BUTTE, MONTANA - Continental Care and Rehabilitation was cited for multiple serious regulatory violations during a May 2025 inspection, including failures to provide necessary vision care that left a resident unable to see her food or read, dangerous smoking practices that exposed residents to fire hazards, and systemic delays in meal service affecting the entire facility population.
Critical Vision Care Denied to Resident with Deteriorating Eyesight
One of the most concerning violations involved a resident whose vision had been deteriorating since October 2024 due to cataracts. By May 2025, the 58-year-old resident reported she could no longer see faces, read books, or even see her food during meals. Despite being diagnosed as needing cataract surgery in January 2025, the facility's repeated failures to schedule appointments properly and ensure timely transportation resulted in the surgery being canceled.
The resident told inspectors that the facility had made and canceled several appointments since November 2024, often without informing her or the medical providers. "I have been late or missed so many appointments, and once you're late they won't see you, and after so many times they won't let you come back," the resident explained to surveyors. The situation became so severe that the surgeon's office refused to reschedule her procedure after she arrived late to a February appointment due to transportation issues.
When the resident contacted the surgeon's office directly, she was told by staff there: "I know it's out of your hands, I'm sorry." The facility's new scheduler, who had only been in the position for three weeks at the time of inspection, was unaware of any pending vision appointments for the resident. Meanwhile, another staff member responsible for care coordination stated there were no vision concerns she could think of for this resident.
The facility's assessment documentation contradicted the reality of the resident's condition. The Minimum Data Set (MDS) assessment incorrectly indicated the resident could see fine detail such as regular print in newspapers and books, when in fact she demonstrated to inspectors that she could not read at all. The resident expressed frustration when she learned another resident had received their eye appointment and surgery quickly, stating it made her angry that she wasn't receiving the same level of assistance.
Dangerous Smoking Practices Create Fire and Health Hazards
Inspectors documented extensive violations of the facility's smoking policies that created significant safety risks for all residents. Three residents who smoked were observed repeatedly violating safety protocols, with staff members aware of but not addressing the violations.
A blind resident with a history of causing fire damage in previous living situations was observed smoking immediately outside the activities room door, despite facility assessments determining he was unable to smoke safely due to his blindness, balance problems, and medication regimen. The resident kept cigarettes and a lighter on his bedside table and would navigate to smoking areas by feeling his way along walls and using his feet to locate the cigarette disposal container.
Staff reported this resident had nearly burned down his apartment previously, with ash everywhere, and had been evicted from another apartment due to smoke damage. Despite these known risks and his documented moderate cognitive impairment (BIMS score of 8.0), the facility failed to provide adequate supervision or enforce safety measures. When staff attempted to redirect him to the designated smoking area, he became belligerent and refused to comply, citing that another staff member had given him permission to smoke near the door.
Another resident required a smoking apron for safety according to his assessment but was observed smoking without one. He reported that staff had only explained smoking rules to him after catching him attempting to smoke while carrying oxygen equipment. A third resident kept cigarettes and a lighter on his bedside table and had never been assessed for smoking safety despite being identified as a "repeat offender" for smoking in unauthorized areas.
Dozens of cigarette butts littered the ground around the activities room windows, doors, tables, and grassy areas. Multiple staff members acknowledged awareness of the violations but indicated they either didn't know it wasn't allowed or chose to "leave those issues for the nurse to handle." The facility's policy clearly stated it was a tobacco-free facility and campus with no accommodations for smoking permitted on the premises.
Widespread Meal Service Delays Affect Entire Facility
The inspection revealed systemic failures in meal service timing that affected residents across all units. Scheduled meal times were consistently missed, with some residents receiving lunch as late as 2:30 PM when it was scheduled for noon. Breakfast scheduled for 8:00 AM was often not served until after 9:00 AM, with some residents reporting they typically received breakfast around 10:00 AM.
Multiple residents reported the chronic nature of these delays. One resident stated that meals were "always late, especially the breakfast and lunch meals," with lunch often delivered between 1:30 PM and 2:30 PM. The delays had become so problematic that this resident had resorted to ordering food from local restaurants when hungry or when meals arrived too late.
Staff acknowledged the problems, with one employee stating that when certain kitchen staff were working, "trays will come out late, food is cold when it's late, and residents complain a lot." The dietary services manager attributed the issues to staffing fluctuations over several months. Medication administration schedules were also disrupted, with nursing staff reporting that most residents were receiving their medications late due to the delayed meal services.
The facility had three different documented meal schedules that conflicted with each other - one posted for residents and staff to see, another provided to surveyors at entrance, and a third in the facility's policy. None of these schedules were being followed consistently.
Medical and Safety Implications
The vision care failures represent a fundamental breakdown in care coordination. Cataracts are a progressive condition that significantly impacts quality of life and independence. The seven-month delay in treatment not only prolonged the resident's visual impairment but also increased her risk of falls, social isolation, and depression. The inability to see food properly affects nutritional intake and dining dignity. Standard medical practice requires timely referral and follow-up for cataract surgery once vision impairment interferes with daily activities.
The smoking violations created multiple serious hazards. Unsupervised smoking by cognitively impaired and physically disabled residents increases fire risk exponentially. Second-hand smoke exposure in areas near activity rooms violates health regulations and endangers other residents, particularly those with respiratory conditions. The presence of oxygen equipment near smoking areas represents an immediate fire and explosion hazard that could result in catastrophic outcomes.
Irregular meal timing disrupts metabolic regulation, particularly problematic for diabetic residents who require consistent food intake for blood sugar management. Delayed meals interfere with medication effectiveness, as many drugs must be taken with food at specific intervals. Cold food poses additional risks for residents with swallowing difficulties, as texture-modified diets lose their therapeutic properties when served at improper temperatures.
Additional Issues Identified
The inspection also revealed failures in comprehensive care planning, with one resident's bowel and bladder incontinence not included in their care plan despite being identified in assessments. Documentation errors included POLST (Physician Orders for Life-Sustaining Treatment) forms with incorrect names and missing signatures, creating potential complications during medical emergencies. The facility failed to implement proper behavioral interventions and comprehensive assessments as required by regulations, with documentation gaps throughout multiple resident records.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Continental Care and Rehabilitation from 2025-05-19 including all violations, facility responses, and corrective action plans.
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