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Benefis Senior Services - Eastview

2621 15th Ave S, Great Falls, MT 59405 · Non profit - Corporation · 64 certified beds · (406) 455-5903 Medicare & Medicaid certified

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Flagged for abuseBehavioral-health or dementia-care citations — no harm found (F0740, F0744)1 actual-harm citation$99,129 in federal fines1 Medicare payment denial
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2026
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $99,129 in federal fines (most recent 2025-10-23)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 3 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1400 29th St S · (406) 454-2171 · Call to confirm hours
Pharmacy
2800 11th Ave S · (406) 727-0070 · Call to confirm hours
Grocery
3160 10th Ave S · (406) 952-1120 · Call to confirm hours
Park
2701 10th Ave S · (406) 771-1265 · Typically dawn to dusk
Place of worship
1221 24th St S · (406) 453-1461

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased33.2%18.7%15.4%worse
Long-stay residents who lose too much weight8.8%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder7.8%2.1%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection3.1%2.9%2.0%worse
Long-stay residents with depressive symptoms5.1%5.6%6.5%better
Long-stay residents who were physically restrained0.0%0.6%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury7.6%4.4%3.3%worse
Long-stay residents whose ability to walk worsened17.5%17.2%16.1%typical
Long-stay residents on antianxiety or hypnotic medication24.2%15.8%18.9%worse
Long-stay residents given the seasonal flu vaccine93.8%93.6%95.3%typical
Long-stay residents with pressure ulcers4.0%6.3%4.7%better
Long-stay residents with worsening bladder/bowel control35.9%24.1%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table21.1%20.4%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine81.8%73.8%79.4%typical
Short-stay residents rehospitalized after admission27.3%19.2%22.6%worse
Short-stay residents with an outpatient ER visit7.8%14.5%12.0%better
Long-stay hospitalizations per 1,000 resident days1.181.381.67better
Long-stay outpatient ER visits per 1,000 resident days0.492.161.80better

‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

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

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

54.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 339 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

54.5%U.S. median 51.5%
Got home and stayed home
8.8%U.S. median 10.7%
Went back to hospital
0.15U.S. median 0.30
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.02hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.15 therapist hours per resident per day in 2025Q4 — more than 12% of the 13,714 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 37% 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 14% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF54.5%CMS range 49.4–57.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.8%CMS range 7.0–11.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.—
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.—
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.—
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified96.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.—
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.—
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay8.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization4.6%CMS range 2.6–8.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.641.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

1.09
RN hours/ resident / day
0.58
LPN hours/ resident / day
2.48
Aide hours/ resident / day
4.15
Total nurse hours/ resident / day
0.79
RN hoursweekends
53.4%
Total nursing turnover
52.4%
RN turnover

How full it usually is: this home is certified for 64 beds and averages 59.9 residents a day — about 94% occupied, or roughly 4 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.15 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.09 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.48 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 3.47 hrs/resident/day on weekends vs 3.92 on weekdays — 12% thinner on weekends. RN hours go from 0.94 to 0.71 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 53% 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

6 ↓
deficiencies at the latest standard inspection (2026-07-16)
12
at the previous standard inspection (2025-06-19)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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.

