Based on interview and record review, the facility failed to ensure an effective Quality Assurance Performance Improvement (QAPI) plan and process was in place to track, monitor, analyze data, and re-evaluate their plan of action to address systemic deficiencies throughout the facility as identified below: - ensure the accurate and timely comprehensive assessments, including admission, annual, and significant changes, were completed for all residents in the facility and resulting in the neglect of care for 5 (#s 44, 48, 73, 78, and 79); (see F600) - ensure the development and implementation of comprehensive care plans were completed, to address all residents' care concerns, based on the comprehensive assessments; (see F656) - ensure revisions to resident care plans were performed in a… …
F865 citations in Montana
QAPI program · Administration Deficiencies
Have a plan that describes the process for conducting QAPI and QAA activities.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Montana cites F865 more often than its own record predicts
2.63 times the share F865 takes of citations nationally.
Of every deficiency written in Montana in 2025, this is the portion that was F865.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Montana surveyors wrote
F865 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 leadership failed to maintain a QAPI system to identify quality of care and quality of life deficient practices, and show how deficiencies were identified, tracked, corrected, and monitored. The facility was cited with 17 deficiencies during the survey. These failures had the potential to affect all the residents of the facility due to needed corrections not being identified and addressed by the facility. Findings include: During an interview on 2/10/26 at 10:40 a.m., staff member A stated the facility talks about QAPI every morning. Staff member A stated, We go through the processes, and QAPI is involved in identifying deficiencies at morning meetings. …
The short window
Recent years
| Year | Share of Montana citations | vs expected |
|---|---|---|
| 2023 | 0.28% | 1.64× |
| 2025 | 0.63% | 2.63× |
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