Powder River Manor
104 N Trautman, Broadus, MT 59317 · Government - County · 41 certified beds · (406) 436-2646 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- a high payroll-based staffing rating (5/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2026
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, 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 (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $48,318 in federal fines (most recent 2025-03-13)
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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 5 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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 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 improved from 2 to 5 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 | 28.6% | 18.7% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.3% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 2.1% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 2.9% | 2.0% | better |
| Long-stay residents with depressive symptoms | 2.4% | 5.6% | 6.5% | better |
| Long-stay residents who were physically restrained | 4.4% | 0.6% | 0.1% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 4.4% | 4.4% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 16.8% | 17.2% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 2.2% | 15.8% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 93.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.8% | 6.3% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 23.6% | 24.1% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 0.0% | 20.4% | 17.1% | check this* — see note marked star below the table |
| Long-stay hospitalizations per 1,000 resident days | 0.86 | 1.38 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.86 | 2.16 | 1.80 | better |
* 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.
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
| 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. 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 discharge | not reported — The number of residents or resident stays is too small to report. 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 discharge | not reported — The number of residents or resident stays is too small to report. 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 discharge | not reported — The number of residents or resident stays is too small to report. 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 identified | not reported — The number of residents or resident stays is too small to report. 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 setting | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. 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
How full it usually is: this home is certified for 41 beds and averages 23.3 residents a day — about 57% occupied, or roughly 18 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 5.32 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.37 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.67 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 4.38 hrs/resident/day on weekends vs 5.70 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 1.55 to 0.92 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 39% is about the same as 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 fewer than at the previous inspection — improving. 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.
25 citations, most serious first. The 12 most serious are shown; the remaining 13 are one tap away and print in full.
- Actual harm · G2025-03-13 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
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 staff were performing cares within their scope of practice; failed to ensure sufficient supervision; and failed to ensure nursing staff performed adequate pain assessment and ongoing monitoring for the application of a heat pack for 1 (#9) of 16 sampled residents. The facility's failures resulted in the development of a partial thickness facial burn for one resident and increased the risk of serious injuries for any resident in need of heat pack application. Findings include: During an interview on 3/11/25 at 10:12 a.m., resident #9 reported he received a burn to his left face approximately five or six months ago when he reported a toothache. During an interview on 3/12/25 at 1:45 p.m., staff member D stated, We don't use hot packs here at all. There was an incident with one in the past. During an interview on 3/12/25 at 2:40 p.m. regarding the 7/1/25 burn incident reported by resident #9, staff member A stated, The CNA went back to physical therapy without permission and got a heat pack from the hydrocollator. As…
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 · G2024-03-14 · 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
Based on observation, interview, and record review, the facility failed to prevent the development and progression of a pressure wound, for 1 (#4) of 1 sampled resident with a Stage 3 sacral pressure wound. Findings include: During an observation and interview on 3/12/24 at 2:10 p.m., resident #4 was seated in a recliner in her room, leaning toward the left arm of the chair. A pressure relieving chair pad was observed on the chair. An air mattress was observed on resident #4's bed. Resident #4 stated she had a butt sore, which made it hard to sit up straight in the chair. Resident #4 stated, I got that new (air) mattress on the bed and this (pressure relieving chair pad) thing not too long ago, but I don't think they are helping much. Resident #4 stated, It's uncomfortable, how would you feel if you had a hole in your butt? During an interview on 3/13/24 at 9:35 a.m., staff member F stated resident #4's wound care had already been completed for the day and was completed by mid-morning, daily. Staff member F stated, I told them (nursing leadership) that she needed specialized wound…
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 · E2026-04-22 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 and interview, the facility failed to label, date, and store food in a manner to maintain food safety and prevent foodborne illness by failing to ensure all open items were dated. This deficient practice had the potential to affect all residents who ate at the facility. Findings include:During an observation and interview on 4/21/26 at 7:40 a.m., the initial kitchen walkthrough showed the following items were stored on the open shelving to the right of the grill and stovetop. The containers were opened for use, and not marked with the date they were opened:- large plastic bottle of cooking oil, capped,- large plastic bottle of butter-flavored oil, capped,- large container of parsley flakes, capped,- large container of dry, chopped onions,- round container of Quaker oats, capped- box of Malt-O-Meal hot breakfast cereal,- box of instant mashed potatoes,- large container of ground ginger, capped- large container of ground coriander, capped, and- large container of whole sesame seeds, capped.Staff member H stated she had been the kitchen manager for 12 years. 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.
