Montana Mental Health Nursing Home

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.

Facility ID:

27A052

IDENTIFICATION NUMBER:

27A052

A.

Building

COMPLETED

11/19/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Montana Mental Health Nursing Home

800 Casino Creek Dr Lewistown, MT 59457

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID:

27A052

IDENTIFICATION NUMBER:

27A052

A.

Building

COMPLETED

11/19/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Montana Mental Health Nursing Home

800 Casino Creek Dr Lewistown, MT 59457

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID:

27A052