Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 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 Immanuel Skilled Care Center during CMS and state inspections, most recent first.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities, as required.
A resident with significant cognitive impairment was restrained in a wheelchair with a seatbelt without a physician's order, proper assessment, or consent. Staff were inconsistent in their understanding of the resident's ability to remove the seatbelt and the rationale for its use, and documentation did not reflect the use of a restraint or a clinical need for it.
The facility failed to implement proper infection control measures, including the absence of enhanced barrier precautions for a resident with a PEG tube, inadequate hand hygiene by staff, and improper handling of clean linens. Additionally, the infection control nurse lacked documentation and tracking for infection surveillance, contributing to the deficiencies identified.
The facility failed to develop comprehensive, person-centered care plans for several residents, resulting in deficiencies in addressing specific medical needs such as pain management, oxygen use, anticoagulant monitoring, and PTSD interventions. Staff acknowledged the issue and mentioned ongoing training efforts.
The facility failed to ensure safe self-administration of medications, as medications were left at the bedside for residents not approved to self-administer. A resident had pills left on her table without authorization, another had medications left on her breakfast tray despite failing the self-administration assessment, and a third resident had eye drops she couldn't open herself. Staff were unaware of proper protocols, leading to unauthorized self-administration.
A facility failed to accurately code a resident's oxygen use on the MDS. The resident was observed using an oxygen concentrator and confirmed continuous use, but the MDS section for oxygen was left blank. A staff member responsible for MDS accuracy acknowledged the error, noting it occurred during a staffing gap, and stated a new MDS staff member was hired to improve accuracy.
The facility failed to complete baseline care plans with necessary signatures and dates, and did not provide copies to two cognitively intact residents. One resident, admitted in January, and another who returned in August, both reported not receiving their care plans. A staff member acknowledged care planning issues and mentioned recent training to address the problem.
A resident was administered oxygen without a physician's order, contrary to the facility's policy and professional standards. The resident, who required oxygen due to respiratory failure, was observed using it without the necessary documentation. Staff interviews confirmed the need for physician's orders for oxygen use, but a review of the resident's records showed no such order was in place.
A facility failed to coordinate care for a resident under hospice, leading to a deficiency. The resident, experiencing cognitive decline and gastric tube issues, relied on hospice for lotion application. However, there was a lack of documentation sharing between hospice and the facility, and updates were only communicated verbally. The facility assumed monthly information sharing, but only received the hospice plan of care after a surveyor request. The resident's care plan did not reflect hospice status, leading to a deficiency in care coordination.
The facility failed to supervise and assess two residents who smoked, allowing them to leave the premises unsupervised and keep smoking paraphernalia in their rooms, contrary to the facility's non-smoking policy. The residents did not sign out as required, and no smoking assessments or physician's orders were documented. Staff interviews revealed a lack of enforcement of the smoking policy.
A facility failed to follow its policy for weighing a resident after readmission. The resident, who was readmitted after a hospital stay, reported infrequent weight checks and desired more frequent weigh-ins. A staff member could not confirm the last weight check, and records showed only one documented weight. The care plan required weekly weights, but this was not adhered to, violating the facility's policy.
A facility failed to ensure proper provider orders for fluid administration during enteral tube feeding and medication administration for a resident. A staff member administered medications and nutrition without specific fluid orders and did not notify the provider for clarification. Medications and enteral nutrition were given four hours late, and orders for flushing the feeding tube were delayed by five days after admission.
A resident with a history of PTSD from serving as a helicopter pilot during the Vietnam War was not provided with trauma-informed care. The resident managed his PTSD by avoiding overwhelming situations, but staff were unaware of his condition due to a missing trauma assessment. Despite annual training, staff did not inquire about the resident's PTSD, and the facility's policy on trauma-informed care was not followed.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt notification and communication regarding an incident that required reporting, as well as the absence of documentation showing that the investigation outcomes were shared with the appropriate external agencies. No additional details about the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Assess and Document Use of Physical Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, specifically by not identifying a seatbelt as a restraint, not assessing the safety or clinical need for its use, and not obtaining a physician's order or consent prior to its application. Observations showed the resident was seated in a wheelchair with a seatbelt in use, and interviews with staff revealed inconsistent knowledge regarding the resident's ability to remove the seatbelt and the rationale for its use. Some staff believed the resident could remove the seatbelt independently, while others stated she could not. Staff were also unaware of the reason for the seatbelt's use, and the resident's family had not been notified or given consent for its placement. Record review indicated there was no physician's order for the seatbelt, and the resident's MDS assessment did not document the use of restraints. The resident was assessed as rarely or never understood, indicating significant cognitive impairment. Occupational therapy evaluation noted the resident had considerable balance impairments and was at high risk for falls, but did not demonstrate a clinical need for a seatbelt at the time of assessment. The seatbelt was in use without proper assessment, documentation, or consent, resulting in the resident being restrained to her wheelchair without a clinical rationale.