- Potential for harm · D2026-04-22 · 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 from sexual abuse 1 (#13) by resident #4; and failed to protect from physical abuse 1 (#5) by resident #8 of 12 sampled residents. Findings include:1. Sexual AbuseReview of the facility investigation for the incident reported to the State Survey Agency on 1/26/26, showed resident #4 was found by staff with his hand down resident #13's brief in a common area. Resident #13 did not have capacity to consent. The facility investigation did not show other residents were interviewed or assessed for potential to be affected by similar sexual abuse incidents.During an interview on 4/21/26 at 4:22 p.m., staff member A stated the incident between residents #13 and #4 was reported to the wrong facility type license as they were unaware, they had an adult day care service license as well as the skilled nursing facility license. Staff member A stated the two residents were assessed and many interventions were put in place, but for the investigation no other residents were present, so no others were asked or…
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 · D2026-04-22 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 accuracy of MDS assessments for 2 (#s 1 and 7) of 12 sampled residents. Resident #1 had a history of pneumonia and resident #7 had limited range of motion to her left arm and shoulder. These were not accurately shown in the resident's MDS assessments. The deficient practice had the potential to affect resident care as the resident's current status was inaccurately documented. Findings include: 1. During an observation on 4/21/26 at 12.41 p.m., resident #1 was seated in the dining room eating lunch. The resident showed no shortness of breath, no cough, or any other respiratory symptoms. The resident was not using oxygen.Review of resident #1's Quarterly MDS assessment, with an ARD of 2/27/26, showed an active diagnosis of pneumonia. Review of resident #1's EHR, accessed on 4/21/26 and 4/22/26, failed to show any treatment, medication, or provider notes related to a pneumonia diagnosis during the past six months.Review of resident #1's diagnoses list in the EHR, accessed on 4/21/26, showed 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 · Dcited before2026-04-22 · 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 ensure direct care staff were aware of a resident's wandering behaviors and the need to increase monitoring when the weather warmed up for 1 (#6) of 12 sampled residents. This deficient practice increased the risk the resident would leave the facility unaccompanied. Findings include: Review of resident #6's dementia care plan, initiated on 4/7/21, showed the resident had memory problems due to her dementia. An intervention, initiated on 7/2/25, showed, Sometimes I attempt to go outside on my own repeatedly so a wander guard bracelet was put on my walker to alert staff .and also have history of going outside alone to try to check the bird feeders . [sic]During an observation on 4/22/26 at 8:00 a.m., resident #6 was seated in the dining room eating breakfast. When the resident had finished eating, she used her wheeled walker to ambulate back to her room.During an interview on 4/22/26 at 8:10 a.m., staff member F stated she had worked at the facility for several years. When asked about resident #6's wandering…
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 · D2025-09-10 · tag F0577 — isolatedAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure readily available results of surveys completed by the State Survey Agency were located in a publicly accessible area. This failure would affect any person wishing to view the survey results. Findings include:During an observation on 9/8/25 at 1:18 p.m., the facility had a wall-mounted file holder viewable upon entrance into the facility's building, located on the wall of the common area TV room. The holder had a label with the words printed on it, SURVEY RESULTS. The holder did not have any binder or documents to view.During an observation on 9/10/25 at 8:22 a.m., the facility did not have any binder or documents to view in the same entry area wall-mounted file holder.During an interview on 9/10/25 at 10:12 a.m. staff member D stated she did not realize the binder with results from surveys was not available in the file holder. Staff member D stated she would check to see where it might be.During an interview on 9/10/25 at 10:51 a.m. staff member D stated she did not know why the binder had not been available in 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 · D2025-09-10 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 completed POLST form with physician signature was readily accessible in the hard chart and the electronic medical record for 1 (#5) of 5 sampled residents. Findings include:During a record review of resident #5's POLST, dated [DATE], showed No CPR and selective treatment was selected, and the form was filled by the resident's responsible party. The form was not signed by resident #5's responsible party. The form was not signed by the provider, it was without a date, and there was not a printed name of the provider.During an interview on [DATE] at 11:23 a.m., staff member F stated admission forms, including POLST forms, were reviewed by staff member F, the resident or responsible party, and or family member. Staff member F stated some forms were given to the resident or responsible party to fill out ahead of time, before entering the facility. Staff member F stated she was not sure why resident #5's POLST had not been completed and filled out…
