Valle Vista Rehabilitation And Nursing LLC
402 Summit Ave, Lewistown, MT 59457 · For profit - Limited Liability company · 101 certified beds · (406) 538-8775 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 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 improved from 3 to 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 9.9% | 18.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 7.6% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.4% | 2.1% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.5% | 2.9% | 2.0% | better |
| Long-stay residents with depressive symptoms | 5.3% | 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 | 2.1% | 4.4% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 11.9% | 17.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 17.0% | 15.8% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 95.9% | 93.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.2% | 6.3% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 31.7% | 24.1% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 21.6% | 20.4% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 97.6% | 73.8% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 12.7% | 19.2% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 3.5% | 14.5% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.35 | 1.38 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.46 | 2.16 | 1.80 | 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.
42.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 41 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.03 therapist hours per resident per day in 2026Q1 — more than 1% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 20% 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 | 42.6%CMS range 28.2–53.6 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.8%CMS range 6.2–15.7 | 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 | 90.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care 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 | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 0.55 | 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 101 beds and averages 53.3 residents a day — about 53% occupied, or roughly 48 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.15 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.71 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.32 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 2.46 hrs/resident/day on weekends vs 3.43 on weekdays — 28% thinner on weekends — a notable drop. RN hours go from 0.80 to 0.49 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 42% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.
- Actual harm · G2026-07-02 · 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
Based on observation, interview, and record review, the facility failed to provide the necessary care and services to evaluate, monitor, and manage a chronic scalp lesion/wound despite changes in the wound condition, including documented drainage; and failed to ensure timely wound management prior to and following the identification of a maggot infestation1 for 1 (#3) of 7 sampled residents. This deficient practice resulted in a decline of the resident's scalp lesion/wound condition and the development of maggot infestation1 requiring additional wound management and evaluation. Findings include:During an observation and interview on 6/30/26 at 2:50 p.m., resident #3 was observed with multiple, black-colored lesions on the scalp. A large central lesion approximately the size of a tennis ball was observed on the scalp. The lesion was black in color and partially covered with a brown-colored material. Yellowish, foul-smelling fluid was present. Resident #3's hair surrounding the lesions was discolored and had crusted, dried material present. Resident #3 stated she had one 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.
- Potential for harm · Fcited before2026-07-02 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 Enhanced Barrier Precautions (EBP) were identified and initiated, including ensuring appropriate signage was posted and personal protective equipment (PPE) was readily accessible at the point of care for 4 (#s 1, 2, 3, and 7) of 7 sampled residents who either had wounds or an indwelling foley catheter; and the facility failed to ensure hand hygiene was completed in accordance with the Centers of Disease Control and Prevention (CDC) recommendations during the distribution of clean linen for 3 (#s 5, 6, and 7) of 7 sampled residents. These deficient practices had the potential to increase the transmission of infection throughout the facility. Findings include:1. Review of a facility document titled Residents on EBP, showed resident #1 had a wound, resident #2 had a wound and an indwelling foley catheter, resident 3 had a skin lesion, and resident #7 had a wound requiring enhanced barrier precautions.During an observation on 6/30/26 at 2:40 p.m., resident #3 had no enhanced barrier precautions signage…
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 · D2026-07-02 · 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 observation, interview, and record review, the facility failed to notify the physician of a significant change in condition related to a chronic scalp lesion/wound, including new onset of drainage, for 1 (#3) of 7 sampled residents. This deficient practice resulted in the physician not being provided with timely information about a change in the resident's condition necessary to evaluate the need for additional assessment, treatment, or intervention. Findings include:During an observation on 6/30/26 at 2:50 p.m., resident #3 had a scalp lesion/wound with black discoloration, drainage, and a foul odor.Review of resident #3's weekly skin assessments dated 11/23/25, 11/30/25, and 12/7/25 showed there was documented drainage from the resident's scalp lesion/wound.Review of resident #3's nursing progress notes dated 11/23/25-12/9/25 showed no documentation that the physician was notified of the change in condition related to the development of drainage from the scalp lesion/wound.During an interview on 6/30/26 at 4:01 p.m., staff member C stated the physician should be notified…
