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Wibaux County Nursing Home

712 Wibaux St S, Wibaux, MT 59353 · Non profit - Other · 40 certified beds · (406) 796-2429 Medicare & Medicaid certified

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Flagged for abuse1 immediate-jeopardy citation$16,985 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • lower-than-typical staff turnover (35% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Sep 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $16,985 in federal fines (most recent 2025-09-24)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (1/5)

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

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

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 3 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
1/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2000 Montana Avenue
Pharmacy
1002 W Bell St · (406) 377-4920 · Call to confirm hours
Grocery
120 W Orgain Ave
Park
Typically dawn to dusk
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 3 of 5
Long-stay residentspeople who live here 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 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.

Overall rating1★
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 increased18.4%18.7%15.4%worse
Long-stay residents who lose too much weight0.9%6.2%5.4%better
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 infection9.1%2.9%2.0%worse
Long-stay residents with depressive symptoms1.9%5.6%6.5%better
Long-stay residents who were physically restrained1.8%0.6%0.1%worse than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury4.5%4.4%3.3%worse
Long-stay residents whose ability to walk worsened12.0%17.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication15.0%15.8%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%93.6%95.3%typical
Long-stay residents with pressure ulcers10.3%6.3%4.7%worse
Long-stay residents with worsening bladder/bowel control19.5%24.1%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table18.1%20.4%17.1%typical
Long-stay hospitalizations per 1,000 resident days0.521.381.67better
Long-stay outpatient ER visits per 1,000 resident days1.282.161.80better

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.

Staffing

0.67
RN hours/ resident / day
0.26
LPN hours/ resident / day
1.86
Aide hours/ resident / day
2.79
Total nurse hours/ resident / day
0.34
RN hoursweekends
35.0%
Total nursing turnover
40.0%
RN turnover

How full it usually is: this home is certified for 40 beds and averages 34.2 residents a day — about 86% occupied, or roughly 6 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.79 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.67 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.86 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.23 hrs/resident/day on weekends vs 3.02 on weekdays — 26% thinner on weekends — a notable drop. RN hours go from 0.80 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 35% is below the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

7
deficiencies at the latest standard inspection (2026-04-09)
9
at the previous standard inspection (2025-03-13)

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.

30 citations, most serious first. The 13 most serious are shown; the remaining 17 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-09-24 · 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 interviews and record reviews, a facility staff member failed to transfer a resident properly while using a mechanical lift and ensure that two staff members were assisting. The resident fell from the lift and sustained a fracture, a head injury, and passed away at the hospital. Documentation reflected that the fall contributed to the resident's death, for 1 (#1) of 7 sampled residents. Findings include: On [DATE] at 11:35 a.m., the facility Administrator, Assistant Administrator/Business Office Manager, and the Director of Nursing were notified of an Immediate Jeopardy (IJ) situation, which involved resident #1 related to a fall with major injuries. The IJ pertained to F689 - Free of Accident Hazards/Supervision/Devices. The Severity and Scope of the Immediate Jeopardy was identified to be at the level of J, and upon removal of immediacy, lowered to G.On [DATE] at 11:40 a.m., the facility provided an acceptable plan to remove the immediacy for the residents residing in the facility who are at continued…

