Copper Ridge Health And Rehabilitation Center
3251 Nettie St, Butte, MT 59701 · For profit - Corporation · 186 certified beds · (406) 723-3225 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)
- it has an abuse, neglect, or exploitation citation (F0600), cited Feb 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — 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 (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $9,311 in federal fines (most recent 2023-09-20)
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) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
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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 | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 16.4% | 18.7% | 15.4% | typical |
| Long-stay residents who lose too much weight | 5.3% | 6.2% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 2.7% | 2.1% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.5% | 2.9% | 2.0% | better |
| Long-stay residents with depressive symptoms | 4.4% | 5.6% | 6.5% | better |
| 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 | 4.7% | 4.4% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 24.1% | 17.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 23.6% | 15.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 93.1% | 93.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.1% | 6.3% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 16.9% | 24.1% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 27.6% | 20.4% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.4% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 68.5% | 73.8% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 14.9% | 19.2% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 15.9% | 14.5% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.00 | 1.38 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.16 | 2.16 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
64.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 145 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 50.0% 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 70 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 0.71 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 11% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 64.5%CMS range 57.3–72.1 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.7%CMS range 7.8–14.8 | 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 | 50.0% | 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 | 45.7% | 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 | 32.9% | 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 | 95.7% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.2% | 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 | 5.9% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.9%CMS range 4.2–11.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.05 | 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 186 beds and averages 67.5 residents a day — about 36% occupied, or roughly 118 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 3.33 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.72 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.98 is below 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 2.92 hrs/resident/day on weekends vs 3.49 on weekdays — 16% thinner on weekends. RN hours go from 0.85 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 46% 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
28 citations, most serious first. The 12 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · G2023-09-20 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, a licensed staff member failed to properly administer enteral tube feedings, for 1 (#1) of 2 sampled residents; and the facility nursing staff failed to have the enteral tube feeding order clarified further on receipt. The failure resulted in the resident being given the incorrect amount of tube feeding formula and the resident had a decline in status. Findings include: Review of a Facility Reported Incident, sent to the State Survey Agency, dated 7/13/23, At 20:00 (8:00 p.m.) [Resident #1] was receiving her bedtime bolus via her feeding tube. [Resident #1] requested her feeding be stopped. This was done per her request. [Resident #1] was left sitting up in her recliner. At 21:30 (9:30 p.m.) [Resident #1] had audible congestion and an oxygen saturation of 46. Oxy mask was placed bringing her O2 sat to 77. At this time son requested transfer to ER for evaluation. This was done and [Resident #1] was transported via ambulance to ER. At 21:50 (9:50 p.m.) son called facility to report [Resident #1] has passed away. Investigation…
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 · G2023-09-20 · 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 observation, interview, and record review, a licensed staff member failed to seek out necessary education or guidance to ensure competency for the skills and knowledge necessary for the administration of enteral tube feedings for a resident who was new to the unit, and who had complications with tube feedings, for 1 (#1) of 7 sampled residents. This deficiency resulted in the resident having a decline in status, and the resident was sent to the emergency room for further evaluation. Findings include: During an interview on 9/20/23 at 1:22 p.m., staff member A stated resident #1 was transferred from the 200 hall of the facility to the 400 hall on 7/13/23. Staff member A relayed staff member C had not cared for resident #1 before. Staff member A stated she got a call around 9:00 p.m., that night, that resident #1 was being sent to the ED for emesis and her O2 saturation was in the 40's. Staff member A stated staff member C administered four cartons of formula to resident #1 during his shift on 7/13/23. He (staff member C) put four cartons of formula into a graduate (cylinder)…
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 · E2026-04-23 · tag F0813 — patternHave a policy regarding use and storage of foods brought to residents by family and other visitors.
