5 CMS Surveys
Inspection Report — Feb 13, 2025
Renewal
Date: Feb 13, 2025
Visit Reason
The survey was a routine renewal inspection of Missoula Health & Rehabilitation Center.
Findings
The facility had multiple deficiencies including failure to maintain comfortable temperatures, incomplete resident assessments, inadequate activity programs, insufficient personal care and hygiene, improper medication administration, lack of dental services, and infection control issues.
Deficiencies (12)
F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely: the facility failed to maintain comfortable temperatures throughout the building and had a tripping hazard from detached sheet metal on a baseboard heater.
F 0636 Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months: the facility failed to complete a comprehensive admission assessment within 14 days for one resident.
F 0675 Honor each resident's preferences, choices, values and beliefs: the facility failed to honor residents' preferences to go outside when weather was comfortable, limiting outdoor activities.
F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: the facility failed to provide regular showers for four residents, resulting in residents feeling dirty and upset.
F 0679 Provide activities to meet all resident's needs: the facility failed to provide group and individual activities that met the interests and needs of two residents, who rarely participated in activities.
F 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason: the facility failed to ensure two residents with limited mobility were repositioned and assisted appropriately to maintain mobility and prevent pain.
F 0697 Provide safe, appropriate pain management for a resident who requires such services: the facility failed to ensure sufficient pain medication and assessment for one resident who reported consistent leg pain.
F 0760 Ensure that residents are free from significant medication errors: the facility failed to dispose of expired medications, administer medications per physician orders, and document medication administration appropriately for two residents.
F 0791 Provide or obtain dental services for each resident: the facility failed to provide dental services or document offering dental services for one resident missing all teeth.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: the facility failed to ensure staff used gloves when handling a resident's food, increasing risk of foodborne illness.
F 0849 Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services: the facility failed to ensure hospice orders were clarified for accuracy and appropriately followed for one resident on hospice.
F 0880 Provide and implement an infection prevention and control program: the facility failed to ensure staff properly handled resident medications, touching tablets with bare hands, increasing risk of infection.
Report Facts
Temperature (°F): 65
Temperature (°F): 66
Temperature (°F): 68
Days without shower: 22
Days without shower: 14
Days without shower: 12
Days without shower: 12
Minutes of restorative therapy: 15
Minutes of restorative therapy: 25
Inspection Report — Feb 15, 2024
Renewal
Date: Feb 15, 2024
Visit Reason
The survey was a renewal inspection of Missoula Health & Rehabilitation Center conducted on February 15, 2024.
Findings
The facility failed to adequately review and revise the care plan for resident #24 to prevent wandering into other residents' personal spaces and rooms, resulting in multiple incidents of resident #24 entering other rooms, taking or destroying belongings, and causing distress among residents. Interventions such as alert stop signs and redirection were inconsistently effective and not fully incorporated into the care plan.
Deficiencies (1)
F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: the facility failed to revise resident #24's care plan to effectively address wandering behaviors that led to entering other residents' rooms, taking or destroying belongings, and invading personal space.
Report Facts
Residents affected: 19
Facility grievances reviewed: 3
Care plan last updated: May 13, 2024
Inspection Report — Feb 15, 2024
Renewal
Date: Feb 15, 2024
Visit Reason
Routine renewal inspection of Missoula Health & Rehabilitation Center to assess compliance with health and safety regulations.
Findings
The facility had multiple deficiencies including failure to maintain resident dignity with catheter bag covers, inadequate grievance process, incomplete care planning for wandering resident, insufficient grooming assistance, medication errors, expired medications in storage, improper food safety practices, and lapses in infection control procedures.
Deficiencies (9)
F 0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights: the facility failed to ensure catheter bags were covered for maintaining resident dignity for 2 of 3 sampled residents.
F 0585 Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances: the facility failed to ensure residents had knowledge of the grievance process, access to grievance forms including anonymous filing, and failed to investigate and resolve grievances for 2 of 19 sampled residents.
F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: the facility failed to review and revise care plan interventions to prevent a resident from wandering into other residents' personal space and rooms and taking or destroying belongings for 1 of 19 sampled residents.
F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: the facility failed to provide necessary grooming services for 1 of 19 sampled residents, who had unshaved facial hair and was not offered assistance.
F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections: the facility failed to provide necessary services related to scheduling medical appointments, communication, and continuity of care for catheter care and changes for 1 of 19 sampled residents.
F 0759 Ensure medication error rates are not 5 percent or greater: the facility failed to ensure medication error rates were under 5% for 4 residents sampled, including crushing extended release medications, administering expired medications, improper medication administration techniques, and unlabeled insulin syringes.
F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs: the facility failed to remove expired medications and properly store food items off the floor in medication rooms and carts, increasing risk of expired or contaminated items being used.
F 0800 Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs: the facility failed to ensure kitchen staff followed safe hygiene practices and properly checked food temperatures, including failure to wear hairnets and dangling jewelry, and documenting food temperatures in Celsius instead of Fahrenheit resulting in under-temperature food.
F 0880 Provide and implement an infection prevention and control program: the facility failed to maintain infection control hand hygiene practices and proper cleaning of communal equipment for 2 residents, including failure to perform hand hygiene between clean and soiled tasks, improper cleaning of glucometers, lack of staff training on wet contact and dry times for disinfectants, and contamination of blood sugar testing supplies.
Report Facts
Residents sampled for medication: 4
Medication error rate (%): 17.86
Residents sampled for grievances: 19
Residents sampled for care planning: 19
Residents sampled for grooming: 19
Residents sampled for catheter care: 19
Expired medication items: 11
Blood glucose test strips expired date: 5.31
Required vegetable holding temperature (°F): 135
Observed vegetable temperature (°F): 129.9
Wet contact time (minutes): 4
Inspection Report — Feb 16, 2023
Renewal
Date: Feb 16, 2023
Visit Reason
Routine renewal inspection of Missoula Health & Rehabilitation Center to assess compliance with health and safety regulations.
Findings
Two deficiencies were identified: one involving medication misappropriation by a nurse who attempted to sell a resident's medication, and another involving a nurse's failure to provide necessary treatment and documentation for a resident's low blood sugar incident. Both nurses were terminated and staff received additional training.
Deficiencies (2)
F 0602 Protect each resident from the wrongful use of the resident's belongings or money: a nurse misappropriated medication by attempting to sell a resident's Zoloft, leading to suspension and termination of the nurse and reeducation of staff.
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: a nurse failed to provide necessary treatment and document a low blood sugar incident for a resident, resulting in termination and staff education.
Report Facts
Blood sugar level: 50
Blood sugar level: 112
Inspection Report — Feb 16, 2023
Renewal
Date: Feb 16, 2023
Visit Reason
The survey was conducted as a routine renewal inspection to assess compliance with state and federal regulations.
Findings
The facility was found deficient in multiple areas including resident room size, medication management, staff training, hospice coordination, and nurse staffing postings. Several residents experienced issues such as inadequate room space, missing consent for bedrails, and lack of timely notifications for transfers. The facility also failed to ensure all nursing staff received behavioral health training and did not maintain complete nurse staffing postings.
Deficiencies (12)
F 0912 Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms: the facility failed to provide resident #20 with a bedroom space of at least 80 square feet, measuring only 75 square feet with uneven room division.
F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely: the facility failed to provide comfortable and safe temperature levels, causing resident #31 to complain of being cold and rely on a space heater that was later removed.
F 0602 Protect each resident from the wrongful use of the resident's belongings or money: the facility failed to protect resident #6 from medication misappropriation by a nurse who attempted to sell the resident's medication; the nurse was arrested and terminated, and the facility conducted a full investigation and staff reeducation.
F 0623 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights: the facility failed to provide a written notice of transfer for resident #35 sent to the emergency room.
F 0625 Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave: the facility failed to provide a bed hold notice for resident #35 being sent to the hospital.
F 0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted: the facility failed to provide resident #31 with a summary of the baseline care plan within 48 hours of admission.
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: a nurse failed to provide necessary treatment to resident #22 when notified of a low blood sugar event, did not document the incident, and was subsequently terminated; the resident had no adverse outcomes.
F 0700 Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail: the facility failed to obtain a signed informed consent for a bedrail from the POA for resident #19.
F 0732 Post nurse staffing information every day: the facility failed to provide all weekend nurse staffing postings from July through September 2022, despite low weekend staffing being a triggered concern.
F 0758 Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited: the facility failed to order PRN psychotropic medications with required stop dates for residents #6 and #22.
F 0849 Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services: the facility failed to provide ongoing collaboration and communication with the contracted hospice company for resident #31, causing resident frustration and anxiety related to wound care.
F 0949 Provide behavior health training consistent with the requirements and as determined by a facility assessment: the facility failed to ensure all nursing staff received behavioral health training to attend to residents with PTSD, including staff members I, J, and K.
Report Facts
Room size (sq ft): 75
Room dimensions (ft): 6
Room dimensions (ft): 12.5
Residents sampled: 13
Residents sampled: 1
Residents sampled: 1
Residents sampled: 2
Residents sampled: 1
Residents sampled: 1
Dates missing nurse staffing postings: 18
Residents sampled: 3
Residents sampled: 1
Staff members without trauma informed care training: 3
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