Based on observation, interview, and record review, the facility failed to ensure staff members did not provide medications for residents to self-administer, for residents who had been assessed by staff and did not qualify for self-administration of medications for 2 (#s 45 and 55) of 31 sampled residents. Findings include: 1. During an interview on 7/28/26 at 10:51 a.m., resident #45 stated she had complained about an issue with a nurse (NF1) having trouble with getting her medications prepared and her insulin ready. Resident #45 stated the nurse no longer worked at the facility. Resident #45 stated she had been uncomfortable with the nurse leaving her insulin pens for her to take on her own on different occasions. …
F554 citations in Montana
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Montana cites F554 more often than its own record predicts
2.21 times the share F554 takes of citations nationally.
Of every deficiency written in Montana in 2025, this is the portion that was F554.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Montana surveyors wrote
F554 findings written in Montana, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
The short window
Recent years
| Year | Share of Montana citations | vs expected |
|---|---|---|
| 2023 | 0.56% | 1.02× |
| 2024 | 1.05% | 1.92× |
| 2025 | 1.25% | 2.21× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Montana surveyors cite →
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