Eastern Montana Veterans Home
2000 Montana Ave, Glendive, MT 59330 · Dawson County · (406) 377-8115
80 certified beds, about 50 residents a day · Government - State · Medicare and Medicaid since 1995
Certified for Medicaid Certified for Medicare
Overall
3 of 5
Health inspections
3 of 5
Staffing
4 of 5
Quality measures
2 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 275144 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on February 13, 2025, inspectors cited 9 health deficiencies (the Montana average is 11.2, the national average 9.2).
Of 31 health citations since February 2023, 6 were rated as actual harm or immediate jeopardy to residents.
CMS lists 3 fines totaling $50,805 in the last three years; the largest was $28,009, and the latest is dated December 10, 2025.
Nurses and nurse aides worked 4.29 hours per resident per day, against 4.05 across Montana and 3.86 nationally. Registered nurses accounted for 0.90 of those hours.
79.7% of nursing staff left within the year CMS measured (Montana average 54.8%).
CMS links it to Eduro Healthcare, an affiliated group of 34 nursing homes.
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.
1002/23
210/23
001/24
410/24
902/25
406/25
212/25
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
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 31 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
6G
0H
0I
Potential for more than minimal harm
18D
3E
3F
Potential for minimal harm
0A
0B
1C
December 10, 2025Complaint inspection · 2 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 ensure staff members followed policies, procedures, and protocols to maintain resident safety by providing sufficient and necessary supervision on a secure care unit, for 4 residents (#s 6, 9, 10, and 12) of 6 residents sampled for injuries/abuse. This deficient practice contributed to resident altercations, and resident #10 sustained a hip fracture, which required hospitalization and surgical repair for the major injury; and resident #10 was not transferred properly and per the facility policies and procedures, after the fall, which may cause or contribute to an injury.
- D Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility failed to ensure a complete investigation of a facility reported incident was provided to the State Survey Agency, and failed to maintain and provide accurate documentation of investigative findings for 3 (#s 2, 4, and 7) of 12 sampled residents.
June 19, 2025Complaint inspection · 4 citations
- G Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review, the facility staff assigned to a resident neglected to ensure he received necessary ADL care and was left in bed for an extended period of time without help. The resident experienced pain, distress, and skin abrasions from the event, for 1 (#4) of 5 sampled residents.
- 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 prevent a resident with dementia from eloping from the facility through the front entrance doors, leaving the facility property without supervision and accessing a public road, for 1 (#1) of 6 subsampled residents at risk for elopement. The resident sustained lacerations to his forehead after falling during the elopement.
- F Provide and implement an infection prevention and control program.
Inspectors wroteBased on interview and record review, the facility failed to ensure a system of communicable disease surveillance was maintained for tracking purposes and to protect residents from further transmission of infection, during an influenza outbreak in the facility, with 2 (#s 7 and 10) of 5 sampled residents, remaining in the same room after one tested positive for the flu and the other was not tested.
- D 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.
Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff were adequately trained and had the knowledge necessary to fulfill the nursing role related to the facility's elopement policy. The failure resulted in a resident eloping from the facility unattended, for 1 (#1) of 6 subsampled residents at risk for elopement.
February 13, 2025Standard inspection · 9 citations
- F Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on interview and record review, the facility failed to have an RN working at least eight consecutive hours a day, per the twenty-four-hour period, seven days per week. This deficient practice had the potential to affect all residents who received nursing services and when an RN was needed, one was not immediately available.
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff prepared food in a sanitary manner; failed to ensure freezer equipment was maintained and that food items in the walk-in refrigerator and freezer were covered, labeled, and dated. This failure increased the risk of food borne illnesses, and may negatively affect all residents receiving services from the dietary department.
- E PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and record review, the facility failed to ensure resident PASRRs (Pre-admission Screening and Resident Reviews) were completed and accurate for 3 (#s 28, 35, and 38) of 17 sampled residents.