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 · F2025-03-13 · 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, interview, and record review, the facility failed to ensure proper hand hygiene was used for 3 (#s 5, 12, and 18); failed to ensure clean medical equipment (lifts) between resident uses for 2 (#s 12 and 18); failed to properly clean blood glucose monitor for 1 (#5); failed to provide effective education related to enhanced barrier precautions (EBP) throughout the facility, and failed to implement the appropriate use of enhanced barrier precautions (EBP) for 1 (#9) of 16 sampled residents. The deficient practices increases the risks of infection for all residents receiving care within the facility. Findings include: 1. During an observation on 3/11/25 at 3:58 p.m., staff member E and F were toileting resident #18, using the sit-to-stand lift. Staff member E began by gloving, without hand hygiene, and moved resident #18 over the toilet. Both staff member E and F removed the soiled brief. Resident #18 urinated. and without removing the dirty gloves, staff members E and F replaced resident #18's brief on and dressed him, while he was in the lift. Staff member E…
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 · E2025-03-13 · tag F0761 — failed to label and store drugs safely — patternEnsure 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
Based on observations and interviews, the facility failed to ensure opened facility-wide use medications were labeled with an expiration date when stored in the medication cart; and expired products in the medication room were disposed of. This deficient practice increased the risk of adversely affecting any resident who was taking these medications or using an inaccurately calibrated glucose monitor. Findings include: During an observation on 3/11/25 at 4:37 p.m., with staff member I, the following items were found: - Robafen DM with no open date, almost empty, - Maxtussin Mucus and chest congestion with no date and was half empty, - Mintox Max antacid with no open date and almost empty, - Cholestyramine 4 gm with no open date, - Metrix level 2 3ml Control solution, expired on 2/28/25, and - 8 IV extension tubing set, expired 4/2021. During an interview on 3/12/25 at 8:13 a.m., staff member D stated all medications were to be marked with an open date, once opened, and disposed of when expired. During an interview on 3/12/25 at 11:40 a.m., staff member C stated all medications were…
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 · D2025-03-13 · 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 accurately document an event sent to the State Survey Agency regarding a resident-sustained facial burn and the resident had pain, due to the application of a heat pack, and failed to provide accurate documentation of the facility's investigative findings, for 1 (#9) of 16 sampled residents. Findings include: During an interview on 3/11/25 at 10:12 a.m., resident #9 reported he had received a burn to his left cheek and ear, approximately five or six months ago, from a heat pack applied for a toothache. During a phone interview on 3/11/25 at 4:15 p.m., NF6 stated he received a complaint from resident #9 pertaining to receiving a burn. NF6 stated he saw the facial burn approximately one week after the incident. At the time of his visit, NF6 stated, There was no blistering remaining, but the entire cheek, from top of the ear to the left jawline, was quite red, inflamed, and was reported by [Resident #9] to be painful. During a phone interview on 3/12/25 at 1:15 p.m., NF5 stated resident #9's left face was red and blistered…
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 · D2025-03-13 · tag F0621 — isolatedTreat residents equally regarding transfer, discharge, and provision of services for all residents, regardless of payment source
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 implement equal practices during the admission process, by failing to complete admissions on residents entering the facility for respite care for 1 (#77) of 16 sampled residents. This deficient practice placed residents at risk for staff providing effective, person-centered care. Findings include: During an observation on 3/10/25 at 3:15 p.m., resident #77 was in her room, with no name on the door, and was not listed on the census list provided by the facility. During an interview on 3/10/25 at 3:30 p.m., staff member C stated resident #77 was a respite patient, and the facility did not fully admit respite patients. Staff member C stated residents who were on respite stays would not be included in the census. Staff member C stated the facility accepted respite patients regularly and did not admit them the way they did for regular admissions. Staff member C stated a paper chart was started for respite patients, including a paper MAR, a facility contract, an initial assessment, and nursing notes. Staff member…
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 13 citations
- Potential for harm · D2025-03-13 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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 complete a baseline care plan for 1 (#77) of 16 sampled residents. This deficient practice put the resident at risk for bedside staff to be unaware of resident care needs and providing effective, person-centered care. Findings include: During an observation on 3/10/25 at 3:15 p.m., resident #77 was in her room, with no name on the door, and was not listed in the census list provided. During an interview on 3/10/25 at 3:30 p.m., staff member C stated resident #77 was a respite patient, who entered the facility on 3/7/25, and the facility did not fully admit respite patients. Staff member C stated a care plan was not necessary because the census was small, and everyone knows the residents who were at the facility for respite stays. Review of resident #77's paper chart did not include a baseline care plan. Review of the facility's policy, Baseline Care Plans, dated August 2024, reflected: - 1. The baseline care plan will: a. Be developed within 48 hours of a resident's admission. b. Include the minimum…
