Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Eastern Montana Veterans Home during CMS and state inspections, most recent first.
Staff failed to maintain adequate supervision and follow safe handling protocols, resulting in a resident being left unsupervised and sustaining a hip fracture after being pulled from a wheelchair by another resident, and in a separate incident, two residents engaged in a physical altercation due to lack of supervision.
The facility did not conduct or document thorough investigations for incidents involving resident altercations and staff-to-resident verbal abuse. Required interviews with involved parties and witnesses were not completed or documented, and findings submitted to the State Survey Agency were incomplete or inaccurate, lacking supporting evidence and details as required by facility policy.
A resident on a special care unit was left unattended in bed for several hours without necessary ADL care, resulting in pain, distress, and multiple skin injuries. The resident was found with his arm caught between the mattress and footboard, covered in BM, and exhibiting combative behavior. Two CNAs assigned to the unit failed to provide care or notify nursing staff, leading to their termination for neglect.
A resident with dementia, identified as at risk for elopement, exited the facility unsupervised and was later found by police with a head injury after a fall. Despite a wander guard and prior incidents of wandering, staff failed to follow elopement protocols, including conducting a head count after a door alarm. Gaps in staff training and incomplete adherence to policy contributed to the resident's unsupervised exit and subsequent injury.
During an influenza outbreak, two residents who were roommates remained together after one tested positive for flu and the other was not tested, despite one having a high-risk respiratory condition. Key infection control staff were absent, leading to missing and inconsistent documentation of testing, isolation, and infection mapping, and the facility did not follow its own policies for surveillance and transmission-based precautions.
Nursing staff did not follow the facility's elopement policy, resulting in a resident leaving the facility unattended. After a door alarm sounded, a staff member checked the perimeter but did not perform a required head count and was unaware of the full policy procedures. The resident was later found outside by police, and the incident revealed gaps in staff training and knowledge regarding elopement protocols.
The facility did not have an RN on duty for at least eight consecutive hours per day on multiple occasions, with the DON only on call and no staffing waiver in place. This left all residents without immediate RN availability when needed.
Staff failed to follow sanitary food preparation practices, including not covering facial hair, not covering or dating food items in storage, and not maintaining freezer equipment, resulting in uncovered and undated food, ice buildup in the freezer, and improper storage of produce. These actions did not meet facility policies for food safety and personal hygiene.
The facility did not complete or maintain required PASRR Level One documentation for three residents with significant mental health and cognitive diagnoses. For one resident, a new PASRR was not submitted after a convalescent stay exceeded the approved period, and for two other residents, no PASRR forms could be found despite their qualifying conditions. Staff were unaware of or did not follow procedures for PASRR completion as outlined in facility policy.
A resident was not properly assessed or monitored for smoking safety, repeatedly left the facility property to smoke without signing out as required, and did not receive a complete smoking safety evaluation. Staff were aware of the resident's noncompliance with the sign-out policy, and the facility did not provide a sheltered area for smoking or ensure adherence to its own smoking policy.
Two residents had POLST forms in their medical records that were missing the required date next to the provider's signature, making the forms incomplete. Staff interviews revealed that POLST forms are reviewed at admission and annually, but not at every quarterly care conference, and there is no specific nurse assigned to oversee their completion. Facility policy requires advance directives to be obtained and communicated, but these steps were not fully followed.
Two residents experienced unsanitary and unmaintained living conditions, including persistent urine stains and odors in a bathroom and a growing, unrepaired hole in a wall. Housekeeping staff reported daily cleaning assignments, but observations and interviews revealed that deep cleaning and repairs were not performed as required by facility policy.
A resident admitted with an order for supplemental oxygen due to COPD did not have a baseline care plan developed within 48 hours that included instructions for oxygen therapy. Staff interviews revealed confusion about the baseline care plan process and whether oxygen needs were addressed, resulting in a deficiency for not meeting immediate care planning requirements.