    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 before2025-09-24 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility staff failed to protect 1 (#1) of 8 residents sampled for neglect of care by the staff when safe lifting practices were not employed during resident transfers with a mechanical lift, and the facility policies were not followed. Findings include:During an interview on [DATE] at 2:01 p.m., NF1 said, “I had been a [position title] for seven years, and I never used mechanical lifts by myself before coming here. I knew I should have a second person to assist because I was trained and have always had two people for lifts. NF1 said she was trained at this facility by CNAs and was told that this facility only used one person to transfer residents with a mechanical lift. During an interview on [DATE] at 2:00 p.m., staff member H said the staff have been completing mechanical lifts without a second person in attendance. Staff member H said this had been going on for over a year and was probably longer. During an interview on [DATE] at 2:33 p.m., staff member C said 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2024-02-29 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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 failed to implement appropriate measures to prevent skin breakdown, to provide consistent care, monitoring, and treatment of pressure ulcers for 1 (#14) of 16 sampled residents, resulting in the development of one Unstageable pressure ulcer on the right ankle and one Stage Two pressure ulcer on the right buttock. The deficient practice had the potential to cause worsening of wounds and infection for the resident. Findings include: During an observation on 2/27/24 at 12:01 p.m., resident #14 was observed sitting in his Geri Chair (special wheelchair) with no pressure relieving cushion in place. During observations of resident #14's bed, on 2/27/24 at 2:40 p.m. and 2/28/24 at 11:23 a.m., a pressure reducing mattress was observed on the bed. During a wound care observation on 2/28/24 at 2:28 p.m., two surveyors observed a Stage Two pressure ulcer on resident #14's right buttock. During an interview on 2/28/24 at 11:23 a.m., staff member I stated the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-04-09 · 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 failed to implement an effective infection prevention and control program, including failure to ensure Enhanced Barrier Precautions (EBP) were implemented for 2 (#s 1 and 4) of 13 sampled residents; and failed to implement a system for the ongoing surveillance, identification, and prevention of infections for all residents. The failures placed residents at risk for developing and transmitting infections. Findings include: Enhanced Barrier Precautions: 1. During an interview on 4/8/26 at 11:52 a.m., staff member J stated resident #1 had an open pressure wound on her left heel and coccyx area. Staff member J stated she was not aware enhanced barrier precautions should be used when providing care for resident #1 due to the pressure ulcers. During an interview on 4/8/26 at 12:10 p.m., staff member K stated she usually works on the Keys unit and was not aware of any residents on enhanced barrier precautions. Staff member K stated resident #1 had two pressure wounds, one on her left heel and one on her coccyx area. 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-04-09 · tag F0882 — widespread
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    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 designated infection preventionist was qualified by education, training, or experience to oversee the infection prevention and control program for the facility. The failure placed all residents at increased risk for the development and transmission of infections. Findings include:During an interview on 4/8/26 at 1:33 p.m., staff member A stated staff member B started in her role at the facility on 11/4/25, and had been taking the CDC Infection Preventionist certification training, but was only up to module eight because she was busy filling in on the floor as needed and had not had time to complete the training. During an interview on 4/9/26 at 9:13 a.m., staff member B stated she started in November 2025 and was responsible for the facility's infection prevention and control program. Staff member B stated, I am still learning . I haven't finished the infection preventionist course yet. Staff member B explained that some of the information she was learning was new to her. Review of a facility document titled…

    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 · E2026-04-09 · tag F0609 — failed to report abuse allegations — pattern
    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 ensure an allegation of neglect was reported to the State Survey Agency within the required timeframe for 1 (#13); failed to ensure allegations of abuse by staff were reported to the administrator and State Survey Agency within the required timeframe for 3 (#s 12, 19, and 25) of 6 residents sampled for abuse and neglect reporting. The failures placed the residents at risk for continued abuse or neglect and delayed investigation and intervention by the State Survey Agency. Findings include:1. Review of a facility-reported event, submitted to the State Survey Agency on 3/20/26, showed an event involving resident #13 that occurred on 3/17/26 during the night shift and involved a lack of hygiene care and a lack of monitoring following episodes of vomiting. During an interview on 4/7/26 at 10:51 a.m., staff member A stated the event with resident #13 was identified on the morning of 3/18/26 after review of video surveillance. Staff member A stated the facility reported the concerns to the travel staffing agency and terminated…

    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 · Dcited before2026-04-09 · 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 develop and implement a baseline care plan, which included the minimum necessary instructions needed to provide effective and person-centered care of a resident for 1 (#2) of 13 sampled residents. Findings include:During an interview on 4/9/26 at 8:56 a.m., staff member B stated nursing was responsible for starting baseline care plans for residents on admission. Staff member B stated that the baseline care plan should include the health information necessary to care for a resident properly. Staff member B stated the facility used a software program to develop the baseline care plans, and facility staff were not able to include all the information related to a resident's care due to limitations with the program. Staff member B stated she would need to research options available for the completion of a thorough baseline care plan. Review of resident #2's physician progress note, dated 3/8/26, showed the resident was to be admitted to the facility 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-09 · 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 — the official record, unedited, may be distressing

