Southwest Montana Veterans Home

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

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.

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

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

Therapy staffing: this home’s payroll records show 0.39 therapist hours per resident per day in 2026Q1 — more than 68% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% 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.

Staffing

How full it usually is: this home is certified for 60 beds and averages 57.3 residents a day — about 96% occupied, or roughly 3 beds typically open. It runs essentially full — expect a waiting list. 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 4.34 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.49 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.14 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 3.81 hrs/resident/day on weekends vs 4.56 on weekdays — 16% thinner on weekends. RN hours go from 1.72 to 0.93 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% 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.

18 citations, most serious first. The 11 most serious are shown; the remaining 7 are one tap away and print in full.

• Actual harm · G2023-05-11 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility staff failed to effectively identify, treat, and reassess the effectiveness of pain management, for 1 (#8) of 9 residents. Findings include: During an interview on 5/9/23 at 7:58 a.m., staff member K stated resident #8 had, Frequent headaches since his fall a couple of months ago. Staff member K stated resident #8 had a muscle relaxer and Norco (for pain), and it seemed like the headaches were coming from the resident's neck. During an observation and interview on 5/9/23 at 3:52 p.m., resident #8 was in bed with blankets over his head, and his knees were pulled up to his abdomen. Resident #8 pulled his blanket down when addressed and had a distressed look on his face (scowling and frown). Resident #8 stated his neck hurts all the time, and now I've been stuck in this bed since the fall the other day, so I can't get up without help. Resident #8 stated his back and left shoulder are hurt, pain is a ten! The resident stated staff gave him pills, but he did not think the facility was, doing a damn thing for my pain, it'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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-06-19 · tag F0605 — failed to not use drugs as a restraint — pattern
  Prevent 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