- E 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 assess a resident for safety with smoking, failed to monitor the resident's location when smoking and ensure the resident signed out of the facility when smoking, and failed to follow and adhere to the facility policy related to resident smoking. These failures occurred over an extended period of time, for multiple shifts and days, and multiple staff failed to adhere to the policy, for 1 (#39) of 17 sampled residents.
- D 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 POLST forms were completed accurately in the electronic medical records, for 2 (#s 45 and 109) of 17 sampled residents.
- D 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.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean, sanitary, and homelike environment for 2 (#s 45 and 109) of 17 sampled residents.
- D Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on observation, interview, and record review, the facility failed to create a baseline care plan with pertinent condition specific information to address resident needs, within the 48-hour timeline following a resident's admission, for 1 (#109) of 17 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 observation, interview, and record review, the facility failed to update resident care plans in a timely manner for 1 (#33) of 17 sampled residents.
- 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 an as needed (PRN) psychotropic medication was limited to 14 days, for 1 (#26) of 17 sampled residents.
October 24, 2024Complaint inspection · 4 citations
- G Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to protect a resident's right to be free from physical and psychosocial abuse by facility staff for 1 (#7) of 13 sampled residents, causing resident #1 skin injuries, ongoing fear, and inability to sleep, fearing the specific staff involved would return to the facility.
- D Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observation, interview, and record review, the facility failed to honor dining preferences for 1 (#7) of 13 sampled residents. The deficient practice had the potential to impact the resident's health and well-being.
- 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 review and update a comprehensive care plan for 1 (#8) of 13 sampled residents. The resident experienced grief and sorrow from the recent death of her husband.
- D Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide social services for a resident who suffered with grief and loss of a spouse, for 1 (#8) of 13 sampled residents.
January 31, 2024Standard inspection · 0 citations
October 11, 2023Complaint inspection · 2 citations
- D Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on interview and record review, the facility failed to identify and address a resident acted out in willful abusive manner, when the resident (#2) had dementia, and the resident attacked another resident (#1), and could have inflicted harm, of 5 sampled residents; and, and failed to ensure a confused resident who displayed elopement behaviors was assessed and managed for safety, specifically when the facility attempted to use a wanderguard for the resident which increased his agitation and anxiety, for 1 (#3) of 5 sampled residents.
- C 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, it was identified the facility abuse education was not adequate to ensure administrative staff had necessary knowledge related the identification of willful abuse for a resident who had cognitive deficits, and management the events for future prevention, for 2 (#s 1 and 2) of 5 sampled residents for abuse.
February 15, 2023Standard inspection · 10 citations
- G Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective system for tracking resident weights, identifying weight loss, and implementing nutritional interventions for 2 (#s 12 and 49) of 2 sampled residents. Resident #49 had a severe weight loss, and #12 had a significant weight loss.
- G Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on interview and record review, the facility failed to ensure the dietitian, and the dietary manager, accurately assessed and communicated the nutritional needs of 1 (#49) of 1 sampled resident. This deficient practice resulted in the failure to intervene for a resident with a severe weight loss.
- E Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility's abuse investigations failed to show sufficient actions taken to prevent future reoccurrences of resident to resident abuse events, for residents who reside on the secured dementia unit and have cognitive deficits, for 5 (#s 13, 41, 47, 51, and 52) of 5 sampled residents.
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's physician was notified of a significant change in condition which included severe weight loss for 1 (#49) of 1 sampled resident.
- 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 ensure allegations of abuse and misappropriation of resident property were reported to the State Survey Agency within 24 hours of the incident for 2 (#s 21 and 23) of 3 sampled residents.
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident MDS data was coded accurately for 3 (#s 7, 19, and 49) of 6 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 observation, interview, and record review, the facility failed to update a care plan to show a resident's severe weight loss and fall prevention interventions, for 1 (#49) of 4 sampled residents.
- D 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.
Inspectors wroteBased on interview and record review, the facility failed to obtain a follow-up weight to confirm or refute an inconsistent documented 21 pound weight loss in a 14-day period for 1 (#9) of 1 sampled resident.
- D Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on observation, interview, and record review, facility staff failed to offer and attempt to use interventions identified on individualized care plans, or offer activities available and provided by the facility, in an attempt to redirect residents displaying behavioral concerns, for 3 (#s 5, 20, and 47) of 4 sampled residents.
