Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Valle Vista Rehabilitation And Nursing Llc during CMS and state inspections, most recent first.
A quadriplegic resident was transferred to another facility without being provided with a wheelchair, despite reliance on it for mobility, and arrived at the receiving facility without one. Additionally, the facility did not document the discharge in the medical record, omitting key information about the transfer and the resident's care.
Surveyors found that a common bathtub had not been cleaned for several months, with visible stains and sediment, and lacked signage indicating it was out of use. Staff confirmed the bathtub was not in use and believed monthly housekeeping audits were occurring, but no documentation of cleaning or audits was provided. Additionally, infection control policies, including water management and Legionella surveillance, had not been reviewed or updated annually as required.
The facility did not maintain complete medical records, as several residents lacked medical provider visit notes in both the EMR and paper charts, and a resident's POLST form was missing a required physician signature. Staff processes for handling provider notes were inconsistent, and the missing POLST signature was not identified during routine reviews.
Two residents were administered psychotropic medications, including antidepressants and antipsychotics, before informed consent was obtained from their representatives. In both cases, medication was started prior to the completion or documentation of consent, contrary to facility policy requiring consent before initiation. Staff interviews confirmed that the required process for obtaining consent was not followed.
Two residents with dementia received PRN antipsychotic medications without the required 14-day limitation or documented provider rationale for continued use. Medication regimen reviews did not address the ongoing use of these medications, and staff were unable to explain the oversight, despite facility policy requiring a 14-day limit for PRN antipsychotics.
A resident with encephalopathy and a conservator was suspected of being financially exploited when staff noticed unpaid bills and possible misuse of funds. Although APS was notified and an investigator assigned, the facility did not report the allegation to the state survey agency or document an internal investigation, contrary to its own policies.
A resident was transferred to the hospital on two occasions without receiving the required written notice explaining the reason for transfer. Staff confirmed that the transfer notices were not completed, and no documentation was found in the medical record or provided upon request, despite facility policy requiring such notification.
A resident with poor vision and limited hand function was not provided with a care plan that addressed her specific activity preferences or physical limitations. She reported spending most of her time in bed without being offered in-room activities or one-on-one visits, and the care plan lacked individualized interventions despite her needs and expressed interests.
A resident with poor vision and limited hand function did not receive group or individual activities to meet her interests or support her well-being. The resident reported no staff visits or in-room activities, and activity participation records showed no documented involvement since admission. The staff member responsible for activities acknowledged documentation issues and lack of time, and no supporting records or assessments were provided.
The facility failed to maintain a sanitary kitchen, affecting all residents consuming food from it. Observations revealed debris and dirt in various areas, and a dark brown substance at the floor's edge. Staff interviews indicated cleaning tasks were not consistently completed due to staff shortages and vacation. The facility's policy required regular cleaning, but checklists showed gaps in completion.
The facility lacked a certified director for food and nutrition services, affecting all residents receiving food. Staff member C, in the role for six months, had no training or oversight due to staff member G's absence. The dietician was only available by phone, and no dietary training documentation existed for staff member C.
The facility was found deficient in maintaining kitchen hygiene and food storage practices. Staff failed to wear required hairnets and beard nets, and several food items were improperly stored without labels or dates. The kitchen was unclean, with dirty equipment and missing laminate on cupboards. Dented cans were improperly stored, and staff admitted to neglecting proper procedures. The dietary manager's supervisor acknowledged a lack of oversight, contributing to these issues.
The facility was found to have expired medications and medical supplies in both the medication and treatment rooms. Items such as test strips, injection solutions, and various catheters were past their expiration dates. Staff acknowledged the oversight, and it was noted that the facility did not have a specific policy for handling expired items.
The facility failed to serve food at safe and appetizing temperatures, affecting three residents. Observations showed food items like eggs and hashbrowns were served below the required 135 degrees Fahrenheit. A resident expressed dissatisfaction with the consistently cold food, and staff acknowledged issues with the steam table and plate warmers. The facility's policy on maintaining hot food temperatures was not followed.
