Hot Springs Health & Rehabilitation Center
600 1st Ave N, Hot Springs, MT 59845 · For profit - Corporation · 40 certified beds · (406) 741-2992 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- 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
- it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2023
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (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 (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $22,614 in federal fines (most recent 2023-12-07)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 22.6% | 18.7% | 15.4% | worse |
| Long-stay residents who lose too much weight | 7.5% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.6% | 2.1% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 2.9% | 2.0% | better |
| Long-stay residents with depressive symptoms | 3.0% | 5.6% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.6% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 9.9% | 4.4% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 20.3% | 17.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 9.0% | 15.8% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 96.8% | 93.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.5% | 6.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 21.0% | 24.1% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.1% | 20.4% | 17.1% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.34 | 1.38 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 4.07 | 2.16 | 1.80 | worse |
‡ 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.
Therapy staffing: this home’s payroll records show 0.29 therapist hours per resident per day in 2026Q1 — more than 45% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 9% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.7%CMS range 5.7–15.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not 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 discharge | not 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 discharge | not 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 identified | not 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 setting | not 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 discharge | not 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 stay | not 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 worsened | not 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 hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.01 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 40 beds and averages 30.7 residents a day — about 77% occupied, or roughly 9 beds typically open. It usually has some room. 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 2.70 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.94 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.58 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 2.41 hrs/resident/day on weekends vs 2.82 on weekdays — 14% thinner on weekends. RN hours go from 1.04 to 0.70 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 45% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
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.
23 citations, most serious first. The 12 most serious are shown; the remaining 11 are one tap away and print in full.
- Actual harm · G2023-12-07 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to properly identify, document, and implement physicians' orders and appropriate interventions to treat the resident's conditions in a timely manner. This included a skin condition on the entire buttocks of a resident, which was found to be related to sepsis and UTI due to incontinence, and required IV antibiotics and catheter placement during hospitalization for 1 (#32) of 15 sampled residents. Findings include: During an interview on 12/5/23 at 8:12 a.m., NF1 stated they had concerns for resident #32 from a hospital stay with high blood sugar and burns on her buttocks from sitting in soiled briefs and then discharged AMA to another facility and passed away. During an interview on 12/6/23 at 11:09 a.m., staff member B stated resident #32 had a long history of behaviors, including during blood sugar checks. The blood sugar checks were discontinued because of the behaviors, and resident #32 was no longer taking insulin. Staff member B stated resident #32'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.
- Actual harm · G2023-12-07 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide scheduled medication, as ordered by the physician, to 1 (#26) of 15 sampled residents. This deficient practice resulted in undue physical symptoms for the resident. Findings include: During an interview on 12/4/23 at 1:18 p.m., resident #26 stated, They (the facility) ran out of my nausea medication on Sunday, and I didn't get any until Friday. I went through such withdrawals; I was so sick and all they said was it was on order day after day. I had hot and cold sweats, puked for days and that's not right. Review of resident #26's medication administration record showed Promethazine HCl Tablet 25 MG was not given on 11/27/23 through 12/1/23 for the following times: -11/27/23 9:00 a.m.: OO=On Order from Pharmacy -11/27/23 8:00 p.m.: OO=On Order from Pharmacy -11/28/23 9:00 a.m.: OO=On Order from Pharmacy -11/29/23 9:00 a.m.: OO=On Order from Pharmacy -11/30/23 9:00 a.m.: OO=On Order from Pharmacy -12/1/23 9:00 a.m.: OO=On Order from Pharmacy During an interview on 12/6/23 at 8:34 a.m., staff member B stated if…
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.
- Potential for harm · Ecited before2026-02-10 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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 interview and record review, the facility failed to develop comprehensive care plans that included resident-specific care items and or accurate levels of care required for ADLs for 4 (#s 2, 11, 22, and 28) of 19 sampled residents. The deficient practice placed residents at risk for unmet care needs and at risk for not maintaining their highest practicable level. Findings include:During an interview on 2/9/26 at 8:08 a.m., staff member A stated the facility followed the RAI manual as the care planning policy. Staff member A stated he wasn't sure why some CAAs were not on the care plan.During an interview on 2/9/26 at 10:38 a.m., staff member A stated they are following the new objectives on cutting down on care plans. During an interview on 2/9/26 at 11:52 a.m., staff member C stated the IDT is involved in care planning, but any nurse can update a care plan as necessary. The care plans are updated as individual needs come up for the residents.During an interview on 2/9/26 at 2:26 p.m., staff member A stated he would expect to see the individual needs of a resident on 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.
