Ivy At Deer Lodge

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.

32.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 27 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.17 therapist hours per resident per day in 2026Q1 — more than 16% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 60 beds and averages 39.3 residents a day — about 65% occupied, or roughly 21 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 3.67 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.63 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.25 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 3.40 hrs/resident/day on weekends vs 3.78 on weekdays — 10% thinner on weekends. RN hours go from 0.69 to 0.49 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 57% is well above the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

38 citations, most serious first. The 16 most serious are shown; the remaining 22 are one tap away and print in full.

• Immediate jeopardy · K2024-11-25 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  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, facility failed to identify, assess, document, measure, obtain, and follow physician orders for wound care for 3 (#s 2, 3, and 4) of 6 sampled residents. The facility failed to identify changes in the resident's skin status, which occurred over a short period of time, and failed to address wound changes timely for the provision of medical assistance or needed interventions. The facility failed to have a wound management system in place that provided the necessary oversight for care and treatment of wounds, based on professional standards of practice. Resident #4 was admitted to the facility with multiple wounds in various stages of breakdown, and the wounds were documented to be getting worse, in part due to his uncontrolled pain. On 11/20/24 at 2:02 p.m. an Immediate Jeopardy was announced to the Administrator and Director of Nursing for F686- Pressure Ulcers Care and Prevention. The Severity and Scope identified for the Immediate Jeopardy was identified to be…

  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
• Immediate jeopardy · Jcited before2024-11-25 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect 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, the facility failed to ensure residents were free of neglect for 3 (#s 2, 3, and 4) of 6 sampled residents. The facility failed to have systems in place for wound care, which resulted in three Immediate Jeopardy deficiencies being identified. Resident outcomes included: a. Resident #2 showed progressive worsening of pressure ulcers from a Stage II (blisters) worsening to Unstageable in ten days, and the resident was admitted to the hospital for the worsening wounds with foul odor, increased assistance with ADLs, and edema. b. Resident #3 showed progressive worsening of pressure ulcers and was placed on hospice, following a hospital stay with sepsis, and passed away at the facility, upon returning. c. Resident #4 was admitted to the facility with skin tears, with varying stages of healing, and pressure injuries. Resident #4's wounds showed worsening over time, progressing from skin tears to wound injuries. Resident #4 was transferred to the hospital on [DATE],…

