Continental Care And Rehabilitation
2400 Continental Dr, Butte, MT 59701 · For profit - Limited Liability company · 100 certified beds · (406) 723-6556 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)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- 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 Jun 2026
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- nursing-staff turnover (60%) 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) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 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 | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 5.1% | 18.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 10.6% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.4% | 2.1% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.3% | 2.9% | 2.0% | better |
| Long-stay residents with depressive symptoms | 16.3% | 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 | 4.0% | 4.4% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 2.9% | 17.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 13.9% | 15.8% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.8% | 93.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.4% | 6.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 23.4% | 24.1% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 26.6% | 20.4% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.3% | 1.2% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 73.5% | 73.8% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 7.8% | 19.2% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 32.2% | 14.5% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.74 | 1.38 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 2.43 | 2.16 | 1.80 | 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.
35.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 59 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 62.8% 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 43 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 0.72 therapist hours per resident per day in 2026Q1 — more than 92% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 22% 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 | 35.0%CMS range 23.7–45.2 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.5%CMS range 7.0–13.8 | 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 | 62.8% | 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 | 69.8% | 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 | 55.8% | 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 | 100.0% | 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 | 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 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 | 1.5% | 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 | 3.1% | 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 | 8.0%CMS range 4.3–15.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.44 | 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 100 beds and averages 86.5 residents a day — about 86% occupied, or roughly 14 beds typically open. It runs fairly full. 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 4.03 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.79 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.63 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 3.38 hrs/resident/day on weekends vs 4.29 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.94 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 60% 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 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.
32 citations, most serious first. The 11 most serious are shown; the remaining 21 are one tap away and print in full.
- Actual harm · G2026-06-04 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 residents with indwelling urinary catheters received care to prevent urinary tract infections; failed to identify a root cause of repeated urinary tract infections for 2 (#s 6 & 9); and failed to follow up timely with urology referrals and appointments for 1 (# 9) of 19 sampled residents. Findings include1. Review of resident #9's medical record showed three hospitalizations occurring in 2026. Review of resident #9's hospital Discharge summary, dated [DATE] - 1/22/26 showed:- Diagnoses: Sepsis due to catheter associated Morganella morganii UTI with bilateral hydronephrosis .- Follow up Recommendations for PCP: Close follow-up with urology .Review of resident #9's hospital Discharge summary, dated [DATE] - 4/17/26 showed:-Diagnoses: Sepsis due to catheter associated Pseudomonas UTI with bilateral hydronephrosis-Follow up Recommendations for PCP: Once daily acetic acid irrigation ordered but can increase to 3 times daily if needed. This is an…
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 · D2026-06-04 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
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 have a consistent process for finding or replacing missing clothing, and the resident had missing clothing, for 1 (#3) of 19 sampled residents. Findings include: During an interview on 6/2/26 at 10:30 a.m., NF1 stated, There was a time when the laundry machine was down and so the facility was taking clothing to the laundromat. NF1 stated all of resident #3's stuff disappeared. NF1 stated she came to visit and resident #3 was wearing a bra, a shirt and had a blanket on her lap. There were no pants in her entire room. NF1 stated all of resident #3's clothing was clearly labeled with her name, including each individual sock. NF1 stated the facility did not replace any of the missing clothing.During an interview on 6/3/26 at 9:09 a.m., staff member B stated if a resident reported something was missing facility staff would check against the resident's inventory sheet and start investigating. If the item was unable to be located the facility would replace it to the best of their ability.A request was made on 6/3/26…
