Deficiencies (last 3 years)
Deficiencies (over 3 years)
12.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
112% worse than Montana average
Montana average: 5.8 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 12
Feb 13, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations at Missoula Health & Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including maintaining comfortable temperatures, completing timely resident assessments, honoring resident preferences, providing adequate personal care and activities, ensuring appropriate pain management, medication administration errors, dental care provision, food handling practices, and infection control measures.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 12
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to maintain comfortable temperature for 5 of 14 sampled residents and failed to repair a baseboard heater with protruding sharp sheet metal. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete a comprehensive assessment within 14 days of admission for 1 of 14 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to honor residents' activity preference for going outside for 2 of 14 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide regular showers for 4 of 14 sampled residents, causing residents to feel dirty or upset. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide group and individual activities to meet interests and support well-being for 2 of 14 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate assistance and positioning to maintain or improve mobility for 2 of 14 sampled residents with limited range of motion. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure sufficient pain medication was provided for 1 of 14 sampled residents who reported consistent pain. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to dispose of expired over-the-counter medications, administer medications per physician order, and properly document medication administration for 2 of 14 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide dental services for 1 of 14 sampled residents with missing dentures and no documentation of dental care offered. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure staff used gloves when handling resident food for 1 of 14 sampled residents, increasing risk of foodborne illness. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure hospice orders were clarified for accuracy and appropriately followed for 1 of 14 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure staff properly handled resident medications for 2 of 14 sampled residents, increasing risk of infection. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Days without shower: 14
Days without shower: 22
Days without shower: 12
Days without shower: 12
Minutes of restorative therapy: 10
Minutes of restorative therapy: 15
Minutes of restorative therapy: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member C | Interviewed about temperature issues and maintenance of baseboard heater. | |
| Staff member H | Interviewed about admission assessments completion. | |
| Staff member E | Interviewed about outside activities and activity documentation. | |
| Staff member G | Interviewed about bathing responsibilities and documentation. | |
| Staff member J | Interviewed about facility being cold and dental care documentation. | |
| Staff member L | Interviewed about medication disposal and administration. | |
| Staff member M | Interviewed about medication handling and infection control. | |
| Staff member N | Interviewed about pain interventions and medication administration. | |
| Staff member O | Interviewed about hospice care differences. | |
| Staff member P | Interviewed about restorative duties. | |
| Staff member Q | Interviewed about medication expiration. | |
| Staff member D | Observed and interviewed about food handling and glove use. | |
| NF3 | Interviewed about resident #27's mobility and pain. | |
| NF4 | Interviewed about morphine order discrepancy for resident #10. | |
| NF5 | Interviewed about medication administration timing and over-the-counter medication disposal. | |
| Staff member K | Interviewed about activities documentation issues. |
Inspection Report
Deficiencies: 1
Feb 15, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with care planning requirements, specifically regarding the management of a resident (#24) who exhibited wandering behaviors that affected other residents' personal space and belongings.
Findings
The facility failed to adequately review and revise care plan interventions to prevent resident #24 from wandering into other residents' rooms and taking or destroying their belongings. Observations and interviews revealed ongoing wandering behaviors, insufficient interventions, and lack of effective care planning to address these issues.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to review and revise care plan interventions to prevent resident #24 from wandering into other residents' personal space and rooms, and taking or destroying their belongings. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 19
Residents affected: 1
Facility grievances reviewed: 3
Care plan last updated: May 13, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member W interviewed regarding resident #24's wandering behavior and interventions | ||
| Staff member N observed calling resident #24 and intervening during wandering | ||
| Staff member C interviewed about interdisciplinary team review and care planning for resident #24 |
Inspection Report
Routine
Deficiencies: 9
Feb 15, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, grievance processes, care planning, grooming, catheter care, medication administration, medication storage, food safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity regarding catheter bag coverage, inadequate grievance process and follow-up, incomplete care planning for wandering behavior, insufficient grooming assistance, lapses in catheter care and appointment scheduling, medication errors exceeding 5%, expired medications and improper storage in medication rooms and carts, unsafe food handling and temperature monitoring in the kitchen, and inadequate infection prevention and control practices including hand hygiene and cleaning of communal equipment.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure residents' catheter bags were covered to maintain dignity for 2 of 3 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents had knowledge of the grievance process, access to grievance forms, and that grievances were investigated and resolved for 2 of 19 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to review and revise care plan interventions to prevent wandering into other residents' personal space and rooms for 1 of 19 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide necessary grooming services for 1 of 19 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide necessary catheter care services including scheduling and communication for 1 of 19 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Medication error rate was 17.86%, exceeding the 5% threshold, involving 4 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to remove expired medications and properly store food items in medication rooms and carts, increasing risk of expired or contaminated items being used. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure kitchen staff followed safe hygiene practices and properly checked food temperatures, including failure to wear hair/beard nets and documenting temperatures in Celsius instead of Fahrenheit. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain infection control hand hygiene practices and proper cleaning of communal equipment for 2 residents, including missed hand hygiene during wound care and blood sugar testing, and lack of knowledge about disinfectant wet contact times. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication error rate: 17.86
Residents sampled for grievance process: 19
Residents sampled for care planning: 19
Residents sampled for grooming: 19
Residents sampled for catheter care: 19
Residents sampled for infection control: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member B | Involved in medication error education, catheter appointment scheduling, and medication storage observations. | |
| Staff member E | Administered medications incorrectly and had expired medications on medication cart. | |
| Staff member F | Performed wound care with missed hand hygiene and had expired test strips on medication cart. | |
| Staff member J | Administered medication without ensuring swallowing and failed to perform proper cleaning of glucometer. | |
| Staff member U | Failed to wear hairnet properly and documented food temperatures incorrectly. | |
| Staff member M | Infection control staff reeducating on cleaning product dry times. | |
| Staff member N | Made resident appointments for catheter care. | |
| Staff member O | Reported on resident appointment supervision practices. | |
| Staff member C | Provided information on care planning for resident #24. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Feb 16, 2023
Visit Reason
The inspection was conducted following complaints related to medication misappropriation by a staff member and failure to provide necessary treatment to a resident when notified of a health concern.
Findings
The facility failed to protect one resident from medication misappropriation by a nurse who attempted to sell the resident's medication and failed to provide necessary treatment and documentation for another resident's low blood sugar incident. Both incidents were investigated, staff were reeducated, and involved staff were terminated.
Complaint Details
The complaint investigation involved medication misappropriation by a nurse who was arrested and terminated, and a failure by a nurse to provide care and document a low blood sugar incident for a resident. Both incidents were reported to the State Survey Agency and Adult Protective Services (APS).
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to protect a resident from medication misappropriation by a staff member who attempted to sell the resident's medication. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide necessary treatment and documentation for a resident with low blood sugar; nurse on duty did not act on health concern and failed to document the incident. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 1
Blood sugar level: 50
Blood sugar level: 112
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| NF3 | Nurse | Involved in medication misappropriation, arrested and terminated |
| NF4 | Nurse | Failed to provide necessary treatment and documentation for resident #22's low blood sugar incident |
| Staff member A | Provided statements regarding investigations and staff training | |
| Staff member H | Provided statements about training and incident awareness | |
| Staff member C | Provided training and assessed resident #22 after incident |
Inspection Report
Routine
Deficiencies: 13
Feb 16, 2023
Visit Reason
The inspection was conducted as a routine regulatory oversight visit to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including inadequate resident room space, failure to maintain comfortable temperature levels, medication misappropriation by a staff member, failure to provide timely transfer and bed hold notices, lack of baseline care plan summaries, failure to provide necessary treatment and documentation, lack of informed consent for bedrails, incomplete nurse staffing postings, missing stop dates on PRN psychotropic medication orders, inadequate hospice coordination, insufficient room size for a resident, and lack of behavioral health training for staff.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 13
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to provide a resident with enough room to ambulate safely with a walker in a shared room; resident had less than 80 sq/ft space. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide comfortable and safe temperature levels causing a resident to complain of being cold. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to protect a resident from medication misappropriation by a staff member. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide a written notice of transfer for a resident sent to the emergency room. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide a bed hold notice for a resident being sent to the hospital. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide a summary of the baseline care plan to a resident within 48 hours of admission. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide necessary treatment and documentation for a resident with a low blood sugar incident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to obtain signed informed consent for a bedrail from the resident's POA. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to post all weekend nurse staffing information from July to September 2022. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to order PRN psychotropic medications with required stop dates for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide ongoing collaboration and communication with contracted hospice company causing resident frustration. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide a resident with a bedroom space of at least 80 square feet in a multiple room. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure all nursing staff received behavioral health training to attend to residents with PTSD. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Room size: 75
Medication misappropriation incident date: Aug 17, 2022
Blood sugar level: 50
Blood sugar re-test level: 112
Missing nurse staffing postings: 14
PRN medication start date: Sep 20, 2021
PRN medication start date: Oct 25, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Interviewed regarding multiple deficiencies including medication misappropriation investigation, transfer and bed hold notices, blood sugar incident investigation, nurse staffing postings, PRN medication orders, hospice coordination, and bedrail consent. | |
| Staff member C | Interviewed regarding baseline care plan summary, PRN medication orders, blood sugar incident education, and psychotropic medication order monitoring. | |
| Staff member E | Measured resident #20's room size and reported on temperature issues affecting resident #31. | |
| Staff member H | Interviewed regarding medication misappropriation, blood sugar incident, and staff training. | |
| Staff member L | Interviewed about resident #20's room space and walker mobility. | |
| Staff member J | Interviewed about lack of PTSD and trauma informed care training. | |
| Staff member K | Interviewed about lack of trauma informed care training. | |
| Staff member I | Interviewed about lack of behavioral health training. | |
| Staff member B | Interviewed about hospice coordination. | |
| Staff member D | Interviewed about hospice coordination. |
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