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Benefis Senior Services - Westview

500 15th Ave S, Great Falls, MT 59405 · Non profit - Corporation · 34 certified beds · (406) 455-5902 Medicare & Medicaid certified

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Flagged for abuse2 actual-harm citations$13,865 in federal fines
Insights

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

Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited May 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $13,865 in federal fines (most recent 2025-05-20)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (1/5)

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 1 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
401 15th Ave S · (406) 452-9504 · Call to confirm hours
Pharmacy
900 13th Ave S · (406) 315-1989 · Call to confirm hours
Grocery
1517 Sunnyside Ave · (406) 453-8057 · Call to confirm hours
Park
4TH St S · Typically dawn to dusk
Place of worship
1000 17th Ave S · (406) 453-0391

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 1 of 5
Long-stay residentspeople who live here 1 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 fell from 2 to 1 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 rating1★
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 increased35.4%18.7%15.4%worse
Long-stay residents who lose too much weight8.9%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder9.5%2.1%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection7.3%2.9%2.0%worse
Long-stay residents with depressive symptoms2.3%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 injury0.9%4.4%3.3%better
Long-stay residents whose ability to walk worsened35.2%17.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication14.6%15.8%18.9%better
Long-stay residents with pressure ulcers18.2%6.3%4.7%worse
Long-stay residents with worsening bladder/bowel control25.1%24.1%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table10.4%20.4%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine90.9%73.8%79.4%better

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.

0.37U.S. median 0.31
Therapy hours / resident / day
0.30hours / resident / day
Physical therapy
0.06hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.37 therapist hours per resident per day in 2026Q1 — more than 63% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 18% 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 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 identifiednot 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 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 — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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

0.58
RN hours/ resident / day
0.62
LPN hours/ resident / day
2.04
Aide hours/ resident / day
3.24
Total nurse hours/ resident / day
0.58
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 34 beds and averages 31.7 residents a day — about 93% occupied, or roughly 2 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 3.24 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.58 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.04 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.23 hrs/resident/day on weekends vs 3.25 on weekdays — 1% thinner on weekends. RN hours go from 0.58 to 0.58 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

13
deficiencies at the latest standard inspection (2025-05-20)
4
at the previous standard inspection (2024-06-20)

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

Inspection deficiencies

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

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.

21 citations, most serious first. The 12 most serious are shown; the remaining 9 are one tap away and print in full.

  • Actual harm · G2025-05-20 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident was free from mental abuse by depriving a resident their rights to private visitations (see F563 & F583) and isolating the resident from social interactions for staff convenience, causing the resident to experience ongoing feelings of being dull, bored, and frustrated which resulted in the resident expressing feelings of being a prisoner, for 1 (#78) of 13 sampled residents. Findings include. During an observation and interview on 5/17/25 at 2:00 p.m., resident #78 was sitting in the common area with another resident and NF3 and NF4. Resident #78 stated she had to visit with her friends in the common area because she was not allowed visitors in her room. (See F563 & F583) During an interview on 5/18/25 at 9:42 a.m., resident #78 stated she was not allowed to have visitors in her room. She stated the facility had been limiting her visitations for several months. She stated on several different occasions, while having…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2025-05-20 · 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

