Riverside Health & Rehabilitation
1301 E Broadway, Missoula, MT 59802 · For profit - Partnership · 72 certified beds · (406) 721-0680 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2026
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0567)
- it has 1 actual-harm citation
- a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $35,139 in federal fines (most recent 2026-01-15)
- nursing-staff turnover (63%) runs well above the national median (45%)
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 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 | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 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 | 20.9% | 18.7% | 15.4% | worse |
| Long-stay residents who lose too much weight | 8.5% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 2.9% | 2.1% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 1.4% | 2.9% | 2.0% | better |
| Long-stay residents with depressive symptoms | 7.3% | 5.6% | 6.5% | worse |
| 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 | 1.8% | 4.4% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 18.4% | 17.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 7.6% | 15.8% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 94.4% | 93.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.1% | 6.3% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 29.1% | 24.1% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 13.9% | 20.4% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.0% | 1.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 76.9% | 73.8% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 22.0% | 19.2% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 11.1% | 14.5% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 0.95 | 1.38 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.95 | 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.
53.3% 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 159 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 60.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 78 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.26 therapist hours per resident per day in 2026Q1 — more than 38% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% 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 | 53.3%CMS range 45.0–61.7 | 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 | 8.7%CMS range 5.7–13.3 | 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 | 60.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 48.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 55.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.1% | 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 | 97.1% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.9% | 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 | 0.9% | 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 | 6.6%CMS range 4.1–10.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.03 | 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 72 beds and averages 66.7 residents a day — about 93% occupied, or roughly 5 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.99 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.85 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.84 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.57 hrs/resident/day on weekends vs 4.16 on weekdays — 14% thinner on weekends. RN hours go from 0.98 to 0.51 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 63% is well above 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 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.
32 citations, most serious first. The 11 most serious are shown; the remaining 21 are one tap away and print in full.
- Actual harm · G2026-01-15 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide pain management which was acceptable to the resident's goals for 1 (#3) of 25 residents sampled. The deficient practice resulted in poor pain management and decreased quality of life for the resident who consistently reported having severe pain. Findings include:During an observation and interview on 1/14/26 at 3:45 p.m., resident #3 stated the pain in his back was horrific and rated it as 8/10. Resident #3 stated he pretty much always had back pain, and he did not feel the facility controlled it well. Resident #3 stated he would consider 5/10 to be an acceptable pain level. Resident #3 stated he had taken pain medication at noon and wanted something more for the pain. Resident #3 was observed lying in bed, grimacing, wincing, and frequently shifting his weight in the bed, during the interview.During an interview on 1/14/26 at 3:53 p.m., staff member M was notified of resident #3's pain and stated resident #3 had chronic pain issues. Staff member M stated nursing staff was responsible for notifying…
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 · Fdisputed · IDR2026-06-17 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide sufficient staffing, which contributed to ADLs not being completed for dependent residents for 4 (#s 1, 3, 6, and 8), low staffing concerns reported by residents for 4 (#s 1, 4, 5, and 9) of 9 sampled residents; and multiple staff concerns of not having enough time to complete assigned tasks or take their breaks. Findings include:During an interview on 6/15/26 at 1:26 p.m., resident #1 stated, I have a private bathroom, and I think they assume I can just walk in there and take my own shower. I need assistance, and my showers are often missed.During an interview on 6/15/26 at 4:54 p.m., staff member G stated, Evening shift showers are probably the task that gets missed the most.During an interview on 6/17/26 at 7:16 a.m., staff member P stated the person working the hall is responsible for doing the daily scheduled baths. Staff member P stated, It's hard when there is only one person on the hall; many of the staff don't feel comfortable leaving the hall long enough to complete a bath or shower.During an interview on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Edisputed · IDR2026-06-17 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide ADL care of bathing for dependent residents for 4 (#s 1, 3, 6, and 8) of 9 sampled residents. This caused resident #1 to feel unclean. Findings include: During an observation and interview on 6/15/26 at 1:29 p.m., resident #1 was lying in his bed, and his nails were long and had a brownish substance under them. Resident #1 had flakes of dry skin peeling off on his arms. Resident #1 stated, I need assistance with showers. I have a private room with a bathroom. I don't trust myself alone in there because the whole bathroom gets wet when I shower, and I might slip. I need assistance, and my showers are often missed. I feel dirty when I miss my showers.During an interview on 6/15/26 at 4:54 p.m., staff member G stated, Evening shift showers are probably the task that gets missed the most.During an interview on 6/17/26 at 7:16 a.m., staff member P stated the person working the hall is responsible for doing the daily scheduled baths. Staff member P stated, It's hard to complete showers when there is 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.
