Discovery Care Centre: Abuse Response Failures - MT
When inspectors asked if she used personal protective equipment during the transfer, the worker said she had not but was "going to go get the PPE supplies." There was no protective equipment caddy hanging outside the resident's door.
The resident told inspectors the next day that staff compliance with protective equipment "would depend on who that person was." The patient said workers used to keep protective gear hanging on the door, "but they took it off for some reason, and the staff have become more relaxed about using PPE."
Federal inspectors found similar lapses throughout Valley Health and Rehab during their September complaint investigation. Staff member D entered another catheter patient's room despite a sign outside clearly marking the need for enhanced barrier precautions and a supply caddy hanging by the door.
The worker entered without putting on protective gear. "I forgot you had a catheter," she told the resident.
Staff member D then assisted the patient with transferring to the toilet using a mechanical lift. She put on gloves, helped pull down the resident's undergarments, and lowered the person to the toilet. She told inspectors that day was the first time anyone had told her protective equipment was supposed to be used for catheter patients.
The worker said she had previously worked in a hospital setting where enhanced barrier precautions were not used for catheters.
Staff member C, interviewed the following day, said she expected enhanced barrier precautions for residents with wounds, catheters, or multidrug-resistant organisms during high-contact care tasks. She identified those tasks as transferring, bed-making, wound care, and cleaning.
The facility's own policy, implemented in April, required enhanced barrier precautions for residents with urinary catheters. The policy defined enhanced barrier precautions as targeted use of gowns and gloves during high-contact care activities to reduce transmission of multidrug-resistant organisms.
High-contact activities specifically included transferring, providing hygiene, and assisting with toileting. The policy required protective equipment to be available immediately near or outside residents' rooms.
Enhanced barrier precautions were supposed to continue for the duration of a resident's stay or until the catheter was removed.
The violations affected residents with indwelling medical devices that put them at higher risk for infections. Urinary catheters create direct pathways for bacteria to enter the body, making proper protective equipment critical during transfers and personal care.
Federal inspectors found the facility failed to ensure staff were educated on the importance of enhanced barrier precautions and failed to ensure workers used appropriate protective equipment for residents with catheters.
The deficient practice increased infection risk for vulnerable residents who relied on staff to follow safety protocols during intimate care tasks like toileting and transfers.
Staff member D's admission that she learned about the catheter protection requirements only on the day of inspection suggested broader training failures. Her hospital experience, where different standards applied, had not been supplemented with facility-specific infection control education.
The resident's observation that staff had "become more relaxed" about protective equipment pointed to deteriorating compliance over time. The missing equipment caddy outside one resident's room indicated supply management problems beyond individual worker choices.
Both residents required enhanced protection during the exact activities where staff failed to use equipment: mechanical lift transfers and toileting assistance. These high-contact tasks create the greatest risk for transmitting infections to catheterized patients.
The facility's April policy implementation showed management recognized the infection risks but failed to ensure consistent staff compliance five months later.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Valley Health and Rehab from 2025-11-18 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
THE VALLEY HEALTH AND REHAB in HAMILTON, MT was cited for abuse-related violations during a health inspection on November 18, 2025.
The worker entered without putting on protective gear.
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.