Based on observation, interview, and record review, facility staff failed to identify and provide the necessary trauma services to maintain the highest well-being, for 1 (#65) of 1 sampled resident who was experiencing post-traumatic stress disorder. Findings include: During an observation and interview on 7/17/23 at 3:22 p.m., resident #65 was lying in bed. An interview was attempted with resident #65. His speech was garbled and not understandable. His appearance was disheveled, his hair was matted, and his beard was long and untrimmed. He was wearing a nasal cannula, and a CPAP (continuous positive airway pressure) device was on a table next to his bed. During an interview on 7/19/23 at 8:37 a.m., NF4 said resident #65 did have PTSD. …
F699 citations in Montana
Quality of Life and Care Deficiencies
Provide care or services that was trauma informed and/or culturally competent.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Montana cites F699 more often than its own record predicts
1.90 times the share F699 takes of citations nationally.
Of every deficiency written in Montana in 2025, this is the portion that was F699.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Montana surveyors wrote
F699 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 that a resident did not experience re-traumatization during transports, for 1 (#4) of 9 sampled residents by use of the individualized care plan and interventions. This deficient practice resulted in a resident being fearful of transportation in the facility van. Findings include:During an interview on 7/8/26 at 10:30 a.m., resident #4 stated, [Staff member H's] driving gives me PTSD. Resident #4 stated that when the van moved too fast on the highway, she was bumped around in her wheelchair and got bruised all over her arms. Resident #4 stated she had told staff before that she was uncomfortable in the facility van when staff drove too fast but said, nobody cares. …
The short window
Recent years
| Year | Share of Montana citations | vs expected |
|---|---|---|
| 2023 | 0.56% | 2.49× |
| 2024 | 0.52% | 1.63× |
| 2025 | 0.63% | 1.90× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Montana surveyors cite →
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