Immanuel Skilled Care Center: Restraint Violation - MT
The finding came during a complaint inspection at Immanuel Skilled Care Center, completed August 20, 2025. Inspectors cited the facility under federal tag F0604, which covers the use of physical restraints, and assessed the violation at a level of minimal harm or potential for actual harm.
The resident at the center of the finding, identified in inspection records only as Resident 5, is non-ambulatory. She cannot self-ambulate or participate in assisted ambulation, and her mobility limitations restrict her ability to perform one or more activities of daily living. She is, in other words, not going anywhere on her own.
The facility had already encountered a problem with her wheelchair earlier in the year. In May, following a report of forward falls, inspectors found that her wheelchair cushion had been installed backwards. Staff corrected it. No further issues were reported, according to the inspection record, until state surveyors returned and observed something else: a seat belt in use.
There was no documentation that Resident 5 clinically needed a seat belt. The inspection record states plainly that she "does not demonstrate a clinical need for a seat belt at this time."
Seat belts on wheelchairs occupy a specific and contested space in nursing home regulation. When a device restricts a resident's movement and is not being used in response to a documented clinical need, it can constitute a physical restraint, regardless of how benign it looks. The concern is not hypothetical. Restraints used without justification or consent have been associated with physical deconditioning, psychological harm, and, in cases of improper use, injury. For a resident who cannot move independently, a strap she did not agree to and does not need is not a safety measure. It is a constraint.
The facility appears to have recognized the problem once surveyors pointed it out. On August 19, 2025, at 4:43 in the afternoon, one day before the inspection closed, a request was made to obtain consent for the seat belt's use. Whether that consent was ever granted is not recorded. Inspectors noted that no documentation had been provided before the survey ended.
The sequence matters. Staff had been using the seat belt. Surveyors arrived and observed it. The facility then sought consent, after the fact, for a practice that had already been ongoing. No documentation arrived before inspectors left.
The inspection does not say how long the seat belt had been in use, who made the decision to use it, or whether anyone had previously flagged the absence of consent. It does not name the staff involved or describe whether Resident 5 was aware of what was happening or had any means to object.
What the record does say is that a woman who cannot walk, who had already been the subject of one equipment-related finding at this facility, was being secured into her wheelchair without her agreement and without a documented reason that justified it. The cushion put in backwards in May was a maintenance error. This was a care decision, made by staff, carried out on a resident who could not remove the belt herself.
Immanuel Skilled Care Center is located at 185 Crestline Ave in Kalispell. The violation was the only deficiency cited in the inspection report.
Resident 5 remains at the facility. Whether she has since consented to the seat belt, whether it is still in use, and whether she was ever told why it was there in the first place, the inspection record does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Immanuel Skilled Care Center from 2025-08-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: October 15, 2026 · Our methodology
IMMANUEL SKILLED CARE CENTER in KALISPELL, MT was cited for violations during a health inspection on August 20, 2025.
The finding came during a complaint inspection at Immanuel Skilled Care Center, completed August 20, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.