A resident experienced significant weight loss and decreased food intake due to skin irritation and pacing, but the care plan was not updated in a timely manner to include interventions addressing these issues. Although a nutritional supplement was ordered, the care plan did not reflect this or provide strategies for the resident's altered nutrition needs.
A resident was subjected to physical and psychosocial abuse by facility staff, resulting in skin injuries and emotional distress. Despite the resident's resistance, staff forcibly transferred her to the dining room, leading to a struggle. The facility's investigation revealed multiple staff involvement but failed to address root causes or prevent future incidents.
A resident's preference to eat meals in her room was disregarded by staff, who insisted she go to the dining room despite her protests. The resident, who was cognitively intact and independent in eating, had personal reasons for avoiding the dining room. Staff members were aware of her preference but took her to the dining room for breakfast, citing safety concerns after a reported fall. Surveillance footage confirmed the resident's resistance to being taken to the dining room, highlighting a failure to respect her right to self-determination.
A resident expressed grief and fear after her husband's death, but the facility failed to update her care plan to address these issues. A staff member provided emotional support but was unaware of the care plan's deficiencies. The social services director position was vacant, and the staff member was temporarily covering the role. The care plan lacked focus on grief, loss, or loneliness.
A resident grieving the recent loss of her spouse did not receive adequate social services support from the facility. Despite expressing fear about a new roommate and showing visible emotional distress, her care plan was not updated to address her grief. A staff member provided emotional support but did not document these interactions, and the facility failed to implement timely interventions to help the resident cope.
Failure to Provide Adequate Supervision and Safe Resident Handling
Penalty
Summary
Staff failed to provide adequate supervision and follow established policies and procedures to maintain resident safety on a secure care unit. On one occasion, two residents were left unsupervised in the dining room when a staff member left to put dishes away in the kitchen, and another staff member left the area to use the restroom. During this period without supervision, one resident pulled another resident's wheelchair, causing the resident to fall to the floor. No staff were present in the immediate area to intervene or prevent the incident, as confirmed by video footage reviewed by facility leadership. The resident who fell was initially assessed and found to have no injuries, but was later discovered to be in significant pain and was transferred to the hospital, where a hip fracture was diagnosed and surgically repaired. The incident revealed that staff did not adhere to the facility's policies regarding supervision and safe resident handling. Staff interviews indicated that there should have been at least two CNAs present for constant supervision, and that staff are expected to have another staff member replace them if they need to leave the unit. However, these protocols were not followed, resulting in a lapse in supervision. Additionally, after the fall, staff manually transferred the injured resident from the floor to a wheelchair without using a gait belt, despite gait belts being available on the unit and required by facility policy for safe transfers. This manual transfer was performed by supporting the resident under the arms and holding the back of his pants, which was not in accordance with the facility's safe handling policy. A separate incident involved a physical altercation between two other residents on the secure care unit, which also occurred when staff supervision was lacking. In this case, a staff member failed to notify a supervisor before leaving for a lunch break, resulting in residents being left unsupervised and leading to a resident-to-resident altercation. Documentation and interviews confirmed that the staff member did not follow instructions for one-to-one supervision, contributing to the occurrence of the incident.
Incomplete Investigation and Documentation of Reported Incidents
Penalty
Summary
The facility failed to conduct and document complete investigations for multiple reported incidents involving residents and staff. Specifically, for an altercation between two residents in the dining room, the facility's documentation was limited to a single paragraph with no supporting evidence, such as interviews with the involved residents, staff, or witnesses. There were also no documented interventions or analysis to prevent recurrence. Additionally, the findings submitted to the State Survey Agency for this incident were inaccurate, referencing unrelated individuals and omitting the actual residents involved. In another incident involving an allegation of staff-to-resident verbal abuse, the facility's investigation was incomplete, lacking details on which residents were interviewed and their responses, as well as missing interviews with staff witnesses. The facility's own policies require thorough documentation, including interviews and written statements from all involved parties, but these procedures were not followed. Staff interviews revealed that documentation practices were inconsistent, with investigation notes being saved as findings without maintaining separate interview records or templates.
