Polson Health & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Polson Health & Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF742Sep 12, 2024

  Based on observation, interview, and record review, the facility failed to provide psychiatric services for 1 (#40) of 1 resident with the diagnoses: Borderline Personality Disorder, Generalized Anxiety Disorder, Major Depressive Disorder, Epilepsy, Other Drug Induced Secondary Parkinsonism, as shown in resident #40's EHR. Findings include: During an interview on 9/10/24 at 1:40 p.m., NF2 stated, [Resident #40] has emotional breakdowns and crying. So, I know the meds are holding her together, but they're not quite right . NF2 expressed frustration during the conversation and stated she knew resident #40 was not completely okay because she was still having hallucinations, and she never used to, prior to admission. NF2 stated, No, I do not think this is her new normal. […]

• No harm, potential for more than minimal, widespreadF812May 20, 2024

  Based on observation, interview, and record review, the facility failed to have and maintain a sanitary kitchen, staff failed to follow hygienic practices, and failed to take and record temperatures for food storage and for food during meal service. These deficient practices had the potential to affect all residents consuming food from the facility kitchen. Findings include: A. Sanitary Kitchen During an observation of the facility kitchen on 5/18/24 at 11:53 a.m., multiple areas of concern for cleanliness showed: - A large window located above the meal serving line and clean dishes was opened several inches and had a buildup of grey and brown dust on it. - A standing black fan, not in current use, had the blades and wire cage covered in grey and brown dust. […]

• No harm, potential for more than minimal, patternF602Nov 17, 2025

  Based on interview and record review, the facility failed to ensure systems were in place to prevent multiple incidents of misappropriation of a residents' medication for 9 (#s 14, 15, 16, 18, 20, 23, 38, 48, and 52) of 25 sampled residents. Findings include:Review of the facility reported incident (for alleged misappropriation of residents' medication) which was reported to the State Survey Agency on 8/24/25 at 10:00 a.m., showed a staff member reported the possible diversion of residents' medication by staff member L. An investigation into the allegations was initiated and three nurses were suspended pending the results of the investigation. […]

• No harm, potential for more than minimal, patternF609Nov 17, 2025

  Based on interview and record review, the facility failed to ensure staff members M and N reported a reasonable suspicion of a crime, related to diversion of medication, in a timely manner to administrative personnel. Findings include: Review of the facility reported incident (for failure to report a reasonable suspicion of a crime), which was reported to the State Survey Agency on 8/25/25 at 1:30 p.m., showed staff members M and N potentially failed to report a concern of possible medication diversion to leadership personnel at the facility. An investigation was initiated, and the two nurses were suspended pending the results of the investigation. […]

• No harm, potential for more than minimal, patternF675Sep 12, 2024

  Based on observations, interviews, and record reviews, the facility failed to answer call lights timely, for 6 (#s 9, 17, 24, 36, 39, and 202) of 13 sampled residents. Findings include: 2. During an interview on 9/10/24 at 7:52 a.m., resident #202 stated during breakfast she can wait up to 30 minutes after pushing the call button. During an interview on 9/10/24 at 7:59 a.m., resident #39 stated the average call light wait time was an hour. He stated, One time it was three hours when I fell down a couple of months ago. During an interview on 9/9/24 at 3:10 p.m., resident #17 stated the average call light wait time was ten minutes. Resident #17 stated the longest he had waited for a call light to be answered was 45 minutes, in the evening. […]