Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
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 Polson Health & Rehabilitation Center during CMS and state inspections, most recent first.
A nurse diverted PRN narcotic medications from nine residents by signing out drugs from the narcotic log without documenting administration on the MAR. Two nurses suspected misappropriation but did not report it. The affected residents did not report unaddressed pain or missing medications, and the diversion was only discovered after a CNA reported concerns.
Two nurses failed to promptly report their suspicions of medication diversion by another staff member, despite having received abuse and crime reporting training. Their inaction delayed leadership awareness and investigation, during which nine residents were found to have had medications diverted.
A facility failed to provide adequate psychiatric services to a resident with multiple mental health disorders, resulting in persistent hallucinations and emotional distress. Despite attempts to arrange psychiatric consultations and telehealth options, the resident's condition remained unaddressed due to limited provider availability and refusal of telehealth. The facility lacked documentation of psychiatric care and staff training in behavioral health.
The facility failed to respond to call lights promptly, with residents experiencing significant delays in care. One resident reported waiting up to 30 minutes during breakfast, while another experienced a three-hour wait after a fall. Observations showed staff prioritizing other tasks over answering call lights, and interviews revealed a lack of clarity in staff responsibilities. The facility lacked a direct call light policy at the time of the survey.
A facility failed to have a resident's advance directive accessible in the Disaster Recovery Binder during an emergency. The document was missing from the binder, and staff indicated they would need to access the electronic health record system to locate it. A staff member acknowledged the oversight and attributed it to the inexperience of the responsible staff member.
A resident's care plan did not accurately reflect the current use of interventions, such as a wheelchair cushion and bedside rails. Observations showed the resident using a thin pillow and other items instead of a proper cushion, and there were inconsistencies in the use of bedside rails. Staff were unaware of the resident's use of these items, and the EHR lacked current orders or updates for a wheelchair cushion, despite an active order for siderails. The care plan included interventions not being utilized, and there was no MDS nurse to update care plans.
A resident with mental health issues experienced severe weight loss due to self-limiting food intake, aiming to reach a weight of 120 pounds encouraged by family. The facility failed to provide timely nutritional interventions or consult psychiatry, despite the resident's care plan requiring monitoring and supplements. Staff were unaware of the resident's weight loss goals, and no snacks or supplements were available in the resident's room during observations.
A facility did not follow physician orders to change a resident's oxygen tubing every two weeks, as the tubing was observed to be over a month old. Staff interviews revealed inconsistencies in practice, with some staff following CDC guidelines instead of the physician's order, leading to a potential risk of respiratory infection.
The facility did not ensure legible daily nurse staffing postings with required information, including the resident census. Staff used an old copy, making it hard to read, and the posting was placed high on a bulletin board, not easily accessible. The facility's policy mandates clear, readable postings in accessible locations.
The facility failed to maintain a sanitary kitchen, with multiple areas of concern for cleanliness, and dietary staff did not follow hygienic practices. Additionally, the facility did not consistently take and record temperatures for food storage and during meal service, leading to potential risks for residents consuming food from the facility kitchen.
The facility failed to report an injury of unknown origin and incident findings within the required timeframe for multiple residents. Delays were due to communication challenges and issues with the state reporting system.
Failure to Prevent and Detect Misappropriation of Resident Medications
Penalty
Summary
The facility failed to implement effective systems to prevent the misappropriation of residents' medications, resulting in multiple incidents where a staff nurse diverted narcotic medications from nine residents. The diversion was discovered after a CNA reported suspicions to a supervisor, leading to an internal investigation. It was found that two nurses had suspicions of medication misappropriation but did not report their concerns to facility leadership. The nurse responsible for the diversion signed out PRN narcotic medications from the narcotic log but did not document the administration on the medication administration record for the affected residents. Despite the narcotic counts being accurate, the diversion went undetected for a period of time. The affected residents were interviewed and none reported unaddressed pain or awareness of not receiving their prescribed pain medications. The investigation confirmed that nine residents had medications diverted, but no other residents were found to be affected. The staff member responsible for the diversion had received prior education on abuse, neglect, and misappropriation of property, and had completed all required background checks. The facility's policy defined misappropriation of resident property to include medications, and the incident involved the deliberate wrongful use of residents' narcotic medications without their consent.