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 · D2026-07-02 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure comprehensive wound assessment, monitoring, and documentation of a chronic scalp lesion/wound in accordance with accepted standards of nursing practice, including complete documentation of wound characteristics including size, shape, color, and drainage for 1 (#3) of 7 sampled residents. This deficient practice limited the ability to accurately monitor and evaluate changes in the resident's chronic scalp lesion/wound, identify changes in lesion/wound status, and determine when additional clinical evaluation or intervention was required. Findings include:Review of resident #3's weekly skin assessments dated 6/2/25-6/29/25, and 11/2/25-11/16/25, showed no documentation of the resident's chronic scalp lesion/wound.Review of resident #3's weekly skin assessment dated [DATE]-[DATE], and 12/14/25-6/14/26, showed the presence of a scalp lesion/wound. There was no documentation describing the scalp lesion/wound characteristics, including shape, size,…
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 · D2026-07-02 · tag F0710 — isolatedObtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
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 physician supervision and ongoing clinical oversight following notification of a significant change in condition involving a maggot-infested scalp wound for 1 (#3) of 7 sampled residents. There was no documented physician assessment or reassessment of the resident's condition or additional clinical guidance to address the significant change in condition while the resident awaited outpatient surgical evaluation. Findings include:During an observation and interview on 6/30/26 at 2:50 p.m., resident #3 had multiple black-colored skin lesions on her scalp. Resident #3 had a large central lesion about the size of a tennis ball, black in color, and was partially covered with a brown-colored material. There was a yellowish, foul-smelling fluid present. During an interview on 6/30/26 at 3:05 p.m. NF1 and NF2 stated resident #3 was admitted to the facility with the skin lesion. NF1 stated [Staff Member D] was aware of the lesion upon admission but only sees [Resident #3] on occasion. NF1 stated the lesion…
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 · Dcited before2026-07-02 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to maintain complete and accurate medical records by failing to ensure the resident's medical record accurately reflected the presence, characteristics, and changes in a scalp lesion/wound for 1 (#3) of 7 sampled residents. This deficient practice resulted in an incomplete medical record that did not accurately reflect the resident's condition or provide a complete picture of the wound status, or care provided.Review of resident #3's weekly skin assessments dated 6/2/25- 6/29/25 and 11/2/25-11/16/25, showed no documentation of the resident's chronic scalp lesion/wound.Review of resident #3's weekly skin assessments dated 7/6/25-9/28/25 and 12/14/25-6/14/26, showed documentation of the presence of a scalp lesion/wound, but the record did not include complete documentation of the lesion/wound characteristics, including size, shape, color, and drainage characteristics.Review of resident #3's electronic medical record dated 6/12/26 showed no documentation that a comprehensive assessment of the chronic scalp lesion/wound 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.
- Potential for harm · Fcited before2026-06-04 · 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 and interview, the facility failed to ensure staff follow safe food labeling and storage processes in accordance with standards for food service safety and failed to maintain sanitary conditions, including employee hygiene. These deficient practices affected all residents receiving food services from the facility's kitchen and dietary staff, and the deficient practices would continue if not addressed. Findings include: 1. During an observation and interview of the kitchen, on 6/1/26 at 11:42 a.m., the following conditions were present:- The maroon cereal bowls were stored upright in a bus tub. Staff member W said the bowls should be turned over when stored so stuff does not fall into the bowl.- Four large metal bowls were observed sitting upright on wire shelves. - A large unlabeled tub of dried beans was noted near the stove. Staff member W identified the contents of the container as pinto beans. Staff member W said the beans should have been thrown away.- Two opened plastic squeeze bottle of Smucker's strawberry jam were on the shelf near the stove. The label…
