Based on interview and record review the facility failed to keep 2 (#s 1 and 3) residents free from significant medication errors, of 3 sampled residents for medication errors. This deficiency resulted in an Immediate Jeopardy level deficiency for 1 (#1) resident, and interventions included medication, emergency medical care, and hospitalization , and the deficiency had the potential to cause life threatening side effects for resident #3. Findings include: On [DATE] at 12:37 p.m., the facility Regional Director of Operations, Administrator, and Director of Nursing was notified an Immediate Jeopardy situation existed for 1 (#1) resident for F726 - Residents Free from Significant Medication Errors. An acceptable plan for the removal of immediacy was provided on [DATE] at 7:32 p.m. …
F760 citations in Montana
Significant medication errors · Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Montana cites F760 less often than its own record predicts
0.96 times the national share — cited less often here than elsewhere.
Of every deficiency written in Montana in 2025, this is the portion that was F760.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Montana surveyors wrote
F760 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 medications were transcribed into a resident's electronic medical record accurately, and failed to identify a high-risk medication ordered for a resident with end-stage renal disease for 1 (#6) of 4 residents sampled for dialysis. This deficient practice resulted in resident #6's altered mental status, requiring hospitalization and treatment. Findings include:During an interview on 5/6/26 at 3:20 p.m., staff member B stated residents were reviewed by the interdisciplinary team as new admissions, and nursing management would enter admission orders. Staff member B stated there were two staff members to check the admission orders that were entered, so they would not miss something with an order. …
Based on observation, interview, and record review, the facility's licensed staff failed to ensure they were safely administering medications using the five rights of medication administration for 1 (#31) of 33 sampled and supplemental residents. This resulted in a nurse being stopped for the risk of administering a high-risk medication, and then the same nurse double-checking the medication, only to later give the incorrect concentration of the medication. This also resulted in a 22.22% medication error rate identified during the survey. Findings include:During an observation and interview on 8/25/26 at 9:00 a.m., staff member G prepared the medication heparin for resident #31. …
The short window
Recent years
| Year | Share of Montana citations | vs expected |
|---|---|---|
| 2023 | 1.98% | 1.78× |
| 2024 | 0.52% | 0.45× |
| 2025 | 1.25% | 0.96× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Montana surveyors cite →
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