Eastern Montana Veterans Home

In the surveyor’s words

From the most serious findings on record at Eastern Montana Veterans Home, in the surveyor’s own words.

• Actual harm, isolatedF689Dec 10, 2025

  Based on interview and record review, the facility failed to ensure staff members followed policies, procedures, and protocols to maintain resident safety by providing sufficient and necessary supervision on a secure care unit, for 4 residents (#s 6, 9, 10, and 12) of 6 residents sampled for injuries/abuse. This deficient practice contributed to resident altercations, and resident #10 sustained a hip fracture, which required hospitalization and surgical repair for the major injury; and resident #10 was not transferred properly and per the facility policies and procedures, after the fall, which may cause or contribute to an injury. Findings include:1. […]

• Actual harm, isolatedF600Jun 19, 2025

  Based on record review, the facility staff assigned to a resident neglected to ensure he received necessary ADL care and was left in bed for an extended period of time without help. The resident experienced pain, distress, and skin abrasions from the event, for 1 (#4) of 5 sampled residents. Findings include: Review of a Facility Reported Incident, dated 3/6/25, showed resident #4 was left unattended in his room. The resident was residing on the special care unit, and he was not provided cares by CNAs (NF10 and NF11) working on the unit. Review of resident #4's nursing progress notes, dated 3/6/25 at 11:42 a.m., showed: CNA called this nurse to resident's room. Upon entering, this nurse noted resident lying on his side at the foot of the bed between the mattress and the footboard. […]

• Actual harm, isolatedF689Jun 19, 2025

  Based on interview and record review, the facility failed to prevent a resident with dementia from eloping from the facility through the front entrance doors, leaving the facility property without supervision and accessing a public road, for 1 (#1) of 6 subsampled residents at risk for elopement. The resident sustained lacerations to his forehead after falling during the elopement. Findings include: Review of a facility reported incident, submitted to the State Survey Agency, dated 5/3/25 at 1:45 p.m., showed resident #1 was found outside of the facility by the police and was transported to the hospital for an evaluation. During an interview on 6/16/25 at 4:18 p.m., NF2 stated she received a call from the facility on 5/3/25. […]

• Actual harm, isolatedF600Oct 24, 2024

  Based on observations, interviews, and record review, the facility failed to protect a resident's right to be free from physical and psychosocial abuse by facility staff for 1 (#7) of 13 sampled residents, causing resident #1 skin injuries, ongoing fear, and inability to sleep, fearing the specific staff involved would return to the facility. Findings include: During an observation and interview on 10/22/24 at 9:07 a.m., resident #7 was sitting in her wheelchair in her room. Resident #7 began to transfer herself from her wheelchair to her reclining chair. Resident #7 stated seven or eight weeks ago, one CNA, and one nurse, entered her room and woke her from a sound sleep and said, Get up, get up. You're going to the dining room. […]

• Actual harm, isolatedF692Feb 15, 2023

  Based on observation, interview, and record review, the facility failed to maintain an effective system for tracking resident weights, identifying weight loss, and implementing nutritional interventions for 2 (#s 12 and 49) of 2 sampled residents. Resident #49 had a severe weight loss, and #12 had a significant weight loss. Findings include: 1. During an observation on 2/14/23 at 9:50 a.m., resident #49 was lying in a low bed on his side. Resident #49 had his eyes closed and did not rouse to his name being spoken in a normal voice. Resident #49 had hollow cheeks with temporal wasting. The resident was left undisturbed. During an interview on 2/15/23 at 9:44 a.m., staff member I stated resident #49 had begun declining before Christmas. […]