Ivy at Deer Lodge
1100 Texas Ave, Deer Lodge, MT 59722 · Powell County · 60 certified beds · avg 39 residents/day · certified since Oct 1, 1989
Part of chain: IVY HEALTHCARE GROUP (4 facilities, chain avg rating 1.8★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Nov 25, 2024 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Dec 19, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Nov 25, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Dec 19, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Nov 25, 2024 · F-0697 · triggered by a complaint
The facility did not provide safe and appropriate pain management for a resident who needed it.
Why it matters: Untreated pain causes needless suffering and can lead to depression, poor sleep, and declining health.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Dec 19, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Dec 3, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Dec 23, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Dec 3, 2025 · F-0745 · triggered by a complaint
The facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life.
Why it matters: Without social services support, residents can struggle emotionally and miss out on help they're entitled to.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Dec 23, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Aug 2, 2023 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 6, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (38)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Dec 3, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Dec 3, 2025 | ▲ G · Actual harm, one-off | The facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life. · from a complaint |
| Dec 3, 2025 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Dec 3, 2025 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Dec 3, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Dec 3, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Nov 25, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Nov 25, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Nov 25, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint |
| Oct 10, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Oct 10, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Oct 10, 2024 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Oct 10, 2024 | B · Minimal risk, repeated | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. |
| Oct 10, 2024 | B · Minimal risk, repeated | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Sep 19, 2024 | E · Potential for harm, repeated | The facility did not honor a resident's right to choose their own attending doctor. Residents get to decide which physician oversees their care. · from a complaint |
| Sep 19, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Sep 19, 2024 | D · Potential for harm, one-off | The facility did not honor residents' right to receive the visitors they choose, at the times they choose. · from a complaint |
| Sep 19, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Sep 19, 2024 | D · Potential for harm, one-off | The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. · from a complaint |
| Jul 17, 2024 | E · Potential for harm, repeated | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. · from a complaint |
| Jul 17, 2024 | E · Potential for harm, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jul 17, 2024 | E · Potential for harm, repeated | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Jul 17, 2024 | E · Potential for harm, repeated | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint |
| Nov 8, 2023 | F · Potential for harm, facility-wide | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. |
| Nov 8, 2023 | F · Potential for harm, facility-wide | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Nov 8, 2023 | E · Potential for harm, repeated | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Nov 8, 2023 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Nov 8, 2023 | E · Potential for harm, repeated | The facility did not properly plan a resident's discharge to meet the resident's goals and needs after leaving. |
| Nov 8, 2023 | E · Potential for harm, repeated | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. |
| Nov 8, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Nov 8, 2023 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Nov 8, 2023 | B · Minimal risk, repeated | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Nov 8, 2023 | B · Minimal risk, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Aug 2, 2023 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Aug 2, 2023 | E · Potential for harm, repeated | The facility did not verify that its nurse aides had completed their required training, or did not retrain aides who had been out of nurse aide work for 2 years. · from a complaint |
| Aug 2, 2023 | E · Potential for harm, repeated | The facility employed staff who were not licensed, certified, or registered as required by state law. · from a complaint |
| Aug 2, 2023 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Aug 2, 2023 | D · Potential for harm, one-off | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (5 → 6).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 15 | 1 | G ▲ |
| 2024 | 17 | 3 | K ▲ |
| 2025 | 6 | 2 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $103,309.
| Date | Type | Amount / length |
|---|---|---|
| Dec 3, 2025 | Fine | $26,685 |
| Nov 25, 2024 | Fine | $76,624 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Montana avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.63 | 4.82 | 3.95 | top 48% in Montana; top 20% in the U.S. |
| Registered Nurse hours | 0.80 | 1.17 | 0.69 | bottom 29% in Montana; top 28% in the U.S. |
| Weekend total nurse staffing | 4.29 | 4.26 | 3.50 | top 41% in Montana; top 16% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.49 | 0.71 | 0.48 | bottom 31% in Montana; top 34% in the U.S. |
| Total nursing staff turnover (%) | 56.8 | 54.8 | 45.8 | bottom 40% in Montana; bottom 22% in the U.S. |
| RN turnover (%) | 0.0 | 48.3 | 42.9 | — |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.67, RN 0.63, weekend 3.40. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: —/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Coane, Ryan | Individual | 5% or Greater Direct Ownership Interest | 45% | 05/19/2019 |
| Coane, Ryan | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/19/2019 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Who provides social services here, and how would they support my family member's emotional and social needs?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "If my family member is able to manage their own medications, would you allow it, and how is that decided?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
No other Medicare-certified nursing homes within 20 miles in the current records.
All facilities in Deer Lodge →
Facility data as of CMS processing date 2026-08-01. CCN 275134.