Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
MONTANA MENTAL HEALTH NURSING HOME
LEWISTOWN, MT · 117 certified beds · Last Life Safety survey October 24, 2024
CMS Certification Number 27A052 · first certified June 1991
Ownership
Independently operated (no chain recorded by CMS) · Government - State
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within MT
20 citations — more than 67% of the 61 certified nursing homes in MT. Compared within MT rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 7 citations; the earlier surveys in the window averaged 6.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (October 2025 to December 2025), and past the point by which nine in ten MT facilities have been surveyed. This facility’s last Life Safety survey was October 2024. Facilities in MT are typically surveyed 12–13 months after the last one (median 12), measured over 104 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
1 of the 20 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 20 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in MT, and nationally. Surveyors differ markedly between states, so the MT figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 20 |
| Median facility in MT | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 18, 2022 | 5 |
| November 8, 2023 | 8 |
| October 24, 2024 | 7 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 3 | 2024-10-24 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2024-10-24 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2023-11-08 |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 2 | 2024-10-24 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2024-10-24 |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 1 | 2024-10-24 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2024-10-24 |
| K-0754 | Provide properly sized and located linen or trash receptacles. | 1 | 2022-08-18 |
What the citations cover
- Smoke Deficiencies 10
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Miscellaneous Deficiencies 4
- Emergency Preparedness Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 10 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Miscellaneous Deficiencies | 4 |
| Emergency Preparedness Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
October 24, 2024 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (December 11, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (February 26, 2025) |
| K-0325 | Have properly installed hallway dispensers for alcohol-based hand rub. | Deficient, Provider has date of correction (December 11, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (December 11, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (December 11, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (December 11, 2024) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (December 11, 2024) |
November 8, 2023 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (January 5, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (January 5, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (January 5, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (January 5, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (January 5, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (January 5, 2024) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (January 5, 2024) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (January 5, 2024) |
August 18, 2022 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (October 20, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 20, 2022) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (October 20, 2022) |
| K-0754 | Provide properly sized and located linen or trash receptacles. | Deficient, Provider has date of correction (October 20, 2022) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (October 20, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.