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 · D2026-06-04 · 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 ensure that a resident (#32) was free from physical abuse from another resident (#62) of the 19 sampled residents. The facility identified the failure and corrected it on 5/11/26, which was before the start of the survey period. This deficient practice is cited as past noncompliance. This failure had the potential to cause resident #32 physicial and or psychosocial harm. Findings include:During an observation on 6/1/26 at 3:54 p.m., resident #62 was sitting in her room with the light off and there was no noise. Resident #62 was unable to verbalize or answer questions.Review of a facility-reported incident dated 3/15/26, showed: [Resident #32's initials] reported that [Resident #62] hit him on the arm. No injuries noted and resident appears to be at baseline. Incident reported to family and provider. Order received to send accused party to the acute (hospital) for evaluation. Investigation initiated. [sic]During an interview with staff members N and M on 6/4/26 at 7:35 a.m., staff member N stated, We could…
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 · D2026-06-04 · tag F0627 — isolatedEnsure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
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 identify a resident had left the facility AMA and failed to inform the resident of the risks of leaving the facility AMA and their rights for 1 (#17) of 21 sampled and supplemental residents. This deficient practice put the resident at risk for a negative medical outcome. Findings include:Review of resident #17's Comprehensive MDS dated [DATE], showed: section C, Cognitive Patterns: BIMS Summary Score (C0500), 12 (Moderate Impairment). During an interview on 6/1/26 at 4:49 p.m., NF4 stated resident #17 never wanted to be at the facility and wanted to leave. NF4 stated that resident #17 had threatened to leave the facility AMA (Against Medical Advice) at one point and eventually did. NF4 stated, I am unsure of the facility's policy on AMA discharge, but there was no documentation filled out when she left.During an interview on 6/2/26 at 3:03 p.m., staff member O stated the facility's process for when a resident leaves is to have the resident sign out 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 · D2026-06-04 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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 provide a resident or resident representative with notice of bed hold or transfer/discharge, which could lead to the resident not knowing their rights for 1 (#10) of 21 sampled and supplemental residents. Findings include:Review of nursing progress notes dated 5/17/26, showed resident #10's family requested resident #10 be sent to the hospital and an ambulance was called for transport.Review of resident #10's electronic medical record failed to show the facility provided resident #10 or their representative with a notice of bed hold or transfer/discharge before the ambulance picked resident #10 up for transport to the hospital.During an interview on 6/3/26 at 4:30 p.m., staff member M stated staff would usually go up to the hospital and have the resident sign the bed hold and transfer notices, and that did not get done with resident #10 since she was sent to a hospital out of town. During an interview on 6/4/26 at 10:15 a.m., staff member A 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 · Fcited before2026-03-04 · 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 maintain a sanitary kitchen by covering a hole in the floor where plumbing was being fixed with plywood, which was an uncleanable surface, and the wood could not be maintained for cleanliness. This failure could affect any resident receiving food from the kitchen. Findings include:During an observation and interview on 3/3/26 at 11:08 a.m., the [NAME] end of the kitchen had two, four by eight-foot sheets of bare plywood laying on the floor over areas where the tile was missing. The sheets of plywood had areas of various shades of black staining on them and the tile floor around the plywood had scattered debris and white/gray stains on it. Staff member E stated maintenance had to dig holes under the flooring to fix the drainpipes. Staff member E further stated the construction had been going on for approximately two weeks, and it was occurring at night when the kitchen was not in use. Staff member E stated they had draped plastic sheeting for barriers, to keep the dust out of the rest of the kitchen.During an…
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 · F2025-05-19 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide meals at the regular scheduled times for 5 (#s 23, 24, 36, 49 and 76) of 25 sampled residents. This deficient practice had the potential to affect all residents of the facility. Findings include: 1. During an observation and interview, on 5/17/25 at 1:01 p.m., resident #49 was lying in bed with no lunch tray. Resident #49 stated food was always late, especially the breakfast and lunch meals. Resident #49 stated he had not received his lunch yet. He stated lunch would often be delivered between 1:30 p.m. and 2:30 p.m. Resident #49 stated he would order food from local restaurants to be delivered if he was really hungry or did not like the food when he finally got it. During an observation on 5/17/25 at 1:10 p.m., eight residents were seated at tables in the C dining room, with drinks in front of them, but no food. Room trays had not been delivered on the unit yet to the residents in their rooms. During an observation on 5/17/25 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-05-19 · tag F0554 — patternAllow residents to self-administer drugs if determined clinically appropriate.
