Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Clark Fork Valley Nursing Home during CMS and state inspections, most recent first.
Incomplete Investigation of Sexual Abuse Allegation: The facility failed to thoroughly document its investigation of an allegation of sexual abuse involving a resident who reported being touched inappropriately by a male staff member during care. Staff said they summarized the investigation but did not record all staff and resident interviews, the details obtained, or the dates of those interviews, and the file contained only a brief summary, APS report, police statement, and bounds report.
Missed PASRR Referral for New Bipolar Diagnosis: A resident with a new bipolar disorder diagnosis was not referred for a new PASRR review after the diagnosis appeared in the EMR and later on the MDS as an active dx. Staff reported the bipolar dx should have triggered another PASRR submission, but the diagnosis was missed and the facility had no policy for PASRR completion or resubmission.
A resident with moderate dementia exhibited aggressive behaviors towards others, leading to multiple abuse incidents. Despite documented declines in mood and mobility, the facility failed to implement effective, individualized interventions or conduct thorough investigations. Staff interventions were inconsistent and largely ineffective, highlighting a deficiency in managing the resident's behaviors.
Facility staff failed to perform proper hand hygiene during medication administration and did not use PPE when handling contaminated laundry. A staff member was observed not washing hands between residents, and another did not wear gloves when placing a dirty mop head into the washing machine, despite being aware of the facility's infection control policies.
A resident in a LTC facility repeatedly engaged in aggressive behaviors towards other residents, including running into them with her wheelchair and physically assaulting them, resulting in injuries. Despite multiple incidents, the facility failed to provide adequate protection or manage the resident's behaviors effectively, as revealed through staff interviews and record reviews.
The facility did not report resident-to-resident abuse allegations involving a resident to the State Survey Agency within the required timeframe. Despite multiple abusive interactions documented in the resident's EHR, no reports were made in 2024. Staff interviews revealed a lack of awareness and action, with the abuse coordinator unaware of the incidents. The facility's policy requires immediate reporting of abuse, which was not followed, indicating a significant deficiency in handling abuse allegations.
A facility failed to recognize and investigate repeated aggressive behavior by a resident towards others, resulting in minor injuries. Despite documented altercations in the resident's EHR, no reports were sent to the State Survey Agency. Staff interviews indicated a lack of thorough investigation, and the facility did not follow its policy on reporting and investigating abuse.
The facility inaccurately completed MDS assessments for three residents regarding restraint use, marking side rails as restraints despite residents using them for assistance. Additionally, an antidepressant medication was not correctly identified on a resident's MDS, as Trazodone was used but not coded as an antidepressant. Staff misunderstandings and lack of a specific MDS policy contributed to these deficiencies.
A facility failed to manage expired medications and secure a medication cart, potentially affecting residents. A travel nurse was unable to explain the process for handling expired medications, and expired items were found in the cart. Additionally, the cart was left unlocked and unattended, contrary to facility policy.
A facility failed to include a resident's anticoagulant use and its side effects in her care plan, despite her tendency to bruise easily. Another resident's preference to sleep in a recliner due to claustrophobia was not documented in her care plan, even though she consistently slept in the common area. These omissions highlight deficiencies in the comprehensive care planning for residents.
A facility failed to update a resident's care plan to include comfort care, despite a physician's order. The care plan lacked focus, goals, or interventions related to comfort care. Staff interviews revealed no formal policy existed, and comfort care was based on conversations with families and residents. This deficiency increased the risk of unmet needs for the resident.
The facility failed to implement a bladder function program for two residents, who were frequently incontinent of urine and not on a toileting schedule, despite being able to use the bathroom independently. Facility assessments indicated they were candidates for retraining or scheduled toileting, but no policy or program was in place, as confirmed by staff.
A resident experienced a significant weight loss over three months, but the facility failed to ensure accurate weight records and did not have a process for re-weighing. Despite staff acknowledging the need for re-weighing due to weight changes, no re-weights were conducted, and the facility lacked a formal policy for managing weight changes.
A resident with a history of significant trauma did not receive trauma-informed care at the facility. Despite the resident's disclosures of past traumatic experiences, there was no trauma-informed care plan or social services notes in her records. Staff members acknowledged the resident's history but lacked formal training on trauma-informed care, and the facility did not have a policy or procedure in place for addressing trauma or PTSD.