Failure to Timely Report Suspected Medication Diversion
Penalty
Summary
Staff members M and N failed to report a reasonable suspicion of a crime related to medication diversion in a timely manner to facility leadership. Staff member N had a conversation with staff member M at the beginning of August regarding suspicions about staff member L and signs of medication diversion, but neither reported these concerns to their supervisor or the administrator. Staff member M had ongoing suspicions over several months but did not communicate these to staff member N until early August. The issue came to light when a CNA reported to staff member A that M and N had suspicions of medication diversion. An investigation revealed that nine residents had medications diverted, but no other residents were found to be affected, and no other staff reported concerns. Both staff members M and N had completed abuse training, including the requirement to report reasonable suspicion of a crime, during their orientation. Their personnel files confirmed current nursing licenses and completed background checks. The facility's policy required immediate reporting of any reasonable suspicion of a crime to the Executive Director, but this was not followed by the involved staff members, resulting in a delay in addressing the medication diversion.
Failure to Provide Adequate Psychiatric Services
Penalty
Summary
The facility failed to provide adequate psychiatric services to a resident diagnosed with multiple mental health disorders, including Borderline Personality Disorder, Generalized Anxiety Disorder, Major Depressive Disorder, and others. The resident experienced emotional breakdowns, crying, and hallucinations, which were not present before admission. Despite attempts by a family member to contact a closer facility for better psychiatric care, no changes or updates were made, and the resident continued to suffer from hallucinations and distress. Interviews with staff revealed that the facility was attempting to arrange a psychiatric consultation for the resident, but there was no clear plan in place. The resident's hallucinations persisted, and staff expressed uncertainty about whether this was the resident's new normal. The facility's emergency department note indicated a possible pharmaceutical issue, with recent increases in medications like Seroquel and olanzapine, and a reduction in Ativan dosage. Despite these concerns, no follow-up orders or rationale were documented by the physician. The facility struggled to secure psychiatric services due to a limited number of providers in the area and the resident's refusal of telehealth options, which were not documented. Staff acknowledged the need for psychiatric care, but the focus shifted to relocating the resident to a different facility closer to family. The facility lacked documentation of psychiatric appointments, physician notes, or referrals, and there was no evidence of staff training in trauma-informed care or behavioral health.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to respond to call lights in a timely manner for several residents, leading to significant delays in care. Resident #202 reported waiting up to 30 minutes after pressing the call button during breakfast. Resident #39 experienced an average wait time of an hour, with one instance of waiting three hours after a fall. Resident #17 mentioned an average wait time of ten minutes, but noted a 45-minute wait during an evening when he experienced chest pains. Resident #24 frequently waited longer in the morning due to perceived staff shortages, resulting in her voiding in her brief and waiting in a soiled state for hours. Observations confirmed that call lights were not promptly answered, with staff members prioritizing other tasks such as passing medications and food trays. Staff interviews revealed a lack of clarity and consistency in responding to call lights. Staff member H indicated that another staff member was responsible for answering call lights, but was unsure of their whereabouts. Staff member E stated that it was the CNAs' job to respond to call lights, but acknowledged that it was also part of their responsibility if CNAs were unavailable. Staff member K believed call lights should be answered within five minutes, but there was no direct call light policy in place at the time of the survey. The facility eventually provided a call light policy before the survey concluded, but the deficiency in timely response to call lights was evident throughout the observations and interviews.
Advance Directive Not Accessible in Emergency Binder
Penalty
Summary
The facility failed to ensure that a resident's advance directive was readily accessible in the Disaster Recovery Binder during an emergency. Specifically, the advance directive for one resident was not located in the designated binder, as observed during a survey. Staff member I confirmed the absence of the document and indicated that staff would need to access the electronic health record system, Point Click Care, to find the resident's POLST. Staff member A acknowledged that the document should have been in the binder and suggested that the staff member responsible for entering the information may not have consistently added it due to inexperience.
Inaccurate Care Plan for Resident's Wheelchair and Bed Interventions
Penalty
Summary
The facility failed to ensure that a resident's care plan accurately reflected the current use of interventions, specifically regarding the non-use of a wheelchair cushion and bedside rails. Observations revealed that the resident was using a thin pillow and other items in place of a proper wheelchair cushion, and there were inconsistencies regarding the presence and use of bedside rails. Staff interviews indicated a lack of awareness about the resident's use of these items, and the electronic health record (EHR) did not contain current orders or care plan updates for a wheelchair cushion, despite a physician's order for bilateral siderails being active since July 2023. The resident's care plan, last reviewed in August 2024, included interventions for mobility bars and a wheelchair cushion, but these were not being utilized. Staff members provided conflicting accounts of the resident's use of siderails and wheelchair cushions, and there was a noted absence of an MDS nurse to update care plans. The facility's policy required bed rail evaluations and care plan updates, but these were not consistently followed, leading to the deficiency.