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

  • Actual harm · Gcited before2025-10-23 · 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 observation, interview, and record review, the facility failed to identify and investigate a major injury of unknown origin in a timely manner for a cognitively impaired resident, which was found to be a femur fracture, even though a staff member thought the resident's leg looked awkward for a while but neglected to address the concern. The surgeon treating the resident found the fracture was already healing and difficult to repair due to the delay in treatment for the injury of unknown origin, for 1 (#1) of 4 sampled residents. This deficient practice increased the risk of further injury, pain, and or decline in status for the resident and increased the risk of a negative outcome for other residents due to the injury not being identified and or investigated as potential abuse/neglect. Findings include: A record review of a Facility Reported Event showed resident #1 sustained a major injury of unknown origin, which was reported to the State Survey Agency on 10/6/25. It was found the resident had a femur fracture, allegedly caused by a heater. During an observation 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-07-16 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure there was an adequate number of staff available to provide resident care needs promptly when residents requested assistance using their call lights or when they needed help with ADL care, for 4 (#s 3, 20, 34, and 59) of 23 sampled and supplemental residents. The failure resulted in the residents being frustrated and going without care for extended periods of time. Findings include:During an interview on 7/13/26 at 2:42 p.m., resident #59 stated, It depends on how busy they (the staff) are, and what time of day it is, regarding how long he waits for help with his activities of daily living. Certain times of the day were not as good as others for availability of staff.During an interview and observation on 7/14/26 at 8:26 a.m., resident #3 stated, I was still waiting to get up for breakfast and called for help just before 7:00 a.m. Resident #3 pushed his call light again at 8:50 a.m. Per resident #3, he received no assistance from 7:00 a.m. to 8:50 a.m.During an observation and interview on 7/14/26 at…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-07-16 · tag F0880 — failed to prevent and control infections — pattern
    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 follow training during resident care and use proper hand hygiene, to include when gloves were used, between dirty and clean procedures for 2 (#3 and #4) out of 2 residents observed for peri-care and wound care; and failed to ensure staff used proper hand hygiene during the medication pass for 4 (#s 2, 4, 56, and 73) out of 6 residents sampled for medication administration. This deficient practice increased the risk of the spread of infection. Findings include:1. Peri-care resident #3During an observation and interview on 7/14/26 at 8:54 a.m., Staff member J entered resident #3's room and did not perform hand hygiene before they donned gloves and a gown. Staff member J grabbed a clean brief and two wet washcloths. Staff member J reached under his gown with his gloved hand to answer a status check using the facility's internal communication system. Staff member J failed to uphold proper infection control for hand hygiene and when reaching under his gown.-Staff member J approached the resident and placed both…

    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 before2026-07-16 · 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 interview and record review, the facility failed to protect the resident's right to be free from neglect of care by a staff member for 1 (#65) of 6 residents sampled for neglect of care. The neglect of care placed the resident at an increased the likelihood of adverse events related to incontinence and immobility. Findings include: Review of a Facility-Reported Incident, dated 12/15/25, and submitted to the State Survey Agency on 12/22/25, showed staff member E was alleged to have neglected resident #65 on 12/15/25. The investigative findings showed staff member E had not provided repositioning and incontinence care for resident #65. The investigative file showed staff member E did not accept assistance offered by other staff members and other staff members assigned to the unit did not take the initiative to assist staff member E when they clearly saw resident #65 had not been turned. The resident was receiving end-of-life care and was totally dependent for assistance. Review of the written statement by staff member F, dated 12/15/25, showed staff member F witnessed neglect…

    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 · D2026-07-16 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to report allegations of resident abuse to the State Survey Agency within 24 hours of the incident for 2 (#s 4 and 74) of 23 sampled and supplemental residents. Findings include:Review of the Facility-Reported Incident, dated 4/1/26 at 3:50 p.m., showed staff member F reported an allegation of abuse to staff member B on 4/1/26. Staff member F stated the incident occurred the week prior. Resident #4 was inappropriately touched by another resident. The allegation of resident-to-resident abuse was not reported to the State Survey Agency within 24 hours of the incident.During an interview on 7/16/26 at 9:40 a.m., staff member F stated she reported, on 6/24/26, to the nurse she found resident #74 in resident #4's room. Staff member F stated resident #74 was rubbing the leg of resident #4. Staff member F stated she failed to effectively communicate the incident to the nurse on duty the evening the incident occurred. During an interview on 7/16/26 at 10:40 a.m., staff member B stated the incident involving resident #4 and #74 which…

