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Village Health & Rehabilitation

2651 South Ave W, Missoula, MT 59804 · For profit - Corporation · 193 certified beds · (406) 728-9162 Medicare & Medicaid certified

Call the home — (406) 728-9162 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Nov 2025Behavioral-health or dementia-care citations — no harm found (F0740, F0758)2 actual-harm citations$27,846 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $27,846 in federal fines (most recent 2025-08-28)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2835 Fort Missoula Rd Ste 200 Bldg 3 · (406) 721-5600 · Call to confirm hours
Pharmacy
Shopko0.1 mi
2510 S Reserve St · (406) 721-2311 · Call to confirm hours
Grocery
2510 S Reserve St · (406) 218-7951 · Call to confirm hours
Park
Place of worship

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 4 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.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased10.6%18.7%15.4%better
Long-stay residents who lose too much weight8.6%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder1.1%2.1%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.5%2.9%2.0%better
Long-stay residents with depressive symptoms4.9%5.6%6.5%better
Long-stay residents who were physically restrained0.0%0.6%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.8%4.4%3.3%better
Long-stay residents whose ability to walk worsened7.9%17.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication16.3%15.8%18.9%better
Long-stay residents given the seasonal flu vaccine99.2%93.6%95.3%typical
Long-stay residents with pressure ulcers6.0%6.3%4.7%worse
Long-stay residents with worsening bladder/bowel control15.5%24.1%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table20.5%20.4%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.5%1.2%1.4%better
Short-stay residents given the seasonal flu vaccine93.8%73.8%79.4%better
Short-stay residents rehospitalized after admission17.7%19.2%22.6%better
Short-stay residents with an outpatient ER visit14.5%14.5%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.631.381.67typical
Long-stay outpatient ER visits per 1,000 resident days1.492.161.80better

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.

57.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 414 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

57.7%U.S. median 51.5%
Got home and stayed home
9.8%U.S. median 10.7%
Went back to hospital
55.9%U.S. median 56.6%
Met the expected recovery
0.46U.S. median 0.31
Therapy hours / resident / day
0.34hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 55.9% 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 247 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 0.46 therapist hours per resident per day in 2026Q1 — more than 76% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 26% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF57.7%CMS range 52.6–62.551.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.8%CMS range 7.3–11.910.7%Oct 2022–Sep 2024no 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 discharge55.9%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge40.9%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge45.3%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified97.1%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting94.2%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge95.1%98.7%Oct 2024–Sep 2025CMS 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 stay0.3%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.9%CMS range 4.0–7.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.041.02Oct 2022–Sep 2024CMS 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

0.97
RN hours/ resident / day
0.33
LPN hours/ resident / day
2.69
Aide hours/ resident / day
3.99
Total nurse hours/ resident / day
0.65
RN hoursweekends
55.2%
Total nursing turnover
40.5%
RN turnover

How full it usually is: this home is certified for 193 beds and averages 147.1 residents a day — about 76% occupied, or roughly 46 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.99 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.97 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.69 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 3.42 hrs/resident/day on weekends vs 4.21 on weekdays — 19% thinner on weekends. RN hours go from 1.09 to 0.65 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 55% 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

3
deficiencies at the latest standard inspection (2025-08-28)
9
at the previous standard inspection (2024-08-01)

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

Inspection deficiencies

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

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

25 citations, most serious first. The 12 most serious are shown; the remaining 13 are one tap away and print in full.

