Montezuma Specialty Care

Based on observation, clinical record review, policy review, and staff interview, the facility failed to maintain adequate kitchen sanitation for 2 of 2 observations of the kitchen. The facility reported a census of 31 residents. Findings: Observations on 4/21/2026 at 10:29 a.m. revealed the following concerns:a. Small plates and dishes placed face down in a cupboard covered with heavy crumbs.b. Cabinets on the left side and back wall of the kitchen sticky to the touch. The cabinets were partially covered with red and dark colored splatters and food debris.c. Styrofoam plates sat in a cupboard on a coating of heavy dust.d. Twelve large serving scoops sat in a layer of heavy crumbs and food debris in the 3rd drawer on the right of the entry door.e. Seven serving scoops sat in a layer of heavy crumbs and food debris in the 4th drawer on the right of the entry door.f. Multiple serving scoops sat in a layer of heavy crumbs in the 5th drawer on the right of the entry door.g. Fifteen plus slotted serving spoons sat in crumbs and red droplets in the 7th drawer on the right of the entry…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, policy review, and staff and resident interviews, the facility failed to update the care plan to reflect a resident's exit seeking behavior for 1 of 12 residents reviewed for care plans (Resident #6). The facility reported a census of 31 residents. Findings included: The Minimum Data Set (MDS) assessment tool, dated 12/19/25, listed diagnoses for Resident #6 which included non-Alzheimer's dementia, bipolar disorder, and depression. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 11 out of 15, indicating moderately impaired cognition. The facility policy Care Plans, Comprehensive Person-Centered, revised December 2016, stated the care plan would incorporate risk factors associated with identified problems.An 8/8/25 Encounter Note stated the resident expressed a strong desire to leave the care facility.A 2/17/26 Nurses Note stated the resident reported to a family member that she tried to remove the window in her room so she could get out. Inspection of the window revealed the resident removed a screw from the window…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interviews and policy review, the facility staff failed to administer oxygen in accordance with physician orders for 1 of 2 residents reviewed (Resident #5). The facility reported a census of 31 residents.The Minimum Data Set (MDS) dated [DATE] for Resident #5 revealed a diagnosis of an irregular heart beat and identified the use of continuous oxygen therapy. Resident #5 had a Brief Interview for Mental Status score of 15 out of 15, which indicated intact cognition. During an observation on 4/20/2026 at 2:18 pm, Resident #5 was in her recliner with oxygen (O2) tube in her nose, the oxygen concentrator was set on 1-liter, and she took deep breaths while relaxing in her recliner.During an observation on 4/21/2026 at 9:05 am, Resident #5 sat in the dining room for breakfast and the portable oxygen tank level indicator not to be in red area, which indicated the tank had an inadequate to no supply of oxygen. Resident #5 was unaware that the O2 tank was not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, clinical record review, resident and staff interviews, the facility staff failed to hold the anticoagulant (blood thinning) medication as ordered by the surgeon that resulted in the delay of a scheduled surgery for 1 of 1 resident's reviewed (Resident #31). The facility reported a census of 31 residents.The Minimum Data Set (MDS) for Resident #31 revealed a diagnosis of atrial fibrillation (a dysrhythmia of the heart) and received an anticoagulant. The Physician Orders for Resident #31 revealed an order for Apixaban (Eliquis) 5 milligram (mg) twice a day, Obtain X-ray of right knee and a referral to orthopedic doctor for a follow up on right knee pain and swelling. The X-ray results dated 3/30/26 for Resident #31revealed a dislocation of the knee joint and a bone fragment concerning for a fracture.A document titled Orthopedic Surgeons dated 4/3/26 for Resident #31 revealed the following:a. A surgical intervention would be necessary for the right dislocated knee.b. The blood thinner must be stopped five days before surgery or the patient can't have anesthesia.c.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, written staff statements, policy review, and staff and resident interviews, the facility failed to ensure residents were treated with respect and dignity for 4 out of 12 residents reviewed for dignity(Residents #6, #8, #11, #12). The facility reported a census of 28 residents. Findings: 1. The Minimum Data Set (MDS) assessment tool, dated 8/21/24, listed diagnoses for Resident #8 which included heart failure, diabetes, and anxiety. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. Care Plan entries, dated 8/18/22, stated the resident had impaired cognitive function/dementia or impaired thought processes related to schizophrenia and directed staff to face her when speaking and keep her routine consistent in order to decrease confusion. 2. The MDS assessment tool, dated 7/15/24, listed diagnoses for Resident #12 which included non-Alzheimer's dementia, anxiety, and depression. The MDS listed the resident's BIMS score as 12 out of 15, indicating moderately impaired cognition. Care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, written staff statements, policy review, and staff and resident interviews, facility administration failed to follow-up on concerns with staff treatment of residents for 4 out of 12 residents reviewed for dignity (Residents #6, #8, #11, #12). The facility reported a census of 28 residents. Findings: 1. The Minimum Data Set (MDS) assessment tool, dated 8/21/24, listed diagnoses for Resident #8 which included heart failure, diabetes, and anxiety. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. Care Plan entries, dated 8/18/22, stated the resident had impaired cognitive function/dementia or impaired thought processes related to schizophrenia and directed staff to face her when speaking and keep her routine consistent in order to decrease confusion. 2. The MDS assessment tool, dated 7/15/24, listed diagnoses for Resident #12 which included non-Alzheimer's dementia, anxiety, and depression. The MDS listed the resident's BIMS score as 12 out of 15, indicating moderately impaired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of Quality Assurance and Performance Improvement (QAPI) meeting documentation, policy review, and staff interview, the facility failed to carry out Quality Assurance (QA) activities to obtain feedback, use data, and take action to conduct structured, systematic investigations and analysis of underlying causes or contributing factors of problems affecting facility-wide processes that impact quality of care, quality of life, and resident safety. The facility reported a census of 28 residents. Findings: The Centers for Medicare and Medicaid Services (CMS) 2567, dated 5/9/24, listed, in part, the following concern: F550. The current survey, conducted 10/1/24-10/3/24 also identified the above concern. Review of QAPI/QA documentation from 1/1/24 to 10/3/24 revealed the facility lacked documentation of QAPI/QA program activities related to resident treatment or dignity concerns. The facility lacked evidence of an ongoing QAPI program related to the above areas including a process of addressing how the committee would conduct the activities necessary to identify and correct…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, resident and staff interviews, the facility failed to provide the diet as ordered for 1 of 2 residents reviewed for nutrition (Resident #28). The facility did not provide double the protein for Resident #28 as recommended by the Registered Dietitian (RD) and as per the physician order. The facility reported a census of 31 residents. Findings include: The Annual Minimum Data Set (MDS) dated [DATE] for Resident #28 revealed a diagnosis of hyponatremia, chronic obstructive pulmonary disease (COPD), pulmonary embolism (blood clot in lung), and osteoarthritis. The MDS identified Resident #28 was at risk for the development of pressure injuries, and was on a therapeutic diet. Resident #28 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated an intact cognition. The Care Plan for Resident #28 directed staff to provide and serve the diet as ordered for a Nutritional Interventions Program (NIP) with double protein two times a day (BID) with initiated date of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, resident interview and Facility Assessment the facility failed to ensure safe transport of resident in a wheelchair for 1 of 3 resident reviewed. (Resident #18). The facility reported a census of 31. Findings include: The admission Minimum Data Set (MDS) for Resident #18 dated 4/10/24 revealed resident scored 13 on a Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS revealed diagnoses of arthritis, osteoporosis, cerebrovascular accident (CVA) referring to stroke and fracture of right humorous. The MDS documented the resident normally used a manual wheelchair for a mobility device, with dependence on staff to operate the wheelchair. The Care plan initiated 4/6/24 documented resident continued to work with therapy, recent fall with fractured humorous. Resident #18 to use a wheel chair for mobility, non-weight bearing to right upper extremity, sling to right upper extremity at all times and required assist of one related to recent fracture. Observation on 5/28/24 at 10:45 AM revealed Staff#C, Certified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, policy review, and resident and staff interviews, the facility failed to treat 2 of 9 residents reviewed for resident rights with dignity (Resident #5 and #11) by failing to assist residents with the bedpan and/or incontinent care and instructing them to urinate/defecate in their incontinent briefs. The facility reported a census of 31 residents. Findings include: 1. The admission Minimum Data Set(MDS) assessment tool, dated 4/24/24, listed diagnoses for Resident #5 which included tibia(a lower leg bone) fracture, weakness, and difficulty walking, and stated the resident required substantial/maximal assistance for toilet transfers and was dependent on staff for toileting hygiene. The MDS listed her Brief Interview for Mental Status(BIMS) score as 15 out of 15, which indicated intact cognition. Care Plan entries, dated 4/18/24, stated the resident required the assistance of 1 staff for toileting and personal hygiene. A 4/19/24 1:38 p.m., Nurses Note documented the resident admitted to the facility following a right ankle fracture and would complete…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, policy review, and resident and staff interviews, the facility failed to report an allegation of abuse (a staff member allegedly failed to assist a resident with the bedpan and/or incontinent care and instructed her to urinate/defecate in her incontinent brief) for 1 of 1 residents reviewed for an allegation of abuse(Resident #5). The facility reported a census of 31 residents. Findings included: 1. The admission Minimum Data Set (MDS) assessment tool, dated 4/24/24, listed diagnoses for Resident #5 which included tibia (a lower leg bone) fracture, weakness, and difficulty walking, and stated the resident required substantial/maximal assistance for toilet transfers and was dependent on staff for toileting hygiene. The MDS listed her Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. Care Plan entries, dated 4/18/24, stated the resident required the assistance of 1 staff for toileting and personal hygiene. A 4/19/24 Nurses Note stated the resident admitted to the facility following a right ankle fracture and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, policy review, and resident and staff interviews, the facility failed to investigate an allegation of abuse (a staff member allegedly failed to assist a resident with the bedpan and/or incontinent care and instructed her to urinate/defecate in her incontinent brief) and ensure protection from further abuse for 1 of 1 residents reviewed for an allegation of abuse(Resident #5). The facility reported a census of 31 residents. Findings include: 1. The Minimum Data Set(MDS) assessment tool, dated 4/24/24, listed diagnoses for Resident #5 which included tibia(a lower leg bone) fracture, weakness, and difficulty walking, and stated the resident required substantial/maximal assistance for toilet transfers and was dependent on staff for toileting hygiene. The MDS listed her Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. Care Plan entries, dated 4/18/24, stated the resident required the assistance of 1 staff for toileting and personal hygiene. A 4/19/24 Nurses Note stated the resident admitted to the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, policy review, and staff interview, the facility failed to create interventions based on root cause analysis of falls in order to prevent future falls for 1 of 4 residents reviewed for falls(Resident #4). The facility reported a census of 31 residents. Findings include: The admission Minimum Data Set(MDS) assessment tool, dated 2/9/24, listed diagnoses for Resident #4 which included pelvic fracture, non-Alzheimer's dementia, and heart failure, and stated the resident depended on staff for transfers and toilet transfers but did not walk due to a medical condition or safety concerns. The MDS documented the resident had a fracture related to a fall within the last 6 months and stated the resident's cognition was severely impaired. The MDS stated the resident was admitted to the facility on [DATE]. An untitled Hospital Report, dated 2/4/24, documented the resident sustained a fracture of the left greater trochanter(the upper part of the thigh bone) and a fracture of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.