Whitefish Care: Dirty Floors, Garbage Under Beds - MT
The resident, who entered Whitefish Care and Rehabilitation weighing 129.8 pounds, had plummeted to 115.8 pounds by the time staff discovered the severe weight loss. She had been admitted with a tooth infection and was taking antibiotics along with a diuretic for congestive heart failure.
Staff member O told inspectors on October 22 that intake and output records for most facility residents had been deleted from the charting system. The missing data meant the resident's hydration status wasn't reflected anywhere in her electronic health record.
Nobody weighed the resident for three weeks, despite a physician's order from September 5 requiring weekly weights every Monday morning. The order specifically instructed staff to reweigh residents if they showed more than a five-pound difference from the previous week.
When staff finally recorded a weight 26 days after admission, they discovered the 14-pound loss represented a severe 10.4 percent drop in body weight.
The registered dietitian had been systematically disabling hydration tracking for each resident when placing meal consumption orders, according to staff member B. This happened even though tracking hydration helps maintain resident health and identifies concerning trends.
Staff member L, interviewed during the inspection, acknowledged she knew the resident was admitted with a tooth infection and was on antibiotics and diuretics for heart failure. She confirmed that hydration documentation wasn't being recorded in medical records for any residents.
By the end of her shift, staff reported the resident wasn't eating or drinking. There was no documentation of nausea or vomiting that might explain her deteriorating condition.
The facility's own hydration policy, implemented just three months earlier on July 1, required staff to offer each resident sufficient fluid to prevent dehydration and maintain health. The policy outlined a systematic approach including identifying hydration risk factors, evaluating assessment information, and consistently implementing appropriate interventions.
The policy specifically required nursing staff to assess hydration status upon admission and throughout each resident's stay according to established protocols.
Instead, the systematic deletion of intake and output records prevented staff from identifying the resident's declining condition or implementing timely interventions. The missing documentation created a blind spot that lasted for weeks while the resident's health deteriorated.
Federal inspectors found the failure to competently ensure proper hydration documentation prevented the facility from identifying concerns or developing appropriate responses. The deleted records meant staff couldn't track fluid intake patterns or spot dangerous trends before they became critical.
The resident's combination of medical conditions made proper hydration monitoring particularly crucial. Tooth infections can make eating and drinking painful, while diuretics increase fluid loss and dehydration risk. Congestive heart failure patients require careful fluid balance monitoring to prevent complications.
The 14-pound weight loss in less than a month represented the kind of severe decline that weekly weighing orders are designed to catch early. The physician's specific instruction to reweigh residents showing five-pound differences suggested awareness that rapid weight changes could signal serious problems.
The facility is disputing the citation, which federal inspectors classified as causing actual harm to a few residents.
The systematic disabling of hydration tracking affected most residents in the facility, according to inspection findings. Staff member O's discovery that intake and output records had been deleted from the charting system revealed the scope of the documentation failures extended far beyond the single resident who lost 14 pounds.
The resident's severe weight loss went undetected for 26 days while staff failed to follow basic monitoring protocols designed to protect vulnerable patients from dehydration and malnutrition.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Whitefish Care and Rehabilitation from 2025-10-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
WHITEFISH CARE AND REHABILITATION in WHITEFISH, MT was cited for violations during a health inspection on October 22, 2025.
She had been admitted with a tooth infection and was taking antibiotics along with a diuretic for congestive heart failure.
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.