Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 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 Village Health & Rehabilitation during CMS and state inspections, most recent first.
The facility did not submit investigation findings for a resident-to-resident incident to the State Survey Agency within the required five-day period, resulting in a late report for two residents involved in the event.
A deficiency was cited when a facility area was not kept free from accident hazards and supervision was inadequate to prevent accidents. The environment and oversight did not meet required standards to minimize accident risks.
A resident with a history of hip replacement complications fell during a transfer when left unsupported by a nurse. Staff did not promptly notify the physician as required by facility protocol, resulting in delayed treatment for a fracture and unmanaged pain. Documentation did not reflect timely physician notification, contrary to facility policy.
Two residents were involved in a physical altercation where one reported being touched inappropriately by another. Although the incident was documented and communicated internally, the allegation was not reported to the State Survey Agency within the required 24-hour period, as required by facility policy. Staff interviews indicated a lack of awareness of the reporting requirement, and video evidence of the incident was no longer available for review.
Staff did not consistently use required PPE when caring for residents on special droplet/contact and contact precautions, with missing N-95 masks and lack of eye protection observed. In addition, staff and visitors were not properly educated or monitored regarding cleaning and precautionary practices for residents with C. diff, resulting in improper room cleaning and delayed notification of necessary precautions. Facility policies outlining PPE and cleaning requirements were not consistently followed or communicated.
The facility failed to maintain a clean environment for residents, with observations revealing sticky substances and debris in rooms. Residents reported infrequent cleaning, and staff confirmed understaffing in housekeeping, leading to inadequate cleanliness. Despite claims of daily cleaning, observations showed neglected areas, particularly under beds.
The facility failed to update care plans in a timely manner for residents with pressure ulcers and behavioral issues. A resident with a stage III pressure ulcer had their care plan updated over two months later, while another resident's care plan for a pressure ulcer was delayed by nearly a month. Additionally, a resident involved in altercations had their care plan updated weeks after the incidents. These delays indicate a failure to provide timely interventions for both pressure ulcer management and behavioral issues.
A facility failed to accurately assess a resident involved in altercations, potentially affecting care and safety. The resident's evaluation inaccurately showed no history of abuse or behaviors making them susceptible to abuse, despite nurse's notes documenting confusion, agitation, and disruptive behaviors. A staff member admitted to not thoroughly considering the resident's behaviors during the evaluation.
A facility failed to limit an as-needed anti-anxiety medication order to 14 days or provide a rationale for its continued extension for a resident using Lorazepam. The medication was re-ordered multiple times without justification, and the facility did not provide documentation of education or consent for its use. The facility administered the medication without addressing the source of the resident's agitation, contrary to its policy.
A resident with a history of falls and impaired mobility fell and sustained a hip fracture after mistakenly using the bed control instead of the call light, which was out of reach. The bed was elevated, and the resident attempted to get up, resulting in the fall. Staff interviews revealed inconsistencies in call light placement, and documentation of rounds was not provided.
The facility failed to ensure proper food safety and hygiene practices, as staff with facial hair did not wear beard coverings, and food items in the walk-in freezer were not labeled or dated. Additionally, leftover chicken was not properly cooled, and the responsible staff member was unaware of the correct procedures, with no food cooling logs available.
A facility failed to implement a baseline care plan within 48 hours for a newly admitted, nonverbal resident with a subdural hematoma and stroke, who was totally dependent on staff for ADLs. The care plan was delayed, with initiation occurring several days post-admission, contrary to the facility's policy. A staff member admitted to occasionally forgetting to complete these plans on time.
A resident with a PTSD diagnosis did not have a care plan in place, leading to staff being unaware of her condition and triggers. This resulted in an incident where her PTSD was triggered by a CNA entering her room abruptly. A staff member confirmed the lack of a care plan and was unaware of the resident's PTSD diagnosis.
A facility failed to update a resident's care plan regarding catheter management after the resident and their POA decided to discontinue urology clinic appointments and focus on comfort care. The care plan, last updated months prior, still listed the clinic as responsible for catheter management, without reflecting the new focus on comfort care and the management of scheduled and PRN catheter changes.