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, as evidenced by several observations and interviews. In one instance, a resident with a PEG tube was not provided with enhanced barrier precautions, such as a gown, mask, or eye protection, during medication administration. The precautions sign was missing from the resident's door, and necessary protective equipment was not available in the precautions cart. Additionally, medications were placed on an unclean surface without a protective barrier, contrary to standard precautions. Staff members were observed not adhering to hand hygiene protocols. For example, a staff member did not sanitize their hands before donning gloves or after doffing them during medication administration. Another staff member failed to perform hand hygiene before entering and after exiting multiple resident rooms while delivering drinks and taking meal orders. These actions were against the facility's infection control policy, which mandates hand hygiene when entering and leaving resident rooms and after removing personal protective equipment. The facility also lacked proper procedures for handling clean linens, as observed when a staff member transported clean clothes without covering them. Furthermore, the infection control nurse admitted to not having documentation or tracking for infection surveillance, despite being responsible for the infection control program. This lack of documentation and adherence to infection control practices contributed to the deficiencies identified during the survey.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for several residents, leading to deficiencies in addressing their specific medical needs. Resident #9, who suffers from Fibromyalgia, Rheumatoid Arthritis, and Chronic Pain Syndrome, reported constant pain, yet her care plan lacked focus, goals, or interventions for pain management, including the use of opioid medications or non-pharmacological approaches. Similarly, resident #10, who was observed using oxygen, had no physician's order or care plan interventions for oxygen use. Resident #32, diagnosed with atrial fibrillation and heart failure, was on the anticoagulant Pradaxa, but her care plan did not address the medication or its potential side effects. Resident #53, a Vietnam War veteran with PTSD, had no care plan interventions for trauma-related issues. Additionally, resident #52's care plan was not specific about oxygen flow settings, and resident #100's care plan was inadvertently closed, resulting in the absence of focus or interventions. Staff member B acknowledged the care plans were not comprehensive or person-centered and mentioned ongoing training efforts. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timetables, but these were not implemented for the residents in question.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were safe to self-administer medications, leading to medications being left at the bedside without proper authorization. Resident #48 was observed with a medication cup containing several pills on her bedside table, which she stated were sometimes left for her to take on her own. However, her self-administration assessment indicated that she was not approved to self-administer medications. Similarly, resident #23 was found with a full medicine cup on her breakfast tray, and staff member O admitted to leaving medications for her to take herself, despite resident #23 not passing the self-administration assessment. The IDT had not reviewed the results of her assessment. Resident #9 had a bottle of artificial tears on her bedside table, which she used for dry eyes. However, she was unable to open the bottle herself and required assistance from staff. Staff member I was unaware of the eye drops in resident #9's room, and the facility's self-administration assessment indicated that resident #9 was capable of opening medication containers, which was not the case. The facility's policy required a self-administration assessment and IDT recommendation for residents to self-administer medications, but these procedures were not properly followed for the residents involved.
Inaccurate MDS Coding for Oxygen Use
Penalty
Summary
The facility failed to ensure that oxygen use was accurately coded on a resident's Minimum Data Set (MDS) assessment. During observations and interviews, it was noted that a resident was using an oxygen concentrator set at 2 liters per minute and wearing a nasal cannula. The resident confirmed that she had been on oxygen for quite some time and needed to wear it continuously. However, a review of the resident's Significant Change MDS, with an Assessment Reference Date (ARD) of 8/30/24, revealed that Section O, which pertains to oxygen use, was left blank. A staff member responsible for MDS accuracy acknowledged the oversight and attributed it to a period when the MDS staff member was unavailable, indicating that a new MDS staff member had been hired to address such issues. The facility's document on Resident Assessments emphasized that MDS assessments should consistently reflect information from progress notes, care plans, and resident observations/interviews.
Incomplete Baseline Care Plans and Lack of Resident Copies
Penalty
Summary
The facility failed to ensure that baseline care plans were completed with the necessary staff signatures, titles, dates of completion, and that copies were provided to the residents or their representatives. This deficiency was identified for two residents, both of whom were cognitively intact with a BIMS score of 15. One resident, who had been at the facility since January 2024, reported never receiving a copy of her care plan after admission. Upon review, her baseline care plan was found incomplete in the section requiring staff and resident signatures and dates. Similarly, another resident who returned to the facility in August 2024 after a hospital visit also reported not receiving any care plans, including the baseline care plan. The review of her baseline care plan revealed the same deficiencies in the signature and date section. During an interview, a staff member acknowledged that care planning was an issue and mentioned that baseline care plans were supposed to be completed by the floor nurse upon admission. The staff member also noted that a recent training session had been conducted to address care planning, indicating ongoing efforts to improve the process.
Oxygen Administered Without Physician's Order
Penalty
Summary
The facility failed to meet professional standards of practice by administering oxygen to a resident without a physician's order. During an observation, a resident was found using oxygen at two liters via nasal cannula, and the resident stated it was necessary due to respiratory failure. Interviews with staff confirmed that physician's orders are required for oxygen use, and a review of the resident's physician's orders showed no order for oxygen was present. The facility's policy on oxygen administration also mandates verification of a physician's order, which was not adhered to in this case.