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 · D2025-03-13 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 observations, interviews, and record review, the facility failed to complete timely revisions to comprehensive fall care plans for 1 (#18) of 16 sampled residents. The failure to update the fall care plan caused staff confusion and increased the risk of additional falls resulting in injuries. Findings include: During an observation on 3/11/25 at 7:32 a.m., resident #18 was in his bed wearing white crew socks without grips, there were no grip strips on floors, the bedside table was next to his bed, and the door to the hallway was closed. The ghost alarm was turned off. No Falling Star magnet (visual tool for staff to know when a resident had frequent falls) was on the door. During an observation on 3/11/25 at 12:09 p.m. through 3:20 p.m., resident #18 was in his wheelchair without foot rests, by the nurses' station, slumped over. Resident #18 was wearing white crew socks without grips on the bottoms. Resident #18 did not move from the nurse's station during the observation period. During an observation on 3/11/25 at 3:58 p.m., resident #18's chair alarm wire was 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 · Dcited before2025-03-13 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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, facility staff failed to uphold professional standards by not following the physician orders to check the wanderguard function daily, for 1 (#20) of 16 sampled residents. The failure increased the risk for elopement and serious harm to the resident. Findings include: During an observation on 3/11/25 at 3:25 p.m., resident #20 was observed wandering the halls, peering into resident rooms, staff offices, and peering out of the exterior door window. Resident #20 was wearing a wanderguard bracelet at the time of the observation. During an interview on 3/12/25 at 2:12 p.m., staff member D stated resident #20 had eloped at some time in the past, and so she had the wanderguard on to prevent another elopement. Staff member D stated the wanderguards were tested daily by the nurses. During an interview on 3/12/25 at 3:50 p.m., staff member C stated she placed the wanderguard checks on the TARs specifically to prevent them from being overlooked. Staff member C stated the EHR system flags the nurses for incomplete orders during their shift,…
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 before2025-03-13 · 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 observations, interviews, and record review, the facility failed to ensure fall interventions were followed by staff for 1 (#18); and failed to ensure staff followed needle safety techniques for 1 (#5) of 16 sampled residents. These deficient practices placed the resident at risk for increased falls for #18 and staff needle injuries. 1. During an observation on 3/11/25 at 7:32 a.m., resident #18 was in his bed wearing white crew socks, not non-skid socks. There were no grip strips on floors, the bedside table next to his bed, and the door to the hallway was closed. The ghost alarm (motion alarm) was turned off. No Falling Star magnet (visual tool for staff to know when a resident had frequent falls) was on the door. During an observations on 3/11/25 from 12:09 p.m. through 3:20 p.m., resident #18 was in his wheelchair without foot rests, by nurses' station, slumped over. Resident #18 did not move from the nursing station during the observation period. During an observation on 3/11/25 at 3:58 p.m., resident #18's chair alarm wire was not connected to the chair alarm device,…
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 · D2025-03-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
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 a resident in respiratory distress, who was coughing and unable to breathe, and afraid he was dying due to it, was provided respiratory care and assessed as needed, for 1 (#23) of 16 sampled residents. Findings include: During an observation and interview on 3/10/25 at 2:44 p.m., resident #23 was in his bed coughing and gurgling, and coughing up phlegm. Staff member B entered the room and sat resident #23 up in bed and went to get medications for the cough. Staff member H entered the room and stated she was giving resident #23 cough syrup, cough drops, and his inhaler. Staff member H stated all of resident #23's vitals were normal, so the doctor was not notified. Staff member B stated vitals are done weekly unless a resident is on daily vitals orders. No respiratory assessment was done for the resident during this observation. Resident #23 asked if the surveyor could find him a way to the hospital because he was dying. During an interview on 3/11/25 at 12:20 p.m., NF2 and NF3 visited resident #23.…
