Village Health & Rehabilitation: Diet Order Failures - MT
The citation, issued August 28, falls under the category of nutrition and dietary deficiencies. Therapeutic diets, which include restrictions or modifications for residents managing conditions such as diabetes, kidney disease, or swallowing disorders, are required to be prescribed by an attending physician. A facility may delegate that responsibility to a registered or licensed dietitian, but only to the extent state law permits. Inspectors found Village Health was not meeting that standard.
The deficiency was classified at Scope/Severity Level D, meaning it was an isolated finding with no documented actual harm to residents, but with potential for more than minimal harm. That distinction matters. A resident receiving the wrong therapeutic diet, or no therapeutic diet order at all, may not show immediate symptoms. The consequences can take time to surface, and by then the connection to a missed or improperly prescribed diet order is easy to overlook.
It was one of six deficiencies cited at the facility during the same inspection.
Village Health reported a correction date of September 23, nearly four weeks after inspectors left the building.
The gap between an inspection finding and a correction date is, in itself, a data point. A facility that identifies a problem on August 28 and reports it fixed on September 23 spent nearly a month operating with a known deficiency in how it managed medically necessary diets for vulnerable residents.
What the inspection report does not say is how many residents were affected, how long the practice had been in place before inspectors arrived, or what specific breakdowns in the ordering process led to the citation. The report's narrative is brief. It confirms the deficiency existed. It does not describe a single resident's situation or explain what the facility's dietary staff were doing in the absence of proper orders.
That brevity is worth noting. A Level D citation is the lowest rung on the severity scale, and facilities cited at this level often face limited public scrutiny. But therapeutic diets are not a paperwork formality. For a resident with end-stage renal disease, a diet that goes unmonitored or improperly ordered can accelerate organ damage. For a resident with dysphagia, a texture modification that isn't formally prescribed and tracked can increase the risk of aspiration. The diet is the treatment.
Village Health & Rehabilitation is not a facility with a single blemish on an otherwise clean record. The August 28 inspection produced six citations in total. The dietary deficiency was one piece of a larger picture that inspectors documented that day, though the full scope of the other five findings is not detailed in this report.
Nursing homes in Montana, as elsewhere, operate under federal oversight through the Centers for Medicare and Medicaid Services. Complaint inspections like the one that produced this citation are typically triggered by a report from a resident, family member, or staff. Someone, at some point before August 28, raised a concern about this facility. The inspection that followed found six things wrong.
The facility's reported correction, submitted nearly a month after the inspection, suggests the problem was not one that could be fixed in a day. Whether that means new protocols had to be written, staff had to be retrained, physician relationships had to be restructured, or something else entirely, the report does not say.
What it does say is that residents at Village Health were receiving, or at risk of receiving, therapeutic diets that lacked the medical authorization they require. In a setting where many residents cannot advocate for their own nutritional needs, where cognitive impairment or physical decline limits what a person can communicate about how they feel, the systems around them are supposed to compensate. The physician order, the dietitian review, the documented prescription, these are the mechanisms that stand between a vulnerable person and a diet that could quietly make them sicker.
For at least some period before late September, those mechanisms were not functioning as required at Village Health & Rehabilitation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Village Health & Rehabilitation from 2025-08-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 30, 2026 · Our methodology
VILLAGE HEALTH & REHABILITATION in MISSOULA, MT was cited for violations during a health inspection on August 28, 2025.
The citation, issued August 28, falls under the category of nutrition and dietary deficiencies.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.