  Based on interview and record review, the facility failed to ensure psychotropic medications were used to treat a residents' specific, diagnosed, and documented condition for 2 (#s 14 & 36); and failed to obtain a GDR signed by the prescribing doctor for five psychotropic medications for 1 (#23) of 13 sampled residents. This deficient practice failed to ensure the medication dosages were either clinically appropriate or a potential dose reduction was clinically contraindicated for the resident. Findings include: 1. Review of resident #14's original medication order, dated 4/1/25, showed Quetiapine Fumarate 200 mg, Give 1 tablet by mouth one time a day for Mental disorder. [sic] Review of resident #14's updated medication order, dated 4/2/25, showed Quetiapine Fumarate 200 mg, Give 1 tablet by mouth one time a day for bipolar depression. During an interview on 6/18/25 at 3:39 p.m., staff member M stated the resident's bipolar diagnosis was related to his Seroquel [Quetiapine Fumarate] medication order. During an interview on 6/18/25 at 3:52 p.m., staff member L stated they were sure…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-06-19 · tag F0644 — pattern
  Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
  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 PASRR Level II was completed for 1 (#32), and failed to ensure the residents' mental health diagnoses, for which they received psychotropic medication, were included on the PASRR for 2 (#s 14 & 36) of 13 sampled residents. Findings include: 1. Review of resident #14's PASRR, dated 4/1/25, showed the diagnoses of: chronic respiratory failure, unspecified mental disorder, post-traumatic stress disorder, and depression unspecified. Bipolar disorder was not listed. Review of resident #14's medication order, dated 4/2/25, showed Quetiapine Fumarate 200 mg, give 1 tablet by mouth one time a day for bipolar depression. 2. Review of resident #36's PASRR, dated 10/30/24, showed the diagnoses of: depression unspecified, cognitive communication deficit, fracture, and unspecified lack of coordination. Bipolar disorder was not listed. Review of resident #36's medication order, dated 1/9/25, showed Risperdal 0.5 mg, one time a day for bi-polar disorder. During an interview on 6/19/25 at 8:26 a.m., staff member A stated they 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-06-19 · tag F0700 — pattern
  Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
  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 obtain physician orders, informed consents, signed statements of understandings, or develop a standardized process, including terminology, for the use of bed rails for 5 (#s 5, 23, 24, 33, and 41) of 13 sampled residents. Findings include: 1. During an observation on 6/16/25 at 11:10 a.m., bed rails were noted on both sides of resident #5's bed. Review of the Care Plan Report for resident #5, with an initiation date of 4/21/24, showed: Bed canes to enable bed mobility. Review of the resident #5's electronic medical record did not show physician orders or consents for bed rails. 2. During an observation on 6/16/25 at 10:27 a.m., bed rails were noted on both sides of resident #23's bed. Review of the Care Plan Report for resident #23, with an initiation date of 3/2/22, showed: Assist rails to aid in repositioning. Review of the resident #23's electronic medical record did not show physician orders or consents for bed rails. 3. During an observation on 6/16/25 at 11:13 a.m., bed rails were noted on both sides…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-06-19 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to ensure there was an updated care plan pertaining to trauma informed care for 1 (#32) of 13 sampled residents. The resident had ongoing nightmares and unpleasant memories, and he did not like talking about his time in the war, so he kept to himself. Findings include: Review of resident #32's Care Plan, with a revision date of 3/27/25, showed: Special Instructions . Trauma Triggers: Loud noises/events potentially increase risk of emotional lability and anxiousness. Interventions: Encourage/assist in establishing and maintaining normal/baseline routines and introduce any necessary change through communication and knowledge with (#32). Assist in noise reduction as possible. The care plan did not specifically address (with a focus, goal, and intervention) resident #32's PTSD or trauma concerning his time in the Vietnam War other than the special instructions shown above. During an interview on 6/16/25 at 2:03 p.m., resident #32 stated he currently had nightmares and many unpleasant memories from his past about the Vietnam War.…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-06-19 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  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 ADL oral care was offered and performed for 1 (#30) resident out of 13 sampled residents. The resident was dependent on the help of staff, and he had noticeable halitosis when conversing, due to the lack of oral care. Findings include: During an observation and interview on 6/16/25 at 1:52 p.m., resident #30 stated staff would sometimes help him with brushing his teeth. During close interactions, there was a noticeable unpleasant odor to resident #30's breath. Resident #30 stated he did not have any dental problems or pain in his mouth. During an interview on 6/17/25 at 10:48 a.m., resident #30's breath had an unpleasant odor when this surveyor leaned in close to the resident. Resident #30 stated he had brushed his teeth himself that morning. During an interview on 6/18/25 at 11:35 a.m., staff member N stated resident #30 was more dependent than some staff realized. Staff member N stated staff had to help get him dressed this morning because he had two shirts on. Staff member N stated they noticed…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-06-19 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide 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 interview and record review, the facility failed to ensure prompt treatment of a urinary tract infection for 1 (#49) of 13 sampled residents which resulted in the infection being untreated for a week after symptoms started. Findings include: Review of resident #49's nursing progress notes, dated 6/2/25, showed he had an elevated temperature of 101 degrees Farenheit. The provider ordered a CBC and urine culture to be sent to the hospital. Review of resident #49's urine culture, with a final result dated 6/4/25, was positive for infection. The antibiotic susceptibilities showed three medications the bacteria was sensitive to and one to which it was resistant. Review of resident #49's Medication Administration Record, dated June 2025, showed the resident was not started on an antibiotic until 6/9/25, five days after his urine culture results were received, and one week after symptoms began. During an interview on 6/18/25 at 2:00 p.m., staff member C stated the urinalysis results were received on a Sunday, and the provider on call was unable to see the results in the 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-06-19 · tag F0742 — isolated
  Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
  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 1 (#32) resident of 13 sampled residents had the appropriate treatment and services for PTSD to allow the resident to attain his highest practicable mental well-being. This had the potential to affect other residents with similar PTSD concerns who did not frequently verbalize their concerns. Findings include: Review of resident #32's EHR showed a medical diagnosis of PTSD. During an interview on 6/16/25 at 2:03 p.m., resident #32 stated he had been a prisoner of war for eight years during the Vietnam War, and he had escaped twice during his time. He described many memories of his past during this conversation. One instance when he had escaped, a bullet flew between his legs. He stated he had been captured again, told he would not escape, and was put in isolation from that point going forward. Resident #32 stated he had shot many people and stated he should have shot more. Resident #32 stated he often had nightmares currently, as well as in the past. He stated in the past he accidentally choked his wife while 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-06-19 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure contact precautions were followed for 1 (#13) of 13 sampled residents. This had the potential to result in the transmission of microorganisms from resident to resident. Findings include: During an observation on 6/16/25 at 11:20 a.m., staff member P transferred resident #13 from his wheelchair, to his recliner, in his room. Resident #13's door had two signs posted: Enhanced Barrier Precautions and Contact Precautions. Staff member P was not wearing a gown or gloves while transferring resident #13. Staff member P had walked into resident #13's bathroom to grab a washcloth for the resident's face, touching the bathroom door handle on the way. Staff member P also touched resident #13's water container. When staff member P was leaving resident #13's room, the staff member grabbed their backpack off of the floor, did hand hygiene with hand sanitizer, and left resident #13's room. During an observation on 6/16/25 at 11:32 a.m., staff member O walked into resident #13's room without donning a gown or 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-06-19 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
  Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure biohazardous waste was stored properly (i.e.: biohazardous waste bags properly stored in the boxes, sealed with a puncture-resistant lid to prevent the attraction of insects or animals). This had the potential to result in a spread of disease or contamination; or an accidental poke of a needle if handled or disposed of improperly. Findings include: During an interview on 6/18/25 at 2:50 p.m., staff member S stated they were unsure where the red biohazard bags were disposed of but stated the CNAs knew where to dispose of the materials at the end of the day. During an interview and observation on 6/18/25 at 3:00 p.m., staff member R showed the biohazardous waste was disposed of in a locked shed near the garage. Upon observation, there were approximately eight biohazard cardboard boxes stacked, two of which were still open and not full. There were approximately eight biohazard bags that were also stacked on top of one another in the back left corner of the shed and not located in a box. The entire…

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

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-06-06 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to allow the POA and decision-maker of the resident to make food preference requests that followed the physician orders, dietary preferences, and swallowing precautions for 1 (#15) of 17 residents. Findings include: During an interview on 6/4/24 at 9:50 a.m., NF1 stated she brought in extra food to provide more nutrition and prevent weight loss for her family member, resident #15. NF1 stated the food brought in was pureed and followed the diet prescribed by the physician. NF1 stated, It seemed that he really liked them because he would eat them quickly. NF1 stated the food was sometimes located in squeeze packets, and some of the staff members considered it to be a dignity issue. Due to the concern for dignity, staff would refuse to let NF1 give the squeeze packets to resident #15. NF1 stated staff had expressed concern that the packets may have looked childlike or very colorful, like they were for children. NF1 stated, I even purposely…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction

“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.

Fines & penalties

No federal fines in the current CMS record.

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 →

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

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.

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 $333K 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