State surveyors inspected 60 of Montana's 61 nursing homes in the 12 months from August 2025 through July 2026 and cited 662 health deficiencies, according to CMS's nursing home health citation file, processed September 1, 2026. The most cited was F689, which CMS words as “ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents”, at 27 of those buildings (45%). 10 of the citations were immediate jeopardy, the most serious level CMS has.
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Montana, the 12 months from August 2025 through July 2026, from CMS's nursing home health citation file.
August 2025 through July 2026. Source: CMS's nursing home health citation file, processed September 1, 2026.
| Rank | Tag | Citations | Buildings cited |
|---|---|---|---|
| 1 | F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents | 36 | 27 (45%) |
| 2 | F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities | 34 | 27 (45%) |
| 3 | F880Provide and implement an infection prevention and control program | 31 | 26 (43%) |
| 4 | F610Respond appropriately to all alleged violations | 30 | 22 (37%) |
| 5 | F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody | 29 | 23 (38%) |
| 6 | F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards | 28 | 27 (45%) |
| 7 | F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals | 25 | 21 (35%) |
| 8 | F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured | 20 | 20 (33%) |
| 9 | F677Provide care and assistance to perform activities of daily living for any resident who is unable | 18 | 15 (25%) |
| 10 | F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies | 17 | 17 (28%) |
| 11 | F658Ensure services provided by the nursing facility meet professional standards of quality | 14 | 13 (22%) |
| 12 | F686Provide appropriate pressure ulcer care and prevent new ulcers from developing | 13 | 12 (20%) |
| 13 | F641Ensure each resident receives an accurate assessment | 12 | 12 (20%) |
| 14 | F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances | 12 | 11 (18%) |
| 15 | F692Provide enough food/fluids to maintain a resident's health | 12 | 11 (18%) |
| 16 | F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely | 11 | 10 (17%) |
| 17 | F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being | 11 | 10 (17%) |
| 18 | F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | 10 | 9 (15%) |
| 19 | F684Provide appropriate treatment and care according to orders, resident’s preferences and goals | 10 | 8 (13%) |
| 20 | F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs | 8 | 8 (13%) |
| 21 | F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status | 8 | 8 (13%) |
| 22 | F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights | 7 | 7 (12%) |
| 23 | F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident | 7 | 7 (12%) |
| 24 | F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections | 7 | 7 (12%) |
| 25 | F697Provide safe, appropriate pain management for a resident who requires such services | 7 | 7 (12%) |
| Rank | Tag | Citations | Buildings cited |
|---|---|---|---|
| 26 | F745Provide medically-related social services to help each resident achieve the highest possible quality of life | 7 | 7 (12%) |
| 27 | F757Ensure each resident’s drug regimen must be free from unnecessary drugs | 7 | 7 (12%) |
| 28 | F759Ensure medication error rates are not 5 percent or greater | 7 | 7 (12%) |
| 29 | F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician | 7 | 7 (12%) |
| 30 | F552Ensure that residents are fully informed and understand their health status, care and treatments | 6 | 6 (10%) |
| 31 | F554Allow residents to self-administer drugs if determined clinically appropriate | 6 | 6 (10%) |
| 32 | F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function | 6 | 6 (10%) |
| 33 | F627Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge | 6 | 6 (10%) |
| 34 | F679Provide activities to meet all resident's needs | 6 | 6 (10%) |
| 35 | F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason | 6 | 6 (10%) |
| 36 | F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature | 6 | 6 (10%) |
| 37 | F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift | 6 | 5 (8%) |
| 38 | F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist | 6 | 5 (8%) |
| 39 | F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive | 5 | 5 (8%) |
| 40 | F695Provide safe and appropriate respiratory care for a resident when needed | 5 | 5 (8%) |
| 41 | F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis | 5 | 5 (8%) |
| 42 | F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia | 5 | 5 (8%) |
| 43 | F883Develop and implement policies and procedures for flu and pneumonia vaccinations | 5 | 5 (8%) |
| 44 | F865Have a plan that describes the process for conducting QAPI and QAA activities | 5 | 4 (7%) |
| 45 | F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment | 4 | 4 (7%) |
| 46 | F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months | 4 | 4 (7%) |
| 47 | F637Assess the resident when there is a significant change in condition | 4 | 4 (7%) |
| 48 | F699Provide care or services that was trauma informed and/or culturally competent | 4 | 4 (7%) |
| 49 | F700Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail | 4 | 4 (7%) |
| 50 | F760Ensure that residents are free from significant medication errors | 4 | 4 (7%) |
| 51 | F835Administer the facility in a manner that enables it to use its resources effectively and efficiently | 4 | 4 (7%) |
| 52 | F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | 4 | 4 (7%) |
| 53 | F881Implement a program that monitors antibiotic use | 4 | 4 (7%) |
| 54 | F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice | 3 | 3 (5%) |
| 55 | F583Keep residents' personal and medical records private and confidential | 3 | 3 (5%) |