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 had a policy, but failed to implement a process to ensure food safety, including checking food expiration dates and monitoring refrigerator temperatures of resident personal refrigerators for 3 (#s 4, 14, and 51) of 34 sampled and supplemental residents. Findings include:During an observation on 4/20/26 at 2:48 p.m., resident #4's personal refrigerator did not have a temperature gauge on the inside of the refrigerator or a temperature log to record the temperature. On the inside of the refrigerator, there was a cup of cauliflower and carrots wrapped in a bag in the back of the refrigerator that had a noticeable odor when the refrigerator door was opened. There was no date on the vegetables. There was also no date on the [NAME] syrup. During a follow up interview on 4/20/26 at 4:12 p.m., resident #4 stated she checked her own fridge for spoiled food. She stated staff did check the temperature, but would not use a thermometer.During an observation…
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 · D2026-04-23 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide notification to a physician regarding a resident's severe weight loss, resulting in a lack of physician assessment and involvement, which did not allow the physician the opportunity to recommend or implement interventions for 1 (#3) of 16 sampled residents. Findings include:Review of resident #3's weight record showed a severe weight loss of 9.73% from the resident's admission date of 3/10/26 to 4/21/26. The resident's weight on admission was 182 pounds and declined to 164.3 pounds.During an interview on 4/21/26 at 3:56 p.m., staff member G stated she had been following resident #3 closely since admission. Staff member G stated she had been making ongoing changes to accommodate the resident's nutritional needs and did not notify the medical provider of the resident's weight loss but would do so today (4/21/26).During an interview on 4/23/26 at 10:28 a.m., staff member B stated the dietician is responsible for reporting a resident's weight loss to the medical provider. Staff member B stated resident #3's weight loss…
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 · D2026-04-23 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 accurately complete an Annual and Significant Change in Status Minimum Data Set (MDS) assessment for a resident's pre-admission screening and resident review (PASARR), for 2 (#s 7 and 11) of 34 sampled and supplemental residents. Findings include:During an interview on 4/23/26 at 8:54 a.m., staff member F stated resident #7's PASARR Level One was completed on 1/15/24, and PASARR Level Two was completed on 1/22/24. Staff member F stated that when she completed section A of resident #7's MDS submission on 12/29/25, she did not think to look at the resident's PASARR information because the system pre-populated the resident's demographic information. Staff member F stated the same thing occurred with resident #11's Significant Change in Status assessment, which was completed on 3/18/26. Staff member F stated, I will need to start double-checking section A of the MDS assessment. Staff member F stated resident #7 and #11 did not have any disruption in…
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 · D2026-04-23 · tag F0646 — isolatedNotify the appropriate authorities when residents with MD or ID services has a significant change in condition.
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 promptly obtain a new PASARR (Preadmission Screening and Resident Review) Level One screen, upon re-admission from the hospital for a resident who had a significant change in mental status, for 1 (#68) of 16 sampled residents. Findings include:A review of a facility document in resident #68's EHR showed a request for a PASARR Level One review, dated 11/4/22.A review of a progress note for resident #68 in the facility's EHR, dated 4/8/26 at 10:35 a.m., showed, [Resident #68] reported to charge nurse and to myself that she had awakened hearing voices and that she was frightened. She reported that the voices were repeating 'Knife, knife, and kill, kill, kill.' [Resident #68] verbalized being afraid that she may act on the hallucinations . [sic]A review of a progress note for resident #68 in the facility's EHR, dated 4/8/26 at 10:45 a.m., showed, . This writer sat with [Resident #68] until EMS arrived to transport [Resident #68] to the Emergency Department…
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 before2026-04-23 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise resident care plans to reflect the Provider Orders for Life Sustaining Treatment (POLST) status for 2 (#s 50 and 74) of 34 sampled and supplemental residents. Findings include:During an interview on [DATE] at 8:21 a.m., staff member J stated resident care plans were updated weekly by the interdisciplinary team. Staff member J stated the nurse can also update the resident's care plan if an immediate update was necessary. Staff member J stated she was not sure why resident #50 and #74's care plan did not reflect their code status.1. Review of resident #50's POLST dated [DATE] showed, section A No CPR.During a review of resident #50's care plan on [DATE], the following entries were documented: Focus: [Resident #50] has an advance Directive as evidenced by: Full codeGoal [Resident #50's] wishes will be honoredIntervention: Will review POLST every 3 months, and upon [Resident #50's] request, to ensure wishes are being followed .2. Review of 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 · D2026-04-23 · tag F0712 — isolatedEnsure that the resident and his/her doctor meet face-to-face at all required visits.
