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.

20
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
5
Tags cited more than once
Across separate surveys
9
Inspection & testing records
Of the citations on file

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

Holding steadyabout the same at the latest survey as at its earlier surveys in the window.

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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Which alerts

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

  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  • F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in MT, and nationally. Surveyors differ markedly between states, so the MT figure is the meaningful one.

This facility20MT median15National median11
Citations on file over three years, compared
MeasureCitations
This facility20
Median facility in MT15
Median facility nationally11

Survey history

Citations at each Life Safety survey
52022-0882023-1172024-10
Citations at each Life Safety survey
Survey dateCitations
August 18, 20225
November 8, 20238
October 24, 20247

Most-cited tags

Most-cited tags at this facility
K-03743K-07122K-03532K-09142K-03632E-00041K-03241K-07541
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.32024-10-24
K-0712Have simulated fire drills held at unexpected times.22024-10-24
K-0353Inspect, test, and maintain automatic sprinkler systems.22023-11-08
K-0914Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.22024-10-24
K-0363Install corridor and hallway doors that block smoke.22024-10-24
E-0004Develop and maintain an Emergency Preparedness Program (EP).12024-10-24
K-0324Provide properly protected cooking facilities.12024-10-24
K-0754Provide properly sized and located linen or trash receptacles.12022-08-18

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 10
  • Gas, Vacuum, and Electrical Systems Deficiencies 5
  • Miscellaneous Deficiencies 4
  • Emergency Preparedness Deficiencies 1
Citations by CMS category
CategoryCitations
Smoke Deficiencies10
Gas, Vacuum, and Electrical Systems Deficiencies5
Miscellaneous Deficiencies4
Emergency Preparedness Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

October 24, 2024 — 7 citations

Citations issued on October 24, 2024
TagWhat the surveyor checksStatus
E-0004Develop and maintain an Emergency Preparedness Program (EP).Deficient, Provider has date of correction (December 11, 2024)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (February 26, 2025)
K-0325Have properly installed hallway dispensers for alcohol-based hand rub.Deficient, Provider has date of correction (December 11, 2024)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (December 11, 2024)
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.Deficient, Provider has date of correction (December 11, 2024)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (December 11, 2024)
K-0914Ensure 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

Citations issued on November 8, 2023
TagWhat the surveyor checksStatus
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (January 5, 2024)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (January 5, 2024)
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.Deficient, Provider has date of correction (January 5, 2024)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (January 5, 2024)
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Deficient, Provider has date of correction (January 5, 2024)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (January 5, 2024)
K-0919Meet requirements for the use of electrical equipment.Deficient, Provider has date of correction (January 5, 2024)
K-0921Ensure that testing and maintenance of electrical equipment is performed.Deficient, Provider has date of correction (January 5, 2024)

August 18, 2022 — 5 citations

Citations issued on August 18, 2022
TagWhat the surveyor checksStatus
K-0321Ensure 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-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (October 20, 2022)
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.Deficient, Provider has date of correction (October 20, 2022)
K-0754Provide properly sized and located linen or trash receptacles.Deficient, Provider has date of correction (October 20, 2022)
K-0914Ensure 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.