Based on interview and record review, the facility failed to recognize and prevent sexual abuse and neglect, and identify the residents' ability to consent to sexual activity, for 9 (#s 9, 12, 17, 44, 61, 77, 78, 80, and 89) of 28 sampled residents. This deficient practice resulted in residents participating in sexual activities who were unable to make their own decisions, which increased the risk of sexual abuse and psychosocial harm for residents, and this was identified to be an Immediate Jeopardy situation; and, based on observation, interview, and record review, the facility failed to ensure a resident was free from physical abuse by a staff member, which resulted in a skin tear on the resident's left hand for 1 (#20) of 28 sampled residents. …
F600 citations in Montana
Abuse and neglect · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Montana cites F600 more often than its own record predicts
1.14 times the share F600 takes of citations nationally.
Of every deficiency written in Montana in 2025, this is the portion that was F600.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Montana surveyors wrote
F600 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.
Based on interview and record review, the facility staff neglected to provide the necessary services to ensure residents were free from emotional or verbal abuse or neglect of care for 2 (#7 and 50) of 7 residents. Both residents had ongoing emotional distress from the care the facility staff provided/did not provide. Findings include:1. During an interview on 8/18/26 at 5:30 p.m., resident #7 stated the following concerns to the surveyor related to neglect of care and emotional abuse:a. She had been at the facility for three long days. Resident #7 said she begged her family and the facility to send her to the hospital because she felt like she was neglected at the facility. …
Based on interviews and record review, the facility failed to ensure residents were free from neglect of care for 2 (#s 1 and 3) of 6 sampled residents. This deficient practice resulted in resident #1 being left in a urine-saturated bed overnight, and a staff member making an inappropriate gesture to resident #2 and not answering his call light. The facility identified the neglect of care and carried out corrections for the deficient practices; therefore, F600 was cited as Past Non-Compliance. Findings include:Review of the facility-reported incident, dated 7/20/26, showed resident #1 had been left in a saturated bed and brief during the nightshift. …
The short window
Recent years
| Year | Share of Montana citations | vs expected |
|---|---|---|
| 2023 | 3.95% | 2.23× |
| 2024 | 2.97% | 1.26× |
| 2025 | 2.97% | 1.14× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Montana surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction