1500 32nd St. S, Great Falls, MT 59405 · Cascade County · (406) 761-4300
189 certified beds, about 147 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1967
CMS Care Compare ratings, data as of September 1, 2026 · CCN 275030 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on April 9, 2026, inspectors cited 11 health deficiencies (the Montana average is 11.2, the national average 9.2).
Of 37 health citations since October 2023, 5 were rated as actual harm or immediate jeopardy to residents.
CMS lists 6 fines totaling $130,272 in the last three years; the largest was $42,770, and the latest is dated April 9, 2026.
Nurses and nurse aides worked 3.46 hours per resident per day, against 4.05 across Montana and 3.86 nationally. Registered nurses accounted for 0.91 of those hours.
36.2% of nursing staff left within the year CMS measured (Montana average 54.8%).
CMS links it to Sweetwater Care, an affiliated group of 8 nursing homes.
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.
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.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents dependent on staff for mobility assistance were turned and repositioned every two hours or as needed to prevent the development of pressure injuries for 3 (#s 2, 3, and 9) of 9 sampled residents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment remained free of accidents and hazards, failed to provide supervision necessary to prevent accidents related to falls, and failed to thoroughly investigate (including interviewing resident #129) and identify the direct root causes of falls for future fall prevention, for 4 (#s 5, 45, 156, and 160) of 29 sampled residents, and the falls resulted in resident #160 sustaining a hip fracture, resident #45 had a closed head injury, and #156 had a laceration above the eye; and the facility failed to ensure interventions and safety assessments were in place for a resident who was smoking on facility property, and who kept his smoking materials, and the facility reported they were a non-smoking facility, for 1 (#86) of 29 sampled residents. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary staff in the kitchen preparing and serving food during meal service wore beard coverings, and failed to ensure kitchen refrigeration temperature logs were monitored and maintained. This deficient practice increased the risk for residents receiving food and meals which were prepared, served, and stored in the kitchen to experience negative food service safety outcomes.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards were followed by protecting patient health information from visitors for 3 (#s 79, 121, and 134) of 29 sampled residents and failed to ensure medication carts were locked when unattended.
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 (#126) of 29 sampled residents. This deficient practice had the potential to affect quality measures, and care planning related to diabetes management.
Inspectors wroteBased on observation, interview, and record review, the facility failed to include interventions related to catheter care on the care plan for 1 (#6) of 29 sampled residents.
Inspectors wroteBased on interview and record review, the facility staff failed to review and revise the comprehensive care plan to reflect changes in resident conditions for 1 (#91) of 29 sampled residents. This deficient practice increased the risk of staff not monitoring or providing cares related to resident #91's treatment for pneumonia with an antibiotic.
Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a reweight with a resident having a 22% weight loss (severe weight loss) after one week for 1 (#72), and failed to complete monthly follow ups with a resident who voiced concern about her consistent low weight for 1 (#110) of 29 sampled residents.
Inspectors wroteBased on observations and interview, the facility failed to ensure appropriate and safe PEG tube practices were followed for 1 (#5) of 29 sampled residents.
Inspectors wroteBased on observation, interview, and record review, the facility staff failed to adhere to nationally recognized standards of hand hygiene when passing meal trays for 2 (#s 85 and 92) of 2 supplemental residents sampled for infection control during meals. This deficient practice had an increased risk of transmitting infections to all residents who received meals in the dining room.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a system was in place, so grievance forms were readily accessible without staff needing to assist in the provision or acceptance of a grievance form, and that grievances received were secured to maintain confidentiality. The deficient practice was widespread and may affect any resident, family member, or visitor who wishes to complete and or submit grievances without staff assistance or maintain confidentiality.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure current, readily available results of surveys completed by the State Survey Agency were located in a publicly accessible area. This deficient practice increased the risk of residents to be uninformed of oversight agency findings as required by the rights of long-term care residents.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident with a history of elopements had a Wander guard in place and doors were secured for 1 (#1) of three sampled residents with elopements; and failed to ensure staff were aware of and employing appropriate fall interventions for 1 (#3) of 5 sampled residents with fall risks.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure proper storage of respiratory equipment in resident rooms for 2 (#11 and 15); ensure the proper-storage and emptying of full urinals for 2 (#s 16 and 17); and ensure proper disposal of trash/recycling for 2 (#s 4 and 5) of 22 sampled residents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident admitted without a pressure ulcer did not develop a pressure ulcer for 1 (#10) of 2 sampled residents with pressure ulcers. Resident #10 was admitted with intact skin on the sacrum and developed a Stage III pressure ulcer which progressed to a Stage IV with healing not achievable. The resident did have refusals of care, and the facility implemented interventions for wound prevention, but failed to identify the wound timely and prevent further deterioration or infection, of the wound, and implement and monitor sufficient intervetnions for healing, or resolve the resident's concerns with refusals and pain management which hindered wount healing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store, label, date, and discard food items by the use by date, in the backroom cooler in the kitchen; and failed to monitor refrigerator and freezer temperatures, in the refrigerator next to the juice dispenser, in the kitchen. These failures may affect any resident using or receiving items from the refrigerator or freezer.
Inspectors wroteBased on observation and interviews, the facility failed to provide a home like setting and correct and control odors emanating on the 400B hallway, for 2 (#s 114 and 130) of 39 sampled residents. This deficient practice affected those residents who resided on the 400B hallway and their visitors, due to the unpleasant odors.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and effective blood-draw practices were utilized by contracted staff to reduce the potential for cross-contamination and contamination from blood-borne pathogens when attempting to draw a resident's blood in the dining room, for 1 (#39); failed to implement the appropriate use of TBP for droplet precautions for 1 (#7); and contact precautions for 1 (#52) of 39 sampled residents; and failed to ensure proper hand hygiene was followed related to glove use in the kitchen. These deficient practices had the potential to increase the risk of infection related to blood-borne pathogens, and the risk of spread of infection for all residents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to assist a resident with obtaining clothing that fit, and change the clothing she had regularly, are attempt to obtain clothes she could use that fit, so the resident did not need to re-wear the same shirts each day. This failure did not enhance enhance the resident's dignity as how she dressed was important to her, and she became teary discussing it, for 1 (#52) of 39 sampled residents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received proper treatment, services, and assistive devices to maintain optimal visual abilities for 1 (#42) of 39 sampled residents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to address an indwelling catheter upon admission for discontinuation, by failing to complete an ordered urinary and cognitive assessment and failed to provide the resident with the appropriate services to maintain or restore previous bladder function for self-catheterization to ensure the resident's optimal urinary outcome and independence for 1 (#22) of 39 residents. This deficient practice had the potential to cause an increase in urinary incontinence, urinary infection, and reduce the resident's independence.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide behavioral health services for 1 (#391) of 1 resident sampled for behavioral health, who showed signs of depression after a life-changing event. This deficient practice had the potential to lead to an increased deterioration in resident #391's health, mood, and behavior and failed to identify any interventions for staff to use related to improving the resident's mood or depressive symptoms.
Inspectors wroteBased on interview and record review, the facility failed to identify a resident's elopement risk and update the care plan with interventions to prevent elopement for 1 (#16) of 4 residents sampled for elopement.
Inspectors wroteBased on interview and record review, the facility failed to identify a resident's elopement risk, implement effective interventions to prevent elopement, and failed to follow facility policy, for 2 (#16 and #23) of 4 residents sampled for elopements.
Inspectors wroteBased on observation, interview, and record review, the facility failed to identify a discrepancy in weight recordings which would have identified a severe 16% weight loss in two weeks, for 1 (#40) of 1 dialysis resident sampled for weight loss.
Inspectors wroteBased on interview and record review, the facility failed to continuously assess and document on a penile ulcer that was progressively worsening for 1 (#40) of 1 resident sampled for wound concerns.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from a medication error ommission, for 1 (#244) of 4 sampled residents. This deficient practice caused a resident to miss 15 days of two medications, which had been prescribed to improve urine flow, and assist in the resident's catheter removal.
Inspectors wroteBased on observation, interview, and record review, the facility staff failed to use standard precautions while doing laundry, resulting in the potential for cross contamination, which could negatively affect anyone coming into contact with the staff who provided laundry service.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dignity and respect to 1 (#1) of 4 sampled residents. This deficient practice caused the resident to feel embarrassed and humiliated. During an interview on 3/27/24 at 8:42 a.m., NF1 stated she had cared for resident #1 during a follow up appointment at a local physician's office on 2/29/24. NF1 stated resident #1 came to her appointment soiled with urine and dried stool. NF1 stated she had to help resident take her pants off, so the provider could look at the surgical incision on her left knee. NR1 stated resident #1's incontinent brief was saturated and had leaked on to her clothing and wheelchair. NF1 stated she had left the room to retrieve supplies so she could clean her up. NF1 stated when she returned to the room and took off the soiled incontinent brief, she had found dried stool on her buttocks. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a thorough investigation to include root cause analysis for a fall with injury for 1(#9) of 3 sampled residents. This deficient practice had the potential to affect all residents that are at risk for falls.
Inspectors wroteBased on observation, interview, and record review, the facility failed to complete an accurate MDS assessment in the area of bowel and bladder in accordance with the RAI requirements for 1 (#1) of 4 sampled residents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a baseline care plan, outlining pertinent information needed to care for a new resident within 48 hours of admission for 1(#1) of 4 sampled residents. This deficient practice had the ability of affect all new admissions receiving care in the facility.
Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a comprehensive, person-centered care plan for 1 (#1) of 4 sampled residents. This deficient practice did not address the proper care needs for the resident.
Inspectors wroteBased on interview and record review, facility staff neglected to assess and monitor a new admission, and ensure antibiotic medications were provided properly and documented, for 1 (#2) of 4 sampled residents, whose condition deteriorated over a weekend. The facility terminated two staff involved, but did not report the event as resident neglect. The resident was later transferred to the hospital and passed away.
Inspectors wroteBased on interview and record review, the facility failed to report an incident of neglect of care for 1 (#2) of 1 sampled resident. This neglect increased the risk for the resident to deteriorate without intervention.
Inspectors wroteBased on interview and record review, the facility failed to have a system in place to ensure new admissions had complete and accurate transcription of physician admission orders for 1 (#2) of 1 sampled resident. This deficient practice resulted in missed medications for a resident with a respiratory infection.
Inspectors wroteBased on interview and record review, the facility failed to identify signs and symptoms of infection which led to septic shock and admission to the hospital, with subsequent surgery and the placement of a Vacuum Assisted Wound Closure system for 1 (#1) of 3 sampled residents.
4 fire safety citations on file: 1 on April 9, 2026, 1 on April 24, 2025, 2 on April 25, 2024.
| Date | Penalty | Amount or length |
|---|---|---|
| April 9, 2026 | Fine | $13,065 |
| April 9, 2026 | Fine | $13,065 |
| April 24, 2025 | Fine | $42,770 |
| March 28, 2024 | Fine | $21,133 |
| December 4, 2023 | Fine | $17,014 |
| October 25, 2023 | Fine | $23,225 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
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) | 3.46 | 4.05 | 3.86 |
| Registered nurses | 0.91 | 0.98 | 0.69 |
| All nursing staff on weekends | 2.85 | 3.59 | 3.42 |
| Nurse aides | 1.78 | ||
| Licensed practical nurses | 0.77 | ||
| Nursing staff turnover (share who left in a year) | 36.2% | 54.8% | 45.8% |
| Registered nurse turnover | 25.0% | 48.3% | 42.9% |
| Administrators who left | 1 |
CMS expects 3.54 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
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 3.71 on weekdays and 2.85 on weekends, 23% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 6.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.56 in April to June 2025 to 3.46 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 | 3.46 | 0.91 | 3.71 | 2.85 | 6.0% | 0 of 90 | 147 |
| Oct to Dec 2025 | 3.47 | 0.81 | 3.70 | 2.88 | 0.0% | 0 of 92 | 140 |
| Jul to Sep 2025 | 3.55 | 0.80 | 3.78 | 2.98 | 0.4% | 0 of 92 | 139 |
| Apr to Jun 2025 | 3.56 | 0.79 | 3.82 | 2.90 | 0.7% | 0 of 91 | 141 |
| 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.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Montana, all employers | |||
| CNAs (nursing assistants) | $19.67 | $18.29 to $22.86 | 4,390 |
| LPNs and LVNs | $29.91 | $27.95 to $32.14 | 1,620 |
| Registered nurses | $41.00 | $38.56 to $48.46 | 10,950 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
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 | 6.3 | 18.7 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.2 | 2.1 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.2 | 2.9 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 3.6 | 4.4 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.3 | 1.3 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 4.6 | 17.2 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 7.4 | 6.3 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 20.0 | 20.4 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 24.7 | 19.2 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 9.2 | 14.5 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.7 | 1.4 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.3 | 2.2 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Park Place Transitional Care and Rehabilitation's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (48.9% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
48.9% this home
No different from the national rate
US median of homes 51.5% · Montana: 7 better, 2 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 184 eligible stays.
10.8% this home
No different from the national rate
US median of homes 10.7% · Montana: 0 better, 0 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 184 eligible stays.
8.2% this home
No different from the national rate
US median of homes 7.1% · Montana: 0 better, 0 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 108 eligible stays.
76.5% this home
Median of homes: Montana58.5% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 102 residents counted.
0.0% this home
Median of homes: Montana0.3% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 176 residents counted.
5.0% this home
Median of homes: Montana2.8% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 175 residents counted.
78.8% this home
Median of homes: Montana97.0% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 85 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: SWEETWATER GF OPCO LLC. CMS links this home to Sweetwater Care, a group of 8 nursing homes averaging 2.4 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Sweetwater Care Opco LLC | 5% or greater indirect ownership interest | Organization | 12/01/2017 | |
| Chesley, Aaron | 5% or greater indirect ownership interest | Individual | 12/01/2017 | |
| Crickmore, Reid | W-2 managing employee | Individual | 02/01/2018 | |
| Guerrero, Stephanie | W-2 managing employee | Individual | 07/01/2019 | |
| Chesley, Aaron | Corporate officer | Individual | 12/01/2017 |
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.
Chosen from this home's own inspection record.
These are the official offices in Montana. NursingHomeClear cannot take or act on complaints.