Montana Mental Health Nursing Home

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

down the hall behind closed doors yelling, so she went to the unit and assisted the resident while staff member R continued to stare at her cart. Staff member R was also found eating lunch on her medication cart, which was against the facility policy, while surveyors were present in the building. Staff member D stated these were not behaviors/actions she had never seen staff member R display prior. Staff member D stated she did not report these changes or concerns to her supervisor, did not investigate the events that occurred, or document the incidents.During an interview on 11/17/25 at 1:00 p.m., staff member E stated staff member R had an incident sometime in April (2025) with medication errors. Staff member R had been found in the lounge and was non-responsive. Staff member E stated staff member R finally roused and ate something, and she appeared to improve afterwards. Staff member E stated the incidents, which included more than 50 medication errors, were investigated by staff member B. Staff member E stated she was directed to review resident charts, medications, treatments, and blood glucose machines. Staff member E stated the blood glucose machines, which were to be used by staff member R, showed no glucose checks had been completed during staff member R's shift. There was also no charting completed on any residents

during staff member R's shift, and it was identified that the medications and treatments had not been completed for 11 residents, which included #s 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, and 12 residents. Staff member E stated she checked in with staff member R on occasion because she was concerned about her weight loss and changes in her cognition. Staff member E stated she received concerns from the licensed nursing staff regarding staff member R, which included the possibility that staff member R had an early onset of dementia and the weight loss, but staff member R seemed okay when she would check in with staff member E. Staff member E stated she did not report these concerns to a supervisor, investigate, or document the concerns about staff member R that was reported by the nurses.During an interview on 11/17/25 at 2:13 p.m., staff member L stated she had reported concerns related to staff member R's performance, after following behind staff member R (working the following shift), which included that she would find medications in different drawers, medications were not being given, and about staff member R's cognition changes. Staff member L stated staff member R had lost a lot of weight, and she believed the incidents were due to and caused by medical issues, and they were not malicious. Staff member L stated that staff member R had been having cognitive issues for three or four months before she went on a leave of absence. Staff member L stated she reported the missed medication administrations, which were not done by staff member R, to staff member I. During an interview on 11/17/25 at 2:30 p.m., staff member A stated, from her perspective, staff member R's care that she provided to the residents was good, and the medication error rate had improved, so she could not really investigate further into the situation for staff member R as it appeared as if it was personal medical issues. Staff member A stated that the concerns of staff member R's slurred speech, cognitive decline, and dementia had not been reported to her.

Event ID:

Facility ID:

27A052

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

27A052

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Montana Mental Health Nursing Home

800 Casino Creek Dr Lewistown, MT 59457

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 0677

Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and record review, a staff member failed to provide necessary ADL care for a dependent resident when the staff member was directed to provide the necessary care, but the staff member left the shift and did not help the resident, and the resident was found with a soiled brief/chair, for 1 (#6) of 17 sampled residents. Findings include: Review of a facility reported incident, dated 11/4/25, reflected staff member G was instructed to change the brief of resident #6. During the staff's change of shift, resident #6 was found with dried feces up his back and in and under his wheelchair cushion. The facility reported the performance concerns as neglect of care. It was identified this was not a resident care system issue but isolated to the resident. Review of a staff member's witness statement, dated 11/4/25, reflected that the nurse had instructed staff member G to change resident #6's brief because the resident was soiled. When the second shift arrived, resident #6 had dried feces up his back, on his clothing, in his wheelchair, and under his wheelchair cushion. During an interview on 11/17/25 at 2:15 p.m., staff member U stated on the day resident #6 was found covered in feces, staff member U was working. Staff member U stated that staff member G did not change resident #6 when the nurse told her to. Staff member U stated that staff in the area could smell that resident #6 had soiled himself, and stated that staff member G had supposedly gone to change #6's soiled brief, but had returned in under five minutes. Staff member U stated resident #6 required full assistance to be ambulated and for his brief to be changed, and this could not have been done in five minutes or less.This surveyor attempted to contact staff member G, who was on administrative leave, on 11/17/25 at 7:35 a.m. and again at 10:40 a.m. There was no option to leave a message with staff member G, as the phone's voicemail option had not been set up to accept messages.