Resident Neglected and Left Unattended, Resulting in Injury and Distress
Penalty
Summary
Facility staff failed to provide necessary ADL care to a resident residing on the special care unit, resulting in the resident being left unattended in bed for an extended period. The resident was found lying on his side at the foot of the bed, with his left arm caught between the mattress and footboard, and was observed to be in significant pain and distress, screaming and crying. The resident was covered in bowel movement, as were the bed, floor, and floor mats, and had sustained skin tears and bruising to his left hand, wrist, and hip, with a large dark-colored mark and indentation likely from pressure. The bed was noted to be elevated except at the foot, and the resident was combative during care, resisting staff assistance. Review of staff witness statements and personnel files revealed that the CNAs assigned to the resident did not provide care from approximately 2:00 a.m. to 7:00 a.m., despite being aware of the resident's needs and distress. One CNA reported not feeling comfortable with the resident due to his behavior and did not inform the nurse of the situation, while the other CNA did not perform any cares during this period. Both CNAs were subsequently terminated for neglect. Facility policy defines neglect as the failure to provide necessary goods and services to avoid physical harm, pain, or emotional distress, and includes recurrent failure to provide incontinence care.
Failure to Prevent Elopement and Ensure Resident Safety
Penalty
Summary
A resident with dementia, identified as being at risk for elopement and wandering, exited the facility through the front doors and left the property unsupervised. The resident was able to access a public road and was later found by police at a nearby apartment complex, having sustained a laceration to the forehead after a fall. The incident was reported to the State Survey Agency, and the resident required hospital evaluation and observation for the injuries sustained during the elopement. Facility records indicate that the resident had a history of wandering behaviors, including previous incidents where the resident attempted to leave the facility or triggered door alarms. The resident had been assessed as at risk for elopement and had a wander guard device placed. Despite these interventions, the resident was able to exit the facility undetected. On the day of the incident, a staff member responded to the front door alarm, briefly scanned the perimeter, but did not see any residents outside and did not conduct a head count as required by facility policy. Interviews with staff revealed gaps in training and adherence to elopement protocols. The staff member who responded to the alarm had not read the facility's elopement policy and was not fully oriented to the procedures. Facility policy required a full head count and further action if a resident could not be located, but these steps were not followed. Documentation and communication with law enforcement regarding the incident were incomplete at the time of the survey.
Failure to Maintain Infection Surveillance and Isolation During Influenza Outbreak
Penalty
Summary
The facility failed to maintain an effective system for communicable disease surveillance and infection control during an influenza outbreak. Two residents who were roommates remained in the same room after one tested positive for influenza, while the other was not tested, despite having a primary diagnosis that placed him at higher risk for respiratory complications. There was no documentation of moving either resident to a different room or of testing the second resident for influenza. The infection preventionist and another key staff member were absent during the outbreak, and infection control responsibilities were delegated to other staff, but there were discrepancies and missing documentation regarding resident testing, isolation, and infection mapping. Record reviews revealed that the infection control binder lacked completed tracking and trending for the outbreak period, and the infection mapping for the relevant month was not done. The facility was unable to provide a complete infection control log for the outbreak period, and available lists did not document testing or isolation actions for the two affected residents. Facility policies required surveillance tools and transmission-based precautions, including private room placement or cohorting for residents with influenza, but these measures were not documented as being implemented.