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and/or enforce appropriate Covid-19 source control for vaccine exempt staff.
Fire safety inspections
3 fire safety citations on file: 3 on February 13, 2025.
Every fire safety citation3 citations
- E Keep aisles, corridors, and exits free of obstruction in case of emergency.
- E Have exits that are accessible at all times.
- D Properly select, install, inspect, or maintain portable fire extinguishes.
Fines and payment denials
| Date | Penalty | Amount or length |
|---|---|---|
| December 10, 2025 | Fine | $12,438 |
| June 19, 2025 | Fine | $10,358 |
| October 24, 2024 | Fine | $28,009 |
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) | 4.29 | 4.05 | 3.86 |
| Registered nurses | 0.90 | 0.98 | 0.69 |
| All nursing staff on weekends | 3.67 | 3.59 | 3.42 |
| Nurse aides | 2.82 | ||
| Licensed practical nurses | 0.58 | ||
| Nursing staff turnover (share who left in a year) | 79.7% | 54.8% | 45.8% |
| Registered nurse turnover | 80.0% | 48.3% | 42.9% |
| Administrators who left | 2 |
CMS expects 2.70 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
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 4.55 on weekdays and 3.67 on weekends, 19% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 32.2% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.87 in April to June 2025 to 4.29 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 | 4.29 | 0.90 | 4.55 | 3.67 | 32.2% | 0 of 90 | 50 |
| Oct to Dec 2025 | 4.33 | 0.68 | 4.47 | 3.96 | 51.4% | 0 of 92 | 50 |
| Jul to Sep 2025 | 4.05 | 0.79 | 4.23 | 3.60 | 36.6% | 0 of 92 | 49 |
| Apr to Jun 2025 | 3.87 | 0.73 | 4.03 | 3.48 | 44.8% | 0 of 91 | 50 |
| 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 | 18.8 | 18.7 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 1.0 | 2.1 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 2.0 | 2.9 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 7.2 | 4.4 | 3.2 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 16.8 | 17.2 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 5.4 | 6.3 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 19.1 | 20.4 | 15.4 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.0 | 1.4 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 3.7 | 2.2 | 1.8 |
Owners and operators
Legal business name: GLENDIVE NURSING AND REHAB CENTER, LLC. CMS links this home to Eduro Healthcare, a group of 34 nursing homes averaging 2.5 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Robinson, Kari | W-2 managing employee | Individual | 03/01/2023 | |
| Bewsey, Michael | Corporate director | Individual | 03/01/2023 | |
| Monroe, Dustin | Corporate officer | Individual | 03/01/2023 |
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 7 problems in this area, most recently on December 10, 2025: "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 6 problems in this area, most recently on December 10, 2025: "Respond appropriately to all alleged violations."
- When is the care plan meeting, and can family attend it?Inspectors cited 6 problems in this area, most recently on February 13, 2025: "PASARR screening for Mental disorders or Intellectual Disabilities"
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 4 problems in this area, most recently on February 13, 2025: "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."
- How long has the current administrator been here?CMS counts 2 administrators who left in the period it measured.
Other nursing homes nearby
- Glendive Medical Center N H Glendive, 0.9 mi · 3 of 5 stars · 14 citations
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 Eastern Montana Veterans Home's Medicare star rating?
- CMS rates Eastern Montana Veterans Home 3 out of 5 stars overall, with 3 for health inspections, 4 for staffing and 2 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Eastern Montana Veterans Home get at its last inspection?
- 9 health deficiencies at the standard inspection on February 13, 2025. The Montana average is 11.2.
- Has Eastern Montana Veterans Home been fined?
- Yes. CMS lists 3 fines totaling $50,805 in the last three years.
- Does Eastern Montana Veterans Home 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 Eastern Montana Veterans Home?
- CMS lists 3 owners and managers, and links the home to Eduro Healthcare. Legal business name: GLENDIVE NURSING AND REHAB CENTER, LLC.
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.