    Based on observation, interview, and record review, the facility failed to revise a care plan to reflect a resident's current care needs for 1 (#1) of 13 sampled residents. Findings include:During an observation on 4/7/26 at 12:30 p.m., resident #1 was sitting in her wheelchair at the dining table. The resident was noted to have heel protectors on her feet.During an interview on 4/8/26 at 11:44 a.m., staff member C stated resident #1 had a pressure wound on her left heel. Staff member C stated resident care plans were updated weekly, and she was not sure why resident #1's care plan had not been revised for the pressure wound. Review of resident #1's physician progress note, dated 4/3/26, showed resident #1 had an Unstageable pressure ulcer on the left heel, as well as a Stage II pressure ulcer on her coccyx.Review of resident #1's current care plan, reviewed on 4/8/26, did not reflect that the resident had developed pressure wounds on her left heel and coccyx area, or the use of heel protectors.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-09 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure nursing staff documented wound care, wound status, and dressing changes in accordance with professional standards of practice for 1 (#4) of 3 residents sampled for wounds. The failure placed the resident at increased risk for ineffective wound healing, undetected changes in condition, and infection. Findings include:During an observation on 4/6/26 at 2:33 p.m., resident #4 was observed in his room with heel protector boots in place over bilateral foot wound dressings.During an interview on 4/7/26 at 4:02 p.m., staff member H stated he only documented wound treatments or dressing changes .if the wound looked a lot better or a lot worse.During an interview on 4/8/26 at 3:30 p.m., staff member C stated she or staff member B was responsible for completing weekly wound assessments, including wound measurements, evaluation, the wound deterioration or healing, and physician notifications, if needed. Staff member C stated the nursing staff was responsible for monitoring wound dressings and completing dressing…

    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 · D2026-04-09 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide necessary care and services to maintain a resident's quality of life for personal dignity, comfort, and safety for 1 (#13) of 13 sampled residents. The failure resulted in the resident remaining in vomit-soiled conditions for an extended period of time. The resident refused care and was periodically checked on by staff, but did not receive the level of care or assessment necessary related to her emesis episodes or risks related to them. Findings include: Review of a facility-reported event submitted to the State Survey Agency on 3/20/26 showed NF8 and NF9 failed to provide hygiene care and failed to assist resident #13 from a recliner following episodes of vomiting. Resident #13 was periodically checked on by staff but did not receive an appropriate assessment or care related to her vomiting episodes. During an observation on 4/8/26 at 7:35 a.m., resident #13 was observed with no skin breakdown. Resident #13 kept her eyes closed and was verbally and physically aggressive to staff during repositioning…

    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 · D2026-04-09 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to implement an effective antibiotic stewardship program, including monitoring of antibiotic use within the facility. The failure placed residents at increased risk for inappropriate antibiotic use, adverse drug reactions, and development of antibiotic-resistant organisms. Findings include:During an interview on 4/9/26 at 9:13 a.m., staff member B stated she started in November 2025 and was responsible for the infection prevention and control program, including oversight of antibiotic use. Staff member B stated providers were good about obtaining cultures and changing or discontinuing antibiotics based on culture and sensitivity reports; however, she was not currently tracking the information. Staff member B stated, I am just learning. It makes perfect sense to track the pathogens and antibiotics, and I will start tracking and monitoring them now.Review of a facility document titled Infection Control Log Book, undated, showed monthly reports generated from the facility's electronic health record system of antibiotics in use;…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-09-24 · tag F0726 — failed to have competent, trained nursing staff — widespread
    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 nurses and certified nurse assistants received training on the procedure and safety requirements for using mechanical lifts for fifteen (D, E, F, G, H, I, J, K, L, M, N, P, Q, R, NF1) of sixteen sampled staff members. The deficient practice increased the risk of harm for the seven residents in the facility still utilizing a mechanical lift. The facility reported a census of 30. Findings include: During an interview on 9/22/25 at 2:01 p.m., NF1 said she started her job at the facility about a month ago. NF1 said the Director of Nursing did not complete any training with her prior to working directly with residents. NF1 said upon hire she signed some paperwork and then trained directly with a certified nurse assistant during orientation. NF1 said during orientation the CNAs who trained her said a resident who required the use of a mechanical lift did not require two staff to assist, and NF1 could perform the task independently. NF1 said the other certified nurse assistants said they also complete the lift…

    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 · F2025-09-24 · tag F0835 — failed to run the facility competently — widespread
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record review the facility failed to ensure the facility was administered in a manner that allowed resident #1 to be provide individualized care related to mechanical lifts and falls and failed to promote the well-being and prevent physical harm, pain and death for 1 (#1) of 10 sampled residents. Findings include: Review of resident #1's care plan dated 8/5/22 showed the resident #1 needed total assistance when transferring from surface to surface. The care plan directed the staff to use a Hoyer lift with two staff members. The care plan failed to identify the size sling to be used for resident #1. Review of resident #1's nurses note dated 9/10/25 at 6:44 p.m., showed resident #1 was seen lying on her right side with the right side of her face on the floor and a large amount of blood noted on the floor around the resident. The certified nurse assistant reported the resident fell from the Hoyer lift. Emergency medical services were on the scene at approximately 6:15. Resident #1 was transported to a local hospital. During an interview 9/23/25 at 2:40 p.m.,…

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

    Administration Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · Ecited before2025-09-24 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record review the facility failed to ensure services were provided according to professional standards related to safe use of mechanical lifts for 1 (#1) of 8 sampled residents. Review of resident #1's care plan, dated 8/5/22, showed that resident #1 was totally dependent upon two staff members for transferring her from surface to surface. The care plan directed the staff to use a Hoyer fully body mechanical lift. During an interview on 9/22/25 at 2:01 p.m., NF1 had not used a mechanical lift by themself before working at the facility, and stated, I knew I should have a second person because I was trained and have always had two people for lifts. During an interview on 9/22/25 at 2:32 p.m., staff member H said she was taught to use two people when using a mechanical lift to transfer people. Staff member H said she had used the lift by herself. Staff member H said she was aware that only using one person for transferring residents with a mechanical lift was not the right way to provide the care. Staff member H said it upset her when the staffing was changed to…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-03-13 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the dietary manager completed a certification program approved by a national certifying body or had higher education in a related field. This had the potential to affect residents and their nutritional status or meal safety for those who consumed food prepared and served by the facility. Findings include: During the initial tour of the kitchen, on 3/10/25 at 11:50 a.m., no documentation of advanced training for the dietary manager was posted. During an interview on 3/13/25 at 9:47 a.m., with staff members A, B, C, and N, staff member N stated one of the issues the facility continued to review monthly had to do with staff member M's lack of certification as a dietary manager. Staff member N stated she received weekly email reports from staff member M about progress on completing the dietary manager certification. Staff member N stated staff member M worked full-time and was still not certified in the role. Staff member N stated this process was ongoing since the last plan of correction was started after…

    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 · Ecited before2025-03-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    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 observation, interview, and record review, the facility failed to timely identify elopement risks, and implement sufficient preventative interventions for residents with elopement(s), for 2 (#s 20 and 23) residents of 2 sampled for elopements who lived on the secure unit. There continued to be elopement hazards, and it was identified necessary staff were not aware of how to identify an elopement, staff failed to use interventions to prevent elopements, and one resident had repeated elopements and was at high risk of eloping. The overall elopement system was not adequate to ensure resident safety. Findings include: A review of the State Operations Manual, Appendix PP, F689 - Accidents and Hazards shows: A situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision, if necessary, would be considered an elopement. This situation represents a risk to the resident's health and safety and places the resident at risk of heat or cold exposure, dehydration…

    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 · E2025-03-13 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to maintain medical records which were accurately documented, dated, labeled, and completed in their entirety, for 5 (#s 4, 14, 18, 20 and 23) of 16 sampled residents. Findings include: 1. The following incomplete records were located in resident #4's medical records: a. A review of resident #4's hard-copy POLST form and alternate medical records, dated 3/17/20, showed: - In the section for the resident's full name, date of birth , and sex, the form had been altered by blocking out information with white out. Resident #4's name had been added to the form in the area which had been altered with white out. - In the mandatory section, where there should be a medical provider signature, the date, the time, and the providers phone number, was incomplete. The POLST form would be invalid due to the altered and missing information. b. Resident #4's staff assessment of daily and activity preference, completed on 3/12/25, was incomplete. c. Resident #4's consent for Zoloft and Zyprexa was incomplete. The observation information…