Failure to Address Severe Weight Loss in Resident
Penalty
Summary
The facility failed to provide sufficient interventions for a resident who experienced severe weight loss. The resident, who had a history of mental health issues including Borderline Personality Disorder, Generalized Anxiety Disorder, and Major Depressive Disorder, was self-limiting her food intake, contributing to a significant weight loss of 12.41% over three months. Despite the resident's weight loss and her expressed desire to weigh 120 pounds, which was encouraged by her family, the facility did not consult with psychiatry or provide adequate nutritional interventions in a timely manner. The resident's care plan included monitoring meal intake and offering substitutes or supplements if intake was 50% or less, but there were no calorie-increasing supplements ordered until late August, and the resident did not have snacks or supplements available in her room during observations. Staff interviews revealed a lack of awareness regarding the resident's intentional weight loss and family influence. A staff member acknowledged that a supplement was discussed due to the resident's weight loss but was unaware of the resident's weight loss goals and family encouragement. The staff member also noted that they do not participate in care conferences or interdisciplinary team meetings, which may have contributed to the lack of coordinated care. The resident's care plan aimed to prevent unplanned significant weight loss or gain, but the interventions were not effectively implemented, leading to the deficiency.
Failure to Change Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to adhere to physician orders regarding the timely change of oxygen tubing for a resident, increasing the risk of respiratory infection and medical decline. Observations revealed that the oxygen tubing on both the portable tank and concentrator for the resident was dated 8/11/24, despite a physician's order from 3/23/24 requiring the tubing to be changed every two weeks and as needed. Interviews with staff indicated a discrepancy in practice, with one staff member stating that the tubing changes were scheduled for the night shift and documented in the Treatment Administration Record (TAR), while another staff member mentioned following CDC guidelines to change tubing only when visibly dirty, contradicting the physician's order.
Deficient Nurse Staffing Information Posting
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information was legible and contained all required details, including the resident census. During an interview and record review, a staff member acknowledged that the nursing staff repeatedly used an old copy of the daily nurse staffing posting, making it difficult to read. The copies provided for review only had handwritten numbers that were readable, and none included the resident census number. An observation revealed that the daily nurse staffing posting was placed high on a bulletin board behind the nurses' station, with only the handwritten numbers being legible and lacking the facility census. The facility's policy, last updated in July 2012, requires that the nurse staffing data be posted daily in a clear and readable format and in a prominent place accessible to residents and visitors.
Sanitation and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a sanitary kitchen, with multiple areas of concern for cleanliness observed. Dust buildup was noted on a window above the meal serving line, a standing fan, ceiling air vents, and walls over the cooking area. Refrigerators and freezers had spills, crumbs, and debris, with one refrigerator containing an expired thickened apple juice. Cleaning logs showed missing checkoffs for several days, and the monthly cleaning log for May 2024 was not provided. Staff interviews revealed that cleaning duties were split among kitchen staff, but the cleaning was not consistently documented or completed as required by the facility's policy. Dietary staff failed to follow hygienic practices, including not wearing hairnets, not washing hands, and not using gloves while handling food. Staff members were observed touching their faces and clothing while preparing and serving food without washing their hands. Staff interviews indicated confusion about the requirements for hairnets and beard nets, and it was noted that staff were educated about kitchen use and hygiene practices only after the deficiencies were observed. The facility also failed to take and record temperatures for food storage and during meal service. Temperature logs for refrigerators and freezers were incomplete, with several days missing PM temperatures. Food temperatures prior to and during meal service were not consistently documented, and staff did not take temperatures of microwaved food during meal service. The facility's policy required food temperatures to be taken and documented daily and monitored periodically throughout meal service, but this was not adhered to, leading to potential risks for residents consuming food from the facility kitchen.
Failure to Timely Report Incidents and Findings
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Survey Agency within the required timeframe for one resident and did not report incident findings within the five-day required timeframe for five residents. Specifically, a resident with a T11 fracture was not reported to the State Survey Agency until two days after the facility was notified of the results. Additionally, the facility did not notify the administrator immediately upon receiving the imaging results. Interviews with staff revealed that there was a lack of communication and adherence to the protocol for reporting injuries and notifying the appropriate personnel. Furthermore, the facility reported several incidents late, including a case of misappropriation of funds, an unwitnessed fall resulting in rib fractures, and an allegation of bullying. The findings for these incidents were submitted beyond the five-day required timeframe. Staff interviews indicated that there were challenges with communication and issues with logging into the state reporting system, which contributed to the delays. The facility's policy on abuse reporting and response mandates that the results of all investigations be reported within five working days, which was not adhered to in these cases.
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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 Polson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Luke Community Nursing Home | 9.8 mi | — | 0 | 0 |
| Hot Springs Health & Rehabilitation Center | 24.7 mi | — | 8 | 0 |
| Clark Fork Valley Nursing Home | 37.1 mi | — | 2 | 0 |
| Immanuel Skilled Care Center | 37.3 mi | — | 11 | 0 |
| Brendan House | 37.5 mi | — | 0 | 0 |
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