    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 · D2026-07-16 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to notify the resident, the resident's representative, and the local Ombudsman of the reason, in writing, for the transfer or discharge and the Bed Hold information, if applicable, for 1 (#10) of 2 residents sampled for discharge or transfer. Findings include: During an interview on 7/16/26 at 9:20 a.m., staff member G stated that when a resident was transferred to the hospital the nurse initiates a Bed Hold in the resident's electronic medical record. Staff member G stated the residents do not get a copy of the Bed Hold or Notice of Transfer, and a resident or power of attorney does not sign the form. Review of resident #10's electronic medical record failed to include a Bed Hold and Notice of Transfer for resident #10's facility-initiated transfer on 6/21/26. On 7/15/26, a request was made for a copy of resident #10's Bed Hold and Notice of Transfer form for the 6/21/26 facility-initiated transfer. No documentation or records were received from the facility by the end of the survey During an interview on 7/16/26 at 10:40…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-07-16 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to provide safe, competent care while performing direct resident care and utilizing a mechanical lift during a transfer. The failures involved staff not performing appropriate hand hygiene (refer to F880 - Infection Control), failing to report a resident's pain, failing to safely supervise a resident while using a mechanical lift, and failing to keep a urinary drainage bag below the bladder to prevent urine backflow, for 1 (#3) of 16 sampled residents. Findings include: During an observation and interview on 7/14/26 at 8:54 a.m., staff member J entered resident #3's room with the Sara lift and the following steps were observed:-Staff member J told resident #3 he could not find pants or socks in the resident's closet. Staff member J exited resident #3's room and returned with hospital scrub pants and a package of hospital grippy socks. Staff member J did not perform hand hygiene before they donned gloves and a gown. -Staff member J placed…

    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 · D2025-12-16 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to promote a dependent resident's preferences, to ensure he received a shower when preferred, and on a shower day, he did not receive the shower as he requested, for 1 (#2) of 6 sampled residents. This deficient practice caused resident #2 to have feelings of frustration, feel trapped, and miss breakfast. Findings include:A review of a Facility Reported Event, dated 10/20/25, showed that staff member I failed to provide shower services to a dependent resident, who was resident #2, and this was upsetting to the resident. A neglect allegation was initiated by the facility.During an interview on 12/15/25 at 1:31 p.m., resident #2 stated, I got my shower today. I haven't had an issue since that incident (on 10/20/25). It was frustrating. I always get up before 8:00 a.m. and have my shower before breakfast. I felt trapped because I couldn't do anything. I am dependent on the staff for assistance. The staff have talked to me about it, and I am happy with the outcome. The staff member doesn't work with me anymore and was supposed 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-16 · 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 interview and record review, the facility failed to ensure a resident was free from verbal abuse for 1 (#1) of 6 sampled residents. This deficient practice caused the resident to have feelings of sadness and withdrawal, and the facility identified the concerns, and addressed them prior to the survey. Findings include:Review of a facility-reported event dated 11/13/25 showed, Life Enrichment Manager was informed that a volunteer had verbally abused a resident during bingo. CNO and CDON were notified. Investigation started.During an interview on 12/16/25 at 9:44 a.m., resident #1 stated a volunteer had been mean to her at one point. Resident #1 said the volunteer talked badly to her and made her feel uncomfortable. Resident #1 said the volunteer always told her to go to the bathroom even when she didn't need to. Resident #1 said the facility did follow up with her after the incident, and she was happy with the outcome. Resident #1 said she hasn't had any further issues with volunteers and feels safe at the facility. Review of a written statement dated 11/12/25, by staff…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · D2025-10-23 · 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, record review, and policy review, the facility failed to ensure a thorough investigation of alleged abuse and neglect was completed for a resident with a documented fracture for 1 (# 1) of 4 sampled residents; and failed to ensure other residents were protected from potential abuse during the investigation. This deficient practice had the potential to place all cognitively impaired residents at risk for abuse and neglect. Findings include: A review of a Facility Reported Incident submitted to the State Survey Agency on 10/6/25, showed: the incident was classified as an injury of unknown origin. Statements were collected from staff member I on 10/15/25 and staff member D on 10/13/25. No other staff, residents, or resident representatives provided statements or interviews. The investigation included notation, On 10/13/2025, [Facility Name] (re)initiated an internal investigation surrounding the allegations of suspected abuse as indicated in the hospital progress notes. [sic]. The investigation file did not contain evidence the time frame investigated was expanded…

