Glendive Medical Center N H

In the surveyor’s words

From the most serious findings on record at Glendive Medical Center N H, in the surveyor’s own words.

• Actual harm, isolatedF686Sep 11, 2025

  Based on observation, interview, and record review, the facility failed to implement appropriate measures to prevent skin breakdown, to provide consistent care and monitoring of the pressure ulcers, and failed to ensure pressure ulcers were identified, classified, and the severity determined and documented accurately, for 1 (#6) of 15 sampled residents, resulting in the development of multiple pressure ulcers. Findings include: Review of resident #6's nurse's note dated 6/27/25 at 11:48 a.m., showed the resident complained because her knee popped. An x-ray was ordered of resident #6's right knee. The results of the x-ray were negative. Review of resident #6's nurse's note dated 6/28/25 at 3:06 a.m., showed the resident was found on the floor. […]

• Actual harm, isolatedF689Oct 28, 2021

  Based on observation, interview, and record review, the facility failed to implement a swallow evaluation to determine a safe diet texture, and failed to provide safe upright positioning, for 1 (#28) of 2 sampled residents, causing the resident to cough and possibly choke on food and fluids; and failed to adequately investigate and provide timely treatment for two falls, resulting in a wrist and shoulder fracture, for 1 (#28) of 5 sampled residents. Findings include: 1. During an observation on 10/26/21 at 10:05 a.m., staff member O was attempting to assist resident #28 with the brunch meal. The resident was lying in her bed. Staff member O gave resident #28 three spoonfuls of oatmeal, which she coughed on after each bite. […]

• Actual harm, isolatedF692Oct 28, 2021

  Based on observation, interview, and record review, the facility failed to indentify and implement interventions for a resident with severe weight loss for 1 (#31) of 3 sampled residents. The deficient practice resulted in a 21% weight loss over six months. Findings include: During an observation on 10/25/21 at 4:32 p.m., resident #31 was sitting in the dining room eating her dinner. The surveyor overheard resident #31 tell a staff member she was, very full. A review of resident #31's weights since admission on 4/4/21, showed a 21.01 percent weight loss in six months. Resident #31's weight on 4/6/21 was 119 pounds and 94 pounds on 10/26/21. […]

• No harm, potential for more than minimal, widespreadF851Aug 13, 2026

  Based on interview and record review, the facility failed to submit complete and accurate Payroll Based Journal information quarterly, for licensed nursing coverage 24 hours each day to the Centers for Medicare and Medicaid Services (CMS). The failure resulted in inaccurate staffing information being reported to the Centers for Medicare and Medicaid Services (CMS) and placed the facility at risk for inaccurate staffing data being used to evaluate the facility, which could impact all residents. Findings include:Review of the Centers for Medicare and Medicaid Services report titled, PBJ Staffing Data Report, for second quarter fiscal year 2026 (1/1/26 through 3/31/26), showed the facility . […]

• No harm, potential for more than minimal, widespreadF801Sep 11, 2025

  Based on observation, interview, and record review, the facility failed to ensure the dietary manager completed a certification program approved by a national certifying body or had higher education in a related field. This had the potential to affect residents and their nutritional status or meal safety for those who consumed food prepared and served by the facility. Findings include:During the initial tour of the kitchen, on 9/8/25 at 11:56 a.m., no documentation of advanced training for the dietary manager was posted.During an interview on 9/9/25 at 3:45 p.m., staff members A, G, and K were present. Staff member G said he did not have the CDM certificate.During an interview on 9/10/25 at 8:50 a.m., staff member E and Q were present. […]