Discovery Care Centre: Daily Living Care Failures - MT
The September incident at The Valley Health and Rehab illustrates how staff routinely ignored infection control protocols designed to protect residents with urinary catheters from dangerous infections.
Federal inspectors found workers skipped required safety gear during high-contact care like transfers and toileting assistance for two residents with catheters. The facility's own policy mandated enhanced barrier precautions for all catheter patients.
Staff member E had just finished transferring resident #4 using the mechanical lift when inspectors encountered her in the hallway at 9:54 a.m. on September 23. No protective equipment caddy hung outside the patient's door. When asked directly if she had used any protective gear during the transfer, the worker admitted she hadn't.
Resident #4 told inspectors the inconsistent safety practices depended on which staff member provided care. The patient said workers "used to have PPE hanging" on the door "but they took it off for some reason, and the staff have become more relaxed about using PPE."
The relaxed attitude extended beyond individual oversights.
That same afternoon, staff member D walked into resident #3's room despite a sign posted outside requiring enhanced barrier precautions and a fully stocked PPE caddy hanging by the door. The worker entered without donning any protective equipment.
"I forgot you had a catheter," staff member D told the resident while beginning transfer assistance.
The worker then helped resident #3 move to the toilet using a mechanical lift, putting on gloves only after pulling down the patient's undergarments and lowering them onto the toilet seat. Staff member D said she had learned that very day that protective equipment was supposed to be used for catheter patients.
Her confusion reflected broader training gaps. Staff member D said she had previously worked in a hospital setting "and EBP was not used for catheters" there.
The facility's infection control supervisor, staff member C, understood the requirements correctly. She told inspectors enhanced barrier precautions should be used for residents with wounds, catheters, or multidrug-resistant organisms during high-contact care tasks including transfers, bed-making, wound care, and cleaning.
Valley Health's written policy, implemented in April 2025, clearly defined enhanced barrier precautions as an infection control intervention designed to reduce transmission of dangerous organisms through targeted gown and glove use during high-contact resident care.
The policy required protective equipment orders for residents with wounds or indwelling medical devices like urinary catheters. It mandated making gowns and gloves available immediately near or outside residents' rooms.
High-contact activities requiring protection included transferring patients, providing hygiene assistance, and helping with toileting. The policy specified that enhanced precautions should continue for a resident's entire facility stay or until catheter removal.
Federal inspectors classified the violations as having minimal harm or potential for actual harm, but noted the deficient practices increased infection risk for residents with urinary catheters.
Catheter-associated infections represent one of the most serious threats in nursing home care. The devices create direct pathways for bacteria to enter the urinary tract, making strict infection control protocols essential for resident safety.
The inspection found that while Valley Health had established appropriate written policies in April, staff education and implementation had failed by September. Workers either forgot basic requirements, misunderstood when protections applied, or simply became "more relaxed" about following safety protocols designed to protect vulnerable residents.
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 violations during a health inspection on November 18, 2025.
The facility's own policy mandated enhanced barrier precautions for all catheter patients.
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.