Based on observation, interview, and record review, the facility failed to place call lights in reachable and seen areas for 1 (#5); ensure there was safety during showers for 1 (#6); and ensure all call lights worked consistently and appropriately for 8 (#s 1, 8, 9, 10, 11, 12, 13, 14) of 12 sampled residents leading to residents feeling their needs were unmet. Findings include:1. During an observation on 12/3/25 at 8:32 a.m., resident #5 had his call light draped over the fall mat located next to the nightstand. Resident #5 was sitting at the edge of his bed, unable to locate his call light, and was attempting to reach his shoes at the end of the bed. The resident was a fall risk. …
F919 citations in Montana
Call system · Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Montana cites F919 more often than its own record predicts
1.05 times the share F919 takes of citations nationally.
Of every deficiency written in Montana in 2025, this is the portion that was F919.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Montana surveyors wrote
F919 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.
The short window
Recent years
| Year | Share of Montana citations | vs expected |
|---|---|---|
| 2024 | 0.70% | 1.58× |
| 2025 | 0.47% | 1.05× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Montana surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction