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Benefis Senior Services - Grandview

3015 18th Ave S, Great Falls, MT 59405 · Non profit - Corporation · 48 certified beds · (406) 771-6200 Medicare & Medicaid certified

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Abuse-prevention, restraint, or reporting citations — no harm found (F0605, F0609) — most recent Jun 20261 immediate-jeopardy citation$48,323 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • 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
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $48,323 in federal fines (most recent 2026-06-08)

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.

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

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
1500 33rd St S · Typically dawn to dusk
Place of worship
3020 18th Ave S · (406) 453-7891

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 3 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 2025-07 to 2026-06, this home’s CMS overall rating improved from 4 to 5 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 rating5★
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 increased48.1%18.7%15.4%check this — see note marked dagger below the table
Long-stay residents who lose too much weight3.7%6.2%5.4%better
Long-stay residents with a catheter left in their bladder0.0%2.1%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection7.4%2.9%2.0%worse
Long-stay residents with depressive symptoms0.0%5.6%6.5%check this — see note marked star below the table
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 injury7.4%4.4%3.3%worse
Long-stay residents on antianxiety or hypnotic medication3.7%15.8%18.9%better
Long-stay residents with pressure ulcers16.0%6.3%4.7%worse
Long-stay residents with worsening bladder/bowel control25.0%24.1%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table8.3%20.4%17.1%better
Short-stay residents who newly got an antipsychotic medication0.8%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine80.8%73.8%79.4%typical
Short-stay residents rehospitalized after admission20.7%19.2%22.6%typical
Short-stay residents with an outpatient ER visit9.5%14.5%12.0%better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.

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.

58.5%U.S. median 56.6%
Met the expected recovery
1.09U.S. median 0.31
Therapy hours / resident / day
0.64hours / resident / day
Physical therapy
0.22hours / resident / day
Occupational therapy
0.23hours / resident / day
Speech therapy

Met the expected recovery: 58.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 106 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 1.09 therapist hours per resident per day in 2026Q1 — more than 97% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 30% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge58.5%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge63.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge59.4%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.2%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 setting96.4%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 stay0.0%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 worsened9.1%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 hospitalizationnot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality 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

1.79
RN hours/ resident / day
0.29
LPN hours/ resident / day
2.22
Aide hours/ resident / day
4.30
Total nurse hours/ resident / day
1.66
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 48 beds and averages 28.6 residents a day — about 60% occupied, or roughly 19 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 4.30 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.79 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.22 hrs/resident/day on weekends vs 4.33 on weekdays — 3% thinner on weekends. RN hours go from 1.85 to 1.66 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

5
deficiencies at the latest standard inspection (2026-06-08)
8
at the previous standard inspection (2025-05-20)

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.

26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.

  • Immediate jeopardy · J2026-06-08 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to identify, assess, measure, document, monitor, and obtain physician orders promptly for the treatment and care of an avoidable pressure ulcer, including failing to develop and implement a baseline care plan for pressure ulcer prevention. The pressure ulcer developed within ten days of the resident's admission to the facility and worsened to a Stage IV, causing the resident pain. She did not want to be repositioned and voiced not wanting to live. The resident was placed in Hospice for end-of-life care and services for 1 (#27) of 5 residents sampled for pressure injuries. This deficient practice increased the risk of negative outcomes of the admission identification process of pressure injuries and residents at risk of developing pressure injuries.On [DATE] at 10:04 a.m., Immediate Jeopardy was announced to the Administrator, Chief Nursing Officer, and Director of Quality and Patient Safety for F686-Pressure Ulcers Care and Prevention. The Severity 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 · D2026-06-08 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    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 obtain informed consent to include an explanation of the risks, benefits, and alternatives before the administration of psychotropic medications for 1 (#36) of 18 sampled residents. Findings include: During an observation and interview on 6/1/26 at 2:22 p.m., resident #36 was lying in bed. Resident #36 stated she was admitted to the facility on [DATE], after she had fallen at home and fractured her hip. Resident #36 stated she had increased sleepiness and all she wanted to do right now was sleep. Resident #36 stated she had a history of depression, but was not sure if that was what was causing her sleepiness.Review of resident #36's pharmacy medication regimen review, dated 5/29/26, showed: . Please obtain consent for duloxetine .Review of resident #36's physician orders, dated 5/29/26, showed duloxetine (antidepressant) 60 milligram capsule daily, which was ordered on 5/30/26.Review of resident #36's psychotropic informed consent form…

