Whitefish Care and Rehab: 11 Deficiencies, No Fix Plan - MT
Resident 3 entered the facility with a tooth infection and congestive heart failure, weighing 129.8 pounds on admission. Twenty-six days later, staff discovered she had lost 14 pounds — a severe 10.4% weight loss that went undetected because basic monitoring systems had been turned off.
The woman wasn't eating or drinking during her stay, but staff failed to document her intake and output in medical records. When inspectors requested hydration documentation on October 22, they learned most residents' intake and output records had been deleted from the facility's electronic health record system.
Staff member O told inspectors during chart review that "the intake and output for most facility residents had been deleted from the charting system." The missing records meant "the resident's intake and output were not reflected in the EHR."
Staff member B revealed the registered dietitian had been "disabling the hydration tracking for each resident when she placed the order for meal consumption." This happened despite the facility's own acknowledgment that "tracking the hydration assists with maintaining a resident's health and is used for identifying concerns or trends related to hydration."
The weight loss went unnoticed for three weeks. The facility's physician had ordered weekly weights on September 5, with instructions to "reweigh if >5# difference from previous week in the morning every Mon." Nursing staff failed to follow the order.
Staff member L knew the resident had been admitted with a tooth infection and was taking antibiotics. She also knew the woman was on a diuretic for congestive heart failure — medications that made hydration monitoring even more critical. Yet she acknowledged that "hydration was not documented and recorded in the medical record for each resident."
During the inspection, staff reported the resident "was not eating or drinking, and there was no report of nausea or vomiting." Without proper intake tracking, staff had no way to identify the developing crisis or intervene before severe weight loss occurred.
The facility's own hydration policy, implemented just three months earlier in July 2025, required a "systematic approach to optimize the resident's hydration status." The policy mandated identifying and assessing each resident's hydration status and risk factors, then developing consistent approaches to address them.
The policy defined sufficient fluid as "the amount of fluid needed to prevent dehydration and maintain health," noting that requirements are "specific to each resident and fluctuates as the resident's condition fluctuates." It required nursing staff to "assess hydration status upon admission and throughout the resident's stay in accordance with assessment protocols."
None of this happened for Resident 3. The systematic deletion of hydration records made it impossible for staff to track trends, identify problems, or provide appropriate care. The 14-pound weight loss — representing more than 10% of her body weight — occurred while staff remained unaware of her deteriorating condition.
Federal inspectors classified the violation as causing actual harm to residents. The facility is disputing the citation.
The case illustrates how seemingly administrative decisions can have serious consequences for vulnerable residents. By disabling hydration tracking systems, staff eliminated their ability to detect and respond to medical emergencies before they became life-threatening.
For Resident 3, the combination of tooth infection, heart failure medication, and poor oral intake created a perfect storm that staff were unable to recognize without proper monitoring systems in place.
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.
Resident 3 entered the facility with a tooth infection and congestive heart failure, weighing 129.8 pounds on admission.
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.