    Based on observation, interview, and record review, the facility failed to consistently assess, measure, and monitor a resident's pressure ulcer; and failed to ensure wound dressings were provided as ordered by the physician, and failed to ensure sufficient wound documentation was completed, to prevent the progression of a worsening Stage III pressure ulcer for 1 (#75). This deficient practice had the potential to cause worsening wounds and infection for the resident; and the facility failed to ensure 1 (#7) of 13 sampled residents properly received perineal care to prevent the occurrence of a wound related to the use of an indwelling catheter. Findings include: 1. During an interview on 5/17/25 at 3:57 p.m., resident #75 stated she had recently returned to the facility after being admitted to the hospital with sepsis. She stated she was very susceptible to developing infections. Resident #75 stated she developed a pressure ulcer on the back of her right upper thigh from not being cleaned, and the area was getting moist. She stated the pressure ulcer developed after 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 · D2026-06-18 · 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 submit two reportable events in the designated required timeline for 2 (#s 20 and 23) out of 19 sampled residents. Resident #20 had an injury of unknown origin identified on 5/24/26, and it wasn't initially reported to the State Survey Agency until 5/26/26. Resident #23 was a victim of physical abuse that occurred on 7/22/25, and it was not initially reported until 9/19/25. Findings include:1. Review of the Facility-Reported Incident submitted 5/26/26, showed the Chief Director of Nursing was completing chart reviews and found a resident with an injury of unknown origin. The report showed resident #20 was found sitting on the floor. Due to increased pain, resident #20 was sent to the emergency room for an evaluation. The emergency room diagnosed resident #20 with a periprosthetic fracture around the internal prosthetic hip joint.Review of resident #20's nursing note showed she fell on 5/24/26, and the abuse allegation report was not submitted until two days after the fall for the injury of unknown origin. 2. Review of 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 no plan of correction
  • Potential for harm · D2026-06-18 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to revise a care plan for a resident who had documented safety concerns related to leaving the facility without supervision for 1 (#40) of 21 sampled and supplemental residents. This failure resulted in the resident exiting the facility unsupervised, placing the resident at risk of harm. Findings include:During an interview on 6/17/26 at 8:52 a.m., staff member F stated the nursing manager was responsible for updating a resident's care plan. Staff member F stated nursing staff did not add additional interventions or change the care plan. During an interview on 6/18/26 at 10:00 a.m., staff member B stated resident #40's care plan should have reflected that the resident was not allowed to leave the facility without supervision. Staff member B stated it was the responsibility of the nursing manager to update resident #40's care plan. Staff member B stated the nurse manager responsible for updating the resident's care plan was no longer employed with the facility. Staff member B stated she did not know why resident #40's care…

    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 no plan of correction
  • Potential for harm · D2026-06-18 · tag F0745 — failed to provide medically-related social services — isolated
    Provide medically-related social services to help each resident achieve the highest possible quality of life.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure social services was provided to one resident needing assistance with transitioning to a long-term care facility and managing the resident's finances for 1 (#1); and ensuring psychosocial well-being was assessed for a resident following a physical altercation for 1 (#23) of 19 sampled residents. The failure could result in undue stress for the residents related to the lack of social service assistance. Findings include:1. During an interview on 6/17/26 at 8:10 a.m., resident #1 was observed sitting in a wheelchair at the breakfast table. Resident #1 asked if the surveyor could find an advocate for him. Resident #1 said that when he was first admitted to the facility on [DATE], there were many staff members to help him with his needs. Resident #1 said, since a day or two after admission, no one has been in to help now. Resident #1 said he had no family or friends to help him. Resident #1 said he needed to get to his home or have someone go to his…

    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 no plan of correction
  • Potential for harm · Ecited before2025-05-20 · tag F0656 — failed to write and follow a full care plan — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan that reflected the care needs, and to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being, for 2 (#s 14 and 68) of 13 sampled residents, which included failing to ensure interventions were in place and documented for dialysis and dialysis related emergencies and monitoring of the resident for #14; failed to ensure interventions were in place to prevent identified elopement risks and/or review and revise interventions in place following elopements for #68. Findings include: 1. Review of resident 14's care plan revealed resident #14 admitted to the facility on [DATE] with the diagnoses of congestive heart failure, osteomyelitis of the thoracic vertebrae, Diabetes Mellitus Type II, Depression with anxiety, and pulmonary fibrosis. The comprehensive care plan identified resident #14 would go to dialysis on Tuesday, Thursday, and Saturday. There…

    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 F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to timely identify elopement risks and implement sufficient preventative interventions for a resident with repeated elopement(s), for 1 resident (#68) and the resident had severe cognitive impairments, of 13 sampled residents. There continued to be elopement hazards for this resident, and it was identified necessary staff were not aware of how to identify or classify an elopement. Findings include: During a facility tour, 5/17/25 at 2:00 p.m., the long-term care unit was on the fourth floor and was accessible by two sets of elevators. The elevators did not require special codes to access and were not monitored. The facility had numerous non-monitored doors and exits on the first floor. Review of resident #68's most current elopement/wander assessment dated , 1/23/23, showed the resident was not at risk for eloping. No current elopement assessment was provided by the end of the survey, but was requested. Review of resident #68's nursing note, dated 2/20/25, showed resident #68 had a BIMS of 7, reflecting severe…

