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Community Nursing Home Of Anaconda

615 Main St, Anaconda, MT 59711 · Non profit - Corporation · 62 certified beds · (406) 563-8414 Medicare & Medicaid certified

Call the home — (406) 563-8414 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0604) — cited Aug 2023Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
435 S Crystal St Ste 300 · (406) 496-3600 · Call to confirm hours
Pharmacy
201 E Park Ave · (406) 563-8441 · Call to confirm hours
Grocery
219 E Commercial Ave · (406) 491-1967 · Call to confirm hours
Park
402 E Commercial Ave · Typically dawn to dusk
Place of worship
501 Cedar St · (406) 563-6632

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased20.8%18.7%15.4%worse
Long-stay residents who lose too much weight0.0%6.2%5.4%check this — see note marked star below the table
Long-stay residents with a catheter left in their bladder7.2%2.1%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%2.9%2.0%better
Long-stay residents with depressive symptoms0.0%5.6%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.6%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.5%4.4%3.3%better
Long-stay residents whose ability to walk worsened22.0%17.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication6.6%15.8%18.9%better
Long-stay residents given the seasonal flu vaccine95.2%93.6%95.3%typical
Long-stay residents with pressure ulcers8.7%6.3%4.7%worse
Long-stay residents with worsening bladder/bowel control32.3%24.1%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table17.0%20.4%17.1%typical

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

0.01U.S. median 0.31
Therapy hours / resident / day
0.01hours / resident / day
Physical therapy

Therapy staffing: this home’s payroll records show 0.01 therapist hours per resident per day in 2026Q1 — more than 0% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

1.14
RN hours/ resident / day
0.79
LPN hours/ resident / day
3.32
Aide hours/ resident / day
5.25
Total nurse hours/ resident / day
0.85
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 62 beds and averages 17.6 residents a day — about 28% occupied, or roughly 44 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.25 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.14 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.32 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.75 hrs/resident/day on weekends vs 5.45 on weekdays — 13% thinner on weekends. RN hours go from 1.26 to 0.85 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

13
deficiencies at the latest standard inspection (2025-12-17)
4
at the previous standard inspection (2024-08-28)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.