    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 · D2025-03-13 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to refer a resident with a newly evident or possible serious mental disorder or related condition for a Level II review, for 1 (#3) of 16 sampled residents. This failure put the resident at risk for not receiving services necessary for mental health. Findings include: Review of resident #3's care plan, last updated on 1/22/25, showed a diagnosis of . unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and other bipolar disorder . Review of resident #3's telehealth psychiatric progress notes showed diagnoses of .bipolar affective disorders or recurrent manic episodes, anxiety disorder, insomnia and unspecified dementia without behavioral disturbances . The psychiatric progress notes also showed, 1/27/25 resident #3 was receiving Seroquel due to impulsivity. On 2/17/25, the resident's psychotropic medications were changed due to delusions. Seroquel was changed from twice a day, to just be given at bedtime, but Zyprexa Zydis 12 mg was added at noon. 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-13 · 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 observation, interview, and record review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours after admission to reflect the residents' care needs, for 4 (#s 20, 23, 24, 77) of 16 sampled residents. This increased the risk of staff not providing necessary care and services due to the lack of the baseline care plan. Findings include: During an interview on 3/11/25 at 10:19 a.m., staff members A, B, and C were present. Staff members B and C said the care plans are done by the two of them, as they were the IDT (interdisciplinary team), with help from staff member N. Staff member C said the facility has an MDS nurse, but she does not complete care plans. Staff members B and C said an attempt is made to start the baseline care plan on the day of admission, but sometimes care planning doesn't get completed. Staff members A, B, and C said they knew about the requirement for a baseline care plan. Staff member B said the computer system had a template which could be…

    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 · D2025-03-13 · 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 observation, interview, and record review, the facility failed to develop and implement individualized comprehensive care plans for 2 (#s 12 and 24) of 16 sampled residents. Findings include: Review of resident #12's comprehensive care plan, with a problem dated 4/12/23, showed the resident was an elopement risk. The care plan did not show the resident lived on the secure unit. The interventions on the care plan failed to identify what approaches should be used to prevent elopements. Resident #12 was observed in the secured unit every day of the survey. During an interview on 3/11/25 at 2:59 p.m., staff member G said resident #24, sometimes listens and will come out to the dining room. Other than that, she sits in her room and cries. Staff member G said he was unaware of what activities the resident prefers. Review of resident #24's current comprehensive care plan showed resident #24 should be encouraged to attend activities. The care plan was not individualized to identify the type of activities resident #24 was interested in. The care plan failed to identify the problem…

    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 · D2025-03-13 · tag F0660 — isolated
    Plan the resident's discharge to meet the resident's goals and needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement an effective discharge planning process for 1 (#26) of 1 sampled resident, who was discharged to another long-term care facility. Findings include: Review of resident #26's care plan, dated 4/23/24, showed the resident was a long-term resident. The interventions showed resident #26 wanted to go live closer to her daughter, to go home, or to go to an assisted living facility. Review of resident #26's nursing notes showed resident #26 eloped from the facility secured unit on the following dates: - 5/23/24, - 8/4/24, - 8/27/24. Review of resident #26's electronic medical record nursing notes, dated 12/19/24, failed to show any notes for the upcoming discharge for resident #26. The Discharge summary, dated [DATE], showed resident #26 was discharged to a long-term care facility in another town. The discharge summary did not inform the receiving facility the resident was at risk for eloping. During an interview on 3/13/25 at 11:11 a.m., with 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
  • Potential for harm · D2025-03-13 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    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 meaningful activities, designed to meet the individual resident preferences and interests, for 2 (#s 20 and 23) of 16 sampled residents. Findings include: 1. During an observation on 3/10/25 at 1:17 p.m., resident #20 was observed standing at the exit door while pushing the door handle. Resident #20 stood there for 3-4 minutes, then turned around, and paced up and down the hall several times. There were no staff interventions offered to the resident, in an attempt to alter the resident's behavior of trying to open the door, or engage resident #20 in any way. During an observation on 3/10/25 at 2:57 p.m., resident #20 was observed pacing up and down the hall. Resident #20 came into the TV room and sat next to the surveyor. When the surveyor talked to resident #20, he relaxed and listened to the surveyor for five minutes. During an interview on 3/10/25 at 3:17 p.m., staff member H said the CNAs try to put out coloring books and puzzles on weekends, but they don't do any activities. There is only one…

