident” with a revision date of [DATE], showed: “Policy: Each resident has the right to be free from abuse… Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals.
Definitions of Abuse: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.
Sexual Abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. …”
275100 08/19/2025
Montana Veterans Home N H 400 Veterans Dr Columbia Falls, MT 59912
During an interview on [DATE] at 4:44 p.m., staff member A stated he was aware of the sexual encounters and behaviors exhibited by the residents on the SCU. He stated staff members B and D were aware.
All three staff were administrative.
The interview with staff members D and E on [DATE] at 4:56 p.m. included: -Staff member D stated there were no residents having sex at this time.
Staff member D stated that resident #80 was able to consent for herself in the past and had declined cognitively in the last six months.
Staff member D stated all of the POAs had been reached out to regarding their family members' sexual activity, and the POAs had all said if the acts were consensual, then it was okay for the resident to continue.
Staff member D stated resident #80 felt comfortable talking with staff member D.
Staff member D stated psychosocial assistance was provided to resident #80 by communication between staff member D and resident #80.
Staff member D stated these conversations were documented in the interdisciplinary notes in resident #80’s chart. -Staff member D stated resident #17 had sexual relations with resident #12 two years ago, and resident #12 was able to consent for himself.
Staff member D stated resident #80 also had relations
275100 08/19/2025
Montana Veterans Home N H 400 Veterans Dr Columbia Falls, MT 59912
During an interview on 8/19/25 at 8:37 a.m., staff member C stated the facility did not contact law enforcement, Adult Protective Services, or the State Survey Agency regarding any sexual abuse with resident #17.
It was identified the facility did not respond to alleged or potential sexual abuse allegations and have evidence that all alleged violations were thoroughly investigated, and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
275100 08/19/2025
Montana Veterans Home N H 400 Veterans Dr Columbia Falls, MT 59912
During an interview on 8/13/25 at 4:52 p.m., staff member D stated resident #80 was able to consent for sexual activity for herself.
Staff member D stated, I don't know if we ever put it on there, when referring to #80's care plan, and if sexual behaviors and preferences were added to the plan.
Review of resident #80's care plan, dated 7/21/25, showed under the ADLs that she preferred female caregivers, and the care plan did not show other areas, concerns, or interventions related to the resident's sexual behaviors or the ability to consent. A request was made on 8/13/25 for all the care plans for residents who displayed sexual interactions towards others.
The care plans provided by the facility were updated with new information for the residents' sexual interaction history and provided on 8/18/25.
The updates did not occur until the facility completed a plan to remove immediacy for the Immediate Jeopardy situation identified in F-F600 - Abuse and Neglect.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.