Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
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 Sweet Memorial Nursing Home during CMS and state inspections, most recent first.
A deficiency was cited for failing to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to inadequate safeguards and oversight.
The facility did not report initial allegations or final summaries of abuse, neglect, or misappropriation of property to the State Survey Agency within required timeframes. Incidents included delayed reporting of suspected drug diversion, physical altercations between residents, and unexplained bruising, with staff confirming that notifications to authorities and final summaries were not made promptly.
The facility did not thoroughly investigate multiple alleged abuse incidents and unexplained bruising among residents. In several cases, altercations such as slapping, choking, and physical aggression were not followed by interviews, root cause analysis, or preventive interventions. Documentation was incomplete, and staff relied only on event reports without conducting further investigation.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
The facility did not maintain a secure or detailed system for tracking controlled substances, allowing significant quantities of medications to go missing for several residents. A nurse continued to access and sign for narcotics for months after discrepancies were first identified, and the consultant pharmacist was not promptly involved in the investigation or monitoring. The facility's policy for immediate notification and reconciliation was not followed, leading to delayed reporting to authorities.
Two residents did not receive appropriate social services interventions after experiencing abuse from another resident, including one who felt isolated and vulnerable after being moved and another who was left upset and crying. Staff failed to assess or document the residents' psychosocial well-being following these incidents, and required depression assessments were not completed as scheduled.
The facility failed to investigate resident-to-resident altercations involving three residents. A staff member suspected an injury was due to an unwitnessed altercation, but the report did not explore this. In another case, two incidents of physical altercations were reported, lacking observations, interviews, and corrective actions. A staff member downplayed the incidents as mistreatment due to cognitive impairments.
The facility failed to oversee personal refrigerators in resident rooms, affecting three residents. Observations revealed missing temperature gauges and unlabeled food items, with one refrigerator having a thick ice buildup. Staff interviews showed unclear responsibility for refrigerator management, and the facility could not provide a relevant policy.
The facility failed to update care plans for several residents, including the discontinuation of a catheter, oxygen use, and bed rails. Additionally, a resident and their representative were not involved in the care planning process. Staff acknowledged the need for improvements in care planning.
The facility had a medication error rate of 8.16%, exceeding the acceptable limit of 5%. Errors included incorrect dosages of gabapentin and vitamin B-12 for two residents, and a failure to document held medications for another resident due to low blood pressure. These issues were identified during observations and interviews with staff.
A staff member failed to perform hand hygiene between administering medications to multiple residents. Despite touching residents' eating utensils and dishes, the staff member did not wash hands between residents, believing it unnecessary as she did not touch the pills directly. Upon interview, the staff member acknowledged the oversight.
A resident with severe cognitive impairment was struck twice by another resident who was having difficulty adjusting to the facility. The incidents were not classified as abuse by staff due to cognitive impairments and lack of injuries, but the facility failed to identify triggers or protect the resident from further abuse.
A facility failed to provide a baseline care plan to a resident or their representative. The resident reported not receiving any information about the care plan, and the representative confirmed the lack of communication. A review of the medical record showed no evidence of the care plan being provided, and no documentation was submitted upon request during the survey.
A facility failed to create a comprehensive care plan for a resident with broken and decayed teeth. Despite the resident's assessment indicating dental problems, the care plan lacked documentation or planning for dental services. A staff member confirmed that dental issues should be included in care planning, highlighting a lapse in the facility's process.
A resident experienced discomfort due to a poorly fitting wheelchair and the positioning of an oxygen tank. Despite informing CNAs, there was a lack of communication among staff, and the resident was not evaluated for proper wheelchair positioning during her physical therapy initial examination.
A resident experienced pain due to a callus on her left foot, which the facility failed to address appropriately. Despite a physician's order for a podiatry consult dated in September, the appointment was not scheduled. The resident reported ongoing pain, and an observation confirmed the presence of the callus. A staff member acknowledged that the consult had not been scheduled.
A facility failed to comply with the 14-day limit on as-needed antipsychotic medications for a resident with dementia, anxiety, and depression. The resident received olanzapine without the required physician evaluation and reordering every 14 days. Staff interviews revealed a misunderstanding of the policy and reliance on the EHR system to manage medication discontinuation, leading to a deficiency in medication administration practices.
The facility failed to discard expired Half and Half cartons in the walk-in cooler. Observations on consecutive days revealed cartons past their use by date, and a staff member confirmed that these should have been discarded, indicating a lapse in food safety protocols.