    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 · D2026-06-08 · 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 investigative findings to the State Survey Agency within the required timeframe of 5-working days for 1 (#6) of 18 sampled residents. Findings include:Review of the facility's reported incident, dated 12/18/25, showed, CNA went into resident (#6's) room during rounding and reports resident was walking back to bed from the bathroom in her socks with her cane. Resident reported to the CNA she had fallen. The resident was favoring her left leg and complaining of pain.Review of the facility's investigative findings for the incident involving resident #6, reported on 12/18/25, showed the investigation findings were submitted to the State Survey Agency on 1/29/26, 42 days after the incident occurred; therefore, the report was untimely. The investigative findings showed resident #6 sustained an acute left-sided pubic rami fracture.During an interview on 6/1/26 at 1:55 p.m., staff member B stated that at the time of the incident involving resident #6's fall, she was unaware that the findings of the investigation for 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
  • Potential for harm · Dcited before2026-06-08 · 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 develop and implement a baseline care plan for a resident that included the minimum necessary information needed to provide person-centered care for 1 (#39) of 18 sampled residents. This deficient practice increased the risk of the resident not receiving necessary care and services. Findings include: During an observation and interview on 6/2/26 at 9:10 a.m., resident #39 was sitting in a wheelchair watching television in her room. Resident #39 stated she was recently admitted to the facility on [DATE]. The resident planned on returning to an assisted living facility after her inpatient physical and occupational therapy. Resident #39 stated she needed staff assistance with her activities of daily living due to weakness and pain she experienced. Resident #39 stated she needed assistance with transferring, and the staff was using a mechanical lift for her transfers. During an interview on 6/2/26 at 9:20 a.m., staff member F stated resident…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-08 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility staff failed to adhere to accepted infection control standards, including proper hand hygiene and glove use, during a medication pass for 2 (#s 33 and 39) of 18 sampled residents. This deficient practice increased the likelihood of the transmission of infections. Findings include:During an observation on 6/2/26 at 9:20 a.m., staff member F entered resident #39's room. No hand hygiene was performed by the staff member before entering the room. Staff member F walked over to the medication cabinet, which was located on the wall in the room. Staff member F used his badge to unlock and open the cabinet. Staff member F placed the handheld charting device called a Rover onto a flat surface. He picked up a medication card and scanned it with the Rover. He then placed the medication card over the plastic medication cup and pushed the medication from the card into the medication cup. Staff member F repeated this process four times. Staff member F walked over to the resident and handed her the medication in the cup. No hand…

    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 before2025-08-12 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure staff member C followed proper infection control practices while performing blood glucose monitoring with a portable handheld glucometer between residents for 2 (#s 1 and 3); and failed to perform hand hygiene before donning clean gloves prior to blood glucose monitoring for 1 (#3) of 2 sampled residents for blood glucose monitoring. These deficient practices increased the risk of transmission of bloodborne pathogens between residents in the facility. Findings include:During an observation on 8/12/25 at 7:37 a.m., staff member C retrieved a portable handheld glucometer from a locked room by the nurses' offices. The glucometer was seated on a charger on the counter, next to a case which contained blood glucose monitoring supplies. During an observation on 8/12/25 at 7:38 a.m., staff member C entered resident #3's room and donned gloves to perform her blood glucose monitoring. Staff member C did not sanitize her hands before donning the gloves. Staff member C performed the blood glucose monitoring 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-20 · tag F0655 — pattern
    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

    Based on observation, interview, and record review, the facility failed to develop and implement a baseline care plan which included the minimum necessary instructions needed to provide effective and person-centered care of the resident for 3 (#s 3, 17, and 21) of 17 sampled residents. Findings include: During an observation on 5/17/25 at 3:02 p.m., resident #17 was lying in bed, receiving oxygen via nasal cannula. Review of resident #17's document titled, Baseline Care Plan, dated 4/7/25, did not include a problem, goals, or interventions for oxygen therapy. During an observation on 5/18/25 at 8:35 a.m., resident #3 was lying in bed, receiving oxygen via nasal cannula. Review of resident #3's document titled, Baseline Care Plan, dated 4/28/25, did not include a problem, goals, or interventions for oxygen therapy. During an observation and interview on 5/18/25 at 8:20 a.m., resident #21 was receiving supplemental oxygen via nasal cannula. Resident #21 stated he had a catheter in place due to urinary retention and needed a lot of assistance with toileting or to even get out of bed…