    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 · D2025-10-23 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and policy review, the facility failed to provide necessary care and services consistent with the resident's assessed needs and care plan for repositioning, toileting, and pressure ulcer prevention, at least every two hours as directed by the plan of care for 1 (#1) of 4 sampled residents. Findings include:During an observation on 10/21/25 at 11:35 a.m., resident #1 was lying in bed, flat on her back, with her left lower extremity elevated on multiple pillows. Resident #1's bed was in the lowest position.During an interview on 10/21/25 at 11:45 a.m. staff member B stated, The facility's policy on turning and repositioning is supposed to be done every two hours, and toileting or checking and changing dependent incontinent residents, was also supposed to be done every two hours. Staff member B stated he could not be sure residents were being turned, repositioned, or checked and changed every two hours.During an observation on 10/21/25 at 3:04 p.m., resident #1 was lying in her bed, flat on her back. Her left lower extremity was elevated…

    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
Show the remaining 18 citations
  • Potential for harm · Dcited before2025-10-23 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, the facility failed to identify and respond to increased behaviors indicative of pain or distress in a cognitively impaired resident for 1 (#1) of 4 sampled residents. Findings include: During an interview on 10/22/25 at 12:15 p.m., staff member C stated when a dementia resident exhibits an increase in behaviors, she would assess possible causes such as pain, positioning, incontinence, and perform a general head-to-toe assessment for other physical causesDuring an interview on 10/22/25 at 1:24 p.m., staff member D stated resident #1 exhibited scratching and pinching. Staff member D stated resident #1 had had done that since she was admitted , and it was usually only in the morning during cares. Staff member D stated there had been an increase in behaviors lately for resident #1 but could not say exactly when the behaviors started to increase.During an interview on 10/22/25 at 2:35 p.m., staff members E and F stated that behavior monitoring was done every shift. Staff member F stated if a resident was unable to verbalize the problem and…

    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 · 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 observations, interviews, and record review, the facility failed to maintain sanitary linens during the handling and processing of laundry, as to prevent the spread of infection for the residents residing at the facility. Findings include: 1. During an observation and interview on 6/18/25 at 9:27 a.m., with staff member A, M, Q, R, and S, the following observations were made: - Floors throughout the clean side of the laundry room were riddled with trash/debris on the floor, including used masks, paper, dirty laundry, used paper towels, and dust balls. - Staff member N was preparing clean sheets to enter the folding machine, and the clean sheets were dragging on the unclean floor. - Staff member O dropped clean laundry out of the dryer, onto the unclean floor. Staff member O then picked the clean laundry up and placed them in the clean linen bin with other clean items. - Staff member O was walking through the clean linen area while putting her hair in a ponytail. Staff member O then began to fold 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-19 · tag F0657 — failed to keep the care plan current — pattern
    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 observation, interview, and record review, the facility failed to review and revise comprehensive care plans for activities and food preferences for 5 (#s 39, 40, 74, 75, and 84) of 23 sampled residents. Findings include: 1. Review of resident #39's, Activities Care Plan, dated 2/22/24, reflected: - . Determine [Resident #39] activity preferences. During an interview on 6/17/25 at 11:51 a.m., resident #39 stated she went to bible study. Resident #39 stated she did not attend any other activities. The activity care plan did not show what other activities the resident was interested in. 2. Review of resident #75's, Activities Care Plan, dated 2/22/24, reflected: - . Determine [Resident #75] activity preferences. During an observation on 6/16/25 at 2:29 p.m., resident #75 was sitting on the side of her bed, anxious, shaking, with erratic breathing, saying unclear words, and the door was closed. Staff member H came in to assist the resident with a sit to stand lift. Staff member H placed resident #75 in her wheel chair, took her to the dining room, and left her at a table…

