Montana was hit with more than $277,000 in civil penalties after its Mental Health Nursing Care Center in Lewistown failed to meet federal documentation requirements related to mental illness care.

A February survey found the operator failed to protect patients from verbal, physical and sexually abusive behaviors by other dementia patients, the Great Falls Tribune reported. Three residents suffered physical and mental harm as a result, the Centers for Medicare & Medicaid Services ruled, earning the building 20 days’ of immediate jeopardy fines.

The Montana Mental Health Nursing Care Center is a 117-bed Medicaid-licensed facility with about 80 residents with mental health diagnoses. More than 70% are over age 65. They have been deemed a danger to themselves and others, cannot be admitted to the Montana State Hospital and have been turned away from three nursing homes or other community placements, according to U.S. News & World Report.

The state has also hired a consultant — at a cost of $70,000 a month — to help the center meet new requirements under a temporary manager.

Administrator Dianne Scotten declined comment to the Great Falls Tribune.

But Zoe Barnard, administrator of the state health department’s Addictive and Mental Disorders Division, said residents are receiving high quality of care, and that much of the issue comes down to documentation.

“Oftentimes with certification it’s about how you document the incident, how it gets reported and who it gets reported to,” she told the newspaper.

For instance, new rules require the facility to report incidents to Montana Adult Protective Services.

However, a federal official said states were given ample time to prepare for the new federal regulations, and that continued failure to comply could lead to the loss of Medicare and Medicaid reimbursements.

The February investigation was triggered by a complaint. It revealed that 13 incidents involving physical, mental or sexual abuse in the dementia wing were not reported to the building’s administrator or other officials.

“It’s a constant challenge from a supervisor standpoint to make sure residents are not inappropriately touching each other,” Barnard said.