    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 · E2025-05-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the oxygen rate of delivery was included in the provider's oxygen orders for 4 (#s 3, 17, 78, and 129); failed to ensure a form of documentation was in place for when oxygen tubing was last changed for 5 (#s 3, 17, 21, 78, and 129); and failed to ensure proper infection control practices were adhered to for a respiratory nebulizer mask/mouthpiece for 1 (#17) of 17 sampled residents. These deficient practices had the potential to affect the correct rate of oxygen delivery and increase the risk for infections in residents with prescribed oxygen. Findings include: 1. Oxygen Orders During an observation on 5/17/25 at 3:02 p.m., resident #17 was lying in bed, receiving oxygen via nasal cannula. The oxygen concentrator was set at three liters per minute. Review of resident #17's Oxygen Therapy orders, dated 4/7/25 at 5:02 p.m., showed oxygen to be delivered continuous, via nasal cannula; and, Keep O2 Sat Above 90%. The provider's order for oxygen did not include a rate of delivery. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-20 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review, the facility failed to provide the required SNF Beneficiary Notification, Form CMS-10055 to 1 (#111) of 3 sampled residents who received Medicare Part A skilled services. Findings include: During an interview on 5/19/25 at 2:27 p.m., staff member A stated the facility had not completed the SNF Beneficiary Notification Form CMS-10055 when resident #111 was discharged from skilled care services. Staff member A was not able to explain why the notice was not completed. Review of the facility-provided document titled, SNF Beneficiary Notification Review, showed the start date for Medicare Part A skilled services was 4/10/25, with the last covered day of 5/12/25. The facility was not able to provide evidence the SNF Beneficiary Notification Form CMS-10055 was completed.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-20 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure psychotropic medications, prescribed on an as needed basis, were limited to 14 days unless the resident's medical record included documented rationale for continued use for 2 (#3 and #6) of 17 sampled residents. Findings include: 1. Review of resident #3's current as needed medication records, as of 5/18/25, showed: - alprazolam 0.25 mg, by mouth, nightly as needed. The medication order for resident #3 did not include an end/stop date or was limited to 14 days. During an interview on 5/19/25 at 7:44 a.m., staff member A stated antipsychotic or psychotropic medication orders were limited to 14 days. He stated there should be a stop date on the medication orders for these medications. 2. During an interview on 5/19/25 at 11:28 a.m., staff member I stated PRN psychotropic medication orders were, usually for less than 14 days, but (resident #6) is on hospice, so I just don't know if it can be ordered for longer. Review of resident #6's physician orders showed two separate and active orders for as needed (PRN) lorazepam…

    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 · D2025-05-20 · 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 — the official record, unedited, may be distressing