A resident with a history of traumatic experiences did not receive medically-related social services at the facility. The resident expressed feelings of anger and sadness and reported not having been spoken to by a social worker or therapist. Staff interviews revealed a lack of awareness and action regarding the resident's need for trauma-related support, and no social services notes were found for the resident. The facility's care document indicated that social services should be provided to help residents achieve the highest practicable level of well-being, but this was not implemented for the resident.
A facility failed to limit the use of PRN Ativan for a resident to 14 days or provide a rationale for its extended use. The resident received seven doses over three months without proper documentation or evaluation. Staff interviews revealed a lack of clarity in medication regimen reviews and physician oversight.
The facility did not post a list of names and contact information for state regulatory and advocacy groups, as required. The bulletin board near the nurses' station only had contact information for the state Ombudsman. Staff revealed that the sign was removed during renovations and not replaced. Resident council members were unaware of the sign's location.
The facility did not post the most recent recertification survey results in an accessible area for residents, family members, or staff. During a resident council meeting, members were unaware of the survey results' location. A staff member indicated the information was removed during renovations and not replaced.
Incomplete Investigation of Sexual Abuse Allegation
Penalty
Summary
The facility failed to document a thorough investigation of an allegation of sexual abuse involving one resident. The resident described an incident in which she felt she was touched inappropriately by a male staff member while he was assisting another staff member with powder application to private areas. She stated the staff member apologized and later quit working at the facility. During surveyor interviews, the resident said the facility handled the incident professionally and discreetly, and she appeared happy, smiling, and not fearful when discussing it. Facility staff stated they were unsure how to conduct the investigation because they had never had an allegation to this extent before. They reported that they removed the staff member and summarized the investigation, but did not document all conversations with other staff or residents. They also stated that because the exact date of the incident could not be determined, they did not perform a physical assessment of the resident. Review of the investigation file for the incident showed only a brief summary of facility events, an APS report, a police statement, and the bounds report, and did not show which residents or staff were interviewed, the details of those interviews, or the dates they occurred.
Missed PASRR Referral for New Bipolar Diagnosis
Penalty
Summary
The facility failed to refer a resident with a new diagnosis of bipolar disorder to the appropriate state-designated mental health authority for PASRR review. Resident #6 had a PASRR screening dated 6/26/23 that was approved and listed diagnoses including cerebral infarct due to embolism, aphasia, dysphagia, depression unspecified, COPD, hypertension, type 2 diabetes mellitus, and osteoarthritis. The resident’s electronic medical record later showed bipolar disorder, unspecified, created 8/29/23, and the quarterly MDS with an ARD of 1/5/26 identified bipolar disorder as an active diagnosis. During interview, staff member H stated her PASRR process was to gather information from the electronic health record and H&P and enter the diagnoses listed there, especially mental health diagnoses other than dementia. She stated that a new diagnosis of bipolar disorder should prompt a new PASRR referral and that, for this resident, bipolar should have been reflected on the PASRR and another PASRR should have been submitted. Staff member H stated that one of the resident’s diagnoses had been missed. The facility did not have a policy for completion of the PASRR or for when to resubmit a PASRR referral.
Failure to Address Aggressive Behaviors in Dementia Resident
Penalty
Summary
The facility failed to adequately address the aggressive and intrusive behaviors of a resident diagnosed with moderate dementia, leading to multiple resident-to-resident abuse incidents. The resident, who was cognitively impaired and rarely understood others, exhibited a range of aggressive behaviors such as pulling hair, hitting, and spitting at other residents. Despite these behaviors being documented over several months, the facility did not report these events as abuse or conduct thorough investigations, as required by regulations. The resident's Minimum Data Set (MDS) assessments over time showed a decline in her mood, mobility, and independence, with increasing signs of depression and pain. Despite these changes, the facility did not implement person-centered, individualized interventions to address the resident's specific behaviors or the antecedents to these behaviors. The care plan lacked detailed strategies to prevent the resident's aggressive actions and protect other residents, failing to adapt to the resident's deteriorating condition and increased behavioral disturbances. Interviews with staff revealed that interventions for the resident's aggressive behaviors were inconsistent and largely ineffective. Staff noted that the resident became overstimulated quickly and required removal from the environment, but interventions such as medication changes and redirection were not successful in the long term. The facility's documentation did not demonstrate sufficient action to protect other residents or provide ongoing behavioral assessments, highlighting a significant deficiency in the care and management of the resident's dementia-related behaviors.
