Based on interview and record review, the facility staff failed to perform a thorough head-to-toe assessment, pain assessment, or transfer a resident appropriately after an unwitnessed fall with injury, which was consistent with professional standards of nursing practice, for 1 (#4) of 12 sampled residents. This deficient practice caused an increase in the resident's signs and symptoms of pain, due to a fall that resulted in a hip fracture. Findings include: During an interview on 8/28/25 at 12:24 p.m., staff member L stated she was getting ready to start laying residents down to bed when a kitchen staff member said a resident had fallen in the dining room. Staff member L stated the nurse, another staff member, and she went over to the dining room and found resident #4 lying on the floor. …
F658 citations in Montana
Professional standards of care · Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Montana cites F658 more often than its own record predicts
1.40 times the share F658 takes of citations nationally.
Of every deficiency written in Montana in 2025, this is the portion that was F658.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Montana surveyors wrote
F658 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 ensure comprehensive wound assessment, monitoring, and documentation of a chronic scalp lesion/wound in accordance with accepted standards of nursing practice, including complete documentation of wound characteristics including size, shape, color, and drainage for 1 (#3) of 7 sampled residents. This deficient practice limited the ability to accurately monitor and evaluate changes in the resident's chronic scalp lesion/wound, identify changes in lesion/wound status, and determine when additional clinical evaluation or intervention was required. …
The short window
Recent years
| Year | Share of Montana citations | vs expected |
|---|---|---|
| 2023 | 1.69% | 1.06× |
| 2024 | 1.92% | 1.17× |
| 2025 | 2.50% | 1.40× |
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