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| Deficiency Category | Inspection Date: 11/13/24 Complaint Reporting Period: 4/1/24 - 3/31/25 | Inspection Date: 11/1/23 Complaint Reporting Period: 4/1/23 - 3/31/24 | Inspection Date: 1/9/23 Complaint Reporting Period: 4/1/22 - 3/31/23 |
|---|---|---|---|
| Emergency Preparedness Deficiencies | |||
| Automatic Sprinkler Systems Deficiencies | |||
| Building Construction Deficiencies | |||
| Services Deficiencies | |||
| Corridor Walls and Doors Deficiencies | |||
| Egress Deficiencies | |||
| Electrical Deficiencies | |||
| Emergency Plans and Fire Drills Deficiencies | |||
| Fire Alarm Systems Deficiencies | |||
| Smoke Deficiencies | |||
| Interior Finish Deficiencies | |||
| Gas, Vacuum, and Electrical Systems Deficiencies | |||
| Hazardous Area Deficiencies | |||
| Illumination and Emergency Power Deficiencies | |||
| Laboratories Deficiencies | |||
| Medical Gases and Anesthetizing Areas Deficiencies | |||
| Smoking Regulations Deficiencies | |||
| Miscellaneous Deficiencies |
| Total number of Fire Safety & Emergency Preparedness Deficiencies for this nursing home: | |
| Average number of Fire Safety & Emergency Preparedness Deficiencies in Montana: | |
| Average number of Fire Safety & Emergency Preparedness Deficiencies in the United States: |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Develop and maintain an Emergency Preparedness Program (EP). | 11/13/24 | 12/31/24 | 2 - Minimal harm or potential for actual harm | Many |
List the names and contact information of those in the facility. | 11/13/24 | 12/31/24 | 2 - Minimal harm or potential for actual harm | Many |
Provide emergency officials' contact information. | 11/13/24 | 12/31/24 | 2 - Minimal harm or potential for actual harm | Many |
Conduct testing and exercise requirements. | 11/13/24 | 12/31/24 | 2 - Minimal harm or potential for actual harm | Many |
| No Automatic Sprinkler Systems Deficiencies were found during this inspection period. |
| No Building Construction Deficiencies were found during this inspection period. |
| No Services Deficiencies were found during this inspection period. |
| No Corridor Walls and Doors Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Have properly located and lighted "Exit" signs. | 11/13/24 | 12/31/24 | 2 - Minimal harm or potential for actual harm | Few |
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | 11/13/24 | 12/31/24 | 2 - Minimal harm or potential for actual harm | Few |
Install emergency lighting that can last at least 1 1/2 hours. | 11/13/24 | 12/31/24 | 2 - Minimal harm or potential for actual harm | Few |
| No Electrical Deficiencies were found during this inspection period. |
| No Emergency Plans and Fire Drills Deficiencies were found during this inspection period. |
| No Fire Alarm Systems Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide properly protected cooking facilities. | 11/13/24 | 12/31/24 | 2 - Minimal harm or potential for actual harm | Few |
Install an approved automatic sprinkler system. | 11/13/24 | 12/31/24 | 2 - Minimal harm or potential for actual harm | Few |
Have approved installation, maintenance and testing program for fire alarm systems. | 11/13/24 | 12/31/24 | 2 - Minimal harm or potential for actual harm | Many |
Inspect, test, and maintain automatic sprinkler systems. | 11/13/24 | 12/31/24 | 2 - Minimal harm or potential for actual harm | Many |
Properly select, install, inspect, or maintain portable fire extinguishes. | 11/13/24 | 12/31/24 | 2 - Minimal harm or potential for actual harm | Some |
| No Interior Finish Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 11/13/24 | 12/31/24 | 2 - Minimal harm or potential for actual harm | Some |
Meet requirements for the installation and maintenance of electrical systems. | 11/13/24 | 12/31/24 | 2 - Minimal harm or potential for actual harm | Few |
Have generator or other power source capable of supplying service within 10 seconds. | 11/13/24 | 12/31/24 | 2 - Minimal harm or potential for actual harm | Many |
Have proper medical gas storage and administration areas. | 11/13/24 | 12/31/24 | 2 - Minimal harm or potential for actual harm | Few |
| No Hazardous Area Deficiencies were found during this inspection period. |
| No Illumination and Emergency Power Deficiencies were found during this inspection period. |
| No Laboratories Deficiencies were found during this inspection period. |
| No Medical Gases and Anesthetizing Areas Deficiencies were found during this inspection period. |
| No Smoking Regulations Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Have simulated fire drills held at unexpected times. | 11/13/24 | 12/31/24 | 2 - Minimal harm or potential for actual harm | Many |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 11/13/24 | 12/31/24 | 2 - Minimal harm or potential for actual harm | Many |
| Total number of Fire Safety & Emergency Preparedness Deficiencies for this nursing home: | |
| Average number of Fire Safety & Emergency Preparedness Deficiencies in Montana: | |
| Average number of Fire Safety & Emergency Preparedness Deficiencies in the United States: |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
List the names and contact information of those in the facility. | 11/1/23 | 11/25/23 | 2 - Minimal harm or potential for actual harm | Many |
Establish staff and initial training requirements. | 11/1/23 | 11/25/23 | 2 - Minimal harm or potential for actual harm | Many |
Conduct testing and exercise requirements. | 11/1/23 | 11/30/23 | 2 - Minimal harm or potential for actual harm | Many |
| No Automatic Sprinkler Systems Deficiencies were found during this inspection period. |
| No Building Construction Deficiencies were found during this inspection period. |
| No Services Deficiencies were found during this inspection period. |
| No Corridor Walls and Doors Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Keep aisles, corridors, and exits free of obstruction in case of emergency. | 11/1/23 | 11/22/23 | 2 - Minimal harm or potential for actual harm | Some |
