Gallatin Rest Home
1221 W Durston Rd, Bozeman, MT 59715 · Government - County · 69 certified beds · (406) 582-3300 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2026
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $55,413 in federal fines (most recent 2025-06-05)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (63%) runs well above the national median (45%)
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 2 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 held steady at 4 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 24.8% | 18.7% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.2% | 6.2% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 3.2% | 2.1% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 17.1% | 2.9% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 11.7% | 5.6% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.6% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 0.6% | 4.4% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 15.1% | 17.2% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 5.9% | 15.8% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 81.8% | 93.6% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 8.0% | 6.3% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 32.4% | 24.1% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.6% | 20.4% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 39.7% | 73.8% | 79.4% | worse |
‡ 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.
64.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 128 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 28.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 53 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.30 therapist hours per resident per day in 2026Q1 — more than 49% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 64.3%CMS range 55.5–72.6 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 8.5%CMS range 5.6–13.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 28.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 26.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 41.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 84.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 85.4% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 discharge | not reported — The number of residents or resident stays is too small to report. 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 10.9% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.0%CMS range 4.3–11.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.94 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this 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
How full it usually is: this home is certified for 69 beds and averages 49.0 residents a day — about 71% occupied, or roughly 20 beds typically open. It usually has some room. 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.
Weekend coverage: total nurse staffing is 4.88 hrs/resident/day on weekends vs 5.96 on weekdays — 18% thinner on weekends. RN hours go from 0.86 to 0.58 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 63% is well above the national median of 45%.
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
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.
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.
17 citations, most serious first. The 12 most serious are shown; the remaining 5 are one tap away and print in full.
- Actual harm · G2025-06-05 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
2. During an observation on 6/5/25 at 7:57 a.m., resident #13 received morning cares from staff members F and K. Resident #13 was lying on her back in the bed. Resident #13 had a wound dressing on her right heel which was left in place. When resident #13 was turned to her right side for incontinence care, an open area was noted on her coccyx. There was no wound dressing in place. Staff member F applied moisture barrier cream, and a new incontinence brief. Resident #13 called out in pain and cried when she was moved in her bed. The crying stopped as soon as the resident was left alone. During an interview on 6/4/25 at 12:47 p.m., staff member G stated the wound nurse had been seeing the resident weekly, otherwise staff did the dressing changes. Review of resident #13's nursing progress notes showed the following: - 3/17/25, bruising to buttocks, present on admission, no measurements documented, - 4/14/25, bruising to buttocks resolved, - 4/21/25, new pressure ulcer on coccyx, scheduled to see the wound nurse on 4/22/25, - 4/22/25, Unstageable pressure ulcer on medial gluteus 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.
- Actual harm · Gcited before2023-06-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 maintain scale equipment, resulting in a fall with an injury, for 1 (#28) of 2 sampled residents. Findings include: Review of an incident for resident #28, dated 2/21/23, showed, Upon entry into room resident was on all fours on the floor with a pool of blood near left leg .Was in the chair scale and fell out when a wheel fell off, Resident thinks she hit her head . [sic]. During an interview on 6/7/23 at 10:16 a.m., staff member F stated resident #28 required assistance with transfers and had a history of falls. During an interview on 6/7/23 at 10:58 a.m., staff member A stated the facility did not have maintenance records for the chair scale, and staff member A did not know why staff did not notify maintenance of any previous issues with the chair, before resident #28's fall on 2/21/23. Staff member A stated maintenance fixed items as needed in the facility. During an interview on 6/7/23 at 12:38 p.m., staff member G stated she recalled the incident with resident #28's fall from the scale chair. Staff member G 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.
- Potential for harm · Ecited before2026-06-18 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 interview and record review, the facility failed to ensure a resident was free from physical abuse by agency staff for 1 (#27); failed to ensure a resident was free from verbal abuse by agency staff for 2 (#s 39 and 60); failed to ensure a resident was free from physical and verbal abuse by another resident for 2 (#s 46 and 59); and failed to ensure a resident was free from neglect of care for 1 (#13) of 8 residents sampled for abuse. The failure placed the residents at risk for physical injury, emotional distress, diminished quality of life, and loss of dignity. Findings include:1. Review of a Facility-Reported Incident, submitted to the State Survey Agency on [DATE], showed NF2 was observed grabbing resident #27 by the arm and directing the resident into a seated position. The facility investigated the incident and substantiated the allegation of abuse. During an interview on [DATE] at 12:05 p.m., staff member B stated NF2 was a travel staff member completing a 13-week contract; however, following 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.
