Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Missoula Health & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to maintain sanitary kitchen conditions by not ensuring staff with facial hair wore beard coverings while working in the kitchen. An employee with facial hair was observed without a beard cover, and another employee with facial hair was also observed without one and stated he should have been wearing a beard covering. A staff member confirmed that employees with facial hair are required to wear beard coverings, and the facility policy states that beard guards are worn for employees with beards.
Missing Refrigerator Temperature Monitoring for Medications and Vaccines: The facility failed to ensure refrigerator temperatures were monitored and documented for a medication refrigerator that stored drugs and biologicals, including Tubersol and FLUAD. An LPN/staff member noted missing entries on the temperature log, and the record showed no initials, times, or temperatures recorded for two days. The facility policy required temperature monitoring and documentation for refrigerated medications and vaccines.
POLSTs and advance directives were not readily accessible in the EMR for two residents. Staff kept the forms in a binder at the nurses station only, and staff had to go to the station to check code status. For one resident, the POLST showed DNR and comfort measures only; for the other, it showed No CPR and selective treatment with a request for oxygen if needed. Neither resident had code status or advance directive info reflected in the care plan or MAR/TAR, and one resident had no POLST or advance directive uploaded to the chart.
The facility failed to complete the BIMS correctly for a resident who was unable to meaningfully participate in the interview. Staff reported the resident gave no responses or nonsensical responses, yet the MDS was coded with a BIMS score of 00 and no required staff assessment was completed, leaving the resident's cognitive status inaccurately represented.
A resident who spent prolonged periods in a reclined wheelchair developed gluteal skin redness that therapy identified as early breakdown. Nursing communication was inconsistent, the wound was not fully assessed or measured when it opened, and wound care orders were not started until later, with documentation that conflicted on the wound location and first observation.
Inaccurate Medication Record for Buspirone: The facility failed to keep a resident’s EMR accurate for buspirone, which was ordered as 1.5 tablets twice daily but was documented on the MAR and medication card as being for hypertension. The resident stated the medication was for anxiety, while staff acknowledged the wrong diagnosis had been attached to the order and that the resident had a history of depression and anxiety.
The facility did not maintain comfortable temperatures in several areas, with multiple residents reporting feeling cold and exhibiting symptoms such as shivering and blue hands. Staff acknowledged ongoing heating issues, lack of temperature documentation, and insufficient measures to address the cold, such as the absence of a blanket warmer. Additionally, a baseboard heater with detached sheet metal created a tripping hazard in a common area, and staff confirmed the risk. These deficiencies resulted in an environment that was not consistently safe or comfortable for residents.
Two residents who expressed a preference for outdoor activities were not provided opportunities to go outside, as confirmed by interviews and review of activity calendars. Staff reported not conducting any outdoor activities for several months, and facility records showed no scheduled outdoor events, despite residents' documented preferences for fresh air and outdoor time.
A resident's comprehensive Admission MDS assessment was not completed and submitted within the required 14-day period after admission, remaining open and 15 days overdue at the time of survey. Staff confirmed that such assessments are expected to be completed within the mandated timeframe.
Four residents who required assistance with activities of daily living did not receive regular showers, as evidenced by their unkempt appearance and self-reports of infrequent bathing. Staff cited short staffing as a reason for missed showers, and documentation confirmed extended periods without bathing for these residents. The facility was unable to provide a bathing policy when requested.
Two residents were not provided with group or individual activities that matched their interests or supported their well-being, resulting in minimal participation and reports of boredom. Staff interviews revealed inconsistent documentation of activity refusals and one-on-one time, and the Activities Director had not been documenting activities as required by facility policy.
Two residents with limited range of motion did not receive consistent assistance with mobility and repositioning. One resident with a recurring coccyx wound was infrequently repositioned and spent extended periods in a wheelchair without movement, despite physician orders for regular turning. Another resident, prone to sores from prolonged sitting, had sporadic documentation of restorative interventions and spent long hours in both bed and wheelchair. Staff interviews confirmed inconsistent implementation of mobility support.