| 56 | F645PASARR screening for Mental disorders or Intellectual Disabilities | 3 | 3 (5%) |
| 57 | F711Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit | 3 | 3 (5%) |
| 58 | F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services | 3 | 3 (5%) |
| 59 | F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures | 3 | 3 (5%) |
| 60 | F791Provide or obtain dental services for each resident | 3 | 3 (5%) |
| 61 | F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident | 3 | 3 (5%) |
| 62 | F825Provide or get specialized rehabilitative services as required for a resident | 3 | 3 (5%) |
| 63 | F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards | 3 | 3 (5%) |
| 64 | F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home | 3 | 3 (5%) |
| 65 | F563Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing | 2 | 2 (3%) |
| 66 | F565Honor the resident's right to organize and participate in resident/family groups in the facility | 2 | 2 (3%) |
| 67 | F577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies | 2 | 2 (3%) |
| 68 | F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered | 2 | 2 (3%) |
| 69 | F602Protect each resident from the wrongful use of the resident's belongings or money | 2 | 2 (3%) |
| 70 | F638Assure that each resident’s assessment is updated at least once every 3 months | 2 | 2 (3%) |
| 71 | F640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment | 2 | 2 (3%) |
| 72 | F685Assist a resident in gaining access to vision and hearing services | 2 | 2 (3%) |
| 73 | F693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube | 2 | 2 (3%) |
| 74 | F712Ensure that the resident and his/her doctor meet face-to-face at all required visits | 2 | 2 (3%) |
| 75 | F730Observe each nurse aide's job performance and give regular training | 2 | 2 (3%) |
| 76 | F742Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder | 2 | 2 (3%) |
| 77 | F790Provide routine and 24-hour emergency dental care for each resident | 2 | 2 (3%) |
| 78 | F808Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law | 2 | 2 (3%) |
| 79 | F813Have a policy regarding use and storage of foods brought to residents by family and other visitors | 2 | 2 (3%) |
| 80 | F838Conduct 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 | 2 | 2 (3%) |
| 81 | F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data | 2 | 2 (3%) |
| 82 | F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action | 2 | 2 (3%) |
| 83 | F940Develop, implement, and/or maintain an effective training program for all new and existing staff members | 2 | 2 (3%) |
| 84 | F551Give the resident's representative the ability to exercise the resident's rights | 1 | 1 (2%) |
| 85 | F553Allow resident to participate in the development and implementation of his or her person-centered plan of care | 1 | 1 (2%) |
| 86 | F555Honor the resident's right to choose his or her attending physician | 1 | 1 (2%) |
| 87 | F559Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made | 1 | 1 (2%) |
| 88 | F607Develop and implement policies and procedures to prevent abuse, neglect, and theft | 1 | 1 (2%) |
| 89 | F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed | 1 | 1 (2%) |
| 90 | F646Notify the appropriate authorities when residents with MD or ID services has a significant change in condition | 1 | 1 (2%) |
| 91 | F675Honor each resident's preferences, choices, values and beliefs | 1 | 1 (2%) |
| 92 | F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason | 1 | 1 (2%) |
| 93 | F678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives | 1 | 1 (2%) |
| 94 | F698Provide safe, appropriate dialysis care/services for a resident who requires such services | 1 | 1 (2%) |
| 95 | F710Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care | 1 | 1 (2%) |
| 96 | F732Post nurse staffing information every day | 1 | 1 (2%) |
| 97 | F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service | 1 | 1 (2%) |
| 98 | F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options | 1 | 1 (2%) |
| 99 | F809Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times | 1 | 1 (2%) |
| 100 | F837Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility | 1 | 1 (2%) |
| 101 | F841Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility | 1 | 1 (2%) |
| 102 | F847Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse | 1 | 1 (2%) |
| 103 | F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services | 1 | 1 (2%) |
| 104 | F850Hire a qualified full-time social worker in a facility with more than 120 beds | 1 | 1 (2%) |
| 105 | F919Make sure that a working call system is available in each resident's bathroom and bathing area | 1 | 1 (2%) |
| 106 | F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members | 1 | 1 (2%) |
| 107 | F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation | 1 | 1 (2%) |
| 108 | F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention | 1 | 1 (2%) |
| 109 | F949Provide behavior health training consistent with the requirements and as determined by a facility assessment | 1 | 1 (2%) |
A tag is ranked by how many times it was cited. “Buildings cited” counts the inspected buildings that drew the tag at least once, and its percentage is of every building inspected; we print a percentage only where 20 or more buildings were inspected. “Rank a year earlier” is the same ranking over August 2024 through July 2025. CMS publishes citations months after the survey, so the newest months are still filling in: compare ranks across the two years, not counts. Immediate jeopardy is CMS severity J, K or L; actual harm is G, H or I. No building is named on this page: open a building for its own inspections.
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