    Based on interview and record review, the facility failed to notify the resident and/or the resident's representative, in writing, of the facility's bed hold policy when transferring a resident to the hospital for 1 (#3) of 17 sampled residents. Findings include: During an interview on 5/19/25 at 2:37 p.m., staff member B stated the facility did not have documentation of a bed hold policy notification for resident #3's hospitalization on 4/26/25. Review of the facility's policy titled, [Facility] Room Hold Policy, last revised 6/2024, showed: - . Policy: - . Resident and/or resident's representative will be notified in writing of [Facility] Room Hold Policy.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · D2025-05-20 · 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 initiate a person-centered comprehensive care plan to include the use of oxygen therapy for 2 (#s 3 and 17); and failed to include an increased risk of aspiration for a resident admitted to the hospital and returned after an event of food aspiration for 1 (#3) of 17 sampled residents. Findings include: 1. Resident #3 During an observation on 5/18/25 at 8:35 a.m., resident #3 was lying in bed, receiving oxygen via nasal cannula. During an interview on 5/19/25 at 12:23 p.m., staff member D stated since resident #3 returned from the hospital after an aspiration event, they (staff) either asked the resident to eat in the dining room, or where she could be watched. Staff member D stated if resident #3 remained in her room for meals, staff sat with her during that time. During an interview on 5/19/25 at 12:26 p.m., resident #3 stated staff never sat with her when she ate in her room, and it was her choice to stay in her room during meals. Review of resident #3's Nursing admission Note, dated 4/29/25, showed 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 · Dcited before2025-05-20 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to update resident care plans to include actual falls and updated fall interventions for 2 (#s 4 and 180) of 17 sampled residents. The failures placed the residents at risk for recurrent falls and injuries. Findings include: 1. During an observation and interview on 5/17/25 at 3:45 p.m., resident #4 was seated in a wheelchair, leaning to the right side, holding both arm rests. Resident #4 stated he had some falls in the past, stating, I think it's this chair. I don't know, I think I just slide out. During an interview on 5/18/25 at 9:15 a.m., staff member I stated, He (resident #4) has had some falls, I think. I am not sure what interventions were placed to keep him from falling. I have not been here a long time, so might not be the best person to talk to . I would look in the (medical) record, or the care plan if I wasn't sure how to care for him. Review of resident #4's progress notes showed he experienced an unwitnessed fall from bed on 10/5/24. Review of the facility document titled, Risk Management…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-20 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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 member H adhered to sanitary hygiene practices, by wearing a beard net/covering while preparing residents' food trays in the kitchen area. This failure increased the risk of hair getting in food for any resident the employee was preparing food for, or from the area the employee was working in, when not wearing protective hair coverings. Findings include: During an observation on 5/19/25 at 8:50 a.m., staff member H was preparing four individual residents' breakfast trays on the countertop located in the 500-hall kitchen area. Staff member H was wearing a hairnet but did not have a beard net covering his facial hair. During an interview on 5/19/25 at 9:04 a.m., staff member H stated he should have worn a beard net while he prepared trays in the kitchen area. Staff members E and F stated a hat or hairnet, and beard net, if indicated, must be worn to prepare food in the kitchen area. Review of the facility's document titled, Food & Nutrition Services Dress Code, last revised 8/26/24, showed: - .…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-02 · tag F0675 — failed to support quality of life — pattern
    Honor each resident's preferences, choices, values and beliefs.
    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 call lights were answered in an appropriate timeframe for 3 (#s 5, 6, and 10) of 4 sampled residents concerning call lights; and the facility failed to prevent falls for 1 resident (#5) requiring help after pushing the call light. This had the potential to result in more falls in the facility with those residents requiring help and pushing the call light button for assistance. Findings include: a. During an interview on 10/2/24 at 10:06 a.m., resident #10 stated she would wait the longest for her call light to be answered when it was shift change or after 6:00 p.m. Resident #10 stated she would often wait 20 minutes for her call light to be answered. Resident #10 stated staff would also turn off her call light and leave the room before all her needs were met. Resident #10 stated when she had spoken up in the past to staff, and she had been reprimanded by the staff about complaining. She stated, They say they'll be back in ten minutes and they don't. And sometimes the pagers (the pagers alert the staff call lights…

    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 · D2024-10-02 · tag F0624 — isolated
    Prepare residents for a safe transfer or discharge from the nursing home.
    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 provide a safe and orderly discharge from the facility, to home, for 1 (#1) of 3 sampled residents, and the resident had not met his goals prior to the discharge, he had a wound/fistula, multiple medications, and needed ongoing rehabilitation services. The failure increased the risk of a poor outcome and safety concerns for the resident due to his inability to care for himself as needed. Findings include: During an interview on 10/2/24 at 10:18 a.m., NF1 stated resident #1 was discharged home alone, and the family had not seen any home health services since the discharge occurred, which was eight days prior. NF1 stated resident #1 lived alone, and the family lived in the same apartment complex but were not planning to provide fulltime care to resident #1 upon discharge. NF1 stated the facility relayed they would be sending physical therapy, occupational therapy, and nursing, to assist with resident #1's care needs and training once home. NF1 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-06-20 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure proper food preparation and storage in the kitchen and in the cottages. This deficiency had the potential to affect all residents who received services from the kitchen. Findings include: During the initial tour of the kitchen on 6/17/24 at 3:30 p.m., the following concerns were observed (staff member G accompanied the surveyor in the kitchen): - The commercial meat slicer was left partially uncovered. The meat slicer had a layer of grease and three white particles of debris on it. - The commercial stand-up [NAME] mixer had dried food splatters. The food splatter contained brown and white debris. - The tomato slicer blade was contaminated with brown debris. - The inside of the microwave contained dried food particles adhering to the walls and top. - The industrial can opener was contaminated with metal shavings. - One can of blueberry pie filling was dented at the top edge. -Six loaves of bread were opened and not dated with when the package 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-06-20 · tag F0554 — pattern
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure residents were assessed and found safe to self-administer their medications prior to doing so, and the facility failed to document the assessments or get a physician order allowing the self medication administration in the electronic health records's for 3 (#s 153, 158, and 168) of 19 sampled residents. Findings Include: 1. During an observation on 6/17/24 at 4:50 p.m., staff member O set resident #158's medications on her bedside table. The medication cup contained a calcium chloride and two hydrocodone/tylenol tablets. The resident was noted to have some physical deformities of her hands. The nurse exited the room and did not watch or encourage the resident to take the medication. Review of resident #158's EHR failed to show that an interdisciplinary team had completed an assessment to determine if self administering medication was clinically appropriate and safe for resident #158. The physician did not identify this was a safe practice and did not give an order to allow the resident to administer…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-06-20 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide services which met professional standards of practice, by allowing residents without assessments and physician orders to self-administer medications, and they were left unattended with medications, for 3 (#s 153, 158, and 168) of 19 sampled residents. Findings include: 1. During a medication pass observation on 6/17/24 at 4:50 p.m., staff member O left two hydrocodone 10/325 mg tablets and one calcium carbonate tablet at resident #158's bedside. Staff member O left the room without having observed resident #158 taking the medications, one was a narcotic. During a medication administration observation on 6/18/24 at 9:05 a.m., staff member P provided nine pills as part of the morning medication pass to resident #158. Staff member P left resident #158's room without waiting until resident #158 had taken any of her medications. 2. During an interview on 6/18/24 at 2:05 p.m., staff member P stated, she did not remember watching and making sure resident #153 took her medication this morning. During an…

