Map showing the location of WHITEFISH CARE AND REHABILITATION in WHITEFISH, Montana
1305 E 7TH ST, WHITEFISH, MT, 59937

Overall Score

CMS Five-Star Quality Rating
1/5Much below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • MontanaLowest tier among peers59 rated homes · average 2.9★
  • Flathead CountyLowest tier among peers5 rated homes · average 2.4★
  • United StatesLowest tier among peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point1★−1.8 vs MT avg
  • StaffingCan add or remove a star1★−2.5 vs MT avg
  • Quality measuresCan add or remove a star4★+1.0 vs MT avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

  • Special Focus Facility candidateThis facility is on the CMS candidate list for the Special Focus Facility program, meaning it is among the poorest-performing facilities in its state on recent inspections.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersMT avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover1★Lowest tier among peersMT avg3.5★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments4★Above 64% of peersMT avg3.0★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff2.55hrsLowest tier among peersMT avg3.97Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.79hrsAbove only 49% of peersMT avg0.94Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better79%Above only 8% of peersMT avg56%RN turnover68%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$447,140Above only 2% of peersMT avg$55,122Fines · denials5 · 1
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
83citations
11inspection dates
9actual harm (G–I)
1immediate jeopardy (J–L)
Oct 22, 2025most recent

Citations by monthMar 2023 – Oct 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Oct 22, 202511 citationsCycle 1worst G · actual harm
  1. F791Provide or obtain dental services for each resident.Quality of Life and CareD · isolatedCorrected Nov 15, 2025
  2. F919Make sure that a working call system is available in each resident's bathroom and bathing area.EnvironmentalE · patternCorrected Dec 24, 2025
  3. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareG · isolatedCorrected Dec 15, 2025
  4. F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesG · isolatedCorrected Nov 15, 2025
  5. F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Infection ControlD · isolatedCorrected Dec 24, 2025
  6. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsE · patternCorrected Dec 24, 2025
  7. F584Honor 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.Resident RightsD · isolatedCorrected Dec 24, 2025
  8. F675Honor each resident's preferences, choices, values and beliefs.Quality of Life and CareE · patternCorrected Dec 24, 2025
  9. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Dec 24, 2025
  10. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Dec 24, 2025
  11. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Dec 24, 2025
Sep 9, 20253 citationsCycle 1worst D · no actual harm$143,650, payment denial
  1. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Oct 22, 2025
  2. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Oct 22, 2025
  3. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Oct 22, 2025
Mar 13, 202514 citationsCycle 1worst F · no actual harm
  1. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Apr 2, 2025
  2. F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlE · patternCorrected Apr 2, 2025
  3. F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Infection ControlF · widespreadCorrected Apr 2, 2025
  4. F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Resident RightsD · isolatedCorrected Apr 2, 2025
  5. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Apr 2, 2025
  6. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Apr 2, 2025
  7. F554Allow residents to self-administer drugs if determined clinically appropriate.Resident RightsD · isolatedCorrected Apr 2, 2025
  8. F578Honor 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.Resident RightsD · isolatedCorrected Apr 2, 2025
  9. F584Honor 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.Resident RightsD · isolatedCorrected Apr 2, 2025
  10. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Apr 2, 2025
  11. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningE · patternCorrected Apr 2, 2025
  12. F693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.Quality of Life and CareD · isolatedCorrected Apr 2, 2025
  13. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Apr 2, 2025
  14. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Apr 2, 2025
Jan 23, 20259 citationsCycle 2worst J · immediate jeopardy$138,410
  1. F838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.AdministrationF · widespreadCorrected Feb 17, 2025
  2. F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.AdministrationF · widespreadCorrected Feb 17, 2025
  3. F945Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.Infection ControlF · widespreadCorrected Feb 17, 2025
  4. Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.Quality of Life and CareJ · isolatedCorrected Feb 17, 2025
  5. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningE · patternCorrected Apr 2, 2025
  6. F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Feb 17, 2025
  7. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareG · isolatedCorrected Feb 17, 2025
  8. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceE · patternCorrected Apr 2, 2025
  9. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Feb 17, 2025
Nov 20, 202410 citationsCycle 2worst F · no actual harm
  1. F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsE · patternCorrected Jan 9, 2025
  2. Assure that each resident’s assessment is updated at least once every 3 months.Resident Assessment and Care PlanningE · patternCorrected Jan 9, 2025
  3. Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Resident Assessment and Care PlanningE · patternCorrected Jan 9, 2025
  4. F552Ensure that residents are fully informed and understand their health status, care and treatments.Resident RightsD · isolatedCorrected Jan 9, 2025
