Village Health & Rehabilitation
2651 South Ave W, Missoula, MT 59804 · Missoula County · 193 certified beds · avg 147 residents/day · certified since Feb 1, 1975
Part of chain: THE GOODMAN GROUP (9 facilities, chain avg rating 3.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5
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)
▲ Actual harm, one-off · Aug 28, 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: Sep 23, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Aug 1, 2024 · F-0689
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: Aug 23, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (25)
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 |
|---|---|---|
| Nov 19, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Aug 28, 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 |
| Aug 28, 2025 | 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. |
| Aug 28, 2025 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Aug 28, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Aug 28, 2025 | 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. |
| Aug 28, 2025 | D · Potential for harm, one-off | The facility did not make sure special medical diets — like low-sodium or diabetic diets — were properly ordered by the resident's doctor or managed by a qualified dietitian as state law allows. |
| Apr 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. · from a complaint |
| Nov 21, 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 |
| Nov 21, 2024 | E · Potential for harm, repeated | 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 |
| Nov 21, 2024 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint |
| Nov 21, 2024 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. · from a complaint |
| Aug 1, 2024 | ▲ 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. |
| Aug 1, 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. |
| Aug 1, 2024 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Aug 1, 2024 | 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. |
| Aug 1, 2024 | 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. |
| Aug 1, 2024 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Aug 1, 2024 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Aug 1, 2024 | D · Potential for harm, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. |
| Aug 1, 2024 | D · Potential for harm, one-off | 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. |
| Jul 20, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Jul 20, 2023 | D · Potential for harm, one-off | 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. |
| Jul 20, 2023 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Jul 20, 2023 | B · Minimal risk, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (9 → 3).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 4 | 0 | D |
| 2024 | 13 | 1 | G ▲ |
| 2025 | 8 | 1 | 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 $27,846.
| Date | Type | Amount / length |
|---|---|---|
| Aug 28, 2025 | Fine | $11,190 |
| Aug 1, 2024 | Fine | $16,656 |
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) | 4.26 | 4.82 | 3.95 | bottom 43% in Montana; top 30% in the U.S. |
| Registered Nurse hours | 1.03 | 1.17 | 0.69 | top 50% in Montana; top 14% in the U.S. |
| Weekend total nurse staffing | 3.65 | 4.26 | 3.50 | bottom 40% in Montana; top 35% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.65 | 0.71 | 0.48 | top 48% in Montana; top 19% in the U.S. |
| Total nursing staff turnover (%) | 55.2 | 54.8 | 45.8 | bottom 43% in Montana; bottom 25% in the U.S. |
| RN turnover (%) | 40.5 | 48.3 | 42.9 | top 33% in Montana; top 49% in the U.S. |
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 3.99, RN 0.97, weekend 3.42. 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: 4/5 · long-stay residents: 4/5 · short-stay residents: 4/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Benson, Randall | Individual | 5% or Greater Direct Ownership Interest | — | 02/28/2017 |
| Community Nursing, INC | Organization | 5% or Greater Direct Ownership Interest | — | 12/30/1986 |
| John B. Goodman 2006 Irrv Grantor Tr | Organization | 5% or Greater Direct Ownership Interest | — | 02/28/2017 |
| Salmen, Thomas | Individual | 5% or Greater Direct Ownership Interest | — | 02/28/2017 |
| South Dakota Trust Company, LLC | Organization | 5% or Greater Direct Ownership Interest | — | 02/28/2017 |
| Weichert, James | Individual | 5% or Greater Direct Ownership Interest | — | 02/28/2017 |
| Wilson, Mark | Individual | 5% or Greater Direct Ownership Interest | — | 02/28/2017 |
| Benson, Randall | Individual | Corporate Officer | NOT APPLICABLE | 06/26/2016 |
| Edinger, Craig | Individual | Corporate Officer | NOT APPLICABLE | 12/19/2016 |
| Knacke, Clinton | Individual | Corporate Officer | NOT APPLICABLE | 10/12/2022 |
| Olson, Denise | Individual | Corporate Officer | NOT APPLICABLE | 09/16/2013 |
| Strauss, Dee | Individual | W-2 Managing Employee | NOT APPLICABLE | 07/26/2018 |
| Weichert, James | Individual | Corporate Director | NOT APPLICABLE | 12/19/2016 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "How do you verify that your nurses and aides have the skills to care for residents with needs like my family member's?"
- "Who oversees residents' therapeutic diets, and how do the doctor and dietitian work together on them?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "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)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Riverside Health & Rehabilitation | 3.5 mi | Missoula, MT | ★★★☆☆ | 3/5 | |
| Missoula Health & Rehabilitation Center | 4.5 mi | Missoula, MT | ★★★★☆ | 4/5 |
Compare this facility with the 2 closest →
Facility data as of CMS processing date 2026-08-01. CCN 275043.