    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 F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    During an observation on 6/17/25 at 2:10 p.m., three residents were sitting in the dining room. The television was on, and a German speaking movie was playing. The movie contained sexual scenes. The staff changed the channel to music. During an interview and observation on 6/17/25 at 2:30 p.m., staff member U said the most common activity on the memory care unit was Trivia. Staff member U said the staff take some of the residents to the main floor for church and dog visits. Staff member U said not many of the residents residing on the unit go on the outings, but two of the residents went fishing that day. The activity calendar showed a trip to Walmart was scheduled. During record review and observation on 6/18/25 at 10:35 a.m., the activity calendar showed the activity scheduled for the residents was crafts. During an observation on 6/18/25 at 10:35 a.m., five residents were sitting at the dining room tables on the dementia unit. No staff were present, no crafts were being done, and no other activities were being offered to residents on the secure unit. During an interview on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-19 · tag F0692 — failed to prevent malnutrition and dehydration — pattern
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    2. During an initial observation on 6/16/25 at 2:00 p.m., resident #8 did not have access to any fluids while she was in her room. A review of resident #8's dietary information showed resident #8 was to receive thickened fluids. Review of resident #8's care plan, dated 2/25/24, showed the staff were to assist with and encourage food and fluid intake on mildly thick liquids. The care plan directed the staff to observe for signs and symptoms of dehydration. The staff were also to monitor and adjust the fluid intake and output. During an observation on 6/18/25 at 10:30 a.m., resident #8 had a pitcher of water at her bedside. The water in the pitcher was regular consistency, and it was not mildly thickened, as ordered. During an interview on 6/17/25 at 8:24 a.m., staff member I said some residents should have water pitchers. Staff member I said the water pitchers disappeared and some residents just don't have a pitcher. During an interview on 6/17/25 at 2:10 p.m., staff member G said the residents should at least have a cup or a large water jug at their bedside. Staff member G said 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
  • Potential for harm · E2025-06-19 · tag F0919 — failed to provide a working call system — pattern
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    What the surveyor found here — an excerpt from the official record, may be distressing

    4. During an observation on 6/16/25 at 3:35 p.m., resident #77's call light was hanging off the light located over the bed. Resident #77 was lying in bed and could not reach the call light for use. During an interview on 6/17/25 at 2:10 p.m., staff member G said there were alarms attached to the resident's door, and the bathroom doors. Staff member G stated the cognitive residents should have a call light. Staff member G said the staff just check on the residents every couple of hours. Review of a facility policy, [Facility Name] Patient Call System, dated 6/2025, reflected: . The DON will verify the system is in working condition at all times . .The call system is located near the patient's bed and in the restroom . Based on observations, interviews, and record review, the facility failed to ensure residents had call lights available for 4 (#s 40, 74, 75, 77) of 23 sampled residents. This deficient practice prevented residents from contacting staff for assistance when they wanted to. Findings include: 1. During an observation on 6/16/25 at 2:05 p.m., resident #40 did not know where…

    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 · D2025-06-19 · 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 update a resident's code status from Full Code to DNR, in the facility's EHR for 1 (#5) of 23 sampled residents, and this failure increased the risk of the resident being resuscitated in a health crisis, when that was not the resident's preference or documented on the resident's POLST form. Findings include: During an interview on [DATE] at 4:07 p.m., staff member D stated if a resident wanted to change their POLST form status from what was entered on admission, he would go over the form with the resident and make sure it is signed by the provider the resident, or the resident's POA. Staff member D stated he was not the person who updated the residents code status in the facility's EHR. Staff member D further stated it was not his expectation that the residents code status on the information bar in the facility's EHR had not matched their POLST form. During an interview on [DATE] at 4:26 p.m., staff member B stated she didn't think there was a concrete…