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 observations, interviews, and record reviews, the facility failed to ensure residents were assessed and found safe to self-administer their own medications, prior to doing so; and the facility failed to document the assessments or a physician order in the EHRs, for 4 (#s 23, 45, 49, and 53) of 25 sampled residents. This deficient practice increased the risk of a negative outcome for the residents, in the event the medication and self/staff monitoring were not handled properly. Findings include: 1. During an observation and interview on 5/18/25 at 7:50 a.m., staff member G entered resident #45's room and placed a cup of pills on his bedside table. Staff member G then left the room without the resident taking the medications. The cup of pills contained loratadine (antihistamine), nifedipine Extended-Release (calcium channel blocker), and a Velphoro chew (treats hypocalcemia). Resident #45 stated he did not like to take his pills without food, and meals were often late, so the nurses routinely left 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 · E2025-05-19 · tag F0578 — failed to honor advance directives / code status — patternHonor 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
Based on interview and record review, the facility failed to failed to correctly reflect the code status of a resident in the EHR for 1 (#68) of 25 sampled residents, and this failure increased the risk of the resident being resuscitated in a health crisis, when that was not the resident's preference or what was documented on the resident's POLST form. Findings include: During an interview on 5/19/25 at 7:59 a.m., staff member E stated social services assures the POLST is reviewed and accurately completed for the resident upon admission. Staff member E further stated the code status on the POLST form should be the same as the code status in the EHR. A review of resident #68's POLST form showed Section A, under the heading Treatment options the box for Do Not Attempt Resuscitation was checked. A review of resident #68's EHR showed his code status as Full Code/Full Treatment A review of a facility policy titled Residents' Rights Regarding Treatment and Advance Directives, with a copyright date of 2025, showed: Policy: It is the policy of this facility to support and facilitate 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 · E2025-05-19 · tag F0605 — failed to not use drugs as a restraint — patternPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
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 interviews and record reviews, the facility failed to ensure gradual dose reductions were attempted, unless the prescriber documented a rationale for the contraindication of the change, for 3 (#s 10, 19, and 54) of 25 sampled residents. Findings include: A review of the State Operations Manual, Appendix PP, under F605, showed: Adequate Indications for use refers to the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident's condition and therapeutic goals, and after any other treatments have been deemed clinically contraindicated. For psychotropic medications, without documentation in the record explaining that the practitioner has determined that other treatments have been deemed clinically contraindicated, the indication for use is inadequate. Also, adequate indication for use means that the medication administered is consistent with manufacturer's recommendations and/or clinical practice guidelines, clinical standards of practice,…
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 · E2025-05-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 reviews, the facility failed to follow smoking assessment safety recommendations for residents who were smoking; failed to monitor the location were residents were smoking; failed to ensure the residents signed out of the facility when smoking (as needed); and failed to follow and adhere to the facility policy related to resident smoking. These failures occurred throughout the survey period, for multiple shifts and days, and multiple staff failed to adhere to the policy, for 3 (#s 40, 75, and 238) of 5 sampled residents who smoke. This deficient practice placed all residents entering the activities room at risk of exposure to second-hand smoke and risk for fire. This deficient practice placed residents at risk of injury while smoking, increased risk of fires, and accidents related to smoking. Findings include: 1. During an observation and interview on 5/18/25 at 2:15 p.m., resident #75 was sitting immediately outside the activity door smoking. Resident #75 stated staff member B stated he could smoke outside the door. Resident #75 stated…
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 21 citations
