Discovery Care Centre: Dementia Care Failures - MT
The violations occurred despite facility policies requiring enhanced barrier precautions for residents with indwelling medical devices. Two residents with catheters received care from workers who skipped gowns and gloves during high-contact activities like transfers and toileting assistance.
On September 23 at 9:54 a.m., inspectors observed staff member E leaving the room of resident #4, who had catheter tubing and a drainage bag. No protective equipment caddy hung outside the door. When asked if she used PPE during the transfer, staff member E admitted she did not but said she was going to get supplies.
Resident #4 told inspectors the inconsistent safety practices depended on which staff member provided care. "It would depend on who that person was, if they used PPE during the catheter care," the resident said. The resident explained that staff previously kept protective equipment hanging on the door, "but they took it off for some reason, and the staff have become more relaxed about using PPE."
Later that afternoon, inspectors watched staff member D enter resident #3's room despite a sign outside indicating enhanced barrier precautions were required and a PPE caddy hanging by the door. Staff member D entered without donning protective equipment.
"I forgot you had a catheter," staff member D told the resident.
Staff member D then assisted resident #3 with a transfer to the toilet using a mechanical lift. The worker put on gloves only after helping the resident pull down undergarments and lowering them to the toilet. Staff member D said she had been told that day that PPE was supposed to be used for residents with catheters, but explained she had worked in hospitals where enhanced barrier precautions weren't used for catheter patients.
The facility's own policy, implemented April 11, 2025, clearly defined enhanced barrier precautions as an infection control intervention designed to reduce transmission of drug-resistant organisms through targeted gown and glove use during high-contact care activities.
The policy required enhanced barrier precautions for residents with wounds and indwelling medical devices like urinary catheters. It mandated making gowns and gloves available immediately near or outside residents' rooms and specified that high-contact activities included transferring, providing hygiene, and assisting with toileting.
Staff member C, interviewed the next day, demonstrated proper understanding of the requirements. She expected enhanced barrier precautions to be used for residents with wounds, catheters, or multidrug-resistant organisms during high-contact care tasks including transfers, bed-making, wound care, and cleaning.
The policy stated enhanced barrier precautions should continue for the duration of a resident's stay or until wounds heal or medical devices are removed.
Federal inspectors determined the facility failed to ensure staff were educated on the importance of enhanced barrier precautions and failed to ensure appropriate personal protective equipment use. The deficient practice increased infection risk for residents with urinary catheters.
The violations affected few residents but represented a breakdown in basic infection control protocols designed to protect vulnerable patients. Residents with indwelling catheters face elevated risks of urinary tract infections and other complications when proper barrier precautions aren't followed consistently.
The inspection found staff knowledge gaps persisted months after the facility implemented its enhanced barrier precautions policy, with some workers admitting they forgot requirements or had different experiences at previous healthcare facilities.
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 violations occurred despite facility policies requiring enhanced barrier precautions for residents with indwelling medical devices.
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.