Eastern 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 0.29 therapist hours per resident per day in 2026Q1 — more than 46% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% 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 80 beds and averages 50.0 residents a day — about 62% occupied, or roughly 30 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 4.29 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.90 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.82 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.67 hrs/resident/day on weekends vs 4.55 on weekdays — 19% thinner on weekends. RN hours go from 1.03 to 0.56 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 80% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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.

31 citations, most serious first. The 16 most serious are shown; the remaining 15 are one tap away and print in full.

• Actual harm · Gcited before2025-12-10 · 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 failed to ensure staff members followed policies, procedures, and protocols to maintain resident safety by providing sufficient and necessary supervision on a secure care unit, for 4 residents (#s 6, 9, 10, and 12) of 6 residents sampled for injuries/abuse. This deficient practice contributed to resident altercations, and resident #10 sustained a hip fracture, which required hospitalization and surgical repair for the major injury; and resident #10 was not transferred properly and per the facility policies and procedures, after the fall, which may cause or contribute to an injury. Findings include:1. Review of a facility reported incident, dated 11/10/25, showed a resident-to-resident altercation occurred on the secure care unit between resident #10 and resident #12 on 11/9/25. The residents were sitting in the dining room together, and resident #12 pulled resident #10's wheelchair over, causing resident #10 to fall to the floor. Resident #12 was placed 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-06-19 · 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

  Based on record review, the facility staff assigned to a resident neglected to ensure he received necessary ADL care and was left in bed for an extended period of time without help. The resident experienced pain, distress, and skin abrasions from the event, for 1 (#4) of 5 sampled residents. Findings include: Review of a Facility Reported Incident, dated 3/6/25, showed resident #4 was left unattended in his room. The resident was residing on the special care unit, and he was not provided cares by CNAs (NF10 and NF11) working on the unit. Review of resident #4's nursing progress notes, dated 3/6/25 at 11:42 a.m., showed: CNA called this nurse to resident's room. Upon entering, this nurse noted resident lying on his side at the foot of the bed between the mattress and the footboard. Resident's Left arm was bent and caught between mattress and footboard, elbow touching the floor. Resident screaming and crying, very combative to all staff. Resident did not want to be touched or moved. Resident was covered in BM, as was the floor, bed, and floor mats. Bed was noted to be high, except 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-06-19 · 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 failed to prevent a resident with dementia from eloping from the facility through the front entrance doors, leaving the facility property without supervision and accessing a public road, for 1 (#1) of 6 subsampled residents at risk for elopement. The resident sustained lacerations to his forehead after falling during the elopement. Findings include: Review of a facility reported incident, submitted to the State Survey Agency, dated 5/3/25 at 1:45 p.m., showed resident #1 was found outside of the facility by the police and was transported to the hospital for an evaluation. During an interview on 6/16/25 at 4:18 p.m., NF2 stated she received a call from the facility on 5/3/25. NF2 stated resident #1 was found at an apartment complex, on the ground, by a passerby who called the police and ambulance. NF2 stated resident #1 sustained a head laceration and was admitted to the hospital for observation. A call was placed to the police department on 6/18/25 at 12:40…

  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 before2024-10-24 · 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 observations, interviews, and record review, the facility failed to protect a resident's right to be free from physical and psychosocial abuse by facility staff for 1 (#7) of 13 sampled residents, causing resident #1 skin injuries, ongoing fear, and inability to sleep, fearing the specific staff involved would return to the facility. Findings include: During an observation and interview on 10/22/24 at 9:07 a.m., resident #7 was sitting in her wheelchair in her room. Resident #7 began to transfer herself from her wheelchair to her reclining chair. Resident #7 stated seven or eight weeks ago, one CNA, and one nurse, entered her room and woke her from a sound sleep and said, Get up, get up. You're going to the dining room. Resident #7 stated she told the nurse and CNA she did not eat in the dining room, and the nurse replied, You will today. Resident #7 stated the nurse and CNA then proceeded to undress her. Resident #7 stated the staff were, Tearing off my nightgown. Resident #7 stated she told the nurse…

  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
• Actual harm · G2023-02-15 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  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 an effective system for tracking resident weights, identifying weight loss, and implementing nutritional interventions for 2 (#s 12 and 49) of 2 sampled residents. Resident #49 had a severe weight loss, and #12 had a significant weight loss. Findings include: 1. During an observation on 2/14/23 at 9:50 a.m., resident #49 was lying in a low bed on his side. Resident #49 had his eyes closed and did not rouse to his name being spoken in a normal voice. Resident #49 had hollow cheeks with temporal wasting. The resident was left undisturbed. During an interview on 2/15/23 at 9:44 a.m., staff member I stated resident #49 had begun declining before Christmas. Staff member I stated she had discussed resident #49's care with his POA and agreed to give the resident what he wanted to eat and drink, and not to force him to get out of bed if the resident did not want to get up. Staff member I stated the resident was sleeping more but would take food and fluids when awake. The staff fed him as much as possible…

