Citations in Montana
Statistics, citations and compliance trends for long-term care facilities in Montana.
Statistics for Montana (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in Montana
A hospice resident with COPD, opioid dependence, chronic pain, and anxiety received Narcan nasal spray from staff without a physician order or standing order after being found unresponsive. After the dose, the resident developed flailing and jerking movements, respiratory distress, and signs consistent with opioid withdrawal, and was transported to the hospital where she received lorazepam and morphine and was admitted.
Failure to obtain proper informed consent for meds, vaccines, and side rails: staff used resident signatures or verbal consent when guardians/POAs were in place, and several consent forms were incomplete or missing key details such as dates, witness info, and goals/behaviors for psychotropic meds. Records showed mismatches between legal decision-makers and the people documented on consents, including a resident with guardianship, a resident with a DPOA, and incomplete documentation for bedrails, vaccines, opioids, and psychotropics.
Late Reporting of Facility-Reported Incidents and Investigations: The facility did not report two incident allegations to the State Survey Agency within the required timeframe and did not submit investigation results within five working days for multiple incidents involving residents. The late reports included allegations of neglect, verbal abuse, staff-to-resident abuse, resident-to-resident verbal abuse, unauthorized Narcan administration, and CPR initiated when a POLST was not readily available. Staff member A stated she was responsible for the reports and acknowledged several findings were submitted late.
Delayed Toileting and ADL Assistance for Multiple Residents A resident was left on the toilet for an extended period after staff failed to return to assist him off the toilet, and he was later described as sore for several days. Two other residents who required staff help with toileting and personal care did not receive the needed assistance during the day shift, with statements indicating the CNA said she would return but did not. Records showed one resident was dependent for toileting hygiene and another had moderate cognitive impairment with significant assistance needs, and both were later found saturated with urine.
Failure to Timely Report Abuse and Neglect Allegations: The facility failed to maintain an effective system for timely reporting allegations of abuse and neglect after a prior F609 citation for the same issue. Surveyors found nine late reports involving multiple residents, and staff and the administrator acknowledged ongoing difficulty tracking when reports were due, with most late reports occurring during the monitoring period after the earlier deficiency.
Failure to provide written transfer and bed-hold notice: A resident with dementia and a BIMS score indicating mild to moderate impairment was found on the floor, sent to the hospital, and admitted. The resident received verbal notice of transfer, but the POA/rep was not sent the required written Notice of Transfer/Discharge with the reason for transfer and bed-hold information; staff said the form probably was not mailed because the responsible staff member was off work.
Unordered Narcan Administration to Hospice Resident
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary drugs when staff administered Narcan (naloxone) to a hospice resident without a physician order or documented clinical indication. Resident #4 had diagnoses including COPD, opioid dependence, anxiety disorder, chronic pain, and polyneuropathy, and was receiving hospice services for COPD with comfort-focused symptom management. The resident’s orders included oxycodone PRN, a fentanyl patch that was increased from 50 mcg/hr to 75 mcg/hr, and morphine sulfate for pain and shortness of breath. The resident’s electronic record did not show an order authorizing Narcan or any standing order for its use. According to staff interviews and records, the resident was found unresponsive and a staff member, believing it looked like an overdose, retrieved Narcan nasal spray from the medication cabinet and administered it without a physician order. After the Narcan, the resident became more active, flailed, and had jerking movements of the upper extremities, appeared in respiratory distress, pushed away the oxygen mask, and was not following commands. EMS documented findings consistent with opioid withdrawal following Narcan administration, and hospice records stated the Narcan was administered inappropriately. The resident was transported to the hospital, where she received multiple doses of lorazepam and morphine, was admitted, and a morphine infusion was started.
Failure to Obtain Proper Informed Consent for Medications, Vaccines, and Side Rails
Penalty
Summary
The facility failed to ensure resident representatives were contacted to provide informed consent before medications, vaccines, and adaptive equipment/restraints were used for 4 of 30 sampled and supplemental residents. The report states that the facility expected nursing staff to locate the responsible party in the EHR or hard chart and obtain consent for new medications, medication increases, vaccines, and side rails, but staff also stated that if the responsible party could not be reached, cognitively intact residents were asked for verbal consent. Staff members also described uncertainty about the differences among POA, DPOA, and guardianship and how those roles could be split among multiple people. For resident #10, the record showed the Western Chapter for the Prevention of Elder Abuse was the conservator, but the psychotropic medication consent for pregabalin was signed by the resident verbally in person, and the bedrail consent listed the guardian without date, type of consent, or witness information. For resident #94, the court order named the Western Chapter for the Prevention of Elder Abuse as guardian, but the bedrail consent lacked date, type, signature, and witness information; the vaccine consent was signed by the guardian; and the psychotropic medication consent for escitalopram and olanzapine lacked the goals or behaviors for use, with the date of consent and witness information left blank. For resident #99, the guardianship record named the Western Chapter for the Prevention of Elder Abuse as guardian, but one bedrail consent lacked date, type, and witness information, another bedrail consent was signed by the resident verbally in person with a nurse witness, and no consent for the current trazodone order was provided before the end of the survey. For resident #60, the durable power of attorney for medical care named a different primary DPOA than the person listed on the consents. The bedrail consent referenced consent by POA through email, but the email was not provided; the opioid medication consent for oxycodone was documented as verbal/telephone consent by the State POA with no witness required per facility policy; the psychotropic medication consent for aripiprazole and bupropion listed the resident as the person providing consent, with the effective date and witness left blank; and the vaccine consent for influenza and Boostrix/TdaP was documented as verbal telephone consent by the POA. The facility policy stated that informed consent for side rails is to be signed by the resident or responsible party, and the vaccine protocol referenced chart review and vaccine consent documentation.
