Missoula Health & Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen by ensuring staff with facial hair wore beard coverings while working in the kitchen. The deficient practice had the potential to affect all residents who received food prepared in the facility's kitchen by increasing the risk of hair contamination in the food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure temperatures were monitored daily by staff for a refrigerator that contained stored medications and vaccines. This failure placed residents who had or used refrigerated medications and vaccines at risk for experiencing adverse effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it had an effective process in place for the most current code status on POLST (Physician Orders for Life-Sustaining Treatment) forms and advance directives to be readily accessible in the electronic medical record, and available to staff, in the event of an emergency, for 2 (#s 30 and 31) of 22 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Brief Interview for Mental Status (BIMS) was completed correctly on the Minimum Data Set Assessment, and failed to conduct the required staff assessment for the resident's mental status when the resident was unable to participate in the Brief Interview for Mental Status (BIMS) for 1 (#7) of 22 sampled residents. The failure resulted in an inaccurate representation of the resident's cognitive status and placed the resident at risk for inappropriate care planning and interventions. Findings Include:During an interview on 3/25/26 at 2:07 p.m., staff member D stated resident #7 was Out of it, when he was admitted to the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure timely assessment, implementation of appropriate wound care orders, and coordinated follow-up after a skin concern was initially identified by the therapy department for 1 (#7) of 22 sampled residents. This failure resulted in delayed assessment and treatment of a developing pressure injury, placing the resident at risk for worsening skin breakdown and impaired healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards and practices to ensure a resident's electronic medical record contained accurate information for the administration of a medication for 1 (#44) of 22 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a comfortable temperature for 5 (#s 1, 9, 20, 26, and 89) of 14 sampled residents throughout the facility; and failed to repair the sheet metal covering on a base board heater in a community area. This deficient practice had the potential to cause cold induced stress, and injure a resident ambulating in the affected area.

Inspectors wroteBased on interview and record review, the facility failed to honor a resident's activity preference for going outside when the weather was comfortable, for 2 (#s 9 and 24) of 14 sampled residents. This deficient practice increased the risk of the resident's of a decline in mood or well-being.

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive assessment of a resident's needs, strengths, goals, life history, and preferences within 14 days of admission, for 1 (#89) of 14 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to provide regular showers for 4 (#s 9, 20, 26, and 89) of 14 sampled residents, which made the residents feel dirty and or upset.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents with group and individual activities to meet their interests and support their physical, mental, and psychosocial well-being for 2 (#s 9 and 26) of 14 sampled residents. Resident #26 stayed in her room most of the time, and neither resident participated often in group activities. 1. During an observation and interview on 2/10/25 at 3:27 p.m., resident #26 was lying in her bed in the dark. Resident #26 stated, They don't have activities that interest me. They do bingo all the time, but I don't like bingo. I stay in my room most of the time. During an observation on 2/12/25 at 3:05 p.m., resident #26 was in her room lying in her bed in the dark. Review of resident #26's activities participation record showed participation in two activities in the 30-day look-back period. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with limited range of motion were provided appropriate assistance and positioning to maintain or improve mobility for 2 (#s 15 and 27) of 14 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient pain medication was provided for a resident who stated she had pain consistently throughout the day, for 1 (#27) of 14 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of expired over the counter medications; and administer medications per physician order, for 2 (#s 10 and 11) of 14 sampled residents; and failed to appropriately document medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dental services for 1 (#26) of 14 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the staff used gloves when handling a resident's food, for 1 (#88) of 14 residents sampled. This deficient practice increased the risk of foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hospice orders were clarified for accuracy and appropriately followed for 1 (#10) of 14 sampled residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure staff were properly handling resident medications for 2 (#s 11 and 22) of 14 sampled residents, which increased the risk of negative outcomes for the residents if infection control prevention measures were not upheld.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to remove expired items for disposal for one medication room and two medication carts; and properly store food items used for medication administration, keeping it off the floor, in one medication room. These failures increased the risk of expired items being or food being used, when stored unsafely, for resident care, if taken from the identified medication room and carts.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents had knowledge of the grievance process and access to grievance forms to file a grievance, to include anonymously; and, the facility failed to ensure all grievances were investigated, resolved, and that residents were made aware of the outcome of the grievance, for 2 (#s 11 and 20) of 19 sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure medication error rates were under 5% for 4 (#s 1, 16, 29, & 132) residents, of 4 residents sampled for medication. The calculated medication error rate was 17.86%.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure kitchen staff followed safe hygiene practices and properly check temperatures of food for serving. This had the potential to effect any residents that consumed the food prepared by the kitchen.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain infection control hand hygiene practices and for cleaning of communal equipment, for 2 (#s 1 and 4) for 19 sampled residents.

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents' catheter bags were covered for maintaining resident dignity, for 2 (#s 29 & 132) of 3 sampled residents for dignity and catheter concerns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise care plan interventions, and identify beneficial interventions, to prevent a resident from wandering into other residents' personal space and rooms, and taking or destroying their belongings, for 1 (#24) of 19 sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide necessary services to maintain grooming for 1 (#13) of 19 sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide the necessary services for a resident related to scheduling medical appointments, communication, and continuity of care, for the resident's catheter care and services, and catheter changes, received at a specialized Urology clinic, for 1 (#8) of 19 sampled residents.