- Potential for harm · D2026-02-10 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to maintain a clean bathroom for the resident(s) to use for 1 (#5) of 19 sampled residents. This deficient practice caused the facility to be odorous of urine. Findings include:During an observation on 2/7/26 at 12:39 p.m., the bathroom located outside of resident #5's room had a urine odor. There was what appeared to be urine built up at the base of the toilet. When wiped with a dry white cloth, the cloth became soiled with urine. During an observation on 2/8/26 at 8:20 a.m., the bathroom near resident #5's room smelled of urine, and there was what appeared to be urine built up around the base of the toilet. There was a toilet riser over the toilet, and the lid to the toilet tank was missing. When a paper towel was used to wipe the spot of urine in front of the toilet, the paper towel became soiled with urine.During an observation on 2/8/26 at 10:27 a.m., staff member J was cleaning the bathroom next to resident #5's room. During an observation on 2/8/26 at 11:11 a.m., the bathroom next to resident #5's room…
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.
- Potential for harm · D2026-02-10 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
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 assess a resident for the risk of entrapment from bed rails and failed to obtain consent from the resident's POA, prior to installation of grab bars for 1 (#38) of 19 sampled residents. The deficient practice had the potential to cause an entrapment risk for the resident. Findings include:During an observation on 2/8/26 at 1:11 p.m., resident #38 was sleeping in his wheelchair, in his room, next to his bed. His bed was noted to have two bed rails/grab bars, one on each side of his bed.During an interview on 2/8/26 at 2:56 p.m., staff member A stated resident #38 should not have had bed rails, they were mounted to his bed and should not have been. Staff member A further stated that both bed rails had been removed.During an observation on 2/9/26 at 10:45 a.m., resident #38 was sitting in his wheelchair watching tv and there was a bed rail up on the room door side of the bed.During an interview on 2/9/26 at 10:51 a.m., staff member E stated he had only removed the bed rail on the window side of the bed.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.
- Potential for harm · F2024-12-19 · tag F0657 — failed to keep the care plan current — widespreadDevelop 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 and maintain current individualized care plans, to include when a change to the resident's care occurred, for activity preferences, or ensure staff were aware of how to use/find the individualized comprehensive care plans for use, for 6 (#s 1, 3, 6, 10, 20, and 22) of 19 sampled residents. Findings include: 1. During an interview on 12/17/24 at 2:56 p.m., staff member B said she had been at the facility for 14 years, and resident #1's behaviors and care had not changed. Staff member B said all resident care plans were accurate for the residents. Record Review of resident #1's comprehensive care plan showed an admission date of 11/16/2007. Resident #1 had multiple diagnoses identified, including severe intellectual disabilities, bipolar disorder, conduct disorder, unspecified psychosis, unidentified mood disorder, anxiety disorder, and moderate dementia with behavioral disturbance(s). Resident #1 was care planned for behavior of hitting, kicking, scratching, and resistant to cares, with an initiation…
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.
- Potential for harm · F2024-12-19 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 followed safe food handling practices and ensure staff used proper hair and beard coverings while meals were prepared and served, which may affect any resident receiving meals or meal services from the staff or kitchen. Findings include: During an observation on 12/17/24 at 12:03 p.m., staff member N had a goatee, which was not covered with a beard net, while N was cooking at the stove. Staff member F was working in the kitchen during meal service, installing new equipment, with no hairnet and beard net. Staff member F had long hair, and a long, full beard. During an observation and interview on 12/17/24 at 12:18 p.m., staff member N was plating resident lunch trays without a beard cover in place. Staff member N said he was to be wearing a beard cover when in the kitchen. Record review of a facility policy, Personal Hygiene Standards, updated June 2021, showed: .a. Hair restraining devices (e.g. hair nets), covering all hair, are worn while on duty. Hair restraining devices are provided 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.
