Sheridan Memorial Nursing Home
440 W Laurel Ave, Plentywood, MT 59254 · Non profit - Corporation · 45 certified beds · (406) 765-3700 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2026
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, 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 (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $10,358 in federal fines (most recent 2025-07-30)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (60%) 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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 16.7% | 18.7% | 15.4% | typical |
| Long-stay residents who lose too much weight | 12.4% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 7.0% | 2.1% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 7.5% | 2.9% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 3.5% | 5.6% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.6% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.2% | 4.4% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 13.6% | 17.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 28.1% | 15.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 96.7% | 93.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.2% | 6.3% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 30.7% | 24.1% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.3% | 20.4% | 17.1% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.87 | 1.38 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 5.99 | 2.16 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Staffing
How full it usually is: this home is certified for 45 beds and averages 24.1 residents a day — about 54% occupied, or roughly 21 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 6.10 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.37 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 4.45 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 5.28 hrs/resident/day on weekends vs 6.43 on weekdays — 18% thinner on weekends. RN hours go from 1.61 to 0.78 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 60% 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
22 citations, most serious first. The 12 most serious are shown; the remaining 10 are one tap away and print in full.
- Actual harm · G2026-04-09 · 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 interview and record review, the facility failed to ensure a resident was free from abuse and neglect of care needs for 1 (#1) of 3 sampled residents. The deficient practice resulted in the resident feeling worthless, anxious, confused, and feeling like she was being punished. Findings include: Review of a Facility-Reported Incident, dated 3/7/26, showed resident #1 reported she was forced to remain in a recliner in the day lounge rather than in her bed. The resident also stated she was denied water upon request and did not have access to a call light or any other way to summon help if needed. The report also showed that the resident repeatedly expressed feeling as if she was being punished for something.During an interview on 4/8/26 at 8:28 a.m., staff member H stated she was assigned to care for resident #1 on the day shift on 3/7/26. Staff member H stated resident #1 was in a recliner in the day lounge when she came on shift on the morning of 3/7/26. Staff member H stated resident #1 was sitting in a recliner, which was unusual for her. The staff member stated that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2025-07-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to safely use a sit-to-stand lift when transferring a resident, causing injuries to include fractured ribs, and the resident was hospitalized for further evaluation, for 1 (#26) of 4 sampled residents for accidents. Findings include:Review of a facility reported incident, sent to the State Survey Agency, dated 6/20/25, showed resident #26 was found to have a large area of bruising over his right chest wall with swelling. The area was firm and tender to touch. Resident #26 was sent to the ED for further evaluation. The facility investigation concluded the used of the sit-to-stand lift for transferring resident #26 was the cause of the injury. The investigation did not show if the facility determined the lift sling being used was appropriate for resident #26. The resident was found to have an elevated PT/INR that caused significant bruising and hematoma on the right chest wall. Resident #26 did not complaint of pain in that area, per 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 · Ecited before2026-04-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 staff failed to use a gait belt when ambulating a resident, resulting in a minor injury, which was a skin tear with tendon exposure to the left fourth digit, requiring only nursing treatment for 1 (#4); and failed to evaluate and modify Interventions to prevent future falls for 3 (#s 2, 4, and 5) of 3 residents sampled for falls. These deficient practices contributed to continued falls for the residents and increased the risk of potential injuries. Findings Include:1. Review of a Facility-Reported Incident, dated 11/4/25, showed resident #4 fell while ambulating with staff member K. Resident #4 was using a rolling walker and was wearing supplemental oxygen. Staff member K turned her back on the resident, and the resident lost her balance, falling backward onto her bottom. The report showed the resident hit her left arm and hand on the door jam and sustained a minor injury, which was a skin tear with tendon exposure on her left fourth finger. The resident was not wearing a gait belt. A dressing was applied by the nurse, and 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.