- Potential for harm · Dcited before2026-06-17 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect a resident's right to be free from non-consensual sexual contact by a staff member and ensure the resident had necessary social services following the alleged event for sexual abuse, and the resident was bothered, embarrassed, and felt humiliated after the event, for 1 (#1) of 9 sampled residents. This deficient practice did not allow the resident the opportunity to heal from the alleged event, which still bothered him as of the survey, and he was reportedly self-isolating due to his fear. Findings include: Review of a facility-reported incident, dated 5/22/26, showed: Resident (resident #1) reported to Unit Manager at 1615 (4:15 p.m.) that while 2 CNAs were changing his brief earlier in the day, (staff member M), CNA inserted her finger in his rectum. ED interviewed him and he states (staff member M) was checking his buttocks for open areas and was spreading his anus and he felt her finger enter his rectum. He believes she inserted it up 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 · D2026-06-17 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to complete a thorough investigation for an allegation of sexual abuse by a staff member for 1 (#1) of 9 sampled residents. This caused the resident to be frustrated that there was no resolution to the investigation. Findings include:Review of a facility-reported incident, dated 5/22/26, showed: Resident #1 reported to a staff member an incident of alleged sexual abuse by a staff member.Review of the facility's findings for this allegation, dated 5/29/26, showed: The investigation found that the allegations are unable to be verified. The witnessing CNA reports she was not in the room for all of the cares. The resident did not say anything at the time, but the witness reports that he was quiet. ED interviewed 5 other residents on the same hallway.During an interview on 6/15/26 at 1:26 p.m., resident #1 stated he reported the incident to the nurse on duty and later filed a police report. Resident #1 stated no one from the facility had followed up with him about the investigation or how he was doing. During an interview on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-01-15 · tag F0803 — failed to meet residents' dietary needs — widespreadEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to serve the substituted menu items to meet the nutritional needs of residents in accordance with established national guidelines and have the facility's dietitian review the changes for nutritional adequacy for 2 (#s 40 and 69) of 25 sampled residents. This deficient practice resulted in the residents becoming frustrated with menu selection and residents receiving food from the kitchen were not having nutritional needs met. Findings include: 1. During an interview on 1/13/26 at 4:11 p.m., resident #40 stated he wanted the chef salad alternate for lunch, but the kitchen sent everyone who ordered the chef salad chicken tenders instead. Resident #40 stated the kitchen often messed up the menus, and she was frustrated by the confusion. Resident #40 stated the CNAs .came around the night before and got your mouth watering for one thing, only to be disappointed the next day, when you did not get what you ordered. 2. During an interview on 1/13/26 at 4:20 p.m., resident #69 stated she would have preferred to receive the salad but…
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 before2026-01-15 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews, the facility failed to ensure food was served that was palatable, attractive, and at a safe and appetizing temperature for 7 (#s 40, 41, 49, 56, 66, 69, and 79) of 25 sampled residents. This deficient practice resulted in the residents' dissatisfaction with the food, and it potentially affected any resident who received food from the kitchen. Findings include: During an interview on 1/12/26 at 12:11 p.m., staff member R stated that when the food trays are delivered to the hall, the floor staff deliver them immediately. Staff member R stated that if the resident was not ready to eat, the tray was left on the bedside table in the room until the resident was ready to eat. Staff member R stated she did not check food temperatures before the residents started eating, and she did not reheat the food before the resident ate. Staff member R was not able to state what the temperatures the food should be served at, and she was unaware of anyone checking the temperatures of the meals/food once it was delivered to the halls to be passed…