    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 · E2025-05-20 · 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 provide sufficient staffing contributing to a worsening pressure ulcer injury for 1 (#75), ADLs not being completed for 2 (#s 5 and 83), long call light times and low staffing concerns reported by residents for 3 (#s 13, 79 and 83), and repositioning not being completed for 3 (#s 7, 13 and 83) of 13 sampled residents. Findings include: During an interview on 5/17/25 at 3:57 p.m., resident #75 stated she had a pressure ulcer on her right upper leg. She stated she thought it was worse because staff did not always change the dressing. She stated she preferred to have her dressing changed during the day, not at night, but often the day staff did not have time to change it. She stated on several different occasions she had been told by staff that they don't have time to change it. During an observation on 5/18/25 at 4:17 p.m., staff member C provided wound care and a dressing change for resident #75. Resident #75 had an oval shaped wound located on the back of her right upper thigh. The wound was approximately 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 · D2025-05-20 · tag F0564 — isolated
    Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges.
    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, implement, and inform residents, to include 1 (#78) of 13 sampled residents, of their policy and procedure for resident visitations. This deficient practice had the potential to affect all residents and their visitors. Findings include: During an observation and interview on 5/17/25 at 2:00 p.m., resident #78 was sitting in the common area with another resident and her two family members. Resident #78 stated she had to visit with her friends in the common area because staff would not allow her to have visitors in her room. During an interview on 5/18/25 at 9:42 a.m., resident #78 stated she was not allowed visitors in her room. She stated she only agreed to have visitors in the common area because she wanted to keep the peace with staff. During an interview on 5/19/25 at 11:06 a.m., NF1 stated staff member A had explained the facility had a specific visitation policy for residents. She stated staff member A had told her there was a condition of that policy which allowed the facility to limit certain…

    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 · D2025-05-20 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 resident privacy during visits for 1 (#78); and failed to provide privacy curtain or a door for a resident's bathroom for 1 (#2) of 13 sampled residents. Findings include: 1. During an interview on 5/18/25 at 9:42 a.m., resident #78 stated she was not allowed to have visitors in her room and was told by staff that she would have to meet with her visitors in the common area. She stated she felt that the staff were not allowing her to meet privately with other residents or her friends. During an interview on 5/19/25 at 10:22 a.m., staff member I stated she was informed by staff member E that resident #78 was not allowed to have visitors and, If you see any visitation in her room ask for it (visitors) to come out into a common area. The vistitation in the common area did not allow for private conversations. During an interview on 5/19/25 at 12:37 p.m., staff member F stated staff member E decided that if resident #78 was going to have visitors they would have to meet in a common area and not her room. The…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-20 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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 free from restraints, unless there had been a documented medical symptom, for 1 (#68) of 13 sampled residents. Findings include: During an observation on 5/18/25 at 1:30 p.m., resident #68 was observed sitting in his wheelchair near the nurse's station. Resident #68 had a loose-fitting seat belt on his wheelchair. Resident #68 was not able to remove the seat belt when asked to do so by the surveyor. Review of resident #68's Evaluation For Use Of Restraints and/or Alarms showed resident #68's last assessment was completed 6/15/22. The evaluation did not show what medical condition or symptoms were being treated with the use of the seat belt. Review of resident #68's electronic health record did not show any ongoing re-evaluation of the need for a physical restraint. Review of resident #68's care plan, most currently updated on 2/10/25, failed to show a seat belt was to be used. During an interview on 5/19/25 at 10:50 a.m., staff member E said resident #68 used the seat belt to prevent…

    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 F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure pre-poured medications were given timely for 3 (#s 7, 79, and 80) of 13 sampled residents. This deficient practice had the potential to result in late medication administration, and time sensitive medications given too closely together, possibly resulting in a high half-life concentration of medication in the body. Findings include: During an interview and observation on 5/18/25 at 8:06 a.m., staff member N had pre-poured medications for seven residents and had these cups of medications locked in the top drawer of the medication cart. Staff member N stated the medications were scanned, and therefore documented in the MAR as given at that time for each resident. Staff member N stated they would sometimes change the administration time to the time after the medication was administered. Staff member N stated they had not changed the administration time that day for any of the residents because they were running behind. Staff member N stated they were late to work that day and this contributed to not…

    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
Show the remaining 9 citations
  • Potential for harm · D2025-05-20 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure basic ADLs were being completed for 2 (#s 5 and 83) of 13 sampled residents. This deficient practice had the potential to result in residents feeling unclean and unkept. Findings include: 1. During an interview on 5/17/25 at 3:12 p.m., resident #83 stated her face was sometimes washed in the morning by staff. Resident #83 stated her hair was only half brushed as she was only able to reach the left side of her head. During an interview on 5/18/25 at 2:05 p.m., NF5 stated resident #83's hair was not brushed, and her teeth were not brushed yet for the day. During an interview on 5/19/25 at 8:35 a.m., resident #83 stated she combed her hair the best she could. She stated she was able to brush the left side of her hair but was unable to brush the right side of her hair due to a stroke, which she had in the past. During an observation and interview on 5/19/25 at 10:03 a.m., NF5 was helping resident #83 brush her hair and teeth. NF5 stated they noticed resident #83 needed these cares done and would just do them for her…