- Potential for harm · Ecited before2026-06-18 · tag F0610 — failed to investigate and act on abuse reports — patternRespond appropriately to all alleged violations.
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 interview and record review, the facility failed to thoroughly investigate allegations of abuse for 7 (#s 13, 27, 37, 39, 46, 55 and 59) of 8 residents sampled for abuse. The failure resulted in incomplete investigations, which did not show the evaluation of ongoing actions taken for the residents' well-being, did not identify resident-specific interventions, revise care planning, or document other measures implemented to protect residents and prevent recurrence of similar incidents. Findings include: 1. Review of a Facility-Reported Incident, submitted to the State Survey Agency on [DATE], showed resident #37 and resident #55 were involved in a physical altercation without injuries. Staff intervened, separated the residents, and completed initial assessments. Resident #55 was transferred to another facility approximately six weeks after the incident. During an interview on [DATE] at 7:50 a.m., resident #37 stated, No one followed up with me, and no one told me to stay away from her (#55). Review of 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.
- Potential for harm · E2025-06-05 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 review and revise resident care plans for 3 (#s 13, 32, and 43) of 21 sampled residents. Findings include: 1. During an observation on 6/2/25 at 4:07 p.m., resident #13 was sitting in her wheelchair with both feet elevated on the foot pedals. There was no evidence of a urinary catheter. During an observation on 6/5/25 at 7:57 a.m., staff member F and K were providing morning care for resident #13. Resident #13 had an incontinence brief on, and there was no evidence of a urinary catheter. Review of resident #13's physician orders, dated 5/6/25, showed an order to remove the indwelling urinary catheter. Review of resident #13's care plan, dated 3/11/25, accessed on 6/4/25, showed the resident had an indwelling Foley catheter due to urinary retention. The goals and interventions, dated 3/11/25, continued to show cares related to the urinary catheter. During an interview on 6/5/25 at 7:50 a.m., staff member B stated all nurses should be updating resident care plans. Staff member B could not explain why resident…
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.
- Potential for harm · Ecited before2025-06-05 · tag F0880 — failed to prevent and control infections — patternProvide 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 maintain proper hand hygiene for 4 (#s 14, 16, 21, and 208) of 7 observed medication passes; failed to maintain cleanable surfaces on floor mats for 2 (#s 1 and 36) of 2 sampled residents with floor mats; failed to maintain clean respiratory equipment for 1 (#36) of 6 sampled residents with respiratory equipment; and failed to properly store tube feeding supply sanitarily for 1 (#1) of 1 sampled resident with tube feeding supplies. These deficient practices had the potential to increase the risk of infections and spread of infections for all residents receiving care. Findings include: 1. During an observation on 6/3/25 at 4:10 p.m., staff member E prepared the medications for resident #208. Staff member E entered resident #208's room without completing hand hygiene, began to assist the resident with medications by feeding her the pills with a spoon and giving her drinks of water between. Resident #208 stopped staff member E and stated she wanted the pills in applesauce. Staff member E obtained the applesauce…
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.
- Potential for harm · D2025-06-05 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
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 resident, and the resident's representative, were made aware of the risks and benefits associated with the use of psychotropic medications prior to the start of treatment for 1 (#32) of 21 sampled residents. Findings include: During an observation on 6/4/25 at 1:05 p.m., resident #32 was ambulating from the dining room towards her room. The resident's gait was slow, and she was using a walker for support. Facility staff had to direct resident #32 towards her room. Review of resident #32's physician orders showed the following psychotropic medications being given to the resident: - 2/11/25 to 3/17/25, Seroquel 25 mg once daily, as needed, for sleeplessness or agitation - 4/29/25 to 5/29/25, olanzapine 2.5 mg twice daily, as needed, for agitation; and, - 5/2/25 to current, sertraline 50 mg daily for mild dementia with psychotic disturbance. Review of resident #32's EHR, accessed between 6/2/25 and 6/5/25, failed to show documentation of the risks and benefits of using the above listed psychotropic…
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.
- Potential for harm · Dcited before2025-06-05 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 fully investigate an allegation of theft to ensure no other residents were affected for 1 (#34) of 21 sampled residents. Findings include: During an observation and interview, on 6/2/25 at 2:35 p.m., resident #34 was in her power wheelchair having a difficult time grabbing the handle and speaking. Resident #34 stated she had several hundred dollars go missing from her purse in her drawer. She stated she told facility management, and they reimbursed her $100.00 of the money missing, but did not tell if they found out who took the money. During an interview on 6/3/25 at 2:48 p.m., NF4 stated resident #34 had $300.00 go missing from her purse in her room. NF4 stated he did not realize she had cashed a check when he transferred resident #34 from the hospital to the facility as she normally would not have that amount of cash on her person. NF4 stated she kept a purse unzipped due to it being too hard to zip shut. NF4 stated the facility informed him they would be conducting an investigation. NF4 stated other than…
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.