    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 · D2025-06-19 · 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 interview and record review, the facility failed to safeguard a resident's personal property when items were missing or sent to laundry and not returned, for 1 (#30) of 23 sampled residents, and the resident was missing a blanket that was very important to him, which was upsetting, and related to his faith. Findings include: During an interview on 6/16/25 at 3:05 p.m., resident #30 said he was missing a blanket, probably some shirts, and the facility had not made any attempts to replace the missing items. Resident #30 stated, It (dirty laundry) goes and never comes back. Resident #30 said he was concerned about the blanket because it (the blanket) had personal meaning to him. During an interview on 6/18/25 at 8:06 a.m., staff member K said a general inventory of the resident's personal belongings was obtained during the admission process, and the inventory was in the electronic health record. Staff member K stated not every personal item was inventoried. During an interview on 6/18/25 at 9:41 a.m., resident #30 said the blanket he was missing was a Jesus blanket, it 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 · D2025-06-19 · 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 interviews and record review, the facility failed to develop a baseline care plan within 48 hours of admission that included the instructions needed to provide effective and person-centered care of the resident, and to meet professional standards of quality care, for 1 (#84) of 23 sampled residents. Findings include: Review of resident #84's face sheet reflected resident #84 admitted on [DATE]. Review of resident #84's baseline care plan, effective 3/19/25 - 4/2/25, reflected the care plan was initiated on 3/19/25, eight days after the resident's admission, and finalized on 3/24/25. During an interview on 6/18/25 at 3:00 p.m., staff member B stated she was not aware the baseline care plan was not completed within 48 hours, or why it was not done. A review of resident #84's MDS assessment, dated 3/17/25, showed the resident had impaired cognition, dementia, anxiety, frequent pain, was supervised, set up, or independent for ADL's, he displayed behaviors and was marked as having depression and anxiety.…

    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 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 observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan and follow the care plan for the resident, for 1 (#31) of 23 sampled residents. Findings include: 1. During an observation on 6/16/25 at 4:37 p.m., resident #31 was in another resident's room. Resident #31 was observed rummaging through the other residents' property. She was observed leaning forward, while sitting in her wheelchair, with her head near the floor, and close to falling out of the chair. Staff were not redirecting her out of the room or providing her diversional activities. During an observation on 6/17/25 at 9:12 a.m., resident #31 was observed behind the nursing station. Resident #31 was unable to be interviewed due to advanced dementia. A nurse removed resident #31 after she had been at the nursing station for a period of time. Resident #31 was not offered diversional activities during her time at the nursing station, or after. During an observation on 6/17/25 at 10:18 a.m., resident #31 was observed in the dining room. She 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-19 · 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

    Based on observations, interviews, and record review, the facility failed to remove access to hand sanitizer containers, or hazardous liquids if consumed, when there was a resident residing in the area who had a recent history of drinking hand sanitizer, for 1 (#40) for 23 sampled residents. Findings include: Review of resident #40's Hospitalist History and Physical, dated 6/30/25, reflected: - . #Alcohol use disorder, with recent hospitalization due to drinking hand sanitizer. During an observation on 6/16/25 at 4:18 p.m., hand sanitizer bottles were found on the top of the unattended medication cart, and two bottles of hand sanitizer were at the nursing station, within reach of anyone passing by. During an observation on 6/17/25 at 7:28 a.m., one alcohol bottle was on top of an unattended medication cart located in the dining room. One bottle of hand sanitizer was within reach of residents at the nursing station. One bottle of [NAME] Diamonds perfume was in an open cabinet at the end of the hall, accessible to residents. During an observation on 6/17/25 at 7:38 a.m., staff member…