A facility failed to manage catheter changes as ordered for a resident with a suprapubic catheter, leading to frequent changes due to clogging. The staff did not adjust scheduled change dates after PRN changes and missed documentation for catheter flushes. The resident reported bladder pain, but no recent infections were documented.
A resident missed a dialysis appointment due to the facility's failure to provide transportation. The resident was waiting for a van but could not open the door due to a coded keypad, and the transportation company left after calling the facility without an answer. The resident was later hospitalized and in the ICU for three days. The facility had an agreement stating it was responsible for arranging transportation.
A resident with PTSD did not receive necessary behavioral health services at the facility. The resident reported a lack of communication about her PTSD and minimal interaction with the social worker. She experienced a triggering incident and expressed a need for support, especially regarding her dialysis treatment decisions. Staff were unaware of her PTSD diagnosis and did not facilitate mental health referrals or contact with her personal counselor. Her care plan lacked guidance for managing her PTSD.
The facility failed to follow infection control practices during pericare and wound care for a resident, as staff did not sanitize surfaces or change gloves and perform hand hygiene. Additionally, enhanced barrier precautions were not implemented for a resident with a PICC line, as required by facility policy.
Late Submission of Investigation Findings for Resident Incident
Penalty
Summary
The facility failed to submit investigation findings for a resident-to-resident incident to the State Survey Agency within the required timeframe for two of nine sampled residents. The incident was initially reported to the State Survey Agency, but the facility's investigation findings were submitted one day late, after the five-day deadline had passed. During an interview, a staff member confirmed that such incidents are to be reported within 24 hours and investigation findings submitted within five days, excluding weekends and holidays. Review of the facility's policy confirmed these reporting requirements.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Promptly Notify Physician After Resident Fall Resulting in Injury
Penalty
Summary
A deficiency occurred when facility staff failed to promptly notify a physician after a resident experienced a fall that resulted in injury and pain. The resident, who had a history of complications following a right hip replacement, reported falling during a transfer when left unsupported by a nurse who went to seek assistance. Staff interviews confirmed that the established fall protocol required immediate notification of the physician and family, but the responsible staff member did not notify the on-call physician after the incident. Documentation in the resident's electronic health record did not show timely physician notification regarding the fall and the resident's increased pain. The delay in physician notification led to a delay in treatment, and the resident was later found to have sustained a fracture. Facility policy and the fall prevention program both required prompt notification of the physician and family following an accident resulting in injury. The lack of timely communication with the physician impacted the opportunity for the physician to provide directives on the resident's care, pain management, and injury assessment.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to the State Survey Agency within the required 24-hour timeframe. Specifically, two residents were involved in a physical altercation in which one resident reported that another had touched his groin. The incident was initially reported by the resident to nursing staff on the evening it occurred, and this was documented in the nursing progress notes. The staff communicated the incident internally to social services and the DON, but the allegation was not reported to the State Survey Agency until several days later. Staff interviews revealed a lack of awareness regarding the reporting requirement and confusion about the need to report when the resident later denied the incident occurred. Facility policy requires immediate reporting of suspected abuse, including sexual abuse, to the State Survey Agency and other authorities within specified timeframes. Despite this, the initial allegation was not reported as required, and the facility's video surveillance of the incident was no longer available for review at the time of the survey. The deficiency was identified through interviews, record review, and examination of facility policy, which clearly outlines the obligation to report such incidents promptly.
Failure to Adhere to PPE and C. diff Cleaning Protocols
Penalty
Summary
Facility staff failed to consistently wear appropriate personal protective equipment (PPE) while caring for residents under special droplet/contact and contact precautions. Observations revealed that PPE supply containers in multiple hallways lacked N-95 masks, and staff were seen entering and exiting rooms with special droplet/contact precaution signage while wearing only procedural masks and without required eye protection. In one instance, a staff member was unaware of the need to wear a mask throughout the facility, and another staff member entered a contact precaution room without donning any PPE, only putting on gloves after entering to handle a resident's catheter bag. Signs indicating required precautions were not always followed, and doors that were supposed to remain closed were observed open. The facility also failed to adequately educate and monitor staff regarding cleaning practices for residents with Clostridioides difficile (C. diff) infections. Family members visiting a resident were not informed of the need to wear gowns and gloves or to avoid bringing an infant into a room where a roommate had tested positive for C. diff, only being notified after several visits. Staff interviews revealed a lack of knowledge about the appropriate cleaning agents and procedures for C. diff, with some staff unable to identify the correct cleaning solution or required contact time for disinfection. There was also uncertainty about whether a written process for cleaning rooms of residents with C. diff existed, and housekeeping staff had not been specifically trained on these procedures. Review of facility policies confirmed that staff were expected to adhere to specific PPE requirements for COVID-19 and C. diff, including the use of N95 respirators, gowns, gloves, and eye protection for COVID-19, and daily cleaning with a sporicidal agent for C. diff. However, these protocols were not consistently implemented or communicated to staff, leading to lapses in infection prevention and control practices for multiple residents.
