Beartooth Rehabilitation and Nursing LLC

In the surveyor’s words

From the most serious findings on record at Beartooth Rehabilitation and Nursing LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 10, 2026

  Based on observations, interviews, and record reviews, the facility failed to implement and operationalize a smoking policy when there were smokers residing at the facility, who were unsafe and kept their smoking materials. Residents smoked in a designated and unmonitored smoking area; one resident (#12) utilized oxygen and kept her nasal cannula and oxygen cannister in close proximity while smoking, to include using a lighter with an open flame; resident (#20) was often in proximity to resident #12 when smoking, which placed her at a higher risk of injury due to the unsafe smoking practices of resident #12. […]

• Immediate jeopardy, isolatedF689Sep 4, 2025

  Based on observation, interview, and record review, the facility failed to provide adequate supervision and monitoring and ensure the safety and well-being of a cognitively impaired resident who displayed frequent wandering patterns, and the resident had an unwitnessed fall with major injury. This failure resulted in the resident being transferred to the ER, a hospitalization, a surgical procedure, and a total loss of independent ambulation for 1 (#4) of 6 residents sampled for falls; and the facility staff failed to follow the established policies and procedures. […]

• Actual harm, isolatedF806Aug 26, 2026

  Based on observation, interview, and record review, the facility failed to ensure that food served to a resident did not contain food/contents the resident was allergic to, given the resident's documented banana allergy. After consuming several bites of food, resident #6 developed symptoms consistent with an allergic reaction, including tongue swelling and tingling, labored breathing, and required administration of Benadryl and transfer to the emergency department for further evaluation and treatment for 1 (#6) of 16 sampled residents. Findings include:During an interview on 8/25/26 at 1:38 p.m., staff member Q said resident #6 was allergic to bananas and had consumed bananas in yogurt. […]

• Actual harm, isolatedF600Sep 4, 2025

  Based on interview and record review, the facility failed to recognize and protect a resident's right to be free from neglect, following a resident's major injury from an unwitnessed fall, and the resident had severe cognitive impairment; for 1 (#4) of 12 sampled residents. The deficient practice resulted in the resident experiencing pain, was not thoroughly assessed after the fall, and there was a delay in timely care, which resulted in the resident's surgery and hospitalization. Findings include:During an interview on 8/26/25 at 10:04 a.m., staff member A stated she had been working and fulfilling the roles of Administrator, Social Services Designee, and the Business Office Manager for the facility. […]

• Actual harm, isolatedF658Sep 4, 2025

  Based on interview and record review, the facility staff failed to perform a thorough head-to-toe assessment, pain assessment, or transfer a resident appropriately after an unwitnessed fall with injury, which was consistent with professional standards of nursing practice, for 1 (#4) of 12 sampled residents. This deficient practice caused an increase in the resident's signs and symptoms of pain, due to a fall that resulted in a hip fracture. Findings include: During an interview on 8/28/25 at 12:24 p.m., staff member L stated she was getting ready to start laying residents down to bed when a kitchen staff member said a resident had fallen in the dining room. Staff member L stated the nurse, another staff member, and she went over to the dining room and found resident #4 lying on the floor. […]