Whitefish Care and Rehabilitation
1305 E 7th St, Whitefish, MT 59937 · Flathead County · 100 certified beds · avg 92 residents/day · certified since Sep 1, 1989
SFF
Part of chain: SWEETWATER CARE (8 facilities, chain avg rating 2.4★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: —/5 · CMS overall rating: —/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, one-off · Jan 23, 2025 · F-0678 · triggered by a complaint
The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes.
Why it matters: In a cardiac or breathing emergency, failure to start CPR promptly can be the difference between life and death.
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: Feb 17, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 12, 2026 · F-0690
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.
Why it matters: Poor continence and catheter care leads to infections, skin breakdown, and loss of dignity.
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: Apr 13, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 22, 2025 · F-0692 · triggered by a complaint
The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.
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 15, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 22, 2025 · F-0726 · triggered by a complaint
The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.
Why it matters: Undertrained caregivers are more likely to miss warning signs and make care mistakes.
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: Nov 15, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jan 23, 2025 · F-0695 · triggered by a complaint
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.
Why it matters: Mistakes in breathing care can quickly become life-threatening for residents who depend on oxygen or equipment.
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: Feb 17, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 23, 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 (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 18, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (77)
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 |
|---|---|---|
| Mar 12, 2026 | ▲ G · Actual 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. |
| Mar 12, 2026 | F · Potential for harm, facility-wide | 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. |
| Mar 12, 2026 | E · Potential for harm, repeated | The facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely. |
| Mar 12, 2026 | E · Potential for harm, repeated | 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. |
| Mar 12, 2026 | 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. |
| Mar 12, 2026 | E · Potential for harm, repeated | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. |
| Mar 12, 2026 | D · Potential for harm, one-off | 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. |
| Mar 12, 2026 | D · Potential for harm, one-off | 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. |
| Mar 12, 2026 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Mar 12, 2026 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Mar 12, 2026 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| Mar 12, 2026 | 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. |
| Mar 12, 2026 | D · Potential for 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. |
| Mar 12, 2026 | D · Potential for 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. |
| Oct 22, 2025 | ▲ G · Actual harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint |
| Oct 22, 2025 | ▲ G · Actual 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 |
| Oct 22, 2025 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Oct 22, 2025 | E · Potential for harm, repeated | The facility did not honor residents' individual preferences, choices, values, and beliefs in their daily life and care. · from a complaint |
| Oct 22, 2025 | E · Potential for harm, repeated | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint |
| Oct 22, 2025 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Oct 22, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Oct 22, 2025 | D · Potential for harm, one-off | 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 |
| Oct 22, 2025 | D · Potential for 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 |
| Oct 22, 2025 | D · Potential for harm, one-off | The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. · from a complaint |
| Oct 22, 2025 | D · Potential for harm, one-off | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. · from a complaint |
| Sep 9, 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 |
| Sep 9, 2025 | 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. · from a complaint |
| Sep 9, 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 |
| Mar 13, 2025 | F · Potential for harm, facility-wide | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. |
| Mar 13, 2025 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Mar 13, 2025 | E · Potential for harm, repeated | 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. |
| Mar 13, 2025 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Mar 13, 2025 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Mar 13, 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. |
| Mar 13, 2025 | D · Potential for harm, one-off | 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. |
| Mar 13, 2025 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Mar 13, 2025 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint |
| Mar 13, 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. |
| Mar 13, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Mar 13, 2025 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Mar 13, 2025 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Mar 13, 2025 | 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. |
| Jan 23, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes. · from a complaint |
| Jan 23, 2025 | ▲ G · Actual harm, one-off | 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. · from a complaint |
| Jan 23, 2025 | F · Potential for harm, facility-wide | The facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies. · from a complaint |
| Jan 23, 2025 | F · Potential for harm, facility-wide | The facility did not develop, carry out, or maintain an effective training program for all new and existing staff members. · from a complaint |
| Jan 23, 2025 | F · Potential for harm, facility-wide | The facility did not include required infection control training — with written standards, policies, and procedures — as part of its infection prevention program. · from a complaint |
| Jan 23, 2025 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Jan 23, 2025 | E · Potential for harm, repeated | 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. · from a complaint |
| Jan 23, 2025 | E · Potential for harm, repeated | 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 |
| Jan 23, 2025 | 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. · from a complaint |
| Nov 20, 2024 | F · Potential for harm, facility-wide | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · from a complaint |
| Nov 20, 2024 | E · Potential for harm, repeated | 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. · from a complaint |
| Nov 20, 2024 | E · Potential for harm, repeated | The facility did not update each resident's care assessment at least once every 3 months. These regular check-ins keep the resident's care plan matched to their current condition. · from a complaint |
| Nov 20, 2024 | E · Potential for harm, repeated | The facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require. · from a complaint |
| Nov 20, 2024 | E · Potential for harm, repeated | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. · from a complaint |
| Nov 20, 2024 | E · Potential for harm, repeated | The facility did not have policies on smoking. · from a complaint |
| Nov 20, 2024 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. · from a complaint |
| Nov 20, 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 20, 2024 | D · Potential for harm, one-off | The facility did not properly plan a resident's discharge to meet the resident's goals and needs after leaving. · from a complaint |
| Nov 20, 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. · from a complaint |
| Oct 23, 2024 | ▲ G · Actual harm, one-off | 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 |
| Oct 23, 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 |
| Oct 23, 2024 | 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 |
| May 8, 2024 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Mar 14, 2024 | 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. |
| Mar 14, 2024 | 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. |
| Mar 14, 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. |
| Mar 14, 2024 | E · Potential for harm, 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. |
| Mar 14, 2024 | E · Potential for harm, repeated | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Mar 14, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Mar 14, 2024 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Mar 14, 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. |
| Mar 14, 2024 | 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. |
| Mar 14, 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. |
| Aug 29, 2023 | E · Potential for harm, repeated | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint |
| Aug 29, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (14 → 14).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 2 | 0 | E |
| 2024 | 24 | 1 | G ▲ |
| 2025 | 37 | 4 | J ▲ |
| 2026 | 14 | 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)
4 fines totaling $373,492, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Mar 12, 2026 | Fine | $82,250 |
| Sep 9, 2025 | Fine | $95,148 |
| Sep 9, 2025 | Payment Denial | 34 days from Nov 20, 2025 |
| Jan 23, 2025 | Fine | $91,314 |
| Oct 23, 2024 | Fine | $104,780 |
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) | 3.80 | 4.82 | 3.95 | bottom 29% in Montana; top 49% in the U.S. |
| Registered Nurse hours | 0.77 | 1.17 | 0.69 | bottom 22% in Montana; top 30% in the U.S. |
| Weekend total nurse staffing | 3.24 | 4.26 | 3.50 | bottom 28% in Montana; bottom 44% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.39 | 0.71 | 0.48 | bottom 17% in Montana; top 49% in the U.S. |
| Total nursing staff turnover (%) | 82.1 | 54.8 | 45.8 | bottom 4% in Montana; bottom 2% in the U.S. |
| RN turnover (%) | 61.9 | 48.3 | 42.9 | bottom 28% in Montana; bottom 19% 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 3.34, RN 0.68, weekend 2.85. Staffing rating: —/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: —/5 · long-stay residents: —/5 · short-stay residents: —/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Sweetwater Care Opco LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 07/01/2019 |
| Gamett, James | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2019 |
| Holt, Jordan | Individual | W-2 Managing Employee | NOT APPLICABLE | 07/01/2019 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Are staff on every shift trained and certified in CPR, and how do they know each resident's resuscitation wishes?"
- "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "How do you verify that your nurses and aides have the skills to care for residents with needs like my family member's?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "Before a resident is discharged or transferred, how do you make sure the new place can actually meet their needs?"
- "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 |
|---|---|---|---|---|---|
| Montana Veterans Home N H | 7.0 mi | Columbia Falls, MT | ★★★☆☆ | 2/5 | abuse |
| Kalispell Rehabilitation and Nursing LLC | 12.9 mi | Kalispell, MT | ★☆☆☆☆ | 1/5 | SFF |
| Brendan House | 13.2 mi | Kalispell, MT | ★★★☆☆ | 3/5 | |
| Immanuel Skilled Care Center | 13.4 mi | Kalispell, MT | ★★★★★ | 4/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 275132.