    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 · E2024-06-20 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure a medication error rate less than 5%. The observed error rate was 40.7%. The errors involved the staff member administering the medication was not staying with the resident to ensure the medications were taken for 3 (#s 153, 158, and 168) of 11 residents sampled for medication administration. Findings include: 1. During a medication administration observation on 6/17/24 at 4:50 p.m., staff member O administered the following medications to resident #158: - calcium carbonate 1500 mg - hydrocodone with acetaminophen 10/325 mg Staff member O placed the medication cup on the bedside table. Staff member O then left the room and did not assist resident #158 or watch to ensure the medications were taken. 2. During an observation on 6/18/24 at 9:05 a.m., staff member P gave resident #153 her medications. The medications included: - Tylenol 650 mg - Aspirin 81 mg - Coreg 6.25 mg - Vitamin D 50 mcg - Celexa 5 mg - D Mannose one tablet - Gabapentin 100 mg - High potency multi vitamin one tablet - Ropinirole 0.25…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-06-20 · 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 ensure staff used appropriate hand hygiene during meal distribution. This practice caused the potential to contaminate food and could effect all residents receiving food from the dietary department. Findings include: 1. During an observation on 6/18/24 at 10:31 a.m., staff member L entered resident #173's room to deliver food and did not wash his hands prior to setting up the residents room tray. During an interview on 6/18/24 at 10:35 a.m., staff member L stated, Staff should perform hand hygiene while performing personal cares, while transferring the resident, when delivering meals, and when you enter or leave a resident's room. 2. During an observation on 6/18/24 at 11:52 a.m., staff member D bent over and picked up a piece of trash off the floor in the dining room with gloved hands. Staff member D proceeded to walk behind the kitchen counter and started dishing up watermelon slices onto plates with the same gloves. Staff member D then grabbed a plate with watermelon that had plastic wrap on it 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-20 · 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 interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission, for 2 (#s 165 and 171) of 19 sampled residents. Findings include: 1. Record review of resident #165's baseline care plan showed resident #165 was admitted on [DATE]. Resident #165's care plan showed he had an altered mental status, decreased oral intake, weakness, and a suprapubic catheter. The falls intervention care plan was started on 5/30/24. Per a note on the care plan, other problems were identified, and no further initial care plan was completed. Care area problems and interventions were not started until 6/10/24. During an interview on 6/19/24 at 1:03 p.m., NF3 stated resident #165 had fallen a lot at home because he had bad balance. NF3 stated resident #165 was admitted with some open sores near his rectum. NF3 stated the staff put some ointment on those areas, but she was unsure if it helped. NF3 stated resident #165 didn't like to move around much due to the pain from…

    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 · Dcited before2024-06-20 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure the comprehensive care plan was updated to reflect a resident's current care requirements for 1 (#169) of 19 sampled residents. Findings include: Resident #169 was admitted to the facility with diagnoses of Type II diabetes, diabetic neuropathy, diabetic foot ulcer with bone necrosis, complete heart block, and hemodialysis due to acute kidney failure. Interview on 6/20/24 at 8:44 a.m., staff member B stated resident #169 goes to dialysis one time per week. Staff member B reviewed the order and the care plan and agreed, the orders and the care plan did not accurately reflect the resident's current care. Review of resident #169's care plan with a problem detail date of 6/19/24, showed a goal for resident #169 to attend dialysis three times per week. Review of resident #169's active physician orders dated 6/4/24, showed the resident was to only have dialysis one time. Review of a facility document titled, FALL SCENE INVESTIGATION REPORT TO DETERMINE ROOT CAUSE ANALYSIS, showed resident #169 fell on 6/6/24 at 1:30 p.m.…