Failure to Provide Wheelchair and Proper Discharge Documentation
Penalty
Summary
A quadriplegic resident, who required a wheelchair for primary mobility due to spastic quadriplegic cerebral palsy, was discharged and transferred to an Adult Services Residential Program facility in Pennsylvania without being provided with a wheelchair. Interviews with staff revealed that although there was discussion about sending a manual wheelchair with the resident, there was no documentation confirming that a wheelchair was actually sent. The receiving facility reported that the resident arrived without any wheelchair, manual or electric, which was his main mode of locomotion. Additionally, the facility failed to document the transfer and discharge of the resident in the medical record. There was no discharge progress note on the day of discharge, and essential information such as a summary of the resident's stay, education on medications and treatments, a list of belongings, details of who picked up the resident, and the reason for discharge were missing. All discharge documentation was handled through email and TEAMS meetings rather than being properly recorded in the medical record as per facility policy.
Inadequate Infection Control Program and Equipment Cleaning
Penalty
Summary
The facility failed to maintain an adequate infection prevention and control program, as evidenced by improper cleaning and maintenance of resident-care equipment and lack of annual review of infection control policies. During an observation, a common bathtub in the North hallway was found with long streaks of dark, rust-colored stains and dried brown sediment around the drain. The bathtub lacked signage or a cover to indicate it was out of use. A staff member reported that the bathtub had not been cleaned in five or six months and confirmed it was not being used by residents, with only the toilet and sink in use in that bathroom. The staff member also believed that housekeeping audits were being conducted monthly by another staff member. Review of facility policies revealed that the cleaning and disinfection policy for resident-care equipment was last updated in April 2025, and both the Water Management Program Policy and Legionella Surveillance Policy had not been reviewed or revised since April 2020. The facility assessment indicated that routine maintenance and cleaning schedules existed for most equipment, with non-routine maintenance conducted as needed. However, when documentation was requested for cleaning or deep cleaning of the North hallway tub and for housekeeping audits from June 2024 to the present, no records were provided by the end of the survey.
Incomplete Medical Records and Missing POLST Signature
Penalty
Summary
The facility failed to maintain complete and accessible medical records for several residents, specifically lacking medical provider visit notes in both the electronic medical record (EMR) and paper charts. For four residents, there were no medical provider visit notes available in the EMR or in the paper charts at the nurse's desk, despite the residents having been admitted months prior. The process for handling provider notes involved receiving them via facsimile, review by the charge nurse, and subsequent scanning into the EMR, with the original faxed copy placed in the paper chart. However, the most recent notes had not been scanned, and in some cases, no notes were found in either record system. Staff confirmed that a nurse was present during provider visits but did not document the visit in the EMR, and the facility was in the process of changing to direct provider entry into the EMR. Additionally, the facility failed to ensure that a resident's Provider Orders for Life-Sustaining Treatment (POLST) form was properly completed, as one resident's POLST lacked a required physician signature. The unsigned POLST had been carried over from a previous facility and was not identified as incomplete during the admission or care planning process. Facility policy required that advance directives be copied and placed on the chart upon admission and reviewed periodically, but this process did not identify the missing signature.
Failure to Obtain Informed Consent Prior to Psychotropic Medication Administration
Penalty
Summary
The facility failed to obtain informed consent prior to administering psychotropic medications for two residents. For one resident, citalopram hydrobromide was ordered and administered before the resident's spouse signed the informed consent form, with the first dose given two days before consent was obtained. The same resident was later started on sertraline HCl, which was also administered before the spouse signed the consent form, with the first dose given two days prior to consent. Another resident received citalopram hydrobromide without any documented consent found in the electronic health record. This resident was also given haloperidol, with the consent form signed by the guardian two days after the medication order was received. Staff interviews revealed that the staff member responsible for obtaining consents could not explain why the consents were not completed prior to starting the medications. The facility's policy requires that residents or their representatives be informed of the risks and benefits of psychotropic medications before initiation, but this was not followed in these cases.