- Potential for harm · F2024-12-19 · tag F0837 — widespreadEstablish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility governing body failed to ensure the facility implemented and operationalized policies and procedures related to Advance Directives, PASARR Screenings, Care Plans, and Accidents/Hazards. This failure increased the risk of any resident in the facility being negatively affected due to the lack policies and procedures. Surveyors identified deficient practices for resident #s (6, 20, 30, and 32.) of 19 residents sampled, and for these specific residents, the facility did not have policies or procedures for the facility or staff to utilize. Findings include: A review of the policies and procedures during the recertification survey, showed the facility failed to develop and operationalize polices for Advance Directives, PASARR Level One and Two screenings, Care planning, and Accidents and Hazards. Advance Directives: During a review of resident #30's POLST, it was found resident #30 had not dated the form, and the physician did not date the form. During an interview on 12/18/24 at 8:44 a.m., staff member B stated the POLST forms are…
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.
- Potential for harm · F2024-12-19 · tag F0867 — failed to act on quality-improvement findings — widespreadSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to take actions aimed at performance improvement, and after implementing those actions, measure its success, and track performance to ensure that improvements were realized and sustained: failed to identify and develope policies and procedures that direct staff on resident care expectations. This deficient practice had the potential to affect all residents within the facility who required complete medical records for medical review, residents who fall, residents who were cared for without accurate comprehensive care plans, and staff direction for resident care. Findings include: During an interview on 12/18/24 at 8:44 a.m., staff member B said the facility did not have the requested policies and procedures to provide the surveyors. Policies and procedures requested; Advance Directives Policy, PASARR Level I and Level II Policy, Care Plan Policy, Significant Change Policy, and a Call Light Safety Policy. During an interview and record review, on 12/19/24 at 9:11 a.m., staff member B stated the facility did not have any active…
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.
- Potential for harm · E2024-12-19 · tag F0578 — failed to honor advance directives / code status — patternHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to ensure advanced directives were complete for 4 (#s 1, 9, 16, and 30) of 19 sampled residents. This deficiency increased the risk of of the resident's wishes not being met or followed. Findings include: Review of resident #1's POLST, dated 7/8/21, showed a verbal consent by resident #1's guardian. No physical signature by the guardian was present on the form. During a review of resident #9's POLST, dated 4/11/17, showed the physician failed to date the document or complete the provider contact information. During a review of resident #16's POLST, dated 8/25/22, it was found the physician failed to complete the sections labeled, Printed Name of Physician, Date and Time, and Provider Phone Number. During a review of resident #30's POLST, it was found resident #30 had not dated the form, and the physician did not date the form. During an interview on 12/18/24 at 8:44 a.m., staff member B stated the POLST forms are required to be fully completed, including dates. Staff member B stated the facility did not have an Advanced…
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.
- Potential for harm · E2024-12-19 · tag F0711 — patternEnsure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
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 physician failed to document resident assessments or physician visits for 4 (#s 1, 4, 6, and 20) of 19 sampled residents. This failure increased the risk of others not having the pertinent medical information available, when needed, to address resident care needs. Findings include: 1. A request was made on 12/17/24 for resident #1's current history and physical. A hospital admission physical, dated 5/5/14, was provided. No current history and physical for resident #1 was located in the resident's electronic medical record. 2. A request was made on 12/17/24 for resident #4's current history and physical, no current history and physical was located in the electronic medical record, or provided by the facility. 3. Review of resident #20's EHR reflected no history and physical had been completed by the physician. Resident #20 was admitted to the facility on [DATE]. A request for the most recent history and physical completed for resident #20 was made, but nothing…
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.
