Cycle 1
Health 2025-05-08 · Fire 2025-05-08
9 health deficiencies
Top issue: Resident Rights (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Ennis, MT
Madison Valley Manor
4-star overall rating with 4-star inspections with 9 recent health deficiencies
211 N Main St, Ennis, MT
(406) 682-7271
Overall
4 / 5
CMS overall stars
Health inspections
4 / 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
32
Certified beds
Average residents
20
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1991-07-01
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
Hours and turnover
RN hours / resident day
1.37
Registered nurse staffing · state 0.94 · national 0.68
LPN hours / resident day
0.43
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
3.38
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
5.18
All reported nurse hours · state 3.97 · national 3.89
Licensed hours
1.80
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
4.83
Weekend nurse staffing · state 3.48 · national 3.43
Weekend RN hours
1.07
Weekend registered nurse coverage · state 0.69 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.71
CMS adjusted RN staffing hours
Adjusted total hours
6.44
CMS adjusted total nurse staffing hours
Case-mix index
1.10
Higher values indicate more complex resident acuity
RN turnover
54%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 56% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 8 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 7 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 1 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 3 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 8.7% |
8.2%
0.5 pts better
|
Numerator 4 · Denominator 46 |
| Staff flu vaccination coverage | 26.83% |
42%
15.2 pts worse
|
Numerator 11 · Denominator 41 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.4%
5.6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.5% |
93.7%
3.2 pts worse
|
95.5%
5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
4.2%
0.4 pts better
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.0% · Q3 5.0% · Q4 5.0% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.2% |
4.7%
3.5 pts better
|
11.4%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% |
| Percentage of long-stay residents who lose too much weight | 7.9% |
5.9%
2 pts worse
|
5.4%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.4% |
17.4%
1 pts better
|
19.6%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.6% |
20.6%
9 pts better
|
16.7%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 5.0% |
0.4%
4.6 pts worse
|
0.1%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 5.0% · Q3 5.0% · Q4 5.0% · 4Q avg 5.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.0% |
19.7%
4.7 pts better
|
16.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.0% |
19.8%
9.2 pts worse
|
14.9%
14.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 29.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.6%
2.6 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.3% |
2.9%
2.4 pts worse
|
1.7%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q4 10.0% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.3% |
25.4%
6.9 pts worse
|
19.8%
12.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 32.3% |
| Percentage of long-stay residents with pressure ulcers | 6.9% |
6.4%
0.5 pts worse
|
5.1%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q4 0.0% · 4Q avg 6.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-08 · Fire 2024-05-08
5 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-05-11 · Fire 2023-05-11
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-08
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 2025-06-12
F · Potential for more than minimal harm
2025-05-08
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-06-12
E · Potential for more than minimal harm
2025-05-08
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 2025-06-12
D · Potential for more than minimal harm
2025-05-08
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 2025-06-12
D · Potential for more than minimal harm
2025-05-08
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 2025-06-12
D · Potential for more than minimal harm
2025-05-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-05-08
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2025-06-12
D · Potential for more than minimal harm
2025-05-08
F725 · Nursing and Physician Services Deficiencies
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 2025-06-12
D · Potential for more than minimal harm
2025-05-08
F849 · Administration Deficiencies
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 2025-06-12
E · Potential for more than minimal harm
2024-09-10
F945 · Infection Control Deficiencies
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-09-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-16
E · Potential for more than minimal harm
2024-05-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-06-12
E · Potential for more than minimal harm
2024-05-08
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 2024-06-12
D · Potential for more than minimal harm
2024-05-08
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 2024-06-12
E · Potential for more than minimal harm
2023-05-11
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2023-06-24
D · Potential for more than minimal harm
2023-05-11
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-06-17
D · Potential for more than minimal harm
2023-05-11
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 2023-06-24
D · Potential for more than minimal harm
2023-05-11
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 2023-06-24
Penalties and ownership
What sits behind the stars
Ownership
Forsythe, Jayne
W-2 Managing Employee · Individual
Hart, James
Corporate Officer · Individual
Nye, Ronald
Corporate Officer · Individual
Schulz, David
Corporate Officer · Individual
Vaughn, Darcel
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
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Tobacco Root Mountains Care Center
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5-star overall rating with 5-star inspections with 1 recent health deficiencies
#2
Gallatin Rest Home
Bozeman, MT
4-star overall rating with 4-star inspections with $63,603 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Pioneer Care And Rehabilitation
Dillon, MT
1-star overall rating with 1-star inspections with $158,103 in total fines with 20 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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