Failure to Train Staff on Elopement Policy Leads to Resident Elopement
Penalty
Summary
Nursing staff failed to follow the facility's elopement policy, resulting in a resident leaving the facility unattended. On the day of the incident, a staff member received a call from the police department notifying them that a resident had been found outside the facility near an apartment complex. A head count was then conducted, revealing the resident was missing. The staff member who responded to the door alarm did not hear the alarm and did not perform a head count after checking the perimeter, as required by facility policy. The staff member was unaware that a head count was necessary and had not read the facility's elopement policy, despite having received orientation at the start of employment. Review of facility documentation confirmed that the elopement policy required a head count and a facility-wide response when a door alarm was triggered without an identified cause. The resident's nursing progress notes and the facility's timeline indicated that the resident exited through the front doors and was not noticed by staff during the initial response to the alarm. The lack of staff knowledge and adherence to the elopement policy directly contributed to the resident's ability to elope from the facility.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least eight consecutive hours per day, seven days a week, as required. Review of the licensed nursing schedules for July and September 2024 revealed that on several specific dates, there was no documentation of eight consecutive hours of RN coverage within a twenty-four-hour period. Staff confirmed that on these dates, there were no RN hours recorded, and the director of nursing (DON) was only on call and did not work the required eight consecutive hours. The facility did not have a staffing waiver in place to cover these absences. This deficiency had the potential to affect all residents who required nursing services, as an RN was not immediately available when needed.
Food Safety and Sanitation Deficiencies in Dietary Department
Penalty
Summary
Staff failed to prepare food in a sanitary manner and did not maintain freezer equipment or ensure proper storage of food items. Observations included a staff member with an uncovered mustache and beard working in food preparation areas, and the same staff member later handling food with multiple uncovered skin tears and scabs on his forearms. The walk-in freezer contained a box with a partially open, undated bag of omelets and an opened, undated bag of pork sausages. There was also significant ice buildup under a compressor fan, with a tray placed to catch ice chunks, and boxes of food stored directly below, some with ice chunks stuck to them. The walk-in refrigerator had uncovered heads of lettuce stored in a colander inside a box on a shelf, which remained unaddressed over multiple days. Staff interviews revealed that there was awareness of the need for beard nets for facial hair longer than half an inch, but this was not enforced. Staff also reported that requests for freezer repairs had been made, but the issue persisted, and the practice of chipping away ice chunks was ongoing. Facility policies required food to be covered, labeled, and dated, and for staff to maintain personal hygiene, including keeping facial hair trimmed and clean, but these standards were not met during the survey period.
Failure to Complete and Maintain Required PASRR Documentation
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Reviews (PASRRs) were completed and accurate for three of seventeen sampled residents. For one resident with multiple mental health diagnoses, including dementia with behavioral disturbance, anxiety disorder, mood disorder, major depressive disorder, post-traumatic stress disorder, and suicidal ideations, the PASRR on file was a categorical approval for a convalescent stay, which required a new Level One PASRR if the stay exceeded 29 days. Staff were unaware of this requirement and had not submitted a new PASRR Level One as needed. Additionally, two other residents with documented mental health and cognitive conditions, such as emotional shock, hallucinations, mood disorder, depression, PTSD, cognitive communication deficit, and violent behavior, did not have PASRR Level One forms available in their records. Staff confirmed that PASRRs should have been initiated for these residents based on their diagnoses but could not provide the required documentation or explain why the forms were not completed. The facility's own assessment documentation indicated that PASRRs are to be completed to ensure appropriate placement for residents with cognitive disabilities.
Failure to Assess and Monitor Resident Smoking Safety
Penalty
Summary
The facility failed to properly assess and monitor a resident's safety with regard to smoking. The resident reported going outside to smoke four to five times daily, leaving the facility property due to a no smoking policy, and not signing out as required. Despite being aware of the sign-out policy, the resident consistently did not comply, and staff were aware of this noncompliance. The facility did not provide a sheltered area for smokers, and residents were expected to smoke off property without shelter. Staff interviews confirmed that residents were expected to sign out and store their smoking materials in a weatherproof metal container, but these procedures were not consistently followed. Review of the resident's records showed that the required smoking safety assessment was incomplete, with key areas such as cognitive ability, visual acuity, dexterity, and the ability to safely light and extinguish cigarettes left unassessed. Nurse practitioner and physician notes repeatedly identified the resident as an active smoker but did not address or document smoking safety. The facility's policy required physician consultation for safety restrictions and designated smoking areas, but these were not adhered to, and multiple staff failed to follow the policy over several shifts and days.