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 · F2026-01-15 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to date and monitor refrigerated foods, dry goods, and items brought in by families, to ensure items were used by the use-by date or discarded, and the facility failed to store food items off the floor. This deficient practice placed residents who received meals from the facility at risk of food-borne illness. Findings include:During an observation and interview on 1/12/26 at 10:10 a.m., the following items were found in the kitchen: - [NAME] sauce with no open or discard dates, brought in by family,- Goddess dressing with no open or discard date, brought in by family,- Soy Sauce with no open or discard date,- Dijon Mustard with no open or discard date, and a manufacturer's expiration of 4/5/25,- Raw honey with no open or discard date,- Vanilla flavoring with no open or discard date,- Olive Oil Mayonnaise with no open or discard date, - Teriyaki sauce with no open or discard date,- Enchilada sauce with no open or discard date,- Heavy-duty…
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 · E2026-01-15 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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 observations and interviews, the facility failed to maintain a comfortable environment for residents by maintaining a temperature range of 71 to 81 F in resident rooms for 1 (#64) of 25 sampled residents. This deficient practice resulted in resident #64 being cold. Findings include: During an observation and interview on 1/12/26 at 4:02 p.m., resident #64 was in her room with the door closed. Resident #64 was in bed covered with several blankets and stated she was cold. The thermostat was set to 75 degrees and the current temperature reading was 65 degrees.During an observation and interview on 1/12/26 at 4:10 p.m., staff member C used a temperature gun and tested the room temperatures at the request of the surveyor. The following temperatures were noted:- Room D102: 64 degrees- Room A112: 66 degrees- Room D104: 66.5 degrees- Room D108: 67 degrees- Room A101: 63 degrees- Room A103: 67 degreesStaff member C stated [Repair company name] had been in the building in the morning to drain a heat system line and had the heat turned off for those repairs. Staff member C stated 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 before2026-01-15 · 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 interviews and record review, the facility failed to ensure a resident was free from misappropriation of resident funds by a staff member for 1 (#48) of 25 sampled residents. This deficient practice resulted in the loss of $500 plus travel expenses for resident #48. The facility identified the failure of a staff member accepting money from a resident and addressed and corrected the deficient practice before the survey, resulting in the findings of past non-compliance. Findings include:During an interview on 1/13/26 at 12:01 p.m., resident #48 stated he met staff member Q at the facility. Resident #48 stated he and staff member Q became friendly and at some point, in December of 2025, staff member Q offered to assist resident #48 with travel to [City] for medical appointments. Resident #48 stated that staff member Q agreed to be paid $1000 plus expenses. Resident #48 stated he purchased two first-class airline tickets and booked hotel rooms for the trip. Resident #48 stated he paid the staff member Q $500 up front and agreed to pay the remaining $500 after the trip. 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 · Dcited before2026-01-15 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to provide clean equipment for respiratory treatment for 1 (#69) of 5 residents sampled. This deficient practice placed the resident at risk for inhalation of foreign material and respiratory infections. Findings include:During an observation on 1/12/26 at 2:03 p.m., resident #69's nebulizer was observed to have a white crust and buildup on the mouthpiece and corrugated aerosol tubing that extended from the mouthpiece.During an interview on 1/14/26 at 12:16 p.m., staff member B stated that nursing staff were responsible for changing the nebulizer equipment and that this was done weekly. Staff member B stated that an order for changing nebulizer tubing was entered into the chart so it would alert the nursing staff to change the tubing each week.During an interview on 1/14/26 at 12:40 p.m., staff member P stated she did not know when resident #69's nebulizer tubing or mouthpiece had been changed. Staff member P stated the respiratory therapist was responsible for changing them weekly and was not sure why 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.