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 · D2025-03-13 · tag F0759 — failed to keep medication error rate low — isolatedEnsure 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 observations, interviews, and record review, the facility failed to ensure medication error rates were under 5% for 2 (#s 9 and 13) of 6 sampled residents for medication errors. The calculated medication error rate was 7.69%. Findings include: 1. During an observation and interview on 3/11/25 at 12:58 p.m., staff member I was administering medications to resident #9. Staff member I administered a pea size amount of Voltaren gel to each knee. Staff member I stated she did not usually apply the gel to his ankles because he usually had compression wraps on from his knees to his toes, and she did not want to create more work for the nurse. Staff member I stated she was aware of the plastic measuring tool to ensure enough gel was applied but forgot to grab it when prepping resident #9's medications. When asked, staff member I was unable to determine how much other nurses would have administered during the day because this was not included on the MAR as an option. Review of resident #9's medication order reflected, Voltaren External Gel 1%. Apply to knees/ankles topically three…
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 · D2025-03-13 · tag F0887 — isolatedEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide COVID-19 vaccinations for residents requesting the vaccine for 2 (#s 9 and 10) of 5 residents sampled for vaccinations. This deficient practice increased the risk of COVID-19 infections for residents in the facility. Findings include: 1. During an interview on 3/11/25 at 3:31 p.m., staff member C stated two of the five sampled residents did not receive their COVID-19 vaccine, as requested. During a phone interview on 3/12/25 at 1:15 p.m., NF5 stated she did sign an approval for the COVID-19 vaccine for resident #9 last fall, and assumed the vaccine had been administered. Review of a facility document titled, Vaccine Intake and Annual Consent, dated 10/28/24, showed NF5's signed approval for resident #9 to receive the COVID-19 vaccine. 2. Review of a facility document titled, Vaccine Intake and Annual Consent, dated 10/23/24, showed resident #10's POA's signed approval for resident #10 to receive the COVID-19 vaccine. Review of a facility written statement, undated, provided by staff member C to the surveyors on…
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 · D2024-12-31 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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 all allegations of neglect by staff were reported to the administrator and State Survey Agency within the required timelines for 2 (#s 1 and 4) of 7 sampled residents. Findings include: During an interview on 12/30/24 at 12:39 p.m., staff member B stated she had witnessed staff member H pushing resident #4 down the hall towards his room. Staff member B stated the resident was sitting on a bath chair and wrapped in a blanket. Staff member B stated staff member H took resident #4 into his room and left him there. Staff member B stated resident #4 began, hollering and yelling for help. Staff member B stated she witnessed staff member G go into the resident's room. Staff member B stated she did not remember how much time elapsed between when staff member H left resident #4 in his room and when staff member G entered the resident's room to help him. During an interview on 12/30/24 at 6:28 p.m., staff member G stated she was working with staff member H on a day shift. Staff member G stated staff member H had given…
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 · F2024-03-14 · tag F0727 — failed to provide required RN coverage — widespreadHave 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 interview and record review, the facility failed to have an RN working at least eight consecutive hours per twenty-four-hour period, seven days per week. This deficient practice had the potential to affect all residents who received nursing services. Findings include: Record review of the October 2023 schedule for licensed nursing, showed the following dates did not have eight consecutive hours of RN coverage documented in a twenty-four-hour period: - 10/14/23, 10/20/23, 10/27/23, and 10/28/23. During an interview on 3/12/24 at 1:28 p.m., staff members B and C reviewed and compared the facility's nursing schedule with the [NAME] payroll-based journal report for the period of October 2023 to December 2023. Staff member B stated there were no RN hours within a twenty-four-hour period on the dates triggered for No RN hours on the [NAME] report. Staff member B stated, Yes, that was me. We had one RN out with short notice, and in my rush to fill those shifts, I didn't confirm there was an RN for at least 8 hours per day. Staff member C stated the facility had not applied for 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 · F2024-03-14 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to maintain a safe environment free from chemicals for the residents. This deficient practice had the potential to adversely affect the well-being and safety of residents in the facility. Findings include: During observations on 3/11/24 at 3:00 p.m. and 5:05 p.m., the shower room door was open into the hallway. There were no staff in the shower room or the immediate area. In the shower room, chemicals were observed in an area that residents could access. The bottles were labeled as Febreeze spray, Sani cloth sanitizing wipes, Comet, Micro Kill Q10, and Classic disinfectant cleaner. One bottle containing yellow liquid had non-legible label. The labels that could be read showed the contents were harmful and should be kept out of the reach of children. During an observation on 3/13/24 at 11:36 a.m., a Microban sanitizing spray was on the counter in the activity room. A cabinet in the activities room was unlocked and contained Purell surface cleaner, a box of Borax, and bottle of citrus cleaner. During an interview on 3/13/24 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.
