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 Montana Veterans Home N H during CMS and state inspections, most recent first.
Multiple residents with cognitive impairment engaged in sexual activities without proper assessment of their ability to consent, while staff and administration failed to intervene or implement safeguards. Care plans lacked individualized interventions, and incidents were not reported as required. Additionally, a resident sustained a skin tear due to physical abuse by a staff member during medication administration.
Staff failed to recognize, investigate, or report incidents of sexual activity involving cognitively impaired residents who could not consent, did not implement protective measures, and did not notify required authorities or complete behavioral assessments, resulting in unaddressed allegations of sexual abuse.
Care plans for two residents with sexual behaviors did not include necessary information or interventions regarding consent or protection of others. One resident's care plan lacked measurable goals and omitted safety considerations, while another's plan failed to address sexual behaviors or consent, aside from caregiver gender preference. Updates to care plans were not made until after an Immediate Jeopardy situation was identified.
The facility failed to provide necessary Medicare Part A coverage notices to residents ending skilled services. Forms were incomplete or lacked signatures, and staff were not well-versed in the process. The facility also lacked a specific policy for beneficiary notices.
Failure to Prevent and Address Sexual and Physical Abuse Among Cognitively Impaired Residents
Penalty
Summary
The facility failed to recognize, prevent, and appropriately respond to incidents of sexual abuse and neglect among residents, particularly those with cognitive impairments. Multiple staff interviews and record reviews revealed that several residents, many with moderate to severe cognitive impairment as indicated by low BIMS and SLUMS scores, engaged in sexual activities with other residents who were unable to consent. Staff were aware of these activities but did not assess the residents' capacity to consent, and in some cases, relied on family or POA consent rather than the residents' own ability to make decisions. Documentation showed repeated incidents where residents with severe cognitive impairment were involved in sexual acts, and staff either did not intervene or were instructed to allow the acts to continue if already in progress. The facility's administrative staff, including the Administrator and DON, were aware of ongoing sexual activities but did not implement measures to ensure resident safety or comply with facility policies regarding abuse and neglect. Care plans lacked individualized information about sexual behaviors, preferences, risks, or interventions, and there was no formal process to assess or address the ability of residents to consent to sexual activity. Staff did not conduct behavioral or cognitive assessments following incidents, and events were not reported to the State Survey Agency as required. The facility's abuse and neglect policy was found to be insufficient, lacking specific guidance on alleged or potential sexual abuse, and staff training did not adequately address these issues. Additionally, the facility failed to protect a resident from physical abuse by a staff member, resulting in a skin tear when a staff member forcefully attempted to retrieve medication from the resident's hand. The incident was documented, and the staff involved were removed from resident care. However, the overall failure to recognize, assess, and prevent abuse and neglect, particularly in relation to sexual activity among cognitively impaired residents, constituted a significant deficiency and led to an Immediate Jeopardy finding.
Failure to Investigate and Report Alleged Sexual Abuse Among Cognitively Impaired Residents
Penalty
Summary
The facility failed to thoroughly investigate and respond to allegations and incidents of sexual abuse involving three residents who were identified as vulnerable and unable to consent to sexual activity due to cognitive deficits. Staff observed incidents where one resident was found unclothed with another resident performing oral sex, and another incident where a resident's pants and brief were found open in the presence of another resident. Despite staff being aware of these events, they did not identify them as potential abuse, did not initiate protective measures, and did not conduct behavioral assessments or root cause analyses related to the incidents. The facility did not document or report these events as required, failing to notify law enforcement, Adult Protective Services, or the State Survey Agency. No facility-reported incidents or investigations were provided for review, and the facility did not follow abuse reporting requirements or thoroughly investigate the events. Staff interviews confirmed a lack of recognition of the incidents as abuse and a lack of appropriate response, including not ensuring the safety of residents who were unable to consent to sexual activity.
Failure to Address Sexual Behaviors and Consent in Care Plans
Penalty
Summary
The facility failed to ensure that care plans for two residents addressed sexual behaviors and interactions, including the ability to consent and interventions to protect other residents. One resident had a documented history of sexual behaviors toward others, but the care plan lacked information on whether the resident posed a risk to themselves or others, did not specify measurable goals, and omitted interventions related to the safety of other residents or the resident's capacity to consent to sexual activity. The care plan only stated a goal of fewer episodes without defining what constituted an episode or how progress would be measured. For another resident, staff confirmed the individual was able to consent to sexual activity, but the care plan did not include any information or interventions regarding sexual behaviors or consent, aside from a preference for female caregivers under ADLs. The facility did not update care plans to address these issues until after an Immediate Jeopardy situation was identified, and only after a plan was developed to remove the immediacy of the situation.
Failure to Provide Required Medicare Coverage Notices
Penalty
Summary
The facility failed to provide the necessary forms to residents who were ending skilled Medicare Part A services, which are required to allow residents or their representatives to accept, appeal, or agree to pay privately for ongoing services. Specifically, the facility did not complete the Advance Beneficiary Notice (ABN) and Notice of Medicare Non-Coverage (NOMNC) forms for three residents. These forms were either not filled out completely or lacked the necessary signatures and documentation of notification. For instance, the ABN forms for the residents did not have the options for accepting, appealing, or paying out of pocket selected, and there were no signatures or dates from the representatives indicating they received the notices. Interviews with staff revealed that the facility's process for handling these forms was inadequate. Staff member L stated that she would notify the residents' representatives by phone and then mail the forms for signatures, but the forms were rarely returned signed. Additionally, staff member B acknowledged that the facility did not have a high skilled care census and was not well-versed in the NOMNC and ABN form process. The facility also lacked a specific policy for beneficiary notices, contributing to the incomplete handling of these forms.
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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 Columbia Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Whitefish Care And Rehabilitation | 7 mi | — | 33 | 0 |
| Kalispell Rehabilitation And Nursing Llc | 12 mi | — | 40 | 0 |
| Immanuel Skilled Care Center | 12.2 mi | — | 11 | 0 |
| Brendan House | 12.3 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.