Show the remaining 21 citations
- Potential for harm · Dcited before2025-03-25 · 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
Based on interview and record review, the facility failed to update a care plan to reflect a new pressure wound, for 1 (#7) of 11 residents sampled for wounds. The failure placed the resident at risk for improper wound care, wound progression, and infection. Findings include: During an interview on 3/24/25 at 2:05 p.m., resident #7 stated she has had wounds in the past and had a buttock wound currently related to paraplegia. During an interview on 3/25/25 at 9:45 a.m., staff member A stated the care plan should reflect all current care concerns for each resident. Staff member A stated the care plans are updated by the wound care nurse for any new wounds, including any new interventions or treatments. Review of resident #7's nursing progress notes showed a new pressure wound identified on 3/4/25, which remained unhealed as of the end of the survey period. Review of resident #7's care plan, initiated on 2/5/25 with revision on 2/17/25, failed to show the pressure wound identified on 3/4/25. The care plan noted an alteration in skin integrity from a sacral wound present on admission…
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 · D2025-03-25 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to implement wound prevention measures for a resident with history of pressure wounds and elevated risk for the development of pressure ulcers; failed to implement pressure relieving measures after the development of a new Stage II sacral wound, and failed to accurately assess and monitor a new Stage II sacral wound for 1 (#7) of 11 residents sampled for wounds. The wound management failures placed the resident at risk for wound progression and infection. Findings include: During an observation and interview on 3/24/25 at 2:05 p.m., resident #7 was seated in a wheelchair in her room. There was no pressure relieving air mattress or overlay on resident #7's bed. Resident #7 stated she had a wound on her buttock and has had several wounds in the past related to paraplegia. Resident #7 stated, I heard through the grapevine that I would be getting an air mattress, but I haven't seen one yet. During an interview on 3/25/25 at 8:35 a.m., staff member B stated resident #7 had a pressure wound on her left buttock which…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-11-07 · 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 interviews and record review, the facility failed to honor a resident's right to privacy by entering the residents' room without consent and going through residents' items for 2 (#s 6 and 14), and the practice upset the two residents involved; and the facility failed to ensure residents had the opportunity to engage in political voting for 2 [#s 5 and 19] of 24 sampled residents, and #5 and 19 wanted to vote if able. Findings include: RIGHT TO PRIVACY: During an interview on 11/5/24 at 9:27 a.m., resident #6 stated staff member K went through her drawers without permission, and she entered her room to find staff member K standing in her room with two knives in the air saying, Look what I found. Resident #6 stated, She was snooping in our drawers while we were out of the room. They were buried in a drawer. We used to cut fresh fruit like apples and such but haven't used the knives in a long time, so they have just stayed in the drawer. Resident #6 stated, A shouting match started, there's no respect, she (staff member K) said she was doing a deep clean. No one asked us or…
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 before2024-11-07 · tag F0585 — failed to handle grievances — patternHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
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 residents knew how to file a grievance and provide residents an option for reporting grievances anonymously, for 4 (#s 6, 14, 23 and 41) of 24 sampled residents. Findings include: During an interview on 11/5/24 at 9:27 a.m., resident #6 stated she had a complaint regarding an incident that occurred in early October. Resident #6 stated she did not know what a grievance was and was worried about retaliation, if the staff knew she had complained. During an interview on 11/5/24 at 10:31 a.m. resident #14 stated he had a grievance about staff showing no respect for his privacy and not being able to access his resident trust account on weekends. Resident #14 did not know how to file a grievance or how to submit one anonymously. During an interview on 11/5/24 at 10:34 a.m., resident #23 stated she could not access her resident trust account on weekends and would beg staff for change in order to use the vending machine. Resident #23 stated she was told residents had to wait until Monday to access their…
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 · E2024-11-07 · tag F0791 — failed to provide routine dental services — patternProvide or obtain dental services for each resident.