Facility Fails to Maintain Clean Environment for Residents
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its residents, as evidenced by observations and interviews with residents and staff. Resident #72 reported that her room had not been mopped for several days, with a sticky substance remaining on the floor. Observations confirmed the presence of a red sticky substance and debris under the bed. Resident #16 and another individual noted that the floors were not cleaned regularly, with dark spots remaining for several days. Resident #95 also mentioned that the rooms were not cleaned frequently, with heavy black stains and debris observed around the door frames. Staff interviews revealed that the facility was understaffed in housekeeping, leading to inadequate cleaning of resident rooms. Staff member F claimed that beds were cleaned under daily, but observations contradicted this, showing dirt and debris under the beds. Staff member G acknowledged that while the halls were relatively clean, the resident rooms were not, and areas under the beds were particularly neglected. Staff member S confirmed the facility's cleanliness issues, attributing them to a shortage of housekeeping staff and the inability of nursing staff to compensate for the lack of cleaning.
Delayed Care Plan Updates for Pressure Ulcers and Behavioral Issues
Penalty
Summary
The facility failed to update and revise care plans in a timely manner for residents with pressure ulcers and behavioral issues. Resident #1 had a new wound identified as a stage III pressure ulcer on the left heel on 9/6/24, but the care plan was not updated to reflect this until 11/18/24. Similarly, resident #16 had a stage III pressure ulcer on the right heel identified on 10/22/24, but the care plan was not updated with interventions until 11/18/24. Resident #55 developed a new in-house acquired pressure ulcer on 10/28/24, but the care plan was not updated until 11/18/24. These delays in updating care plans indicate a failure to provide timely interventions for pressure ulcer management. Additionally, the facility failed to revise the care plan for resident #33 in response to repeated resident-to-resident altercations. On 8/29/24, resident #33 was involved in an altercation where he smacked another resident, and on 8/30/24, he was hit by another resident. The care plan was not updated until 9/10/24, and further updates were not made until 10/11/24. The care plan updates included interventions such as sitting on the opposite side of the dining room from louder residents and using music as a form of expression. The delay in updating the care plan for behavioral interventions highlights a lack of timely response to resident behavioral issues.
Inaccurate Resident Assessment in LTC Facility
Penalty
Summary
The facility failed to complete accurate assessments for a resident involved in two altercations, which could potentially affect resident care and safety. The resident's vulnerable resident evaluation dated 9/30/24 inaccurately indicated that the resident did not have a history of abuse toward others or behaviors that would make them susceptible to abuse by others. Additionally, the resident's MDS with an ARD of 10/3/24 showed no physical, verbal, or other behavior symptoms directed toward others. However, nurse's notes from 9/28/24 and 10/2/24 documented the resident's increasing confusion, agitation, and disruptive behaviors, which required administration of prn antianxiety medication. During an interview, a staff member admitted to completing the evaluation without thoroughly considering the resident's behaviors, acknowledging that the evaluation should have been more accurate.
Failure to Limit and Justify PRN Anti-Anxiety Medication Use
Penalty
Summary
The facility failed to limit an as-needed anti-anxiety medication order to 14 days or provide a rationale for its continued extension for a resident using Lorazepam. The medication was initially ordered for 4 days but was not administered during that period. Despite this, the medical provider re-ordered the medication for another 14 days without justification, and again for 6 months, even though the resident had not received any doses until later. The facility did not provide documentation of education or consent for the use of Lorazepam, and the resident's representative was not informed about the risks or benefits of the medication. The facility's policy requires that psychotropic medications be initiated only after addressing medical, physical, functional, psychosocial, and environmental causes. However, the facility administered Lorazepam to the resident without addressing the source of agitation, which was related to a staff member. The physician was aware of the medication's administration but did not document a rationale or diagnosis for its continuation. The facility's failure to adhere to its policy and lack of documentation for the medication's use contributed to the deficiency.