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 · D2026-06-04 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised to accurately reflect individual resident-centered care needs for 3 (#s 4, 18, and 61) of 18 sampled residents. Findings include: 1. Review of resident #61's EHR, dated from admission on [DATE] to discharge on [DATE], showed the resident displayed frequent behaviors, which included refusing care, refusing to eat, refusing to use the call light, and yelling out for help for extended periods of time. The resident's refusals of care and yelling behavior continued throughout the resident's stay. The nursing notes showed the staff attempted to meet the resident's needs without a corresponding decrease in behaviors. During an interview on 6/1/26 at 12:30 p.m., NF4 stated resident #61 was admitted to the facility for strengthening physical therapy with a goal to return home with her spouse. NF4 stated he did not remember the facility discussing behavioral health services in an effort to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-04 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the interview and record review, the facility and staff failed to provide the necessary behavioral health services and oversight for a resident who displayed disruptive yelling, refusals of care, and verbal abuse toward staff regularly, and failed to document the resident's responsible party's refusal of behavioral health services. The medical record did not include evidence to show the facility consistently attempted to identify, trend, implement, monitor, or modify behavioral interventions consistently as the behaviors continued without change, to assist the resident with maintaining or improving her mental health and well-being, for 1 (#61) of 18 sampled residents. Due to these failures, the resident continued her disruptive yelling and refusals of care. Findings include:Review of resident #61's EHR, dated from 6/2/25 to 10/19/25, showed the resident displayed frequent behaviors, which included refusing care, refusing to eat, refusing to use call light, and yelling out for help for extended periods of time. Refusals of care and yelling behaviors continued to occur. 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 · Dcited before2025-11-21 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide a quadriplegic resident with a wheelchair after discharging and transferring him to an Adult Services Residential Program facility on the East coast and failed to document the transfer discharge of the resident in the medical record, for 1 (#2) of 4 sampled residents. This deficient practice resulted in a resident not having his main mode of locomotion. Findings include:During an interview on 11/5/25 at 8:00 a.m., NF3 stated when his ambulance service picked up resident #2, there was no wheelchair included in the resident's belongings that were to go with him on the transport to the Pennsylvania facility.During an interview on 11/5/25 at 8:32 a.m., staff member D stated having a wheelchair for mobility was important for resident #2 to get up to go to meals and sit at the nurses' station for extra supervision. During an interview on 11/5/25 at 8:59 a.m., NF5 stated he came to the facility a few days before resident #2 was to discharge to the Pennsylvania facility, to fit him for a new power wheelchair. NF5 stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-05-20 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 an adequate infection prevention and control program was maintained, to include appropriate cleaning of facility equipment, and an annual review of all policies and procedures including the facility's water management system and Legionella surveillance. This deficient practice increased the likelihood of residents acquiring a healthcare-associated communicable disease or infection in the facility. Findings include: During an observation and interview on 5/19/25 at 4:26 p.m. with staff member E, the North hallway common bathtub was observed during a tour of a shower room. The bathtub had multiple long streaks of dark, rust color stains on the sides and floor of the tub. The drain had dried dark brown sediment around it. The bathtub did not have signage or a cover which notified staff and residents it was not to be used. Staff member E stated she had not cleaned the North hallway bathtub in maybe five or six months. Staff member E stated the bathtub was not being used by residents. She stated the only…
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.
Show the remaining 14 citations
- Potential for harm · Ecited before2025-05-20 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to maintain complete medical records, including medical provider visit notes, for 4 (#s 2, 17, 23, and 32); and failed to ensure a resident's Provider Orders for Life-Sustaining Treatment (POLST) was signed by a medical provider for 1 (#33) of 15 sampled residents. Findings include: 1. Review of resident #2's electronic medical record, accessed 5/17/25 through 5/20/25, showed a lack of medical provider visit notes. Resident #2 was admitted to the facility in April of 2025. 2. Review of resident #17's electronic medical record, accessed 5/17/25 through 5/20/25, showed a lack of medical provider visit notes. Resident #17 was admitted to the facility in January of 2025. 3. Review of resident #23's electronic medical record, accessed 5/17/25 through 5/20/25, showed no medical provider visit notes. Resident #23 was admitted to the facility in February of 2025. 4. Review of resident #32's electronic medical record, accessed 5/17/25 through 5/20/25, showed no medical provider visit notes in resident #32's chart after December of…
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 · D2025-05-20 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure consent for the use of psychotropic medications was obtained prior to starting a psychotropic medication for 2 (#s 33 and 48) of 18 sampled and supplemental residents. Findings include: 1. Review of resident #48's physician order, dated 2/21/25, showed an order for citalopram hydrobromide, 10 mg, one tablet daily. The diagnosis associated with the order was, unspecified dementia, severe, with other behavioral disturbance. Review of resident #48's Informed Consent for Anti-depressant Medication Use, dated 2/24/25, showed, Note: All information must be explained, and consent obtained PRIOR to administering medication. The consent was signed by the resident's spouse on 2/24/25, after the medication was started. Review of resident #48's MAR, dated February of 2025, showed the first dose of citalopram hydrobromide, 10 mg, was given on 2/22/25, two days before the consent was completed. 2. Review of resident #48's physician order, dated 4/25/25, showed an order for sertraline HCl, 100 mg, one tablet daily. The diagnosis…