- Potential for harm · E2024-12-19 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility staff failed to remove expired medications, and allowed the expired items to remain in the same location as the unexpired medications, which increased the risk of misuse. Findings include: During an observation on 12/19/24 at 8:48 a.m., there were the following expired medications located in the facility stock medication cupboard: - Two bottles of Magnesium Chloride, expiration date of 9/2024, - Three bottles of Ferrous Gluconate, expiration date of 5/2024, - One bottle of Iron 27 mg, expiration date of 4/2024, - Three bottles of Meclizine, expiration date of 7/2024, - One bottle of COQ10, expiration date of 8/2024, and - One bottle of Senna Plus, expiration date of 9/2024. During an interview on 12/19/24 at 8:50 a.m., staff member K stated the process of checking on expiration dates and removing medication was supposed to be done by pharmacy as they maintained the medication supply.
Show the remaining 11 citations
- Potential for harm · D2024-12-19 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — the official record, unedited, may be distressing
Based on interviews and record review, the facility failed to complete a PASARR level I or II for 1 (#6) of 19 sampled residents. Findings include: Review of resident #6's EHR reflected no PASARR Level I or II was completed. During an interview on 12/18/24 at 12:10 p.m., staff member B stated resident #6 did not have a PASARR Level I or II since admission to the facility. Staff member B stated she did not know why a PASARR I had not been completed, but one was being completed now. Staff member B stated the facility did not have a policy regarding PASARR Level I's or II's. During an interview on 12/18/24 at 3:23 p.m., NF1 stated when a resident transferred from one nursing facility to another, the new facility should complete their own PASARR Level I, no later than the day of admission, to determine if they are able to provide the resident the services needed.
- Potential for harm · Dcited before2024-12-19 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to implement a comprehensive, resident centered care plan, which identified the resident's physical and psychological needs and wishes, for 1 (#32) of 19 sampled residents. Findings include: During an interview on 12/18/24 at 8:44 a.m., staff member B stated the facility did not have a care plan policy or a significant change policy, and the facility followed the RAI manual. Review of resident #32's electronic medical record showed an admission date of 11/12/24. Review of resident #32's care plan showed a baseline care plan was initiated on 11/12/24, with revisions made on 11/15/24. No comprehensive care plan had been developed following the resident's admission.
- Potential for harm · D2024-12-19 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 observations and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living for oral care received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene, for 1 (#10) of 19 sampled residents. Findings include: During an observation and interview on 12/17/24 at 3:10 p.m., resident #10 had no dentures in his mouth and stated the dentures were still over on the sink. Resident #10 stated, No one gave them to me or put glue on them, so I haven't had them in today. During an observation and interview on 12/18/24 at 10:11 a.m., resident #10 stated, They (CNAs) haven't put them in yet, they are still on the sink, just need some glue, and (to) give them to me. During an interview on 12/18/24 at 10:20 a.m., staff member H stated the CNAs often did not put his dentures in for a few days to allow his mouth to rest, so he did not get a mouth sore. Staff member H stated the nurse made the decision on who and when residents got dentures. Staff member H stated she was not aware no one had put 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.
- Potential for harm · D2024-12-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 and interviews, the facility failed to ensure a resident's environment was addressed for safety related to hazards, and the resident had dementia, and misused the call light/cord, and a staff member reported a concern related to the resident's use of a pillow, for 1 (#20) of 19 sampled residents. Findings include: During an observation on 12/17/24 at 1:19 p.m., resident #20 was lying half on the bed, and her feet and legs were off the bed, and her head was lying against the wall. Staff member J assisted resident #20 back into the bed and offered to get the resident up, but she didn't want up. Resident #20 was mumbling, but her words were not clear and comprehensable. Resident #20 was grabbing the call light and wrapping it across her body and her head. Staff member J stated resident #20 had a severe decline over the past couple of months, and the resident was sleeping most of the time, not walking the halls as she had prior. Resident #20 continued to grab the call light cord, mumbling loudly. During an observation and interview on 12/17/24 at 1:27 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.