Inadequate Hand Hygiene and PPE Use During Medication Pass and Laundry Handling
Penalty
Summary
The facility staff failed to adhere to proper hand hygiene protocols during medication administration. A staff member was observed dispensing medications to residents without performing hand hygiene between residents, despite being aware of the facility's policy that requires hand hygiene before and after touching any patient and after touching items in patient rooms. The staff member expressed confusion about the correct process for hand hygiene, indicating a lack of clarity or training on the facility's hand hygiene policy. Additionally, another staff member did not use appropriate personal protective equipment (PPE) when handling contaminated laundry. The staff member was observed placing a dirty mop head into the washing machine without donning gloves or any other PPE, contrary to the facility's guidelines for handling contaminated laundry. The staff member acknowledged the oversight and stated that they had been educated on infection control practices, suggesting a lapse in adherence to established protocols.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically resident-to-resident abuse incidents involving resident #19, who was identified as the aggressor. Resident #19's electronic medical record documented multiple altercations with other residents, where she exhibited aggressive behaviors such as running into people with her wheelchair, attempting to hit others with objects, and physically assaulting other residents. These incidents resulted in injuries to at least one resident, #10, and affected several others. The report details a series of events where resident #19 engaged in aggressive and harmful behaviors towards other residents. These behaviors included intentionally running into residents with her wheelchair, attempting to hit them with objects like a recliner remote, and physically grabbing and pulling at other residents. Despite these repeated incidents, the facility failed to provide adequate protection to prevent further abuse or to effectively manage resident #19's behaviors. Interviews with staff members revealed a lack of consistent reporting and awareness of the abuse incidents. Staff member P acknowledged that resident-to-resident altercations occurred with resident #19, but there was a lack of comprehensive understanding and communication among staff regarding these incidents. Staff member F noted the difficulty in determining intent in cognitively impaired residents, which contributed to the facility's inadequate response to the abuse. The facility's failure to address these behaviors and protect residents from harm constitutes a significant deficiency in care.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report allegations of resident-to-resident abuse involving a specific resident to the State Survey Agency within the required reporting period. The electronic health record (EHR) of the resident showed multiple interactions with other residents, some of which were abusive and purposeful. Despite these incidents, no reports of resident-to-resident abuse involving this resident were forwarded to the State Survey Agency in 2024. Interviews with staff revealed a lack of awareness and action regarding these incidents, with staff member P documenting the interactions but not ensuring they were reported up the chain of command. Staff member F, the abuse coordinator, was unaware of the abuse allegations and had provided education on abuse reporting, indicating a breakdown in communication and reporting processes. The facility's policy mandates immediate reporting of abuse, neglect, or suspicion thereof, but this was not adhered to in this case. The policy also requires that results of investigations be reported to the State agency within five business days, which was not done. The failure to report these incidents highlights a significant deficiency in the facility's handling of abuse allegations.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to recognize and investigate potential abuse involving a resident who repeatedly engaged in aggressive behavior towards other residents, resulting in minor injuries. Despite multiple resident-to-resident altercations documented in the electronic health record (EHR) of the involved resident, there were no reports of these incidents sent to the State Survey Agency in 2024. Staff interviews revealed that there was a lack of thorough investigation into these altercations, and a staff member had restricted another staff member's access to write progress notes due to concerns about the documentation. The facility's policy on abuse, neglect, and exploitation mandates that all alleged violations, including resident-to-resident incidents, be reported and thoroughly investigated. However, the facility did not adhere to this policy, as evidenced by the absence of social service notes related to the incidents and follow-up for potential victims. The failure to report and investigate these incidents indicates a significant oversight in the facility's responsibility to protect residents from abuse and ensure their safety.
Inaccurate MDS Assessments for Restraint Use and Antidepressant Identification
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments regarding restraint use for three residents and the identification of an antidepressant medication for one resident. Observations and interviews revealed that three residents used side rails on their beds to assist with repositioning and standing, and they did not perceive these side rails as restraints. However, their MDS assessments inaccurately marked the side rails as daily restraints. The facility did not have a specific written policy for MDS assessments, and staff members were following the Resident Assessment Instrument (RAI) guidelines. A staff member admitted to mistakenly coding the side rails as restraints due to a misunderstanding. Additionally, the facility failed to accurately identify an antidepressant medication for another resident. The resident's Medication Administration Record indicated the use of Trazodone, an antidepressant, for insomnia. However, the resident's Significant Change MDS did not reflect the use of an antidepressant, as it was incorrectly marked as 'No' under the section for high-risk drug classes. A staff member acknowledged the error, confirming that Trazodone is an antidepressant and should have been coded as such on the MDS.
Expired Medications and Unsecured Cart Found in Facility
Penalty
Summary
The facility failed to properly manage expired medications and secure the medication cart, which could potentially affect residents receiving medications. During an observation, a staff member, who was a travel nurse and unfamiliar with the facility's procedures, was unable to explain the process for handling expired medications. Expired medications, including Senna Plus Tablets, Acetaminophen Suppositories, and Glucagon Injection, were found in the medication cart. The facility's policy requires monthly monitoring of expiration dates and the return of expired medications to the pharmacy, but this was not adhered to. Additionally, the medication cart was left unlocked and unattended by the same staff member in the activity/dining room area. The staff member left the cart to walk down the main hallway, leaving medications unsecured in the top drawer. Upon returning, the staff member acknowledged the mistake, stating that the cart should have been locked. The facility's medication administration policy emphasizes the importance of maintaining the security of medications, which was not followed in this instance.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to ensure a comprehensive care plan for a resident who was on a high-risk medication, specifically an anticoagulant, which was not documented in the care plan. During an observation, a resident was noted to have a bruise on her hand, which she attributed to bumping into her bedside table. The resident mentioned that she bruised easily and often had unexplained bruises. A staff member confirmed that the resident bruised easily and acknowledged that the care plan did not include information about the resident's anticoagulant use or its side effects. A review of the resident's physician orders confirmed the use of apixaban, an anticoagulant, but the care plan lacked any focus, goals, or interventions related to this medication. Additionally, the facility did not account for another resident's sleeping preferences in her care plan. This resident preferred to sleep in a recliner in the common area due to claustrophobia, which made her uncomfortable in her room. Observations and interviews with staff and the resident confirmed that she slept in the common area recliner and felt claustrophobic in her room. However, her care plan did not document her preference to sleep in the recliner or her feelings of claustrophobia, indicating a lack of comprehensive care planning for her needs.
Failure to Revise Care Plan for Comfort Care
Penalty
Summary
The facility failed to revise the care plan for a resident to include comfort care, despite a physician's order dated 10/2/24 indicating the need for such care. The resident's care plan, initiated on 7/25/24, lacked any updates to address comfort care, including focus, goals, or interventions. During the survey, a request for the facility's comfort care policy was made, but no policy was provided. Interviews with staff members revealed that there was no formal comfort care policy or procedure in place. Staff member F indicated that comfort care was based on conversations with the family and resident, while staff member N mentioned that she would discuss comfort care with residents and families and order medications as needed, but was unaware of any existing policy. This lack of a formalized approach increased the risk of the resident's needs being unmet by facility staff.
Lack of Bladder Function Program for Residents
Penalty
Summary
The facility failed to implement a program to maintain or restore bladder function for two residents, leading to a deficiency in care. During interviews, staff member K revealed that the residents were frequently incontinent of urine and were not on a set toileting program or schedule, despite being able to independently use the bathroom. The care plans did not address a toileting schedule or program. Facility assessments indicated that one resident was a good candidate for retraining and could independently manage bathroom tasks, while the other was a candidate for scheduled toileting. Despite requests, no bladder/incontinence policy or bladder retraining program was provided, and staff member F confirmed the absence of such a program or written policies.
Failure to Ensure Accurate Weight Monitoring
Penalty
Summary
The facility failed to ensure accurate and correct weight records for a resident, leading to a significant weight loss that was not properly addressed. The resident, who was observed eating breakfast and reported losing weight since admission, experienced a 13.77% weight loss over three months. Despite this, the facility did not have a process in place for re-weighing the resident, even though staff member C acknowledged the inaccuracy of the weights due to edema and the need for re-weighing if there was a significant weight change. Staff member N expected to be notified of any weight changes, but no re-weighs were conducted, and the physician's progress notes did not address the weight loss or the resident's refusal of a diuretic. The facility lacked a formal policy or procedure for managing weight loss or gain, as confirmed by staff member F. Although a document titled "Long Term Care Weight Management Orders" outlined procedures for weight loss and gain, it was undated, and no re-weights were documented during the period in question. Staff member M expressed concerns about the need for a re-weight but was unsure if these concerns were communicated to the physician. The facility's failure to implement a consistent process for monitoring and addressing significant weight changes contributed to the deficiency.