Incomplete POLST Forms in Medical Records
Penalty
Summary
The facility failed to ensure that POLST (Physician Orders for Life-Sustaining Treatment) forms were completed accurately in the electronic medical records for two of seventeen sampled residents. Specifically, the POLST forms for these residents were missing the required date next to the provider's signature, which is necessary for the validity of the form and the associated physician order. One resident's POLST indicated a preference for CPR and full treatment, while the other indicated no CPR and selective treatment, but both forms lacked the provider's signature date. A hard copy of one resident's POLST form also showed the same omission. Interviews with staff revealed that POLST forms are reviewed by nursing staff during admission and annually at care conferences, but not at every quarterly care conference. There is no designated nurse responsible for overseeing or reviewing the completion of POLST forms for new admissions; this task is typically handled by the admitting nurse. The provider who completes the POLST form is expected to review it. Facility policies require that advance directives, including POLST forms, be obtained, maintained in the medical record, and communicated to the attending physician and during care planning meetings.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean, sanitary, and homelike environment for two residents. One resident's bathroom was found on multiple occasions to have colored stains and dark brown crusted debris around the edges of the toilet and along the walls, as well as a caked and dried dark yellow substance on the floor that appeared to be urine. A strong odor of urine was consistently present. Despite daily cleaning assignments reported by housekeeping staff, the unsanitary conditions persisted over several days, and staff interviews confirmed that deep cleaning had not been performed in the affected bathroom since the staff member began working at the facility. Additionally, another resident's room had a peeling hole in the wall below the heater near the sink, with paint cracking and lifting from the edges. The resident reported that the hole had been present since admission and appeared to be getting larger, with no attempts by staff to repair or cover it. Facility policy required regular cleaning of housekeeping surfaces and prompt cleaning of body fluid spills, but these standards were not met in the observed cases.
Failure to Develop Timely Baseline Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to develop a baseline care plan with pertinent, condition-specific information to address a resident's needs within 48 hours of admission. Observations showed that the resident was using a nasal cannula connected to an oxygen concentrator set at two liters, as ordered for a respiratory condition related to COPD. However, review of the resident's care plan indicated that the initiation date for supplemental oxygen was not until several days after admission, and there was no evidence that the baseline care plan included the necessary instructions for oxygen therapy within the required 48-hour timeframe. Interviews with staff revealed uncertainty regarding the process for creating and locating the baseline care plan, as well as whether oxygen treatment information was included in the plan. Facility policy requires that a baseline plan of care be developed within 48 hours of admission to address immediate health and safety needs, including essential healthcare information. The lack of timely and complete documentation in the baseline care plan resulted in the deficiency identified by surveyors.
Failure to Timely Update Care Plan for Significant Weight Loss
Penalty
Summary
The facility failed to update the care plan in a timely manner for a resident who experienced significant weight loss. The resident's weight dropped from 143 pounds to 131 pounds, representing an 8.39% loss over 26 days. Despite this notable change, the care plan was not updated to include interventions to address the weight loss until several months later. The resident was observed to be pacing and unable to sit still due to skin irritation, and reported not eating well because of a rash. A nurse practitioner's note confirmed the resident was not eating or drinking adequately due to being focused on the skin condition. Although a nutritional supplement was ordered, the care plan did not reflect this intervention or include strategies to address the resident's decreased intake related to his skin issues and pacing. Staff interviews revealed that each discipline was responsible for updating their respective sections of the care plan, and updates were typically made after the MDS assessment reference date was added. However, the care plan was not promptly revised to address the resident's acute weight loss or the factors contributing to decreased intake. The lack of timely care plan updates resulted in a failure to implement appropriate interventions to address the resident's nutritional needs during the period of significant weight loss.