  • Actual harm · Gcited before2025-08-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was free from accidents for a resident who sustained a fall with pain resulting in a fracture, who was on a blood thinner; and failed to promptly notify the physician of a fall with pain resulting in a fracture impacting the physician's opportunity to determine if a higher level of care or treatment was necessary at the time of the fall for 1 (#85) of 34 sampled residents. This deficient practice contributed to delayed care, increased pain and a femur fracture.During an interview on 8/26/25 at 9:36 a.m., resident #85 explained that she was admitted to the facility in July after she developed complications from a right hip replacement. Resident #85 stated she had a fall when her leg got caught during a transfer, and she fell because the nurse went to get help and left her standing at the edge of the bed with nothing to hold on to. Resident #85 said the nurse who was on told a bunch of CNAs to say I wouldn't allow them help me. Resident…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-08-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide a safe environment for 1 (#90) of 36 sampled residents. This resulted in the resident falling and sustaining a significant injury. Findings include: Review of resident #90's EMR admission assessment, dated 2/3/2023, showed, .2. Fall Risks . 3. Requires use of assistive devices . 5. Impaired mobility/assist with toileting . 8. hx of falls in last month, 9. hx of falls in last 1-6 months . 4. Current fall preventative measures in place . 5. Frequent checks . 8. Call light within reach when in room . [sic] Review of resident #90's EMR nursing progress notes, dated 3/17/2024, showed, Nurse's Description: Heard CNA radio for help saying a resident is out of bed. Seen resident on the floor next to his bed, laying on his left side, with head under table metal leg . Injuries?: Left elbow skin tear with minimal bleed. Res. c/o left hip pain . Predisposing factors: Noted res bed on highest position with res saying I kept on pressing the emergency button but it doesn't work Call light not in reach . [sic] Review of resident…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-19 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to submit investigation findings for an incident in a timely manner, to the State Survey Agency, for 2 (#s 5 and 6) of 9 sampled residents. Findings include: A review of a facility-reported incident, submitted to the State Survey Agency on 9/4/25, involving a resident-to-resident interaction for residents #'s 5 and 6, showed the facility's investigation findings were submitted on 9/12/25 and were due by 9/11/25.During an interview on 11/19/25 at 10:30 a.m., staff member B stated a resident-to-resident incident was to be reported to the State Survey Agency with 24 hours, and the facility investigation findings were to be submitted within five days, not including weekends and holidays.A review of a facility policy, titled Incidents and Accidents, with a last reviewed date of 10/27/25, showed:Policy:It is the policy of this facility for staff to utilize the facility on-line risk management system to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-08-28 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store and prepare food under sanitary conditions, staff failed to wear hair restraints in the kitchen area, and the facility failed to provide food at a safe and appetizing temperature for 4 (#s 6, 14,72, and 154) of 34 sampled residents. These deficient practices placed all residents who consumed meals prepared by the facility at risk of exposure to food-borne pathogens and or illness. Findings include:During an observation of the kitchen on 8/25/25 at 3:12 p.m., the following concerns were identified: - The juice dispenser had a sticky liquid on the dispenser nozzles, the front panel of the dispenser, and the backsplash.- The coffee dispenser had dried coffee on the front tray and on the dispenser nozzles.- A light brown liquid was spilled on the counter by the coffee dispenser. A drawer containing utensils was open under the spill, and the brown liquid had spilled into the utensil drawer.- There was ice buildup in the freezer, and there was ice on the floor of the freezer, which made the floor slick 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-28 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide prompt physician notification for a resident who sustained a fall resulting in injury with pain for 1 (#85) of 34 sampled residents. This deficient practice contributed to a delay in treatment, and the resident was found to have a fracture. Findings include:During an interview on 8/26/25 at 9:36 a.m., resident #85 explained that she was admitted to the facility in July after she developed complications from a right hip replacement. Resident #85 stated she had a fall when her leg got caught during a transfer, and she fell because the nurse went to get help and left her standing at the edge of the bed with nothing to hold on to. During an interview on 8/27/25 at 9:48 a.m., staff member O stated the fall protocol was to notify the family, the physician, and write up a fall report. Staff member O stated he did not notify the physician on call after resident #85 fell. Staff member O stated resident #85's care was delayed by a couple of hours.During an interview on 8/27/25 at 2:54 p.m., staff member B stated the fall…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-28 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on the interview and record review, the facility failed to report allegations of resident abuse to the State Survey Agency within 24 hours