Cooney Healthcare And Rehabilitation
Inspection Findings
F-Tag F0550
Federal health inspectors cited COONEY HEALTHCARE AND REHABILITATION in HELENA, MT for a deficiency under regulatory tag F-F0550 during a standard health inspection conducted on 2025-09-11.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 20 deficiencies cited during this inspection of COONEY HEALTHCARE AND REHABILITATION.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-24.
F-Tag F0609
F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Based on interview and record review, the facility exceeded the required two hour window for reporting alleged sexual abuse to the State Survey Agency for 1 (#59) of 26 sampled residents. This deficient practice increased the risk for all residents to be unprotected from the alleged sexual abuse perpetrator.
Findings include: During an interview on 9/8/25 at 12:56 p.m., NF3 stated she reported an incident which appeared sexual in nature to staff member D, and the incident made her feel uncomfortable. NF3 reported it to staff member D on 9/3/25 at approximately 10:30 a.m. NF3 stated she had expressed to staff member D when she walked into resident #59's room, at approximately 10:00 a.m., she saw what appeared to be romantic relations between resident #59 and a man she thought could be her husband. NF3 stated when
she saw the incident, she immediately went into the hallway and waited for approximately 30 minutes. NF3 stated, I left to give them privacy, then began to worry resident #59 was being taken advantage of, and reported the incident to staff member D. NF3 stated when she went into resident #59's room initially, she had observed a man standing up from his wheelchair, even though she could see he was a double amputee, he looked like he was vigorously turning butter, with his hips and making noises. NF3 stated resident #59's hand was near the man's groin, resident #59 was lying flat in her bed, and when resident #59 saw her (NF3), resident #59 looked shocked. NF3 stated after reporting the incident to staff member D,
she left the facility and returned two hours later to complete her visit, and that was when she found out the man she had observed was resident #59's son. NF3 stated she and staff member D tried to rationalize other possibilities of what he could have been doing, then stated, But we couldn't.During an interview on 9/10/25 at 9:21 a.m., staff member A stated his policy for reporting incidents of this nature to the State Survey Agency was within two hours. Staff member A stated the Bounds (reporting system) time stamp was 10:45 a.m. on 9/4/25 for the reporting of the incident to the State Survey Agency. Staff member A stated the following reasons for not reporting the incident within two hours like he typically would were:1) There were conflicting stories,2) The family had requested the facility not to,3) He didn't know resident #59's son was a registered sex offender, 4) Resident #59 was pleasant, in no distress, and did not have any signs of negative interactions with her son,5) The allegation was vague, stating I think NF3 heard a weird sound and he was moving funny, was vague, and6) Resident #59's daughter had already asked resident #59's son to leave the facility. Staff member A stated, Once we felt it was potential sex abuse we reported it
in within 2 hours.Review of a facility policy, titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, Revised April 2021, showed: . 9. Investigate and report any allegations within timeframes required by federal requirements. Review of the Facility Reported Incident #2608463, showed
the State Survey Agency received the report of the incident on 9/4/25 at 12:00 p.m. This was 25 hours after
the incident occurred.
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
09/11/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Cooney Healthcare and Rehabilitation
2555 E Broadway Helena, MT 59601
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-Tag F0610
Federal health inspectors cited COONEY HEALTHCARE AND REHABILITATION in HELENA, MT for a deficiency under regulatory tag F-F0610 during a standard health inspection conducted on 2025-09-11.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
The facility was found deficient in the following area: Respond appropriately to all alleged violations.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 20 deficiencies cited during this inspection of COONEY HEALTHCARE AND REHABILITATION.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-24.
F-Tag F0628
Federal health inspectors cited COONEY HEALTHCARE AND REHABILITATION in HELENA, MT for a deficiency under regulatory tag F-F0628 during a standard health inspection conducted on 2025-09-11.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 20 deficiencies cited during this inspection of COONEY HEALTHCARE AND REHABILITATION.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-24.
F-Tag F0640
Federal health inspectors cited COONEY HEALTHCARE AND REHABILITATION in HELENA, MT for a deficiency under regulatory tag F-F0640 during a standard health inspection conducted on 2025-09-11.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 20 deficiencies cited during this inspection of COONEY HEALTHCARE AND REHABILITATION.
Correction Status: Past Non-Compliance.
The facility reported correction as of 2025-08-01.
F-Tag F0657
Federal health inspectors cited COONEY HEALTHCARE AND REHABILITATION in HELENA, MT for a deficiency under regulatory tag F-F0657 during a standard health inspection conducted on 2025-09-11.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 20 deficiencies cited during this inspection of COONEY HEALTHCARE AND REHABILITATION.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-24.
F-Tag F0686
Federal health inspectors cited COONEY HEALTHCARE AND REHABILITATION in HELENA, MT for a deficiency under regulatory tag F-F0686 during a standard health inspection conducted on 2025-09-11.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity Level G: isolated, actual harm that is not immediate jeopardy.
Actual harm to residents was documented as a result of this deficiency.
This was one of 20 deficiencies cited during this inspection of COONEY HEALTHCARE AND REHABILITATION.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-24.
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
member P stated the facility would consider a resident to have had eloped if they got to the end of the walkway or passageway. Staff member P stated, Personally, (I would not be comfortable with them going that far) not even that far. Staff member P stated they felt a resident would be unsafe if they got out of the facility for safety reasons because many of the residents were confused, a resident could get into an unknown vehicle, the resident could fall, or the resident could get hit by a car.During an interview on 9/10/25 at 3:52 p.m., staff member II stated the facility could not do both 1:1 and 15-minute checks. Staff member II stated it did not make any sense for the same person to do those two tasks at the same time.
