Polson Health & Rehab: Financial Exploitation - MT
The employee, identified in inspection records only as Staff Member L, was pulling as-needed narcotic medications from residents' PRN medication cards and pocketing them without entering any record of the administration. The medication administration record, which nurses are supposed to fill out every time a controlled substance is given, showed nothing. The narcotics were simply gone.
The scheme came to light through audits comparing the narcotic books to the medication administration records. A staff member interviewed during the investigation said he had knowledge those audits were being conducted but had not participated in them directly. The audits were apparently how someone finally noticed the numbers didn't match.
The facility's own quality assurance records from a meeting held August 26, 2025 spell out what happened with unusual clarity. Leadership staff attended that meeting, along with the medical director. The notes identify the residents who were affected. They confirm Staff Member L was the one taking the medications. They note that the PRN narcotics being stolen were pain medications, and then they note something that raises its own questions: pain was not considered a concern for the residents affected by the diversion.
That conclusion deserves scrutiny. As-needed pain medications exist because someone determined, at some point, that a resident might need them. A PRN narcotic on a medication card is not decorative. It is there because a physician ordered it for a patient who experiences pain. Whether those residents went without relief they needed, or whether they were not in active pain at the moments Staff Member L was taking their medications, the inspection record does not say. What it says is that the facility concluded pain was not a concern. Other residents in the facility, interviewed separately, reported no medication concerns.
Physicians were notified. So were family members. Adult Protective Services received notification of the incidents, and the local ombudsman was contacted as well.
The facility moved quickly once the diversion was discovered. On August 27, 2025, the day after the quality assurance meeting, all nurses and certified nursing assistants were educated on medication diversion. The monitoring that followed was structured and escalating: audits of two nurses' narcotic medication logs were matched against the medication administration record, covering two residents per medication cart per shift for one week. Then two residents weekly for three weeks. Then two residents monthly for three months.
The director of nursing reviewed those audits and reported compliance findings back to the quality assurance committee on September 4, 2025. The next meeting was scheduled for September 26, 2025 to assess whether compliance had held.
By September 25, 2025, when a recertification survey exited the facility, inspectors found it in substantial compliance. The corrective actions were complete. The deficiency cited in the November 2025 complaint inspection was rated at minimal harm or potential for actual harm, affecting some residents.
The facility's own written policy, last updated in September 2017, defines misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without their consent. The policy lists examples of resident property. Medications are on that list.
That framing matters. What Staff Member L did was not a medication error. It was not a documentation lapse or a training failure or a system breakdown. It was theft. The medications belonged to the residents. They were taken without consent, deliberately, and without record. The facility's own policy calls that misappropriation. Federal inspectors, citing the relevant deficiency, agreed.
What the record does not contain is what happened to Staff Member L. No termination is mentioned. No referral to law enforcement appears in the excerpted inspection materials, though the staff member interviewed during the investigation used the word "crime" in describing what he understood about the situation. The inspection documents describe what the facility did institutionally in response. They do not describe consequences for the individual who took the medications.
Polson Health and Rehabilitation Center is a nursing home at 9 14th Avenue West in Polson, Montana, a small city on the southern shore of Flathead Lake. The facility serves residents who depend on its staff for basic care, including pain management. Some of those residents had a nurse assigned to give them medication when they needed it. That nurse took the medication instead.
The quality assurance notes say pain was not a concern for those residents. That may be true. But the residents never got to find out for themselves.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Polson Health & Rehabilitation Center from 2025-11-17 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: August 4, 2026 · Our methodology
POLSON HEALTH & REHABILITATION CENTER in POLSON, MT was cited for violations during a health inspection on November 17, 2025.
The medication administration record, which nurses are supposed to fill out every time a controlled substance is given, showed nothing.
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.