A resident experienced ongoing leg pain and reported difficulty accessing staff for pain relief, while documentation frequently indicated no pain was present. Family and staff interviews revealed infrequent pain assessments, lack of repositioning, and minimal non-pharmacological interventions, resulting in inadequate pain management.
Staff failed to administer medications as ordered for two residents, including not crushing medication for a resident with a CVA and giving Carafate after meals instead of before as prescribed. Expired over-the-counter medications were also found in medication carts, and medication administration was documented before the medication was actually given.
A resident without teeth reported not being offered dental services or a referral for new dentures after her previous set did not fit, despite staff accommodating her by cutting food. Documentation and dental notes confirming a referral or dental care were not found, contrary to facility policy requiring timely referral and documentation for lost or damaged dentures.
A staff member handled a resident's food with bare hands, placing bacon on toast without gloves, in violation of facility policy prohibiting bare hand contact with food. The staff member did not immediately remove the contaminated plate, and later transferred hashbrowns from the contaminated plate to a new one before serving it to the resident. Staff interviews confirmed that such food handling practices were not permitted.
A resident who transitioned from comfort care to hospice care continued to have conflicting medication orders, with staff administering medications based on comfort care protocols instead of hospice orders. Staff interviews revealed confusion about the roles of facility and hospice staff, and documentation showed discrepancies in morphine administration instructions, indicating a lack of coordination and communication between the facility and hospice providers.
Staff did not follow infection control protocols when administering oral medications to two residents, handling tablets with bare hands and failing to use gloves as required by facility policy. This practice was observed during medication passes and confirmed as unacceptable by another staff member.
Kitchen Staff Failed to Wear Beard Covers
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen by not ensuring staff with facial hair wore beard coverings while working in the kitchen. During an observation on 3/23/26 at 1:56 p.m., staff member L was observed with facial hair and was not wearing a beard cover while working in the kitchen. During an interview and observation on 3/25/26 at 11:51 a.m., staff member M was observed working in the kitchen with facial hair and was not wearing a beard cover; staff member M stated he should have been wearing a beard covering because of his facial hair. During an interview on 3/25/26 at 11:53 a.m., staff member L stated staff with facial hair are required to wear beard coverings while working in the kitchen. Review of the facility's policy titled, Personal Hygiene Standards, updated June 2021, showed that for employees with beards, beard guards are worn.
Missing Refrigerator Temperature Monitoring for Medications and Vaccines
Penalty
Summary
The facility failed to ensure temperatures were monitored daily for a refrigerator used to store medications and vaccines. During an observation and interview on 3/26/26 at 8:51 a.m., staff member Q stated the two refrigerators in the provider office were used to store medications and supplements, and that the night shift nurse was supposed to check the refrigerator temperatures during the shift. Staff member Q also stated that some temperatures were missing from the log sheets displayed on both refrigerators. The refrigerator contained multiple medications and biologicals, including Tubersol boxes and influenza vaccine (FLUAD) boxes. Review of the facility's temperature log for the refrigerator showed two pages of entries for March 2026, with one page covering days 1-15 and the second covering days 16-31. For March 20 and 21, there were no staff initials, times, or temperatures recorded on the log. The facility policy titled, Storage of Medication, stated that medications requiring refrigeration are to be kept in a refrigerator with a thermometer and that a temperature log or tracking mechanism is maintained to verify temperatures remain within accepted limits. The policy also stated that the temperature of any refrigerator storing vaccines should be monitored and recorded twice daily, and if no vaccines are stored, temperature checks should be documented at least once daily.
POLST and Advance Directives Not Readily Accessible in EMR
Penalty
Summary
The facility failed to ensure the most current code status on POLST forms and advance directives was readily accessible in the electronic medical record and available to staff in an emergency for 2 of 22 sampled residents. During interviews, staff stated resident POLST forms and advance directives were kept in hard copy only at the nurses station in a binder and were not scanned into the electronic medical record, although staff said the forms needed to be available and updated for emergent situations. An observation showed staff going to the nurses station to use the binder to check resident code statuses, and staff confirmed they had to come to the nurses station to review that information. For one resident, the POLST was completed by the medical power of attorney and indicated DNR, no artificial nutrition by tube, and comfort measures only, but the care plan did not include code status or advance directive information, the MAR/TAR had no physician orders for code status, and the electronic record only directed staff to the Disaster Recovery binder at the nurses station. For the second resident, the POLST was completed by the medical power of attorney and indicated No CPR, no artificial nutrition by tube, and selective treatment with a note requesting oxygen if needed, but the care plan did not include code status or advance directive information, the MAR/TAR had no physician orders for code status, and the electronic record also directed staff to the Disaster Recovery binder at the nurses station; this resident had no advance directives or POLST uploaded to the documents section.
Incomplete BIMS and Missing Staff Assessment
Penalty
Summary
The facility failed to ensure the Brief Interview for Mental Status (BIMS) was completed correctly on the Minimum Data Set for resident #7, and failed to complete the required staff assessment when the resident was unable to participate meaningfully in the interview. During an interview, staff member D stated that resident #7 was "out of it" when admitted to the facility and that, while completing Section C of the MDS, the resident either did not respond to the interview questions or gave nonsensical responses throughout the interview. Review of the admission MDS with an assessment reference date of 3/6/26 showed resident #7 was coded in Section B as usually making himself understood and usually understood others. In Section C, the BIMS score was coded as 00 for severe cognitive impairment, and no staff assessment was completed. The record contained no documentation supporting a completed BIMS interview that met criteria for completion, and there was no evidence that the required staff assessment was initiated after the incomplete interview.
Delayed Assessment and Inconsistent Documentation of Developing Pressure Injury
Penalty
Summary
The facility failed to ensure timely assessment, implementation of wound care orders, and coordinated follow-up after a skin concern was first identified for a resident who was frequently observed seated in a wheelchair in a reclined position. Therapy staff documented on 3/19/26 that the resident’s gluteal skin was reddened and at risk for breakdown, and noted that nursing was notified so cream and a protective barrier could be applied. During later observations, the resident continued to be up in the wheelchair for prolonged periods, and staff stated the resident was kept up in the chair for meals and then laid down after lunch because of the buttock area. Staff interviews showed inconsistent communication about the skin concern. One staff member stated she was not informed of the initial identification on 3/19/26 and first learned of the issue on 3/24/26, while another staff member said the area had been identified the prior week as dry and reddened and had progressed to being open and peeling by 3/24/26. A nurse who provided wound care stated she was notified on 3/24/26 during morning cares, cleansed the area, and applied a dressing, but did not obtain measurements or perform a full assessment because she was not familiar with pressure injury staging and the wound care nurse was out on leave. On 3/25/26, observation showed a reddened gluteal area with a dressing covering the intergluteal cleft, coccyx, and gluteal region; when the dressing was removed, an open circular area with partial thickness skin loss exposing the dermis was seen. The wound care nurse was not present, and the nurse performing care stated she had notified another staff member. The record showed wound care orders were not initiated until 3/24/26, despite the earlier 3/19/26 identification, and the weekly skin evaluation on 3/25/26 inconsistently described the wound as the first observation and located it on the right buttock. The facility policy required documentation of measurements, location, size, color, odor, exudate, and pain for new skin impairment.
