Village Health & Rehabilitation

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Based on interview and record review, the facility failed to provide prompt physician notification for a resident who sustained a fall resulting in injury with pain for 1 (#85) of 34 sampled residents. This deficient practice contributed to a delay in treatment, and the resident was found to have a fracture. Findings include:During an interview on 8/26/25 at 9:36 a.m., resident #85 explained that she was admitted to the facility in July after she developed complications from a right hip replacement. Resident #85 stated she had

a fall when her leg got caught during a transfer, and she fell because the nurse went to get help and left her standing at the edge of the bed with nothing to hold on to. During an interview on 8/27/25 at 9:48 a.m., staff member O stated the fall protocol was to notify the family, the physician, and write up a fall report. Staff member O stated he did not notify the physician on call after resident #85 fell. Staff member O stated resident #85's care was delayed by a couple of hours.During an interview on 8/27/25 at 2:54 p.m., staff member B stated the fall protocol was to notify everyone of the fall, including the family and the doctor.Review of resident #85's EHR, showed a documentation note, dated 8/9/25 at 3:07 p.m., and the note failed to show the physician was notified of the resident's fall and increased pain.Review of resident #85's EHR showed a Secure Conversations note, dated 8/11/25 at 1:54 p.m., which included, Messages: Subject ED transfer .[8/9/25 22:45 PM] (10:45 p.m.) . she (resident #85) reports intolerable pain 10/10 above her R knee. Pain becomes worse if R leg is moved or R knee is bent, very tender to touch and unable to use it for support. R leg looks like a little bent/twisted out of shape going inward . At around 1940H (7:40 p.m.), called on call provider [provider on call], to send to ED .During an interview on 8/28/25 at 9:45 a.m., staff member A questioned this surveyor about a document that was provided by the facility, which showed the provider was notified about the fall at the time of the event. This surveyor clarified for staff member A that staff member O stated he did not notify the physician on call after resident #85 fell.Review of the facility document titled Notification of Changes, last review date of 10/14/24, showed: Policy: The facility will inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or appropriate family members(s) of the following:1. An accident resulting in injury to the resident that potentially requires physician intervention. 2. A significant change in the physical, mental, or psychosocial status of the resident. Policy Explanation and Compliance Guidelines:1. In the case of a competent resident, the facility will contact the resident's physician and appropriate family member(s) .5.

Document in the resident's clinical record the date and time of the notification. Review of the facility's document titled Fall Prevention Program, last review date 1/23/25, showed: . 5. When a resident experiences a fall, the facility will:.d. Notify physician and family.The delay of physician notification impacted

the physician's opportunity to provide directives on the resident's care, pain, and injury.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Village Health & Rehabilitation

2651 South Ave W Missoula, MT 59804

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on the interview and record review, the facility failed to report allegations of resident abuse to the State Survey Agency within 24 hours of an incident for 2 (#s 99 and 129) of 5 residents sampled for Facility Reported Incidents. Findings include:Review of the facility reported incident dated 6/27/25 at 8:15 p.m., showed resident #99 and resident #129 were involved in a physical altercation. Resident #99 reported to