The facility failed to document and offer pneumococcal vaccines to two residents. One resident's history showed no record of receiving any pneumococcal vaccines, and the staff member responsible for immunizations could not provide information on the offering or declination of these vaccines. Another resident's history showed receipt of the Prevnar 13 vaccine but lacked documentation for Prevnar 20 or Pneumovax 23. The staff member was unable to explain the absence of these records.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight. Specific details about the actions or inactions leading to the deficiency, as well as information about the residents involved or their conditions at the time, are not provided in the report. The deficiency centers on the lack of comprehensive protection for residents against abuse and neglect, as required by regulatory standards.
Failure to Timely Report Abuse, Neglect, and Misappropriation Incidents
Penalty
Summary
The facility failed to report initial allegations and final summaries of abuse, neglect, or misappropriation of property to the State Survey Agency within the timelines required by federal regulations for multiple residents. In one instance, a potential drug diversion involving resident medications was identified, but the facility delayed reporting the suspicion to the State Survey Agency and local law enforcement, choosing instead to complete an internal medication audit first. The initial report to the State Survey Agency was not made until several weeks after the investigation began, and law enforcement and the board of nursing were not contacted until even later. Additional incidents involved delayed reporting of physical altercations between residents and a case of unexplained bruising. In several cases, the initial reports or final summaries were submitted days after the events occurred, exceeding the required reporting timelines. Interviews with staff confirmed the delays and revealed a lack of immediate action in notifying authorities as required. The facility did not provide timely final summaries for several incidents, and in one case, no further investigation was conducted into the cause of a resident's bruising.
Failure to Investigate Alleged Abuse and Unexplained Injuries
Penalty
Summary
The facility failed to thoroughly investigate multiple alleged abuse incidents and unexplained injuries among residents. In one case, a resident was found with bruises of unknown origin on her foot, thigh, and calf, but there was no clear documentation in the medical record describing the bruises or their causes. Staff acknowledged that no further investigation was conducted beyond noting that the resident bruised easily, and no interventions or root cause analysis were completed. Additionally, several resident-to-resident altercations were not adequately investigated. These included incidents where one resident slapped, punched, or choked other residents, and another incident where a resident sprayed alcohol and sanitizer on another's face. The facility's documentation did not include interviews with involved parties, root cause analysis, or implementation of interventions to prevent recurrence. Progress notes often lacked details about the events, contributing factors, or steps taken to protect residents. Staff interviews revealed that the facility relied solely on event reports and risk management forms for investigations, with no further investigative actions taken.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Secure and Monitor Controlled Substances Resulting in Drug Diversion
Penalty
Summary
The facility failed to maintain an adequate system for storing and monitoring controlled substances, resulting in missing medications for multiple residents. The investigation revealed that the facility used loose-leaf, unnumbered paper in a binder to track controlled drugs, which did not correspond to the medication cards and allowed for easy removal of both medication and records. This lack of a secure and detailed tracking system enabled discrepancies to go undetected, and several residents were found to be missing significant quantities of their prescribed medications, including Seroquel, Alprazolam, Mirtazapine, Tramadol, and Norco. The initial missing medication was identified when a resident ran out of Seroquel 14 days earlier than expected, and further review uncovered additional losses affecting other residents. Staff interviews indicated that a specific nurse was the common factor in the missing medication cases, yet this nurse continued to work and sign for narcotics for over two months after the first discrepancy was identified. The consultant pharmacist was not promptly informed of the diversion and did not participate in the investigation or monitor narcotics reconciliation logs. The facility's policy required immediate notification and monitoring in the event of discrepancies, but these procedures were not followed, and the local police and board of nursing were not contacted until months after the initial discovery of missing medications.
Failure to Provide Social Services After Abuse Incidents
Penalty
Summary
The facility failed to provide adequate medically-related social services to support the psychosocial well-being of two residents following incidents of abuse by another resident. One resident reported feeling isolated after being moved to a different area of the building due to repeated incidents involving another resident, including having hand sanitizer squirted in her eyes, which resulted in ongoing eye issues and feelings of vulnerability. Despite these events, there were no documented interventions or follow-up by social services to address her emotional well-being, and required assessments such as the PHQ-9 were not completed as scheduled. Another resident was observed crying and upset after being physically grabbed by the same resident, but staff attributed her distress to her usual behavior and did not assess or document her psychosocial or emotional health following the incident. Progress notes lacked information on interventions to prevent further abuse or to address the resident's emotional response to the event. These actions and omissions demonstrate a failure to ensure residents' highest practicable level of physical and psychosocial well-being through appropriate social services interventions.
