Based on interview and record review, the facility failed to identify risks, provide training for van drivers, and ensure the safety of two unrestrained residents who fell to the floor when the van made abrupt stops for 2 (#s 1 and 2) of 9 sampled residents. This deficient practice increased the risk of negative outcomes and injury for residents required to use the facility van.On 7/9/26 at 9:55 a.m., an Immediate Jeopardy (IJ) was announced to the Administrator and Director of Nursing related to F689-Free of Accidents and Hazards and Supervision affecting two residents. The Severity and Scope identified for the Immediate Jeopardy were identified to be at the level of J, and upon verification for the removal of the immediacy, lowered to a D. …
F689 citations in Montana
Accidents and supervision · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Montana cites F689 less often than its own record predicts
0.99 times the national share — cited less often here than elsewhere.
Of every deficiency written in Montana in 2025, this is the portion that was F689.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Montana surveyors wrote
F689 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 neglected to ensure resident-specific care plan interventions were implemented requiring use of a gait belt and continuous physical support during transfers. for 1 (#1) of 3 residents sampled for falls. The failure resulted in the resident sustaining an uncontrolled fall with increased pain requiring emergency department evaluation and subsequent transition to palliative care for pain management. Findings include:Review of a Facility-Reported Incident, submitted to the State Survey Agency on 5/11/26, showed resident #1 experienced a witnessed fall on 5/3/26 while staff assisted the resident from her room to a recliner in the sitting area. …
Based on observations, interviews, and record review, the facility failed to ensure safe smoking practices were in place and followed, and the location for smoking was safe with hazards mitigated; and failed to ensure the monitor for the smoking sessions had the knowledge to uphold a safe environment during smoking sessions. This failure would affect any resident who smoked in the smoking area, including 3 (#s 49, 51, and 91) of the residents sampled who smoked. The failures increased the risk of injuries, hazards, and the spread of pathogens. Findings include: During an observation on 8/25/26 at 8:34 a.m., seven residents were in the courtyard when the supervised smoking session started. Multiple safety hazards were identified, and some smokers at the facility included #s 49, 51, and 91. …
The short window
Recent years
| Year | Share of Montana citations | vs expected |
|---|---|---|
| 2023 | 4.80% | 0.97× |
| 2024 | 4.55% | 0.84× |
| 2025 | 5.48% | 0.99× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Montana surveyors cite →
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