    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 · D2025-03-13 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to review the risks and benefits of using grab/assist bars attached to the bed, for 2 residents (#s 4 and 12) of 16 sampled residents. Findings include: During an observation on 3/10/25 at 1:10 p.m., a grab bar was observed on the left side of resident #12's bed. During an observation on 3/10/25 at 1:15 p.m., a grab bar was observed on both sides of resident #4's bed. 1. During an interview on 3/12/25 at 12:10 p.m., staff member K said resident #4 does not use his side rails during personal cares. Staff member K said he does not use them to help turn himself in bed at all. Staff member K said resident #4 may occasionally grab onto the assist bar when he is being transferred while he is sitting on the edge of the bed. Staff member K said resident #12 doesn't use the grab bars every time he gets up and out of bed. During an interview on 3/13/25 at 9:56 a.m., staff member H said resident #4 does not use his grab bars at all when she provides care or when she transfers him in or out of bed. Review of resident #4's…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-14 · 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 notify a resident's provider and family member of the events surrounding an elopement, so they may have made the necessary medical decisions for the resident following the elopement for 1 resident (#1) of 6 sampled residents. This deficient practice had the potential to affect all residents who require informed care from family and medical providers. Findings include: A review of the facility's policy and procedure titled, Elopement and Wandering Residents, with a revision date of 5/22/24, reflected: - . 6. Procedure post-elopement a. A nurse will perform a physical assessment, document, and report findings to physician. b. Any new physician orders will be implemented and communicated to the family/authorized representative . Review of resident #1's MDS: Section C, dated 7/8/24, reflected resident #1 had a BIMS of 4, a score considered to be a severe cognitive impairment. During an interview on 8/13/24 at 2:00 p.m., NF1 stated they were aware resident #1 had eloped from the facility, but were not made aware of the details…

    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 before2024-08-14 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to complete a comprehensive physical assessment to ensure the patient's physical and sexual health remained intact after an elopement which had the potential for harm of the resident related to sexual trauma, and to become withdrawn from regular activities for 1 (#1) of 6 sampled residents. Findings include: During an interview on 8/14/24 at 1:30 p.m., staff member E stated the man who came to the facility was a construction guy from the road crew. Staff member E stated the man found resident #1 in his car and thought she was drunk. He told the facility staff he took resident #1 to his RV park cabin to let her sleep it off. The man then realized, in the morning, resident #1 was confused, and was talking about finding her children while pointing to the facility. The man then decided to go ask the facility if they were missing a resident. During an observation and interview on 8/13/24 at 11:05 a.m., resident #1 was sitting at the dining room table, she was not completing any activities or watching television. 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-14 · 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 observations, interviews, and record review, the facility failed to secure the memory unit and monitor a cognitively impaired resident with a known history of elopement attempts, which resulted in the resident leaving the building unsupervised overnight, putting the resident at risk for serious injury or death, for 1 (#1) of 6 sampled residents. Findings include: Review of a Facility Reported Incident, sent to the State Survey Agency for resident #1, dated 8/4/24, reflected, . review of facility cameras, resident went out the memory lane dining room door and alarm did not sound when resident went out at 1924 (7:24 p.m.). Resident then went out the fence gate which did not alarm.8/5/24 facility staff started search for resident again and resident was found across the road at the RV park inside someone's cabin sleeping on the couch. During an interview on 8/13/24 at 12:30 p.m., staff member M stated the dining room door alarms, in the memory unit, had been broken for approximately two weeks before…

    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 · Fcited before2024-02-29 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews, the facility failed to ensure dietary staff were qualified to perform the duties necessary to manage the dining services department which increased the risk of a negative outcome related to nutrition for all residents who consumed food prepared and served by the facility's dietary department. Findings include: 1. During an observation of the kitchen on 2/27/24 at 8:06 a.m., breadcrumbs, pretzels, and powdered vanilla pudding packages stored in the dry storage were observed to be open and undated. During an interview on 2/27/24 at 2:00 p.m., staff member C stated, All items should have an open date on them and include the expiration date. We (the dietary department) are so short-staffed, I barely have time to do my supervisory duties. I am a cook and dishwasher all week. I have been in the supervisory role for about a year. I don't have my dietary manager certification yet, and my Serv-Safe certification has expired. I am enrolled in a certification program; I just don't have the time to work on it. I do work with a dietician, but he is only here…

    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 · F2024-02-29 · 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, prepare, and distribute food in accordance with professional standards for food service safety. This deficient practice had the potential to affect all residents receiving food from the dietary department. Findings include: During an observation on 2/27/24 at 7:56 a.m., a jar of salsa and a gallon of milk were in the unit refrigerator on Memory Lane and were not dated with an open date. There was also a personal lunch box in the refrigerator on Memory Lane, and it was not labeled. During the initial brief tour of the kitchen on 2/27/24 at 8:06 a.m., breadcrumbs, pretzels, and powdered vanilla pudding packages were observed to be open with no open date identified. During an observation on 2/27/24 at 8:10 a.m., staff member N was wearing gloves and scratched her head, and then at 8:15 a.m., used the same gloves to place toast on a plate that was being served to residents. During an interview on 2/27/24 at 2:00 p.m., staff member C stated, All items should have an open date on them and include 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-29 · 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

    Based on observation and interview, the facility failed to provide a clean resident room for 1 (#17) of 16 sampled residents, and failed to provide a clean environment, including the hallways and television room, which may affect all residents using the unclean areas. Findings include: During an observation on 2/27/24 at 7:56 a.m., resident #17's room had a chunk of brown debris and a cream colored substance that resembled melted ice cream on the floor next to the bed. The bathroom had brown splatter on the tank of the toilet, and the toilet bowl was dingy and discolored. The vent in the hallway outside of resident #17's room had dust and cobwebs covering the entire panel. The ceiling tiles in the hallway outside of resident #17's room had large brown stains. During an observation on 2/27/24 at 8:41 a.m., resident #17's room had the same chunk of brown debris and cream colored substance that resembled melted ice cream on the floor, and the bathroom toilet tank still had brown splatter on it. The toilet bowl still had not be cleaned. During an observation on 2/27/24 at 10:10 a.m.,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2026-04-09 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately complete multiple comprehensive Minimum Data Set (MDS) assessments for the resident's Pre-admission Screening and Resident Review (PASRR), for 1 (#12) of 13 sampled residents. Findings include:During an interview on 4/8/26 at 12:22 p.m., staff member F stated resident #12's PASRR Level One was completed on 1/3/23, and a PASRR Level Two was completed on 1/27/23. Staff member F stated that when she completed section A of the resident's MDS submission on 1/21/25 and 1/12/26, she overlooked adding PASRR information because the system pre-populated the resident's demographic information.Review of resident #12's electronic medical record showed the resident was admitted to the facility on [DATE] with a diagnosis of Anxiety, Depression, Schizoaffective Disorder, and Cerebral Palsy. A Level One PASRR was completed on 1/3/23, and the resident qualified for a Level Two screening, which was completed on 1/27/23, with recommended services received 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.

    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

$16,985 in federal fines across 1 penalty.

  • $16,985 — penalty dated 2025-09-24

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 / managerTypeRoleShareSince
COUNTY OF WIBAUXOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/08/2013
BERTELSEN, TINAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/02/2013
ROBERTS, LISAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 10/01/2017

1 organizational owner 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.

$2.6M
Net patient revenuemost recent cost report
-33.6%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 48%Medicare 0%Other / private 51%

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

$329per resident / day
operating cost
$9,987per month
≈ monthly operating cost
$246per 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 275079. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-09, 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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