- Potential for harm · F2025-07-30 · tag F0585 — failed to handle grievances — widespreadHonor 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 establish a grievance policy which included information on how to file a grievance anonymously for 2 (#s 19 and 20) of 21 sampled residents; and failed to post the grievance officer's address and phone number in a prominent location. This deficient practice affected all who have the right to file a grievance anonymously and who to contact if they wish to file a grievance. Findings include: During an interview on 7/29/25 at 9:21 a.m., resident #20 said he did not know anything about how to file a grievance or the grievance process. He did not know there was a process to file a grievance anonymously. Resident #20 said he had not seen a grievance form or a place to deposit the form. During an observation on 7/30/25 at 9:56 a.m., there was no information posted identifying who the grievance officer was and the required contact information for the grievance officer. During an interview on 7/30/25 at 11:44 a.m., resident #19 stated she had not filled out a complaint or grievance before. Resident #19 stated she did…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-07-30 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to maintain documentation of the Medical Director's (or Designee's) attendance and participation for Quality Assurance and Performance Improvement (QAPI) meetings, which were at a minimum, required to be completed quarterly. The Medical Director had involvement in the oversight of the care and services, and ensuring services met professional standards for care, and provided oversight for the review and approval of policies and procedures. This failure could affect all residents. Findings include:During a record review of the facility QAPI binder, on 7/30/25 at 4:18 p.m., one document for April 2025 was found in which a medical provider attended the scheduled facility QAPI meeting. Review of documents with meeting dates from September 2024 to March 2025, and May 2025 to July 2025, did not show a medical provider or director in attendance at the QAPI meetings, although attendance was required. During an interview on 7/30/25 at 4:33 p.m., staff member B and staff member D stated they were filling in to answer QAPI-related…
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 · E2025-07-30 · 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 staff failed to uphold proper infection prevention and control practices during medication administration for 3 (#s 2, 22, and 27) of 4 residents receiving medication. Findings include:During an observation on 7/29/25 at 3:52 p.m., staff member Q prepared medications for resident #27, and failed to perform hand hygiene prior to handling the medications for the administration to resident #27. One of the two medications to be given to #27 was dropped onto the surface of the cart by a staff member Q, and then picked up with a plastic spoon. The medication was placed in the medication cup. Staff member Q failed to perform hand hygiene before administering the medications to resident #27, and the surface of the medication cart was not observed to be sanitized prior to the medication preparation. During an observation on 7/30/25 at 7:23 a.m., staff member Q administered medication to resident #22, but failed to perform hand hygiene prior to handling medications for the resident and administering them.During an observation 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 · D2025-07-30 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to identify a resident's past history of trauma and failed to identify triggers to avoid re-traumatization for 1 (#5) of 21 sampled residents. Findings include: Review of resident #5's electronic health record showed the resident was seen for the treatment of chronic post-traumatic stress disorder, by NF4. Review of the NF4 provider notes for resident #5 showed the following: -1/30/24, . 1. Chronic post-traumatic stress disorder - Recent medication changes have actualized and been effective . - 4/8/24, .2. Chronic post-traumatic stress disorder - Will increase the venlafaxine by double from 75 mg to 150 mg. - 5/6/24, .2. Chronic post-traumatic stress disorder - She was either in a dissociative state today or acutely confused. Regardless she still having quite a bit of depression. Will increase the venlafaxine from 150 mg daily to 225 mg. [sic] - 8/20/24, .2. Chronic post-traumatic stress disorder, F43.12 Post-traumatic stress disorder, chronic. - 12/11/24, .2. Chronic post-traumatic stress disorder, F43.12 Post-traumatic…
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 · D2025-07-30 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each 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 promptly refer a resident with lost partial dentures to dental services for 1 (#11) of 21 sampled residents. The deficient practice caused the resident to go without his partial denture, and the resident had experienced a weight loss. Findings include:During an interview on 7/30/25 at 12:46 p.m., NF1 stated when she came to pick up resident #11 for a home visit on the Christmas holiday, he was not wearing his upper partial dentures. NF1 stated she was informed by staff when she came to pick up resident #11 that his upper partial dentures were missing. NF1 stated the partial dentures were never found, and the facility had not offered to refer the resident to dental services for the missing partial dentures or to replace them. NF1 stated she, and her family, were disappointed that the partial dentures were missing because they planned to take a family photo, and the loss of dentures would compromise how resident #11 looked in the family photo. NF1 stated resident #11 was on a pureed diet, and he didn't like the pureed…
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 · D2025-07-30 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to recognize, identify, and call a physician for confirmation of a coumadin order not being discontinued or held, for a resident with a critical lab value, for 1 (#26) of 3 sampled residents on coumadin. Findings include:During an interview on 7/30/25 at 10:47 a.m., staff member B said resident #26 was discharged from the emergency department with no medication changes. Resident #26's Coumadin dosage was not stopped, and it was not questioned by the nursing staff. Staff member B said his expectation was for staff to use their nursing judgment and if they had a question, contact the provider for clarification. Staff member B said critical thinking should have been used, especially when the patient had a known elevated PT and INR.During an interview on 7/30/25 at 2:40 p.m., staff member C said he had intended to hold the Coumadin for resident #26. The medication was held in the hospital EMR system but the hold order did not follow through to the long-term…
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 · D2024-07-03 · tag F0553 — failed to let residents help plan their care — isolatedAllow resident to participate in the development and implementation of his or her person-centered plan of care.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility staff failed to include 1 (#14) of 16 sampled residents, in care plan meetings. Findings include: During an interview on 7/2/24 at 8:05 a.m., resident #14 said she was not invited to any care plan meetings. Resident #14 stated her family goes, but she was not invited. Resident #14 said she would like to go to the meeting. Review of resident #14's electronic medical record failed to show any documentation of the resident being invited to attend her care plan meetings. Review of resident #14's MDS showed resident #14 was assessed for her cognitive condition using a Brief Interview for Mental Status. The result was a score of 13; cognitively intact. During an interview on 7/2/24 at 9:00 a.m., staff member C said she calls, emails, or talks to resident family members to invite them to care plan meetings. Staff member C said she does not document the invitations to the care plan meetings. Staff member C stated she will invite resident #14 to her care plan meetings going forward.