During an interview on 11/17/25 at 1:15 p.m., staff member A stated the Human Resources department, and herself had also reached out to staff member G and received no response. Staff member A stated staff member G was supposed to be available between the hours of 8:00 a.m. and 5:00 p.m. Staff member A stated staff member G had been placed on administrative leave for the third time related to performance issues since September (2025). Staff member A stated some staff complained staff member G was lazy and did not complete her duties. Review of a facility policy, Activities of Daily Living, revised 3/20/25, reflected: .Care and services will be provided for the following activities of daily living per the CNA training Manual to include: . 3. Toileting .Review of a facility policy, Abuse, Misappropriations, and/or Neglect of Residents, revised 11/18/24, reflected: .12. Neglect is the failure of the facility, its employees, or service provider to provide goods and services to a resident necessary to avoid physical harm, pain mental anguish or emotional distress.

Residents Affected - Few

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

Event ID:

Facility ID:

27A052

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

27A052

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Montana Mental Health Nursing Home

800 Casino Creek Dr Lewistown, MT 59457

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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

medications were returned to the pharmacy, and the medications were not accounted for. Staff member I stated if a medication was declined or not given for a specific reason, the box on the medication record should be circled, initialed, and then a progress note was to be documented by the nurse on the back of the medication administration record, which would explain the missed dose. Staff member I stated she was not sure who reviewed the medication records for missed doses or holes (undocumented administrations).

Review of a facility policy, Medication Error Reporting and Prevention, dated 8/14/25, reflected:- . 4.

Examples of Medication Errors: Incorrect dose, route, dosage form, or time, Medication omission .Review of

a facility policy, Medication Administration & Safe Handling, Principles of, revised 3/20/25, reflected:- . 3.

DOCUMENTATIONa. Document on the MAR immediately after the administration of each patient's medication.b. Document on the MAR refusals, PRN's reason and response, STAT medications, medications administered at times other than prescribed.

Event ID:

Facility ID:

27A052

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

27A052

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Montana Mental Health Nursing Home

800 Casino Creek Dr Lewistown, MT 59457

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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

four months, and then she went on a leave of absence. Staff member L stated she reported the missed medication administrations to staff member I. During an interview on 11/17/25 at 2:30 p.m., staff member A stated the care staff member R provided was good, and the medication error rate had improved. She stated

she could not investigate someone (a staff member) for cognitive issues because they were personal issues. Staff member A stated the concerns of staff member R's changes, such as the slurred speech, cognitive changes, and dementia, had not been reported to her by the supervisors. 2. During an

observation and interview on 11/18/25 at 9:48 a.m., staff member I stated she reviewed the medications listed on the resident medication records to ensure accuracy. Staff member I stated she was not sure who reviewed the medication records for missed doses or holes in the chart. Staff member I stated she submitted a medication error report to the QAPI team monthly, but the missed doses were only considered when the medication was returned to the pharmacy without an explanation.Review of medication administration records for resident #1, 2, 3, 4, 5, 7, 8, 9, 11, 14, 16, 17, dated 9/1/25 - 11/18/25, reflected 138 medications were missed, 59 fentanyl patch checks were missed, and 17 lidocaine removals were missed. The medication administration concerns were not addressed by the facility administrative staff or per the facility policies. Review of a facility policy, Medication Error Reporting and Prevention, dated 8/14/25, reflected:- . 4. Examples of Medication Errors . Medication omission .Review of a facility policy, Medication Administration & Safe Handling, Principles of, revised 3/20/25, reflected:- . 3.

DOCUMENTATIONa. Document on the MAR immediately after the administration of each patient's medication.b. Document on the MAR refusals, PRN's reason and response, STAT medications, medications administered at times other than prescribed.

Event ID:

Facility ID:

27A052

If continuation sheet