Failure to Limit PRN Antipsychotic Medications to 14 Days
Penalty
Summary
The facility failed to ensure that as needed (PRN) psychotropic medications, specifically antipsychotics, were limited to a 14-day duration unless a medical provider documented a rationale for continued use. For one resident with vascular dementia and delusional disorders, an order for PRN olanzapine did not specify a 14-day limit, and subsequent medication regimen reviews did not address the need to monitor or discontinue the medication after 14 days. The medication remained active beyond the allowed period without appropriate documentation or evaluation by a provider. Similarly, another resident with severe dementia and behavioral disturbances had a PRN order for quetiapine fumarate that also lacked the required 14-day limitation. The medication regimen review process did not identify or address the ongoing use of the PRN antipsychotic within the required timeframe. Staff interviews revealed a lack of understanding regarding the review process for PRN antipsychotic medications, and facility policy required PRN antipsychotic orders to be limited to 14 days, with a new evaluation needed for continued use.
Failure to Report and Investigate Suspected Financial Exploitation
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime, specifically regarding the possible misappropriation of a resident's property by their conservator. A resident with encephalopathy and an appointed conservator was the subject of concern after staff noted issues with unpaid bills and suspected the conservator might be using the resident's funds for personal use. Staff discussed the issue in an interdisciplinary team (IDT) meeting, and Adult Protective Services (APS) was notified, resulting in the assignment of an APS investigator. However, there was uncertainty among staff about who was responsible for following up on the concern after the IDT meeting. Despite the facility's policy requiring immediate investigation and timely reporting of suspected exploitation to the state survey agency and other authorities, there was no evidence that the allegation was reported through the State Survey Agency reporting portal. Additionally, the facility could not provide documentation of an internal investigation into the exploitation allegation. This failure to report and investigate as required by policy and regulation constituted the deficiency.
Failure to Provide Written Transfer Notice to Resident and Representative
Penalty
Summary
The facility failed to provide written notification to a resident and/or the resident's representative regarding the reason for transfer when the resident was transferred to the hospital on two separate occasions. During interviews, a staff member confirmed that no transfer notice was completed for the resident's hospitalizations, and review of the electronic medical record did not show any documentation of such notices for the specified transfers. Additionally, when requested, the facility was unable to produce any records or documentation of the required transfer notices. The facility's own policy requires that transfer/discharge notices be provided to residents or their representatives in a language and manner they can understand.
Failure to Develop and Implement Comprehensive Activity Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that addressed a resident's activity preferences and physical abilities. Observations showed the resident spent most of her time in bed, with limited engagement in activities. The resident reported poor vision and limited hand function, which prevented her from participating in group activities, and stated that staff had not offered her in-room activities or one-on-one visits. She expressed a desire for staff to visit her in her room, as she was unable to participate in most activities due to her physical limitations. Review of the resident's care plan revealed it did not identify her specific life roles, activities of interest, or provide for one-on-one visits, despite her expressed preferences and needs. The care plan included only general interventions such as encouraging participation in activities and supplying leisure materials as needed, without customization to her abilities or preferences. Staff interviews indicated issues with documentation and care plan customization due to changes in the facility's computer system and staffing limitations. The resident's MDS assessment confirmed she required maximal assistance for mobility and self-care, further highlighting the need for individualized activity planning.
Failure to Provide and Document Activities to Meet Resident Needs
Penalty
Summary
A deficiency was identified when a resident, who had poor vision and limited hand function, reported not participating in activities since admission. The resident stated that staff did not offer or provide one-on-one visits or in-room activities, and expressed a desire for staff to visit her, as she spent most of her time in her room. Observation confirmed the resident was alone in her room, awake, with the television off, and no activities being offered. Review of the resident's activity participation record showed no documented participation in any activities since admission. During interviews, the staff member responsible for activities acknowledged issues with documentation and stated that, due to working in two positions and limited time, she had not been documenting resident participation as required. Despite claims that the resident had participated in several activities, no documentation or records were provided to support this, and no activity assessment or evidence of one-on-one visits was available by the end of the survey.