- Potential for harm · D2024-07-03 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to identify bilateral grab bars as a potential restraint, and did not complete a risk assessment, obtain a consent, or have restraint monitoring, for 1 (#10) of 16 sampled residents with bilateral grab bars in place. Findings include: During an observation on 7/1/24 at 1:53 p.m., bilateral grab bars were observed on resident #10's bed. During an interview on 7/1/24 at 4:16 p.m., NF3 said he probably gave consent for the bilateral grab bars, because resident #10 fell out of bed and got bruised up. NF3 said resident #10 had head scans due to falls and hitting her head. During an observation on 7/2/24 at 10:05 a.m., bilateral grab bars were observed on resident #10's bed. Review of resident #10's electronic medical record failed to show documentation a risk assessment was completed, a physician's order obtained, or a signed consent authorizing the use of bilateral grab bars on resident #10's bed. Review of resident #10's MDS with an assessment reference date of 4/11/24, showed resident #10 is dependent for turning…
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 · D2024-07-03 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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 the pharmacist was monitoring a resident receiving an as needed psychotropic medication for an excessive duration for 1 (#8) of 16 sampled residents. Findings include: Review of resident #8's MAR, dated from 2/29/24 to 7/3/24, showed the resident received as needed doses of lorazepam on 4/4/24 at 5:43 p.m. and 4/11/24 at 10:30 a.m. During an interview on 7/3/24 at 11:21 a.m., staff member B stated she was not aware resident #8 had an order for as needed lorazepam which was in place for more than 14 days. Staff member B did not know why the pharmacist did not address the situation with the medical provider. Review of resident #8's Medication Regimen Reviews, dated March of 2024 thru May 2024, failed to show the pharmacist identified the as needed use of lorazepam for more than 14 days. The review forms failed to show the pharmacist contacted the provider regarding the issue. Review of the facility policy titled, Psychotropics, dated 8/23/23, showed the pharmacist was responsible for monitoring the use of psychotropic…
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 10 citations
- Potential for harm · D2024-07-03 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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 observation, interview, and record review, the facility failed to ensure as needed psychotropic medications were limited to 14 days unless there was provider documentation explaining the rationale for continuing the medication, for 1 (#8) of 16 sampled residents. Findings include: During an observation on 7/1/24 at 3:58 p.m., resident #8 was lying in her bed with her eyes closed. Resident #8 did not rouse or open her eyes to her name being spoken in a normal voice. Review of resident #8's provider order, dated 2/29/24, showed the resident had an order for lorazepam, twice a day, as needed, for anxiety or shortness of breath. Review of resident #8's MAR, dated from 2/29/24 to 7/3/24, showed the resident received as needed doses of lorazepam on 4/4/24 at 5:43 p.m. and 4/11/24 at 10:30 a.m. No other as needed doses of lorazepam were documented as given. During an interview on 7/3/24 at 11:21 a.m., staff member B stated she was not aware resident #8 had an order for as needed lorazepam which was in place for more than 14 days. Staff member B stated the medication nurse, or 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 before2024-07-03 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to report an allegation of verbal abuse within 24 hours of the incident, for 1 (#19) of 16 sampled residents for abuse reporting. Findings include: Review of a Facility Reported Incident submitted to the State Survey Agency, dated 10/10/23, showed there was an allegation of verbal abuse by a staff member, towards resident #19. The report showed the incident occurred before 8:00 a.m. on 10/5/23 and was reported to staff member F at 11:30 a.m. on 10/5/23. The initial report of the incident was not submitted until 10/10/23, which was five days after the required reporting timeline. During an interview on 7/3/24 at 9:15 a.m., staff member B stated she was responsible for submitting abuse allegations to the state reporting portal. Staff member B was not able to explain why the initial report to the incident portal was not submitted within 24 hours of the incident. Staff member B stated she was aware of the required reporting timelines. Review of the facility's policy titled, Abuse, dated 8/27/23, showed, B. The Nursing Home will…
