Community Nursing Home of Anaconda

In the surveyor’s words

From the most serious findings on record at Community Nursing Home of Anaconda, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 28, 2023

  Based on observation, interview, and record review, the facility failed to identify the direct root causes of falls for implementation of individualized interventions and update resident care plans with the individualized interventions related to fall safety for 4 (#s 11, 16, 17, and 18) of 6 sampled residents; and failed to ensure staff had the necessary training to provide fall prevention interventions for 1 (#18) of 6 sampled residents. Findings include: 1. Review of a facility reported incident, dated 1/10/23, showed resident #11 had been assisted to the toilet following an episode of incontinence. While the CNA was getting clean clothing, resident #11 self-transferred off the toilet and fell when exiting the bathroom. […]

• Actual harm, isolatedF686Aug 17, 2022

  Based on observation, interview, and record review, the facility failed to prevent the development and worsening of a pressure injury, document wound progression, notify the appropriate physician, and failed to prevent a new pressure injury for 1 (#11) of 2 sampled residents. Findings include: During an observation on 8/16/22 at 12:10 p.m., resident #11 was asleep in his recliner. Both his feet had on thin (1/2 inch) foam heel protectors. His heels appeared to have pressure on them from the recliner foot rest. Staff member B was asked to view his feet on the recliner, and she stated the resident should have had pillows under his feet to float his heels to prevent pressure. She stated the resident's pressure injury started as a blister on his right heel. […]

• No harm, potential for more than minimal, widespreadF727Dec 17, 2025

  Based on observation and interview, the facility failed to have a designated registered nurse to serve as the director of nursing on a full-time basis. This deficient practice resulted in a failure of clinical oversight for all residents residing in the facility. Findings include: During an observation on 12/15/25 at 9:00 a.m., the Director of Nursing was not present at the facility. During an interview on 12/15/25 at 9:15 a.m., staff member A stated the Director of Nursing resigned on 12/2/25, and a new Director of Nursing would start on 12/29/25. Staff member A stated she did not assign an interim Director of Nursing because she knew the new Director of Nursing would be starting soon. […]

• No harm, potential for more than minimal, widespreadF851Dec 17, 2025

  Based on interview and record review, the facility failed to submit mandatory payroll-based data to CMS. This deficient practice prevented CMS review of the level of staff, employee turnover, and tenure to ensure safe staffing levels. Findings include:Review of the PBJ Staffing Data Report, dated 12/9/25, for quarter four (7/1/25-9/30/25) reflected the facility failed to submit data for the quarter. During an interview on 12/15/25 at 9:15 a.m., staff member A stated the facility did not submit the PBJ for the fourth quarter of 2025 and once the facility realized the data had not been submitted, it was too late to submit the data.

• No harm, potential for more than minimal, widespreadF865Dec 17, 2025

  Based on interviews and record review, the facility failed to ensure the QAPI team identified, reported, investigated, and documented the development, implementation, and evaluation of corrective actions for performance improvement projects related to known activities department deficient practices for 2 (#s 2 and 6) of 14 sampled residents, and this failure increased the risk of all residents being affected due to the lack of necessary or preferred activities. Findings include:During the survey from 12/15/25-12/17/25, the facility failed to provide activities to meet the interests and preferences of residents who remained in their rooms for resident #s 2 and 6. […]