    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 · D2024-06-20 · 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 properly monitor a resident with difficulty swallowing during medication pass for 1 (#168) of 19 sampled residents. Findings include: During an observation and interview on 6/18/24 at 10:27 a.m., resident #168 was sitting in her nightgown in a wheelchair in her room with a vomit bag in front of her. Resident #168 stated, I do not feel good, I'm going to the hospital soon. I have been having stomach issues for a while. During an observation and interview on 6/20/24 at 9:48 a.m., staff member O had just left resident #168's room and closed the door. Resident #168 was lying in bed with her head elevated. Her breakfast, and a medication cup full of unidentified medications, were on the bedside table. Resident #168 stated, Only certain staff leave my medication in here for me to take. I take my time swallowing them. During an observation and interview on 6/20/24 at 10:03 a.m., staff member O was sitting in a back room of the facility working on the computer. Staff member O stated, I leave resident #168's…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-20 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and record review, the facility failed to provide pharmaceutical services to ensure safe administration of a Schedule II controlled substance for 1 (#158) of 11 residents sampled for medication administration. Findings include: During an observation on 6/17/24 at 4:50 p.m., staff member O provided resident #158 with two hydrocodone tablets. Each tablet contained 10 mg of hydrocodone and 325 mg of Tylenol. The medication cup containing the two pills was left unsupervised on the bedside table. The medication was not observed to be taken by resident #158. Review of resident #158's EHR showed the medication was checked off as being given. Staff member O failed to ensure accountability for a schedule II controlled substance by leaving the medication unsupervised in resident #158's room.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-20 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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 or provide immunization, education, or obtain a declination, for 6 (#s 153, 157, 158, 160, 168, and 173) of 6 sampled residents for immunizations. Findings include: During an interview on 6/20/24 at 8:15 a.m., staff member B stated the facility does not have any documentation to show that resident #s 153, 157, 158, 160, 168, and 173 had been offered pneumococcal and influenza immunizations. Staff member B stated, What is in the record is what we have. I have staff going around today to provide education and obtain declinations from those residents. During an interview on 6/20/24 at 9:51 a.m., resident #168 stated, The facility has never offered those (pneumococcal or influenza) immunizations to me. I don't think I had them done anywhere else either. During an interview on 6/20/24 at 10:15 a.m., resident #160 stated she thought she had the flu shot but couldn't remember. Resident #160 stated the facility hadn't offered her pneumococcal or influenza immunizations or spoken with her about them. Review of electronic…

    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

“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

$48,323 in federal fines across 1 penalty.

  • $48,323 — penalty dated 2026-06-08

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
EHLINGER, FORRESTIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 06/03/2014
GOODNOW, JOHNIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 12/02/2002
HARRIS, PATRICIAIndividualW-2 MANAGING EMPLOYEEsince 06/18/2012
HILL, KATHYIndividualW-2 MANAGING EMPLOYEEsince 02/11/2015
HOULIHAN, BRUCEIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 01/09/2022
TIERNEY, GREGORYIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 01/01/2021
BAKER, JEFFREYIndividualCORPORATE DIRECTORsince 08/01/2018
BORLAND, JUDYIndividualCORPORATE DIRECTORsince 03/01/2012
FERRIN, WILLIAMIndividualCORPORATE DIRECTORsince 10/01/2008
JONES, LLEWELYNIndividualCORPORATE DIRECTORsince 06/01/2016
LACEY, TAMMYIndividualCORPORATE DIRECTORsince 08/01/2018
LOUCKS, BRIANIndividualCORPORATE DIRECTORsince 05/01/2012
MARGARIS, MELCHISEDEKIndividualCORPORATE DIRECTORsince 06/01/2015
RICHARDS, PHILLIPIndividualCORPORATE DIRECTORsince 01/01/2015
ROSE, MARILYNIndividualCORPORATE DIRECTORsince 10/01/2008
BENEFIS HEALTH SYSTEM, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROLsince 07/16/2008

CMS files one row per role, so the 20 rows in the source record cover these 16 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 2026-08-01 — CMS provider number 275157. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-08, 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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