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 before2024-06-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent elopements resulting in a fall with injury for 1 (#1) out of 1 sampled resident. Findings include: Review of a facility incident for resident #1 dated, 5/29/24 showed, .Resident (#1) eloped from the facility. Resident fell out of w/c in the street outside the building and received injuries to his head. Facility was not aware resident had eloped from the building . Incident Description: Resident was attempting to get onto elevator prior to elopement .Staff that were downstairs outside came up the stairs and informed us that one of our residents were downstairs. Staff down immediately to assist. Resident had fallen out of his wheelchair into the street .Noted bleeding and hematoma to his R upper eyebrow. Superficial rash to hairline .On call provider to unit to assess resident .Findings .The resident went down the elevator to door B4 and exited out as another person entered the building. The resident fell out of their chair in the road next to the curb. A right-side…
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 · F2023-06-07 · tag F0761 — failed to label and store drugs safely — widespreadEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to ensure storage of schedule II-V medications were in separately locked, permanently affixed compartments; ensure that all drugs and biologicals used in the facility were labeled in accordance with professional standards, including expiration dates; and failed to remove expired items for disposal for one medication room and one medication cart. Findings include: During an observation on 6/6/23 at 4:18 p.m., staff member C was present during the medication room and medication cart review, and the following items were found: - pneumococcal 13 valent was in the refrigerator with an expiration date of [DATE], - acetaminophen suppositories 650 mg were in the refrigerator with an expiration date of 6/1/23, - Lidocaine liquid was in the refrigerator with an expiration date of 3/23, - [NAME] occult liquid was in the cabinet with an expiration date of 4/22, - Aspercreme was in the cabinet with an expiration date of 2/23, - brimonidine tartrate…
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 · E2023-06-07 · tag F0552 — patternEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility staff failed to provide psychotropic consent forms explaining the risks and benefits to residents or family members for 6 (#s 17, 19, 20, 22, 28, and 30) of 8 sampled residents. Findings include: 1. During an observation on 6/6/23 at 8:33 a.m., resident # 17 was lying in bed with her eyes closed. During an interview on 6/6/23 at 12:20 p.m., staff member C stated resident #17 went in cycles where she was more active and alert. Staff member C stated resident #17 was more active in the afternoons and evenings. On 6/6/23 at 2:33 p.m., a call was placed to NF4 regarding the risks and benefits consent form for psychotropic medications. NF4 had not called back by the end of the survey. During an interview on 6/7/23 at 7:58 a.m., staff member B stated psychotropic consents were completed on admission or with any changes. A record review of resident #17's medication administration record, dated June 2023, showed the following psychotropic medications: - Lorazepam…
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 before2023-06-07 · tag F0609 — failed to report abuse allegations — patternTimely 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 in interview and record review, facility staff failed to complete and report findings in a timely manner for investigations for 5 (#s 6, 13, 14, 17, and 28) of 5 sampled residents. Findings include: Centers for Medicare and Medicaid services had directed long term facilities to report the findings of their investigations within five days of the date of incident occurring. 1. Review of a facility reported incident showed an allegation of staff to resident abuse for resident #6. This allegation occurred on 8/21/22, and was reported to the State Survey Agency on 8/21/22. The facility's investigation and findings were not reported to the State Survey Agency until 10/8/22. There was 48 days between the submission of the allegation, and the submission of the final investigation. During an interview on 6/7/23 at 2:23 p.m., staff member B was not aware of the delay in reporting the findings of this incident. Staff member B said the findings for all investigations should be reported to the State Survey Agency within five days from the date the incident occurred, which would have been…
