Blackfeet Care Center
728 S Government Sq, Browning, MT 59417 · Glacier County · (406) 338-2686
47 certified beds, about 29 residents a day · For profit - Individual · Medicare and Medicaid since 1989
CMS Care Compare ratings, data as of September 1, 2026 · CCN 275133 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on March 26, 2026, inspectors cited 12 health deficiencies (the Montana average is 11.2, the national average 9.2).
Of 37 health citations since January 2024, 3 were rated as actual harm or immediate jeopardy to residents (2 immediate jeopardy).
CMS lists 4 fines totaling $176,965 in the last three years; the largest was $102,325, and the latest is dated July 9, 2026.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 37 health citations on file.
July 9, 2026Complaint inspection · 5 citations
- J Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review, the facility failed to identify risks, provide training for van drivers, and ensure the safety of two unrestrained residents who fell to the floor when the van made abrupt stops for 2 (#s 1 and 2) of 9 sampled residents. This deficient practice increased the risk of negative outcomes and injury for residents required to use the facility van. On 7/9/26 at 9:55 a.m., an Immediate Jeopardy (IJ) was announced to the Administrator and Director of Nursing related to F689-Free of Accidents and Hazards and Supervision affecting two residents. The Severity and Scope identified for the Immediate Jeopardy were identified to be at the level of J, and upon verification for the removal of the immediacy, lowered to a D. An acceptable plan for the Removal of Immediacy was approved by the State Survey Agency on 7/9/26 at 1:30 p.m. [...]
- F Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an effective training program for all staff who transported residents in the facility vans to ensure the residents were safe when transported and seat belts and safety harnesses were secured properly. This failure contributed to the Immediate Jeopardy situation(s) identified in F869 - Accidents and Hazards, and if not corrected, this failure may affect any resident not transferred properly by untrained staff.
- D 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.
Inspectors wroteBased on interview and record review, the facility failed to ensure a system was in place for grievances to be filed orally, and the facility staff failed to address or act upon a grievance submitted for 1 (#4) of 9 sampled residents. This deficient practice resulted in the resident's ongoing feelings of fear during van transports.
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, the facility failed to submit an incident for a Facility Reported Incident timely to the State Survey Agency for 1 (#1) of 9 sampled residents.
- D Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident did not experience re-traumatization during transports, for 1 (#4) of 9 sampled residents by use of the individualized care plan and interventions. This deficient practice resulted in a resident being fearful of transportation in the facility van.
March 26, 2026Standard inspection, Complaint inspection · 12 citations
- J Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and record review, the facility nursing staff failed to ensure a resident's anticoagulant medication was clarified on admission for 1 (#36) of 19 sampled and supplemental residents, and the resident received a medication that was discontinued while in the hospital before being admitted . Therefore, the medication was unnecessary and should not have been provided to the resident. The resident experienced a significant change and decline in status due to the medication being given, which resulted in a low hemoglobin of 6.9 g/dl and required a blood transfusion. On 3/25/26 at 4:22 p.m., the facility Administrator and Office Manager were notified of an immediate jeopardy situation for F757. This involved one resident, #36. The severity and scope were identified at the level of J, and when the immediacy was removed, lowered to a G. [...]
- F Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Inspectors wroteBased on interview and record review, the facility failed to ensure the accuracy of staffing data submitted to CMS (the Centers for Medicare and Medicaid Services) through the PBJ (Payroll-Based Journal) system for October 1, 2025, through December 31, 2025.
- E Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility failed to complete a thorough investigation, monitoring, and documentation for allegations of staff-to-resident abuse for 1 (#28), resident-to-resident physical abuse for 2 (#s 40 and 41), and resident-to-resident sexual abuse for 2 (#s 6 and 40) of 17 sampled residents. This deficient practice had the potential to place all residents at risk of abuse.
- E Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, interview and record review, the facility failed to revise an individualized, comprehensive care plan to address end-of-life/comfort care needs for 1 (#8); failed to revise a resident's care plan addressing a suprapubic catheter, and interventions for a suprapubic catheter for 1 (#5); and failed to address psychotropic medication use for 1 (#6) of 17 sampled residents. This deficient practice increased the risk for resident #8 not receiving proper catheter care/services, for resident #5 not receiving necessary care/services for the suprapubic catheter, and for resident #6 to have unmet care needs related to end-of-life care and services.
- E Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents were seen by a physician within required timeframes (at least every 30 days for the first 90 days after admission and at least once every 60 days thereafter) for 6 (#s 1, 3, 5, 6, 15, and 28) of 17 sampled residents. This deficient practice had the potential for an increased risk of unidentified changes in condition, delayed treatment, worsening of medical conditions, avoidable complications, or decline in resident health and safety.
- D Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's representative was provided information necessary to make an informed decision, including the risks, benefits, and alternatives, before the initiation of psychotropic medications; and the facility failed to obtain informed consent for the use of the medications, for 1 (#6) of 17 sampled residents.
