Cycle 1
Health 2024-12-19 · Fire 2024-12-19
4 health deficiencies
Top issue: Infection Control (1 deficiency)
12 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
Clancy, MT
Elkhorn Healthcare And Rehabilitation
5-star overall rating with 5-star inspections with 4 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
474 Hwy 282, Clancy, MT
(406) 933-8311
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
65
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Eduro Healthcare
Operator or chain grouping
Approved since
1977-05-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
36 facilities
Chain averages 2 overall / 3 health / 2 staffing / 3 quality stars
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
Hours and turnover
RN hours / resident day
0.52
Registered nurse staffing · state 0.94 · national 0.68
LPN hours / resident day
0.39
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
1.83
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
2.73
All reported nurse hours · state 3.97 · national 3.89
Licensed hours
0.90
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
2.33
Weekend nurse staffing · state 3.48 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.69 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.66
CMS adjusted RN staffing hours
Adjusted total hours
3.45
CMS adjusted total nurse staffing hours
Case-mix index
1.08
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
53%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,055
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.58
Composite VBP score used to determine payment impact.
Payment multiplier
0.9827
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.19
Baseline 18.82% · Performance 19.03% · Measure score 5.19 · Achievement 5.19 · Improvement 0
Healthcare-associated infections
2.17
Baseline 6.28% · Performance 7.19% · Measure score 2.17 · Achievement 2.17 · Improvement 0
Total nurse turnover
1.27
Baseline 69.23% · Performance 61.36% · Measure score 1.27 · Achievement 0.57 · Improvement 1.27
Adjusted total nurse staffing
0
Baseline 2.97 hours · Performance 2.83 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.96% |
10.72%
1.8 pts better
|
No Different than the National Rate · Eligible stays 72 · Observed rate 4.17% · Lower 95% interval 5.58% |
| Discharge to community | 42.88% |
50.57%
7.7 pts worse
|
No Different than the National Rate · Eligible stays 50 · Observed rate 36% · Lower 95% interval 30.03% |
| Medicare spending per beneficiary | 0.66 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 98% |
95.27%
2.7 pts better
|
Numerator 49 · Denominator 50 |
| Falls with major injury | 2% |
0.77%
1.2 pts worse
|
Numerator 1 · Denominator 50 |
| Discharge self-care score | 21.88% |
53.69%
31.8 pts worse
|
Numerator 7 · Denominator 32 |
| Discharge mobility score | 28.13% |
50.94%
22.8 pts worse
|
Numerator 9 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 50 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.19% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 38 · Observed rate 7.89% · Lower 95% interval 3.58% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 59 |
| Staff flu vaccination coverage | 16.67% |
42%
25.3 pts worse
|
Numerator 16 · Denominator 96 |
| Discharge function score | 25% |
56.45%
31.5 pts worse
|
Numerator 8 · Denominator 32 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 10% |
25.2%
15.2 pts worse
|
Numerator 2 · Denominator 20 |
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 1.1 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.2
0.9 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.4 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.9% |
94.4%
0.5 pts worse
|
93.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.3% · Q2 90.3% · Q3 94.9% · Q4 94.9% · 4Q avg 93.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.9% |
93.7%
4.8 pts worse
|
95.5%
6.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.2% |
4.2%
3 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 1.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 17.3% |
4.7%
12.6 pts worse
|
11.4%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 22.0% · Q3 19.6% · Q4 13.0% · 4Q avg 17.3% |
| Percentage of long-stay residents who lose too much weight | 3.1% |
5.9%
2.8 pts better
|
5.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 5.9% · Q3 0.0% · Q4 0.0% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.5% |
17.4%
14.1 pts worse
|
19.6%
11.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.0% · Q2 32.7% · Q3 26.7% · Q4 25.0% · 4Q avg 31.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 47.6% |
20.6%
27 pts worse
|
16.7%
30.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.2% · Q2 51.6% · Q3 50.0% · Q4 48.4% · 4Q avg 47.6% · 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 | 26.2% |
19.7%
6.5 pts worse
|
16.3%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 38.8% · Q3 24.0% · Q4 20.6% · 4Q avg 26.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.3% |
19.8%
3.5 pts worse
|
14.9%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.5% · Q2 36.7% · Q3 18.6% · Q4 11.4% · 4Q avg 23.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
2.6%
0.9 pts better
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.0% · Q3 1.8% · Q4 1.5% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
2.9%
1.6 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 1.8% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.1% |
25.4%
6.3 pts better
|
19.8%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 28.1% · Q3 11.8% · Q4 15.1% · 4Q avg 19.1% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
6.4%
3.1 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 6.9% · Q4 4.9% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 52.7% |
78.7%
26 pts worse
|
81.7%
29 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 46.4% · Q2 60.7% · Q3 52.4% · Q4 52.1% · 4Q avg 52.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.4% |
15.0%
3.4 pts worse
|
12.0%
6.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.4% · Observed 21.7% · Expected 13.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
1.6%
0.8 pts worse
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 48.3% |
73.8%
25.5 pts worse
|
79.7%
31.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 48.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.7% |
19.4%
