18 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Great Falls, MT
2-star overall rating with 2-star inspections with abuse icon flag with $81,927 in total fines with 18 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
2621 15th Ave S, Great Falls, MT
(406) 455-5903
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
64
Certified beds
Average residents
63
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.90
Registered nurse staffing · state 0.94 · national 0.68
LPN hours / resident day
0.62
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.10
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
3.62
All reported nurse hours · state 3.97 · national 3.89
Licensed hours
1.52
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.22
Weekend nurse staffing · state 3.48 · national 3.43
Weekend RN hours
0.65
Weekend registered nurse coverage · state 0.69 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.06
CMS adjusted RN staffing hours
Adjusted total hours
4.27
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
61%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
63%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Program rank
1,231
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
58.59
Composite VBP score used to determine payment impact.
Payment multiplier
1.0138
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
3.75
Baseline 15.22% · Performance 19.70% · Measure score 3.75 · Achievement 3.75 · Improvement 0
Healthcare-associated infections
10
Baseline 4.54% · Performance 4.62% · Measure score 10 · Achievement 10 · Improvement 0
Total nurse turnover
5.09
Baseline 34.65% · Performance 42.86% · Measure score 5.09 · Achievement 5.09 · Improvement 0
Adjusted total nurse staffing
4.59
Baseline 4.26 hours · Performance 4.38 hours · Measure score 4.59 · Achievement 4.59 · Improvement 0.34
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.79% |
10.72%
1.9 pts better
|
No Different than the National Rate · Eligible stays 350 · Observed rate 6.86% · Lower 95% interval 7.03% |
| Discharge to community | 54.47% |
50.57%
3.9 pts better
|
No Different than the National Rate · Eligible stays 339 · Observed rate 51.03% · Lower 95% interval 49.4% |
| Medicare spending per beneficiary | 0.64 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 98.44% |
95.27%
3.2 pts better
|
Numerator 126 · Denominator 128 |
| Falls with major injury | 0.78% |
0.77%
About the same
|
Numerator 1 · Denominator 128 |
| Discharge self-care score | 61.7% |
53.69%
8 pts better
|
Numerator 58 · Denominator 94 |
| Discharge mobility score | 57.45% |
50.94%
6.5 pts better
|
Numerator 54 · Denominator 94 |
| Pressure ulcers or injuries, new or worsened | 3.91% |
2.29%
1.6 pts worse
|
Numerator 5 · Denominator 128 · Adjusted rate 5.03% |
| Healthcare-associated infections requiring hospitalization | 4.62% |
7.12%
2.5 pts better
|
No Different than the National Rate · Eligible stays 177 · Observed rate 1.69% · Lower 95% interval 2.64% |
| Staff COVID-19 vaccination coverage | 9.78% |
8.2%
1.6 pts better
|
Numerator 27 · Denominator 276 |
| Staff flu vaccination coverage | 67.8% |
42%
25.8 pts better
|
Numerator 139 · Denominator 205 |
| Discharge function score | 68.09% |
56.45%
11.6 pts better
|
Numerator 64 · Denominator 94 |
| Transfer of health information to provider | 99.06% |
95.95%
3.1 pts better
|
Numerator 105 · Denominator 106 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.3
0.5 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.6 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
2.2
1.6 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
94.4%
3 pts better
|
93.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.1% · Q2 100.0% · Q3 100.0% · Q4 98.3% · 4Q avg 97.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.8% |
93.7%
0.1 pts better
|
95.5%
1.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.8% |
4.2%
2.6 pts worse
|
3.3%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 7.5% · Q3 9.4% · Q4 6.8% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.4% |
4.7%
1.3 pts better
|
11.4%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 1.4% · Q3 2.6% · Q4 4.9% · 4Q avg 3.4% |
| Percentage of long-stay residents who lose too much weight | 8.3% |
5.9%
2.4 pts worse
|
5.4%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 5.9% · Q3 5.8% · Q4 12.5% · 4Q avg 8.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.3% |
17.4%
1.9 pts worse
|
19.6%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 19.8% · Q3 25.0% · Q4 22.8% · 4Q avg 19.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.9% |
20.6%
0.7 pts better
|
16.7%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 18.0% · Q3 20.5% · Q4 23.9% · 4Q avg 19.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 22.1% |
19.7%
2.4 pts worse
|
16.3%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.5% · Q2 23.8% · 4Q avg 22.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 34.6% |
19.8%
14.8 pts worse
|
14.9%
19.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.1% · Q2 45.0% · Q3 28.3% · Q4 28.3% · 4Q avg 34.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 9.5% |
2.6%
6.9 pts worse
|
1.0%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 12.7% · Q3 7.7% · Q4 7.7% · 4Q avg 9.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
2.9%
0.5 pts better
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 3.3% · Q3 0.0% · Q4 3.4% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.5% |
25.4%
9.1 pts worse
|
19.8%
14.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.5% · Q2 34.9% · Q3 32.3% · Q4 37.5% · 4Q avg 34.5% |
| Percentage of long-stay residents with pressure ulcers | 6.3% |
6.4%
0.1 pts better
|
5.1%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 7.1% · Q3 6.0% · Q4 0.0% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.3% |
78.7%
7.6 pts better
|
81.7%
4.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 81.4% · Q2 93.9% · Q3 93.5% · Q4 88.9% · 4Q avg 86.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.3% |
15.0%
7.7 pts better
|
12.0%
4.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.3% · Observed 7.7% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.6%
1.6 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.8% |
73.8%
8 pts better
|
79.7%
2.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.6% |
19.4%
9.2 pts worse
|
23.9%
4.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.6% · Observed 27.7% · Expected 23.1% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (7 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Quality of Life and Care (9 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-07-03
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-07-03
Fire Safety
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Corrected 2025-07-24
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-07-03
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-03
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-01
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-07-01
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-07-01
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-08
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-06-08
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-06-08
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-08
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-08
Inspection history
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-12-30
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-11-19
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-11-14
Health
Respond appropriately to all alleged violations.
Corrected 2025-11-14
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-11-14
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-11-14
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-04
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-07-04
Health
Provide activities to meet all resident's needs.
Corrected 2025-07-04
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-07-04
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-07-04
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-07-04
Health
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.
Corrected 2025-07-04
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-07-04
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-07-04
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-04
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-07-04
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2025-07-04
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-01-21
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-01-21
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-10-30
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-10-30
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-02-21
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-14
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-06-14
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-06-14
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-14
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-14
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-06-14
Health
Respond appropriately to all alleged violations.
Corrected 2023-06-14
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-06-14
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-14
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-06-14
Health
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected 2023-06-14
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-06-14
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-06-14
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-06-14
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-06-14
Health
Honor 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.
Corrected 2023-06-14
Health
Post nurse staffing information every day.
Corrected 2023-06-14
Penalties and ownership
Fine · fine $62,752
Fine
Payment Denial · denial start 2024-08-27 · 64 days
64 day denial
Fine · fine $19,175
Fine
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Organization
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
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