    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 · Dcited before2025-06-19 · tag F0740 — failed to provide behavioral / mental-health care — isolated
    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    2. During an observation on 6/16/25 at 4:37 p.m., resident #31 was in another resident's room. Resident #31 was observed rummaging through the property in the room. Resident #31 was in a wheel chair, and she was wedged between the other resident chair, and the bed. She was observed leaning far forward with her head near the floor, almost falling out of the chair forward. During an observation on 6/17/25 at 9:12 a.m., resident #31 was observed behind a nurse's station. Resident #31 was unable to be interviewed due to advanced dementia. A nurse removed resident #31 after she had been at the nursing station for some time. Resident #31 was not offered diversional activities during the time she was at the nursing station or after. During an interview on 6/17/25 at 2:10 p.m., staff member G said resident #31 cries and wanders down the hall in her chair. The nurse tried a bunch of different medications to help the resident, and said the other residents did get upset at #31. Staff member G stated they, Mostly they yell at her, but they did throw things at her, like tissues because she 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 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 a referral was made for cognitive rehabilitation with a speech therapist for 1 (#5) of 23 sampled residents. This deficient practice increased the risk of the resident having a cognitive decline due to the lack of speech therapy treatment. Findings include: A review of a Behavioral Health OP (Outpatient) Psychosocial Evaluation, for resident #5, dated 1/27/25, signed by NF4, and cosigned by NF5, showed: Reason for evaluation: Depression, schizophrenia, bipolar . Plan: According to the information gathered in this evaluation, appears that patient would benefit from cognitive rehabilitation with a speech therapist and medication management with a psychiatrist. Will refer to cognitive rehabilitation with speech therapist [sic] During an interview on 6/18/25 at 11:07 a.m., staff member D stated he could not find speech therapy referrals or notes for resident #5. During an interview on 6/19/25 at 8:53 a.m., NF5 stated she was not able to find a referral for speech therapy from her facility for resident #5. NF5 relayed…

    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 · Fcited before2024-12-31 · tag F0725 — failed to have enough nursing staff — widespread
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to have sufficient nursing staff to ensure residents call lights were answered in a timely manner and to address their safety and care needs timely for 4 (#s 1, 3, 4, 5) of 7 sampled residents. This deficient practice had the potential to result in residents not having their needs met. Findings include: 1. During an observation and interview on 12/30/24 at 9:42 a.m., resident #5 was in bed waiting to get up and stated her back was hurting from lying in bed too long. Resident #5 stated the facility did not have enough help. Resident #5 stated she regularly had to wait in bed for a long time to have someone help her up. Resident #5 stated the CNAs came in the room earlier and turned her call light off and stated they would be back as soon as they could. A staff member entered the room to assist resident #5 out of bed and getting her dressed at 10:37 a.m. 2. During an observation and interview on 12/30/24 at 9:51 a.m., resident #3 was in bed and stated he was waiting for staff to get him up for the day. Resident #3…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-12-31 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure ADL cares were provided timely for 3 (#s 3, 4, and 5) of 7 sampled residents. This deficient practice had the potential to increase resident's risk for infections, skin breakdown, pain, and overall decline. Findings include: 1. During an observation and interview on 12/30/24 at 9:42 a.m., resident #5 was in bed waiting to get up and stated her back was hurting from lying in bed too long. Resident #5 stated the facility did not have enough help. Resident #5 stated she regularly had to wait in bed for a long time to have someone help her up. Resident #5 stated the CNAs came in the room earlier, turned her call light off, and stated they would be back as soon as they could. A staff member entered the room to assist resident #5 out of bed and getting her dressed at 10:37 a.m. Review of resident #5's Care Plan, dated 12/30/24, reflected: - . [Resident #5] transfer with a Hoyer lift. [Resident #5] ambulates at w/c level. [Resident #5]…

