F609 in Montana. Pick another state for the same tag.
Against expectation — 2025
Montana cites F609 more often than its own record predicts
Versus expected share1.66×
1.66 times the share F609 takes of citations nationally.
Share of Montana citations4.07%
Of every deficiency written in Montana in 2025, this is the portion that was F609.
Montana4.07%
National2.45%
Share of all citations that were F609.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Montana surveyors wrote
F609 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.
G · Actual harm, isolatedNovember 15, 2018
Based on observation, interview, and record review, the facility failed to ensure a resident was protected and free of abuse; and the facility failed to act on a report of verbal abuse by a staff member, which caused the resident to have ongoing fear and anger, for 1 (#34) of 13 sampled residents. Findings include:
During an interview on 11/13/18 at 11:40 a.m., NF1 stated she reported an incident of verbal abuse to staff member C, About a month ago. She stated that her husband (resident #34) told her that a night nurse came into his room one evening and stated, What do you want? You are using the call light too often. NF1 stated that her husband was very upset by the remarks, so she wanted to make sure that the situation was addressed. …
D · No harm, potential for more than minimal, isolatedAugust 26, 2026
Based on interview and record review, the facility failed to ensure that allegations of abuse and mistreatment were reported to the State Survey Agency within the required timeframes for 3 (#s 1, 2, 3) and failed to ensure the results and findings of investigations were submitted to the State Survey Agency within five working days for 2 (#s 4 and 5) of 16 sampled residents. Findings include:1. Review of the facility's investigation of a facility-reported incident involving residents #2 and #3 showed that a verbal altercation occurred in the facility hallway on 4/19/26 at approximately 5:00 p.m. The incident was reported to the abuse coordinator the following morning, 4/20/26. …
B · No harm, potential for minimal, patternNovember 18, 2025
Based on interview and record review, facility staff failed to report investigative findings for reportable events, within the required timeframe, for 2 (#s 16 and 123) of 2 residents sampled for injuries. Findings include:1. Review of a facility-reported incident, submitted to the State Survey Agency on 8/28/25, showed resident #16 sustained a hematoma of unknown origin to the left lower extremity. The facility's investigative findings were not reported to the State Survey Agency until 9/9/25; two days after the submission deadline.During an interview on 11/18/25 at 10:42 a.m., staff member A stated he was responsible for submitting the facility's reportable incidents through the incident reporting system. …
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