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 a physician personally conducted an initial comprehensive visit within the first 30 days after admission for 1 (#3) of 16 sampled residents. The failure increased the risk of missed resident care needs. Findings include:During an interview on 4/22/26 at 3:00 p.m., staff member A stated resident #3 was seen by a physician assistant at the facility on 4/21/26. Staff member A stated there was 10-day slippage for provider visits and the visit on 4/21/26 would meet the deadline for resident #3's 30-day physician visit. Staff member A stated the facility had contracted with a new physician; however, the physician's state license was still pending.During an interview on 4/23/26 at 10:28 a.m., staff member B stated she thought resident #3 was seen by the provider the week of 4/8/26. Staff member B stated she would look for the physician's note.Review of resident #3's hospital discharge noted dated 3/10/26, showed resident #3 had several chronic medical conditions which would require monitoring and medical management,…
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 · D2026-04-23 · 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 observation, interview, and record review, the facility failed to ensure there was not a 5% or greater medication error rate. The observed medication error rate was 10.34% for 2 (#s 13 and 38) of 34 sampled and supplemental residents. Findings include:1. During an observation and interview on 4/21/26 at 8:15 a.m., staff member K prepared the medications for resident #38 (amlodipine, clopidogrel, aspirin, multivitamin, norco, Senna Plus, and pantoprazole). The pantoprazole administration time shown on the MAR was 7:00 a.m. and was shown to be late. Staff member K stated the pantoprazole should have been given before resident #38 ate breakfast for the medication to have the best efficacy. Staff member K stated they often had to give this medication at the same time as the other medications (at 8:00 a.m.) if staff member K was running late on morning tasks. Staff member K stated resident #38 was currently in the dining room. Staff member K also put one tablet of Senna Plus in the medication cup and then continued to prepare the norco (hydrocodone/acetaminophen). The surveyor…
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 · E2025-04-10 · 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 staff failed to ensure each resident had access to call lights for 4 (#s 16, 24, 49, and 54); and failed to prevent elopements for 1 (#54) of 22 sampled residents. These deficient practices placed residents at risk of falls, injuries, elopements, or a negative outcome if a medical crisis occurred, and the resident could not call for assistance. Findings include: 1. Call lights not in reach a. During an observation on 4/7/25 at 10:00 a.m., resident #16 was attempting to access his call light. Resident #16 had left-sided weakness from a stroke and was unable to maneuver his wheelchair to the call light hanging off the wall tied to his bed. Resident #16 continued to attempt to reach his call light for three minutes and then called for help by yelling at a staff member walking by. b. During an observation and interview on 4/7/25 at 2:29 p.m., resident #24 stated he needed help, and no one would help him. Resident #24 stated, I can't breathe. Resident #24's call light was not within reach. This surveyor pushed the call…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-04-10 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure staff were educated on policies and procedures for the use of personal protective equipment, for a resident on enhanced barrier precautions, for 1 (#57) of 16 sampled residents for enhanced barrier precautions. This deficient practice increased the risk of infection for all residents related to staff not adhering to proper EBPs. Findings include: During an observation and interview on 4/7/25 at 10:22 a.m., staff member P was exiting a resident's room with trash. A sign was on the door reflecting the resident was on EBP precautions. Staff member P stated she did not know what EBP stood for or what the precautions were for the resident. Staff member P stated she was in orientation, but she was currently working the floor by herself. Staff member P stated her trainer went to lunch. During an interview on 4/9/25 at 11:24 a.m., staff member Q stated, I don't know what EBP is . I think Enhanced Barrier Precautions are used when someone has an infection or C-Diff; we (staff) would then wear a gown and gloves…
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 before2025-04-10 · 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 maintain areas of the building in need of repair for 3 (#s 11, 19, and 27) of 22 sampled residents; and, failed to maintain a clean environment related to housekeeping services, for 1 (#57) of 22 sampled residents. Residents were concerned about lack of repairs and unclean areas identified. Findings include: 1. Wall repairs a. During an observation and interview, on 4/7/25 at 12:30 p.m., resident #19's room had 13 circular shaped holes, approximately one centimeter each in diameter, in the wall next to a grab bar. Resident #19 stated she told staff member M a while ago, I guess he just forgot, it would be nice if he fixed it soon, someday I guess he will. b. During an observation and interview on 4/8/25 at 10:08 a.m., in resident #11's room, there was long vertical jagged gouges, in the wall and above the head of her bed, all approximately twelve to twenty inches in length and one inch in width. Resident #11 stated, My wall has been really banged up for a while. I'm not sure if there are plans to fix it. c.…
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 16 citations
- Potential for harm · Dcited before2025-03-12 · 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 interview and record review, the facility failed to collect and act on admission information necessary to provide a safe, comfortable, and homelike environment accommodating a resident's physical size, for 1 (#1) of 6 residents sampled. Findings include: Review of resident #1's hospital history and physical, dated 2/5/25, listed the resident's height and weight. Review of facility admission paperwork, not dated, showed a handwritten nurse handoff report between the hospital and the facility. At the top of this report showed resident #1's weight, which was 337 pounds, and a height of 6 feet and 8 inches tall. In addition, his diagnosis, code status, allergies, and medications were noted. Review of a photo, taken on 2/10/25, showed a standard resident bed, with the head of the bed tilted, at a slight downward angle. At the foot of the bed was a bench to extend the length of the bed by several feet. This bench was kept in place by a chair wedged between the edge of the bench and the wall. During an interview on 3/11/25 at 1:30 p.m., resident #1 stated they told him to sleep in…
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 before2025-02-24 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, a staff member removed a resident's oxygen for the provision of care, knowing it was necessary to maintain the resident's oxygen levels, and the resident showed signs of signs of hypoxia prior to being placed back on the oxygen, for 1 (#5) of 5 sampled residents. Findings include: Review of a complaint made on 2/4/25 showed resident #5 was admitted to the facility on [DATE], and during the admission process the resident's oxygen was removed for a period of time while a staff member wheeled the resident down the hallway to obtain an admission weight. The complaint showed resident #5 became nauseated and vomited while his oxygen had been removed. Review of the signed and typed personal statement from staff member G, dated 1/31/25, showed: . the CNA had taken his (resident #5's) Oxygen cannula off to get his weight and brought him back to the room. The resident's family was present and then [staff member G] was called to the room because the family thought he 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 · D2025-02-24 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an incident of neglect where a resident's oxygen was removed for care, which resulted in the resident exhibiting symptoms of hypoxia during the admission process. The facility did not report the incident to the State Survey Agency within 24 hours, and failed to report a follow up investigation within 5 working days, as required, for 1 (#5) of 5 sampled residents. Findings include: Review of a complaint made on 2/4/25 showed resident #5 was admitted to the facility on [DATE], and during the admission process the resident's oxygen was removed for a period of time while a staff member wheeled the resident down the hallway to obtain an admission weight. The complaint showed resident #5 became nauseated and vomited while his oxygen had been removed. Review of the Facility Reported Events for the facility, submitted to the State Survey Agency, showed the event was not entered into the the reporting system for resident #5. During an interview 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 · D2025-02-24 · tag F0635 — isolatedProvide doctor's orders for the resident's immediate care at the time the resident was admitted.