Failure to Provide Trauma-Informed Care for Resident with Past Trauma
Penalty
Summary
The facility failed to provide trauma-informed care for a resident who had experienced significant past trauma. The resident, identified as #24, shared her history of traumatic experiences, including a childhood with a drug-addicted mother, an abusive marriage, and the murder of her sister. Despite these disclosures, the facility did not have a trauma-informed care plan in place for her, and there were no social services notes in her progress records. Interviews with staff members revealed that the resident frequently spoke about her past trauma, but there was no evidence that she had been assessed for trauma or referred to a counselor or therapist since her admission. Staff members expressed awareness of the resident's traumatic history but indicated a lack of formal training or education on trauma-informed care. One staff member mentioned that the facility had a behavioral counselor available, but it was unclear if the resident had been referred. Additionally, there was no policy or procedure for trauma-informed care or post-traumatic stress disorder available at the facility, highlighting a systemic issue in addressing the needs of residents with traumatic backgrounds.
Failure to Provide Social Services for Resident with Traumatic History
Penalty
Summary
The facility failed to provide medically-related social services to a resident, identified as #24, who had a history of traumatic experiences. During an interview, the resident expressed feelings of anger and sadness when recalling past traumatic events and mentioned that she had not been spoken to by a social worker or therapist since her admission. The resident felt that her experiences were not believed by the staff, despite having shared them with some caregivers. Interviews with staff members revealed a lack of awareness and action regarding the resident's need for trauma-related support. One staff member acknowledged the resident's traumatic past but was unsure if any discussions or assessments had been conducted. Another staff member admitted uncertainty about the existence of a trauma care plan or policy and could not find any social services notes for the resident. The facility's document on care within the long-term care unit indicated that social services should be provided to help residents achieve the highest practicable level of well-being, but this was not implemented for the resident in question.
Failure to Limit PRN Antianxiety Medication Use
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the administration of as-needed (PRN) antianxiety medication for a resident. Specifically, the facility did not limit the use of Ativan, a psychotropic medication, to 14 days or provide a documented rationale for its continued use beyond this period. The resident in question, identified as #24, reported feeling disoriented by a medication she believed was for anxiety, which she did not understand the need for and did not like how it made her feel. The medication orders for Ativan were initiated on September 17, 2024, and discontinued on December 18, 2024, with the resident receiving a total of seven doses over three months. The facility's documentation, including the Consultant Pharmacist's Progress Notes and the physician's progress notes, lacked the necessary evaluation and documentation to justify the extended use of Ativan beyond the 14-day limit. Interviews with staff members revealed a lack of clarity and communication regarding the medication regimen reviews and the physician's role in reviewing and acting on these recommendations. The facility's policy on psychotropic medications required PRN orders to be time-limited and accompanied by a clear rationale, which was not adhered to in this case.
Failure to Post Required Contact Information for State Agencies
Penalty
Summary
The facility failed to post a list of names and contact information for state regulatory and advocacy groups, the State Survey Agency, or State licensure office, which is required for residents wishing to file a complaint. This deficiency was observed during a survey when the bulletin board next to the nurses' station only contained contact information for the state Ombudsman, lacking the complete required information. During interviews, it was revealed that the facility had been provided with a laminated poster containing all necessary information by the state ombudsman office. However, staff member F stated that the sign was removed during renovations at the nurses' station and had not been replaced afterward. Additionally, resident council members were unaware of the location of any sign containing this information.
Failure to Post Recertification Survey Results
Penalty
Summary
The facility failed to post the results of the most recent recertification survey in an area that was easily accessible to residents, family members, residents' legal representatives, or staff. This deficiency was identified during an observation on February 12, 2025, at 7:26 a.m., when no binder containing the survey results was found within the long-term care area of the facility. During a resident council meeting later that day, council members were unaware of the location of the binder with the survey results. Additionally, a staff member revealed that the survey information had been removed during renovations at the nurses' station and had not been replaced afterward.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Plains
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hot Springs Health & Rehabilitation Center | 13.8 mi | — | 8 | 0 |
| St Luke Community Nursing Home | 35.4 mi | — | 0 | 0 |
| Polson Health & Rehabilitation Center | 37.1 mi | — | 6 | 0 |
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