  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 · G2023-02-15 · tag F0801 — isolated
  Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
  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 dietitian, and the dietary manager, accurately assessed and communicated the nutritional needs of 1 (#49) of 1 sampled resident. This deficient practice resulted in the failure to intervene for a resident with a severe weight loss. Findings include: During an interview on 2/15/23 at 4:30 p.m., staff member H stated she was responsible for performing nutritional assessments for residents. Staff member H stated she visited the facility monthly, either in person or via video conference. Staff member H stated she depended on staff member G to notify her if there were any nutritional issues with the residents. Staff member H stated she had not been notified by staff member G of any nutritional issues with resident #49, and was not aware of his severe weight loss. When asked why she had used resident #49's weight from 1/1/23 in the 1/25/23 nutrition note, rather than a more current weight, staff member H stated she was not sure why she had not used the most current weight. Staff member H stated she may have questioned…

  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 · Dcited before2025-12-10 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to ensure a complete investigation of a facility reported incident was provided to the State Survey Agency, and failed to maintain and provide accurate documentation of investigative findings for 3 (#s 2, 4, and 7) of 12 sampled residents. Findings include:During an interview on 12/10/25 at 1:03 p.m., staff member A stated he could do better with documentation of facility reports of incidents. Staff member A stated that one of the incidents being looked at took place four weeks ago, and he could not provide more documentation for it. Staff member A stated it was busy in November (2025), and four incidents happened in one week, and all of them needed to be reported. Staff member A stated, I don't have anything else for that incident (between resident #4 and resident #7). The documentation provided included one paragraph of findings that would have been submitted to the State Survey Agency, and no other event forms, documents, or evidence related to the event. During an interview on 12/10/25 at 2:50 p.m., staff member A stated…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-06-19 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a system of communicable disease surveillance was maintained for tracking purposes and to protect residents from further transmission of infection, during an influenza outbreak in the facility, with 2 (#s 7 and 10) of 5 sampled residents, remaining in the same room after one tested positive for the flu and the other was not tested. Findings include: During an interview on [DATE] at 8:55 a.m., staff member L stated residents and staff members began to get sick very quickly during the influenza outbreak (week of [DATE]). Staff member L stated resident #7 and resident #10 were roommates who had been ill during that time. Staff member L stated NF4 was the infection preventionist. Staff member L stated both NF3 and NF4 were out of the facility during the time of the outbreak, so she coordinated the response between the facility and State health department. Staff member L stated there were discrepancies in NF4's data that had been documented,…

  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 · Dcited before2025-06-19 · tag F0726 — failed to have competent, trained nursing staff — isolated
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to ensure nursing staff were adequately trained and had the knowledge necessary to fulfill the nursing role related to the facility's elopement policy. The failure resulted in a resident eloping from the facility unattended, for 1 (#1) of 6 subsampled residents at risk for elopement. Findings include: During an interview, on 6/18/25 at 12:55 p.m., staff member F stated on 5/3/25 at 11:30 a.m., he received a call from the police department stating a resident was located near an apartment complex. Staff member F stated the facility did a head count of all residents and realized resident #1 was missing from the facility. Staff member F stated he did not hear the alarm sound the day (5/3/25) resident #1 eloped. Staff member F stated NF6 responded to the door alarm, but did not see any residents when he scanned the outside perimeter of the facility. Staff member F stated he was not sure why NF6 did not do a head count of facility residents after the alarm sounded. During an interview, on 6/19/25 at 8:37 a.m., NF6 stated he…

  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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-02-13 · tag F0727 — failed to provide required RN coverage — widespread
  Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to have an RN working at least eight consecutive hours a day, per the twenty-four-hour period, seven days per week. This deficient practice had the potential to affect all residents who received nursing services and when an RN was needed, one was not immediately available. Findings include: Record review of the July and September 2024 schedule for licensed nursing, showed the following dates did not have eight consecutive hours of RN coverage documented in a twenty-four-hour period: - 7/6/24, 7/7/24, 7/13/24, 7/14/24, 07/20/24, and 9/1/24. During an interview on 2/13/25 at 11:30 a.m., staff member A reviewed and compared the facility's nursing schedule with the [NAME] payroll-based journal report for the period of July 2024 to September 2024. Staff member A stated on the [NAME] report there were no RN hours within a twenty-four-hour period on the dates triggered for No RN hours. Staff member A stated the facility had one RN out with short notice. Staff member A stated the director of nursing had been on call but did not work…

