Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 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 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.
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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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.
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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 | — | 16 | 0 |
| Village Health & Rehabilitation | 4.5 mi | — | 1 | 0 |
| The Living Centre | 26.8 mi | — | 5 | 0 |
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