Resident Fall Due to Inaccessible Call Light and Elevated Bed
Penalty
Summary
The facility failed to provide a safe environment for a resident, resulting in a fall and significant injury. The resident, who had a history of falls and required assistive devices, was found on the floor with a left elbow skin tear and complained of left hip pain. The resident's bed was in the highest position, and the call light was not within reach, leading the resident to mistakenly use the bed control instead of the call light. This caused the bed to elevate, and the resident attempted to get up, resulting in a fall and a left hip fracture. Interviews with staff revealed discrepancies in the availability and placement of the call light. One staff member stated that the call light was on the bedside table, too far for the resident to reach, while another mentioned that the call light was on the floor due to a short cord. The resident had called 911 himself after the fall. Documentation of rounds and the facility's rounding policy were requested but not provided before the survey exit, indicating a lack of proper documentation and adherence to safety protocols.
Food Safety and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure proper food safety and hygiene practices in the kitchen, as observed during a series of inspections. Staff members with facial hair were repeatedly seen not wearing beard coverings while working in the kitchen, despite the facility's policy requiring hair restraints to prevent hair from contacting food. This was observed on multiple occasions with different staff members, indicating a lack of adherence to the established guidelines for food preparation and handling. Additionally, the facility did not label or date food items stored in the walk-in freezer, including Danish pastries, birthday cakes, and a yellowish substance in small drink cups. This lack of labeling was confirmed by staff members who acknowledged the oversight. Furthermore, the facility failed to properly cool leftover chicken, as it was left sitting out on the counter for an extended period before being placed in the cooler. The staff member responsible was unaware of the proper cooling procedures and could not locate the required food cooling logs, which are essential for ensuring food safety. These deficiencies in food handling and storage practices had the potential to affect all residents consuming food from the facility's kitchen.
Failure to Implement Timely Baseline Care Plan for New Resident
Penalty
Summary
The facility failed to implement a baseline care plan within the required 48-hour timeframe for a newly admitted, nonverbal resident diagnosed with a subdural hematoma and stroke. This resident was totally dependent on staff for activities of daily living, including eating. The electronic health record indicated that the resident was admitted at 1:00 PM, but the baseline care plan was not initiated until several days later, with one focus area starting on the third day and others not until the fifth day or later. During an interview, a staff member acknowledged that the baseline care plan should have been completed on the first day of the resident's stay, as per the facility's policy. The staff member admitted to occasionally forgetting to complete these plans in a timely manner, and the delay in completing the baseline care plan for this resident did not meet her expectations. The facility's policy, reviewed in October 2023, clearly states that a baseline care plan must be developed within 48 hours of admission to ensure effective and person-centered care.
Failure to Develop PTSD Care Plan for Resident
Penalty
Summary
The facility failed to initiate a care plan for a resident diagnosed with unspecified PTSD upon admission. The absence of a care plan meant that staff were not informed of the resident's PTSD triggers or the best ways to assist her in coping with triggering events. A trauma screening tool was completed, but the resident denied experiencing trauma, and no further documentation was provided to identify trauma despite the diagnosis. During an interview, the resident reported that her PTSD was triggered when a CNA entered her room abruptly, suggesting that staff awareness of her condition could have prevented this incident. Additionally, a staff member confirmed being unaware of the resident's PTSD diagnosis and acknowledged that no care plan had been developed to address it.
Failure to Update Care Plan for Catheter Management
Penalty
Summary
The facility failed to update the care plan for a resident regarding catheter care. The resident, who had been under the care of a local urology clinic for catheter management, decided with their Power of Attorney (POA) to discontinue appointments with the clinic and focus on comfort care. Despite this change, the care plan was not updated to reflect the new approach to care, including the discontinuation of urology appointments and the management of scheduled and PRN catheter changes. The care plan still listed the urology clinic as responsible for the catheter management, which was last updated several months prior to the decision to focus on comfort care.