  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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-02-13 · 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 staff prepared food in a sanitary manner; failed to ensure freezer equipment was maintained and that food items in the walk-in refrigerator and freezer were covered, labeled, and dated. This failure increased the risk of food borne illnesses, and may negatively affect all residents receiving services from the dietary department. Findings include: During an observation on 2/10/25 at 12:44 p.m., staff member H was working in a food preparation area, with a grown mustache and beard, which was not covered with a beard net. Staff member H failed to uphold infection control measures related to food safety. During an observation on 2/10/25 at 12:47 p.m., the walk-in freezer had a box with a plastic bag of omelets inside, which was left partially open, and not dated. There was an opened plastic bag holding the undated pork sausages. During an observation and interview, on 2/10/25 at 12:48 p.m., the walk-in freezer had large chunks of ice buildup under one of the compressor fans on the top shelf. There was a…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-02-13 · tag F0645 — pattern
  PASARR screening for Mental disorders or Intellectual Disabilities
  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 resident PASRRs (Pre-admission Screening and Resident Reviews) were completed and accurate for 3 (#s 28, 35, and 38) of 17 sampled residents. Findings include: 1. Review of resident #28's EMR, accessed 2/12/25, showed the resident was admitted to the facility on [DATE]. The resident's diagnoses included, . Dementia other disease class with behavioral disturbance, anxiety disorder unspecified, mood disorder known psychological condition unspecified, major depressive disorder single episode unspecified, post-traumatic stress disorder chronic, and suicidal ideations . Review of resident #28's PASRR, dated 06/29/22, showed: Categorical approval - convalescent stay, if he (#28) stays past 29 days a new L 1 (level one) must be submitted . [sic] During an interview on 2/12/25 at 4:00 p.m., staff member A stated resident #28 had a PASRR completed on 6/29/22 and was not aware it was a categorical approval. Staff member A stated a new PASRR Level One…

  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 · Ecited before2025-02-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  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 interview and record review, the facility failed to assess a resident for safety with smoking, failed to monitor the resident's location when smoking and ensure the resident signed out of the facility when smoking, and failed to follow and adhere to the facility policy related to resident smoking. These failures occurred over an extended period of time, for multiple shifts and days, and multiple staff failed to adhere to the policy, for 1 (#39) of 17 sampled residents. Findings include: During an interview on 2/10/25 at 3:11 p.m., resident #39 said he goes outside to smoke four to five times a day. He said he must go off the facility property to smoke because there is a no smoking policy. Resident #39 said he had a warm coat and gloves for standing outside. Resident #39 said there is nowhere to go to be sheltered from the wind and cold weather when out smoking. Resident #39 said he knows that he is supposed to sign out when he goes out and smokes, however he said he doesn't sign out. Resident #39 was unable to explain why he did not sign out. Resident #39 said he had never…

  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 · D2025-02-13 · tag F0578 — failed to honor advance directives / code status — isolated
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure POLST forms were completed accurately in the electronic medical records, for 2 (#s 45 and 109) of 17 sampled residents. Findings include: A review of resident #45 and #109's electronic medical records, showed POLST forms with no date of the signature, which is required on the form for validity and the physician order. The dates should have been filled in next to the provider's signature. Resident #45's POLST form showed a checkmark next to, Yes CPR, and Full Treatment. Resident #109's POLST form showed a checkmark next to, No CPR, and Selective Treatment. During an interview on [DATE] at 8:29 a.m., staff member A stated POLST forms are reviewed by nursing staff members during a resident's admission. Staff member A stated POLST forms were reviewed annually during a resident's care conferences but not during all quarterly care conferences. Staff member A stated there is no specific nurse overseeing or reviewing POLST form completion for new…

  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 · D2025-02-13 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  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, interview, and record review, the facility failed to provide a clean, sanitary, and homelike environment for 2 (#s 45 and 109) of 17 sampled residents. Findings include: During an observation on 2/11/25 at 9:35 a.m., resident #45's bathroom floor had color stains around the edges of the toilet, towards the wall, behind the toilet. There was dark brown crusted debris along the linings of the walls to the left of, in front of, and behind the toilet. The bathroom had caked and dried dark yellow substance on the floor which appeared to be urine, and there was a strong odor of urine. During an observation on 2/11/25 at 2:29 p.m., resident #45's bathroom floor still had colored stains around the edges of the toilet, towards the wall, behind the toilet. There was dark brown crusted debris along the linings of the walls to the left of, in front of, and behind the toilet. There was still a strong odor of urine. During an observation on 2/11/25 at 2:59 p.m., along the bottom of resident #109's wall below the heater, close to the sink area, was a peeling hole in the wall…

  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 · D2025-02-13 · tag F0655 — isolated
  Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to create a baseline care plan with pertinent condition specific information to address resident needs, within the 48-hour timeline following a resident's admission, for 1 (#109) of 17 sampled residents. Findings include: During an observation on 2/11/25 at 4:34 p.m., resident #109 was sleeping in bed and wearing a nasal cannula, connected to an oxygen concentrator, turned on to two liters of oxygen. During an observation on 2/12/25 at 9:59 a.m., resident #109 was sleeping in his bed and wearing a nasal cannula, connected to an oxygen concentrator, turned on to two liters of oxygen. Review of resident #109's electronic medical record showed resident #109 was admitted to the facility on [DATE]. Review of resident #109's treatment administration record, dated February 2025, showed the oxygen at 2 liters per nasal cannula was ordered to start on 1/25/25 at 6:00 a.m. Review of resident #109's care plan, showed an initiation date of 2/1/25 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 Assessment and Care Planning 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

$51,041 in federal fines across 3 penalties.

• $12,674 — penalty dated 2025-12-10
• $10,358 — penalty dated 2025-06-19
• $28,009 — penalty dated 2024-10-24

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 →

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

The source lists no ownership percentage for any party here — 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 $461K 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