The Valley Health And Rehab

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 complete a thorough investigation on an event of staff to resident abuse by failing to complete resident monitoring, failed to carry out interventions identified and documented on the report, and failed to complete other resident interviews to rule out other concerns of abuse by the staff member, for 1 (#2) of 6 sampled residents. Findings include:Review of the facility reported incident investigation, completed by the facility on 6/26/25, showed NF4 was witnessed by several management staff verbally abusing resident #2. NF4 was immediately walked out and released from the position at the facility. The facility reported incident documentation showed, .Resident [#2] placed on every-shift monitoring x72 hours One-on-one [sic] emotional support provided. No other resident interviews or assessments were conducted during the investigation to rule out other concerns of abuse by the staff member. During an interview on 8/26/25 at 11:57 a.m., staff member A stated he was not in the office when

the former DON handled the incident for resident #2 and NF4 and was unaware of other resident interviews. Staff member A stated that everything for the investigation was in the file provided.During an

interview on 8/27/25 at 12:29 p.m., staff member C stated when a resident was put on alert charting or monitoring, it would be placed on the resident's MAR and TAR for the floor nurses to document and enter

the monitoring progress notes.Review of resident #2's nursing progress notes and the MAR and TAR, for

the 72 hours following the event, showed the only progress note was on 6/28/25 at 10:33 p.m., two days

after the incident. The note was categorized as a behavior note and it included Resident appears somnolent tonight 6/28. Resident refusing some cares which is out of character for her. No interventions were noted for resident #2's change in behavior. There was no other documentation of the incident, one on one support, or the 72 hour monitoring in the progress notes. Review of resident #2's June 2025 MAR and TAR failed to include every shift monitoring for 72 hours.Review of the facility policy, Abuse, Neglect, and Exploitation, dated 4/11/25, showed: .Possible indicators of abuse include, but are not limited to: .Verbal abuse of a resident overheard.Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place, or feelings of guilt or shame.identifying and interviewing all involved persons, including.others who might have knowledge of the allegations.determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause.F. Providing emotional support and counseling to

the resident during and after the investigation.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

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

Facility ID:

If continuation sheet

Event ID:

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

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Valley Health and Rehab

601 N 10th St Hamilton, MT 59840

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 0627 Level of Harm - Actual harm Residents Affected - Few

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

documentation, communication, or care planning with resident #1 prior to his discharge.During an interview

on 8/27/25 at 3:45 p.m., NF5 stated resident #1 was a very sick person and had multiple rehospitalizations prior to his stay at the facility. NF5 stated resident #1 had home health support services to help with wound care and comorbidity management before he stayed at the facility and would expect the facility to order this again on the resident's discharge. NF5 stated he could not find a discharge order for resident #1, but the practice was to get the physician's order near the day of, or on the day of, discharge, and this would include any other orders for home health. NF5 stated there was a chance another provider wrote the physician order, but he could not find it at the time. NF5 stated resident #1 would have preferred being home and was not the best at managing his health conditions. NF5 stated he was recently notified resident #1 was admitted to a local hospital and had written a physician's order to place resident #1 on hospice due to his decline and osteomyelitis.During an interview on 8/26/25 at 4:32 p.m., staff member A stated the facility did not have any discharge orders or other discharge documentation other than the NOMNC notice.During an

interview on 8/27/25 at 4:48 p.m., staff member B provided a progress note and then stated the physician was notified on 8/27/25 of resident #1's discharge.Review of the facility admissions and discharge report from June 2025 to August 2025 listed resident #1 admitted on [DATE REDACTED] from a local hospital and discharged home with home health services on 8/8/25.Review of resident #1's MDS dated [DATE REDACTED], showed he had a BIMS score of 12 out of 15, reflecting moderate cognitive impairment.Review of resident #1's EHR did not include a form signed by the resident with the nurse who reviewed discharge instructions. Only a NOMNC notice was given on 8/6/25, to the discharge on [DATE REDACTED], which resident #1 signed.Review of resident #1's progress notes, from 7/15/25 to 8/28/25, did not show any discharge planning prior to or on the day of discharge. The only progress note linked from the MAR showed discharged as the reason ordered medications were not given after the discharge. A request was made on 8/27/25 for all discharge communication and documentation from resident #1's stay from 7/15/25 to 8/8/25. No other information was provided by the end of the survey.Review of the facility policy, Transfer and Discharge (including AMA), dated 4/11/25, showed: 12. Anticipated Discharge to the Communitya. Facility will obtain a physician's order for transfer or discharge and instructions or precautions for ongoing care.b. A member of the interdisciplinary team will complete relevant sections of the Discharge Summary. The nurse caring for the resident at the time of discharge is responsible for ensuring the Discharge Summary is complete and includes, but is not limited to, the following: i. A recap of the resident's stay that includes diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. ii. A final summary of

the resident's status. iii. Reconciliation of all pre-discharge medications with the resident's post discharge medications. iv. A post discharge plan of care that is developed with the participation of the resident, and

the resident representative(s).c. Orientation for transfer or discharge will be provided and documented to ensure safe and orderly transfer or discharge from the facility.may be provided by multiple members of the interdisciplinary team.f. Supporting documentation shall include evidence of.a discharge plan, and documented discussions with the resident and/or resident representative.

Event ID:

Facility ID:

If continuation sheet