Discovery Care Centre: Infection Control Gaps - MT
The September incident at The Valley Health and Rehab illustrates how staff ignored the facility's infection control protocols designed to protect vulnerable residents. Federal inspectors found that workers routinely skipped safety measures when caring for patients with indwelling catheters, increasing their risk of dangerous infections.
Staff member D told inspectors she had been informed that day that personal protective equipment was required for catheter patients. She said she previously worked in a hospital where enhanced barrier precautions weren't used for catheters.
The facility's own policy, implemented in April, requires gowns and gloves for "high-contact resident care activities" involving patients with urinary catheters. Those activities include transferring, providing hygiene, and assisting with toileting — exactly what staff member D was doing when inspectors observed her.
Resident #4 noticed the inconsistent safety practices. The patient told inspectors whether staff used protective equipment "would depend on who that person was." The resident said workers used to keep PPE supplies hanging outside the door, "but they took it off for some reason, and the staff have become more relaxed about using PPE."
That relaxed attitude was evident when inspectors watched staff member E exit the resident's room pushing a mechanical lift. No PPE caddy hung outside the door. When asked if she used protective equipment during the transfer, the worker admitted she didn't but said she was "going to go get the PPE supplies."
The facility's Enhanced Barrier Precautions policy defines the intervention as designed "to reduce transmission of multidrug-resistant organisms" through targeted gown and glove use. The policy requires orders for enhanced precautions for residents with wounds or indwelling medical devices like urinary catheters.
Staff member C, interviewed by inspectors, correctly understood the requirements. She said enhanced barrier precautions should be used for residents with wounds, catheters, or multidrug-resistant organisms during high-contact care tasks including transferring, bed making, wound care, and cleaning.
Yet the policy wasn't being followed. When inspectors observed resident #3's care, they found a sign outside the room indicating enhanced barrier precautions were needed, and a PPE caddy hung by the door. Staff member D entered without donning protective equipment.
The worker then assisted the catheter patient with a transfer to the toilet using a mechanical lift. She put on gloves, helped the resident pull down undergarments, and lowered the person to the toilet — all activities the facility's policy identifies as requiring full protective equipment.
According to the policy, enhanced barrier precautions "should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device." The requirements aren't optional or situational.
Urinary catheters create significant infection risks for elderly residents. The devices provide a direct pathway for bacteria to enter the urinary tract, and improper handling by staff can introduce dangerous pathogens. Enhanced barrier precautions serve as a critical defense against these preventable infections.
The inspection found that staff education had clearly failed. Workers either didn't understand the requirements or chose to ignore them. Some, like staff member D, relied on outdated practices from previous jobs rather than following current facility protocols.
Federal inspectors documented the violations after observing routine care activities over two days in September. The failures affected residents with urinary catheters who depended on staff to follow basic safety measures during intimate personal care.
Resident #4's observation that staff had "become more relaxed" about protective equipment suggests the problem extended beyond individual mistakes to a broader culture of cutting corners on infection control.
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.
Staff member D told inspectors she had been informed that day that personal protective equipment was required for 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.