Pioneer Care and Rehabilitation

• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 5 of 5.

• Star rating

  The CMS overall star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS health inspection star rating changed from 1 of 5 to 2 of 5.

• Fine

  CMS changed the fine from February 19, 2026 from $7,360 to $4,784.

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 3 of 5.

CMS lists this as a standard inspection and a complaint inspection.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on June 16, 2026.

  CMS has cited this home for F0812 2 times since 2024.

• Citation F0585. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor 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.

  CMS lists it as corrected on June 22, 2026.

• Citation F0689. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on June 18, 2026.

  CMS has cited this home for F0689 4 times since 2024.

• Citation F0880. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on June 18, 2026.

  CMS has cited this home for F0880 3 times since 2024.

• Citation F0550. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS lists it as corrected on June 29, 2026.

• Citation F0645. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: PASARR screening for Mental disorders or Intellectual Disabilities

  CMS lists it as corrected on June 16, 2026.

• Citation F0711. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

  CMS lists it as corrected on June 30, 2026.

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CMS lists this as a standard inspection.

• Citation K0918. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on June 22, 2026.

• Citation K0321. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  CMS lists it as corrected on June 22, 2026.

• Citation K0324. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide properly protected cooking facilities.

  CMS lists it as corrected on September 30, 2026.

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• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS staffing star rating changed from 1 of 5 to 2 of 5.

• Special Focus Facility

  CMS no longer lists this home as a Special Focus Facility candidate.

• Fine

  CMS changed the fine from August 27, 2024 from $29,000 to $18,850.

• Fine

  CMS changed the fine from December 5, 2024 from $19,275 to $12,529.

• Fine

  CMS changed the fine from May 8, 2025 from $74,560 to $48,464.

CMS fine of $4,784 on February 19, 2026.

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• Special Focus Facility

  CMS now lists this home as a Special Focus Facility candidate.

CMS lists this as a complaint inspection.

• Citation F0744. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

  CMS lists it as corrected on January 23, 2026.

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• Special Focus Facility

  CMS no longer lists this home as a Special Focus Facility candidate.

• Fine

  CMS changed the fine from May 21, 2024 from $62,525 to $40,641.

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS quality measures star rating changed from 1 of 5 to 2 of 5.

• Special Focus Facility

  CMS now lists this home as a Special Focus Facility candidate.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 1 of 5.

CMS lists this as a standard inspection and a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

24 of 61 Montana homes (39%) got a citation at the actual harm level in 2025.

• Citation F0689. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on May 30, 2025.

• Citation F0841. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.

  CMS lists it as corrected on May 30, 2025.

• Citation F0865. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have a plan that describes the process for conducting QAPI and QAA activities.

  CMS lists it as corrected on May 30, 2025.

• Citation F0882. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

  CMS lists it as corrected on May 30, 2025.

• Citation F0578. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor 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.

  CMS lists it as corrected on May 30, 2025.

• Citation F0756. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  CMS lists it as corrected on May 30, 2025.

• Citation F0881. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Implement a program that monitors antibiotic use.

  CMS lists it as corrected on May 30, 2025.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on May 30, 2025.

  CMS has cited this home for F0609 2 times since 2024.

• Citation F0627. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

  CMS lists it as corrected on May 30, 2025.

• Citation F0628. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

  CMS lists it as corrected on May 30, 2025.

• Citation F0655. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

  CMS lists it as corrected on May 30, 2025.

• Citation F0676. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

  CMS lists it as corrected on May 30, 2025.

• Citation F0692. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide enough food/fluids to maintain a resident's health.

  CMS lists it as corrected on May 30, 2025.

• Citation F0695. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on May 30, 2025.

• Citation F0697. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe, appropriate pain management for a resident who requires such services.

  CMS lists it as corrected on May 30, 2025.

• Citation F0760. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that residents are free from significant medication errors.

  CMS lists it as corrected on May 30, 2025.

  CMS has cited this home for F0760 2 times since 2024.

• Citation F0761. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  CMS lists it as corrected on May 30, 2025.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on May 30, 2025.

• Citation F0943. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

  CMS lists it as corrected on May 30, 2025.

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CMS lists this as a standard inspection.

• Citation E0022. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish policies and procedures for sheltering.

