Based on observation, interview, and record review, the facility failed to revise interventions on the resident's plan of care after multiple falls for 8 (#s 4, 6, 7, 8, 9, 17, 19, and 22) of 8 sampled residents. This deficient practice affected half of the facility resident population, and had the potential to further increase the risk of falls, with or without injury, for the vulnerable or non vulnerable residents, and act proactively for preventing the falls vs being reactive and responding to the falls. Findings include: Refer to F689 - Free of Accident Hazards/supervision/devices for detailed fall information. 1. Review of resident #22's Brief Interview for Mental Status exam, dated 5/7/22, showed she scored a 0, for severe cognitive impairment. …
F657 citations in Montana
Care plan timing and revision · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Montana cites F657 more often than its own record predicts
2.18 times the share F657 takes of citations nationally.
Of every deficiency written in Montana in 2025, this is the portion that was F657.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Montana surveyors wrote
F657 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 revise a resident's care plan to reflect a resident's current pressure wounds and care needs for 1 (#2) of 31 sampled residents. The failure placed the resident at a greater risk for delayed wound healing. Findings include:During an interview on 7/30/26 at 7:58 a.m., resident #2 stated, I had a surgical wound after surgery and a pressure sore on my bottom. Resident #2 stated he had been in the facility approximately one year and had multiple wounds. …
Based on interview and record review, the facility failed to update a care plan to reflect a resident's ability to transfer from a wheelchair to a bed. The failure increased the resident's risk of injury during transfer for 1 (#16) of 2 residents sampled for injuries. Findings include:Review of a facility-reported incident, submitted to the State Survey Agency on 8/28/25, showed resident #16 sustained a hematoma of unknown origin to the left lower extremity. The facility's investigation determined the injury likely occurred as a result of a difficult resident transfer from a wheelchair to a bed.During an interview on 11/17/25 2:02 p.m., staff member L stated a resident's ability to transfer and any devices required would be found in the resident's care plan.During an interview on 11/18/25… …
The short window
Recent years
| Year | Share of Montana citations | vs expected |
|---|---|---|
| 2023 | 5.08% | 2.37× |
| 2024 | 5.77% | 3.02× |
| 2025 | 4.07% | 2.18× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Montana surveyors cite →
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