- Potential for harm · D2024-03-26 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, facility staff failed to ensure a resident's medical condition remained confidential for 1 (#1) of 5 sampled residents. Findings include: During an interview on 3/25/24 at 2:53 p.m., NF1 (not employed by the facility) stated she had seen resident #1's right foot on or about 3/6/24, the day after the resident fell and noticed it was swollen. NF1 alerted a staff member. NF1 stated I have broken my foot before, and I told the staff member (about resident #1) I'll bet it's broke. During an interview on 3/25/24 at 3:14 p.m., NF1 stated an x-ray was done on resident #1, and the next time she came to the facility [Staff member C] told her that there was a fracture to resident #1's foot. During an interview on 3/25/24 at 10:51 a.m., staff member C stated she was informed during shift report resident #1 had a fracture to her foot and she might have told NF1 resident #1 had a fracture. During an interview on 3/26/24 at 11:45 a.m., NF2 stated I don't want [NF1] told things about [Resident #1's] conditions. During an interview on 3/26/24 at 12:27 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.
- Potential for harm · E2023-12-07 · tag F0880 — failed to prevent and control infections — patternProvide 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 medication administration for 4 (#s 9, 26, 29, and 31) of 15 sampled residents; and failed to dispose of a moldy, rotten pumpkin, resulting in foul odor and a dusty fly covered fly tape trap in the common area. Findings include: 1. During an observation on 12/4/23 at 2:16 p.m., staff member I administered medications to resident #26. Staff member I did not use hand hygiene before or after administering the medications. During an observation on 12/4/23 at 3:26 p.m., staff member I administered medications to resident #29. Staff member I did not use hand hygiene before or after administering the medications. During an observation on 12/4/23 at 3:33 p.m., staff member I administered a medication to resident #31. Staff member I did not use hand hygiene before administering the medication. During an interview on 12/4/23 at 3:45 p.m., staff member I stated staff were to wash their hands if they were soiled, otherwise they can use antibacterial gel. Staff member I…
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.
- Potential for harm · D2023-12-07 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, facility staff failed to respect the dignity of residents when they were talking about them at the nursing station, and a resident overheard them and filed a grievance, for 1 (#24) if 15 sampled residents, and this had the potential to affect others. Findings include: Review of the grievance by resident #24 showed the grievance was received on 9/25/23 at 6:45 a.m., and: - the grievance reported was, 9/22 or 9/23 around 0200 (2:00 a.m.) I heard [staff members P and O] talking from the nurses' desk, negatively about other staff and residents. I am mad . - the grievance investigation showed, .upon returning to his room [resident #24] was able to hear the staff's conversation. Interviewed other residents and all denied staff talking too loudly at night. - action taken as, Spoke with [staff members P and O] reminded them to make sure conversations at the nurses' station are appropriate and to maintain a quiet environment during noc shift . Signed and dated on 9/27/23 by staff member B. - findings were confirmed as, Staff were talking too loudly…
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.
- Potential for harm · D2023-12-07 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to notify the physician of medication errors for 1 (#26) of 15 sampled residents. Findings include: During an interview on 12/4/23 at 1:18 p.m., resident #26 stated, They (the facility) ran out of my nausea medication on Sunday, and I didn't get any until Friday. I went through such withdrawals, I was so sick and all they said was it was on order day after day. I had hot and cold sweats, puked for days and that's not right. Review of resident #26's medication administration record showed Promethazine HCl Tablet 25 MG was not given on 11/27/23 through 12/1/23 for the followiong times: 11/27/23 9 a.m.: OO=On Order from Pharmacy 11/27/23 8 p.m.: OO=On Order from Pharmacy 11/28/23 9 a.m.: OO=On Order from Pharmacy 11/29/23 9 a.m.: OO=On Order from Pharmacy 11/30/23 9 a.m.: OO=On Order from Pharmacy 12/1/23 9 a.m.: OO=On Order from Pharmacy During an interview on 12/6/23 at 8:34 a.m., staff member B stated if medication ran out, the nurse should have called the pharmacy and obtained the medication from the Cubex, if possible. If…
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.