- Potential for harm · E2024-03-14 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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 interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan, for residents receiving anticoagulant medication for 3 (#s 9, 18, and 22), and a resident receiving psychotropic medications for 2 (#s 10 and 22) of 20 sampled residents. Findings include: 1. During an interview on 3/13/24 at 4:08 p.m., Staff member H, who assisted with the care of resident #22, stated that important resident information was shared during report at the start of the shift. Staff member H denied knowing that any resident was on a medication that had the potential to increase the risk of bleeding. Review of resident #22's medical record showed resident #22 was prescribed and taking an injectable anticoagulant, Lovenox for prevention of blood clots, and psychotropic medications mirtazapine and depakote for dementia with behaviors. Review of resident #22's care plan, initiated on 3/7/24, failed to show focus, goals or interventions for anticoagulant and psychotropic medications. 2. Review of resident #9's medical record showed resident #9 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.
- Potential for harm · Dcited before2024-03-14 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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 interview and record review, the facility failed to meet professional standards of practice for the prevention, treatment, and documentation of pressure wounds for 1 (#4) of 1 sampled resident with a pressure wound. Findings include: During an interview on 3/13/24 at 9:35 a.m., staff member F stated, The CNAs do the baths twice a week, and if they (residents) have skin concerns, they let us know and we (nurses) check it. Staff member F also stated her wound care education and experience was received through her nursing education and not at the facility. During an interview on 3/13/24 at 1:22 p.m., staff member H stated, If there is a wound, we don't chart them, we just let the nurses know and then they would notify the doctor or put it in the chart (EMR) I think. During an interview on 3/14/24 at 8:25 a.m., regarding pressure wound documentation, staff member F stated, There are just certain expectations nurses have for documentation, such as 72-hour monitoring documentation after an event, daily wound notes if someone has a wound, etcetera. Staff member F 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 · D2024-03-14 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from unnecessary medications, failed to evaluate the medication effects, and failed to obtain consent for psychotropic medication use for 1 (#22) of 20 sampled. This deficient practice had the potential to adversely affect a resident's ability with maintaining highest practicable level of well-being. Findings include: During an observation and interview on 3/12/24 at 8:30 a.m., resident #22 was sitting in a Geri chair near the nurses station. An interview was attempted with resident #22. Resident #22 failed to respond to verbal stimulation. During an observation on 3/12/24 at 11:53 a.m., resident #22 was sitting at a dining room table in a reclined Geri chair. Resident #22 did not awaken when staff attempted to assist him with eating. During an interview on 3/12/24 at 9:57 a.m., with staff members B and C, staff member C stated resident #22 was not taking any psychotropic medications. Staff member B identified…
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
$48,318 in federal fines across 2 penalties.
- $12,438 — penalty dated 2025-03-13
- $35,880 — penalty dated 2024-03-14
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 |
|---|---|---|---|---|
| POWDER RIVER COUNTY | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 08/01/1977 |
| RANDALL, LEE | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | — | since 01/17/2025 |
| HOSTETTER, JEFFREY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2015 |
| RANDALL, KYLIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2020 |
CMS files one row per role, so the 9 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.
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 275087. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-22, 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.