Based on observation, interview, and record review, the facility failed to ensure the Facility Assessment identified appropriate staffing levels to provide basic care needs for residents, which caused mental anguish for 1 (#49), and caused 3 (#s 60, 64, and 70) of 7 sampled residents to voice concerns about staffing due to care needs not being met; and failed to update the Facility Assessment to include COVID-19 care and services. These failures increased the risk of a negative outcome for residents residing at the facility. Findings include: 1. Basic Care Needs: a. During an interview on 8/30/22 at 10:29 a.m., resident #49 stated he had not had a shower in two weeks and had made requests. Resident #49 said, I am a grown man and I have an issue with wetting the bed. …
F838 citations in Montana
Facility assessment · Administration Deficiencies
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Montana cites F838 less often than its own record predicts
0.62 times the national share — cited less often here than elsewhere.
Of every deficiency written in Montana in 2025, this is the portion that was F838.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Montana surveyors wrote
F838 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 accurately complete a facility assessment and failed to identify 1 resident (#46) of 1 resident sampled for care needs. The failure resulted in elevated risk for resident needs not to be accurately and safely met. Finding include:Review of the facility assessment completed on 8/1/25 showed residents requiring hemodialysis would be transported to an outside facility. The assessment also showed Individuals who present (as) an elopement risk that cannot be safely managed with a Wander Guard system will not be admitted .During an interview on 2/9/26 at 5:30 p.m., staff member A said she was not sure whose facility assessment was in the facility folder. …
Based on interview and record review, the facility failed to ensure the Facility Assessment included information related to COVID-19 care and services. The deficient practice had the potential to affect any resident who received care and services at the facility. Findings include: Review of the Facility Assessment, dated 2/26/2022, failed to show any information related to COVID-19 care and services. The assessment did not include: - COVID-19 as an infectious or communicable disease. - Isolation needs as a result of COVID-19. - Changes in staffing as a result of COVID-19. - An updated Infection Prevention and Control risk assessment which addressed COVID-19. During an interview on 5/11/22 at 3:32 p.m., staff member A said the Facility Assessment had been reviewed and updated recently. …
The short window
Recent years
| Year | Share of Montana citations | vs expected |
|---|---|---|
| 2024 | 0.17% | 0.90× |
| 2025 | 0.16% | 0.62× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Montana surveyors cite →
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