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 · E2023-06-07 · tag F0610 — failed to investigate and act on abuse reports — patternRespond 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, facility staff failed to protect all residents in the facility during an investigation of allegations of abuse for 6 (#s 1, 6, 12, 17, 20 and 28) of 6 sampled residents. Findings include: 1. Review of a facility reported incident, dated 8/21/22, showed resident #6 had made allegations of physical abuse against staff member J. The facility reported incident did not show staff member J had been removed from resident care contact during the investigation. During an interview on 6/7/23 at 2:26 p.m., staff member B said staff member J was not suspended during the investigation into allegations of abuse made by resident #6. Staff member B said staff member J could not provide care to resident #6. Staff member J continued to provide direct resident care to all the other residents in the facility. The facility failed to protect all residents from potential abuse during a staff to resident investigation of physical abuse by a staff member. Staff member B did not provide any additional information on monitoring staff member J as he continued to provide…
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 · D2023-06-07 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to develop a comprehensive care plan which addressed monitoring and interventions for a resident on an antiplatelet aggregate medication (Plavix) for 1 (#19) of 2 sampled residents. This deficient practice had the potential for more than minimal harm due to not having any monitoring or interventions in place for medication side effects. Findings include: During an observation on 6/6/23 at 9:35 a.m., resident #19 was sitting in a Broda (reclining) chair with his eyes closed, he appeared to be asleep. On the back of his right and left hands there were large bruises noted. The bruising appeared brown. During an interview on 6/6/23 at 2:17 p.m., NF2 stated resident #19 did get a medication that increased bruising. NF2 stated resident #19 always had bruises because of the Plavix (clopidogrel). NF2 stated resident #19 frequently fell, and when he fell the bruising was worse. During an interview on 6/7/23 at 10:00 a.m., staff members D and F…
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 · D2023-06-07 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to prevent a pressure ulcer for 1 (#19) of 2 sampled residents. This deficient practice resulted in harm for the resident due to surgical intervention, ongoing dressing changes, and a MRSA infection in the wound. Findings include: During an observation on 6/6/23 at 7:45 a.m., resident #19 was sitting in a Broda chair and appeared to be sleeping. During an observation on 6/6/23 at 9:35 a.m., resident #19 was sitting in a Broda chair by the nurse's station. Resident #19 was in the same position that he was in 2 hours earlier in the morning. During an interview on 6/6/23 at 2:17 p.m., NF2 stated resident #19 developed a wound on his coccyx after he was admitted to the facility. Resident #19 was admitted to the facility on [DATE]. NF2 stated resident #19 had to have the wound surgically debrided, and a wound machine to help heal the sore. NF2 stated resident #19's wound is much better now. During an observation and interview on 6/7/23 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 · D2023-06-07 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, facility staff failed to administer prescribed medication in accordance with the manufacturer's specifications, and within standards of practice for optimal therapeutic effect, for 1 (#22) of 5 sampled residents. Findings include: During an observation and interview on 6/7/23 at 7:45 a.m., staff member I administered the following medications to resident #22: - furosemide 80 mg - amlodipine 10 mg - eliquis 5 mg - florigen 1 cap - ferrous gluconate 324 mg - gabapentin 300 mg - isosorbide mononitrate 60 mg - levothyroxine 88 mcg (pharmacy tag showed 6:00 a.m. administration and it was in a purple cartridge) - lisinopril 40 mg - metoprolol 25 mg - omeprazole 20 mg - sodium bicarb 650 mg - venlafaxine 75 mg Staff member I stated, The purple cartridge does not have a meaning, pharmacy gives us various colors sometimes. During an interview on 6/7/23 at 1:32 p.m., staff member B stated, The purple cartridge means night shift should be giving the medication. Yes, all levothyroxine should be given at six a.m. unless resident is set up for 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$10,358 in federal fines across 1 penalty.
- $10,358 — penalty dated 2025-07-30
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| RUSBULT, LAURA | Individual | W-2 MANAGING EMPLOYEE | since 04/25/1981 |
| BENSON, DONALD | Individual | CORPORATE DIRECTOR | since 03/22/2017 |
| HANSEN, PAUL | Individual | CORPORATE DIRECTOR | since 02/16/2021 |
| JENSEN, NANCY | Individual | CORPORATE DIRECTOR | since 08/23/2017 |
| MILLER, MYRNETTE | Individual | CORPORATE DIRECTOR | since 03/01/2011 |
| SAMPSEN, CORY | Individual | CORPORATE DIRECTOR | since 02/16/2021 |
| NELSON, KODY | Individual | CORPORATE OFFICER | since 08/21/2020 |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
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 275070. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-30, 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.