Whitefish Care and Rehab: Nutrition Harm Found - MT
The 129.8-pound resident dropped to around 116 pounds over 26 days at Whitefish Care and Rehabilitation, a severe 10.4% weight loss that went undetected because nursing staff failed to follow doctor's orders for weekly weighing.
Staff member O discovered the problem during a chart review on October 22. "The intake and output for most facility residents had been deleted from the charting system," she told inspectors. "Due to this, the resident's intake and output were not reflected in the EHR."
The resident, identified as resident #3 in inspection records, had been admitted with a tooth infection and was taking antibiotics. She also had congestive heart failure and was on diuretics. Despite these conditions requiring careful fluid monitoring, the facility's registered dietitian had been "disabling the hydration tracking for each resident when she placed the order for meal consumption."
Staff member B explained the dietitian's actions to inspectors, noting 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 weeks. A physician had ordered on September 5: "Obtain weekly weights; reweigh if >5# difference from previous week in the morning every Mon [Monday]." Nursing staff simply didn't follow the order.
The resident's medical record showed no weight documentation for three weeks after admission. When staff finally weighed her again, they discovered she had lost more than 10% of her body weight.
Staff member L, interviewed during the shift change, said she knew the resident "was not eating or drinking" and that "there was no report of nausea or vomiting." She acknowledged being aware of the resident's tooth infection, antibiotic treatment, and diuretic use for heart failure.
Yet L also admitted that "hydration was not documented and recorded in the medical record for each resident."
The facility had implemented a hydration policy just three months earlier, on July 1, 2025. The policy required staff to "utilize a systematic approach to optimize the resident's hydration status" through identifying risk factors, evaluating assessment information, and developing consistent approaches.
The policy specifically stated that nursing staff "shall 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 disabling of hydration tracking meant that even when residents showed signs of dehydration or poor intake, staff had no electronic records to identify patterns or trends. The deletion of intake and output data from the charting system affected "most facility residents," according to staff member O.
Federal inspectors determined the facility's failure to monitor hydration and weight "prevented the facility and staff from identifying concerns or trends timely." They classified the violation as causing actual harm to few residents.
The nursing home is disputing the citation.
But the numbers tell a stark story: a woman entered the facility weighing nearly 130 pounds, stopped eating and drinking, and lost more than a tenth of her body weight while staff systematically eliminated the tools designed to catch exactly this kind of deterioration.
The resident's physician had specifically ordered weekly weighing with instructions to reweigh if there was more than a five-pound difference from the previous week. A 14-pound loss over 26 days should have triggered multiple interventions under that order.
Instead, it took a chart review prompted by a federal inspection to discover that the facility's electronic health records had been stripped of the basic hydration data needed to keep residents safe.
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.
Staff member O discovered the problem during a chart review on October 22.
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.