Northern Montana Care Center

In the surveyor’s words

From the most serious findings on record at Northern Montana Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF761Aug 2, 2023

  Based on observation, interview, and record review, the facility staff failed to remove expired items for disposal for two out of four medication rooms. Findings include: During an observation on 8/2/23 at 8:47 a.m., the following were found in medication room number one: - 1 green tip culture swab with an expiration date of 10/31/21, - 1 red tip culture swab with an expiration date of 12/31/22, - 1 blue tip culture swab with an expiration date of 3/22/23, - 3, 30 gauge, half inch syringes with an expiration date of 5/28/22, -Cavilon barrier film with an expiration date of 07/22, and -1 vial of open PPD solution, with no open or discard date. […]

• No harm, potential for more than minimal, patternF689Jun 30, 2025

  Based on observation, interview, and record review, the facility failed to ensure 1 (#57) of 30 sampled residents were safe from wandering the facility and into 4 other residents' rooms (#s 7, 31, 41, and 64). This deficient practice increased the risk of negative interactions between the residents related to safety and infection control concerns. Findings include: During an interview on 6/28/25 at 3:38 p.m., resident #64 stated resident #57 was often confused and would wander into his room, sometimes at night. Resident #64 stated he did have a history of PTSD, and resident #57 walking into his room made him feel uncomfortable. Resident #64 stated resident #57 would sometimes steal things from his room. […]

• No harm, potential for more than minimal, isolatedF628Jul 16, 2026

  Based on interview and record review, the facility failed to document required information for resident transfers/discharges for 2 (#s 76 and 78) of 21 sampled residents and failed to inform the Ombudsman's office of all resident transfers/discharges. Findings include: During an interview on 7/15/26 at 4:17 p.m., staff member F stated that when a resident would go on LOA or transfer to another facility, the floor nurse would fill out the same form for a transfer and/or bed hold and then mark the reason for leaving. The nurse would then fax the form to the admission department to hold the resident's chart. […]

• No harm, potential for more than minimal, isolatedF636Jul 16, 2026

  Based on observation, interview, and record review, the facility failed to complete a Discharge Minimum Data Set Assessment for a resident who passed away in the facility for 1 (#67) of 24 sampled and supplemental residents. Findings include: Review of resident #67's discharge summary with a date of 2/20/26 showed: . Narrative: Patient passed peacefully with her family by her side.Review of resident #67's electronic medical record showed:Minimum Data Set Assessment list: Tracking entry MDS with an accepted date of 2/12/26 had been completed.Comprehensive MDS with an accepted date of 2/19/26 had been completed.The electronic medical record failed to show that a Tracking (Death record) MDS had been completed after resident #67 passed away. […]

• No harm, potential for more than minimal, isolatedF883Jul 16, 2026

  Based on interview and record review, the facility failed to administer an influenza vaccine for 1 (#12) of 5 sampled residents for vaccinations. Findings include:Review of the vaccination consent/declination form, signed on 10/31/25, showed resident #12's POA consented to receiving the influenza vaccine.During an interview on 7/18/26 at 8:06 a.m., staff members A and C stated resident #12 did not have documentation of receiving an influenza vaccine the resident consented to on admission. Staff member C stated she had not been working at the time. […]