Failure to Manage Catheter Changes as Ordered
Penalty
Summary
The facility failed to manage catheter changes as ordered by the physician for a resident with a suprapubic catheter, leading to multiple catheter changes within short intervals. The resident's catheter was supposed to be changed every three weeks, but due to clogging issues, it was changed more frequently without adjusting the scheduled change dates. This resulted in the catheter being changed four times in three weeks in May, three times in June, and three times in July. The staff did not document the necessary adjustments to the scheduled catheter change dates after performing as-needed (PRN) changes, which were required due to clogs or malfunctions. Interviews with staff revealed a lack of awareness regarding the need to adjust the scheduled catheter change dates following PRN changes. Additionally, there was missing documentation for the administration of catheter flushes intended to prevent clogging, which were ordered to be performed twice daily. The resident reported experiencing burning pain in the bladder, which was known to the facility staff, yet there was no indication of recent infections or pain complaints documented. The failure to adhere to the physician's orders and properly document catheter care increased the risk of infection and complications for the resident.
Failure to Provide Transportation for Dialysis Appointment
Penalty
Summary
The facility failed to ensure transportation was provided for a dialysis appointment for a resident who required such services. On the morning of February 10, 2024, the resident was waiting in the reception area for transportation to a dialysis appointment. Although the transportation van arrived, the resident was unable to open the front door due to a coded keypad, and the transportation company left after calling the facility without receiving an answer. As a result, the resident missed the dialysis appointment. Following the missed appointment, the resident had to be hospitalized and was in the ICU for three days. Interviews with staff revealed that the transportation company would not wait if there was no answer from the facility, and the facility would provide transportation if they found out a resident missed the bus. The facility had a Memorandum of Agreement with the dialysis facility, stating that the LTC facility was solely responsible for arranging transportation for its patients.
Failure to Provide Behavioral Health Services for Resident with PTSD
Penalty
Summary
The facility failed to provide necessary behavioral health services to a resident diagnosed with PTSD. The resident reported that none of the facility's staff had discussed her PTSD with her, and she experienced a triggering incident when a certified nurse assistant abruptly entered her space. Despite this incident, the resident stated that she had minimal interaction with the social worker and had not developed any relationships with the staff, who were perceived as too busy. The resident expressed a need for someone to talk to, especially as she was struggling with decisions regarding her dialysis treatment. She also mentioned that she had not been offered an appointment with a mental health provider or assistance in contacting her personal mental health provider. Staff member G, during an interview, admitted to not being aware of the resident's PTSD diagnosis and did not make any local referrals for mental health care. Additionally, staff member G was unaware of the resident's existing mental health counselor and did not assist in facilitating contact or arranging a private space for communication. A review of the resident's electronic medical record revealed no referrals for mental health services, and her care plan lacked identification of PTSD triggers or guidance for staff on managing her condition.
Infection Control and Barrier Precaution Deficiencies
Penalty
Summary
The facility failed to ensure proper infection control practices during pericare and wound care for a resident. During an observation, a staff member did not sanitize the bedside table before placing wound care supplies on it. Another staff member, who was assisting with the dressing change, did not change gloves or perform hand hygiene after removing a soiled brief and performing pericare. This staff member acknowledged the failure to change gloves or practice hand hygiene during the procedure. The facility's policy required hand hygiene before and after resident contact and after handling soiled items, which was not followed in this instance. Additionally, the facility did not implement enhanced barrier precautions for a resident with a PICC line. Observations revealed that there was no signage or personal protective equipment indicating the need for enhanced barrier precautions outside the resident's room. A staff member confirmed that enhanced barrier precautions were required for residents with indwelling medical devices, such as a PICC line, and that a sign should have been placed on the door. The facility's policy stated that enhanced barrier precautions should be initiated for residents with indwelling medical devices, which was not adhered to in this case.
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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 | 3.5 mi | — | 16 | 0 |
| Missoula Health & Rehabilitation Center | 4.5 mi | — | 6 | 0 |
| The Living Centre | 23.3 mi | — | 5 | 0 |
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