Resident Abuse and Neglect by Facility Staff
Penalty
Summary
The facility failed to protect a resident from physical and psychosocial abuse by staff, resulting in skin injuries, fear, and sleep disturbances. The incident involved a resident who was forcibly woken up and undressed by a nurse and a CNA, despite her resistance and verbal objections. The staff insisted on taking her to the dining room against her will, leading to a physical struggle that left the resident in shock and fear for several nights. The resident, who was cognitively intact and had a history of osteoarthritis pain, was accustomed to eating in her room. However, staff decided to move her to the dining room for closer monitoring after a fall. Despite the resident's resistance, staff maintained a firm approach, transferring her to a stationary chair to prevent her from leaving the dining room. Surveillance footage confirmed the resident's resistance and the staff's forceful actions. The facility's investigation revealed that multiple staff members were involved in the incident, yet none intervened or reported the abuse immediately. The resident was left with bruises and emotional distress, fearing the return of the staff involved. The facility reported the incident to the State Survey Agency and suspended the staff, but the investigation failed to address the root causes or prevent future occurrences.
Failure to Honor Resident's Dining Preferences
Penalty
Summary
The facility failed to honor a resident's dining preferences, impacting her right to self-determination. The resident, who preferred to eat meals in her room due to personal reasons related to her husband's past experience in the dining room, was forced to go to the dining room against her wishes. This incident occurred when a CNA and a nurse entered her room, woke her up, and insisted she go to the dining room despite her protests. The resident expressed her discomfort and preference to eat in her room, but staff members did not respect her choice. Staff members involved in the incident were aware of the resident's preference to eat in her room due to her emotional distress associated with the dining room environment. Despite this knowledge, staff member I decided to take the resident to the dining room for breakfast, citing concerns about her safety after a reported fall. The staff maintained a firm approach to get the resident ready for breakfast, disregarding her resistance and preference to remain in her room. Surveillance footage confirmed that the resident was taken to the dining room against her will. The footage showed the resident attempting to leave the dining room and resisting staff efforts to transfer her to a stationary chair. The resident's care plan indicated she was cognitively intact and independent in eating, with a preference to eat in her room. The facility's actions violated the resident's right to self-determination and choice, as outlined in her care plan.
Failure to Update Care Plan for Grieving Resident
Penalty
Summary
The facility failed to review and update a comprehensive care plan for a resident who experienced grief and sorrow following the recent death of her husband. During an observation and interview, the resident expressed fear about a new roommate moving in and shared her emotional distress over her husband's passing. The resident noted that facility staff had not addressed her grief or concerns about a new roommate. A staff member acknowledged providing emotional support to the resident but was unaware that the care plan had not been updated. The facility's social services director had recently left, and the staff member was temporarily fulfilling that role. A review of the resident's care plan, last revised two months prior, showed no focus area or interventions related to grief, loss, or loneliness.
Failure to Provide Grief Support to Resident
Penalty
Summary
The facility failed to provide adequate social services to a resident who was grieving the recent loss of her spouse. During an observation and interview, the resident expressed fear about the possibility of a new roommate moving into the room she shared with her late husband. She was visibly emotional, with tears running down her face, and stated that the facility staff had not addressed her concerns or provided any grief support since her husband's passing. The resident's care plan, last revised in August 2024, did not reflect any updates or interventions to address her emotional distress following her husband's death. A staff member acknowledged providing emotional support to the resident but admitted that these interactions were not documented in the electronic medical record (EMR). The staff member also mentioned that the resident's family was involved in her care and intended to consult them about appropriate services for the resident. However, the facility did not timely identify or address the resident's emotional distress, and the social services department failed to implement necessary interventions to help the resident cope with her grief and loneliness.
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Illustrative
What surveyors actually found near you
We read the 20 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Glendive
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Glendive Medical Center N H | 0.9 mi | — | 20 | 0 |
| Wibaux County Nursing Home | 25.6 mi | — | 7 | 1 |
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