Montana Veterans Home N H

In the surveyor’s words

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

• Immediate jeopardy, patternF600Aug 19, 2025

  Based on interview and record review, the facility failed to recognize and prevent sexual abuse and neglect, and identify the residents' ability to consent to sexual activity, for 9 (#s 9, 12, 17, 44, 61, 77, 78, 80, and 89) of 28 sampled residents. This deficient practice resulted in residents participating in sexual activities who were unable to make their own decisions, which increased the risk of sexual abuse and psychosocial harm for residents, and this was identified to be an Immediate Jeopardy situation; and, based on observation, interview, and record review, the facility failed to ensure a resident was free from physical abuse by a staff member, which resulted in a skin tear on the resident's left hand for 1 (#20) of 28 sampled residents. […]

• No harm, potential for more than minimal, widespreadF761Jun 22, 2023

  Based on observation, interview, and record review, the facility failed to properly label medications by only using the residents last name on medications removed from their original container and failed to properly store a narcotic during the practice of pre-pouring medications during the morning medication pass, for the residents on the 400 hall. This deficiency increased the risk of medication administration errors, and the potential for a narcotic medication to be mishandled. Findings include: During an interview on 6/21/23 at 7:40 a.m., staff member N stated, I already have the medications poured. […]

• No harm, potential for more than minimal, patternF610Aug 19, 2025

  Based on interview and record review, the facility failed to thoroughly investigate allegations and resident actions of sexual abuse for 3 (#s 9, 17, and 89) out of 28 sampled residents. This deficient practice increased the risk of incidents occurring in the future for these residents, and others, and the residents were identified to be vulnerable and unable to consent to sexual activity. The facility staff did not identify the resident actions as potential abuse or protect them, and staff were aware of the resident actions but did not address the alleged potential abuse, reflecting the facility's abuse education program was not sufficient to ensure resident safety. […]

• No harm, potential for more than minimal, patternF658Jun 22, 2023

  Based on observation, interview, and record review, the facility failed to adhere to professional standards of care during medication administration pass and medications were pre-poured. This deficiency resulted #11 being handed the wrong cup of medications to take during morning med pass, and the medications were for resident#58. This practice had the potential to affect #58 or others residing on the 400-hall. Findings include: During an interview on 6/21/23 at 7:40 a.m., Staff member N stated, I already have all the medications poured. We are allowed to pre-pour medications here, everything but narcotics. She asked the surveyor to return at 8:30 a.m. […]

• No harm, potential for more than minimal, isolatedF600Aug 13, 2026

  Based on interview and record review, the facility failed to protect residents from physical and verbal abuse for 2 (#s 25 and 63) of 22 sampled residents. Findings include:Review of the facility investigation for an incident involving residents #25 and #63 showed that a verbal and physical abuse incident occurred in the dining room on 6/13/26 at 5:35 p.m. The two residents had a verbal incident that quickly escalated into a physical altercation, with one resident being placed in a chokehold after receiving several hits to the face by the other resident. Staff intervened immediately and separated the two residents. […]