Inaccurate Medication Record for Buspirone
Penalty
Summary
The facility failed to follow professional standards and practices to ensure resident #44’s electronic medical record contained accurate information for a medication order. The resident’s physician order listed buspirone HCl 15 mg, 1.5 tablets by mouth twice a day, with the medication categorized as active, but the supply information and medication directions in the record stated the medication was for hypertension. Resident #44 stated her medications had previously been messed up but had been straightened out, and she stated buspirone was for anxiety. Staff interviews showed the order had been entered by the ADON and double-checked by the DON, but staff member B did not know why the diagnosis of hypertension was attached to the order and stated an audit revealed the wrong diagnosis, which was changed immediately. Staff member N stated the medication card also showed buspirone was for hypertension and that the MAR matched the medication card from the pharmacy. Staff member O stated buspirone does not have any hypertensive agents but could be used to reduce anxiety and, as a result, reduce hypertension. NF3 stated the resident had a history of depression and anxiety and that the medication was definitely not for hypertension.
Failure to Maintain Safe and Comfortable Environment Due to Inadequate Temperature Control and Physical Hazards
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents by not ensuring adequate temperature control throughout the building and not repairing hazardous physical conditions. Observations revealed that the baseboard heater at the end of the North Hall near the nurses' station had detached sheet metal with sharp edges protruding, creating a tripping hazard. Staff confirmed the hazard and acknowledged the need for preventative maintenance as outlined in facility policy, which was not followed. Additionally, temperature readings in various areas of the facility were consistently low, with the North Hall at 65°F, the nurses' station at 66°F, and the South Hall at 68°F. Staff reported that the building's heating system, which relied on a boiler, was insufficient in colder weather, particularly in the North Hall, and there was no system in place to document or address temperature fluctuations. Multiple residents reported feeling cold, with some experiencing physical symptoms such as blue hands, shivering, and purple lips. Residents were observed wrapped in multiple blankets, and staff provided additional blankets as needed, but there was no blanket warmer available. Staff interviews indicated that the cold temperatures were a recurring issue each winter, and no measures were in place to improve the situation. The lack of consistent temperature monitoring and failure to address maintenance issues contributed to an environment that was neither comfortable nor safe for residents.
Failure to Honor Residents' Outdoor Activity Preferences
Penalty
Summary
The facility failed to honor the outdoor activity preferences of two residents, as evidenced by interviews and record reviews. One resident's family member reported that after admission, she was told the resident could only go outside with the smokers, who went out five times a day, but also stated that residents could go months without going outside. Another resident stated she had not been outside except for appointments and expressed a desire to go outside when the weather was comfortable, but staff had not taken her out, citing being busy. The Minimum Data Set (MDS) assessments for both residents indicated that going outside for fresh air was either 'somewhat important' or 'very important' to them. Staff interviews revealed that the activities staff member had not conducted any outside activities or used the facility's courtyard since starting in July, only feeling comfortable to do so months later. A review of the facility's activities calendars for several months showed no scheduled outside activities. The facility's policy requires the activity program to meet residents' interests and promote their well-being, but the lack of outdoor activities did not align with these stated procedures.
Failure to Complete Timely Comprehensive Admission Assessment
Penalty
Summary
The facility failed to complete a comprehensive assessment of a resident's needs, strengths, goals, life history, and preferences within the required 14 days of admission. Review of the medical record showed that the comprehensive Admission MDS assessment for one resident was still 'in progress' and had not been completed or submitted within the mandated timeframe, resulting in the assessment being 15 days late as of the last day of the survey period. During an interview, a staff member stated that Admission assessments are typically completed within 14 days of admission, but this was not the case for the resident in question.
Failure to Provide Regular Showers to Dependent Residents
Penalty
Summary
Facility staff failed to provide regular showers to four residents who were unable to perform activities of daily living independently. Observations revealed that these residents had greasy, unkempt hair and, in some cases, significant facial hair. Interviews with the residents confirmed that showers were not provided according to their expected schedule, with some residents reporting intervals of up to three weeks without a shower. Documentation review corroborated these reports, showing gaps of 12 to 22 days between showers for the affected residents. Staff interviews indicated that Certified Nursing Assistants (CNAs) were responsible for bathing tasks, but showers were sometimes missed due to short staffing or call-offs. Bathing was supposed to be documented in the electronic health record and on assignment sheets, but the records showed extended periods without showers for the residents in question. The facility was unable to provide a bathing policy when requested during the survey.