Failure to Investigate Resident Altercations
Penalty
Summary
The facility failed to thoroughly investigate resident-to-resident altercations, alleged to be abuse, involving three residents. In one incident, a staff member reported an injury of unknown origin on a resident's forehead, suspecting it was not from a fall due to the resident's inability to get back into her wheelchair without assistance. The staff member believed the injury might have resulted from an unwitnessed altercation with her roommate, who was known to be aggressive. However, the facility's report did not explore this possibility or document the resident's room change for safety. In another case, two incidents of physical altercations between two residents were reported, where one resident was seen punching and hitting the other. The investigations lacked observations of the aggressor's interactions with others, interviews with residents and staff, and documentation of corrective actions to protect the victim and other vulnerable residents. A staff member involved in the investigation downplayed the incidents as mistreatment rather than abuse due to the cognitive impairments of the residents involved.
Lack of Oversight for Personal Refrigerators in Resident Rooms
Penalty
Summary
The facility failed to provide proper oversight for the use of personal refrigerators in residents' rooms, affecting three sampled residents. During observations, it was noted that the personal refrigerators lacked temperature gauges, which are necessary to ensure food is stored at safe temperatures. Additionally, there were multiple instances of food items being stored without labels or dates, and one refrigerator had a thick layer of ice built up inside and outside the freezer compartment. These deficiencies were observed in the personal refrigerators of three residents, indicating a lack of consistent management and oversight. Interviews with facility staff revealed a lack of clarity and responsibility regarding the management of personal refrigerators. A staff member from the housekeeping department indicated that the housekeeping supervisor was responsible for managing the refrigerators, but there was no clear protocol for when the supervisor was absent. Another staff member was unaware of how many residents had personal refrigerators or how they were managed for food safety. The facility was unable to provide a policy on personal refrigerators when requested, further highlighting the oversight issues.
Deficiencies in Care Plan Updates and Resident Involvement
Penalty
Summary
The facility failed to update and revise comprehensive care plans for several residents, leading to deficiencies in care documentation and planning. Resident #18's care plan did not reflect the discontinuation of a Foley catheter, despite a physician's order to begin bladder training and remove the catheter. Additionally, the care plan for resident #15 lacked details on the administration of oxygen, which was observed to be improperly used, and the resident experienced difficulty breathing without it. Furthermore, the care plans for residents #12, #18, and #27 did not document the use of bed rails or their intended purpose, indicating a lack of comprehensive care planning. The facility also failed to involve resident #20 or their representative in the care planning process. Resident #20 reported not being asked about their care plan, and their representative confirmed no communication from the facility regarding the plan of care. The electronic health record for resident #20 lacked documentation of their involvement in care planning, and no care plan meeting was held after the development of the comprehensive care plan. Staff member B acknowledged the need for updates and improvements in care plans, highlighting a gap in the facility's care planning process.
Medication Administration Errors and Documentation Issues
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a calculated error rate of 8.16%. This deficiency was observed in three residents. For one resident, a staff member incorrectly administered gabapentin by using a 1 ml syringe and filling it to the 0.1 ml line instead of the required 1 ml, leading to an underdose. The error was realized and corrected after the initial administration. Another resident was supposed to receive 5000 mcg of vitamin B-12 but was given only 500 mcg due to the staff member administering a single tablet of 500 mcg instead of the required dosage. Additionally, a staff member held two medications for a resident due to a systolic blood pressure reading below 110 mmHg, as per the facility's standing order. However, the staff member failed to document that the medications were held, and the Medication Administration Audit Report inaccurately showed that the medications were administered. This discrepancy was acknowledged by the staff member during a follow-up interview.
Failure in Hand Hygiene During Medication Administration
Penalty
Summary
The facility staff failed to perform proper hand hygiene during medication administration for three residents. During observations in the main dining room, a staff member was seen administering medications to residents without performing hand hygiene between each resident. Specifically, the staff member did not wash hands after administering medications to one resident before preparing medications for another. This occurred despite the staff member touching residents' eating utensils and dishes during the medication pass. When interviewed, the staff member acknowledged that she should have performed hand hygiene between residents but believed it was unnecessary since she did not touch the pills directly.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a vulnerable resident from physical abuse by another resident. Resident #30, who had severe cognitive impairment and exhibited wandering behaviors, was struck on two separate occasions by resident #29. The first incident occurred on 10/17/24, when resident #29, who was having difficulty adjusting to the new environment, struck resident #30 on the right shoulder. The facility's investigation did not identify any possible triggers for the abuse or how resident #30 would be protected from further incidents. Additionally, resident #30's care plan did not address the increased risk of abuse due to her wandering behaviors. A second incident occurred on 10/24/24, when resident #29 hit resident #30 on the head and pulled her hair. Despite the facility's policy to prevent abuse, the care plan for resident #29 did not identify resident #30 as a potential target of abusive interactions. Staff members involved in the investigations of both incidents did not classify them as abuse, citing the residents' cognitive impairments and lack of injuries. However, the facility's failure to protect resident #30 from further abuse was evident, as no effective measures were implemented to prevent recurrence.