- Potential for harm · Dcited before2025-05-19 · 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 accurately assess the vision needs of a resident on the comprehensive assessment, for 1 (#23) of 25 sampled residents, and the resident was unable to read or see her food when eating. Findings include: During an observation and interview on 5/17/25 at 1:05 PM, resident #23 stated her vision started to deteriorate in October of 2024, due to cataracts. Resident #23 showed this surveyor she could not read the book her roommate had given her. Resident #23 stated, I can't see you, my food, anything now. During an interview on 5/18/25 at 4:23 p.m., staff member K stated there was no vision concerns or appointments needed that she could think of for resident #23. Staff member K stated she would bring up vision needs for residents during care conferences, and if there were any, it would get reported on the MDS, and staff member K stated questions were asked, like, do you need glasses? Staff member K also looked into making appointments if there was a need. Staff member K stated during the last care conference 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 · Dcited before2025-05-19 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 implement a comprehensive care plan to include bowel and bladder incontinence for 1 (#241) of 25 sampled residents. Findings include: Review of resident #241's admission MDS, with an ARD of 5/12/25, showed the resident was always incontinent of bowel and bladder. Section V, Care Area Assessment Summary, showed the bladder incontinence care area had triggered and should be care planned. A review of resident #241's Baseline Care Plan, dated 4/30/25, showed the resident was frequently incontinent of bowel and bladder. A review of resident #241's comprehensive care plan failed to show the resident was incontinent of bowel and bladder. During an interview on 5/18/25 at 4:22 p.m., staff member B stated the nurse managers and MDS Coordinators developed the residents care plans, and she assumed that bowel and bladder incontinence should be on the care plan. Staff member B further stated that resident #241 was relatively new to the facility, and his care plan may not be completed yet. A review of a facility policy titled, Care Plan…
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 · D2025-05-19 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
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 assist with making appointments and arranging timely transportation for a resident with impaired vision needs, and this failure caused an eye surgery to be canceled, and appointments were not able to be scheduled due to missed appointments, for 1 (#58) of 25 sampled residents. The resident had difficulty doing things she loved, as well as fear of leaving her room, because she may run into someone due to her poor eyesight. Findings include: During an observation and interview on 5/17/25 at 1:05 p.m., resident #58 stated her biggest concern living at the facility was getting vision appointments, and then getting transportation to the appointments on time. Resident #58 stated the facility had made and canceled several appointments for her since November of 2024, without telling her, or the doctor's offices. Resident #58 stated some of the provider offices will not see her now as a patient because, I have been late or missed so many appointments, and once you're late they won't see you, and after so many times…
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 · D2025-05-19 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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 complete a POLST form with the resident's first name, for 1 (#241), and failed to have the resident/POA sign the POLST form placed in the EHR, for 1 (#24) of 25 sampled residents. These deficient practices had the potential to create complications, or hinder emergency treatment necessary, related to a resident's DNR wishes. Findings include: During an interview on 5/19/25 at 7:59 a.m., staff member E stated social services assures the POLST is reviewed and accurately completed for the resident upon admission. Staff member E stated the code status is in the residents EHR within seven days after admission. Staff member E further stated the code status on the POLST form should be the same as the code status in the EHR, the POLST form should accurately reflect the residents first name, and it was very important the POLST form was signed by the resident or the residents POA. 1. A review of resident #241's POLST form showed the first name was not the resident's first name, middle name, or a name the resident used. 2.…
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 before2024-10-22 · tag F0808 — failed to follow doctor-ordered diets — patternEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
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 observations, interviews, and record review, the facility failed to provide therapeutic meals that followed physician orders for 2 (#13 and 14) of 2 sampled dialysis residents. Findings include: During an interview on 10/22/24 at 11:51 a.m., NF1 stated the facility did not properly provide appropriate meals for dialysis patients. NF1 stated, They just can't properly care for . dialysis patients. NF1 stated residents often told them their meals were commonly high in salt, and the meal would consist of something like a ham sandwich and chips. NF1 stated this extra salt would lead the residents to drink more water which had a negative impact on their kidneys, and required more dialysis. During an observation and interview on 10/22/24 at 1:39 p.m., the surveyor had walked into resident #13's room and he stated, That soup was really really salty. When asked, resident #13 stated he can control his dialysis better with water, but his water limit was one liter per day. Resident #13 stated he commonly had…