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 · D2025-05-20 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure as needed psychotropic medications were limited to 14 days, unless the rationale for continuing the medication was documented by a medical provider, for 2 (#s 33 and 48) of 18 sampled and supplemental residents. Findings include: 1. Review of resident #33's physician order, dated 1/7/25, showed an order for olanzapine, 5 mg, every six hours, as needed, for agitation or delusions related to vascular dementia and delusional disorders. The as needed order failed to include the 14 day duration for antipsychotic medications. Review of resident #33's medication regimen review, dated 1/9/25, showed no irregularities and failed to show the need to monitor the use of olanzapine after 1/21/25 (14 days). Review of resident #33's medication regimen review, dated 2/26/25, showed the pharmacist notified the attending physician about the as needed olanzapine order. The form showed, . CMS doesn't allow for PRN (as needed) antipsychotics for more than 14 days. Consider discontinuing this medication to comply with CMS guidelines. 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 · D2025-05-20 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 (#46) of 18 sampled and supplemental residents. This deficient practice increased the risk of allowing resident #46's further potential misappropriation of property when allegations were not reported and investigated with facility oversight. Findings include: Review of resident #46's electronic medical record showed an admission date of 1/8/25. Resident #46 had a diagnosis of [NAME] encephalopathy, with a family member as an appointed conservator. Review of resident #46's social services progress note, dated 3/6/25, showed involvement of an assigned APS investigator to investigate possible misappropriation of property, and IDT discussed the possible allegation. During an interview on 5/20/25 at 9:50 a.m., staff member C stated resident #46's conservator had been notified of a bill owed to [Facility - state…
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 · Dcited before2025-05-20 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to notify the resident and or the resident's representative, in writing, of the reason for transfer when transferring a resident to the hospital, for 1 (#23) of 15 sampled residents. Findings include: During an interview on 5/19/25 at 2:37 p.m., staff member B stated the facility did not have a transfer notice for resident #23's hospitalizations on 3/7/25 and 5/9/25. Staff member B stated the nurse on duty was responsible for completing the transfer notice prior to a resident's transfer to a hospital. Review of resident #23's electronic medical record failed to include a transfer notice for resident #23's facility-initiated transfer on 3/7/25 and 5/9/25. On 5/20/25 a request was made for a copy of resident #23's Notice of Transfer, for the 3/7/25 and 5/9/25 facility-initiated transfers. No documentation or records were received from the facility by the end of the survey. Review of the facility policy titled, Transfer and Discharge (including AMA) Policy, dated 4/11/25, showed: - . Policy Explanation and Compliance Guidelines:…
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 · D2025-05-20 · 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 — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan based on resident activity preferences and physical abilities, for 1 (#2) of 15 sampled residents. Findings include: During an observation on 5/17/25 at 12:15 p.m., resident #2 was lying in bed with the head of the bed elevated. The resident appeared to be sleeping. During an observation and interview on 5/18/25 at 8:00 a.m., resident #2 was lying in bed with the head of the bed elevated. The resident appeared awake and was wearing glasses, and the resident was staring forward at the television which was not turned on. Resident #2 stated she did not participate in activities because her vision was poor, and her hands did not work very well anymore. Resident #2 stated she had attended church service one time since she was admitted (4/17/25) to the facility. Resident #2 stated staff did not come into her room to do one-on-one visits and have never offered her activities or other things to do in her room. Resident #2 stated she would have liked staff to come into…
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 · D2025-05-20 · 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 a resident with group and individual activities to meet the resident's interests, and support their physical, mental, and psychosocial well-being for 1 (#2) of 15 sampled residents. Findings include: During an observation and interview on 5/18/25 at 8:00 a.m., resident #2 was lying in bed with the head of the bed elevated. The resident appeared awake wearing glasses staring forward at the television which was not turned on. Resident #2 stated she did not participate in activities because her vision was poor, and her hands did not work very well anymore. Resident #2 stated she had attended church service one time since she was admitted (4/17/25) to the facility. Resident #2 stated staff did not come into her room, to offer and complete one-on-one visits, and they have never offered her things to do in her room to stay busy. Resident #2 stated she would have liked staff to come into her room and visit with her since she was in 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.