  CMS lists it as corrected on June 6, 2025.

• Citation E0024. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish policies and procedures for volunteers.

  CMS lists it as corrected on June 6, 2025.

• Citation E0026. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish roles under a Waiver declared by secretary.

  CMS lists it as corrected on June 6, 2025.

• Citation E0039. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Conduct testing and exercise requirements.

  CMS lists it as corrected on June 6, 2025.

• Citation K0211. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Keep aisles, corridors, and exits free of obstruction in case of emergency.

  CMS lists it as corrected on June 6, 2025.

• Citation K0271. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have exits that are accessible at all times.

  CMS lists it as corrected on June 6, 2025.

• Citation K0355. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Properly select, install, inspect, or maintain portable fire extinguishes.

  CMS lists it as corrected on June 6, 2025.

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CMS fine of $48,464 on May 8, 2025.

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• Star rating

  The CMS overall star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 1 of 5.

CMS lists this as a complaint inspection.

• Citation F0835. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Administer the facility in a manner that enables it to use its resources effectively and efficiently.

  CMS lists it as corrected on April 4, 2025.

• Citation F0755. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  CMS lists it as corrected on April 4, 2025.

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• Star rating

  The CMS overall star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS health inspection star rating changed from 1 of 5 to 2 of 5.

• CMS abuse icon

  CMS removed its abuse icon from this home.

CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

20 of 61 Montana homes (33%) got a citation at the actual harm level in 2024.

• Citation F0760. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure that residents are free from significant medication errors.

  CMS lists it as corrected on January 3, 2025.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on January 3, 2025.

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CMS fine of $12,529 on December 5, 2024.

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• Star rating

  The CMS staffing star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5.

• Fine

  CMS changed the fine from January 4, 2024 from $19,670 to $12,786.

CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

20 of 61 Montana homes (33%) got a citation at the actual harm level in 2024.

• Citation F0689. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on September 5, 2024.

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CMS fine of $18,850 on August 27, 2024.

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• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 3 of 5.

• Health citation

  CMS changed citation F0622 from severity G to D. It is from the health inspection on February 27, 2024. Severity D: potential for more than minimal harm, isolated.

CMS lists this as a standard inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

20 of 61 Montana homes (33%) got a citation at the actual harm level in 2024.

• Citation F0689. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on June 28, 2024.

• Citation F0803. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

  CMS lists it as corrected on June 28, 2024.

• Citation F0812. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on June 28, 2024.

• Citation F0584. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor 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.

  CMS lists it as corrected on June 28, 2024.

• Citation F0657. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  CMS lists it as corrected on June 28, 2024.

  CMS has cited this home for F0657 2 times since 2023.

• Citation F0677. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on June 28, 2024.

• Citation F0740. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

  CMS lists it as corrected on June 28, 2024.

• Citation F0745. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide medically-related social services to help each resident achieve the highest possible quality of life.

  CMS lists it as corrected on June 28, 2024.

• Citation F0825. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide or get specialized rehabilitative services as required for a resident.

  CMS lists it as corrected on June 28, 2024.

• Citation F0883. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement policies and procedures for flu and pneumonia vaccinations.

  CMS lists it as corrected on June 28, 2024.

• Citation F0887. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Educate 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.

  CMS lists it as corrected on June 28, 2024.

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CMS fine of $40,641 on May 21, 2024.

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• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 4 of 5.

• CMS abuse icon

  CMS added its abuse icon to this home.

CMS lists this as a complaint inspection.

• Citation F0622. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

  CMS lists it as corrected on March 11, 2024.

• Citation F0623. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

  CMS lists it as corrected on March 11, 2024.

• Citation F0626. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

  CMS lists it as corrected on March 11, 2024.

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• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 3 of 5.

• CMS abuse icon

  CMS removed its abuse icon from this home.

CMS lists this as a complaint inspection.

• Citation F0602. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Protect each resident from the wrongful use of the resident's belongings or money.

  CMS lists it as corrected on February 27, 2024.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on February 27, 2024.

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CMS fine of $12,786 on January 4, 2024.

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CMS lists this as a complaint inspection.

• Citation F0657. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  CMS lists it as corrected on November 27, 2023.

• Citation F0726. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

  CMS lists it as corrected on November 27, 2023.

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