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 · D2024-10-22 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, and record review, the facility failed to provide the scheduled showers for 3 (#s 1, 3, and 8) of 6 sampled residents for hygiene care. Findings include: During an interview on 10/22/24 at 11:51 a.m., NF1 stated resident #1 visited [Facility Name] and was . so filthy our staff didn't want to touch her. NF1 stated resident #1 visited [Facility Name] on 10/11/24, had significant body odor, and her ponytail was matted at the base of her hair. NF1 stated the staff was concerned resident #1 might have hair loss because the ponytail had been in so long. During an interview on 10/22/24 at 11:25 a.m., resident #3 stated his last shower was last Saturday. Resident #3 stated, I don't seem to be asked a lot (if he wanted a shower). He stated he rarely refused showers except when the staff would offer him a shower at 9:30 p.m. or 10:00 p.m. Resident #3 stated this was too late in the day, and he wanted to go to bed at this time. Resident #3 stated he did not get asked about a shower the morning of 10/22/24 (at 3:00 a.m.). Review of resident #3's EHR showed resident #3…
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 · D2024-10-22 · tag F0725 — failed to have enough nursing staff — isolatedProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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 schedule a sufficient number of CNAs as identified in the facility assessment recommendations, resulting in 2 (#s 18 and 19) of 20 sampled residents waiting over 20 minutes for the call light to be answered timely; 6 (#s 8, 9, 16, 18, 19, and 20) of 20 sampled residents expressing concern and complaints regarding long call light times and short staffing; and for 2 (#s 1 and 8) of 20 sampled residents not receiving enough showers; and 5 nursing staff expressed concerns with staffing ratios and not recieving breaks. Findings include: During an interview on 10/21/24 at 12:22 p.m., resident #9 stated he had waited up to 40 minutes for his call light to be answered. During an interview on 10/21/24 at 4:37 p.m., staff member B stated the facility did call light audits, kind of indirectly, but never kept a record of this. Staff member B stated they would test the call light times once a month by pushing the button in a resident's room and testing the staff's reponse time. Staff member B stated they would test this…
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 · D2024-10-22 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and 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 interviews and record reviews, the facility failed to identify the root cause, address, and obtain necessary services for the behavioral health care needs for 1 (#2) of 20 sampled residents which could result in harm to staff or other residents, and it did affect 1 (#15), due to resident #1's aggressive behaviors. Findings include: Review of a Facility Reported Incident, with an initial report date of 10/5/24, showed both resident #2 and resident #15 resided in the dementia care unit. Resident #2 punched resident #15 in the jaw which resulted in resident #15 hitting resident #2 back. During an interview on 10/21/24 at 12:02 p.m., staff member C stated resident #2 had moments of being verbally aggressive and would yell at staff or residents. Staff member C stated they worked the night prior to resident #2 hitting resident #15. Staff member C explained a situation where resident #2 had been confused and was wearing resident #15's belt. Staff member C stated resident #2 would often go through 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 · D2024-08-14 · 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 observation, interview, and record review, the facility failed to meet professional standards of practice by administering an opioid medication in conjunction with a benzodiazepine. This deficient practice had the potential to cause an increase in respiratory depression, over sedation, increased confusion, coma, or death for 1 (#1) of 16 sampled residents. Findings include: During an interview on 8/12/24 at 1:58 p.m. NF1 stated, The nursing staff were giving [Resident #1] oxycodone and Ativan at the same time. I had asked the nurses repeatedly not to give them together because it would cause him (the resident) to be too sedated. I also worried about the possibility for other side effects, like slowed breathing. That really worried me because he (the resident) has COPD. There was one nurse that just would not listen to us. During an interview on 8/13/24 at 2:03 p.m., staff member B stated, The expectation for medication administration is following the five rights of medication administration. The nurses are expected to administer medications using the safest route. 