the nurse resident #129 grabbed resident #99's groin. The initial allegation of resident-to-resident abuse was not received by the State Survey Agency until 6/30/25.During an interview on 8/27/25 at 11:22 a.m., staff member A stated she was not aware the facility failed to report the allegations of resident-to-resident abuse to the State Survey Agency within 24 hours for the facility reported incident which occurred on 6/27/25, involving residents #99 and #129. Staff member A stated the facility's video surveillance of the incident was no longer available for review. During an interview on 8/28/25 at 8:52 a.m., staff members A and C were present. Staff member C stated the incident involving residents #99 and #129, on 6/27/25, was not reported to the State Survey Agency within 24 hours because resident #99 denied that the incident occurred. Staff member C stated resident #99 met with and reported to social services on 6/30/25 resident #129 touched resident #99's groin area on 6/27/25. Staff member C stated the facility then reported the incident to the State Survey Agency. Review of resident #99's nursing progress note, dated 6/28/25 at 5:21 a.m., showed resident #99 went to the nursing station on 6/27/25 at 8:13 p.m. and reported that resident #129 had touched his groin. Resident #99 was ambulating in his wheelchair, from the 700 hall, back to the nursing station. When doing so, resident #99 passed resident #129, and resident #129 had his head down looking at the rug, and he was swinging his hands down. The nursing progress note showed resident #129 stated he wasn't paying attention, and it was an accident (touching #99 on groin). Resident #99 calmed down and seemed to accept the actions of resident #129 were not on purpose. A message was sent to social services and nursing, and a text message was sent to the director of nursing, to make them all aware of the incident.Review of the facility's policy titled, ABUSE, NEGLECT AND EXPLOITATION, last revision dated 1/11/25, showed: 1. Definitions. Sexual Abuse is non-consensual sexual contact of any type with a resident. V. Identification of Abuse, Neglect, Exploitation and MisappropriationThe facility will identify factors indicating possible abuse, neglect, exploitation of residents, or misappropriation of resident property, including, but not limited to, the following possible indicators:-Resident, staff or family report of abuse; . VII.

Response and Reporting of Abuse, Neglect, Exploitation, and MisappropriationAnyone with knowledge or concerns about the care of a resident in the facility must report suspected abuse to the Facility administrator, abuse agency hotline or file a complaint with the state survey agency and adult protective services (if applicable under state law) immediately (but not later than 2 hours after an allegation is made if

the events that lead to the allegation involve abuse or result in serious bodily injury) or not later than 24 hours if the events that lead to the allegation do not involve abuse and do not result in serious bodily injury.

Reporting and investigation should be in accordance with state law/regulation.When abuse, neglect or exploitation is suspected, the Administrator or designee should:. Contact the state agency and the local Ombudsman office to report the alleged abuse; . [sic]

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Village Health & Rehabilitation

2651 South Ave W Missoula, MT 59804

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

p.m.), called [Ambulance Service], arrived at around 2000H (8:00 p.m.) and res transported to [Facility Name] ED at around 2020H (8:20 p.m.).[8/9/25 22:47 PM] (10:47 p.m.)[Staff RN]: At around 2200 (10:00 p.m.), called [Facility Name] for update. Talked to ER secretary and res will be admitted for significantly fractured femur. FYI[8/11/25 10:23AM][Staff Physician]: noted agree with ED eval after fall with significant pain, thanks for the update, will await her return. [sic]Review of a facility document title, [Facility Name] Incident Audit Report dated 8/27/25, showed, it was a follow up to resident #85's fall on 8/9/25 15:00 (3:00 p.m.), and included: .Injuries.Mental Status, Oriented to Person, Oriented to Place, Oriented to Situation; Oriented to time . Note.Resident is A&O X4 .It was determined post-fall to send [Resident #85] to the emergency room for further evaluation. [Resident #85] declined to go initially, but then was agreeable later as pain increased in her leg.Review of the admitting hospital's Discharge summary, dated [DATE REDACTED], showed, .Assessment & Plan, Femur fracture (HCC), Patient had a mechanical fall while trying to get from her bed to a wheelchair on 8/9. XR identified a moderately displaced periprosthetic R femur fracture.

Event ID:

Facility ID:

If continuation sheet

Federal health inspectors cited VILLAGE HEALTH & REHABILITATION in MISSOULA, MT for a deficiency under regulatory tag F-F0726 during a standard health inspection conducted on 2025-08-28.

Category: Nursing and Physician Services Deficiencies

The facility was found deficient in the following area: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 6 deficiencies cited during this inspection of VILLAGE HEALTH & REHABILITATION.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-23.

Federal health inspectors cited VILLAGE HEALTH & REHABILITATION in MISSOULA, MT for a deficiency under regulatory tag F-F0808 during a standard health inspection conducted on 2025-08-28.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 6 deficiencies cited during this inspection of VILLAGE HEALTH & REHABILITATION.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-23.

Federal health inspectors cited VILLAGE HEALTH & REHABILITATION in MISSOULA, MT for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-08-28.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 6 deficiencies cited during this inspection of VILLAGE HEALTH & REHABILITATION.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-23.