- Potential for harm · Fcited before2024-08-28 · 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 maintain the kitchen in a sanitary and clean condition. This had the potential to effect all residents in the facility who consumed food or services from the kitchen. Findings include: During an observation of the kitchen, on 8/28/24 at 10:23 a.m., the following was found: - Corners of the kitchen floor: had white debris resembling crumbs - Underneath the shelves there was white, tan, and brown debris resembling crumbs and dirt - Underneath the workspace, next to the stove, there were white and tan debris resembling crumbs and food particles - At the edge of the floor where the mop boards meet the floor was a dark brown substance. During an interview on 8/28/24 at 1:19 p.m., staff member G stated employees on shift were the ones who did the cleaning. Staff member G stated there was a list of tasks, and the checklist needed to be completed by the employee doing the cleaning. Staff member G stated he was requiring the checklist to be done weekly, but it was not getting checked off, so he switched to daily…
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 · F2024-05-21 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interviews, the facility failed to have a certified person to serve as the director of food and nutrition services. This practice had the potential to affect all residents who receive food from the kitchen. Findings include: During an interview on 5/18/24 at 4:20 p.m., staff member C stated, I've been here six months and had to pull a lot of shifts, so I haven't had any orientation or training. I was supposed to have training, but [staff member G] had a car accident, and I never got any training. I've had zero training. I heard about dietary courses I need to do, but just planning on doing the ServSafe course. I'm not signed up to do any courses as of now. During an interview on 5/19/24 at 12:05 p.m., staff member C stated he took over the position in November, and had no corporate training or oversight. Staff member C stated the dietician was available by phone for substitution changes for approval, but she does not supervise or oversee him in the kitchen. During an interview on 5/19/24 at 4:40 p.m., Staff member A stated he did not have any specific…
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 · Fcited before2024-05-21 · 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 observations, interviews, and record review, the facility failed to ensure: food was stored and prepared in a clean kitchen; staff wore beard nets and hair nets appropriately; and dated and labeled open food items. These practices had the potential to affect all residents who received food from the kitchen. Findings include: During an observation on 5/18/24 at 1:40 p.m., upon entrance into the kitchen, staff member D stated the kitchen did not have any hairnets or beard nets available. Staff member D looked through the shelf next to the door and the cabinets and found no hairnets. Staff member E entered the kitchen wearing a baseball cap and no hairnet. Staff member E had a ponytail hanging down from his neckline to his mid-back. Staff member E stated he only ever wore a baseball cap and no hairnet. Signage on the door of the kitchen stated no one could enter the kitchen without a hairnet. Staff member D stated the yellow square on the floor of the entry reflected the limit of entry into the kitchen, without a hairnet. During an observation on 5/18/24 at 1:45 p.m., 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 · E2024-05-21 · 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 — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility failed to remove and dispose of expired medications and medical supplies in one medication room and one treatment room. These failures increased the risk of expired medications and medical supplies being used for any resident at the facility. Findings include: During an observation on 5/19/24 at 8:20 a.m., with staff member B, the following items were found in the medication room: - Coaguchek XS PT test strips, exp. 9/30/22, two bottles, - Glucose control solution set, exp. 1-11-24, one set, - 0.9% sodium chloride injection solution, exp. 1-1-2024, four bottles, - Red top blood collection tube, exp. 3/31/24, one tube, - Monoject standard 25-gauge hypodermic needles, exp. 4-2020, one box of 100, and - Monoject standard 18-gauge hypodermic needles, exp. 4-2020, one box of 25. During an observation on 5/20/24 at 3:40 p.m., with staff member B present, the following items were found in the treatment room: - Red rubber foley catheters 14FR, exp. 8/28/23, 10 catheters, - Self-Cath 14FR, exp. 1/30/23, 1 catheter, - Coude Foley catheter…