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 a resident was referred for dental services after dentures were lost, while the resident was living at the facility for 1 (#41) of 24 sampled residents. This practice led to resident #41 being required to eat soft and pureed foods, and the facility had the opportunity to address the concerns over an extended period of time, and had multiple opportunities to correct the concerns, but did not. Findings include: During an observation and interview on 11/4/24 at 1:21 p.m., resident #41 did not have her dentures in her mouth. Resident #41 stated she did not have her dentures because somebody took them. Resident #41 stated she had to find soft foods to eat because she did not have her dentures. During an interview on 11/6/24 at 8:01 a.m., NF2 stated resident #41 had dentures when she was admitted to the facility. NF2 stated he asked several staff about the missing dentures, but the dentures were not found. NF2 stated he went to the previous administrator about the missing dentures and getting resident #41…
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 · E2024-11-07 · tag F0919 — failed to provide a working call system — patternMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, the facility failed to ensure call lights were within reach for 3 (#s 5, 37, and 55) of 24 sampled residents, and the residents were not able to reach or use the call lights. Findings include: During an observation on 11/6/24 at 9:41 a.m., resident #5's call light was under her bed, with the bed against the wall. Resident #5 could not reach the call light. During an observation on 11/6/24 at 9:43 a.m., resident #37's call light was out of reach, on a nightstand on the right side, approximately two feet back from the bed. Resident #37 stated she did not know where her call light was located. During an observation on 11/6/24 at 9:44 a.m., resident #55's call light was on the nightstand, approximately one and a half feet away from the bed. Resident #55 stated she did not know where her call light was located. During an observation and interview on 11/6/24 at 9:46 a.m., NF1 stated he had just arrived and was not aware of the location of the call lights for residents #5, 37, and 55. NF1 stated the call lights for residents #5, 37, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-07 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each 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 accommodate a resident's needs when he was sitting in his wheelchair, and complete an assessment for positioning aids, for 1 resident (#7) of 2 sampled residents with one sided weakness who require a wheelchair for mobility, but he was unable to hold up his torso/head, which would often lean forward. Findings include: During an observation on 11/4/24 at 4:11 p.m., resident #7 was sitting in his wheelchair in his room. His body was leaning far forward in the chair. Resident #7 appeared to be sleeping. During an observation on 11/6/24 at 8:23 a.m., resident #7 was in the dining room. He was sitting in his wheelchair, leaning forward with his face almost touching his food. Resident #7 was dozing off, but when his face would touch his plate, he would sit back up. During an interview on 11/6/24 at 9:41 a.m., staff member Q said resident #7 liked to stay in his wheelchair. She said he tipped (leans) forward frequently, and she would try to get him back to his room. She said sometimes he wouldn't want to go. 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 · D2024-11-07 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure the accuracy of the Quarterly MDS assessment, for medications and hearing, for 2 (#s 11 and 23) of 24 sampled residents. Findings include: 1. During an observation and interview on 10/6/24, staff member P walked into resident #11's room. Resident #11 was having a hard time hearing the surveyor's questions. Staff member P stated, Let me get her hearing aid. Staff member P put one hearing aid in resident #11's ear. The hearing aid did not help resident #11's ability to hear. Review of resident #11's EMR, showed her Care Plan showed resident #11 used two hearing aids. A Significant Change MDS, on 9/16/24, showed resident #11 did not use hearing aids, but she had highly impaired hearing. A Quarterly MDS, dated [DATE], showed resident #11 did not use a hearing aid and had highly impaired hearing. A Quarterly MDS on 5/31/24 showed resident #11 did use hearing aids, and she had moderate hearing difficulty. During an interview on 10/7/24 at 11:17 a.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 · D2024-11-07 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a baseline care plan for a resident's foley catheter care within 48 hours of admission for 1 (#61) of 4 sub-sampled residents with a urinary catheter. Findings include: During an observation and interview on 11/6/24 at 3:09 p.m., resident #61 was observed sitting in a chair, in the activities room. Resident #61 stated he discharged from the hospital on [DATE]. Resident #61 stated the foley catheter was placed in the hospital, and he was hoping it would be removed soon. During an interview on 11/7/24 at 10:46 a.m., staff member B stated resident #61 was admitted to the facility on [DATE]. Staff member B stated the nurses were responsible for developing baseline care plans for residents on admission. Staff member B stated the admission assessment would trigger care areas for the resident's baseline care plan. Staff member B stated she did not know why resident #61's baseline care plan did not address resident #61'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.
- Potential for harm · D2024-11-07 · 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 interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan, for a resident receiving anticoagulant medication, for 1 (#61) of 7 sub-sampled residents receiving anticoagulation therapy. Findings include: Review of resident #61's medical record showed resident #61 was prescribed and taking an anticoagulant medication for the diagnosis of atrial fibrillation; Eliquis. During an interview on 11/7/24 at 10:46 a.m., staff member B stated the interdisciplinary team was responsible for ensuring care plans remained current. Staff member B stated high risk medications, such as anticoagulants, should be included on resident care plans for monitoring side effects. Staff member B stated resident #61's current care plan did not reflect the use of an anticoagulant medication, which was for the Eliquis. Review of resident #61's current care plan, with a revision date of 10/25/24, did not show resident #61 was prescribed an anticoagulant medication (Eliquis), or the need to monitor for potential side effects of the medication 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 · Dcited before2024-11-07 · 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
Based on observations, interviews, and record review, the facility failed to review and revise the comprehensive care plan after Quarterly and Annual assessments, for 1 (#41) of 24 sampled residents. Findings include: During an observation and interview on 11/4/24 at 1:21 p.m., resident #41 was sitting in the hallway greeting other residents and staff as they passed by. Resident #41 did not have her dentures in her mouth. Resident #41 stated she did not have her dentures because somebody took them. Resident #41 stated she had to find soft foods to eat because she did not have her dentures. During an interview on 11/4/24 at 1:40 p.m., staff member O stated resident #41 had not had dentures for as long as she had been living at the facility as far as she was aware. Staff member O stated she was not aware the care plan showed resident #41 had dentures. During an interview on 11/6/24 at 9:14 a.m., staff member C stated the care plan did have an active intervention for denture care twice daily. Review of resident #41's Nursing Care Plan, with a last revision date of 9/9/24, reflected: -…
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 · D2024-11-07 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to replace a missing hearing aid for 1 resident (#11) of 1 sampled resident who required hearing aids. This deficiency affected resident #11's ability to hear since July of 2024. Findings include: During an observation and interview on 10/6/24, staff member P walked into resident #11's room. Resident #11 was having a hard time hearing the surveyor's questions. Staff member P stated, Let me get her hearing aid. Staff member P put one hearing aid in resident #11's ear. The hearing aid did not appear to help resident #11's ability to hear. Review of resident #11's Care Plan showed resident #11 used two hearing aids. During an interview on 10/6/24 at 3:52 p.m., staff member B said resident #11 had been missing a hearing aid since sometime in August (2024). She said, There had been one (hearing aide) missing and found, then another one missing and found. She said typically the process for replacing a lost hearing aid would be (the concerned party) to fill out a grievance form and then follow the pathway from there.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-07 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 observation, interview, and record review, the facility failed to record medication refrigerator temperatures daily and add dates to medications when opened. This deficient practice may negatively affect any resident who utilized the facility's refrigerated medications if the refrigerator temperatures were not maintained or medications were used beyond expiration dates. Findings include: During an observation on 11/7/24 at 11:06 a.m., one medication refrigerator was identified located on Hall B in the medication storage room. A thermometer was located inside the refrigerator. One vial of Tuberculin Purified Protein Derivative (PPD), 1 ml, was observed to be previously opened. The half empty, multi-dose vial, was not dated with the date the vial was originally opened. No refrigerator temperature logs were found during the observation to show the temperatures were within a safe range. During an interview on 11/7/24 at 10:37 a.m., staff member B stated refrigerator temperature logs were located at the nurse's station. Staff member B stated the medication room and carts were…
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 · D2024-11-07 · tag F0810 — isolatedProvide special eating equipment and utensils for residents who need them and appropriate assistance.
