Montana Veterans Home N H

F 0600

Review of resident #44’s chart showed a BIMS of 3 (severe cognitive impairment), dated [DATE REDACTED].

Level of Harm - Immediate jeopardy to resident health or safety

Review of resident #80’s chart showed a SLUMS of 6 (severe dementia), dated [DATE REDACTED].

Residents Affected - Some

1. 5. Facility Reported Incident

Review of resident #77 chart showed a BIMS of 11 (moderate cognitive impairment), dated [DATE REDACTED].

Review of a Facility-Reported Incident, for resident #20, submitted to the State Survey Agency, on [DATE REDACTED], 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 REDACTED], 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 REDACTED] 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 REDACTED], 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 REDACTED].

Review of a facility policy titled Abuse-Resident” with a revision date of [DATE REDACTED], 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. …”

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Montana Veterans Home N H

400 Veterans Dr Columbia Falls, MT 59912

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and record review, the facility failed to thoroughly investigate allegations and resident actions of sexual abuse for 3 (#s 9, 17, and 89) out of 28 sampled residents. This deficient practice increased the risk of incidents occurring in the future for these residents, and others, and the residents were identified to be vulnerable and unable to consent to sexual activity. The facility staff did not identify the resident actions as potential abuse or protect them, and staff were aware of the resident actions but did not address the alleged potential abuse, reflecting the facility's abuse education program was not sufficient to ensure resident safety. Findings include: During an interview on 8/13/25 at 1:57 p.m., staff member L stated

they received a report of an incident with resident #89 and resident #17, where resident #89 had no clothes on, and resident #17 was on top of resident #89 performing oral sex. This had occurred four months prior, and approximately three weeks ago, resident #17 went into resident #9's room, and staff found resident #9

in the bed. Resident #9's pants were around his ankles, and his brief was open. Staff member L stated staff walked in on the two residents just before sexual activity occurred. Staff member L stated the residents on

the SCU were not able to consent to sexual activity due to cognitive deficits.During an interview on 8/13/25 at 4:43 p.m., staff member A stated he was aware of some resident sexual relations between the residents, but not aware of the extent of the resident sexual relationships. Staff member A was to be notified of all alleged or potential abuse for the facility.During an interview on 8/13/25 at 4:56 p.m., staff members D and E stated the sexual acts between the residents were not considered sexual abuse due to no physical contact being made between the residents. Staff member E stated the facility never completed a root cause analysis investigating why the events were occurring or to identify concerns related to them and the facility did not identify or address any behavioral assessments for #17 related to his sexual advances and activities. The staff did not identify the sexual acts between the two residents as alleged abuse and did not ensure protective measures were implemented to prevent potential abuse.During an interview on 8/19/25 at 9:13 a.m., staff member O stated resident #17 never should have been given a roommate due to his behaviors. Staff member O stated there were more instances of sexual activities with resident #89, as he had been at the facility for about a month. The facility moved resident #17 to an area of the facility where there were vulnerable residents, without addressing the risk factors related to #17's sexual behaviors, or the behavior of those on the SCU. A request was made on 8/14/25 for documentation of the Facility Reported Incidents and investigations with resident #17's sexual behavior towards other residents. None were provided by the end of the survey, as the facility did not identify the events as potential or alleged abuse.

The facility did not follow the abuse reporting requirements or thoroughly investigate the events. 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.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Montana Veterans Home N H

400 Veterans Dr Columbia Falls, MT 59912

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Based on interview and record review, the facility failed to ensure the care plan contained a care area and interventions regarding sexual behaviors and interactions between residents, for 2 (#s 17 and 80) of 28 sampled residents. Findings include:During an interview on 8/13/25 at 11:37 a.m., staff member H stated there were many residents who participated in sexual activity who were unable to consent.A review of resident #17's care plan problem, goals, and interventions, all undated, showed the resident had a history of sexual behaviors that were exhibited towards other residents. There was no information for if he was a risk to other residents or himself. The goal was documented as the resident would have fewer episodes, but

the goal did not show what episodes would be fewer or how this would be measured. The goal did not include information about the residents' safety. The interventions listed did not include any interventions related to protecting other residents from potential sexual abuse, or if the resident was able to consent to

the sexual activities. 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.

Event ID:

Facility ID:

If continuation sheet