  5. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Jan 9, 2025
  6. F660Plan the resident's discharge to meet the resident's goals and needs.Resident Assessment and Care PlanningD · isolatedCorrected Jan 9, 2025
  7. F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Quality of Life and CareD · isolatedCorrected Jan 9, 2025
  8. F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.AdministrationF · widespreadCorrected Jan 9, 2025
  9. F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.AdministrationE · patternCorrected Jan 9, 2025
  10. F926Have policies on smoking.EnvironmentalE · patternCorrected Jan 9, 2025
Oct 23, 20243 citationsCycle 2worst G · actual harm$104,780
  1. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Oct 26, 2024
  2. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected Dec 18, 2024
  3. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Oct 26, 2024
May 8, 20241 citationCycle 2worst E · no actual harm
  1. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Jun 7, 2024
Mar 14, 202410 citationsCycle 2worst F · no actual harm
  1. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Apr 26, 2024
  2. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Apr 26, 2024
  3. F758Implement 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.Pharmacy ServiceD · isolatedCorrected Apr 26, 2024
  4. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareE · patternCorrected Apr 26, 2024
  5. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Apr 26, 2024
  6. F584Honor 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.Resident RightsE · patternCorrected Apr 26, 2024
  7. F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Resident RightsD · isolatedCorrected Apr 26, 2024
  8. F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Nutrition and DietaryF · widespreadCorrected Apr 26, 2024
  9. F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Apr 26, 2024
  10. F881Implement a program that monitors antibiotic use.Infection ControlE · patternCorrected Apr 26, 2024
Aug 29, 20232 citationsCycle 3worst E · no actual harm
  1. F602Protect each resident from the wrongful use of the resident's belongings or money.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Sep 13, 2023
  2. F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Sep 13, 2023
May 24, 20233 citationsCycle 3worst G · actual harm$26,175
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Jun 20, 2023
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareG · isolatedCorrected Jun 20, 2023
  3. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningE · patternCorrected Jun 14, 2023
Mar 2, 202317 citationsCycle 3worst G · actual harm$34,125
  1. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningE · patternCorrected Mar 23, 2023
  2. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Mar 24, 2023
  3. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Mar 24, 2023
  4. F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Resident Assessment and Care PlanningD · isolatedCorrected Mar 24, 2023
  5. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Mar 23, 2023
  6. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected Mar 22, 2023
  7. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareG · isolatedCorrected Mar 24, 2023
  8. F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesF · widespreadCorrected Mar 24, 2023
  9. F727Have 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.Nursing and Physician ServicesF · widespreadCorrected Mar 24, 2023
  10. F741Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.Quality of Life and CareG · isolatedCorrected Mar 24, 2023
  11. F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.Nutrition and DietaryF · widespreadCorrected Mar 24, 2023
  12. F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryF · widespreadCorrected Mar 24, 2023
  13. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Mar 24, 2023
  14. F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Mar 24, 2023
  15. F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlE · patternCorrected Mar 24, 2023
  16. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Mar 22, 2023
  17. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Mar 24, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined2.55hrsLowest tier among peers−1.42 vs MT avg
  • Registered nursesRN hours only0.79hrsAbove only 49% of peers−0.15 vs MT avg
  • Licensed practical nursesLPN hours0.35hrs
  • Nurse aidesCNA hours1.41hrs
  • Weekend nursingAll staff on Saturdays and Sundays2.14hrs
  • Montana average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better79%Above only 8% of peersMT avg 56%
  • RN turnoverRegistered nurses only68%Not ranked by CMS
  • Administrators who leftIn the past year1Leadership changed
  • Occupancy100 certified beds · ~90 residents a day90%Above 86% of peersMT avg 67%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $447,140In fines
  • 5Fines
  • 1Payment denial
  • $55,122MT avg in fines
Above only 2% of peersFewer fines than 2% of rated homes in Montana

Actions on record

  1. Sep 9, 2025Civil money penalty$143,650
  2. Sep 9, 2025Denial of payment for new admissionsfrom Nov 20, 2025
  3. Jan 23, 2025Civil money penalty$138,410
  4. Oct 23, 2024Civil money penalty$104,780
  5. May 24, 2023Civil money penalty$26,175
  6. Mar 2, 2023Civil money penalty$34,125

Ownership

As filed with CMS

Structure

Ownership type
For profit - Limited Liability company
Chain
Sweetwater Care9 facilities in the chain2.8★ chain average
Certification
Medicare and Medicaid
Location type
Rural
Ownership change
None in the last 12 months

People and entities on file

Indirect owners (5%+)
  • Sweetwater Care Opco LLC
  • James Gamett
Corporate officers
  • James Gamett
Managing employees
  • Jordan Holt

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 275132 · 1305 E 7TH ST, WHITEFISH, MT, 59937.
  • Percentiles compare this facility with every rated nursing home in Montana and Flathead County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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