    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 · Ecited before2024-10-09 · tag F0744 — failed to care for residents with dementia — pattern
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    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 individualize interventions for the dementia residents residing in the memory care unit; failed to assess the efficacy of the wanderguard intervention placed on each resident after an elopement; and failed to follow protocol when obtaining the verbal consent for the wanderguards for 3 (#s 7, 110, and 400) of 3 residents sampled for elopement concerns. Findings include: Review of two Facility Reported Events, initially reported on 8/29/24 and 9/2/24, showed: - Resident #110 eloped from the facility on 8/29/24 by following an environmental services staff member out of the memory care locked unit, and was found on the facility campus. - Review of the Facility Reported Event, dated 9/2/24, showed resident #400, who resided on the demential unit, eloped from the facility by following a staff member out of the activity room, and staff were not watching the activity room door to ensure the dementia resident was safe, when she attended an activity off the secured dementia unit. 1. During an observation on 10/7/24 at…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-09 · tag F0740 — failed to provide behavioral / mental-health care — isolated
    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to identify, address, and obtain necessary services for the behavioral health care needs; failed to develop and implement person-centered care plans that included and supported the behavioral health care needs; and develop individualized interventions related to the resident's diagnosed conditions, for 2 (#s 13 and 71) of 5 sampled residents. Findings include: Review of a Facility Reported Event, initially reported 9/30/24, showed: Resident #13 was in an altercation with resident #71. In this altercation, both resident #71 and resident #13 had hit one another. The reported findings showed the residents were initially friends, and resident #71 would follow resident #13 around, but due to resident #71's developmental delay, resident #13 lost patience with resident #71, and acted out against him. Review of the PASARR Level 1, dated 11/13/23, showed an updated PASARR Level 1 was not completed for resident #71, after his convalescent stay. Resident #71 had previously had a PASARR Level 2 completed on a previous stay due 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
  • Potential for harm · Dcited before2024-01-29 · 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 provide necessary care and services for a dependent resident, and the resident had skin breakdown, was on hospice, needed assistance with toileting/care and repositioning for pressure relief, for 1 (#1) of 4 sampled residents. Without proper timely care, the resident's skin breakdown could worsen. Findings include: During an interview on 1/29/24 at 11:12 a.m., staff member B stated resident #1 had a clipboard in her room, which was a log for staff to complete when toileting occurred for the resident, and for oxygen tank checks. Staff member B stated she emailed NF1 daily with feedback regarding nursing care and concerns. Record review on 1/29/24 at 1:24 p.m., of the facility's, 02 Tank and Continence Monitoring (At least EVERY 2 HOURS) sign in log on the clipboard in resident #1's room, dated 1/27/24 through 1/29/24, showed: - 1/27: 14:00 dry (2:00 p.m.) - 1/28: 2300 wet (11:00 p.m.) - 1/29: 0430 wet (4:30 a.m.) - 1/29: 0630 dry/changed (6:30 a.m.) During an interview on 1/29/24 at 12:12 p.m., staff member C…

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

    Quality of Life and Care 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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$99,129 in federal fines across 2 penalties. 1 Medicare payment denial on record.

  • $36,377 — penalty dated 2025-10-23
  • $62,752 — penalty dated 2024-07-29
  • Medicare payment denial — starting 2024-08-27 for 64 days

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.

Who owns this facility

Owner / managerTypeRoleSince
BENEFIS HEALTH SYSTEM, INC.OrganizationDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/16/2008
GOODNOW, JOHNIndividualINDIRECT OWNERSHIP INTERESTsince 12/02/2002
AMMONDSON, DEBRAIndividualCORPORATE DIRECTORsince 01/01/2025
BAKER, JEFFREYIndividualCORPORATE DIRECTORsince 08/01/2018
BORLAND, JUDYIndividualCORPORATE DIRECTORsince 03/01/2012
FERRIN, WILLIAMIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 10/01/2008
GINNATY, RAYNIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2024
HOYER, HEATHERIndividualCORPORATE DIRECTORsince 01/01/2025
JONES, LLEWELYNIndividualCORPORATE DIRECTORsince 06/01/2016
LOUCKS, BRIANIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 05/01/2012
MARGARIS, MELCHISEDEKIndividualCORPORATE DIRECTORsince 06/01/2015
RICHARDS, PHILLIPIndividualCORPORATE DIRECTORsince 01/01/2015
STUART, DUSTINIndividualCORPORATE DIRECTORsince 01/01/2025
TIERNEY, GREGORYIndividualCORPORATE DIRECTORsince 01/01/2021
HOULIHAN, BRUCEIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/09/2022
ADDISON, THOMASIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/06/2015
BRADY, SHELIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/07/2024
KREBS, DAVIDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/04/2019
LINDER, AMYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
SLY, MACKENZIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/03/2025

CMS files one row per role, so the 34 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

What families pay in MT

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Montana Medicaid page.

Typical monthly cost in Montana
$8,973/mo
Nursing home (semi-private)
$9,581/mo
Nursing home (private)
$6,075/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-09-01 — CMS provider number 275012. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-07-16, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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