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 1 (#5) of 5 sampled residents received appropriate respiratory services on admission, and failed to have physician orders and necessary equipment on hand, and staff were not aware of or educated on the resident's respiratory care needs or risks related to them, and this resulted in neglect of care when a staff member removed the resident's oxygen, and then the resident showed signs of hypoxia. Findings include: Review of a complaint made on 2/4/25 showed resident #5 was admitted to the facility on [DATE], and during the admission process the resident's oxygen was removed for a period of time while a staff member wheeled the resident down the hallway to obtain an admission weight. The complaint showed resident #5 became nauseated and vomited while his oxygen had been removed. During an interview and observation on 2/24/25 at 12:13 p.m., staff member E stated on 1/31/25, they were floated to another hall to work. Staff member E stated that day 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 · Dcited before2025-02-24 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure respiratory care and services were provided for a new resident admitted on a high rate of oxygen, and this the oxygen was removed by a staff member, which resulted in signs of hypoxia for 1 (#5). The facility also failed to ensure physician orders were followed for 3 (#s 1, 2, and 4) of 5 sampled residents receiving oxygen. This deficient practice showed a potential concern for neglect and serious adverse effects to residents receiving oxygen services. Findings include: Review of a complaint made on 2/4/25 showed resident #5 was admitted to the facility on [DATE], and during the admission process the resident's oxygen was removed for a period of time while a staff member wheeled the resident down the hallway to obtain an admission weight. The complaint showed resident #5 became nauseated and vomited while his oxygen had been removed. 1. Review of resident #5's EHR showed an admission date of 1/31/25. Review of resident #5's EHR…
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 before2024-12-04 · 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 of a facility security video, interview, and record review, the facility failed to protect 1 resident (#3) who could not consent to sexual contact from 1 resident (#2), of 7 sampled residents for abuse. Findings include: During an interview on 11/21/24 at 10:26 a.m., staff member A stated there had been an incident on 11/3/24 between resident #2 and resident #3. Staff member A stated resident #2 was witnessed by a staff member in resident #3's room with his hands under her covers touching her. Staff member A said resident #3 was not capable of consenting to sexual contact. Staff member A stated resident #2 was capable of understanding what he was doing but had impulse control issues. Staff member A stated she interviewed both residents after the incident, and resident #3 told her resident #2 had touched her breasts and vagina. Staff member A stated resident #2 told her he had touched resident #3's breasts and her vagina. Staff member A stated the police were called, and they arrived and interviewed the residents. Staff member A said resident #3 could not tell…
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 before2024-12-04 · 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 interview and record review, the facility failed to care plan interventions to keep a resident safe from unwanted sexual advances or abuse from another resident, for 1 (#3) of 7 sampled residents for abuse. Findings include: During an interview on 11/21/24 at 10:26 a.m., staff member A said resident #3 had been the subject of another resident's sexual advances on 5/13/24 and on 11/3/24. Staff member A said the first incident was just a quick touch of her (#3's) breast on 5/13/24, but the most recent incident on 11/3/24, the same male resident was found in resident #3's room with his hand under her bed covers. Resident #3 told staff the male resident had touched her breasts and her vagina. During an interview on 11/21/24 at 1:35 p.m., staff member A stated there had not been any changes made to resident #3's care plan after the 5/13/24 incident, or after the 11/3/24 incident, to protect resident #3 from the male resident. Staff member A said they made multiple changes to the male resident's care plan but not resident #3's. Review of resident #3's care plan, revised 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 · F2024-03-28 · tag F0761 — failed to label and store drugs safely — widespreadEnsure 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, interviews, and record review, the facility failed to remove and dispose of expired medications and medical supplies in three medication rooms, three medication carts, and one wound supply cart; and, failed to properly store medical supplies, keeping the supplies off the floor in one medication room. These failures increased the risk of expired medications and medical supplies being used for any resident at the facility. Findings include: During an observation on 3/26/24 at 8:10 a.m., with staff member G, the following was found in the 400-hall medication room and cart: - Wound vac supplies on the floor, including open cases of canisters with gel, Grandufoam dressings, unopened cases of Whitefoam dressings, and canisters with gel. - Expired medications, and medical supplies with expired dates, included: 1 box Pen needles box open 100, with dated expiration of 4/30/23 1 Sharp debridement tray, dated 11/20/23 2 Natural Dermal Templates, dated 1/31/24 1 box of anti-diarrheal, dated 8/16 1 bottle of nasal decongestant, dated 5/23 2 bottles of ear drops, dated 5/23…