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 assistive utensils for 1 (#11) of 2 sampled residents. This deficiency affected resident #11's ability to handle her utensils while eating and increased her risk of weight loss. Findings include: During an observation on 11/6/24 at 8:15 a.m., resident #11 was in the dining room and using regular silverware while eating her meal. She was having difficulty keeping the food on the silverware and struggling to lift her silverware to her mouth without spilling the food on herself and the floor. Resident #11's tray card showed she was to receive Built up utensils (adaptive silverware). Resident #11 was not observed to have built up utensils at the dining table. During an interview on 10/6/24 at 11:32 a.m., staff member W stated there was only one resident who required assistive utensils. The resident name she provided was not resident #11. She stated there was usually a communication slip that would show them when a resident had an order for assistive utensils. She did not know resident #11 required…
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 before2023-11-20 · tag F0585 — failed to handle grievances — patternHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
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 promptly address resident grievances for 6 (#s 8, 17, 22, 28, 35, and 126) of 36 sampled residents. Findings include: Review of a resident grievance form, dated 10/19/23, reflected resident #126 was concerned the food had been cold. Review of a resident grievance form, dated 11/18/23, reflected resident #22 was frustrated with cold food, and stated every meal came out cold and did not stay warm with paper plates. During an observation and interview on 11/18/23 at 12:27 p.m., dietary staff were serving food to the residents in the dining room on disposable plates with disposable cutlery. Resident #35 stated the food was always cold and served on paper. During an interview on 11/18/23 at 1:37 p.m., resident #8 stated the soup was cold, and the facility always used paper plates. During an interview on 11/18/23 at 1:44 p.m., resident #28 stated she had concerns with meals being cold and served on paper plates (would not hold heat from food). During an interview on 11/19/23 at 10:08 a.m., staff member E 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 · Ecited before2023-11-20 · 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 observation, interview, and record review, the facility failed to serve food that was palatable, attractive, and at a safe and appetizing temperature for 7 (#s 6, 8, 17, 28, 35, 42, and 58) of 36 sampled residents. Findings include: During an observation and interview on 11/18/23 at 12:27 p.m., staff were serving residents their meals in the dining room, and the food was on paper plates. Resident #35 stated the food was cold. During an interview on 11/18/23 at 1:17 p.m., resident #6 stated, I don't like the food, it is always cold . During an interview on 11/18/23 at 1:37 p.m., resident #8 stated, The soup is cold, they constantly use paper plates . During an interview on 11/18/23 at 1:38 p.m. resident #17 stated, I get cold mac and cheese every single night. I worked in food services and knew the temperature should be 140 degrees, it is a disgrace. During an interview on 11/18/23 at 1:44 p.m., resident #28 stated she had concerns with the meals being cold all the time, and she did not like the paper plates. During an observation on 11/19/23 at 11:35 a.m. staff were…
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 · E2023-11-20 · 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 hand hygiene during medication administration for 6 (#s 14, 48, 63, 68, 123, and 126) of 36 sampled residents. Findings include: During an observation on 11/19/23 at 8:27 a.m., staff member G administered medications to resident #68. Staff member G did not perform hand hygiene after leaving the resident's room, or before preparing the next resident's medications. During an observation on 11/19/23 at 11:45 a.m., staff member G prepared resident #123's medications, took the medications to the resident's room to administer, and left the room. Staff member G then began to prepare the next resident's medications. Staff member G did not use hand hygiene before or after preparing and administering resident #123's medications. During an observation on 11/19/23 at 11:48 a.m., staff member G prepared resident #68's medications, and went into the resident's room to administer them. Staff member G did not perform hand hygiene before entering resident #68's room. During an observation on 11/19/23 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure nursing staff failed to change oxygen tubing for 1 (#2) of 36 sampled residents, increasing the risk for respiratory infection. Findings include: During an observation on 11/18/23 at 1:07 p.m., the oxygen concentrator tubing for resident #2 showed a date of 11/11 with the initials documented on it. During an observation on 11/20/23 at 8:41 a.m., the oxygen concentrator tubing for resident #2 showed a date of 11/11 with the same initials documented on it. During an interview on 11/20/23 at 9:03 a.m., staff member D stated the nurse typically changed the oxygen tubing. Staff member C stated a task would pop up on the EMR for the nurse to change the oxygen tubing when it was due. Review of resident #2's Treatment Administration Record, showed the following order: Change O2 Tubing and DATE Clean Concentrator filter (per manufacturer's recommendations) in the morning every Sat for Oxygen use. [sic] The task was checked off as completed on 11/11/23 with the initials of a staff member, and on 11/18/23 with…