of an incident for 2 (#s 99 and 129) of 5 residents sampled for Facility Reported Incidents. Findings include:Review of the facility reported incident dated 6/27/25 at 8:15 p.m., showed resident #99 and resident #129 were involved in a physical altercation. Resident #99 reported to the nurse resident #129 grabbed resident #99's groin. The initial allegation of resident-to-resident abuse was not received by the State Survey Agency until 6/30/25.During an interview on 8/27/25 at 11:22 a.m., staff member A stated she was not aware the facility failed to report the allegations of resident-to-resident abuse to the State Survey Agency within 24 hours for the facility reported incident which occurred on 6/27/25, involving residents #99 and #129. Staff member A stated the facility's video surveillance of the incident was no longer available for review. During an interview on 8/28/25 at 8:52 a.m., staff members A and C were present. Staff member C…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-28 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    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 licensed nursing staff had the necessary knowledge and skillset on the facility's post-fall protocol and physician notification, and a resident had a fall, with an injury and pain, and the proper notifications were not all made, for 1 (#85) of 34 sampled residents, and this resulted in a delay in care. Findings include:During an interview on 8/26/25 at 9:36 a.m., resident #85 explained she had a fall when her leg got caught during a transfer, and she fell because the nurse went to get help and left her standing at the edge of the bed with nothing to hold on to. During an interview on 8/27/25 at 9:48 a.m., staff member O stated resident #85 transferred with a walker and a one-person assist and was 50% weight bearing on her right leg. Staff member O stated the resident fell when moving from the bed to the recliner. Staff member O stated resident #85 was reporting pain in her right knee at the time of the fall. Staff member O stated the fall protocol was to notify the family, the physician, and write up a fall report.…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-28 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    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 a thickened therapeutic diet as ordered for 1 (#91) of 34 sampled residents. The failure increased the risk of aspiration for the resident. Findings include:Review of resident #91's care plan, dated 8/12/25, showed resident #91 was to be provided nectar-thick fluids, as prescribed by the Speech Language Pathologist on 8/16/24.Review of resident #91's medication administration record for August 2025 showed the resident was to have Boost Breeze, which was to be thickened to a nectar-thick consistency, or the Boost may be replaced with a thickened preferred supplement.During an observation and interview on 8/27/25 at 8:05 a.m., resident #91 was sitting at the breakfast table. Staff member D was observed putting three pumps of gel thickener into a glass of cranberry juice. The thickener was observed in the bottom of the glass. The juice was floating on top of the thickener. Staff member D did not stir the thickener into the juice to mix it to a nectar-thick consistency. Resident #91 had a thin consistency…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-04-03 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility staff failed to wear appropriate PPE while caring for residents for 2 (#s 3 and 16); and failed to educate and monitor staff on cleaning practices for residents positive for c-diff, for 2 (#s 14 and 17) of 17 sampled residents. The deficient practices increased the risk to others for contracting infections due to the deficient practices. Findings include: 1. During an observation on 4/1/25 at 12:14 p.m., 12 resident rooms were identified for special droplet/contact precautions, eight resident rooms were identified for enhanced barrier precautions, and three resident rooms were identified for contact precautions. Inspection of two PPE supply containers were found to have no N-95 masks available for use in the 300 hallway. The PPE supply containers held only yellow procedural masks. Staff member D was observed entering a resident room, identified with a special droplet/contact precaution sign, wearing a yellow procedural mask, no eye protection, and a yellow gown with a pair of gloves. Inspection of two PPE supply…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-11-21 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide clean resident rooms for 3 (#s 72, 16 and 95) of 28 sampled residents, and failed to provide clean hallways, which had the potential to affect all staff and visitors. Findings include: During an observation and interview on 11/19/24 at 3:12 p.m., resident #72 said she did not know when the last time her floor had been mopped. Resident #72 said she knows she was not always in her room, but the same sticky substance had been on her floor for several days. Resident #72 said she did not like her room and the floor being dirty. The observation made of resident #72s room showed, a plastic knife, a pen, and three clear plastic wrappers were under the bed. Resident #72's floor was observed to have a red sticky substance in the middle of her floor beneath her overbed table. A [NAME] brown sticky substance was also observed under the edge of her nightstand. The substance looked like it had leaked onto the floor spread out onto the floor. During an…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-11-21 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to update resident care plans in a timely manner for 3 (# 1, #16 and #55) of 4 residents sampled for pressure ulcers and failed to revise a resident care plan to show effective behavior interventions following repeated resident to resident altercations for 1 (#33) of 3 residents sampled for behavior. Findings include: 1. Review of resident #1's nurses notes, dated 9/6/24, showed a new wound and the wound care was completed for a stage III pressure ulcer with full-thickness skin loss on the left heel. Review of resident #1's nurses notes written by the certified wound nurse on 9/6/24, showed resident #1 had a left heel wound. The wound nurse applied a dressing which was approved by the medical provider. Review of resident #1's nurses note documented on 9/10/24 showed the wound which was initially assessed as a stage III pressure ulcer was now noted to be a callous. Review of resident #1's care plan showed the care plan was updated on 11/18/24 and the potential for skin alteration changed from a potential to an actual wound.…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-21 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 accurate assessments for 1 (#33) of 3 sampled residents who had been involved in two altercations. This deficient practice had the potential to affect resident care and safety as it inaccurately depicted the residents' care needs. Findings include: Review of resident #33's vulnerable resident evaluation dated 9/30/24, showed resident #33 did not have a history of any type of abuse toward others. The evaluation also showed the resident did not have behaviors which make the resident susceptible to abuse by others or behaviors which increase the resident's risk of abuse to others. Review of resident #33's MDS with an ARD of 10/3/24 showed the resident did not have any physical, verbal or other behavior symptoms directed toward others. Review of resident #33's nurse's note dated 10/2/24 showed, .Resident increased his voice .Resident has increasing confusion and increasing upset behaviors . The resident was administered a prn antianxiety medication because of the increasing behavior, agitation and inability of 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · D2024-11-21 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to limit an as needed anti-anxiety medication order to 14 days or provide a rationale for continued extension of the medication, for 1 (# 33) of 1 sampled resident using an as needed medication. Findings include: A review of resident #33's medication administration record for September 24, showed, Lorazepam Concentrate 2MG/ML, give 0.5ml by mouth every 8 hours as needed for Anxiety for 4 days was ordered on 8/30/24. Lorazepam is the generic name for Ativan, an anti-anxiety medication. The MAR showed the medication had not been given during those 4 days. A review of the September 2024 MAR, showed, on 9/3/24, the medical provider re-ordered the Lorazepam to be continued at 1mg every 6 hours for another 14 days. During those 14 days, the Lorazepam had not been administered. A review of the Advanced Practice Nurse Practitioner note dated 9/6/24 showed she had assessed resident #33. The NP note showed, .9/3-acute visit with Doctor for agitation which had resolved at the time of the visit. As needed Ativan available, none given in…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-08-01 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the kitchen staff wore beard coverings in the kitchen, failed to label and date food items in the walk-in freezer, and failed to properly cool left-over chicken. This deficient practice had the potential to affect all residents eating food from the facility's kitchen. Findings include: 1. During an observation on 7/28/24 at 1:35 p.m., staff member N was observed with facial hair and was not wearing a beard net in the kitchen. During an observation and interview on 7/29/24 at 1:50 p.m., staff member P was observed not wearing a beard covering in the kitchen. Staff member P stated he should have been wearing a beard covering in the kitchen. During an observation on 7/30/24 at 2:20 p.m., staff member Q had facial hair and was not wearing a beard covering in the kitchen. Review of the facility's policy, General Food Preparation and Handling, reviewed 8/10/23, showed, Hair restraints - Dietary staff must wear hair restrains (e.g., hairnet, hat and/or beard restraint) to prevent hair from contacting food. 2.…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-01 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement a baseline care plan, for five days, for a newly admitted , nonverbal resident with a diagnosis of a subdural hematoma and stroke for 1 (#138) of 36 sampled residents. This deficient practice had the potential to affect the resident's quality of care. Findings include: A review of resident #138's EHR progress note, dated 4/26/24 at 3:08 p.m., showed: Note Text: [Resident #138] admitted on [DATE] 1:00 PM for SDH, CVA.Resident is unable to talk.Totally dependent on staff for late loss ADLs. Eating: Total dependence . A review of resident #138's care plan showed 18 focus areas. One focus area had an initiated date of 4/29/24, all other focus areas had an initiated date of 5/1/24 or later. During an interview on 7/31/24 at 10:35 a.m., staff member J stated the resident care coordinator nurse would perform an admission assessment and then trigger the baseline care plan for newly admitted residents. The expectation was the baseline care plan would…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-01 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to initiate a care plan for PTSD (Post-Traumatic Stress Disorder) for 1 (#55) of 36 sampled residents. Findings include: Review of resident #55's electronic medical record showed the resident had unspecified PTSD as an admission diagnosis. Resident #55 did not have a plan of care for her PTSD. Due to the lack of a care plan, the staff would not be informed of PTSD triggers, and the best way to help resident #55 cope with events that trigger her PTSD. A SS- Trauma Screening Tool was completed on 6/18/24. Resident #55 answered no to the question of, have you ever experienced trauma in your life. There was no further documentation noted to identify trauma as shown on her diagnoses. During an interview on 7/30/24 at 11:18 a.m., resident #55 said her PTSD had been triggered because a CNA busted through her curtain and scared her. Resident #55 said if the staff knew what triggered her PTSD, the staff members would potentially knock before barging into her room. During an interview on 7/31/24 at 9:26 a.m., staff member G said 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-01 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to update the care plan related to catheter care for 1 (#107) of 36 sampled residents. Findings include: During an interview on 7/31/24 at 3:01 p.m., staff member L stated resident #107 had been followed by a local urology clinic and they managed his catheter orders. During an interview on 8/1/24 at 8:15 a.m., staff member B stated resident #107 and his POA decided to discharge from the urology clinic and focus on comfort care. Staff member B stated the nurses were supposed to change the scheduled catheter date if they used the PRN catheter change. Review of resident #107's progress note dated 5/14/24, showed, POA requested to DC out of facility appt at [local urology] and to focus on comfort needs at this time. Provider aware. Review of resident #107's Care Plan area for suprapubic catheter last updated on 2/1/24, showed an intervention as, [Resident #107] is followed by [Local Urology Clinic] for management of his suprapubic catheter. There was no intervention listed for the scheduled and PRN catheter changes. There was no…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-01 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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 manage catheter changes as the physician ordered for 1 (#107) of 36 sampled residents. This deficient practice had the potential to increase risk of infection and complications from multiple catheter changes. Findings Include: During an interview on 7/31/24 at 3:01 p.m., staff member L stated resident #107 had something wrong with his bladder which caused the catheter to keep clogging. Staff member L stated his catheter had not gone a full month without having to be changed. Staff member L stated she was not aware of any pain or recent infections for resident #107 related to his catheter. During an interview on 8/1/24 at 8:15 a.m., staff member B stated the nurses on the floor should have been moving the scheduled catheter change date out if they used the as needed catheter change order for resident #107. Staff member B stated resident #107 and his POA decided to discontinue urology and focus on comfort care in May 2024. Staff member B stated she was not aware of resident #107 complaining of any pain 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-01 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure transportation was provided for a dialysis appointment for a resident receiving dialysis at a nearby facility for 1 (#121) of 36 sampled residents. This deficient practice had the potential to cause health complications for the resident. Findings include: During an interview on 7/30/24 at 2:51 p.m., resident #121 stated on or about the morning of 2/10/24, he was waiting for his transportation to his dialysis appointment in the reception area, near the front door of the facility and had seen the [bus company name] van pull up out front. He was unable to open the front door due to the coded keypad. Resident #121 further stated that [bus company name] would call the facility and if nobody had answered they would leave. During an interview on 7/30/24 at 3:07 p.m., NF2 stated the [Bus Company name] called the facility and nobody answered and they left. NF2 further stated that resident #121 had to go to the hospital the day after missing his dialysis appointment and was in ICU for three days. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-01 · tag F0740 — failed to provide behavioral / mental-health care — isolated
    Ensure 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 observation, interview, and record review, the facility failed to provide behavioral health services for a resident with PTSD, who had previously attended counseling for managing her mental health for 1 (#55) of 36 sampled resident. Findings include: During an interview on 7/30/24 at 11:18 a.m., resident #55 said none of the facility's staff had ever talked to her about her PTSD. Resident #55 said her PTSD was triggered once while here, but she was unable to remember the date. Resident #55 said a certified nurse assistant burst through her privacy curtain which triggered her PTSD. Resident #55 said the incident scared her. Resident #55 said the social worker came in to see her twice, maybe. Resident #55 stated she had developed no relationships here, because the staff were too busy to take any time with her. Resident #55 stated she had no one she could talk to other than one bus driver. Resident #55 said it would help to have someone to talk to and someone to help her deal with the changes going on in her life. Resident #55 was recently started on dialysis, resident #55…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-01 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure nursing staff changed gloves and practiced hand hygiene, according to standard infection control practices, during pericare and wound care for 1 (#111); and failed to initiate enhanced barrier precautions for a resident with a PICC line for 1 (#390) of 36 sampled residents. Findings include: 1. During an observation on 7/31/24 at 2:14 p.m., staff member E gathered wound care supplies and placed them on resident #111's bedside table. Staff member E opened a drape and laid it on the bedside table. Staff member E did not sanitize the table before placing the drape and wound care supplies on the surface. Staff member E had gloves in her pants pockets to use during the resident's wound care and dressing change. Staff member F had gloves on and removed resident #111's brief prior to assisting staff member E with the dressing change for the resident's pressure ulcer. The brief was soiled and staff member F threw it away. Staff member F performed pericare around resident #111's foley catheter with clean wipes.…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-20 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to report an allegation of sexual abuse within the required timeframe of two hours to the State Survey Agency and local law enforcement, for 1 (#16) of 1 sampled resident. Findings Include: During an interview on 7/20/23 at 8:36 a.m., staff member B stated the sexual abuse allegation made by resident #16 was reported to the weekend manager at 1900 (7:00 p.m.) on 4/2/23. Staff member B stated the weekend manager did not notify her, and the administrator, until 4/3/23 at 9:00 a.m., and therefore, the weekend manager had been removed from that position. Review of the facility reported incident received by the State Survey Agency showed the event for resident #16 was submitted on 4/3/23 at 7:10 a.m., and the five-day investigation was completed on 4/8/23. Review of the facility copy of the facility reported incident investigation included a typed document titled, Chronological Review of [Resident #16] Abuse Allegation, showing the manager on duty and social services were notified of the allegation on 4/2/23 at 7:00 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-20 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond 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 immediately start investigating an allegation of sexual abuse by a staff member, for 1 (#16) of 1 sampled resident. Findings include: Review of a facility reported incident investigation, by the facility, showed an allegation of abuse was made on 4/2/23 at 7:00 p.m. to multiple staff members. Resident #16, who was involved, was not interviewed for the investigation until 4/4/23. Resident #16 was assessed by a facility nurse but never sent to the hospital for a sexual abuse assessment and or necessary treatment. The investigation showed the initial alleged perpetrator was not notified of the allegation until 4/3/23 at 2:00 p.m., and was only removed from resident #16's care at the time of the allegation, but was not removed from providing care for other residents. There was no documentation of resident #16's physician being notified of the sexual abuse allegation. Review of other resident interviews for resident #16's sexual abuse allegation showed they were all documented on 4/7/23, with no times. The questions asked 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-20 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to protect a resident from a significant medication error, for 1 (#22) of 1 sampled resident. This deficient practice had the potential to cause an increased risk of bleeding. Findings include: Review of a facility document, Medication Error Details Report - Occ #594157, dated 7/8/23, showed resident #22 received the incorrect medications 40 (mg) lovenox (a blood thinner) and 20 (mEq) potassium. Review of resident #22's MAR showed the resident was prescribed 15 mg Xarelto, a blood thinner. Resident #22's MAR showed the resident received the prescribed Xarelto on 7/8/23. During an observation and interview on 7/17/23 at 4:21 p.m., resident #22 stated she came to the facility after a fall at home. Resident #22 stated she needed assistance from staff to the bathroom to prevent her from falling again. Resident #22 stated she was taking a blood thinner medication. During an interview on 7/19/23 at 1:32 p.m., staff member E stated if a resident was accidentally given both blood thinners, lovenox and Xarelto, it would increase a…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2023-07-20 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    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 accurately code the MDS (Minimum Data Set) for 3 (#s 16, 26, and 75) of 8 sampled residents. Findings include: A. Antibiotic Use During an interview on 7/20/23 at 9:38 a.m., staff member C stated each department completed their assigned sections of the MDS, and the MDS coordinators completed the nursing sections and signed for completion of the MDS. Staff member C stated the care plans were updated weekly with the information from the MDS and EHR. Staff member C stated, once the MDS assessment was completed, they did not do a review of an MDS assessment before submitting it. Review of resident #16's current physician orders showed an order for Methanimine Hippurate (urinary antibacterial), started on 4/21/23, and given prophylactically to prevent recurrent UTI's. No other antibiotics were given through 6/30/23. Review of resident #16's Quarterly MDS, with an ARD of 6/8/23, under Section N, for medications, showed an antibiotic was not taken during the look-back period. Review of resident #16's Discharge MDS,…

