Montana Mental Health Nursing Home
Lewistown, Montana · CCN 27A052
21 surveys since 2011, 18 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 133
- Surveys
- 21
- Harm or worse
- 18
- Immediate jeopardy
- 9
Findings at the most serious level CMS records.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 117
- Ownership
- Government - State
- Chain
- Independent
- County
- Fergus · rural
- Medicare-certified since
- 1991
CMS ratings
- Overall
- 4
- Health inspection
- 3
- Staffing
- 5
- Quality measures
- 3
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded more weighted findings than most of its peer group.
Weighted by harm level, against 61 facilities in Montana.
Last survey on record
Nov 19, 2025
355 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 6.95 | 5.68 |
| Registered-nurse hours per resident day | 1.68 | — |
| Annual nurse turnover | 54.1% | 58.4% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Payment denials
- 1
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G38.1% | H— | I— |
| No harm, potential for more than minimal | D2362.2% | E924.3% | F25.4% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F6923×
Provide enough food/fluids to maintain a resident's health.
- F7263×
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
- F5802×
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- F6002×
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- F6572×
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
In the surveyor’s words
From the most serious findings on record at Montana Mental Health Nursing Home, in the surveyor’s own words.
- Immediate jeopardy, widespreadF578Mar 18, 2021
Based on interview and record review, the facility initiated Cardio [MEDICAL CONDITION] Resuscitation on one of four sampled residents, (resident #1) who had elected a DNR (do not resuscitate) status on a POLST (physician's orders [REDACTED]. This deficient practice did not follow resident #1's end-of-life directives when an emergent situation arose, and placed all 76 residents on census at the facility in a position to not have their end-of-life directives followed when emergent situations arise. […]
- Immediate jeopardy, patternF684Mar 18, 2021
Based on interview and record review, the facility failed to comprehensively assess and evaluate one resident's clinical condition and risk factors, and failed to implement interventions that were consistent with the resident's needs during an episode of Lo blood glucose levels, for one of four sampled residents (#1). Resident #1 did not receive services to the level of professional standards. This deficient practice may have contributed to resident #1's demise and could potentially place all 26 current diabetic residents at risk for adverse events. […]
- Immediate jeopardy, patternF726Mar 18, 2021
Based on interview and record review, staff member D failed to accurately assess, by not performing a second blood glucose test to confirm a Lo reading; Evaluate the circumstance that put the resident at risk; Plan and implement care in an expiditious manner, and respond to one of four sampled resident's needs (#1), when a change in condition occurred in the form of a critically low blood glucose level, for one (#1), and the resident passed away during the change of condition. This failure placed all 26 current diabetic residents at risk for adverse outcomes related to low blood glucose levels. […]
- Immediate jeopardy, patternF755Mar 18, 2021
Based on interview and record review, the facility failed to have glucose immediately available for use in medication carts, when one of four sampled residents (#1) experienced an episode of a critically low blood glucose level. This deficient practice contributed to the decline of resident #1, placed all 26 current diabetic residents at risk for adverse outcomes, and resident #1 expired after choking from food given after a low blood glucose change of status. IMMEDIATE JEOPARDY On [DATE] at 5:15 p.m., the facility Administrator of Addictive and Mental Disorders Division, the Superintendent/Administrator, and the Director of Nursing, were notified that an Immediate Jeopardy existed in the area of F755 (§483.45.) Severity and Scope identified for the Immediate Jeopardy was identified to be… […]
- Actual harm, isolatedF692Jul 30, 2025
Based on observation, interview, and record review, the facility failed to identify two areas of concern, which were contributing factors for a resident's severe weight loss of 11.86% over 3 months, which included the resident's increased sedation [sleeping through meals], and the resident had an ADL decline. The facility did not address the two contributing factors timely manner, in an attempt to intervene and prevent the severe loss, for 1 (#1) of 14 sampled residents. Findings include:During an interview on 7/29/25 at 2:35 p.m., staff member O stated that when resident #1 was first admitted , he was very agitated. Now the resident had stabilized on his medications and was more mellow, and maybe he had a little bit of a decline. […]
Read 37 findings in full →The most serious and the most recent: 37 of 133 on record.
Every survey on record
FindingsAt actual harm or above
- Nov 19, 2025Complaint4 findings
- Jul 30, 2025Complaint3 findings · 1 harm
- Oct 24, 2024Standard and complaint8 findings
- Apr 9, 2024Complaint3 findings
- Nov 8, 2023Standard and complaint6 findings
- Aug 16, 2023Complaint3 findings · 1 harm
- Jan 19, 2023Complaint12 findings
- Aug 18, 2022Standard10 findings · 1 harm
Show the 13 earlier surveys
- Aug 4, 2021Standard and complaint7 findings
- Mar 18, 2021Complaint4 findings · 4 harm
- May 13, 2020Infection control1 finding
- Apr 18, 2019Standard5 findings
- Jul 19, 2018Complaint4 findings
- Feb 22, 2018Standard18 findings · 6 harm
- Jun 23, 2017Complaint7 findings · 3 harm
- Sep 1, 2016Standard6 findings
- Jun 18, 2015Standard2 findings
- Apr 10, 2014Standard7 findings · 2 harm
- Feb 28, 2013—4 findings
- Feb 16, 2012—4 findings
- Jan 6, 2011—15 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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