Failure to Coordinate Care with Hospice
Penalty
Summary
The facility failed to coordinate care for a resident who was under hospice care, leading to a deficiency in providing appropriate treatment and care according to orders, resident’s preferences, and goals. The resident, who was experiencing cognitive decline and had a gastric tube, expressed discomfort due to itching and leaking issues with the tube. The resident relied on hospice staff to apply lotion to areas she could not reach, but there was a lack of coordination between the facility and hospice staff. The hospice nurse confirmed that documentation was not shared between hospice and the facility, and updates were only communicated verbally during visits. The facility staff assumed that hospice information was sent monthly, but they only received the hospice plan of care and notes after the State Survey Agency requested them. The resident's care plan, last updated in August, did not reflect her hospice status or the coordination of care between the facility and hospice. The hospice admission packet indicated that care plans and updates should be shared, but this was not done until prompted by the surveyors. This lack of communication and documentation led to the deficiency in coordinating the resident's care with hospice services.
Failure to Supervise and Assess Smoking Residents
Penalty
Summary
The facility failed to adequately assess and supervise residents who smoke, leading to potential safety hazards. Two residents, identified as #53 and #77, were observed leaving the facility to smoke without notifying staff or signing out, as required by the facility's policy. Both residents kept smoking paraphernalia, such as lighters and cigarettes, in their rooms, which is against the facility's non-smoking policy. Resident #53 mentioned that he often walked off the property to smoke, which was exhausting for him, and he was not monitored by staff during these times. Similarly, resident #77, who used an electric wheelchair, also left the property to smoke without supervision or signing out. The care plans for both residents indicated that they were smokers and included goals to prevent injury from unsafe smoking practices. However, the interventions listed, such as instructing residents on smoking risks and the facility's smoking policy, were not effectively implemented. There were no physician's orders or smoking assessments completed for either resident, which further indicates a lack of proper evaluation and monitoring of their smoking habits. Interviews with staff revealed a lack of awareness and enforcement of the facility's non-smoking policy. Staff member A admitted to not knowing what actions would be taken if an incident occurred while the residents were smoking outside. Additionally, the facility failed to provide requested documentation, such as the smoking policy, list of residents who smoke, smoking assessments, and physician's orders, before the survey concluded.
Failure to Document Resident's Weight as Per Policy
Penalty
Summary
The facility failed to adhere to its policy for weighing and documenting a resident's weight at designated intervals following a readmission. A resident, who was readmitted in August 2024 after a hospital stay, reported not having her weight checked frequently and expressed a desire to be weighed more often. During an interview, a staff member was unable to confirm the last time the resident was weighed. A review of the resident's electronic medical record showed only one documented weight on September 1, 2024. The resident's care plan, revised on September 10, 2024, indicated that weights should be recorded weekly. The facility's policy required residents to be weighed upon admission, then the following two days to establish a baseline, followed by weekly weights for four weeks, and then monthly. This policy was not followed for the resident in question.
Deficiency in Enteral Feeding and Medication Administration
Penalty
Summary
The facility failed to ensure proper provider orders were in place for the administration of fluids during enteral tube feeding and medication administration for a resident. During an observation, a staff member verified the placement of the resident's feeding tube and administered medications and nutritional supplements without specific orders for fluid administration. The staff member used her knowledge to administer fluids between medications and before and after tube feeding, but acknowledged that she should have contacted the provider or dietician for clarification since there were no orders in place. Additionally, the staff member administered medications and enteral nutrition four hours after the scheduled time, without notifying the provider for clarification or adjustment of the next administration times. The resident's medication administration record indicated that orders for flushing the feeding tube with water before and after medication and bolus administration were not in place until five days after the resident's admission. This resulted in a failure to adhere to the facility's policy of administering medications within one hour before or after the scheduled time.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to identify and address PTSD, provide trauma-informed care, and meet professional standards for a resident who was a Vietnam War veteran and helicopter pilot. The resident expressed that being around many people could trigger flashbacks, and he managed his PTSD by sometimes eating in his room to avoid overwhelming situations. Despite the resident's history of PTSD, he reported that facility staff had never inquired about his PTSD or experiences, leading to a tearful reaction during an interview. Interviews with staff revealed that a trauma assessment was supposed to be completed upon admission and reviewed annually, but the assessment for this resident was missing. Staff members who worked with the resident were unaware of his PTSD, despite receiving annual online training on PTSD and trauma care. The facility had implemented a PTSD screening process in October 2023, but the resident was overlooked, and no trauma assessment was conducted for him. The facility's policy on trauma-informed and culturally competent care emphasized minimizing re-traumatization and conducting universal screening and assessment, which was not adhered to in this case.
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What surveyors actually found near you
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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 Kalispell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brendan House | 0.5 mi | — | 0 | 0 |
| Kalispell Rehabilitation And Nursing Llc | 0.7 mi | — | 40 | 0 |
| Montana Veterans Home N H | 12.2 mi | — | 0 | 0 |
| Whitefish Care And Rehabilitation | 13.4 mi | — | 33 | 0 |
| Polson Health & Rehabilitation Center | 37.3 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.