  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
• Immediate jeopardy · J2024-11-25 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess, document, treat, and monitor pain for 1 (#4) of 6 sampled residents. Resident #4 had severe pain during pressure ulcer dressing changes and turning and repositioning, which caused the resident to refuse care and dressing changes. Resident #4 expressed to the staff the pain regimen he had in place had not worked in relieving his pain during dressing changes and cares, resulting in increased skin breakdown. Resident #4 was transferred to the hospital on [DATE], and he passed away on 11/10/24. The facility failed to provide adequate pain management in a timely and effective manner to meet the resident's pain needs. The facility failed to identify and treat the resident's changes in condition as needed, and failed to utilize a root cause analysis process to determine the root causes of the resident's pain, for the identification and implementation of pain interventions. On 11/20/24 at 4:52 p.m., an Immediate Jeopardy was announced to 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-12-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility staff failed to correctly position a mechanical lift sling to prevent an accident, which caused injury to a resident when she fell from the lift, for 1 (#5) of 14 sampled residents. This deficient practice caused the resident to experience pain, she had an injury to the head, and a fear of the lift, which has not subsided. Findings include:Review of a Facility Reported Event, for 2/18/25, showed resident #5 had fallen from a mechanical lift during a transfer from the bed to the wheelchair. The report showed a staff member had failed to hook the lift sling properly to the lift, causing resident #5 to fall to the floor. During an interview on 12/2/25 at 1:32 p.m., resident #5 stated, I remember that incident. Staff were getting me up, but they didn't hook the sling right. When they went to move me with the lift, I fell out of the sling and hit the bed, and then the floor. I had hit my head on the metal part of the bed. It hurt really bad. I had a giant goose egg on my head. It could have been worse.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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-12-03 · tag F0745 — failed to provide medically-related social services — isolated
  Provide medically-related social services to help each resident achieve the highest possible quality of life.
  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 identify psychosocial harm after a resident's traumatic experience and fall from a mechanical lift, and failed to provide medically necessary social services for 1 (#5) of 14 sampled residents. This deficient practice caused the resident to continue to be fearful of transfers with the lift and falling, which increased her anxiety. Findings include:During an interview on 12/1/25 at 1:03 p.m., resident #5 stated, I have a hard time with some of the staff. It is like they don't listen to me when I tell them how to do things. There are some staff here I don't trust.During an interview on 12/2/25 at 1:32 p.m., resident #5 stated, I remember the incident with the lift. Staff were getting me up, but they didn't hook the sling right. When they went to lift me, I fell out of the sling and hit the bed and then the floor. It hurt really bad. I didn't want to go to the clinic because I hurt so badly . I had a goose egg on my head. I am scared of falling from the lift again. I am even scared when they [staff] pull 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-08-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility staff failed to intervene when noticing 1 (#1) of 1 sampled resident vaping in another resident room. This resulted in staff finding the resident at a later time, and staff were unable to get a response from the resident due to intoxication. The Resident required emergency transport to the hospital. Findings include: A review of resident #1's Facility Reported Incident investigation, from 3/17/23 showed: - Staff member D stated she observed what she thought to be smoke as she walked past the resident room. Staff member D stated she could smell marijuana five to ten minutes later. Staff member D stated after she checked on another resident, she walked back past the room she had seen what she believed to be smoke, and she saw resident #1, .slumped in her chair, gray in color, not responding to commands. At that time, she called for staff member G to come evaluate resident #1. - Staff member G stated she came in to find resident #1 in her power chair, .eyes closed…

  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 · F2025-12-03 · tag F0880 — failed to prevent and control infections — widespread
  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 observations, interviews, and record reviews, the facility failed to ensure staff performed appropriate hand hygiene during meal service; failed to ensure laundry staff removed personal protective equipment appropriately after working with dirty laundry and linens; and failed to ensure staff performed all resident cares wearing personal protective equipment for Enhanced Barrier Precautions per CDC guidelines. These failures placed residents at increased risk for transmission of infectious organisms. Findings include:1. During an observation on 12/2/25 at 7:51 a.m., staff member I entered the kitchen without performing hand hygiene and came out with a drink which was delivered to a resident.During an observation on 12/2/25 at 7:59 a.m., staff member J exited the kitchen wearing gloves, served a drink to a resident, went back into the kitchen touching the door, did not change gloves or perform hand hygiene, and then continued with the meal service preparing drinks for multiple residents.During an observation and interview on 12/2/25 at 8:02 a.m., staff member K was observed…

  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 · D2025-12-03 · tag F0554 — isolated
  Allow 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 review, the facility failed to ensure an assessment was completed to evaluate the safety of residents who desired to self-administer medications for 2 (#8 and #43) of 4 observed medication administration residents. Findings include: 1. During an observation on 12/2/25 at 7:45 a.m., staff member C prepared the following medications to administer to resident #43 orally: - finasteride 5 mg, - lisinopril 2.5 mg, - meloxicam 15 mg, - omeprazole 20 mg, - oxybutynin chloride 5 mg, - torsemide 20 mg, - tamsulosin 0.4 mg, - gabapentin 300 mg, - glipizide 10 mg, - vitamin B12 1,000 mcg, and - vitamin D3 2,000 units. During an observation on 12/2/25 at 7:55 a.m., staff member C left all of resident #43's oral medications on his bedside table and reminded him to take his medications. Staff member C then left resident #43's room and closed the door. During an interview on 12/2/25 at 7:59 a.m., staff member C stated resident #43 was cognitively intact and took his medications independently. She stated resident #43 had an assessment for…