- Potential for harm · Dcited before2025-06-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 observation, interview, and record review, the facility failed to utilize a system for identifying root causes for falls, and failed to develop and implement individualized fall prevention strategies for 1 (#32) of 21 sampled residents. Finding include: During an observation on 6/4/25 at 1:00 p.m., resident #32 was seen ambulating with a walker and accompanied by an unknown staff member. The resident required verbal cues to locate her room. Review of resident #32's nursing progress note, dated 12/11/25, showed the resident sustained an unwitnessed fall in her room. The note failed to show any contributing factors or possible causes for the fall. Review of resident 32's nursing progress note, dated 3/26/25, showed the resident had an unwitnessed fall and was complaining of knee pain. The note failed to show any contributing factors or possible causes for the fall. Review of resident #32's nursing progress note, dated 5/31/25, showed the resident sustained an unwitnessed fall in her room. The note failed to show any contributing factors or possible causes for the fall. Review…
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.
- Potential for harm · D2025-06-05 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
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 have policies for dialysis care and management, policies for dialysis transportation, a contract and communication with the dialysis center providing dialysis treatment, and failed to have proper dialysis monitoring of the resident before and after dialysis appointments, for 1 (#207) of 1 sampled resident for dialysis. Findings include: During an observation and interview on 6/4/25 at 8:04 a.m., staff member J stated resident #207 was on dialysis and stated the resident's electronic chart would show orders for the dialysis, and resident #207 went twice a week, leaving at 10:30 a.m. Staff member J pulled up the chart of resident #207, and the orders did not show resident #207 was on dialysis, when he was to go to dialysis, or any monitoring for his dialysis. Staff member J stated she would get the order input into the chart, but knew she added the dialysis information to resident #207's care plan. Staff member J stated the facility did not…
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.
- Potential for harm · F2024-07-02 · tag F0809 — failed to serve meals on a reasonable schedule — widespreadEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility failed to provide residents with meals with no more than 14 hours between the evening meal and breakfast; failed to provide a nourishing snack at bedtime; and failed to document a resident group approval of the mealtime hours for 7 (#s 2, 9, 17, 18, 19, 21, and 28) of 13 sampled residents. This practice had the potential to affect all residents who receive meals from the dining service. Findings include: During an observation on 7/2/24 at 8:20 a.m., breakfast began to be served in the dining room. The sign posted on the entry to the dining room showed breakfast was to start at 8:00 a.m., lunch at 12:00 p.m., and dinner at 5:00 p.m. The times scheduled included a 15-hour gap between dinner and breakfast. Residents #21 and #28 were sitting together in the dining room waiting for their meal to arrive. Resident #21 stated she was very hungry. When asked, residents #21 and #28 stated they did not receive snacks at night, before bed. Resident #21 stated they had never been offered snacks at bedtime as far as she could recall. Resident #28…
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.
- Potential for harm · Fcited before2024-07-02 · tag F0880 — failed to prevent and control infections — widespreadProvide 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, interviews, and record review, the facility failed to ensure implementation and monitoring of measures to prevent the growth of Legionella or other opportunistic waterborne pathogens in the building's water systems; and maintain cleanable surfaces on ice/water dispenser machine. This practice had the potential to affect all residents. Findings include: 1. During an observation on 7/1/24 at 3:30 p.m., the ice/water dispenser, on the rehabilitation unit, was dirty with a black film, white mineral deposits and rust on the tray where you place the cups and along the bottom wall of the dispensing area. The dispenser tray was no longer cleanable. 2. During an interview on 7/2/24 at 7:10 a.m., staff member H stated, I haven't been documenting anywhere that we do flushes or clean the ice machines. Maybe [staff member B] does that, he may be going around and flushing the lines and documenting. I've been here 14 years, and have never been asked about documentation, so I don't have any. During an interview on 7/2/24 at 8:30 a.m., staff member B stated, I have a water…
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.
