Crest Nursing Home

Lawyers Representing Injured Residents of Crescent Nursing Home

The state of Montana and the Centers for Medicare and Medicaid Services (CMS) regularly conduct unannounced surveys and investigations of every nursing facility statewide. Thoroughly evaluating these facilities help identify horrific deficiencies and serious violations that could cause harm or have caused injuries to one or more residents.

Nursing homes with the most egregious deficiencies are typically placed on a federal watch list under the Medicare and Medicaid program. Additionally, some are designated a Special Focus Facility (SFF) and must undergo additional surveys and investigations throughout the year until regulators are satisfied that significant improvements made by the nursing staff and administration are permanent.

In recent months, nursing home regulators designated Crest Nursing Home as a Special Focus Facility. The Home was given the opportunity to revise their policies and procedures and make corrections to improve the substandard care given to the residents. Likely, the facility will remain on the watch list for many years to come or lose their contract to provide care and services to funded Medicare and Medicaid patients.

Crest Nursing Home

This Long-Term Care Center is a “for-profit” 103-certified bed Home providing cares to residents of Butte and Silver Bow County, Montana. The Facility is located at

3131 Amherst Ave.
Butte, MT 59701
(406) 494-7035

In addition to providing long-term skilled nursing care, the facility also offers:

  • Stroke care and rehabilitation
    • Pain management
    • Alzheimer’s and dementia care
    • Diabetic care
    • Joint replacement therapy
    • Dialysis care
    • Cardiac care
    • Behavioral care
    • Palliative and hospice care
    • And of life care
    • Medication management
    • Complex wound care
    • Restored of care
    • Short-term rehabilitation
    • Memory care
    • Intravenous therapy
    • Postoperative care
    • Non-invasive mechanical ventilation
    • Cognitive improvement
    • Tracheostomy
    • Feeding tubes
    • Discharge planning

More than $175,000 of Monetary Penalties

Both federal and state nursing home regulatory agencies issue monetary penalties to ensure that the nursing facility makes immediate improvements to the level of care they provide and the policies and procedures they follow. Within the last three years, Crest Nursing Home received a fine of $178,671 on May 4, 2015. On the same date, Medicare denied a request by the facility for payment for services rendered. Additionally, state surveyors investigated seven formal complaints that resulted in a citation.

Current Nursing Home Resident Safety Concerns

Both the State of Montana and the Centers for Medicare and Medicaid Services routinely update the national Medicare.gov website with information gathered by investigators and surveyors. This data contains facts on opened investigations, safety concerns, incident inquiries, health violations, dangerous hazards, and filed complaints. Additionally, the site provides a star rating summary system as an analysis tool used by families to compare the level of care every facility provides in their community.

Currently, Crescent Nursing Home maintains a much below average one out of five stars overall ranking compared to all other nursing homes nationwide. This ranking includes one out of five stars for health inspections, three out of five stars for staffing, and one out of five stars for quality measures. The serious concerns about the facility listed below are gathered from publicly available information.

  • Failure to Review or Revise the Resident’s Care Plan after a Major Change in the Resident’s Condition

In a summary statement of deficiencies dated September 7, 2017, the state surveyor noted the facility’s failure “to complete a significant change [in a resident’s] Minimum Data Set (MDS) assessment.” This change shoulld have occurred “after [the resident experienced a change in their medical condition] with an increase in assistance needed, pain and for weight.”

The state investigator reviewed a resident’s August 3, 2017, Discharge Progress Note that revealed the resident “had fallen and fractured her hip. She was sent to the hospital, declined surgery, and returned to the facility.” A review of the resident’s Nursing Charting Note dated August 6, 2017 “shows the resident was offered dinner, with complaints of pain.” The Nursing Charting Note dated the following day “shows the resident complained of her right leg hurting. Backboards inserted behind calves to hold the pillow in.”

The document revealed that “after dinner, the daughter came up and stated that her mother was still in pain. Pillows place between legs.” The Nursing Charting Note dated August 10, 2017, revealed that “the resident was screaming, get me a pain pill NOW.” A review of the resident’s Annual Weight Report dated July 10, 2017 “showed a weight of 91 pounds.” The resident’s records noted that one month later on August 7, 2017, showed a readmittance to the facility “weight of 112 pounds” revealing the resident had “an 18% significant and severe weight gain in one month.”

A staff member interviewed on the afternoon of September 6, 2017 “stated she did not know why a significant change had not been completed. The staff member responsible for the decisions no longer worked at the facility.”

In a summary statement of deficiencies dated September 7, 2017, the state investigator noted the facility had failed “specifically, to notify Adult Protective Services in the facility abuse reporting policy for all residents in the facility.” The investigator reviewed the facility’s July 2017 Resident Safety Abuse Policy that “failed to show documentation that the Adult Protective Services was to be notified of all suspected abuse violations.”

A member of the staff was interviewed on the early morning of September 7, 2017, stated that “a corporate office personnel updated the policy for abuse and had meant to add the required reporting to Adult Protective Services in the policy, but had forgotten to add it.”

  • Failure to Ensure That Every Resident Receives an Accurate Assessment by Qualified Health Professional

In a summary statement of deficiencies dated September 7, 2017, the state surveyor made a notation that the facility had failed “to code the Minimum Data Set (MDS) correctly for communication [for a resident].” It was also noted that the facility failed to accurately reflect the cognitive status and ability to communicate [for a different resident].”

