Montrose Health Center

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with severely impaired cognition remained free from a burn from hot liquids when the resident sustained a second degree burn (involving the first two layers of skin) to the thigh from a hot beverage believed to have occurred on 7/8/24, and had a second hot liquid spill from a beverage on 9/17/24 resulting in redness to the skin for one of four residents reviewed for accidents (Resident #11). This deficient practice resulted in tenderness of burn area and documented voiced discomfort during treatment. The facility reported a census of 36 residents.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on clinical record review, resident interview, staff interviews, and facility policy review, the facility failed to appropriately provide assessment and interventions for the necessary care and services during a change in condition for 2 of 3 residents (Resident #3 and #6) reviewed for condition change. The facility failed to promptly identify change in respiratory condition and intervene in a timely manner for a resident with known history of chronic obstructive pulmonary disease (COPD) and respiratory failure. (Resident #6) found unresponsive with no palpable carotid or radial pulse and required emergency transport to the hospital. Resident #6 diagnosed with respiratory distress, respiratory syncytial virus (RSV) and respiratory failure with hypercapnia at hospital. [...]

Inspectors wroteBased on clinical record review, observations, and staff interviews the facility failed to prevent pressure ulcer development, failed to ensure accurate assessment of a pressure ulcer, and failed to implement timely interventions to prevent the development and worsening of a pressure ulcer for one of one resident reviewed for pressure ulcers (Resident #4). The facility reported a census of 36 residents.

Inspectors wroteBased on observation, resident interviews, provider interview, staff interviews, and clinical record review, the facility failed to identify and adequately treat pain related to an open ulcer on a residents right ankle during wound care for 1 of 2 residents (Resident #8) reviewed for pain management. The facility reported a census of 36 residents.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.