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 · Ecited before2024-03-28 · 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 observations, interviews, and record review, the facility failed to administer respiratory treatments in accordance with professional standards of practice for 4 (#s 22, 33, 36, & 49) of 6 sampled residents for respiratory services. Findings include: During an observation on 3/27/24 at 11:01 a.m., staff member K entered the room of resident #49 to administer a nebulizer treatment of albuterol 0.5-2.5. The nebulizer machine canister already had a full dose of liquid in the chamber, the mask was soiled with a white film, and white chunks of an unknown substance was on the inside of the mask. Staff member K added the additional dose of albuterol to the dose already in the chamber and went to hand it to resident #49. When asked by the surveyor, what the liquid was that was already in the chamber, resident #49 stated it was an earlier nebulizer treatment dose, which he had forgotten to take. Staff member K then stopped and said, Oops, I should clean it out then. Staff member K cleansed the mask and chamber and went to get another dose of the albuterol nebulizer treatment. 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 · D2024-03-28 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 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 in the EHRs, for 4 (#s 22, 33, 36, & 49) of 6 sampled residents for self administration of medication. Findings include: During an observation on 3/27/24 at 11:01 a.m., staff member K entered the room of resident #49 to administer a nebulizer treatment of albuterol 0.5-2.5. After preparation of the treatment, staff member K offered the nebulizer mask to resident #49, who stated he would complete the treatment, in a bit. Staff member K left the room, returned to her cart, and proceeded to complete medication administrations for other residents. During an interview on 3/27/24 at 1:28 p.m., NF1 stated, [Resident #49] does not have orders to self-administer any medications. I saw him on Monday, and I'm not sure he is appropriate for self-administration. During an interview on 3/27/24 at 1:54 p.m., staff member K stated, [Resident #49] starts and stops 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 before2024-03-28 · 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 — the official record, unedited, may be distressing
Based on observation, interview, and record review, the facility failed to review and revise comprehensive care plan interventions for catheter care for a resident that is at risk of infection for 1 (#9) of 26 sampled residents. Findings include: During an observation on 3/25/24 at 3:31 p.m., resident #9's room smelled of strong urine, the catheter tubing was cloudy, and had chunks of white debris in it. During an interview on 3/27/24 at 8:45 a.m., staff member G stated catheters are changed based on the physician's order in the Medication Administration Record. Review of resident #9's physician's order for the catheter, dated 1/2/24 showed, Foley cath: 18fr. Inflate balloon to 30 cc for stage IV pressure sore to sacrum. Change for occlusion, leakage, dislodgement or s/s of infection. As needed. [sic] Review of resident #9's care plan, revision date of 2/19/21, showed, .change catheter monthly . The care plan was not revised for the physician's order.
- Potential for harm · D2024-03-28 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide incontinence care and repositioning for dependent residents, which had the potential to increase skin breakdown, and may cause discomfort for the residents, for 2 (#s 2 and 14) of 26 sampled residents. Findings include: 1. During an observation on 3/26/24 at 8:30 a.m., resident #14 was lying in bed flat on her back, with her head elevated. During an observation on 3/27/24 at 8:43 a.m., resident #14 was lying flat on her back in bed, her head was slightly elevated by her pillow, and she was attempting to eat breakfast. During an observation on 3/27/24 at 10:18 a.m., resident #14 was lying flat on her back with her head only elevated by her pillow. During an observation and interview on 3/27/24 at 10:43 a.m., resident #14 was in the same position, flat on her back with her head only elevated by her pillow. Resident #14 stated, Staff don't encourage me to get on my side. I use these positioning bars to help me relieve pressure…
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 · D2024-03-28 · 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