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 · E2024-05-21 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure 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 and interviews, the facility failed to provide palatable food at an appetizing temperature for 3, (#s 31, 38, and 200) of 23 sampled residents. Findings include: During an observation and interview on 5/18/24 at 4:02 p.m., resident #200 stated the food was, .not so good, they can't cook and it's always cold. During an observation and interview on 5/19/24 at 9:35 a.m., staff member C temperature checked the following foods on the cart on west hall: - eggs: 116.3 degrees F, - hashbrowns: 107.8 degrees F, - cream of wheat: 112.7degrees F. During an observation on 5/20/24 at 12:31 p.m., staff member C temperature checked the steam table on the south hall and found the steam table was not plugged in. Staff member C instructed the servers to plug in the steam table so food will stay hot. During an observation on 5/20/24 at 12:40 p.m., the steam table was moved to the south dining hall. Staff member C checked the temperature of the minced dish and found the temperature to be 110 degrees F. Staff member C noted the steam table was plugged in but not turned on. Staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-05-22 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility staff failed adhere to infection control practices by not performing hand hygiene after touching dirty surfaces during meal service, touching dirty surfaces after completing hand hygeine, and not wearing gloves while serving meals. This deficient practice caused an increased risk for the spread of infection and cross-contamination to all residents which ate in the north and south dining rooms, and lived on the south hallway. Findings include: 1. During an observation on 5/21/23 at 12:37 p.m., dietary staff were leaving the south dining room with the steam table. Staff pushed the steam table down the hallway to the north dining room. Once the steam table was in place in the north dining room, dietary staff started to serve the lunch meal. No hand hygiene was completed before the staff started to serve the meal. Staff member G began to set up resident meal trays. Staff member G grabbed resident drinks, silverware, and dessert and placed them on the serving tray. Staff member G touched a cart handle and a cupboard. Staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-05-22 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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 observation, interview, and record review, the facility staff failed to treat residents with dignity, by not assisting residents with personal hygiene tasks (shaving) for 3 (#s 6, 15, and 40) of 6 sampled residents. This deficient practice caused the residents embarrassment. Findings include: During an observation on 5/21/23 at 12:29 p.m., resident #'s 6, 15, and 40 were in the south dining room waiting for lunch. Resident #6 was observed with multiple long, white chin hairs approximately one-half inch long. Resident #15 was sitting close to resident #6. Resident #15 was observed with multiple long, dark hairs around her upper lip and chin area. Resident #40 was sitting at the table adjacent to resident #'s 6 and 15. Resident #40 was noted to have multiple long, dark-colored strands of hair across her upper lip and chin area. During an interview on 5/21/23 at 2:11 p.m., resident #40 stated she was bothered by the presence of facial hair. Resident #40 stated, Whiskers are something only a man should have, not me. It is embarrassing. Resident #40 stated she was not sure when…
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
No federal fines in the current CMS record.
Part of a chain
This home belongs to THE CHARLY BELLO FAMILY, THE MAZE FAMILY, THE SWAIN FAMILY, & WALTER MYERS — 19 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 | 3 of 5 | 1.7 | +1.3 vs chain |
| Health inspection | 2 of 5 | 1.8 | +0.2 vs chain |
| Staffing | 4 of 5 | 2.2 | +1.8 vs chain |
| Quality measures | 5 of 5 | 3.0 | +2.0 vs chain |
The other 18 homes this chain runs (chain average 1.7★, per CMS)
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 | Share | Since |
|---|---|---|---|---|
| CASHMER LLC | Organization | DIRECT OWNERSHIP INTEREST | — | since 07/01/2023 |
| FEY, KRISTIN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 24% | since 07/01/2023 |
| FEY, DANIEL | Individual | INDIRECT OWNERSHIP INTEREST | — | since 07/01/2023 |
| COTTONWOOD HEALTHCARE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/12/2025 |
| PROFESSIONAL BUSINESS ADVISORS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/12/2025 |
| WIPFLI LLP | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/12/2025 |
| ANDERSON, WENDY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2023 |
| MCFADDEN, STEVE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2023 |
| MYERS, WALTER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2023 |
| SURA, MICHAEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2023 |
CMS files one row per role, so the 17 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
4 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.
This home reported $340K paid to related parties — landlords or management companies under common ownership — equal to about 16% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
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 275021. 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 →
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