Meet other general requirements that are deficient. | 11/1/23 | 11/25/23 | 2 - Minimal harm or potential for actual harm | Some |
| No Electrical Deficiencies were found during this inspection period. |
| No Emergency Plans and Fire Drills Deficiencies were found during this inspection period. |
| No Fire Alarm Systems Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide properly protected cooking facilities. | 11/1/23 | 11/25/23 | 2 - Minimal harm or potential for actual harm | Many |
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 11/1/23 | 11/25/23 | 2 - Minimal harm or potential for actual harm | Some |
Inspect, test, and maintain automatic sprinkler systems. | 11/1/23 | 11/25/23 | 2 - Minimal harm or potential for actual harm | Many |
Install corridor and hallway doors that block smoke. | 11/1/23 | 11/25/23 | 2 - Minimal harm or potential for actual harm | Some |
| No Interior Finish Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Have generator or other power source capable of supplying service within 10 seconds. | 11/1/23 | 11/25/23 | 2 - Minimal harm or potential for actual harm | Many |
Ensure that testing and maintenance of electrical equipment is performed. | 11/1/23 | 11/25/23 | 2 - Minimal harm or potential for actual harm | Some |
| No Hazardous Area Deficiencies were found during this inspection period. |
| No Illumination and Emergency Power Deficiencies were found during this inspection period. |
| No Laboratories Deficiencies were found during this inspection period. |
| No Medical Gases and Anesthetizing Areas Deficiencies were found during this inspection period. |
| No Smoking Regulations Deficiencies were found during this inspection period. |
| No Miscellaneous Deficiencies were found during this inspection period. |
| Total number of Fire Safety & Emergency Preparedness Deficiencies for this nursing home: | |
| Average number of Fire Safety & Emergency Preparedness Deficiencies in Montana: | |
| Average number of Fire Safety & Emergency Preparedness Deficiencies in the United States: |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Conduct testing and exercise requirements. | 1/9/23 | 2/2/23 | 2 - Minimal harm or potential for actual harm | Many |
| No Automatic Sprinkler Systems Deficiencies were found during this inspection period. |
| No Building Construction Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Have properly installed electrical wiring and gas equipment. | 1/9/23 | 2/2/23 | 2 - Minimal harm or potential for actual harm | Many |
Enure that solid fuel-burning fireplaces are not in patient sleeping areas. | 1/9/23 | 2/2/23 | 2 - Minimal harm or potential for actual harm | Many |
| No Corridor Walls and Doors Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Keep aisles, corridors, and exits free of obstruction in case of emergency. | 1/9/23 | 2/2/23 | 2 - Minimal harm or potential for actual harm | Some |
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | 1/9/23 | 2/2/23 | 2 - Minimal harm or potential for actual harm | Many |
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | 1/9/23 | 2/2/23 | 2 - Minimal harm or potential for actual harm | Some |
| No Electrical Deficiencies were found during this inspection period. |
| No Emergency Plans and Fire Drills Deficiencies were found during this inspection period. |
| No Fire Alarm Systems Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Install corridor and hallway doors that block smoke. | 1/9/23 | 2/2/23 | 2 - Minimal harm or potential for actual harm | Some |
Install an approved automatic sprinkler system. | 1/9/23 | 2/2/23 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1/9/23 | 2/2/23 | 2 - Minimal harm or potential for actual harm | Some |
Inspect, test, and maintain automatic sprinkler systems. | 1/9/23 | 2/2/23 | 2 - Minimal harm or potential for actual harm | Many |
Properly select, install, inspect, or maintain portable fire extinguishes. | 1/9/23 | 2/2/23 | 2 - Minimal harm or potential for actual harm | Some |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | 1/9/23 | 2/2/23 | 2 - Minimal harm or potential for actual harm | Many |
| No Interior Finish Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Meet requirements for the installation and maintenance of electrical systems. | 1/9/23 | 2/2/23 | 2 - Minimal harm or potential for actual harm | Some |
Have power receptacles that are properly grounded. | 1/9/23 | 2/2/23 | 2 - Minimal harm or potential for actual harm | Some |
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 1/9/23 | 2/2/23 | 2 - Minimal harm or potential for actual harm | Many |
Have generator or other power source capable of supplying service within 10 seconds. | 1/9/23 | 2/2/23 | 2 - Minimal harm or potential for actual harm | Many |
Have proper medical gas storage and administration areas. | 1/9/23 | 2/2/23 | 2 - Minimal harm or potential for actual harm | Many |
| No Hazardous Area Deficiencies were found during this inspection period. |
| No Illumination and Emergency Power Deficiencies were found during this inspection period. |
| No Laboratories Deficiencies were found during this inspection period. |
| No Medical Gases and Anesthetizing Areas Deficiencies were found during this inspection period. |
| No Smoking Regulations Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Have simulated fire drills held at unexpected times. | 1/9/23 | 2/2/23 | 2 - Minimal harm or potential for actual harm | Many |
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | 1/9/23 | 2/2/23 | 2 - Minimal harm or potential for actual harm | Many |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 1/9/23 | 2/2/23 | 2 - Minimal harm or potential for actual harm | Many |
| This nursing home has not been cited for any deficiencies from incidents reported by the nursing home or complaints in the last 3 years. |