Based on observation, interview, and record review, the facility failed to complete a Significant Change MDS (Minimum Data Set) assessment for a resident's change in condition, for 1 (#9) of 10 sampled residents. This deficient practice increased the risk of resident #9 not receiving services for his care to prevent further decline. Findings include:During an observation on 4/28/26 at 1:33 p.m., resident #9 was walking in a hallway on the secure care unit, following a housekeeper pushing her cart to his room. Staff member I stated resident #9 wanted to help the housekeeper with work, and he was usually interactive with staff. …
F637 citations in Montana
Assessment after a significant change · Resident Assessment and Care Planning Deficiencies
Assess the resident when there is a significant change in condition
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Montana cites F637 more often than its own record predicts
1.30 times the share F637 takes of citations nationally.
Of every deficiency written in Montana in 2025, this is the portion that was F637.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Montana surveyors wrote
F637 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 | 0.85% | 2.76× |
| 2025 | 0.31% | 1.30× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Montana surveyors cite →
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