- D Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Inspectors wroteBased on observation, interview and record review, the facility failed to afford residents the right to receive visitors at a time of their choosing for 2 (#s 15 and 23) of 17 sampled residents. This deficient practice placed residents at risk for social isolation and or decreased quality-of-life due to unnecessary limitations on visitation and interference with their ability to maintain relationships with family or others.
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to ensure accurate coding of medications on the Minimum Data Set (MDS) in accordance with the Resident Assessment Instrument (RAI) Manual for 1 (#5) of 17 sampled residents.
- D Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Inspectors wroteBased on interview and record review, the facility failed to ensure physician services provided appropriate assessment and adjustment of treatment for a resident's medical condition for 1 (#15) of 17 sampled residents. This deficient practice resulted in frequently elevated blood sugar levels.
- D Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired medications and medical supplies were removed from the medication and supply rooms and that medications and biologicals were stored securely in 1 of 1 sampled medication room and 1 of 2 sampled supply rooms.
- D Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Inspectors wroteBased on interview and record review, the facility failed to ensure the medical director was active in his role for QAPI and review, development, and revision of the facility policies and procedures.
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and interview, the facility staff failed to ensure staff adhered to accepted infection control standards, including proper hand hygiene and glove use, during a medication pass for 2 (#s 3 and 5) of 17 sampled residents. This deficient practice had the potential for an increased risk of the transmission of infections.
June 18, 2025Complaint inspection · 3 citations
- E Respond appropriately to all alleged violations.
Inspectors wroteBased on observation, interview, and record review, the facility failed to complete thorough incident investigations and address psychosocial impacts of abuse for those affected, for (#s 3, 7, 31, 32, and 34) of 9 sampled resident abuse allegations and investigations. Resident #32 was then reportedly afraid, #31 was uncomfortable with the employee's actions and lack of follow up by the facility, and #3 was tearful during the investigation.
- D Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and update a care plan with interventions for wandering for 1 (#7) of 9 sampled residents. This deficient practice increased the risk of injury to resident #7 and increased the risk of lack of privacy for other. Review of a facility reported event, dated 3/20/25, showed resident #7 was wandering and opening and closing other residents' doors, causing other residents to become angry. Review of resident #7's electronic health record showed resident #7 had dementia, low vision, and was hard of hearing. During an interview on 6/18/25 at 10:16 a.m., staff member B stated, Interventions for resident #7 are to work with the doctor on medication management. We don't do a formal assessment of behaviors. During an observation on 6/18/25 at 2:05 p.m., resident #7 was observed wandering the halls in the facility. [...]
- D Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services for the assessment and identification of underlying cause(s) of behaviors displayed for a resident with dementia, for 1 (#7) out of 9 sampled residents.
January 30, 2025Standard inspection, Complaint inspection · 5 citations
- G Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review, the facility failed to identify the root causes of falls for 1 (#12) of 17 sampled residents, and the resident continued to fall, and this resulted in the resident sustaining a head injury from a subsequent fall.
- F Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and follow enhanced barrier precautions (EBP) for 4 (#s 3, 9, 14, and 19) of 17 sampled residents; and failed to ensure staff member H adhered to standard precautions during medication administration via a tube feeding, by placing medications to be administered on an unclean surface without a protective barrier in place, for 1 (#14) of 2 sampled residents observed during enteral medication and nutritional supplement administration.
- D Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity and privacy of a resident was protected for 1 (#25) of 17 sampled residents. Resident #25 had a sign on the outside of her door which showed her name and instructions for the emptying of her nephrostomy tube bag.
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, the facility failed to report the findings of an alleged allegation of abuse to the State Survey Agency, within five days for 1 (#83) of 17 sampled residents.
- D Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Inspectors wroteBased on interview and record review, the facility failed to ensure the care and services for a nephrostomy tube were completed and documented in the medical record for 1 (#25) of 17 sampled residents. Resident #25 had a nephrostomy tube which required dressing changes. The facility failed to obtain orders for dressing changes for the nephrostomy tubing. The facility failed to document the care of the nephrostomy tube in the medical record.
January 4, 2024Standard inspection, Complaint inspection · 12 citations
- F Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Inspectors wroteBased on interview and record review, the facility failed to ensure staff had abuse training, while an investigation was in progress for 2 (#s 9 & 11) of 21 sampled residents.
- E 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.
Inspectors wroteBased on interview and record review, the facility failed to ensure the code status for 3 (#s 3, 12, and 18) were consistent between the paper and electronic records; and failed to ensure a POLST was dated by the provider for 1 (#20) of 21 sampled residents.
- E Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review, the facility failed to prevent further potential abuse while an investigation was in progress for 2 (#s 9 and 11) of 21 sampled residents, and concerns related to the relationship between the two residents had been ongoing over an extended period of time.
- E 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.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' tube feeding enteral nutrition formula met the caloric content ordered by the physician, for 3 (#s 4, 13, and 17) of 21 sampled residents.
- E Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control and prevention was used during use of a communial glucometer machine for 1 (#24) of 21 sampled residents.
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, the facility failed to report and submit incident findings, within the required five-day timeframe, for 1 (#13); and failed to submit an initial incident report within the two-hour timeframe for a possible crime, for 2 (#s 9 and 11) of 21 sampled residents.
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately complete MDS assessments for 3 (#s 14, 21, and 22) of 21 sampled residents.
- D Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on interview and record review, the facility failed to update the care plan post incident for 1 (#13) of 21 sampled residents.
- D Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan to address individual care and service needs for physical therapy for 1 (#21) of 21 sampled residents, related to the resident's ability to carry out his ADLs, without decline, and desire to return to another level of living.
- D 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.
Inspectors wroteBased on interview and record review, the facility failed to ensure a psychotropic medication consent was obtained for 1 (#22) of 21 sampled residents.
- D Provide or get specialized rehabilitative services as required for a resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was assessed and treated in a timely manner by physical therapy for 1 (#21) of 21 sampled residents.
- D Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review, the facility failed to obtain signed consents for administered pneumococcal vaccines for 2 (#s 18 and 21 ) of 21 sampled residents.
Fire safety inspections
16 fire safety citations on file: 9 on March 26, 2026, 4 on January 30, 2025, 3 on January 4, 2024.
Every fire safety citation16 citations
- F List the names and contact information of those in the facility.
- F Conduct testing and exercise requirements.
- F Install emergency lighting that can last at least 1 1/2 hours.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Properly select, install, inspect, or maintain portable fire extinguishes.
- F Have generator or other power source capable of supplying service within 10 seconds.
- D 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.
- D Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- D Have properly located and lighted "Exit" signs.
- F Keep aisles, corridors, and exits free of obstruction in case of emergency.
- F Have a battery powered remote alarm panel in a location accessible by operating personnel.
- D Inspect, test, and maintain automatic sprinkler systems.
- D Properly select, install, inspect, or maintain portable fire extinguishes.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Ensure that testing and maintenance of electrical equipment is performed.
- E Properly select, install, inspect, or maintain portable fire extinguishes.
Fines and payment denials
| Date | Penalty | Amount or length |
|---|---|---|
| July 9, 2026 | Fine | $22,205 |
| July 9, 2026 | Fine | $23,520 |
| March 26, 2026 | Fine | $102,325 |
| March 26, 2026 | Payment Denial | 3 days from April 28, 2026 |
| January 30, 2025 | Fine | $28,915 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Montana | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | not reported | 4.05 | 3.86 |
| Registered nurses | not reported | 0.98 | 0.69 |
| All nursing staff on weekends | not reported | 3.59 | 3.42 |
| Nurse aides | not reported | ||
| Licensed practical nurses | not reported | ||
| Nursing staff turnover (share who left in a year) | not reported | 54.8% | 45.8% |
| Registered nurse turnover | not reported | 48.3% | 42.9% |
| Administrators who left | not reported |
CMS note on this home's staffing data: The accuracy of the staffing data for this measure could not be validated by CMS.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.57 on weekdays and 4.30 on weekends, 6% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 32.4% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.31 in July to September 2025 to 4.49 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 4.49 | 0.94 | 4.57 | 4.30 | 32.4% | 0 of 90 | 29 |
| Oct to Dec 2025 | 4.10 | 0.86 | 4.22 | 3.80 | 0.0% | 2 of 92 | 32 |
| Jul to Sep 2025 | 4.31 | 0.76 | 4.47 | 3.88 | 0.1% | 0 of 92 | 33 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Montana, Jan to Mar 2026 | 3.91 | 0.89 | 4.10 | 3.46 | 11.6% | 0.4% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Montana | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 11.5 | 18.7 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 5.0 | 2.1 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 7.1 | 2.9 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 3.9 | 4.4 | 3.2 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 28.5 | 17.2 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 2.3 | 6.3 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 10.5 | 20.4 | 15.4 |
Owners and operators
Legal business name: Legal Business Name Not Available.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Ownership data not available |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 8 problems in this area, most recently on July 9, 2026: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
- How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 7 problems in this area, most recently on July 9, 2026: "Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 5 problems in this area, most recently on July 9, 2026: "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."
- When is the care plan meeting, and can family attend it?Inspectors cited 5 problems in this area, most recently on March 26, 2026: "Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals."
Montana contacts for a concern about a nursing home
These are the official offices in Montana. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Montana DPHHS, Office of Inspector General, Certification Bureau, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Montana Long-Term Care Ombudsman Program, Senior and Long Term Care Division, (800) 332-2272. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: Certification Bureau Survey Results and Plans of Correction, where Montana publishes its own records on licensed homes.
Common questions
- What is Blackfeet Care Center's Medicare star rating?
- CMS rates Blackfeet Care Center 1 out of 5 stars overall, with 1 for health inspections, 1 for staffing and 4 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Blackfeet Care Center get at its last inspection?
- 12 health deficiencies at the standard inspection on March 26, 2026. The Montana average is 11.2.
- Has Blackfeet Care Center been fined?
- Yes. CMS lists 4 fines totaling $176,965 in the last three years.
- Does Blackfeet Care Center accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Blackfeet Care Center?
- CMS lists 1 owner or manager. Legal business name: Legal Business Name Not Available.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.