  • Potential for harm · F2025-12-17 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to have a designated registered nurse to serve as the director of nursing on a full-time basis. This deficient practice resulted in a failure of clinical oversight for all residents residing in the facility. Findings include: During an observation on 12/15/25 at 9:00 a.m., the Director of Nursing was not present at the facility. During an interview on 12/15/25 at 9:15 a.m., staff member A stated the Director of Nursing resigned on 12/2/25, and a new Director of Nursing would start on 12/29/25. Staff member A stated she did not assign an interim Director of Nursing because she knew the new Director of Nursing would be starting soon. Review of a facility provided document, Survey Information, dated 8/18/25, reflected that the Director of Nursing resigned on 12/2/25, and a new Director of Nursing would start on 12/29/25. Review of a facility policy, Nursing Services, with a revision date of 10/2022, reflected: - . 3. b. Except when waived the facility must designate a registered nurse to serve as the director of nursing on a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-12-17 · tag F0851 — widespread
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review, the facility failed to submit mandatory payroll-based data to CMS. This deficient practice prevented CMS review of the level of staff, employee turnover, and tenure to ensure safe staffing levels. Findings include:Review of the PBJ Staffing Data Report, dated 12/9/25, for quarter four (7/1/25-9/30/25) reflected the facility failed to submit data for the quarter. During an interview on 12/15/25 at 9:15 a.m., staff member A stated the facility did not submit the PBJ for the fourth quarter of 2025 and once the facility realized the data had not been submitted, it was too late to submit the data.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-12-17 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespread
    Have a plan that describes the process for conducting QAPI and QAA activities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record review, the facility failed to ensure the QAPI team identified, reported, investigated, and documented the development, implementation, and evaluation of corrective actions for performance improvement projects related to known activities department deficient practices for 2 (#s 2 and 6) of 14 sampled residents, and this failure increased the risk of all residents being affected due to the lack of necessary or preferred activities. Findings include:During the survey from 12/15/25-12/17/25, the facility failed to provide activities to meet the interests and preferences of residents who remained in their rooms for resident #s 2 and 6. (See F0679)During an interview on 12/16/25 at 9:50 a.m., staff member A stated there had been a struggle to get activities to take charge and work the activities programs. Staff member A stated she was aware the one-to-one visits and activities the activities staff should be doing were not being done. During an interview on 12/17/25 at 11:07 a.m., staff member A stated she interviewed staff after surveyors questioned the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-12-17 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the required personal protective equipment, i.e. N95 respirator, was available to staff and visitors. upon entry to the facility during a COVID-19 outbreak; failed to ensure staff properly wore N95 respirators during a COVID-19 outbreak; and failed to ensure staff wore faceshield/masks while in residents' rooms who had tested positive for COVID-19 for 4 (#s 6, 9, 12, and 16) of 4 confirmed COVID-19 positive residents, which remained on contact and droplet precautions. These failures likely contributed to the spread of COVID-19 and could affect all residents, staff, or visitors at the facility. Findings include:1. Entrance Personal Protective Equipment During an observation when entering the facility on 12/15/25 at 9:00 a.m., a sign was posted on the outside window beside the entrance door, which showed the facility was in outbreak status for COVID-19. Inside the entrance door was a small vestibule, which had a desk with a notebook to sign in as a visitor and screening for signs and symptoms of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-17 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure medication error rates were not 5 percent or greater by crushing medications administered to residents without a physician's order for 2 (#s 7 and 13) of 5 residents observed for medication administration. The medication error rate was 24 percent. Findings include:During a medication administration observation on 12/16/25 at 8:21 a.m., staff member B prepared resident #7's medications. The following medications were placed into a plastic medication cup, crushed, then added to applesauce:- citalopram hydrobromide 20 milligram tablet, give one tablet,- acetaminophen 500 milligram tablet, give two tablets, and- sennosides-docusate sodium 8.6-50 milligram tablet, give two tablets.Staff member B administered the crushed medications to resident #7. These medications were administered without a physician's order for crushed medications.During a medication administration observation on 12/16/25 at 8:38 a.m., staff member B prepared resident #13's medications. The following medications were placed into a plastic medication…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-17 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review, the facility failed to ensure catheter bags were covered for 1 (#6) of 14 sampled residents. This deficient practice resulted in resident #6 feeling embarrassed to have the catheter bag visible to others. Findings include:During an observation and interview on 12/15/25 at 10:40 a.m., resident #6 was in his recliner in his room with the door open. Resident #6 had a catheter bag hanging from the pocket of his recliner filled half full of dark yellow urine. The catheter bag was facing the door and visible to