  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
• Potential for harm · Dcited before2025-12-03 · tag F0657 — failed to keep the care plan current — isolated
  Develop 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 comprehensive care plan with interventions after an incident with a mechanical lift and failed to include psychosocial interventions for 1 (#5) of 14 sampled residents. Findings include: During an interview on 12/3/25 at 9:42 a.m., resident #5 stated, I am most afraid when I don't know the staff or when I don't trust them. I double-check the straps on the lift every time I get transferred now. Social services never talked to me about the incident, and no one from the facility did. I am terrified, and it sucks. During an interview on 12/3/25 at 10:08 a.m., staff member P stated, After an incident like hers [resident #5], I would usually go talk to her and enter a progress note. Staff member P said she was unaware that resident #5 was afraid of the lift or falling again and had not completed an assessment for psychosocial well-being.During an interview on 12/3/25 at 11:46 a.m., staff member B said each department was in charge of its section for care planning. Staff member B stated she was unsure if 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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-03 · tag F0658 — failed to meet professional standards of care — isolated
  Ensure services provided by the nursing facility meet professional standards of quality.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure staff member C primed an insulin pen prior to administration of insulin for 1 (#43) of 4 observed medication administration residents. Findings include:During an observation and interview on 12/2/25 at 7:56 a.m., staff member C prepared resident #43's medication and insulin for administration. Staff member C stated they (nurses) did not prime insulin pens prior to dialing the insulin dosage for residents at this facility. She stated some facilities did prime insulin pens and other facilities did not prime insulin pens. Staff member C stated she was unsure what the facility's policy and procedure showed for insulin administration related to priming an insulin pen.During an interview on 12/2/25 at 8:51 a.m., staff member B stated per the facility policy and procedure, insulin pens were to be primed before dialing the dosage of insulin.During an interview on 12/2/25 at 9:05 a.m., staff member D stated the nursing staff were required to prime an insulin pen prior to dialing the insulin dosage into the pen.…

  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 · F2024-10-10 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure food items in the refrigerator and freezer were labeled and dated, failed to maintain a clean and sanitary environment in the kitchen, and the facility failed to ensure kitchen staff wore beard coverings while serving food. This deficient practice had the potential to affect all residents receiving food from the facility's kitchen. Findings include: 1. During the initial tour of the kitchen on 10/7/24 at 12:20 p.m., the following was observed: Refrigerator: - An undated and unlabeled clear container with a green lid containing sliced cheese - Two undated and unlabeled gray plastic cups containing an unknown liquid - An undated and unlabeled container with mixed vegetables in the refrigerator. Freezer: - Four undated and unlabeled plastic storage bags of diced rhubarb - An undated and unlabeled plastic storage bag containing pepperoni - An open and undated bag containing blueberries During an interview on 10/8/24 at 3:17 p.m., staff member J stated all food stored in the refrigerator and freezer, to…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-10-10 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure 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 observation and interview, the facility failed to remove and dispose of expired medical supplies in the medication room. These failures increased the risk of expired medical supplies being used for any resident at the facility. Findings include: During an observation on 10/10/24 at 9:55 a.m., the following items were observed in the medication room: - 2 needles, 25-gauge x 1 labeled with an expiration date of 9/30/24 - 38 dark blue topped vacutainers labeled with an expiration date of 8/31/24 - 4 light blue vacutainers labeled with an expiration date of 8/31/24 - 7 light blue vacutainers labeled with an expiration date of 9/30/24 - 54 orange topped vacutainers labeled with an expiration date of 11/30/23 - 1 Luer Loc 30ml syringe labeled with an expiration date of 9/20/24 - 1 ml syringe labeled with an expiration date of 8/16/24 - 1 collection swab labeled with an expiration date of 4/7/24 During an interview on 10/10/24 at 10:55 a.m., staff member F stated she is the one responsible for checking for expired medications and supplies. Staff member F stated she had just gone…