Failure to Provide Individualized Activities and Adequate Documentation
Penalty
Summary
The facility failed to provide group and individual activities that met the interests and supported the physical, mental, and psychosocial well-being of two residents. One resident reported staying in her room most of the time because the available activities, such as bingo, did not interest her, and she was observed lying in bed in the dark on multiple occasions. Her activity participation record showed involvement in only two activities over a 30-day period. Another resident expressed that she did not have much to do, did not like most scheduled activities, and was never offered in-room activities, despite her interest in coloring. She was also observed lying in bed and had participated in only one activity in the same period. Staff interviews revealed that the staff member responsible for care planning did not consistently document residents' refusals to participate in group activities or one-on-one time spent with residents. It was also noted that documentation of activities had been identified as an issue, with the Activities Director not documenting any activities until recently. The facility's activity program policy requires a multifaceted approach to meet the needs and interests of all residents, including individual and group activities, but these requirements were not met for the two residents involved.
Failure to Provide Consistent Mobility and Repositioning for Residents with Limited ROM
Penalty
Summary
The facility failed to provide appropriate assistance and positioning to maintain or improve mobility for two residents with limited range of motion. One resident reported a recurring coccyx wound and expressed a desire for more mobility work, noting that she participated in physical therapy three times a week. Observations and record reviews revealed that this resident was repositioned only once during each of two consecutive day shifts, with no consistent documentation of repositioning during night shifts as ordered by the physician. The resident was observed sitting in her wheelchair for extended periods without being moved, and both the resident and a family member expressed concerns about insufficient mobility support and infrequent repositioning. Another resident stated he developed sores on his coccyx from prolonged sitting and described a daily routine of sitting in a wheelchair for twelve hours and lying in bed for another twelve hours. Review of his records showed that restorative interventions, such as assisted transfers to a wheelchair for meals, were documented only sporadically over a 30-day period, with most days showing no activity. Staff interviews indicated that restorative duties were performed only after other CNA tasks were completed, and there was an effort to encourage more out-of-bed time, but this was not consistently implemented.
Failure to Provide Adequate Pain Management and Assessment
Penalty
Summary
A resident consistently reported significant leg pain throughout the day, stating that her legs hurt badly and that she often could not find her call light to request pain medication. She also reported that staff did not frequently ask her to rate her pain. Review of her electronic health record showed her pain was documented as 0/10 for both day and evening shifts on the day in question, despite her verbal reports of pain. The treatment administration record indicated that out of 216 opportunities from December to February, pain and an intervention were only documented 14 times, with all other days marked as not applicable. Interviews with a family member revealed ongoing concerns about the resident's pain, noting that the resident often complained of leg pain and had difficulty accessing staff for assistance. The family member also observed that staff did not reposition the resident or perform range of motion exercises, and that the resident was kept in bed for extended periods, which may have contributed to her discomfort. Staff interviews indicated no changes in pain interventions were considered necessary, and the resident continued to report pain from sitting in the same position all day.
Medication Administration and Documentation Deficiencies
Penalty
Summary
Staff failed to administer medications according to physician orders and facility policy for two residents. One resident, with a history of cerebrovascular accident (CVA), was observed receiving Tylenol 1000 mg without the medication being crushed and mixed with applesauce as specified in the medication administration record (MAR). Additionally, expired over-the-counter medications, including Vitamin B Complex, Colace, and Vitamin C, were found in medication carts on two separate halls, indicating a failure to dispose of medications past their expiration dates. Another resident was scheduled to receive Carafate 1000 mg before meals for GERD, but the medication was administered after the resident had already eaten, contrary to the physician's order and facility policy, which require administration on an empty stomach or before meals. The MAR had been preemptively checked off before the medication was actually given, and staff did not obtain a physician's order to accommodate the resident's preference for a different administration time. Facility policy requires medications to be administered as ordered and documentation to occur immediately after administration.