For both residents, observations and interviews conducted in September 2017 revealed that they were able to discuss their cares and were understood. However, a review of a resident’s “quarterly MDS” dated June 15, 2017, showed the resident was sometimes understood, and sometimes understands.” The resident’s Brief Interview for Mental Status (BIMS) revealed that the resident “had severely impaired cognition. However, she was able to complete an Interview, with no signs and symptoms of depression. She was coded as rarely understood, for pain review, and it was not completed by the resident.”

This resident was documented as having “cognitive status [that fluctuated].” During an interview on the morning hours of September 6, 2017, a staff member “stated that the facility had an MDS nurse who did not leave the office.”

  • Failure to Provide Medical Cares and Services at a Level That Meets Minimum Standards of Quality

In a summary statement of deficiencies dated September 7, 2017, there was a notation made in the surveyed the facility had failed to “ensure a catheter drainage bag was lower than the level of the bladder.” The facility also “failed to provide education for a resident regarding the importance of keeping the catheter bag below the level of the bladder, and maintaining septic storage of the drainage bag to reduce complications from urinary return resulting in urinary tract infections, obstruction, and pain.”

The deficiency by the nursing staff resulted in a resident experiencing “recurrent urinary tract infections, urinary obstruction, and pain. These deficient findings had the potential to affect all residents with indwelling catheters.”

As a part of the investigation, the state surveyor reviewed the facility’s policy and procedure title Catheter Management that read in part:

“Purpose. All residents receive the appropriate care and services to prevent catheter-associated urinary tract infections.”
Unobstructed flow should be maintained to achieve a free flow of urine, the catheter and collecting two should be kept from kinking.”
“The collecting bag should be emptied regularly using a separate collecting container for each resident; poorly functioning or obstructed catheter should be kept below the level of the bladder, and not resting on the floor.”

In a summary statement of deficiencies dated September 7, 2017, it was noted that the facility had failed to “ensure an antipsychotic medication had an appropriate indication for use.” The investigator noted that a review “of a resident’s clinical record did not show an adequate indication for the use of an antipsychotic. The resident’s September 2017 Medication Administration Record revealed that “monitoring for side effects and behaviors related to an antipsychotic.”

The investigator interviewed a staff member on the morning of September 6, 2017, who stated that “she did not know what behaviors antipsychotic medication was given for.” That staff member “stated the medication was given on the night shift.” Two additional staff members were interviewed on the morning of September 7, 2017, who stated that the resident’s “targeted behaviors for the antipsychotic were lashing out at a family, crying, unrealistic expectations, hiding objects, and withdrawal.” Both staff members had “sent a fax to [the resident’s] physician to address the issue.”

  • Failure to Ensure That the Nursing Home Area Remained Free from Accident Hazards

In a summary statement of deficiencies dated September 7, 2017, the state investigator noted that the facility had failed to “prevent multiple falls, one with a hip fracture, and failed to implement intervention falls for [four residents at the facility].” The investigator also noted that the facility had “failed to assess the mobility status of a resident with a nonsurgical hip fracture for safety and comfort.”

In one incident concerning the deficiency, a review was made of the facility’s Fall Log over the previous year that revealed a resident “had 11 falls from November 11, 2016, through August 3, 2017.” Documented incident reports revealed “no incident reports for the falls on November 11, 2016, December 25, 2016, January 6, 2017, March 12, 2017, March 16, 2017, April 24, 2017 [two falling incidents], and July 12, 2017.”

The documented Incident Report dated May 12, 2017, revealed that a resident “was observed sitting on the floor next to the side of the bed. The Pan Alarm did not sound at this time even though it was turned down [which was] determined to be semi-functional after the fall. No root cause was identified [and] no new interventions were implemented.”

The Incident Report dated June 29, 2017, revealed that “the alarm was off, the resident was found lying on the floor. There was an injury to the left shoulder blade. The plan was to lower the bed, and [the resident] was placed on the Care Plan, after seven falls. No root cause was identified.”

The resident’s August 3, 2017, Incident Report revealed that the resident “was transferring out of the wheelchair and had an unwitnessed fall. She sustained a hematoma, superficial laceration, and a right hip fracture. The cause of the accident was a weakness, confusion, and poor perception of ability to self-transfer. The chair alarm properly functions. The steps to prevent recurrence were Care Plan updated.”

However, the investigator interviewed a staff member on the afternoon of September 6, 2017, who stated that “the typical course for a non-surgical bone fracture was bed rest. She stated [the resident] wanted to get out of bed, so the physician said it was okay. She stated she really worried about [the resident’s] transfers because the wrong movement could really damage and harm the hip. She did not evaluate the resident or provide education for the Certified Nursing Assistants for safe positioning in transfers because [another staff member] was going to provide the education.”

The surveyor observed the resident at 9:55 AM on September 5, 2017, while two staff members “proceeded to transfer [the resident] out of bed to the commode, using two persons and a gait belt.” At this time, the resident “stated it hurts. Staff cued her to stand on her good leg.” The resident asked “should I drag my other leg? [One of the staff members] stated they brought [the resident] to the shower room, because it was a better transfer, and she would not have to move or twist her hip.”

Were You Injured by Nursing Home Abuse or Neglect?

Were you, or loved one, injured by the neglect or abuse of staff members at your nursing home? If so, you are likely entitled to file a compensation claim to ensure your family receives the monetary recover they deserve for your injuries. However, resolving these cases are complex and require the skills of a dedicated, reputable lawyer who specializes in abuse, mistreatment, and neglect claims.

Typically, these cases are handled through contingency fee arrangements. These agreements allow immediate access to counsel, advice and legal representation to build a case for compensation. All fees are paid after the case is resolved through a negotiated out-of-court settlement or at the successful conclusion of a jury trial.

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