those who walked past his room. Resident #6 stated, It's whatever, when the catheter bag and dignity was discussed. During an observation and interview on 12/16/25 at 9:10 a.m., resident #6's catheter bag was hanging from his right pocket of his recliner, uncovered, and was 1/4 filled with urine. The catheter bag was facing the doorway, and the door was open to the hallway. Resident #6 stated, It's a bit embarrassing, when asked about the catheter bag. During an interview on 12/16/25 at 11:40 a.m., staff member J stated the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-17 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to honor a resident's preferences of not being woken up in the morning and given a breakfast tray for 1 (#2) of 14 sampled residents. This deficient practice caused resident #2 frustration and anger leading to behaviors. Findings include:During an observation and interview on 12/15/25 at 10:45 a.m., resident #2 stated she was angry the staff continued to wake her and bring in a breakfast tray every morning even though she repeatedly asked them not to bring in a breakfast tray. Resident #2 stated she had never eaten breakfast and was not going to start. Resident #2 stated it was frustrating the facility would not listen to her wishes. The breakfast tray was sitting on her bedside table uneaten. During an interview on 12/15/25 at 11:45 a.m., staff member J stated resident #2 had not eaten breakfast since she was admitted to the facility. Staff member J stated she was told by the kitchen that resident #2 must receive a tray even if she refuses it. Staff member J stated that resident #2 would become very angry and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-17 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure staff member B protected a resident's right to privacy and confidentiality of her medical record for 1 (#9) of 5 residents observed for medication administration. Findings include:During an observation on 12/17/25 at 7:43 a.m., staff member B was in resident #9's room, administering her medications. The medication cart was parked outside resident #9's room. The computer used for medication administration was on top of the medication cart, with the computer screen open to resident #9's medication listing with her picture visible. At the time of the observation, another resident had exited her room and passed directly next to the medication cart.During an interview on 12/17/25 at 10:54 a.m., staff member B stated the computer on the medication cart should be locked each time she (staff member B) stepped away from the cart so a resident's record could not be seen by others.Review of the facility's policy titled, Confidentiality of Information, undated, showed:- .Confidentiality of the patient record shall…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-17 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record review, the facility failed to develop a comprehensive person-centered care plan, including the residents' preferences, for 2 (#s 2 and 6) of 14 sampled residents. This deficient practice resulted in resident #s 2 and 6 not having activities to meet their preferences. Findings include: 1. During an observation and interview on 12/15/25 at 10:45 a.m., resident #2 stated she did not get out of bed anymore and did not have activities available in her room. She discussed her activities of interest, to include reading and quilting, but these things were not offered to her.Review of resident #2's care plan, dated 11/10/25, reflected resident #2 had little or no interest in activities. The care plan reflected, . [Resident name] enjoys watching television in her room, visiting in her room with friends and family, and going on outings with her family as able. The care plan did not include information related to the interest's resident #2 relayed during the interview. Review of resident #2's Kardex, dated 12/16/25, reflected a variety of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-17 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure staff member B adhered to medication administration best practice by crushing a medication indicated on a Do Not Crush medication listing for 1 (#13) of 5 residents observed for medication administration. Findings include:During a medication administration observation on 12/16/25 at 8:38 a.m., staff member B prepared resident #13's medications. The following medications were placed into a plastic medication cup, crushed, then added to applesauce:- cholecalciferol 1,000 unit tablet, give two tablets,- oxybutynin chloride 5 milligram tablet, give 0.5 tablet,- sennosides-docusate sodium 8.6-50 milligram tablet, give one tablet, and- trazodone hydrochloride 50 milligram tablet, give 0.5 tablet.Staff member B administered the crushed medications to resident #13.During an interview on 12/16/25 at 12:28 p.m., staff member B stated she knew which residents' medications to crush from the facility's roster/shift change sheet for nurses. Staff member B stated there were not any labels on any resident's medication…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · Dcited before2025-12-17 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record review, the facility failed to provide activities to meet the interests and preferences of residents who remain in their rooms for 2 (#s 2 and 6) of 14 sampled residents. This deficient practice led to boredom for resident #6 and frustration for resident #2. Findings include:1. During an observation and interview on 12/15/25 at 10:45 a.m., resident #2 stated, I'm just laying here playing dead I guess. Resident #2 stated she did not get out of bed anymore and did not have activities in her room. Resident #2 stated she used to quilt and read. Resident #2 stated she liked to read modern romance and adventure books, but they were not offered to her. Resident #2 stated, I guess they just leaving me to play dead.Review of resident #2's care plan, dated 11/10/25, reflected resident #2 had little or no interest in activities. The care plan reflected, . [resident #2] enjoys watching television in her room, visiting in her room with friends and family and going on outings with her family as able.Review of resident #2's Kardex, dated 12/16/25,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-17 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record review, the facility failed to maintain collaborative records for medication administration and care plans which aligned with the hospice agency for 2 (#s 2 and 15) of 3 hospice patients sampled. Findings include: 1. Review of resident #2's paper chart and EHR reflected no documents for hospice, including there not being a care plan or medication reconciliation for hospice and the resident. The care plan and medication list were requested from the hospice agency.Review of resident #2's faxed, Hospice Medication Profile, undated, reflected the following items were not listed on the facility medication list:- Alendronate Sodium 70 mg tabs, one time weekly on Tuesday for bone reabsorption,- Cholecalciferol (D3) 50 mcg tabs, one tablet daily for vitamin supplement, - Apixaban 5 mg tabs, one tablet twice per day for anticoagulation,- Escitalopram 10 mg tabs, one tablet daily for depression,- Famotidine 20 mg tab, one tablet daily GERD,- Diflucan 150 mg, one tablet with catheter changes and three days later for yeast infections,- Magnesium Hydroxide 30 mL…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-17 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, interview, and record review, staff member B failed to ensure the security of all medications in a locked storage medication cart, limiting access to unauthorized personnel, and or residents. Findings include: During an observation on 12/17/25 at 7:43 a.m., staff member B was in a resident's room passing medications. The medication cart was parked outside of the room, in the hallway. The medication cart was not locked.During an interview on 12/17/25 at 10:54 a.m., staff member B stated the medication cart should be locked when a nurse was not by the cart. She stated she left her medication cart unlocked in the hallway earlier in the morning.Review of the facility's policy titled, Medication Floor Stock, last revised 8/17, showed:- .2. Medications contained in floor stock shall be stored in either locked cabinet or a tamper evident cart. Responsibility for security of the floor stock shall rest with the supervising licensed practitioner or supervising nurse overseeing the unit in which the floor stock is stored.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-17 · tag F0730 — isolated
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure an agency staff member, who was contracted with the facility for over 12 months, had an annual performance review completed. Findings include:During an interview on 9/22/25 at 1:15 p.m., staff member A stated she did not have performance reviews for agency staff.During an interview on 9/22/25 at 1:57 p.m., staff member B stated the facility did not conduct performance reviews for agency staff. Staff member A said staff member C had contracted with the facility for over 12 months. Staff member A said she thought staff member C had been contracted with the facility since COVID.During an interview on 9/22/25 at 2:08 p.m., staff member E stated, My agency does not do performance reviews; They just tell me when a facility compliments my work. Staff member E stated she does not receive annual education based on her performance reviews.Review of the staffing contract for staff member C with the facility showed, .Contract will commence on 01/22/22.A request was made for performance reviews for staff member C on 9/22/25 at…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-08-28 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan based on resident activity preferences and physical abilities, for 4 (#s 4, 10, 14, and 15) of 10 sampled residents. Findings include: 1. During an observation on 8/26/24 at 11:13 a.m., resident #15 was sitting in her wheelchair in her room. The room was quiet, and she was facing the wall, looking forward. During an interview on 8/28/24 at 3:56 p.m., NF2 stated, It would be nice if there were more for (resident #15) to do. I understand it is hard because she really can't communicate, though. Review of resident #15's care conference review, dated 7/29/24, showed on the Activities Summary: Problems/Needs (resident #15), . She spends the majority of her time in her room watching TV, napping, and 1:1 visit with family and staff. Evaluation/Goals: Continue to invite and encourage (resident #15) to attend group activities of her choice 3-4 X per week . Review of resident #15's care plan dated…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-08-28 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide residents with group and individual activities to meet their interests and support their physical, mental, and psychosocial well-being for 4 (#s 4, 10, 14, and 15) of 10 sampled residents. 1. During an observation and interview on 8/26/24 at 11:13 a.m., resident #15 was sitting in her wheelchair in her room. The room was quiet, and she was facing the wall, looking forward. Resident #15 had trouble answering questions and was mostly nonverbal, but when asked if she was bored, she nodded her head in an up-and-down motion. During an interview on 8/28/24 at 3:56 p.m., NF2 stated, It would be nice if there were more for [Resident #15] to do. I understand it is hard because she really can't communicate, though. Review of resident #15's task documentation report dated August 2024 showed resident #15 participated in 7 activities out of 28 days. 2. During an interview on 8/26/24 at 2:34 p.m., NF1 stated, I think cartoons are okay if there…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-28 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide dignity for a resident when transferring the resident to the shower room for 1 (#9) of 10 sampled residents. Findings include: During an observation on 8/26/24 at 9:17 a.m., the surveyors entered the facility. Staff member F was