Sanitation Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary and clean condition, which had the potential to affect all residents consuming food or services from the kitchen. During an observation, surveyors found white debris resembling crumbs in the corners of the kitchen floor, white, tan, and brown debris resembling crumbs and dirt underneath the shelves, and white and tan debris resembling crumbs and food particles underneath the workspace next to the stove. Additionally, a dark brown substance was observed at the edge of the floor where the mop boards meet the floor. Interviews with staff revealed that the cleaning tasks were assigned to employees on shift, with a checklist that was initially required to be completed weekly but was changed to daily due to non-compliance. Staff member G mentioned that some staff were on vacation, and there was a loss of employees after school started. A review of the facility's policy on dietary sanitization indicated that all kitchen and dining areas should be kept clean, with the food services manager responsible for scheduling regular cleaning. However, a review of the kitchen checklists for the last two months showed gaps where the checklists were not completed.
Lack of Certified Director in Food and Nutrition Services
Penalty
Summary
The facility failed to employ a certified individual to serve as the director of food and nutrition services, which could potentially affect all residents receiving food from the kitchen. Staff member C, who took over the position in November, reported having no orientation or training due to the absence of staff member G, who was involved in a car accident. Despite being in the role for six months, staff member C had not received any corporate training or oversight and was not enrolled in any dietary courses, although he planned to take the ServSafe course. The dietician was available only by phone for substitution changes and did not supervise or oversee staff member C in the kitchen. Additionally, there was no documentation of specific dietary orientation or training for staff member C.
Deficiencies in Kitchen Hygiene and Food Storage Practices
Penalty
Summary
The facility failed to maintain proper food storage and preparation standards in the kitchen, as observed during a survey. Staff members were found not wearing required hairnets and beard nets, with one staff member wearing a baseball cap instead. The kitchen had several open food items without labels or dates, including large tubs of rice, brown sugar, flour, and other ingredients. Additionally, the kitchen was found to be unclean, with dirty toasters, drink dispensers, and a chest freezer with food debris and frost buildup. The cupboards above the food prep area were also dirty, with missing laminate chunks. Further observations revealed dented cans in the dry storage room, which should have been discarded according to facility policy. Staff members admitted to not following proper procedures, with one stating that the staff often got in a hurry and neglected to label and date food items. The dietary manager's supervisor acknowledged a lack of oversight in the kitchen, contributing to the ongoing issues. The facility's policies on food labeling and hairnet usage were not being adhered to, as evidenced by the conditions found during the survey.
Expired Medications and Supplies Found in Facility
Penalty
Summary
The facility failed to remove and dispose of expired medications and medical supplies in both the medication room and the treatment room, as observed during a survey. In the medication room, expired items included Coaguchek XS PT test strips, glucose control solution set, sodium chloride injection solution, a red top blood collection tube, and Monoject hypodermic needles. In the treatment room, expired items included various types of catheters. During interviews, staff members acknowledged the oversight, with one staff member admitting to missing the expired items during checks. Additionally, it was revealed that the facility lacked a specific policy addressing the management of expired medications and supplies.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide palatable food at an appetizing temperature for three residents. Observations and interviews revealed that the food served was consistently cold. Resident #200 expressed dissatisfaction with the food quality, stating it was always cold. Temperature checks conducted by staff member C on various dates showed that food items such as eggs, hashbrowns, and cream of wheat were served at temperatures significantly below the required 135 degrees Fahrenheit. Additionally, the steam table used to keep food warm was found unplugged and not turned on, contributing to the issue. Further observations indicated that the steam table was not functioning properly, and a new steam table was available but not assembled. Resident #38 also complained about cold food, opting to eat only her salad. Staff members acknowledged the problem, noting that food was served on cold plates with unheated plate warmers, exacerbating the issue. The facility's policy on meal assistance, which mandates that hot foods be held at 135 degrees or above until served, was not adhered to, leading to the deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 4 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lewistown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Montana Mental Health Nursing Home | 0.6 mi | — | 4 | 0 |
| Central Montana Nursing & Rehabilitation Center | 0.8 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Valle Vista Rehabilitation And Nursing Llc.
100% money-back within 48 hours.
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.