Based on interview and record review, the facility failed to ensure the medical director or his designee attended and/or participated in the Quality Assurance (QA) program at least quarterly. This deficient practice increased the risk of negative outcomes for residents with respect to quality assessment and assurance activities. The facility reported a census of 54 residents. Findings include:During an interview on 4/20/26 at 3:13 p.m., staff member A stated staff member G was onsite at the facility once a month. She stated when staff member G was onsite at the facility, it did not always correspond with when QA was scheduled to meet. …
F868 citations in Montana
Quality assurance committee · Administration Deficiencies
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Montana cites F868 more often than its own record predicts
3.38 times the share F868 takes of citations nationally.
Of every deficiency written in Montana in 2025, this is the portion that was F868.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Montana surveyors wrote
F868 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 the medical director participated in the QAPI program at least quarterly, which had the potential to affect all the residents in the facility. Findings include: During an interview on 8/23/18 at 8:30 a.m., staff member B said the medical director was sent an invitation every month for the quality assurance meeting. Staff member B said she had been attending the quality assurance meetings for the last two months and the medical director had not attended either meeting. Staff member B said she did not know of the last time the medical director had attended a quality assurance meeting. …
What else Montana surveyors cite →
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