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 · Fcited before2024-05-20 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure sanitary conditions and storage were maintained in the kitchen, which could affect all residents who eat food made by, or stored in, the kitchen facility. Findings include: During an observation on 5/18/24 at 12:17 p.m., staff member Q was mopping the kitchen floor without a hairnet on. Staff member Q was located behind the taped black line on the floor signifying hairnets were required. During an observation on 5/18/24 at 12:18 p.m., The following food was found directly on the floor: two boxes of hamburger buns, two boxes of grape juice, and two boxes of Folgers coffee. Sixteen other boxes were stacked on top of the food boxes, located on the floor. During an observation of the inside of the ice machine on 5/18/24 at 12:22 p.m., the plastic surface that serves as a barrier, preventing the ice from falling out of the machine, was dirty and had a tan and slight pink film on it. During an observation and interview on 5/18/24 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 · E2024-05-20 · tag F0655 — patternCreate 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 reviews, the facility failed to complete baseline care plans timely for 8 (#s 44, 50, 53, 54, 58, 59, 61, and 221) of 25 sampled residents. This deficient practice had the potential for resident's needs to be unmet by staff. Findings include: Review of resident #44's baseline care plan showed an admission date of 3/27/24. The baseline care plan was created on 3/27/24 and completed and locked on 4/2/24. Four days after the 48-hour time frame. Review of resident #50's electronic medical record showed an admission date of 2/7/24. Resident #50's baseline care plan was created on 3/21/24, 43 days after admission, and it was completed and locked on 4/1/24; 52 days after the 48-hour time frame. Review of resident #58's electronic medical record showed an admission date of 5/7/24. Resident #58's baseline care plan was created on 5/9/24, two days after admission, and it was completed and locked on 5/14/24; seven days after the 48-hour time frame. Review of resident #61's electronic medical record showed an admission date of 3/1/24. Resident #61's…
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 before2024-05-20 · 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 observations, interviews, and record reviews, the facility failed to complete comprehensive, person-centered care plans to include oxygen information for 4 (#s 5, 37, 58, and 61) of 25 sampled residents. Findings include: During an observation and interview on 5/19/24 at 10:25 a.m., resident #37 was in her room and had oxygen on via nasal cannula at two liters. Resident #37 stated she had to use oxygen all the time now and received two liters. Resident #37 stated she used a concentrator while she was in her room but had a portable oxygen tank for when she left her room. A review of resident #37's comprehensive care plan showed oxygen use at two liters via nasal cannula was initiated on 6/9/23. The care plan did not include if the oxygen was to be intermittent or continuous, if there was oxygen saturation monitoring, or the type of oxygen equipment used by the resident. During an observation and interview on 5/18/24 at 1:49 p.m., resident #58 was sitting on her bed with oxygen in place. On the bedside table was a BI-PAP machine. Resident #58 stated she was to use two 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 · E2024-05-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide 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 observation, interview, and record review, the facility failed to label oxygen tubing when it was changed for 2 (#s 3 and 5) of 25 sampled residents, and failed to follow the physician orders for prescribed oxygen amounts for 2 (#s 3 and 13) of 25 sampled residents. Findings include: 1. Review of resident #5's physician orders, dated 10/1/23 showed, Change oxygen tubing and storage bag every Sunday and prn. Label with date. During an observation on 5/18/24 at 2:15 p.m., it was noted there were no labels on the oxygen tubing or oxygen equipment for resident #5. 2. During an interview and observation on 5/18/24 at 3:43 p.m., resident #3 stated, I'm on two liters (of oxygen). Resident #3's oxygen concentrator was set to one and a half lpm and had not been in the resident's nose during the interview. The nasal cannula tubing was dated 5/2. Review of resident #3's EHR showed the following physician's orders: Change oxygen tubing and storage bag every Sunday Please label with date, [sic] and Continuous oxygen at 2 liters via Nasal cannula. During an interview on 5/20/24 at 10:01…
