Southwest Montana Veterans Home

In the surveyor’s words

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

• Actual harm, isolatedF697May 11, 2023

  Based on observation, interview, and record review, the facility staff failed to effectively identify, treat, and reassess the effectiveness of pain management, for 1 (#8) of 9 residents. Findings include: During an interview on 5/9/23 at 7:58 a.m., staff member K stated resident #8 had, Frequent headaches since his fall a couple of months ago. Staff member K stated resident #8 had a muscle relaxer and Norco (for pain), and it seemed like the headaches were coming from the resident's neck. During an observation and interview on 5/9/23 at 3:52 p.m., resident #8 was in bed with blankets over his head, and his knees were pulled up to his abdomen. Resident #8 pulled his blanket down when addressed and had a distressed look on his face (scowling and frown). […]

• No harm, potential for more than minimal, patternF605Jun 19, 2025

  Based on interview and record review, the facility failed to ensure psychotropic medications were used to treat a residents' specific, diagnosed, and documented condition for 2 (#s 14 & 36); and failed to obtain a GDR signed by the prescribing doctor for five psychotropic medications for 1 (#23) of 13 sampled residents. This deficient practice failed to ensure the medication dosages were either clinically appropriate or a potential dose reduction was clinically contraindicated for the resident. Findings include: 1. Review of resident #14's original medication order, dated 4/1/25, showed Quetiapine Fumarate 200 mg, Give 1 tablet by mouth one time a day for Mental disorder. […]

• No harm, potential for more than minimal, patternF644Jun 19, 2025

  Based on interview and record review, the facility failed to ensure a PASRR Level II was completed for 1 (#32), and failed to ensure the residents' mental health diagnoses, for which they received psychotropic medication, were included on the PASRR for 2 (#s 14 & 36) of 13 sampled residents. Findings include: 1. Review of resident #14's PASRR, dated 4/1/25, showed the diagnoses of: chronic respiratory failure, unspecified mental disorder, post-traumatic stress disorder, and depression unspecified. Bipolar disorder was not listed. Review of resident #14's medication order, dated 4/2/25, showed Quetiapine Fumarate 200 mg, give 1 tablet by mouth one time a day for bipolar depression. 2. […]

• No harm, potential for more than minimal, patternF700Jun 19, 2025

  Based on observations, interviews, and record review, the facility failed to obtain physician orders, informed consents, signed statements of understandings, or develop a standardized process, including terminology, for the use of bed rails for 5 (#s 5, 23, 24, 33, and 41) of 13 sampled residents. Findings include: 1. During an observation on 6/16/25 at 11:10 a.m., bed rails were noted on both sides of resident #5's bed. Review of the Care Plan Report for resident #5, with an initiation date of 4/21/24, showed: Bed canes to enable bed mobility. Review of the resident #5's electronic medical record did not show physician orders or consents for bed rails. 2. During an observation on 6/16/25 at 10:27 a.m., bed rails were noted on both sides of resident #23's bed. […]

• No harm, potential for more than minimal, patternF657May 11, 2023

  Based on observation, interview and record review, facility staff failed to update individualized care plans to show current focus areas, goals, and interventions to address the focus areas, for 4 (#s 3, 15, 30, and 36) of 12 sampled residents. Findings include: 1. During an interview on 5/9/23 at 9:45 a.m., NF2 said she had brought resident #3's scooter from home. NF2 said resident #3 had hearing aids, but he had not been wearing them because he was missing the charging base. NF2 said resident #3 was pretty hard of hearing. […]