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 resident with a chronic scalp lesion had ongoing drainage and foul odor, but the wound was not adequately evaluated or managed despite repeated skin assessments documenting the condition. No wound care orders were in place until maggots were found and removed, and staff did not complete a comprehensive reassessment afterward. The resident was not seen by a provider until several days later, when a surgeon documented fly-laid maggots, drainage, odor, and growth, and a biopsy later showed basal cell carcinoma.
EBP was not identified or initiated for residents with wounds, a skin lesion, or an indwelling Foley catheter, as signage was missing and PPE was not readily accessible at the point of care. In addition, a staff member distributing clean linen entered multiple residents’ rooms and handled clean clothing without performing hand hygiene before entering, after exiting, or before touching clean linen.
Failure to Notify Physician of Wound Change: The facility did not notify the MD of a significant change in condition for a resident with a chronic scalp wound when new drainage developed. The wound was observed with black discoloration, drainage, and a foul odor, and skin assessments documented drainage, but nursing notes showed no documentation that the MD was informed. Staff stated the MD should be notified of wound changes such as drainage, size, shape, or color, though notification was handled case by case.
The facility failed to fully assess and document a resident’s chronic scalp wound. Weekly skin checks noted the lesion at times, but documentation lacked wound size, shape, color, and full drainage details, and no comprehensive skin assessment was documented after maggots were removed. Staff stated wound changes should be reported and documented, but the record did not show complete follow-up assessment of the wound.
Failure to provide physician reassessment after a significant change in condition: a resident with a large, foul-smelling scalp lesion was found to have maggots in the wound. Staff notified the MD, who gave wound care instructions by phone, but did not come to assess the resident or document a reassessment before the resident’s outpatient surgery visit.
Incomplete Documentation of Chronic Scalp Wound: A resident with a chronic scalp lesion/wound had inconsistent and incomplete skin/wound documentation in the EMR. Weekly skin assessments sometimes omitted the lesion entirely, and when it was documented, key details such as size, shape, color, and drainage were missing. The record also lacked documentation of a comprehensive assessment after maggots were found and removed from the wound, and staff acknowledged the chart did not provide a complete picture of the wound status or care provided.
Failure to Monitor and Manage Chronic Scalp Wound With Maggot Infestation
Penalty
Summary
The facility failed to provide necessary care and services to evaluate, monitor, and manage a chronic scalp lesion/wound for one resident despite ongoing changes in the wound condition, including documented drainage. The resident was observed with multiple black lesions on the scalp, including a large central lesion about the size of a tennis ball that was black, partially covered with brown material, and draining yellowish, foul-smelling fluid. The hair around the lesions was discolored and had crusted, dried material present, and the resident stated the lesions had drained off and on and that one lesion had been present for years while the smaller ones were newer. Record review showed weekly skin assessments documented the scalp lesion/wound over many months, with drainage noted on several assessments, but there were no wound care orders for the lesion until after maggots were identified and removed. Facility staff stated the resident was admitted with the lesion and that the staff member aware of it only saw the resident on occasion. After maggots were found and removed from the scalp lesion/wound, staff did not complete a skin assessment, and there was no documentation of a comprehensive assessment of the lesion/wound following removal of the maggots. The resident was evaluated by a general surgeon five days after the maggots were identified and removed, and during that time there was no documentation of a physician or other provider evaluation or a comprehensive reassessment of the lesion/wound. The surgeon’s consultation noted that flies laid maggots on the wound and that it had drainage, odor, and growth, with a history of infection. A biopsy was taken, and later notes showed the biopsy was positive for basal cell carcinoma.
EBP Not Initiated and Hand Hygiene Not Performed During Linen Distribution
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions (EBP) were identified and initiated for residents with wounds or an indwelling Foley catheter. Review of the facility’s EBP list showed that resident #1 had a wound, resident #2 had a wound and an indwelling Foley catheter, resident #3 had a skin lesion, and resident #7 had a wound requiring EBP. During observations, resident #3 had no EBP signage outside the room and no PPE readily accessible, and there was one PPE caddy for the west hallway serving the Special Care Unit hallway. Additional observations showed resident #1 had no EBP signage outside the room or PPE readily accessible. Resident #2 was observed lying in bed with an indwelling Foley catheter bag located in a basin on the floor and also had a documented wound; there was no EBP signage outside the room or PPE readily accessible. Resident #7 also had no EBP signage outside the room or PPE readily accessible. Later, one PPE caddy was observed in the hallway serving residents #1, #2, and #7, but PPE was not located immediately outside or readily accessible. Staff stated EBP should be used for residents with infections, wounds, or an indwelling Foley catheter, and that residents on EBP should have a shield sign posted on the door frame. The facility also failed to ensure hand hygiene was completed during the distribution of clean linen. During observation, a staff member entered resident #5’s room, placed clean clothing in the closet, and exited without performing hand hygiene before entering or after leaving the room. The staff member then handled clean clothing on the linen cart and repeated the same process for resident #6 and resident #7 without performing hand hygiene before entering or exiting those rooms. The staff member stated she had been educated on proper hand hygiene and was to perform hand hygiene before entering a resident’s room, after leaving a resident’s room, and before touching any clean linen, but acknowledged that she did not perform proper hand hygiene.
