Kalispell Rehabilitation: Missing Items Crisis - MT

"I literally spend one third of my time looking for missing items," one staff member told inspectors on January 15.

The scope of the problem became clear when resident #67 discharged from the facility still missing an iPad, an Apple Watch, and clothing. A family member had requested the resident's inventory sheet, but the items remained unaccounted for despite being listed on the facility's personal belonging inventory.

Multiple staff members described a facility overwhelmed by missing belongings. "There were missing items all the time, more so clothing," one staff member said. "The residents never had clothes, their closets were empty, and we never had anything to dress them in."

The memory care unit faced particular challenges. "There was a lot of missing clothing in the memory care unit, there were a lot of moving parts, and things can get lost quickly," another staff member explained. When asked about policies for handling missing items, the staff member said she had not seen one.

The facility's labeling system proved inadequate. Staff used a label maker that was frequently unavailable, writing on clothing with Sharpie markers, or asking families to label items themselves. One staff member said they worked with activities monthly to return piled-up clothes, but the label maker was "currently in activities because of the influx of Christmas clothing."

Lost items ended up in multiple locations throughout the facility. Staff described a "no name cart" and various lost-and-found areas, including one in C hall created specifically because "we had so many missing items." Items were sorted "every once in a while," but no systematic process existed.

The facility's grievance system failed to address the ongoing crisis. Two grievance forms from March 2024 captured residents' frustration: "Why do we fill out grievances? Nothing changes" and "Grievances not being addressed."

The grievance officer, a staff member identified as C, explained that administrators and the director of nursing determined what qualified as a grievance regarding missing items. But the process broke down regularly.

"Missing items are elevated to a grievance if they were aware of them," one administrator said. "When something doesn't get put on a grievance form they try to do a concern form for it, try to address the concern, and it doesn't always get in the grievance log."

The administrator acknowledged that "resident inventory is an area the facility could improve on" and said completing inventory listings on admission was an expectation, though not consistently followed.

Staff training on inventory procedures reached only a fraction of employees. An October 2024 in-service on inventory listing for nursing assistants had 11 attendees out of 116 total staff members, leaving 105 employees without training on the process.

The facility's grievance log showed additional problems. The administrator said the grievance log for August 2024 was missing and attributed previous issues to a former social worker who "was not very strong in her skillset."

Residents voiced their concerns through official channels. Meeting notes from the resident council showed ongoing resident concern about missing clothing, but these complaints failed to generate effective responses.

When inspectors requested documentation about lost and missing items for the previous 30 days, the facility provided nothing related to resident #67's missing belongings. A request for the facility's missing items policy also went unfulfilled by the end of the survey.

The systemic failure affected daily operations across the facility. Staff described constantly responding to reports of missing items, checking with laundry, and asking colleagues about whereabouts of resident belongings. The cycle consumed significant staff time while failing to resolve the underlying problems.

Federal inspectors found the facility's grievance system violated regulations requiring nursing homes to honor residents' rights to voice complaints without discrimination and establish effective processes for prompt resolution. The deficiency affected all residents who had concerns about grievances or lost items that management failed to elevate to formal grievance status.

The inspection revealed a facility where residents' personal belongings disappeared into an untracked system of carts, storage areas, and lost-and-found locations. Staff spent hours searching for items that might never be recovered, while residents like #67 left the facility without treasured possessions like iPads and Apple Watches.

Resident council meeting notes showed the problem persisted despite ongoing complaints. Staff acknowledged the scope of missing items but lacked policies, training, or systematic approaches to prevent losses or track belongings effectively.

The facility's inability to maintain basic inventory control or respond to resident grievances left families requesting documentation for items that had vanished into the facility's chaotic system of unlabeled clothing and misplaced personal property.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Kalispell Rehabilitation and Nursing LLC from 2025-01-16 including all violations, facility responses, and corrective action plans.

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