F835 in Montana. Pick another state for the same tag.
Against expectation — 2025
Montana cites F835 more often than its own record predicts
Versus expected share1.59×
1.59 times the share F835 takes of citations nationally.
Share of Montana citations0.47%
Of every deficiency written in Montana in 2025, this is the portion that was F835.
Montana0.47%
National0.29%
Share of all citations that were F835.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Montana surveyors wrote
F835 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.
J · Immediate jeopardy, isolatedMay 24, 2018
Based on interview, record review, and observation, facility administration failed to provide adequate oversight for the safety of residents, while smoking, which affected 3 (#s 1, 2, and
3) of 20 sampled residents. Resident #1 had actual harm from second [MEDICAL CONDITION] while smoking with oxygen. Resident #1 had three incidents of smoking in inappropriate places, times, and with oxygen in place. The facility failed to asses the smoking area for safety, perform smoking assessments, care plan, follow through with the smoking policy, provide smoking aprons and equipment as needed for residents, monitor and supervise residents while smoking, and provide for the safety of others. …
Based on interview and record review, the facility administrative staff, who were identified and participated in the oversight of the facility QAPI program and daily operations, failed to ensure a system and staff were in place for the timely completion of resident MDS assessments, for all residents in the facility. This failure led to the lack of the development, implementation, and revision of comprehensive care plans to address residents' care needs; and failed to identify these quality of care, system failures and act on them timely for correction. These combined deficient practices placed all 58 residents residing in the facility at risk of harm. …
E · No harm, potential for more than minimal, patternJuly 30, 2026
Based on interview and record review, the facility failed to ensure an effective system for timely reporting of allegations of abuse and neglect following a previous F609 deficiency for the same concern. The facility's continued failure to timely report allegations after implementing corrective measures demonstrated ineffective administrative oversight and failure to implement, monitor, and sustain the reporting process for 9 (#s 4, 5, 9, 10, 11, 12, 13, 14 and 16) of 19 residents. …
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