Failure to Notify Physician of Wound Change
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for resident #3 related to a chronic scalp lesion/wound, including the new onset of drainage. During an observation on 6/30/26 at 2:50 p.m., resident #3 was noted to have a scalp lesion/wound with black discoloration, drainage, and a foul odor. Weekly skin assessments dated 11/23/25, 11/30/25, and 12/7/25 documented drainage from the scalp lesion/wound. Review of nursing progress notes dated 11/23/25 through 12/9/25 showed no documentation that the physician was notified of the change in condition related to the drainage from the scalp lesion/wound. During interviews, staff stated the physician should be notified of new skin concerns and changes in a wound, including size, shape, color, or drainage, although one staff member said notification was done on a case-by-case basis and earlier changes were not reported because the physician was aware of the lesion on admission. Another staff member stated he did not recall being notified about concerns with the scalp lesion/wound before being notified of a maggot infestation.
Incomplete Assessment and Documentation of Chronic Scalp Wound
Penalty
Summary
The facility failed to ensure comprehensive wound assessment, monitoring, and documentation of a chronic scalp lesion/wound for one sampled resident. Weekly skin assessments for the resident showed periods when the scalp lesion/wound was present, but the documentation did not include complete wound characteristics such as size, shape, color, or drainage details. In some assessments, drainage was noted without describing the lesion/wound itself or the drainage characteristics, including color, consistency, or odor. The record also showed no documentation that a comprehensive skin assessment of the scalp lesion/wound was completed after maggots were identified and removed from the lesion/wound on 6/12/26. During interviews, staff stated that skin assessments were completed weekly, that physicians should be notified of changes in a wound, and that wound documentation should include measurements and descriptive characteristics. Staff also stated the facility did not have a dedicated wound nurse and that nursing staff completed wound care and documentation.
Failure to Provide Physician Reassessment After Maggot-Infested Scalp Wound
Penalty
Summary
The facility failed to ensure physician supervision and ongoing clinical oversight after being notified of a significant change in condition for one resident with a large scalp lesion. During observation, the resident had multiple black-colored lesions on the scalp, including a large central lesion about the size of a tennis ball that was partially covered with brown material and had yellowish, foul-smelling drainage. Staff reported that the resident was admitted with the lesion, that it intermittently drained, and that on 6/12/26 a staff member found maggots in the wound. After the maggot infestation was reported, a staff member assessed the resident and called the physician, who instructed staff to clean the area with soap and water, apply petroleum jelly, and cover the wound. The resident received a shower and the lesion was dressed per orders, but the physician did not come to the facility to assess the resident after notification. The physician later stated he did not evaluate or reassess the resident because an outpatient general surgery appointment was already scheduled. Record review showed no physician progress note documenting reassessment of the resident’s condition between the report of maggots and the outpatient surgical evaluation.
Incomplete Documentation of Chronic Scalp Wound
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with a chronic scalp lesion/wound. Weekly skin assessments from 6/2/25-6/29/25 and 11/2/25-11/16/25 contained no documentation of the resident’s scalp lesion/wound, while assessments from 7/6/25-9/28/25 and 12/14/25-6/14/26 documented the presence of the lesion/wound but did not include complete details such as size, shape, color, or drainage characteristics. The resident’s electronic medical record also showed no documentation that a comprehensive assessment of the chronic scalp lesion/wound was completed after maggots were identified and removed from the lesion/wound on 6/12/26. During interviews, staff stated that weekly skin assessments were completed, that nursing staff were expected to document skin and wound assessments, and that documentation should include at minimum a description of the skin concern, wound description or measurements, shape, color, drainage, and odor. Staff acknowledged the record did not contain all information needed to provide a complete picture of the resident’s wound status and related care provided.
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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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