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 · E2024-05-20 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 serve meals at a palatable temperature for 7 (#s 2, 14, 19, 24, 47, 49, and 218) of 25 sampled residents, for those who received room trays. Findings include: During an interview on 5/18/24 at 2:39 p.m., resident #49 stated the food was terrible, tasteless, and the hot food was lukewarm when he ate in his room. During an interview on 5/18/24 at 2:49 p.m., resident #19 stated she ate in her room and the hot food was often cold. Resident #19 stated the pork chops were tough and dry as well. During an interview on 5/18/24 at 3:24 p.m., resident #47 stated the hot food was warm and the pork chops were very tough. During an interview on 5/18/24 at 3:52 p.m., resident #2 stated he believed his food was never hot because his room was located at the end of the hallway which was served last. During an interview on 5/20/24 at 9:58 a.m., staff member L stated she had heard complaints from residents about the cold food served to residents in the rooms. During an interview on 5/20/24 at 10:48 a.m., NF3 stated resident #49…
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 · E2024-05-20 · 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 adhere to infection control practices and PPE use during a COVID-19 outbreak, involving 2 ( #11 and 217), for 25 sampled residents. Findings include: During an observation and interview on 5/18/24 at 11:55 a.m., facility staff were wearing N-95 masks. Staff member P stated the facility was in a COVID-19 outbreak. During an observation on 5/18/24 at 2:05 p.m., the door to resident #11 and #217's room was open to the hallway. Both resident #11 and resident #217 were COVID-19 Positive. Resident #11's bed was next to the door. Resident #11 was lying in bed, and was frequently coughing. During an observation and interview on 5/18/24 at 2:14 p.m., the door to resident #11 and #217's room was still open to the hallway. Staff member E stated, [Resident #11] does not like his door closed, so we leave it open. We just try to encourage other residents to put a mask on when they leave their rooms. Staff member E stated resident #s 11 and 217 had no safety risks that would require the door to be open. 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 · E2024-05-20 · tag F0881 — failed to use antibiotics responsibly — patternImplement a program that monitors antibiotic use.
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 address the extended duration of antibiotic use through the Antibiotic Stewardship Program for 3 (#s 4, 26, and 37) of 23 sampled residents. Findings include: Review of resident #37's physicians orders dated, 11/24/23, showed: Methenamine Hippurate 1 GM. Give one tablet by mouth two times a day for UTI prevention. Resident #37 had been taking this medication for 154 days. Review of resident #37's physicians orders dated 4/24/24 showed: Macrobid capsule 100 mg. Give 100 mg by mouth one time a day for UTI prevention. Resident #37 had been taking this medication for 20 days. No duration or stop date was present on the order. Resident #37 continued to receive both medications through the end of the survey. Review of resident #26's physicians orders dated, 1/5/22, showed: Macrobid capsule 100 mg. Give 100 mg by mouth two times a day for UTI prophylaxis for 10 days and Give 100 mg by mouth in the morning for UTI prophylaxis. Resident #26 had been taking this…
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 · D2024-05-20 · 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 observation, interview, and record reviews, the facility failed to revise and update a resident's care plan to address a PICC line, for 1 (#50) of 25 sampled residents. Findings include: During an observation and interview on 5/18/24 at 4:08 p.m., resident #50 was sitting in his wheelchair in the doorway, dressed in a short sleeve shirt and pants. Resident #50 was unable to answer questions appropriately. A review of resident #50's 5-day MDS, with an ARD of 2/9/24, showed resident #50 was unable to answer BIMS questions (Brief Interview of Mental Status) and was considered severely cognitively impaired. A call was placed to NF1 on 5/19/24 at 10:55 a.m., 5/20/24 at 10:16 a.m., and 12:37 p.m., regarding resident #50's cognition, and the care the resident received at the facility. No call back was received prior to the end of the survey. Review of resident #50's comprehensive care plan showed: . Focus: The resident is on IV Medications .administered by PICC line to LUA. Date initiated 2/9/24, revised 2/12/24. Goals: The resident will not have any complications related to IV…
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 before2024-05-20 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
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 food served to 1 (#219) of 25 sampled residents followed the dietician's recommendations. Findings include: During an observation and interview on 5/20/24 at 12:50 p.m., the food served to resident #219 consisted of a ham sandwich with two slices of bread and one slice of ham, potato chips, a bowl of white bean soup with three packages of saltine crackers, and a fruit cup. Resident #219 stated his blood sugar had been significantly higher since he has been at the facility. Resident #219 stated he felt he had needed more insulin due to his diet, and the increase in carbohydrates in the food he was served. Review of resident #219's lunch order, on 5/20/24, showed the dietary order, Regular-Carbohydrate Controlled. During an interview on 5/20/24 at 4:45 p.m, staff member O stated the carbohydrate-controlled meal served for lunch on 5/20/24 should have consisted of: One slice of bread with deli meat, a pickle spear if they were serving it, soup like everyone else, and fruit. Staff member O stated two…
