Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gallatin Rest Home during CMS and state inspections, most recent first.
Two residents experienced the development and worsening of Stage II and Stage III pressure ulcers due to inconsistent wound care, lack of regular repositioning, incomplete documentation, and failure to use prescribed preventive devices. Staff did not consistently follow care plans or perform required interventions, resulting in chronic pressure injuries.
The facility did not update care plans for three residents after significant changes in their care needs, including removal of a urinary catheter, multiple unwitnessed falls, and resolution of a UTI. Care plans continued to reflect outdated information and lacked documentation of new interventions, with staff unable to explain the omissions.
Surveyors observed multiple failures in infection prevention, including staff not performing hand hygiene before and after medication administration, not changing gloves between clean and dirty tasks, and not cleaning medication equipment. Unsanitary storage of tube feeding supplies, unclean respiratory equipment, and non-cleanable floor mats were also noted. Staff lacked documented hand hygiene education, and there was no policy for cleaning suction equipment.
A resident was administered multiple psychotropic medications, including Seroquel, olanzapine, and sertraline, for conditions such as sleeplessness, agitation, and mild dementia with psychotic disturbance, without documented evidence that the risks and benefits were explained to the resident or their representative. Staff interviews confirmed inconsistent completion of consent forms, and no documentation was available for review during the survey.
A resident with multiple unwitnessed falls did not have root causes identified or individualized fall prevention strategies implemented. Staff reported needing more training in root cause analysis, and care plans only included general interventions rather than those tailored to the specific circumstances of the falls.
A resident requiring dialysis did not have appropriate facility policies, physician orders, or monitoring in place for dialysis care and transportation. Staff were unaware of communication protocols with the dialysis center, and the facility lacked a contract with the dialysis provider. Documentation of pre- and post-dialysis monitoring was absent, and the only record was a care plan entry and ambulance transport form.
A resident with mobility and speech difficulties reported several hundred dollars missing from her purse. The facility partially reimbursed her and notified law enforcement, but did not interview potential witnesses, other residents, or investigate further to determine if others were affected or if there was a trend of missing items.
The facility failed to provide meals within a 14-hour window between dinner and breakfast and did not offer bedtime snacks to residents. Observations showed a 15-hour gap between meals, and residents reported not being offered snacks, although they were available at the nurses' station. Staff confirmed snacks were not routinely offered, and there was no documentation of resident approval for mealtime hours.
The facility did not implement and monitor measures to prevent Legionella growth in water systems. An ice/water dispenser was found dirty and uncleanable. Staff interviews revealed a lack of documentation and implementation of the water management plan, despite having a binder for it. The facility's plan required documentation and monitoring, which was not effectively done.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development and worsening of pressure ulcers for two residents. One resident was observed with a wound dressing on her right heel but had an open area on her coccyx without a dressing during morning care. Staff applied only a moisture barrier cream and a new incontinence brief, and the resident expressed pain when moved. Nursing progress notes indicated a history of bruising and the development of a pressure ulcer on the coccyx, which progressed to an unstageable ulcer and later a Stage III ulcer with maceration. The wound nurse was reportedly seeing the resident weekly, but dressing changes were otherwise performed by staff. Another resident was repeatedly observed lying on his back in bed with the head of the bed elevated, and his head tilted forward to the left side, with a neck pillow/collar not in use as care planned. Observations over multiple days showed the resident remained in the same position for extended periods, and staff interviews confirmed that turning and repositioning were not consistently performed every two hours as required. The resident had a history of pressure injuries and maceration on his ear and neck due to positioning and moisture, and current assessments revealed multiple pressure wounds on the buttocks, including Stage I and Stage II ulcers. The care plan specified the use of a soft cervical collar-type pillow and routine repositioning, but these interventions were not consistently implemented. Documentation and wound tracking for both residents showed ongoing issues with pressure ulcer management, including incomplete wound documentation, inconsistent use of preventive devices, and lack of adherence to turning and repositioning protocols. These failures contributed to the development and chronicity of Stage II and Stage III pressure ulcers in both residents, as evidenced by direct observation, staff interviews, and record review.
Failure to Review and Revise Resident Care Plans After Changes in Condition
Penalty
Summary
The facility failed to review and revise care plans for three residents following significant changes in their conditions or care needs. For one resident, the care plan continued to document the presence of an indwelling urinary catheter and related interventions, despite physician orders for catheter removal and multiple observations confirming the absence of a catheter. Staff interviews confirmed that the care plan was not updated to reflect the resident's current status. Another resident experienced multiple unwitnessed falls over several months, with nursing progress notes lacking documentation of contributing factors or any new interventions implemented after each fall. The care plan did not reflect all falls or show updates with new interventions following these incidents. A third resident's care plan failed to indicate the resolution of a urinary tract infection after completion of antibiotic therapy, despite physician orders and medication administration records confirming treatment. In each case, staff were unable to explain why care plans were not revised to reflect current conditions and interventions.
Infection Control Deficiencies in Hand Hygiene, Equipment Cleaning, and Environmental Sanitation
Penalty
Summary
Multiple instances of improper hand hygiene were observed during medication administration for several residents. Staff members failed to perform hand hygiene before entering resident rooms, before and after gloving, and between dirty and clean tasks. In one case, a staff member prepared and administered medications, handled food items, and used a pill cutter without cleaning it or performing hand hygiene at any point. Another staff member applied topical medications and performed personal care tasks without changing gloves or performing hand hygiene between tasks, and then proceeded to prepare medications for another resident without washing hands. Additionally, a staff member washed hands only after leaving the unit and did not perform hand hygiene between contaminated and clean activities. Environmental cleanliness and equipment maintenance were also found lacking. Observations revealed that tube feeding supplies were stored in unsanitary conditions, with bottles showing signs of spoilage and residue present on cupboard surfaces. A suction machine used for a resident had a canister filled with old, crusted liquid, indicating it had not been cleaned after use. Floor mats used for residents were found to be cracked, dirty, and not cleanable, with staff acknowledging the issue but stating it had not been addressed as a priority. A review of facility policies showed that while there was a hand hygiene policy in place, staff education files lacked documentation of hand hygiene training. Furthermore, the facility did not have a policy specific to the maintenance and cleaning of intermittent suction equipment. These deficiencies were identified through direct observation, staff interviews, and record reviews, and were found to have the potential to increase the risk of infection for all residents receiving care.
Failure to Obtain and Document Psychotropic Medication Consent
Penalty
Summary
The facility failed to ensure that a resident and the resident's representative were informed of the risks and benefits associated with the use of psychotropic medications prior to the initiation of treatment. Observation showed the resident ambulating slowly with a walker and requiring staff direction. Review of the resident's physician orders revealed administration of Seroquel, olanzapine, and sertraline for conditions including sleeplessness, agitation, and mild dementia with psychotic disturbance. Examination of the electronic health record did not show documentation that the risks and benefits of these medications were discussed with or provided to the resident or their representative. Staff confirmed that the process for obtaining consent with documented risks and benefits was inconsistent, particularly when the responsible staff member was unavailable, and no consent documents were provided for review during the survey period.
Failure to Identify Root Causes and Individualize Fall Prevention Strategies
Penalty
Summary
The facility failed to utilize a system for identifying root causes for falls and did not develop or implement individualized fall prevention strategies for a resident with a history of multiple unwitnessed falls. Observations showed the resident ambulating with a walker and requiring verbal cues to locate her room. Nursing progress notes documented several unwitnessed falls, but did not include any analysis of contributing factors or possible causes for these incidents. Review of the resident's electronic health record also failed to show documentation of root cause identification for the falls. Interviews revealed that staff felt they needed further training in root cause analysis and struggled to understand the process. The resident's care plans, while noting fall risk and listing general interventions such as assistance with ambulation, call light availability, and therapy referrals, did not include interventions tailored to the specific causes of the resident's falls. The facility's fall prevention policy outlined general risk protocols but did not ensure that individualized interventions were developed based on root cause analysis for residents who experienced falls.
Failure to Establish and Implement Dialysis Care Policies and Monitoring
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care and services for a resident requiring dialysis. There were no facility policies in place for dialysis care and management, dialysis transportation, or communication with the dialysis center. The facility also lacked a contract with the dialysis provider. Staff interviews revealed that the resident's electronic chart did not contain dialysis orders, schedules, or monitoring instructions, and staff were unaware of any communication or monitoring protocols related to the resident's dialysis care. The only documentation available was a care plan entry noting dialysis and a form for ambulance transport, with no evidence of pre- or post-dialysis monitoring by facility staff. The resident, who had a dialysis port and required regular treatments, reported that transportation was arranged prior to admission and that he did not receive meals from the facility for dialysis days. Staff confirmed that dialysis assessments and weights were performed at the dialysis center, but no information was sent back to the facility. Review of the resident's records showed only an admission weight and no ongoing monitoring or physician orders related to dialysis. The facility was unable to provide requested documentation for dialysis monitoring, relevant policies, or a contract with the dialysis provider during the survey.
Failure to Fully Investigate Resident Theft Allegation
Penalty
Summary
The facility failed to fully investigate an allegation of theft involving a resident who reported several hundred dollars missing from her purse. The resident, who had difficulty with mobility and speech, stated that she informed facility management of the missing money and was partially reimbursed, but was not told if the perpetrator was identified. Staff interviews revealed that the theft was reported to administration, and local law enforcement was notified. However, the facility did not conduct interviews with potential witnesses or other residents who may have been affected, nor did they attempt to determine if there was a pattern of missing items. The investigation was limited to the initial report, and no further steps were taken to identify the responsible party or assess the impact on other residents. Documentation showed inconsistencies in the reported amount stolen, with staff noting the resident initially reported $200 missing, later stating $300. The resident's purse was typically left unzipped due to her physical limitations, and staff acknowledged that many individuals could have accessed her room during the relevant period. Despite these factors, the facility's response was limited to partial reimbursement and advising the resident's family to provide a lockbox, without a comprehensive investigation or review of other possible victims.
Failure to Provide Timely Meals and Snacks
Penalty
Summary
The facility failed to adhere to the requirement of providing meals with no more than 14 hours between the evening meal and breakfast, as well as offering a nourishing snack at bedtime. Observations revealed that breakfast was served at 8:20 a.m., resulting in a 15-hour gap from the dinner served at 5:00 p.m. the previous evening. Several residents, including those who were blind or had mobility issues, reported not being offered snacks at bedtime, although snacks were available at the nurses' station. Staff interviews confirmed that snacks were not routinely offered, and there was a misunderstanding about the requirement to maintain a 14-hour gap between meals. Additionally, the facility did not document resident group approval of the mealtime hours, which is necessary to ensure that meal schedules align with residents' needs and preferences. Staff members indicated that residents had previously been asked about mealtime changes, but no documentation was available to support this claim. The lack of proactive snack offering and the extended gap between dinner and breakfast had the potential to affect all residents receiving meals from the dining service.
Failure to Implement Water Management Plan
Penalty
Summary
The facility failed to implement and monitor measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building's water systems. During an observation, the ice/water dispenser on the rehabilitation unit was found to be dirty, with a black film, white mineral deposits, and rust on the tray and bottom wall of the dispensing area, rendering the tray uncleanable. Interviews with staff members revealed a lack of documentation and implementation of the water management plan. Staff member H admitted to not documenting flushes or cleaning of ice machines, while staff member B acknowledged having a water management plan binder but admitted it was not fully implemented. The facility's Risk Management Plan for Legionella Control indicated that documentation should be housed in the maintenance department and monitored through infection control surveillance, but this was not being done effectively.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bozeman
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Livingston Health & Rehabilitation Center | 23.3 mi | — | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.