  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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-10-10 · tag F0623 — isolated
  Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
  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 written notice of the reason for a facility-initiated transfer to a resident or the resident's representative, for 3 (#s 36, 54, and 149) of 3 sampled residents for transfers, and staff were not aware of the process of the transfer notices, who completed them, and a policy and procedure was not provided to show it was operationalized; and the facility failed to notify the Office of the State Long-Term Care Ombudsman, for 1 (#36) of 3 residents sampled for hospitalizations. Findings include: 1. Review of resident #36's medical record showed the resident was transported to the hospital for an acute change in condition on 9/27/24. The medical record failed to show the required written notice of the reason for the transfer was provided to the resident or representative. During an interview on 10/9/24 at 9:12 a.m., staff member G stated social services sends notifications to the Ombudsman for transfers and discharges. Staff member G stated there is no physical form that residents sign or receive before being…

  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
• Potential for harm · E2024-09-19 · tag F0555 — pattern
  Honor the resident's right to choose his or her attending physician.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews and record reviews the facility failed to allow the residents a choice for their attending physician for 3 (#s 2, 3, and 4) of 3 sampled residents for physician services. Findings include: During an interview on 9/17/24 at 3:22 p.m., resident #2 said he did not want to see staff member C as his physician. Resident #2 stated he told staff member C he did not want her to be his physician on multiple occasions. Resident #2 said staff member C told him he did not have a choice because he was a VA (Veterans Administration) resident. Resident #2 said he had a right to be able to choose his physician, and the facility would not honor that right. During an interview on 9/18/24 at 10:25 a.m., resident #2 said NF1 was his physician and staff member C kept changing the orders NF1 wrote for him. NF3 was in the room, and she said she would see resident #2 weekly. She stated she did not understand why the facility would not let NF1 be the primary care provider for resident #2. NF3 said she knew residents had a right to choose their own physician. During an interview on 9/18/24…

  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
• Potential for harm · Ecited before2024-09-19 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  Honor 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 and interview the facility failed to provide a clean homelike environment for 3 (#s 2, 3, and 4) of 3 sampled residents and had the potential to affect all residents who go to the dining room. Findings include: During an observation and interview on 9/17/24 at 3:22 p.m., resident #2 was observed in his room on his bed wearing an incontinence brief. The brief was torn off on one side exposing the residents left hip and half of his left glute. Resident #2 was not covered with a sheet or a blanket and was not wearing any clothing. There were two urinals in his garbage can. One of the urinals was full to the handle with dark amber urine. The other was full above the handle with clear yellow urine. The room smelled of stale urine. There was a sticky material on the floor. Resident #2 said the staff would come to empty the urinals if he used his call light to ask. He said occasionally the staff would empty the urinals without being told but usually not. Resident #2 said he would wear clothing if he had any that fit properly but he had not had any clothing that 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-09-19 · tag F0563 — failed to protect the right to visitors — isolated
  Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility failed to allow free access to visitors for 1 (#2) of 2 sampled residents. Findings include: During a telephone interview on 9/18/24 at 8:46 a.m., NF2 said she came to visit resident #2 on 9/4/24 for his weekly hospice visit, and a staff nurse accompanied her to resident #2's room. The staff member told NF2 she was no longer allowed to visit resident #2 without a facility staff member present at all times. During an interview on 9/18/24 t 10:25 a.m., NF3 said she came to visit resident #2 and was told she had to have a facility staff member with her while she was visiting resident #2. She said the hospice CNA came to see resident #2, and she was told she could not go in resident #2's room alone. The CNA told her resident #2 had to tell the staff member to leave when the CNA was going to give him a bed bath. The staff member would not leave and required the hospice CNA give the bed bath with the staff member in the room. Review of resident #2's EMR showed a General Note, dated 9/4/24 at 5:25 p.m., Accompanied Hospice Aide while she…

  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

$103,309 in federal fines across 2 penalties.

• $26,685 — penalty dated 2025-12-03
• $76,624 — penalty dated 2024-11-25

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 IVY HEALTHCARE GROUP — 4 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 2 rows in the source record cover these 1 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

About 72% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $703K paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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