Based on interview and record review, the facility failed to ensure 1 (#5) of 5 sampled residents received appropriate respiratory services on admission, and failed to have physician orders and necessary equipment on hand, and staff were not aware of or educated on the resident's respiratory care needs or risks related to them, and this resulted in neglect of care when a staff member removed the resident's oxygen, and then the resident showed signs of hypoxia. Findings include: Review of a complaint made on 2/4/25 showed resident #5 was admitted to the facility on [DATE], and during the admission process the resident's oxygen was removed for a period of time while a staff member wheeled the resident down the hallway to obtain an admission weight. …
F635 citations in Montana
Resident Assessment and Care Planning Deficiencies
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Montana cites F635 more often than its own record predicts
2.83 times the share F635 takes of citations nationally.
Of every deficiency written in Montana in 2025, this is the portion that was F635.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Montana surveyors wrote
F635 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 |
|---|---|---|
| 2023 | 0.28% | 4.41× |
| 2025 | 0.16% | 2.83× |
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