Based on interview, and record review, the facility failed to complete accurate Admission and Quarterly assessments for 3 (#'s 48, 49, and 73) of 6 sampled residents. This deficient practice had the potential to affect resident care and safety. Findings include: During an interview on 9/14/22 at 12:33 p.m., staff member J stated it was the admitting nurse's responsibility for completing the initial nursing assessment on new admissions. Staff member J said the admitting nurse refused to do the admission assessment for resident #49, and left it for day shift to complete. Staff member J said she was the day shift nurse and was unable to complete the assessment back in the secured unit because she was too busy out on the floor with other residents. 1. …
F641 citations in Montana
Accuracy of assessments · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Montana cites F641 less often than its own record predicts
0.51 times the national share — cited less often here than elsewhere.
Of every deficiency written in Montana in 2025, this is the portion that was F641.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Montana surveyors wrote
F641 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 failed to ensure resident medications were accurately coded on MDS assessments for 1 (#10) of 30 sampled and supplemental residents. Findings include:Review of resident #10's Quarterly MDS Assessment, with an ARD of 7/16/26, showed the resident was receiving antipsychotics on a routine basis.Review of resident #10's medication list did not show any active antipsychotic medications.During an interview on 7/29/26 at 12:20 p.m., staff member J stated resident #10 was coded for antipsychotics because she took long-term lithium. Staff member J stated they did not realize lithium was a mood stabilizer versus an antipsychotic, and they would go back and correct the previous MDS assessments.
Based on interview and record review, the facility failed to accurately complete multiple comprehensive Minimum Data Set (MDS) assessments for the resident's Pre-admission Screening and Resident Review (PASRR), for 1 (#12) of 13 sampled residents. Findings include:During an interview on 4/8/26 at 12:22 p.m., staff member F stated resident #12's PASRR Level One was completed on 1/3/23, and a PASRR Level Two was completed on 1/27/23. Staff member F stated that when she completed section A of the resident's MDS submission on 1/21/25 and 1/12/26, she overlooked adding PASRR information because the system pre-populated the resident's demographic information.Review of resident #12's electronic medical record showed the resident was admitted to the facility on [DATE] with a diagnosis of Anxiety,… …
The short window
Recent years
| Year | Share of Montana citations | vs expected |
|---|---|---|
| 2023 | 1.98% | 1.16× |
| 2024 | 2.27% | 1.35× |
| 2025 | 0.94% | 0.51× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Montana surveyors cite →
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