7.3 pts worse
|
23.9%
2.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.7% · Observed 26.1% · Expected 23.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-19 · Fire 2023-12-19
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
9 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Cycle 3
Health 2023-01-05 · Fire 2023-01-05
5 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
14 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-15
F · Potential for more than minimal harm
2024-12-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-15
F · Potential for more than minimal harm
2024-12-19
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-01-17
F · Potential for more than minimal harm
2024-12-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-15
F · Potential for more than minimal harm
2024-12-19
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-01-15
E · Potential for more than minimal harm
2024-12-19
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 2025-01-15
E · Potential for more than minimal harm
2024-12-19
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-01-15
E · Potential for more than minimal harm
2024-12-19
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-01-15
E · Potential for more than minimal harm
2024-12-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-15
E · Potential for more than minimal harm
2024-12-19
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-01-15
E · Potential for more than minimal harm
2024-12-19
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-01-15
D · Potential for more than minimal harm
2024-12-19
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-01-15
F · Potential for more than minimal harm
2023-12-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-06
F · Potential for more than minimal harm
2023-12-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-06
F · Potential for more than minimal harm
2023-12-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-06
F · Potential for more than minimal harm
2023-12-19
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-02-06
E · Potential for more than minimal harm
2023-12-19
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-02-06
E · Potential for more than minimal harm
2023-12-19
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-02-06
D · Potential for more than minimal harm
2023-12-19
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-02-06
D · Potential for more than minimal harm
2023-12-19
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-02-06
D · Potential for more than minimal harm
2023-12-19
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-02-06
F · Potential for more than minimal harm
2023-01-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-02
F · Potential for more than minimal harm
2023-01-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-02-02
F · Potential for more than minimal harm
2023-01-05
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-02-02
F · Potential for more than minimal harm
2023-01-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-02
E · Potential for more than minimal harm
2023-01-05
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-02-02
D · Potential for more than minimal harm
2023-01-05
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2023-02-02
D · Potential for more than minimal harm
2023-01-05
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2023-02-02
D · Potential for more than minimal harm
2023-01-05
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-02-02
D · Potential for more than minimal harm
2023-01-05
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-02-02
D · Potential for more than minimal harm
2023-01-05
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-02-02
D · Potential for more than minimal harm
2023-01-05
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-02-02
D · Potential for more than minimal harm
2023-01-05
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-02-02
D · Potential for more than minimal harm
2023-01-05
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-02-02
D · Potential for more than minimal harm
2023-01-05
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-02-02
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-12-19
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 2025-01-10
E · Potential for more than minimal harm
2024-12-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-12-19
F584 · Resident Rights Deficiencies
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 2025-01-10
D · Potential for more than minimal harm
2024-12-19
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 2025-01-10
D · Potential for more than minimal harm
2024-12-19
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 2025-01-10
E · Potential for more than minimal harm
2023-12-19
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-01-10
E · Potential for more than minimal harm
2023-12-19
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 2024-01-10
D · Potential for more than minimal harm
2023-12-19
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 2024-01-10
D · Potential for more than minimal harm
2023-12-19
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 2024-01-10
D · Potential for more than minimal harm
2023-12-19
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-01-10
F · Potential for more than minimal harm
2023-01-05
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2023-02-07
F · Potential for more than minimal harm
2023-01-05
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 2023-02-07
F · Potential for more than minimal harm
2023-01-05
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-02-02
F · Potential for more than minimal harm
2023-01-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-02
E · Potential for more than minimal harm
2023-01-05
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-02-07
Penalties and ownership
What sits behind the stars
Ownership
Bewsey, Michael
5% Or Greater Indirect Ownership Interest · Individual
Eduro Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
Dodge, Jenifer
W-2 Managing Employee · Individual
Eduro Healthcare LLC
Operational/Managerial Control · Organization
Mcgaha, Brenda
W-2 Managing Employee · Individual
Monroe, Dustin
Corporate Officer · Individual
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