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

Compare this facility

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

Staffing

Hours and turnover

RN hours / resident day

1.37

Registered nurse staffing

LPN hours / resident day

0.43

Licensed practical nurse staffing

Aide hours / resident day

3.38

Nurse aide staffing

Weekend hours

4.83

Weekend nurse staffing

RN turnover

54%

Annual RN turnover

Total nurse turnover

59%

Annual nurse turnover

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
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
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
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
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
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
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
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
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
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
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
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
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
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

Survey summary

Recent inspection cycles

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.

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

0% 2 facilities 2015-12-09
Hart, James

Corporate Officer · Individual

0% 3 facilities 2007-01-01
Nye, Ronald

Corporate Officer · Individual

0% 2 facilities 2015-01-01
Schulz, David

Corporate Officer · Individual

0% 1 facilities 2011-01-01
Vaughn, Darcel

W-2 Managing Employee · Individual

0% 2 facilities 2013-06-12

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