Late Reporting of Facility-Reported Incidents and Investigations
Penalty
Summary
The facility failed to ensure Facility-Reported Incidents were reported to the State Survey Agency within the required timeframe for residents 10 and 14, and failed to submit the results of investigations to the State Survey Agency within the required five-working-day timeframe for residents 4, 5, 9, 10, 11, 12, 13, 14, and 16 of 19 residents reviewed for Facility-Reported Incidents. During interview, staff member A stated she was responsible for submitting both the initial reports and the investigative findings for all of the facility's reported incidents to the State Survey Agency within the required timeframes and acknowledged that several investigative findings were submitted late. The record review showed an allegation of neglect involving resident 14 and an allegation of verbal abuse involving resident 10 were not initially reported to the State Survey Agency within the required timeframe, and both also had investigative findings submitted late. Additional late investigative findings were identified for incidents involving resident-to-resident verbal abuse between residents 9 and 16, unauthorized administration of Narcan to resident 4, CPR initiated for resident 12 when a POLST was not readily available, an allegation of staff-to-resident abuse involving resident 11, and resident-to-resident verbal abuse between residents 5 and 13. The facility policy titled, Abuse Reporting and Response, stated that suspected abuse, neglect, exploitation, misappropriation, mistreatment, and injuries of unknown source are to be reported immediately, and that the results of investigations are to be reported to the State Survey Agency within five working days of the incident.
Delayed Toileting and ADL Assistance
Penalty
Summary
The facility failed to provide timely toileting and ADL assistance for 3 of 6 sampled residents who required staff help with toileting and personal care. For resident #2, a facility-reported incident stated he was left unattended on the toilet for approximately 30 minutes, but staff interviews during the survey described the event as lasting much longer. One staff member recalled resident #2 remaining on the toilet for nearly two hours, calling out for help, and eventually moving from the toilet to his seated walker before being able to activate the call light. The resident was described as cognitively aware, with limited mobility and little to no muscle tone, and he reportedly was sore for several days afterward. Record review showed resident #2 had diagnoses including low back pain, constipation, and overactive bladder. His quarterly MDS indicated he was dependent on staff for toileting and toileting hygiene, requiring moderate to maximal assistance, and needed supervision or touch assistance for toilet transfers. The facility’s investigation did not identify why the staff member failed to return to assist him off the toilet in a timely manner, and no written statement from that staff member was included in the investigative file. The resident’s care plan also did not show fall interventions related to bathroom safety. The facility also substantiated neglect involving residents #5 and #6 after they did not receive required toileting and ADL assistance during the day shift. Resident #5, who had diagnoses including metabolic encephalopathy, anxiety disorder, multiple vertebral fractures, cerebrovascular accident, and polyneuropathy, was assessed as cognitively intact but completely dependent on staff for toileting hygiene and maximally dependent for personal hygiene. Resident #6, who had diagnoses including COPD, heart failure, cognitive communication deficit, and wheelchair dependence, had moderate cognitive impairment and required moderate to maximal assistance for toileting and personal hygiene. Statements from the residents and staff indicated the assigned CNA said she would return to provide care but did not, and another staff member later found both residents saturated with urine when care was finally provided.
Failure to Timely Report Abuse and Neglect Allegations
Penalty
Summary
The facility failed to ensure an effective system for timely reporting allegations of abuse and neglect after a previous F609 deficiency for the same concern. Based on interview and record review, the facility continued to submit late reports for allegations involving 9 of 19 residents, identified as residents 4, 5, 9, 10, 11, 12, 13, 14, and 16. The report states that the late reporting placed residents at risk for delays in notification, investigation, protection, and response following allegations of abuse or neglect. A prior F609 deficiency dated 1/29/26 showed the facility had already been cited for late reporting of allegations of neglect and abuse for three residents. During an interview on 7/29/26, staff member A stated, "I'm still learning . there's been a lot going on here ." The administrator also stated, ". I need to develop a system, so I know when they are due." The current complaint investigation found that the facility administrator and staff continued to report allegations throughout the plan of correction monitoring period, and eight of the nine late reports occurred between 2/22/26 and 5/22/26.
Failure to Provide Written Transfer and Bed-Hold Notice
Penalty
Summary
The facility failed to notify the resident's representative in writing of the reason for transfer and the required bed-hold information for one resident. After the resident was found on the floor following a fall and sent to the local hospital, the resident was admitted. The resident had a diagnosis of unspecified dementia, moderate with agitation, and a BIMS score of 12, indicating mild to moderate dementia. The electronic health record showed a Notice of Transfer/Discharge form dated the same day as the transfer, and the resident received verbal notice of transfer. During interviews, staff stated that discharge notices were given verbally to residents and that the power of attorney was supposed to receive the Notice of Transfer/Discharge by mail, but in this case the form probably was not sent because the staff member responsible was off work and there was likely no one available to send it. The resident's representative stated that the facility had called to inform her of prior hospital transfers, but she did not receive written documentation for those times.
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Compliance trends in Montana
Data through Jun 2026Comparisons below measure the most recent period Jul 2025 – Jun 2026 against the prior period Jul 2024 – Jun 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
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