A list of the most recent deficiencies for Montrose Healthcare 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 services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-16 | 2023-08-28 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-07-07 | 2023-07-17 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-02-07 | 2023-03-13 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-04 | 2022-05-27 | 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 | 2022-05-04 | 2022-05-27 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-05-04 | 2022-05-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-04 | 2022-05-27 | 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 | 2022-05-04 | 2022-05-27 | 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 | 2022-05-04 | 2022-05-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-04 | 2022-05-27 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-05-04 | 2022-05-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-04 | 2022-05-27 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-05-04 | 2022-05-27 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-05-05 | 2022-05-27 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-05-05 | 2022-05-27 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-05-05 | 2022-05-27 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-05-05 | 2022-05-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-05 | 2022-05-27 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2022-05-05 | 2022-05-27 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-03-04 | 2022-03-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-06 | 2021-12-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-29 | 2021-10-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-10 | 2021-09-20 | 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 | 2019-09-15 | 2019-10-08 | 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 | 2019-09-15 | 2019-10-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-15 | 2019-10-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-15 | 2019-10-08 | 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 | 2019-09-15 | 2019-10-08 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-09-15 | 2019-10-08 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-09-15 | 2019-10-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-15 | 2019-10-08 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-09-15 | 2019-10-08 | 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 | 2019-09-15 | 2019-10-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-15 | 2019-10-08 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-09-15 | 2019-10-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-15 | 2019-10-08 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-09-15 | 2019-10-08 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-09-15 | 2019-10-07 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-09-15 | 2019-10-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-15 | 2019-10-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-09-15 | 2019-10-07 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-10-03 | 2018-11-07 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-10-03 | 2018-11-07 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-10-03 | 2018-11-07 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-10-03 | 2018-11-07 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-10-03 | 2018-11-07 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-10-03 | 2018-11-07 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-10-03 | 2018-11-07 | N |
| Meet other general requirements. | Fire Safety | 2018-10-03 | 2018-11-07 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-09-27 | 2018-10-26 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-09-27 | 2018-10-26 | 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 | 2018-09-27 | 2018-10-26 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-09-27 | 2018-10-26 | 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 | 2018-09-27 | 2018-10-26 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-09-27 | 2018-10-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-09-27 | 2018-10-26 | 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 | 2018-09-27 | 2018-10-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-09-27 | 2018-10-26 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-09-27 | 2018-10-26 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-09-27 | 2018-10-26 | 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 | 2018-09-27 | 2018-10-26 | 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 | 2018-09-27 | 2018-10-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-09-27 | 2018-10-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-27 | 2018-10-26 | N |