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 before2023-11-20 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 observation, interview, and record review, the facility failed to ensure blood glucose test strips were labeled with an open date for 4 (#s 39, 63, 122, and 126) of 36 sampled residents. Findings include: During an observation on 11/19/23 at 12:01 p.m., staff member G checked resident #63's blood sugar using test strips from the hall A medication cart tube. During an observation on 11/19/23 at 12:05 p.m., staff member G checked resident #122's blood sugar, using a test strip from the same tube from the previous observation with resident #63, from the hall A medication cart. There was no label, on the tube of test strips, indicating when the tube was opened. During an observation on 11/19/23 at 3:59 p.m., staff member H checked resident #122's blood sugar, using a test strip from the hall A medication cart tube. During an observation on 11/19/23 at 4:09 p.m., staff member H checked resident #126's blood sugar, using a test strip from the hall A medication cart tube. During an interview on 11/19/23 at 4:11 p.m., staff member H stated she did not check the blood glucose test…
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 · D2023-11-20 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to administer the pneumococcal vaccine, or obtain declinations for them, for 2 (#s 2 and 41) of 36 sampled residents. Findings include: Review of resident #2's medical record showed the resident had not received the PCV20 or PPSV23 vaccine, which she was due for on 6/29/21. There were no declinations or education for the vaccine documented in resident #2's chart. During an interview on 11/19/23 at 3:26 p.m., resident #2 stated she would like a pneumococcal vaccine if offered. Review of resident #41's chart showed resident #41 had not received a PCV15 or PCV20 vaccine which she was due for on 7/16/23. There were no declinations or education for the vaccine documented in resident #41's chart. During an interview 11/19/23 at 3:04 p.m., staff member B stated the facility was in the process of going through all the residents immunization records and identifying who needed updated pneumonia vaccines. Staff member B stated the facility was putting together a process now for monitoring and tracking pneumococcal vaccines. 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.
- No harm found · B2024-11-07 · tag F0567 — failed to protect residents' money held by the home — patternHonor the resident's right to manage his or her financial affairs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to make personal funds available to residents on the same day, for amounts less than $100 for Medicare residents or $50 for Medicaid residents, on weekends for 3 (#s 6, 14, and 23) of 24 sampled residents. This practice required residents to wait until business hours on Monday to access their personal funds for food, drinks, activities, or outings. Findings include: During an interview on 11/4/24 at 1:43 p.m., resident #14 stated he could not access his personal funds from his resident trust account on weekends for soda from the vending machine. During an interview on 11/5/24 at 9:37 a.m., resident #6 stated she was not able to access her personal funds on the weekends and would also have to find someone willing to give her change for the vending machines. Resident #6 stated the staff have told her they were discouraged from making change for residents. During an interview on 11/5/24 at 10:34 a.m., resident #23 stated she could not access her resident trust fund on the weekend and would beg staff for change in order to use…
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.
“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.
- 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
$35,139 in federal fines across 1 penalty.
- $35,139 — penalty dated 2026-01-15
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 THE GOODMAN GROUP — 9 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 | 3.2 | -0.2 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 4 of 5 | 3.7 | +0.3 vs chain |
| Quality measures | 4 of 5 | 4.2 | -0.2 vs chain |
The other 8 homes this chain runs (chain average 3.2★, 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 |
|---|---|---|---|---|
| CARON CORPORATION | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; GENERAL PARTNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/01/1988 |
| JBGRS INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; GENERAL PARTNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/01/1996 |
| RIVERSIDE HEALTH CARE CENTER | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 09/04/1987 |
| JOHN B. GOODMAN 2006 IRRV GRANTOR TR | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; GENERAL PARTNERSHIP INTEREST | 25% | since 02/28/2017 |
| BENSON, RANDALL | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; GENERAL PARTNERSHIP INTEREST | 10% | since 02/28/2017 |
| SALMEN, THOMAS | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; GENERAL PARTNERSHIP INTEREST | 10% | since 02/28/2017 |
| WEICHERT, JAMES | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; GENERAL PARTNERSHIP INTEREST | 10% | since 02/28/2017 |
| WILSON, MARK | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; GENERAL PARTNERSHIP INTEREST | 10% | since 02/28/2017 |
| WAYLETT, ANNIE | Individual | W-2 MANAGING EMPLOYEE | — | since 12/04/2020 |
| EDINGER, CRAIG | Individual | CORPORATE OFFICER | — | since 10/21/2016 |
| KNACKE, CLINTON | Individual | CORPORATE OFFICER | — | since 10/12/2022 |
| OLSON, DENISE | Individual | CORPORATE OFFICER | — | since 09/16/2013 |
CMS files one row per role, so the 21 rows in the source record cover these 12 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 $612K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
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 275126. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-15, 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.