Whitefish Care and Rehab: 11 Deficiencies, No Fix Plan - MT
The patient, identified as resident #3, weighed 129.8 pounds when she arrived at Whitefish Care and Rehabilitation with a tooth infection and congestive heart failure. Twenty-six days later, staff discovered she had dropped to 115.8 pounds — a severe 10.4 percent weight loss that should have triggered immediate medical attention.
During the three-week gap without weighing, the woman was reportedly not eating or drinking. Staff member L, interviewed on October 22, acknowledged the resident was taking antibiotics for her tooth infection and diuretics for heart failure — medications that can affect fluid balance and require careful monitoring.
But the facility's hydration tracking had been systematically disabled.
Staff member B told inspectors the registered dietitian had been "disabling the hydration tracking for each resident when she placed the order for meal consumption." The dietitian made this decision despite the facility's own policy stating that hydration tracking "assists with maintaining a resident's health and is used for identifying concerns or trends related to hydration."
The tracking system's removal created a cascade of oversights. Staff member O discovered during the inspection that "intake and output for most facility residents had been deleted from the charting system." Without these basic measurements, the facility couldn't identify which residents were becoming dehydrated or losing dangerous amounts of weight.
The physician had ordered weekly weights for resident #3 on September 5, with specific instructions to "reweigh if >5# difference from previous week in the morning every Mon." Nursing staff ignored the order entirely.
When staff finally weighed the resident after three weeks, the 14-pound loss represented more than double the 5-pound threshold that should have triggered immediate re-weighing and medical evaluation.
Staff member L admitted to inspectors that "hydration was not documented and recorded in the medical record for each resident." This left doctors and nurses without critical information needed to adjust medications, identify medical complications, or prevent further deterioration.
The facility's own hydration policy, implemented just three months before the inspection, required staff to use "a systematic approach to optimize the resident's hydration status." The policy specifically mandated "identifying and assessing each resident's hydration status and risk factors" and "nursing staff shall assess hydration status upon admission and throughout the resident's stay."
None of this happened for resident #3.
The woman arrived with multiple conditions requiring careful fluid management. Her tooth infection could affect eating and drinking. Her congestive heart failure medication could cause dehydration. Her advanced age made her particularly vulnerable to rapid weight loss.
Yet for nearly a month, no one tracked whether she was drinking enough fluids. No one recorded what she consumed. No one weighed her to catch the steady decline that was literally wasting her away.
The dietitian's decision to disable hydration tracking affected not just resident #3, but "most facility residents," according to staff member O. The systematic removal of this basic safety monitoring left an unknown number of vulnerable patients without essential oversight.
By the time staff discovered the 14-pound weight loss, resident #3 had endured nearly a month of inadequate nutrition and hydration monitoring. The severe weight loss — classified as actual harm by federal inspectors — occurred while staff followed meal orders from a dietitian who had deliberately removed the tools designed to prevent exactly this outcome.
The facility is disputing the citation, but the inspection findings reveal a fundamental breakdown in basic care monitoring that left a sick, elderly woman to waste away largely unnoticed for weeks.
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.
During the three-week gap without weighing, the woman was reportedly not eating or drinking.
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.