Show the remaining 5 citations
- Potential for harm · F2023-06-08 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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 kitchen staff wore proper hair and beard coverings while preparing and serving meals, and label and date food items located in the freezer. These failures had the potential to cause food borne illness for the residents living and eating in the facility. Findings include: 1. During an observation and interview on 6/6/23 at 11:22 a.m., staff member J was observed to be wearing a black soiled baseball cap, with hair exposed below the baseball cap, and had a beard with no beard covering. Staff member K was observed to be wearing a baseball cap, and had a beard with no beard covering, while dishing up resident meals on the service tray line. Staff member J said he just wore a hat, it was all that was required. He was not sure a hair net would fit under his hat. Staff member L said she was not familiar with the state of Montana requirements for hair covering because it was different in each state. During an interview on 6/6/23 at 12:32 p.m., staff member M said the corporate policy stated a hair net or hat…
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.
- Potential for harm · F2023-06-08 · tag F0867 — failed to act on quality-improvement findings — widespreadSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to perform annual performance improvement projects and involve QAPI in abuse system issues. Findings include: During an interview on 6/8/23 at 8:02 a.m., staff member A stated abuse was monitored in the facility by depending on the staff and residents to bring up concerns. Staff member A stated abuse allegations throughout the year, were not talked about in QAPI. Staff member A stated abuse was only happening by contract staff, so the facility staff was not trained in abuse prevention after abuse allegations. Staff member A also stated there had been no official performance improvement projects through QAPI over the past year. Staff member A stated she and staff member D were revamping the QAPI process to identify areas of need. Review of the facility's QAPI Plan, dated 8/16/22, showed, The facility conducts PIPs to examine and improve care and/or services in specifically identified areas .The facility sees to prioritize projects in high risk, high frequency and/or problem prone areas that impact quality of care and quality…
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.
- Potential for harm · Ecited before2023-06-08 · tag F0880 — failed to prevent and control infections — patternProvide 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 staff followed proper infection control practices of hand hygiene when providing meal service for residents dining in their rooms. Findings include: During an observation of meal tray delivery to residents living on the E hallway, on 6/6/23 at 11:52 a.m., staff member F received the tray cart and was checking each lunch tray for accuracy of the diet order. Staff member F did not perform hand hygiene prior to opening the cart, handling each tray, or when delivering trays to residents. Staff member N was observed receiving meal trays from staff member F, and delivering them to multiple resident's rooms in the E wing of the facility. Staff member N was observed to provide set up for each resident without performing hand hygiene between residents. There were 18 residents living in the E hallway. During an interview on 6/6/23 at 12:38 p.m., staff member N said hand hygiene was done between residents when the facility was experiencing COVID, but was no longer required when serving trays. During an interview…
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.
- Potential for harm · Dcited before2023-06-08 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 protect 1 (#33) of 3 residents from staff to resident verbal abuse, causing the resident psychosocial harm at the time, and she felt threatened and vulnerable. Findings include: Review of a facility document titled, Record of Complaint, dated 10/6/22, showed, resident #33 complained to the facility about staff member H refusing to take her to the bathroom. Record review of a facility document, not titled or dated, showed, on 10/6/22, resident #33 used her call light to ask for help to go to the bathroom. Staff member H came in and told resident #33 to just go in your pants and she did not have time to help her. Resident #33 used her call light again to ask for assistance with going to the bathroom and staff member H told her she did not have time to help her. The interaction between the two escalated to the two raising their voices. Staff member I came in to see what was going on and found staff member H yelling at resident #33. Staff member I excused staff member H from the room and assisted resident #33 to…
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.
- Potential for harm · Dcited before2023-06-08 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to thoroughly investigate an alleged abuse for 1 (#33) of 4 sampled residents. This deficiency had the potential for the facility to not identify other residents that may have been affected by the staff member's verbal abuse, and the potential to allow additional abuse to occur. Findings include: Record review of a facility document, not dated or titled, showed, on 10/6/22, resident #33 used her call light to ask for help to go to the bathroom. Staff member H came in and told resident #33 to just go in your pants and she did not have time to help her. Resident #33 used her call light again to ask for assistance with going to the bathroom and staff member H told her she did not have time to help her. During an interview on 6/6/23 at 4:20 p.m., staff member A stated the facility had not provided abuse education or training over the past year, including after abuse allegations. During an interview on 6/7/23 at 10:31 a.m., staff member B stated she investigated the alleged abuse for resident #33 and immediately terminated staff…
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.
“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.
- 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.
Fines & penalties
$55,413 in federal fines across 1 penalty.
- $55,413 — penalty dated 2025-06-05
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| GALLATIN COUNTY | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 01/01/1966 |
| BOYER, JENNIFER | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2025 |
| VANCE, MELISSA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2023 |
| VAUGHN, DARCEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/19/2019 |
CMS files one row per role, so the 10 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.
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.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $28K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MT
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.
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 275066. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-05, 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.