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

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

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

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$27,846 in federal fines across 2 penalties.

  • $11,190 — penalty dated 2025-08-28
  • $16,656 — penalty dated 2024-08-01

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 →

RatingThis homeChain avg
Overall 3 of 53.2-0.2 vs chain
Health inspection 3 of 52.8+0.2 vs chain
Staffing 4 of 53.7+0.3 vs chain
Quality measures 4 of 54.2-0.2 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 / managerTypeRoleShareSince
COMMUNITY NURSING, INCOrganization5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/30/1986
JOHN B. GOODMAN 2006 IRRV GRANTOR TROrganization5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/28/2017
SOUTH DAKOTA TRUST COMPANY, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/28/2017
BENSON, RANDALLIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICERNO PERCENTAGE PROVIDEDsince 02/28/2017
SALMEN, THOMASIndividual5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/28/2017
WEICHERT, JAMESIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTORNO PERCENTAGE PROVIDEDsince 02/28/2017
WILSON, MARKIndividual5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/28/2017
STRAUSS, DEEIndividualW-2 MANAGING EMPLOYEEsince 07/26/2018
EDINGER, CRAIGIndividualCORPORATE OFFICERsince 12/19/2016
KNACKE, CLINTONIndividualCORPORATE OFFICERsince 10/12/2022
OLSON, DENISEIndividualCORPORATE OFFICERsince 09/16/2013

CMS files one row per role, so the 13 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.

3 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.

$17.4M
Net patient revenuemost recent cost report
-10.3%
Operating marginrevenue minus expenses
$2.3M
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 52%Medicare 20%Other / private 28%

This home reported $2.3M paid to related parties — landlords or management companies under common ownership — equal to about 12% 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. 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

$393per resident / day
operating cost
$11,945per month
≈ monthly operating cost
$356per day
avg. revenue, all payers

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

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Montana Medicaid page.

Typical monthly cost in Montana
$8,973/mo
Nursing home (semi-private)
$9,581/mo
Nursing home (private)
$6,075/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 275043. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-28, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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