wheeling resident #9 in a bath chair to the shower room. Resident #9's upper body was covered by a bath poncho, but the lower body of resident #9 was exposed and visible underneath the shower chair. During an interview on 8/27/24 at 11:25 a.m., staff member C showed the surveyor the bath poncho and how it was used to cover the residents. Staff member C stated staff would use an extra blanket over the resident's lap if needed. Staff member C stated, I usually change them (the residents) in their room and then transfer them to the shower room . The shower rooms are so small that it is hard to get the residents changed in there. Staff member C stated she ensured the residents were covered before moving them out of their room and into the hallway. During an interview on 8/28/24 at…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-28 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to consult wound care services consistently to promote wound healing, and failed to sufficiently document the wound measurements, severity (Stage), and characteristics of the wound, for 1 (#6) of 10 sampled residents. This failure resulted in the wound continuing to remain as a Stage II pressure ulcer for four months (4/9/24 to 8/15/24) with little improvement or intervention, and the wound first started approximately a year ago (7/21/23). Findings include: During an interview on 8/28/24 at 9:43 a.m., staff member E stated resident #6 did not usually refuse wound care treatments. Staff member E stated she may have to make multiple attempts, but was always able to get wound care completed daily for resident #6's left buttock wound. During an interview on 8/28/24 at 10:44 a.m., staff member A stated, The wound is kind of at a standstill. Staff member A stated the status of the left buttock wound would get better for some time and then get worse and repeat that cycle. Staff member A stated wound orders were not updated unless…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-30 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to remove expired medical supplies from the medical supply room and the medical supply cart for 1 of 1 sampled the medical room and medical cart. Findings include: During an observation on 8/29/23 at 8:20 a.m., the following expired items were found: - 23 Protexis PI blue with [NAME]-Thera gloves expired 9/2022. - 55 tongue blades expired 8/9/23. - Six 25 gauge 5/8 needles expired 7/31/23. - 27 glucose test strips expired 2/20/23. - Three Luer-Lok 5mL syringes expired 3/31/23. - 50 Sani cloth wipes expired 5/2023. During an interview on 8/29/23 at 8:45 a.m., staff member B stated the night shift nurses were supposed to check for expired medications monthly. Staff member B showed a spreadsheet hanging on the wall with nurses signed off as having completed the medication room and cart audit, through July 2023. Staff memebr B stated this was done at the end of the month, and August had not been done yet. Staff member B stated she could not explain the items…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-30 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to notify the physician of a severe weight loss for 1 (#7) of 2 sampled residents. Findings include: During an interview on 8/29/23 at 12:31 p.m., staff member D stated she attended a meeting with the facility administration every Wednesday to look over resident's weights, and provide interventions if needed. Staff member D stated she did remember resident #7 had severe weight loss, and stated he went from periods of eating his meals to refusing to eat. Staff member D stated the facility was having an issue with their scale not being accurate, but that was just the last couple of weeks. Staff member D stated she did not remember if she put in any interventions for his weight loss, and believed the reason he looked like he lost so much was because of a scale malfunction. Staff member D stated the facility would notify the doctor of a severe or significant weight loss after it was identified in the weekly meeting with administration. Documentation of the notification of resident #7's severe weight loss, to the doctor, was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-30 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure a resident was free from a physical restraint, for 1 (#8) of 1 sampled resident. Findings include: During an observation on 8/28/23 at 11:55 a.m., resident #8 was in her room in her recliner, lying flat in the seat, with the chair reclined, and the resident's feet were in the reclined position. The chair remote was inside the chair pocket, and the chair power was unplugged. During an interview on 8/28/23 at 11:58 a.m., staff member A stated she knew the chair was a restraint with the power unplugged, but it was the last resort. Staff member A stated the staff could not get resident #8 out of a regular chair, because she was a hard transfer, and the resident could not use a sit-to-stand mechanical lift related to shoulder pain. During an observation on 8/29/23 at 7:53 a.m., resident #8 was in her recliner, lying flat on her buttocks, with her feet elevated on the footrest of the chair. The power chair was unplugged, and the remote was in the side pocket of the chair. During an observation on 8/29/23 at…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-30 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to prevent and promote healing of skin breakdown for 1 (#8) of 1 sampled resident. Findings include: During an observation on 8/28/23 at 11:55 a.m., resident #8 was in her room in her recliner, lying flat in the seat, with her chair reclined, and her feet up in reclined position. During an interview on 8/28/23 at 11:58 a.m., staff member A stated staff could not get resident #8 out of a regular chair, because she was a hard transfer, and the resident could not use a sit-to-stand mechanical lift. During an observation on 8/29/23 at 7:53 a.m., resident #8 was in her recliner lying flat, with her feet elevated on the footrest of her chair. During an observation on 8/29/23 at 10:09 