Montrose Health Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical record review, hospital record review, facility policy and staff interviews, the facility failed to ensure sufficient nursing staff available to meet the needs of a residents readmission after a hospitalization, delaying the residents return to the facility by three day for 1 of 3 residents (Resident #3) reviewed for hospitalizations. The facility reported a census of 37 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 scored a 12 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition moderately impaired. The MDS indicated medical diagnoses for chronic obstructive pulmonary disease with acute exacerbation, pneumonia, and respiratory failure.Review of the electronic health record (EHR) Census Report revealed Resident #3 status STOP BILLING effective 1/21/26, and as of 1/26/26 Active. Review of progress notes revealed a Health Status Note entered on 1/21/26 at 8:15 AM which documented this nurse was…

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 record review, observations, and staff interviews, the facility failed to administer the correct amount of fluid and liquid nutrition to a resident dependent on tube feeding for 1 of 1 residents (Resident #1) reviewed for tube feedings. The facility reported a census of 36 residents. Findings include: Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #1 scored a 13 out of 15 on the BIMS exam, which indicated cognition intact. The MDS list of diagnoses included transient ischemic attack, malnutrition, and dysphagia (difficulty swallowing) following cerebral infarction (stroke). The MDS indicated eating not attempted due to medical condition or safety concern. The MDS indicated resident utilized a feeding tube. Review of the Care Plan, Date Initiated 7/29/25, revealed a Focus area to address The resident requires PEG (a percutaneous endoscopic gastrostomy tube is a feeding tube inserted through the skin and stomach wall with an endoscope to deliver nutrition, fluids, 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 and staff interview the facility failed to ensure Minimum Data Set (MDS) assessments were submitted per required regulatory timeframe's for one of one resident reviewed for Resident Assessment Instrument Task (Resident #33). The facility reported a census of 36 residents. Findings include: Review of the Resident Assessment Task indicated Resident #33 had an MDS record over 120 days old. Review of the resident's MDS history revealed not all assessments documented as accepted and/or submitted. Review of Resident #33's census revealed the resident initially admitted to the facility 5/8/24, and discharged on 8/19/24. On 9/18/24 at 3:50 PM, the Nurse Consultant explained did not think got submitted, and was an oversight. The Nurse Consultant explained although assessment completed, did not change a question to yes (in system) which had auto-populated from a previous assessment, and now the assessment export ready and would be late to federal. Continued review of the resident's MDS assessments revealed the following Assessment Reference Date (ARD) and date…

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 interview, record review, and policy review, the facility failed to ensure resident care plans were revised following a resident's hot liquid spill with burn, failed to address a diagnosis of diabetes mellitus, and to accurately reflect insulin use related to steroid-induced hyperglycemia for three of twelve residents reviewed for care plans (Resident #11, Resident #26, Resident #139). The facility reported a census of 36 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment for Resident #11 dated 5/28/24 revealed the resident scored 06 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Per this assessment, the resident required set-up or cleanup assistance with eating. The Care Plan dated 2/9/22, revised 5/29/24, revealed the following: The resident with potential for altered nutritional status r/t (related to) PMH (past medical history) of bradycardia, hypothyroidism, weakness, HLD (hyperlipidemia), CKD (chronic kidney…

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 clinical record review, interview, and facility policy review the facility failed to ensure digoxin administered per Physician Order adhering to established parameters for one of six residents reviewed for medications (Resident #26). The facility reported a census of 36 residents. Findings include: Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #26 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. The Physician Order dated 2/13/24 revealed, Digoxin Tablet 125 MCG (microgram) with instructions to give 1 tablet by mouth one time a day for heart failure hold if pulse below 60. Review of Medication Administration Records (MARs) revealed the following dates and documented pulse rate when the resident received the medication outside of parameters: a. On 7/8/24 for 6:00 AM scheduled dose: pulse of 59, and medication documented as administered. b. On 8/14/24 at 6:00 AM scheduled dose: pulse of 55 and medication documented as…