Based on observations, interviews, and record review the facility failed to change a residents catheter, this had the potential to increase the risk of infection for 1 (#9) of 26 sampled residents. During an observation and interview on 3/25/24 at 3:31 p.m., resident #9's room smelled of strong urine. Resident #9 stated she had a catheter due to her wounds. The catheter tubing was cloudy and had chunks of white debris in it. Resident #9 could not remember if her catheter had ever been changed. During an interview on 3/27/24 at 8:45 a.m., staff member G stated catheters are changed based on the physician's order in the residents Medication Administration Record. Record review of resident #9's catheter order, dated 1/2/24, showed, Foley cath: 18fr. Inflate balloon to 30 cc for stage IV pressure sore to sacrum. Change for occlusion, leakage, dislodgement or s/s of infection. As needed. [sic] Review of resident #9's care plan, with a revision date of 2/19/21, showed, Change catheter monthly and prn per MD order using sterile technique. Review of resident #9's Treatment Administration…
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 before2024-03-28 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
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 staff used appropriate hand hygiene during catheter care or wound care, for 2 (#s 9 and 37) of 26 sampled residents. Findings include: 1. During an observation on 3/26/24 at 2:45 p.m., staff members B and I entered the room of resident #37 to complete pericare and catheter care. Resident #37 was sitting in his recliner. Staff member B stood at the entry and observed while staff member I completed the following resident care: Staff member I completed initial hand hygiene, closed the door, gathered supplies, then gloved. Staff member I then moved the wheel chair out of the way, grabbed a brief from the closet, placed a gait belt around resident #37, and stood him up. Staff member I removed the old brief and placed it into the garbage. Staff member I grabbed a package of wipes from the bathroom that were unopened and used her keys in her pocket to open the wipe package, then put the keys back into her pocket. Staff member I wiped the front peri area of resident #37 while he was standing. Staff member I…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-20 · 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 interview and record review the facility failed to revise a resident's care plan to reflect an intervention with regards to gravity enteral tube feeding complications, for 1 (#1) of 7 sampled residents. Findings include: During an interview on 9/20/23 at 1:35 p.m., staff member A stated when tube feeding was administered for resident #1, multiple staff reported the tube feeding formula would not always flow with gravity. Staff member A further stated, the formula flow seemed to be positional and if staff would sit the resident upright while administering the feeding, there was less complications with the feeding. Staff member A stated staff member E reported this in the 24-hour handoff to staff member C. Staff member A further stated sitting the resident up during enteral feeding was not addressed in the resident's care plan, and her expectation was that it should have been put in the care plan. During an interview on 9/20/23 at 2:30 p.m., staff member C stated he did not receive a report for tube feeding administration (for resident #1) from any of the nurses that 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 · C2026-04-23 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
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 the designated infection preventionist had completed specialized training in infection prevention. The failure placed residents at risk for inconsistent infection prevention and control practices due to the lack of specialized training for the infection preventionist. Findings include:During an interview on 4/21/26 at 9:50 a.m., staff member C stated staff member D was the facility's infection preventionist. Staff member C stated staff member D had completed infection preventionist coursework in 2021 but was unable to retrieve a certificate of completion from the CDC (Centers for Disease Control and Prevention) website.During an interview on 4/22/26 at 11:45 a.m., staff member D stated she worked in infection control since approximately 2019 and completed the first 12 (of 23) modules in the CDC infection preventionist training between 2020 and 2021, but did not complete the training and did not have an infection preventionist certification.Review of a facility policy titled Infection Prevention and Control Program,…
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
$9,311 in federal fines across 1 penalty.
- $9,311 — penalty dated 2023-09-20
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.
Part of a chain
This home belongs to EDURO HEALTHCARE — 34 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 | 4 of 5 | 2.4 | +1.6 vs chain |
| Health inspection | 4 of 5 | 2.4 | +1.6 vs chain |
| Staffing | 3 of 5 | 2.2 | +0.8 vs chain |
| Quality measures | 4 of 5 | 3.1 | +0.9 vs chain |
The other 33 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 | Since |
|---|---|---|---|
| THOMPSON, CHRISTOPHER | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | since 02/01/2018 |
| EDURO HEALTHCARE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 09/28/2017 |
CMS files one row per role, so the 3 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $443K paid to related parties (affiliated landlords or management companies) in its most recent 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 275060. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-23, 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.