Village Health & Rehabilitation: Fall Breaks Resident's Femur - MT
The resident, identified in inspection records as Resident 85, fell at 3:00 p.m. on August 9. She was alert and oriented, aware of who she was, where she was, and what had happened. When staff determined she needed to go to the emergency room, she declined.
She changed her mind as the pain grew worse.
An ambulance was called and arrived. By 8:20 that evening, she was at the emergency department. A staff nurse called for an update around 10:00 p.m. and reached the ER secretary, who relayed that the resident would be admitted. The nurse logged the reason: a significantly fractured femur.
The facility's own incident audit report, dated August 27 and reviewed by inspectors, described the fall as a follow-up matter. It noted her mental status — oriented to person, place, situation, and time — and recorded that she had initially declined transport but agreed to go as her pain increased.
The hospital's discharge summary filled in what the X-ray found: a moderately displaced periprosthetic right femur fracture. Periprosthetic means the break occurred around an existing implant, the kind of fracture that complicates surgery and recovery and carries serious risks for elderly patients.
The facility's physician was notified. His note, logged August 11, two days after the fall, read: "agree with ED eval after fall with significant pain, thanks for the update, will await her return."
Federal inspectors cited the fall under F0689, the tag covering accidents and the environment of care, and assigned it a harm level of actual harm. That designation means inspectors concluded the fall and its consequences were not a near-miss or a theoretical risk. The fracture was the outcome.
The inspection was triggered by a complaint. What the complaint alleged, and whether it pointed to a specific lapse in supervision or equipment or care planning before the fall, is not detailed in the portion of the report reviewed. What the report documents is what happened after: a woman in pain who initially said no to the ambulance, then said yes, and ended up admitted to a hospital with a broken bone around a prior implant while her facility's doctor waited for word of her return.
She was alert for all of it.
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 resident, identified in inspection records as Resident 85, fell at 3:00 p.m.
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.