F691 in Montana. Pick another state for the same tag.
Against expectation — 2025
Montana cites F691 more often than its own record predicts
Versus expected share2.07×
2.07 times the share F691 takes of citations nationally.
Share of Montana citations0.16%
Of every deficiency written in Montana in 2025, this is the portion that was F691.
Montana0.16%
National0.08%
Share of all citations that were F691.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Montana surveyors wrote
F691 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.
G · Actual harm, isolatedApril 9, 2020
Based on observation, interview, and record review, the facility failed to ensure care needs were met, leading to skin excoriation surrounding the [MEDICAL CONDITION], and to include a physician's orders [REDACTED].#3) of 12 sampled residents. Findings include:
During an observation on 4/9/20 at 3:10 p.m., staff member D wheeled resident #3 to her room, to evaluate the resident's [MEDICAL CONDITION]. On resident #3's abdomen, on the lower left side of the adhered [MEDICAL CONDITION] bag, was an opened area with reddened and excoriated skin. The reddened area extended two inches beyond the tape holding the [MEDICAL CONDITION] bag to the abdomen. …
D · No harm, potential for more than minimal, isolatedJanuary 30, 2025
Based on interview and record review, the facility failed to ensure the care and services for a nephrostomy tube were completed and documented in the medical record for 1 (#25) of 17 sampled residents. Resident #25 had a nephrostomy tube which required dressing changes. The facility failed to obtain orders for dressing changes for the nephrostomy tubing. The facility failed to document the care of the nephrostomy tube in the medical record. Findings include:
During an interview on 1/30/25 at 8:15 a.m., staff member B stated resident #25 had a nephrostomy tube and colostomy. Staff member B stated the dressing change was as needed. Staff member B stated there were no orders for dressing changes for the nephrostomy tube. …
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