Failure to Provide Dental Services and Document Denture Referral
Penalty
Summary
A deficiency was identified when a resident, who was observed to be edentulous, reported that she previously had dentures that did not fit properly and that staff had not inquired about her interest in obtaining new dentures. Instead, staff accommodated her by cutting up her food, but there was no evidence that dental services were offered or arranged. The resident was alert and oriented, and staff could not provide documentation showing that dental services had been offered or that a referral had been made for denture replacement. Review of the resident's care plan indicated a problem with oral/dental health due to having no teeth, with interventions including coordinating dental care and transportation as needed. Facility policy required referral for dental services within three days of notification of lost or damaged dentures, with documentation in the medical record. However, no dental notes or documentation of referral for dental services were found for this resident during the survey period.
Failure to Use Gloves During Food Handling
Penalty
Summary
Staff failed to use gloves when handling a resident's food, as observed when a staff member picked up slices of cooked bacon with bare hands and placed them on a piece of toast on a resident's plate. The staff member acknowledged that this action was not in accordance with facility policy, which prohibits bare hand contact with food. Despite recognizing the error, the staff member did not immediately remove the contaminated plate, and the resident proceeded to eat the food. Later, the same staff member provided the resident with a new plate but transferred hashbrowns from the previously contaminated plate onto the new one. Interviews with staff confirmed that CNAs were not supposed to touch residents' food and that the facility's glove use policy specifically prohibited bare hand contact with food. The incident was directly observed and confirmed through staff interviews and policy review.
Failure to Clarify and Follow Hospice Orders for Resident
Penalty
Summary
The facility failed to ensure that hospice orders were clarified for accuracy and appropriately followed for a resident who had transitioned from comfort care to hospice care. Despite the resident being placed on hospice, staff interviews revealed confusion and inconsistency regarding the implementation of hospice versus comfort care orders. Staff members provided conflicting statements about the roles of facility staff and hospice in the care of hospice residents, with some indicating that hospice would take over care and others stating that the facility would continue to provide most care. Documentation showed that the resident continued to have active comfort care orders even after being placed on hospice, and some medications were administered according to comfort care protocols rather than hospice orders. A review of the resident's medication orders revealed discrepancies between the hospice orders and the facility's physician orders, particularly regarding the administration of morphine. The hospice order specified morphine to be given sublingually every 15 minutes as needed, while the facility's physician order indicated a different dosage and frequency. Staff interviews confirmed awareness of these discrepancies, with some staff expressing uncertainty about why the orders differed and who was responsible for clarifying them. The facility's documentation and staff responses indicated a lack of coordination and communication between the facility and hospice providers, resulting in the resident not consistently receiving care in accordance with hospice protocols.
Failure to Follow Infection Control Protocols During Medication Administration
Penalty
Summary
Staff failed to properly handle resident medications during administration for two residents. On two separate occasions, a staff member touched oral medications with bare hands before placing them in medication cups and administering them to the residents. In one instance, the medication was picked up from the medication cart after being dropped, again using bare hands. Facility policy required handwashing and glove use prior to handling tablets, but this protocol was not followed. An interview with another staff member confirmed that touching medications with bare hands was not acceptable practice due to infection control concerns and the risk of medication absorption through the skin.
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Illustrative
What surveyors actually found near you
We read the 21 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Missoula
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverside Health & Rehabilitation | 2 mi | ★★★★★ | 20 | 0 |
| Village Health & Rehabilitation | 4.5 mi | ★★★★★ | 1 | 0 |
| The Living Centre | 26.8 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.