    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 before2025-05-20 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 getting turned to prevent skin breakdown throughout the day, for 3 (#s 7, 13, and 83) of 13 sampled residents. This deficient practice increased the risk of skin breakdown for any resident who did not get turned frequently enough. Findings include: 1. During an interview on 5/17/25 at 3:12 p.m., resident #83 stated staff only repositioned her in her Broda chair when she asked them to. She stated staff kept putting cream on her buttock area, and said something amongst themselves, but never said anything to resident #83 directly about her buttock area being red. Resident #83 stated staff would let her sit in her chair all day without turning or standing occasionally. She stated some staff would not clean her properly. She stated most staff were pretty good, but some will just change her brief and that was all they would do. She stated she gets recurrent UTIs and worried about skin breakdown. During an observation and interview on 5/19/25 at 7:45 a.m., staff members L and J 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-20 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure residents who received dialysis were provided services, consistent with professional standards of practice, to include physician orders for the dialysis and appropriate nutrition and per the resident's preferences, for 1 (#14) of 13 sampled residents. The deficient practice placed the resident at risk for pre-dialysis and post-dialysis complications. Findings include: During an interview on 4/22/25 at 8:29 a.m., resident #14 said he had been getting dialysis at a dialysis center across town. Resident #14 said he goes to dialysis on Tuesday, Thursday, and Saturday. Resident #14 said he left the facility at approximately 6:00 a.m., and returned to the facility at approximately 11:00 or 11:30 a.m., depending upon how long he had to wait for the facility van. Review of resident #14's admission physician orders, dated 8/22/24, showed the resident did not have a physician order for the dialysis treatment. Review of resident #14's physician order received on 5/19/25, showed the physician order for hemodialysis…

    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 F0759 — failed to keep medication error rate low — isolated
    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 prescribed medications were given for 2 (#s 7 and 79) and failed to follow physician ordered parameters for one medication, digoxin, for 1 (#80) of 13 sampled residents. The facility's medication error rate was calculated at nine percent. This deficient practice had the potential to cause harm for a resident if their pulse was too low and the medication was given, or if the medications were not given at all. Findings include: 1. During an observation and interview on 5/18/25 at 8:16 a.m., resident #80's medication, digoxin, was given at 8:34 a.m. Staff member N stated they had taken resident #80's pulse prior to the medication administration and stated the pulse was taken first thing in the morning. Review of resident #80's Flowsheets and TAR, in the EHR, showed no vitals (including resident #80's pulse) were taken on 5/18/25. Review of resident #80's MAR showed: digoxin . Hold for pulse less than 50. 2. During an interview and observation on 5/18/25 at 8:24 a.m., resident #79's medication, Lotrimin…

    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 · Dcited before2025-02-10 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 referral for an orthopedic consult was followed up on, and there was a delay of three months, where the facility did not follow up on it, for 1 (#2) of 4 residents sampled. Findings include: During an observation and interview on 2/10/25 at 1:20 p.m., resident #2 showed the deformities on her right hand to her index and ring fingers. She stated it was from an old bone break and it still caused her discomfort. Review of resident #2's physician progress notes, dated 11/18/24, showed, . She is requesting to see orthopedic doctor about deformities in her right hand that are causing discomfort. Right index finger and right ring finger have significant deformities present . referral to hand surgeon. Review of resident #2's EMR failed to show a result of this referral. During an interview on 2/10/25 at 4:05 p.m., staff member B stated they could see where the order was sent, and it had appeared ortho had called the resident's personal cell phone instead of the unit's line. Staff member B stated the referral…

