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Deficiency Records for Montrose Springs Skilled Nursing and Wellness Center
A list of the most recent deficiencies for Montrose Springs Skilled Nursing and Wellness Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Montrose Springs Skilled Nursing and Wellness Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-07-19 | 2024-08-12 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2024-07-19 | 2024-08-12 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-07-19 | 2024-08-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-07-12 | 2024-08-05 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-07-12 | 2024-08-05 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-07-12 | 2024-08-05 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-07-12 | 2024-08-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-07-12 | 2024-08-05 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-07-12 | 2024-08-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-07-12 | 2024-08-05 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-07-12 | 2024-08-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-07-12 | 2024-08-05 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-07-12 | 2024-08-05 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-07-12 | 2024-08-05 | N |
| Post nurse staffing information every day. | Health | 2024-07-12 | 2024-08-05 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-07-12 | 2024-08-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-07-12 | 2024-08-05 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-07-12 | 2024-08-05 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-07-12 | 2024-08-05 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-07-12 | 2024-08-05 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-07-12 | 2024-08-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-07-12 | 2024-08-05 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2024-07-12 | 2024-08-05 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2024-07-12 | 2024-08-05 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-07-12 | 2024-08-05 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2024-05-17 | 2024-06-14 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-05-17 | 2024-06-14 | Y |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2024-05-10 | 2024-06-03 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2024-05-10 | 2024-06-03 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-04-09 | 2024-04-29 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2024-04-09 | 2024-04-29 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-09 | 2024-04-29 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-06 | 2024-03-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-06 | 2024-03-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-27 | 2024-03-20 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-29 | 2023-12-26 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-06-13 | 2023-06-29 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-06-02 | 2023-06-28 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-06-02 | 2023-06-28 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-07 | 2023-06-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-07 | 2023-06-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-07 | 2023-06-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-08 | 2022-10-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-21 | 2022-09-15 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-03-24 | 2022-04-26 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-03-24 | 2022-04-26 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-03-24 | 2022-04-26 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-03-24 | 2022-04-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-24 | 2022-04-26 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-03-24 | 2022-04-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-24 | 2022-04-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-24 | 2022-04-26 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-03-24 | 2022-04-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-24 | 2022-04-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-03-24 | 2022-04-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-24 | 2022-04-26 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-03-24 | 2022-04-26 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-03-24 | 2022-04-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-24 | 2022-04-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-24 | 2022-04-26 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-03-24 | 2022-04-26 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2022-03-24 | 2022-04-26 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-03-24 | 2022-04-26 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-03-07 | 2022-03-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-23 | 2022-02-25 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-23 | 2022-02-01 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-01-14 | 2022-01-20 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-05-02 | 2019-06-05 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2019-05-02 | 2019-06-05 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-05-03 | 2019-06-03 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-05-03 | 2019-06-03 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-05-03 | 2019-06-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-05-03 | 2019-06-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-03 | 2019-06-03 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-05-03 | 2019-06-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-05-03 | 2019-06-03 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-05-03 | 2019-06-03 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-05-03 | 2019-06-03 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-05-03 | 2019-06-03 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-05-03 | 2019-06-03 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2019-05-03 | 2019-06-03 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-05-03 | 2019-06-03 | N |
| Have policies on smoking. | Health | 2019-05-03 | 2019-06-03 | N |
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