a.m., resident #8 was flat in her recliner, with her feet elevated on the footrest of her chair. During an interview on 8/29/23 at 10:10 a.m., staff member M stated the CNAs do not reposition resident #8 in her chair with pillows or other devices. During an interview on 8/29/23 at 10:38 a.m., staff member B stated staff should be…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to identify root causes of falls for 2 (#s 7 and 8) of 5 sampled residents; and implement fall interventions for 1 (#8) of 1 sampled resident. Findings include: 1. During an interview on 8/19/23 at 8:35 a.m., staff member M stated resident #7 fell frequently. Staff member M stated she thought the reasons for his falls were because he liked to be independent, and do things himself. Staff member M stated staff often tried to reapproach him if he refused help, or asked another staff member to attempt to assist him. Staff member M stated any new interventions for falls that were discussed in the weekly fall huddle were written down in the communications book. Staff member M stated this book is not updated often. Staff member M stated administration updated the book, and if a fall happened on the weekend, the book would not be updated. Staff member M stated there was a gap in communication with fall interventions. During an interview on 8/29/23 at 9:11 a.m., staff member A stated, after a fall occured, the nurse on shift would…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-30 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to identify and provide interventions for a resident with a severe weight loss of 10% in three months, for 1 (#7) of 2 sampled residents. Findings include: During an interview on 8/29/23 at 8:35 a.m., staff member M stated resident #7 had days where he would eat all his meals, and days where he would not want to eat them at all. Staff member M stated weights are taken weekly on Sundays. Staff member M stated the doctor may order more frequent weights if the resident is having weight loss. Staff member M stated she did not think resident #7 had any weight loss. Staff member M stated if there was a five-pound difference in the last weight that was recorded, they would reweigh. Staff member M stated if there was a five pound loss the electronic health record would notify the nurse, and CNAs are supposed to verbalize it to the nurse as well. During an interview on 8/29/23 at 9:25 a.m., staff member A stated every Wednesday staff member D came to the facility to review weights, and discuss any weight loss, residents were having.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-30 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to document a rationale for extending a PRN psychotropic medication beyond 14 days, for 2 (#s 3 and 11) of 2 sampled residents. Findings include: a. Review of resident #3's, Medication Administration Record showed an order for, Alprazolam Oral Tablet 0.5 MG (Alprazolam) Give 1 tablet by mouth every 6 hours as needed for anxiety with a start date of 7/14/23. Records were requested on 8/30/23 at 10:16 a.m., for the rationale extending the PRN psychotropic medication beyond 14 days for resident #3. The facility did not provide any documentation for this request by the end of the survey. During an interview on 8/30/23 at 1:21 p.m., staff member A stated the facility did not have the requested documented rationale for extending resident #3's prn psychotropic medication beyond 14 days, and was unaware of the requirement. b. Review of resident #11's Medication Administration Record, showed an order for Lorazepam Tablet 0.5 MG Give 1 tablet by mouth every 6 hours as needed for Anxiety; Insomnia with a start date of 12/6/21. Records…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-30 · tag F0908 — failed to keep essential equipment working — isolated
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to secure a bed cane, and provide a fully functioning bed, for 1 (#14) out of 3 sampled residents. This failure resulted in discomfort for the resident, and had the potential to lead to injury for resident #14. Findings include: During an observation and interview on [DATE] at 12:32 p.m., resident #14's right bed cane was not properly secured to the bed. The head of the bed for resident #14 was elevated with several blankets underneath the mattress. Resident #14 stated the head of the bed did not raise or lower with the bed control, and it had been broken for about a month. During an observation and interview on [DATE] at 9:03 a.m., resident #14's right bed cane was still not properly secured to the bed. The head of the bed for resident #14 was elevated with several blankets underneath the mattress. Staff member B stated the bed cane should be secured to the bed. Staff member B stated maintenance would need to be notified to secure the bed…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
ASPHOLM, AUDREYIndividualCORPORATE DIRECTORsince 01/01/2018
BARTOLETTI, LEEIndividualCORPORATE DIRECTORsince 01/01/2005
BLAZ, STANIndividualCORPORATE DIRECTORsince 09/01/1999
CONNORS, CHRISTINEIndividualCORPORATE DIRECTORsince 01/01/2018
MCKAY, KRISTYIndividualCORPORATE DIRECTORsince 01/01/2018
DENHAM, STEPHANIEIndividualCORPORATE OFFICERsince 10/04/2021
HICKEY BOYNTON, MARGARETIndividualCORPORATE OFFICERsince 03/01/2005
COMMUNITY HOSPITAL OF ANACONDAOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/1969
FORSBERG, ANDREAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2023
PAFFORD, ROGERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2019

CMS files one row per role, so the 13 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

What families pay in MT

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Montana Medicaid page.

Typical monthly cost in Montana
$8,973/mo
Nursing home (semi-private)
$9,581/mo
Nursing home (private)
$6,075/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 275065. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-17, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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