    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 · F2024-06-20 · tag F0804 — failed to serve food at safe, palatable temperature — widespread
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    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 provide residents with food at a safe and appetizing temperature for 4 (#s 101, 104, 117, and 121) of 16 sampled residents, this this could affect more residents who received food from the kitchen. Findings include: 1. During an interview on 6/17/24 at 1:00 p.m., resident #101 stated the food was, . mostly all cold and you don't get what you ask for . 2. During an interview on 6/17/24 at 1:25 p.m., resident #104 stated, The food is horrible, always cold . 3. During an observation and interview on 6/17/24 at 1:25 p.m., resident #121 stated, I got a peanut butter and jelly sandwich today . the bread is wet, I won't eat it . the food is crap and it is cold . The surveyor observed the bread on the plate for resident #121 was wet and soggy. 4. During an interview on 6/18/24 at 8:48 a.m., NF2 stated, . the food is, well, the residents complain about the food all the time. There were times I would have to have it warmed up for her (resident #117), typically when she was having meals in her room . 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-06-20 · tag F0561 — failed to honor residents' choices — pattern
    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 interviews and record review, the facility failed to provide residents' choices related to the timing and frequency of showers for 3 (#s 104, 114, and 126) of 16 sampled residents. Findings include: 1. During an interview on 6/17/24 at 1:24 p.m., resident #104 stated the facility only allowed her to have one shower a week, and sometimes that shower would also be missed. Resident #104 stated she would like to have two showers a week, but did not think the facility would allow it. Resident #104 stated the staff come, and tell her when she will have her shower with little or no notice. Resident #104 stated she takes the showers when she is told, but she would prefer to be able to plan her day around a scheduled shower time. Review of resident #104's electronic medical record documentation for showers/baths, dated 5/1/24-6/19/24, reflected showers were given on: - Friday 5/3/24, - Tuesday 5/21/24: 18 days after previous shower, - Thursday 6/6/24: 16 days after previous shower, and - Thursday 6/13/24, seven days after the prior shower. No documentation was found to show 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-06-20 · 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

    Based on interviews and record review, the facility failed to provide residents assistance with bathing, which resulted in dependent residents going extended periods of time without a bath or shower, for 3 (#s 119, 121, and 127) of 16 sampled residents. Findings include: During an interview on 6/17/24 at 1:25 p.m., resident #121 stated, . they don't give me showers very often . During an interview on 6/17/24 at 1:40 p.m., resident #127 stated, . sometimes it is a while between showers . During an interview on 6/17/24 at 3:32 p.m., NF1 stated, He (#128) gets a little flakiness if they don't use the right shampoo . They try to keep up giving showers. Review of resident #119's monthly charting flow sheet for bathing showed showers given on 4/28/24, 5/9/24 (11-day period with no shower), 5/15/24, and 5/28/24 (13-day period with no shower). The shower schedule shows resident #119 is scheduled for a shower on Wednesday and Sunday of each week. Review of resident #121's monthly charting flow sheet for bathing showed showers given on 5/1/24, 5/11/24 (10-day period with no shower), 5/22/24…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-20 · 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, interviews, and record review, the facility failed to develop and implement a comprehensive care plan for a resident with concerns related to skin, nutrition, activities of daily living, mobility, and urinary concerns, for 1 (#128) of 16 sampled residents. Findings include: Review of resident #128's admitting paperwork, dated 2/16/24, showed he was admitted with diagnosis' that include: rectal ulceration, deep partial thickness 2nd degree burn of abdomen, incomplete paraplegia, and a suprapubic catheter. Activity of daily living problems listed were eating, toileting/hygiene, mobility, bathing, dressing, and transfers. During an observation and interview on 6/17/24 at 1:40 p.m., resident #128 was observed to be reliant on a wheelchair for mobility. Resident #128 stated he does rely on staff for help with transfers and hygiene. During an interview on 6/18/24 at 11:42 a.m., staff member D stated the manager makes a daily schedule of who should be showered, and the staff try to get the showers completed. Staff member D stated getting showers completed was often…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

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

$13,865 in federal fines across 1 penalty.

  • $13,865 — penalty dated 2025-05-20

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
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 01/09/2002
BENEFIS HEALTH SYSTEM, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/16/2008
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
BOURRET, WILLIAMIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 02/03/2026
CAMERON, TANYAIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 02/04/2026
GOODNOW, JOHNIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 02/03/2026
HAMILTON, DONIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 02/04/2026
HOILAND, SHANNONIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 02/04/2026
MCALLISTER, EUGENEIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 02/04/2026
MCGREGOR, WILLIAMIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 02/04/2026
MILBURN, MIKEIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 02/04/2026
THAYER, EUGENEIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 02/04/2026
MOSS ADAMS LLPOrganizationADP OF THE SNFsince 01/01/2024

CMS files one row per role, so the 40 rows in the source record cover these 28 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.

2 organizational owners 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 275158. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-20, 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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