Failure to Provide Baseline Care Plan to Resident
Penalty
Summary
The facility failed to provide a copy of the baseline care plan to a resident or the resident's representative, as required. During an interview, the resident stated she did not receive any information or communication regarding her baseline care plan from the facility. Additionally, the resident's representative confirmed that they had not received any communication from the facility about the baseline care plan. A review of the resident's medical record showed no documentation or evidence that the baseline care plan was provided to either the resident or the representative. Despite a request for documentation regarding the provision of the baseline care plan, no information was provided before the end of the survey.
Failure to Address Dental Issues in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, resident-centered care plan for a resident with dental issues. During an observation, the resident was noted to have broken teeth in her lower jaw. The Social Service History & Initial Assessment documented that the resident had dental problems, specifically broken and decayed teeth. Despite this assessment, the resident's care plan did not include any documentation or planning related to her dental issues or the provision of dental services. A staff member confirmed that such issues should be care planned, indicating a lapse in the facility's care planning process.
Failure to Assess Wheelchair Positioning Needs
Penalty
Summary
The facility failed to identify and assess the wheelchair positioning needs for a resident, leading to discomfort due to a poorly fitting wheelchair. The resident reported that her wheelchair was too narrow and that the oxygen tank positioned on the back of her wheelchair caused her discomfort. Despite informing CNAs about the pain, there was a lack of communication and awareness among staff members regarding the issue. One staff member acknowledged being informed by the resident about the pain and had notified the maintenance department, but another staff member was unaware of any wheelchair maintenance concerns. Additionally, a review of the resident's physical therapy initial examination revealed that she was not evaluated for proper wheelchair positioning.
Failure to Provide Proper Foot Care for Resident
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, resulting in the resident experiencing pain due to a callus on her left foot. The resident reported on December 2nd that she had been experiencing pain from the callus and that the facility had not addressed it. A progress note from September 6th indicated the presence of the callus and mentioned that the foot clinic had been treating it, with the resident expressing a desire for a podiatrist to evaluate the residual callus. A physician's order dated September 9th called for a podiatry consult for the callus, but the appointment was not scheduled. On December 4th, an observation confirmed the presence of the callus, and a staff member stated that the consult had not been scheduled despite the doctor's order.
Failure to Reorder PRN Antipsychotic Medication Every 14 Days
Penalty
Summary
The facility failed to ensure compliance with the 14-day limit on as-needed antipsychotic medications for a resident diagnosed with dementia, anxiety, and depression. The resident was prescribed olanzapine 2.5 mg twice daily as needed for agitation, but the order did not specify a duration or stop date. The resident's medication administration records (MAR) showed multiple doses were administered over several months without the required physician evaluation and reordering every 14 days. Despite a pharmacy progress note indicating the need for reordering, the medication was not appropriately managed, leading to a deficiency in medication administration practices. Interviews with facility staff revealed a lack of adherence to the policy requiring physician evaluation and documentation for the continuation of as-needed psychotropic medications. Staff members were aware of the 14-day limit but failed to ensure the medication was reordered as required. One staff member mistakenly believed the electronic health record system would automatically discontinue the medication, while another did not address the need for reordering in the monthly medication regimen review. The facility's policy on psychotropic medication use was not followed, resulting in the deficiency.
Failure to Discard Expired Dairy Products
Penalty
Summary
The facility failed to properly manage the storage of dairy products, specifically Half and Half, in their walk-in cooler. During observations on two consecutive days, cartons of Half and Half with a use by date of 12/3/24 were found on the top shelf to the right of the entrance. On 12/4/24, 11 cartons were observed, and on 12/5/24, eight cartons remained. During an interview, a staff member acknowledged that dairy products should have been discarded by their use by date, indicating a lapse in adherence to food safety protocols.
Failure to Document and Offer Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure proper screening and documentation for pneumococcal vaccinations for two residents. Resident #27's vaccination history did not indicate receipt of any pneumococcal vaccines, and staff member J, responsible for immunizations for two months, could not provide information on whether the vaccines were offered, received, or declined since the resident's admission. Similarly, resident #16's vaccination history showed receipt of the Prevnar 13 vaccine but lacked documentation of the Prevnar 20 or Pneumovax 23 being offered, given, or declined. Staff member J was unable to explain the absence of these records.
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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 Chinook
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Northern Montana Care Center | 20.5 mi | — | 0 | 0 |
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