Based on interview and record review, the facility failed to document the wound identified by the physician, to properly assess during skin checks, treat, and monitor a facility acquired diabetic ulcer for a resident with a history of diabetes, neuropathy, and sores on the feet, for 1 (#1) of 13 sampled residents. The deficient practice contributed to the deterioration of the wound, which resulted in the resident's right great toe being amputated. Findings include: On 11/4/25 at 11:45 a.m., the Administrator, Chief Nursing Officer, and Corporate Resource Nurse, were notified that an Immediate Jeopardy existed in the area of F684, Quality of Care, related to the failure to identify, monitor, and treat a diabetic ulcer for a resident with a history of neuropathy, diabetes, and sores on the… …
F684 citations in Montana
Quality of care · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Montana cites F684 less often than its own record predicts
0.29 times the national share — cited less often here than elsewhere.
Of every deficiency written in Montana in 2025, this is the portion that was F684.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Montana surveyors wrote
F684 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 provide the necessary care and services to evaluate, monitor, and manage a chronic scalp lesion/wound despite changes in the wound condition, including documented drainage; and failed to ensure timely wound management prior to and following the identification of a maggot infestation1 for 1 (#3) of 7 sampled residents. This deficient practice resulted in a decline of the resident's scalp lesion/wound condition and the development of maggot infestation1 requiring additional wound management and evaluation. Findings include:During an observation and interview on 6/30/26 at 2:50 p.m., resident #3 was observed with multiple, black-colored lesions on the scalp. …
Based on interview and record review, the facility failed to provide necessary care and services to maintain the highest practicable physical well-being for 1 (#1) of 8 sampled residents. The facility failed to administer an anticoagulant medication as ordered, resulting in the omission of 27 doses of Eliquis (Apixaban), increasing the risk for complications including stroke and blood clots; and failed to implement physician-ordered medication hold instructions before a scheduled vascular procedure, resulting in the cancellation and rescheduling of the resident's fistula surgery on two separate occasions and causing the resident frustration. These failures delayed medically necessary treatment. Findings include:1. …
The short window
Recent years
| Year | Share of Montana citations | vs expected |
|---|---|---|
| 2023 | 1.69% | 0.47× |
| 2024 | 1.75% | 0.44× |
| 2025 | 1.25% | 0.29× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Montana surveyors cite →
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