Based on interview and record review, the facility failed to ensure a resident's comprehensive care plan contained information related to the diagnosis, care, and monitoring of a diabetic ulcer on a resident with a history of diabetes and neuropathy for 1 (#1) of 13 sampled residents. Findings include:Review of a facility document titled Nurse/Provider Communication Form, dated 1/23/24, showed the resident presented with an open friction area to the right great toe and a scabbed area to the right middle toe.Review of a document titled, Wound Tracker Form, dated 6/29/24, showed Resident #1 was seen by wound care that day, and notes showed the resident had wounds on the Right distal 4th and 5th toe, both due to being cut while clipping his nails. …
F656 citations in Montana
Comprehensive care plan · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Montana cites F656 more often than its own record predicts
1.05 times the share F656 takes of citations nationally.
Of every deficiency written in Montana in 2025, this is the portion that was F656.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Montana surveyors wrote
F656 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 observation, interview, and record review, the facility failed to develop and maintain a comprehensive care plan, which included the presence of a resident's hearing aids and the need for staff to assist the resident with putting the hearing aids in his ears, for 1 (#6) of 18 sampled residents. Findings include:During an observation and interview on 6/2/26 at 10:50 a.m., resident #6 was lying in bed, not wearing his hearing aids. When asked why he was not wearing his hearing aids, the resident stated he was not sure where they were. Resident #6 stated he thought they may have been missing for approximately six months. The charger for resident #6's hearing aids was plugged in and sitting on the bedside table next to the sink in the resident's room. …
Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person centered care plan that included problems, goals, and interventions for alteration in respiratory status or the use of oxygen over a period of 11 months, and completion of three MDS assessments and care plan reviews, for 1 (#67) of 31 sampled residents. Findings include: During observations on 3/18/19 at 12:14 p.m., 12:25 p.m., 12:41 p.m., and 3:02 p.m., resident #67 was noted to be wearing oxygen via nasal cannula. Review of resident #67's physician's orders [REDACTED]. …
The short window
Recent years
| Year | Share of Montana citations | vs expected |
|---|---|---|
| 2023 | 4.24% | 1.18× |
| 2024 | 3.32% | 0.97× |
| 2025 | 3.60% | 1.05× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Montana surveyors cite →
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