Cycle 1
Health 2025-07-17 · Fire 2025-07-17
16 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Kalispell, MT
Brendan House
3-star overall rating with 3-star inspections with $35,815 in total fines with 16 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
350 Conway Dr, Kalispell, MT
(406) 751-6500
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
110
Certified beds
Average residents
95
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1985-04-17
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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
1.25
Registered nurse staffing · state 0.94 · national 0.68
LPN hours / resident day
0.37
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.89
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
4.51
All reported nurse hours · state 3.97 · national 3.89
Licensed hours
1.63
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
4.15
Weekend nurse staffing · state 3.48 · national 3.43
Weekend RN hours
1.00
Weekend registered nurse coverage · state 0.69 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.35
CMS adjusted RN staffing hours
Adjusted total hours
4.87
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
51%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
613
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
66.54
Composite VBP score used to determine payment impact.
Payment multiplier
1.0204
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.14
Baseline 17.68% · Performance 17.66% · Measure score 8.14 · Achievement 8.14 · Improvement 0
Healthcare-associated infections
8.87
Baseline 5.83% · Performance 5.18% · Measure score 8.87 · Achievement 8.87 · Improvement 7.23
Total nurse turnover
4.9
Baseline 34.91% · Performance 43.65% · Measure score 4.9 · Achievement 4.9 · Improvement 0
Adjusted total nurse staffing
4.70
Baseline 3.93 hours · Performance 4.42 hours · Measure score 4.70 · Achievement 4.70 · Improvement 2.13
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.37% |
10.72%
2.4 pts better
|
No Different than the National Rate · Eligible stays 246 · Observed rate 5.69% · Lower 95% interval 6% |
| Discharge to community | 57.37% |
50.57%
6.8 pts better
|
Better than the National Rate · Eligible stays 254 · Observed rate 53.54% · Lower 95% interval 51.4% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.62% |
95.27%
4.4 pts better
|
Numerator 260 · Denominator 261 |
| Falls with major injury | 0.77% |
0.77%
About the same
|
Numerator 2 · Denominator 261 |
| Discharge self-care score | 51.16% |
53.69%
2.5 pts worse
|
Numerator 110 · Denominator 215 |
| Discharge mobility score | 46.51% |
50.94%
4.4 pts worse
|
Numerator 100 · Denominator 215 |
| Pressure ulcers or injuries, new or worsened | 2.3% |
2.29%
About the same
|
Numerator 6 · Denominator 261 · Adjusted rate 3.08% |
| Healthcare-associated infections requiring hospitalization | 5.18% |
7.12%
1.9 pts better
|
No Different than the National Rate · Eligible stays 148 · Observed rate 2.7% · Lower 95% interval 3.23% |
| Staff COVID-19 vaccination coverage | 8.43% |
8.2%
0.2 pts better
|
Numerator 14 · Denominator 166 |
| Staff flu vaccination coverage | 30.95% |
42%
11.1 pts worse
|
Numerator 65 · Denominator 210 |
| Discharge function score | 48.37% |
56.45%
8.1 pts worse
|
Numerator 104 · Denominator 215 |
| Transfer of health information to provider | 92.31% |
95.95%
3.6 pts worse
|
Numerator 36 · Denominator 39 |
| Transfer of health information to patient | 98.76% |
96.28%
2.5 pts better
|
Numerator 159 · Denominator 161 |
| Resident COVID-19 vaccinations up to date | 38.56% |
25.2%
13.4 pts better
|
Numerator 59 · Denominator 153 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.3
0.3 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
2.2
0.5 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
94.4%
5.3 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.7% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.4% |
93.7%
1.7 pts better
|
95.5%
0.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.2% |
4.2%
1 pts better
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 4.2% · Q4 7.6% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.7% |
4.7%
5 pts worse
|
11.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 13.3% · Q3 7.5% · Q4 6.2% · 4Q avg 9.7% |
| Percentage of long-stay residents who lose too much weight | 10.7% |
5.9%
4.8 pts worse
|
5.4%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 10.3% · Q3 12.3% · Q4 8.3% · 4Q avg 10.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.5% |
17.4%
3.1 pts worse
|
19.6%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 20.3% · Q3 20.6% · Q4 21.9% · 4Q avg 20.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.5% |
20.6%
4.9 pts worse
|
16.7%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 26.2% · Q3 23.6% · Q4 25.9% · 4Q avg 25.5% · 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 | 26.1% |
19.7%
6.4 pts worse
|
16.3%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 21.4% · Q3 21.6% · Q4 33.8% · 4Q avg 26.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.6% |
19.8%
6.8 pts worse
|
14.9%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 31.6% · Q3 28.8% · Q4 24.6% · 4Q avg 26.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 6.3% |
2.6%
3.7 pts worse
|
1.0%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 5.3% · Q3 5.2% · Q4 6.9% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
2.9%
1.2 pts better
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.2% · Q3 0.0% · Q4 2.6% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.4% |
25.4%
3 pts better
|
19.8%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 23.6% · Q3 22.9% · Q4 19.6% · 4Q avg 22.4% |
| Percentage of long-stay residents with pressure ulcers | 8.8% |
6.4%
2.4 pts worse
|
5.1%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 5.7% · Q3 10.4% · Q4 10.4% · 4Q avg 8.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
78.7%
19.2 pts better
|
81.7%
16.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.3% · Q2 97.2% · Q3 99.5% · Q4 99.3% · 4Q avg 97.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.2% |
15.0%
0.8 pts better
|
12.0%
2.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.2% · Observed 14.7% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.2% |
1.6%
1.6 pts worse
|
1.6%
1.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 3.9% · Q3 4.1% · Q4 2.9% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.2% |
73.8%
17.4 pts better
|
79.7%
11.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.8% |
19.4%
1.6 pts better
|
23.9%
6.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.8% · Observed 17.5% · Expected 23.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-29 · Fire 2024-08-29
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Cycle 3
Health 2023-09-14 · Fire 2023-09-14
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-17
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-08-27
E · Potential for more than minimal harm
2025-07-17
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-08-31
E · Potential for more than minimal harm
2025-07-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-31
D · Potential for more than minimal harm
2024-08-29
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-08-29
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-08-29
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-08-29
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-10-11
F · Potential for more than minimal harm
2023-09-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-02
F · Potential for more than minimal harm
2023-09-14
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-10-26
E · Potential for more than minimal harm
2023-09-14
K902 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of medical gas and medical vacuum systems.
Corrected 2023-11-08
Inspection history
Recent health citations
G · Actual harm
2025-07-17
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-08-31
E · Potential for more than minimal harm
2025-07-17
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-08-31
E · Potential for more than minimal harm
2025-07-17
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-08-31
E · Potential for more than minimal harm
2025-07-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-08-31
D · Potential for more than minimal harm
2025-07-17
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-08-31
D · Potential for more than minimal harm
2025-07-17
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-08-31
D · Potential for more than minimal harm
2025-07-17
F585 · Resident Rights Deficiencies
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 2025-08-31
D · Potential for more than minimal harm
2025-07-17
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-08-31
D · Potential for more than minimal harm
2025-07-17
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-08-31
D · Potential for more than minimal harm
2025-07-17
F657 · Resident Assessment and Care Planning Deficiencies
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 2025-08-31
D · Potential for more than minimal harm
2025-07-17
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-08-31
D · Potential for more than minimal harm
2025-07-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-08-31
D · Potential for more than minimal harm
2025-07-17
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-08-31
D · Potential for more than minimal harm
2025-07-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-08-31
D · Potential for more than minimal harm
2025-07-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-31
D · Potential for more than minimal harm
2025-07-17
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-08-31
F · Potential for more than minimal harm
2024-08-29
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-08-29
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-08-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-08-29
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-08-29
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-08-29
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-08-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-08-29
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-10-11
G · Actual harm
2023-09-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-29
G · Actual harm
2023-09-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-10-29
D · Potential for more than minimal harm
2023-09-14
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2023-10-29
D · Potential for more than minimal harm
2023-09-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-10-29
D · Potential for more than minimal harm
2023-09-14
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-10-29
D · Potential for more than minimal harm
2023-09-14
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-10-29
D · Potential for more than minimal harm
2023-09-14
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-10-30
Penalties and ownership
What sits behind the stars
$35,815
2023-09-14
Fine
Fine · fine $35,815
Fine
Ownership
Mtwy Health
5% Or Greater Indirect Ownership Interest · Organization
Abel, Kevin
Corporate Officer · Individual
Abel, Kevin
W-2 Managing Employee · Individual
Burke, Brigid
Corporate Officer · Individual
Gibson, William
Corporate Officer · Individual
Goguen, Michael
Corporate Director · Individual
Harris, Michelle
Corporate Director · Individual
Karas, Jane
Corporate Director · Individual
Robbins, Anna
Operational/Managerial Control · Individual
Robbins, Anna
Corporate Director · Individual
Nearby options
Other facilities in reach
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Kalispell, MT
1-star overall rating with 1-star inspections with Special Focus status with $326,610 in total fines with 24 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Immanuel Skilled Care Center
Kalispell, MT
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Montana Veterans Home N H
Columbia Falls, MT
3-star overall rating with 2-star inspections with abuse icon flag with $142,240 in total fines with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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