Based on interview and record review, the facility failed to document the basis for a resident's facility-initiated immediate transfer and discharge, for 1 (#2) of 1 resident sampled for discharge concerns. This deficient practice resulted in the resident being improperly discharged from the facility, to the hospital, and then the facility would not accept the resident for readmission. This resulted in the resident being discharged to a location 4 hours away. Findings include: Review of resident #2's nursing progress notes, dated 2/1/24, showed, .she (resident #2) rounded the nurses station and went into the med room . I tried to calm her down and she grabbed my throat and tried to shove me out of the way. I pried her fingers off my throat . she tried to head butt me . …
F622 citations in Montana
Transfer and discharge · Resident Rights Deficiencies
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Montana cites F622 more often than its own record predicts
1.35 times the share F622 takes of citations nationally.
Of every deficiency written in Montana in 2025, this is the portion that was F622.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Montana surveyors wrote
F622 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, facility staff failed to provide pertinent medical information to the receiving facility at the time of transfer for 2 (#s 35 and 43) of 17 sampled residents. Findings include: 1. Review of resident #35's nursing progress notes, dated 6/3/24, showed the resident was transferred to a hospital with low blood pressure, elevated heart rate, and decreased urine output. Review of resident #35's electronic medical record failed to show facility staff had sent required medical information with the resident for the accepting medical provider. On 4/10/25, a request was made for a copy of resident #35's medical information provided to the receiving facility for the resident's hospital transfer on 6/3/24. …
The short window
Recent years
| Year | Share of Montana citations | vs expected |
|---|---|---|
| 2024 | 0.35% | 1.09× |
| 2025 | 0.16% | 1.35× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Montana surveyors cite →
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