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 before2024-02-29 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide a diet which followed the physician's diet order for each resident, for 4 (#s 2, 3, 4, and 6) of 6 sampled residents. Findings include: During an interview on 2/28/24 at 7:49 a.m., NF2 stated, There have always been issues with food . [#2 name] is diabetic and has food allergies. Her diet is not being followed . they said they would adjust her diet but that only lasted a few days. On one occasion she witnessed the meal brought to resident #2 consisted of brussel sprouts and peaches. After NF2 requested more, the staff brought resident #2 pasta. During an interview on 2/28/24 at 9:10 a.m., resident #2 stated, I am a diabetic and gluten intolerant. I am still getting things with wheat. They will send up cake. As far as low carb, I don't think they know what that is .I give them ideas, but they don't do what I suggest. This place has made me hate chicken because I have it all the time . During an interview on 2/28/24 at 10:14 a.m., resident #4 stated, The food needs work. The diabetic and heart healthy…
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 · D2024-02-29 · tag F0810 — isolatedProvide special eating equipment and utensils for residents who need them and appropriate assistance.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide adaptive equipment for the resident meals, which were ordered by the physician, for 2 (#s 3 and 6) of 6 sampled residents. Findings include: During an interview on 2/28/24 at 12:07 p.m., staff member E stated, Some of the residents should have special utensils and cups . the diets are not followed. An observation on 2/28/24 at 12:10 p.m., showed resident #6 eating lunch. Resident #6's meal card showed she should have liquids in the nosy cup. The resident did not have a nosy cup. She was given a regular cup for fluids which was filled to the top of the cup. Review of resident #6's physician order, dated 11/9/19, showed, Nosy cup, extra gravy/moisture added to food when possible. Monitor amount in cups - half full to help her from getting too much liquid at one time. An observation on 2/28/24 at 12:10 p.m. showed resident #3 being served lunch. Resident #3's meal card showed she should be served the meal on a lip plate, and have adaptive utensils. The resident's meal was on a regular plate. There 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.
- No harm found · Ccited before2024-05-20 · tag F0641 — widespreadEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews, the facility failed to ensure resident MDS assessments contained accurate information for 6 (#s 17, 37, 44, 48, 50, and 54) of 25 sampled residents. Findings include: During an observation and interview on 5/20/24 at 10:14 a.m. resident #37 was lying in bed. Resident #37 had metal bars attached to her bed. Resident #37 stated she used the bars on the bed to help position herself while in bed, and they do not restrict her from moving. Review of resident #37's Quarterly MDS, with an ARD of 4/8/24, showed resident #37 was coded for restraints used daily, under the bedrails section. During an observation and interview on 5/19/24 at 1:50 p.m., resident #44 was sitting in his room. Resident #44 had metal bars attached to his bed. Resident #44 stated the bars on his bed do not interfere with him getting in or out of bed. Resident #44 stated the bars helped him get in and out of bed and helped him move around in bed. Resident #44 stated he did not feel restricted. Review of resident #44's admission MDS, with an ARD of 4/8/24, showed…
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
No federal fines in the current CMS record.
Part of a chain
This home belongs to SWEETWATER CARE — 8 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.4 | +0.6 vs chain |
| Health inspection | 3 of 5 | 2.1 | +0.9 vs chain |
| Staffing | 4 of 5 | 3.0 | +1.0 vs chain |
| Quality measures | 4 of 5 | 3.9 | +0.1 vs chain |
The other 7 homes this chain runs (chain average 2.4★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SWEETWATER CARE OPCO LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 07/01/2019 |
| PLASSCHAERT, GARY | Individual | W-2 MANAGING EMPLOYEE | — | since 07/01/2019 |
| GAMETT, JAMES | Individual | CORPORATE OFFICER | — | since 07/01/2019 |
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 2023. 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, FY2023). 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 275103. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-04, 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.