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, staff interviews, clinical record review, and facility policy review the facility failed to ensure residents remained free from resident to resident altercations including one resident running their wheelchair over another resident's foot, and multiple instances of one resident hitting another resident and/or mutual hitting between residents for three of six residents reviewed for abuse (Resident #1, Resident #5, Resident #18, Resident #141). The facility reported a census of 36 residents. Findings include: 1. The Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating severe cognitive impairment. Diagnoses included: non-Alzheimer's dementia, depression, and cancer. The MDS revealed that both physical and verbal behaviors occurred on 1 to 3 days of the 7 day reference period. Resident #18 required anti-anxiety, anti-depressant, and antibiotic medications. The Care Plan, initiated 11/08/23, revealed a focus area for Resident…

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 clinical record review and staff interview, the facility failed to ensure accurate coding of pressure ulcers on the Minimum Data Set (MDS) assessment for one of six residents reviewed for MDS accuracy (Resident #4). The facility reported a census of 36 residents. Findings include: Review of the MDS assessment dated [DATE] revealed the resident scored 5 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Per this assessment, Resident # 4 was at risk to develop pressure ulcers/injuries, and did not have one or more unhealed pressure ulcers/injuries. The assessment also revealed the resident did not have venous or arterial ulcers present. Review of Census information for Resident #4 revealed the resident readmitted to the facility on [DATE]. The Nursing admission Screening/History V2 form for Resident #4 dated 1/15/24 revealed the following per the Skin section: a. The assessment documented a pressure area to the left toes, documented as stage II…

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, interview, and record review, the facility failed to ensure safety of residents when transporting residents without foot pedals during transport in a wheelchair for three of six residents reviewed for falls (Resident #7, Resident #9, Resident #92). The facility reported a census of 36 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #9 revealed the resident scored 14 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. The Care Plan dated 9/20/22, revised 2/14/24, documented, the resident at risk for falling r/t (related to) muscle weakness and edema. Observation on 4/22/24 at 8:26 AM revealed Staff A, Certified Nursing Assistant (CNA) assisted Resident #9 and pushed the resident in their wheelchair. The resident did not have foot pedals present to the wheelchair pushed in the wheelchair by staff. The resident had shoes present to their feet at the time of observation. Observation on 4/22/24…

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 staff interviews, provider interview, clinical record review, and hospital record review, the facility failed to identify and notify the provider in a timely manner, of changes in urine and catheter for 1 of 2 residents (Resident #8) reviewed for urinary catheter care. The facility reported a census of 36 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Diagnoses included: vesicointestinal fistula, neurogenic bladder, and renal insufficiency, renal failure, or End Stage Renal Disease (ESRD). Resident #8 required an indwelling catheter and dependent on staff assistance with transfers and toileting hygiene. The Care Plan, revised on 04/15/24, revealed a focus area for indwelling urinary catheter due to neurogenic bladder with a goal that Resident #8 will have catheter care managed appropriately by not exhibiting signs of infection or urethral trauma. The Care Plan instructed staff…

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, facility record review, staff interviews and facility procedure review the facility failed to ensure a resident received medications only prescribed to them for one of eight residents reviewed for medication administration (Resident #14), when staff administered Resident #14 medications prescribed to Resident #10. The facility reported a census of 36 residents. Findings include: 1.The Minimum Data Set (MDS) for Resident #14 dated 12/23/23 documented the resident scored 13 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Review of the Medication Error Report dated 1/23/24 at 3:05 PM documented the following description of error: Wrong meds given to resident. The Type of Error section marked wrong resident, and the Reason for Error section documented, Failure to identify resident. The Progress Note dated 1/23/24 at 4:28 PM documented, the resident received Risperdal 0.25 mg (milligram) (an antipsychotic medication), Atrovastatin 40 mg, Calcium plus Vitamin D 600-400 mg, Corlanor 5 mg, Depakote 250 mg, 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 training records review, staff interview, and facility assessment review, the facility failed to ensure training for communication and behavioral health occurred prior to a staff member working independently with residents for one of five employees reviewed for staff training (Staff D, Registered Nurse). The facility reported a census of 36 residents. Findings include: Review of a Hire and Termination list provided by the facility revealed Staff D, Registered Nurse, rehired to the facility on 8/8/23. Review of training records provided for Staff D revealed communication training completed 11/6/20, and behavioral health training completed 9/3/22. On 4/25/24 at 11:31 AM, proof of trainings provided on orientation for Staff D requested via email from the facility's Administrator. On 4/25/24 at 11:44 AM, the Administrator explained via email she did not have them. Review of the Facility assessment dated 1/2024 updated 2/13/24 did not include requirements for behavioral health or communications training for all employees.