- Potential for harm · D2023-12-07 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from verbal abuse by staff for 1 (#12) of 15 sampled residents, resulting in the resident feeling scared. Findings include: During an observation and interview on 12/4/23 at 1:14 p.m., resident #12 stated she felt she did not get along with staff member K, who worked nights and handed out the resident's medications. Resident #12 stated the night before last, staff member K went into her room and yelled at the resident, saying the resident needed to always have a light on in her room, even at 2:00 a.m., because her room was always rearranged, and she could fall trying to give her medications. Resident #12 stated staff member K then yanked on the light string so hard, it broke off. Resident #12 stated, [Staff member K] scared me to death, and I have been scared of her ever since. Resident #12 stated, [Staff member K] told me I am way too emotional. Resident #12 also stated staff member J came into her room, when she was using a bell in place of the call light because she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-07 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 an allegation of verbal abuse from staff to resident, during the appropriate time frame, for 1 (#12) of 15 sampled residents. Findings include: During an interview on 12/4/23 at 1:14 p.m., resident #12 stated there was an incident with staff member K where the resident felt 'scared to death' after the staff member yelled at her and broke her light string. Resident #12 also stated staff member K told the resident she was, .way too emotional. Resident #12 stated she had feared staff member K ever since. Resident #12 also stated staff member J yelled at her that night for using a bell to get someone's attention when she had been waiting a while for assistance to the bathroom. Resident #12 stated she reported this incident to staff member I, who then reported it to staff member G. During an interview on 12/4/23 at 3:16 p.m., staff member I stated resident #12 reported a staff member yelled at the resident for using a call bell. Staff member I stated resident #12 told untrue stories in the past, so the staff member did…
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.
- Potential for harm · D2023-12-07 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
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 provide an ongoing activities program, meeting the individual needs of the resident, for 1 (#26) of 15 sampled residents. Findings include: During an interview on 12/4/23 at 1:18 p.m., resident #26 stated, The activity calendar is a fraud, bingo every once in a while, no cart or station is brought around to us, activities gal is never here after 4:00 p.m., and the activity director was gone the first two weeks of November so none of that (activities on the calendar) happened. I reported all of this to the Ombudsman too. Most of the stuff on the calendar isn't an activity anyway, it's stuff that is her job. Resident #26 stated she had not had any visitors for 1:1 visits since she had been at the facility. Resident #26 stated she attended resident council several times and had made recommendations for activities she would enjoy, including, . latch hook and adult craft projects, not the kid stuff they have here (the facility). It's just sad…
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.
“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.
- 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.
Fines & penalties
$22,614 in federal fines across 1 penalty.
- $22,614 — penalty dated 2023-12-07
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to EVERGREEN HEALTHCARE GROUP — 44 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.5 | +1.5 vs chain |
| Health inspection | 4 of 5 | 2.4 | +1.6 vs chain |
| Staffing | 4 of 5 | 3.3 | +0.7 vs chain |
| Quality measures | 2 of 5 | 3.0 | -1.0 vs chain |
The other 43 homes this chain runs (chain average 2.5★, per CMS)
Showing 40 of 43; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| PACIFIC NORTHWEST 12 LEASED OPERATIONS HOLDINGS LLC | Organization | DIRECT OWNERSHIP INTEREST | since 08/31/2023 |
| CH PNW 12 HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 08/31/2023 |
| WITZCORP PNW 12 LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 08/31/2023 |
| HERZKA, YISROEL | Individual | INDIRECT OWNERSHIP INTEREST | since 08/31/2023 |
| YENOWITZ, YITZCHOK | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/31/2023 |
| MONTANA ASSOCIATES, LLC | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | since 06/17/2025 |
| CHEEKS, DONALD | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/31/2023 |
| HOHN, JAMES | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 08/31/2023 |
| COUVE FINANCIAL SERVICES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/28/2025 |
| COUVE HEALTHCARE CONSULTING LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/08/2025 |
| PNW 12 OPCO MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/08/2025 |
| PNW 12 SNF CONSULTING LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/08/2025 |
| HARLOW, WILLIAM | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/31/2023 |
| HOVET, HETHAR | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/31/2023 |
| SPIELMAN, SHIMON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/31/2023 |
CMS files one row per role, so the 28 rows in the source record cover these 15 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.
8 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.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 88% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $71K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MT
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.
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 275069. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-10, 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.