During an observation and interview on 9/10/25 at 8:01 p.m., staff member II opened the front door of the facility from the inside. No keys or code was needed to open the door. Staff member II stated this was normal for this door to open from the inside, but to be locked from the outside.During an interview on 9/10/25 at 8:00 p.m., staff member K stated, Staffing is terrible here at night. We need more help to answer all the call lights. We have several dementia patients wandering all night, multiple two-person Hoyer patients, and only three CNAs.During an interview on 9/10/25 at 8:03 p.m., staff member J stated, We only have three CNAs in the building; we can't keep track of all these residents, much less the elopers.During an
interview on 9/10/25 at 8:06 p.m., staff member JJ stated being assigned to the 1:1 with resident #6, and staff member JJ also had to verify #6's location every 15 minutes.
Event ID:
Facility ID:
If continuation sheet
F-Tag F0690
Federal health inspectors cited COONEY HEALTHCARE AND REHABILITATION in HELENA, MT for a deficiency under regulatory tag F-F0690 during a standard health inspection conducted on 2025-09-11.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 20 deficiencies cited during this inspection of COONEY HEALTHCARE AND REHABILITATION.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-24.
F-Tag F0692
Federal health inspectors cited COONEY HEALTHCARE AND REHABILITATION in HELENA, MT for a deficiency under regulatory tag F-F0692 during a standard health inspection conducted on 2025-09-11.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide enough food/fluids to maintain a resident's health.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 20 deficiencies cited during this inspection of COONEY HEALTHCARE AND REHABILITATION.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-24.
F-Tag F0697
Federal health inspectors cited COONEY HEALTHCARE AND REHABILITATION in HELENA, MT for a deficiency under regulatory tag F-F0697 during a standard health inspection conducted on 2025-09-11.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide safe, appropriate pain management for a resident who requires such services.
Scope/Severity Level G: isolated, actual harm that is not immediate jeopardy.
Actual harm to residents was documented as a result of this deficiency.
This was one of 20 deficiencies cited during this inspection of COONEY HEALTHCARE AND REHABILITATION.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-24.
F-Tag F0725
Federal health inspectors cited COONEY HEALTHCARE AND REHABILITATION in HELENA, MT for a deficiency under regulatory tag F-F0725 during a standard health inspection conducted on 2025-09-11.
Category: Nursing and Physician Services Deficiencies
The facility was found deficient in the following area: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 20 deficiencies cited during this inspection of COONEY HEALTHCARE AND REHABILITATION.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-24.
F-Tag F0726
Federal health inspectors cited COONEY HEALTHCARE AND REHABILITATION in HELENA, MT for a deficiency under regulatory tag F-F0726 during a standard health inspection conducted on 2025-09-11.
Category: Nursing and Physician Services Deficiencies
The facility was found deficient in the following area: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 20 deficiencies cited during this inspection of COONEY HEALTHCARE AND REHABILITATION.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-24.
F-Tag F0727
Federal health inspectors cited COONEY HEALTHCARE AND REHABILITATION in HELENA, MT for a deficiency under regulatory tag F-F0727 during a standard health inspection conducted on 2025-09-11.
Category: Nursing and Physician Services Deficiencies
The facility was found deficient in the following area: Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 20 deficiencies cited during this inspection of COONEY HEALTHCARE AND REHABILITATION.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-24.
F-Tag F0757
Federal health inspectors cited COONEY HEALTHCARE AND REHABILITATION in HELENA, MT for a deficiency under regulatory tag F-F0757 during a standard health inspection conducted on 2025-09-11.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure each resident’s drug regimen must be free from unnecessary drugs.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 20 deficiencies cited during this inspection of COONEY HEALTHCARE AND REHABILITATION.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-24.
F-Tag F0759
Federal health inspectors cited COONEY HEALTHCARE AND REHABILITATION in HELENA, MT for a deficiency under regulatory tag F-F0759 during a standard health inspection conducted on 2025-09-11.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure medication error rates are not 5 percent or greater.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 20 deficiencies cited during this inspection of COONEY HEALTHCARE AND REHABILITATION.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-24.
F-Tag F0761
Federal health inspectors cited COONEY HEALTHCARE AND REHABILITATION in HELENA, MT for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-09-11.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 20 deficiencies cited during this inspection of COONEY HEALTHCARE AND REHABILITATION.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-24.
F-Tag F0790
Federal health inspectors cited COONEY HEALTHCARE AND REHABILITATION in HELENA, MT for a deficiency under regulatory tag F-F0790 during a standard health inspection conducted on 2025-09-11.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide routine and 24-hour emergency dental care for each resident.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 20 deficiencies cited during this inspection of COONEY HEALTHCARE AND REHABILITATION.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-24.
F-Tag F0880
Federal health inspectors cited COONEY HEALTHCARE AND REHABILITATION in HELENA, MT for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-09-11.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Provide and implement an infection prevention and control program.
Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 20 deficiencies cited during this inspection of COONEY HEALTHCARE AND REHABILITATION.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-24.
F-Tag F0881
Federal health inspectors cited COONEY HEALTHCARE AND REHABILITATION in HELENA, MT for a deficiency under regulatory tag F-F0881 during a standard health inspection conducted on 2025-09-11.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Implement a program that monitors antibiotic use.
Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 20 deficiencies cited during this inspection of COONEY HEALTHCARE AND REHABILITATION.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-24.
COONEY HEALTHCARE AND REHABILITATION in HELENA, MT inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in HELENA, MT, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from COONEY HEALTHCARE AND REHABILITATION or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.