Deficiency Records for Montrose Springs Skilled Nursing and Wellness Center
Updated as of March 01, 2024
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? |
|---|---|---|---|---|
| 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 |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2018-05-24 | 2018-07-09 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-05-24 | 2018-07-09 | 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 | 2018-05-24 | 2018-07-09 | 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 | 2018-05-24 | 2018-07-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-24 | 2018-07-09 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2018-05-24 | 2018-07-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-24 | 2018-07-09 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-05-24 | 2018-07-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-05-24 | 2018-07-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-05-24 | 2018-07-09 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2018-05-24 | 2018-07-09 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2018-05-24 | 2018-07-09 | 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 | 2018-05-24 | 2018-07-09 | 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 | 2018-05-24 | 2018-07-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-05-24 | 2018-07-09 | 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 | 2018-05-24 | 2018-07-09 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-05-24 | 2018-07-09 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2018-05-23 | 2018-06-18 | N |
| Provide emergency officials' contact information. | Fire Safety | 2018-05-23 | 2018-06-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-05-23 | 2018-06-18 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-05-23 | 2018-06-18 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-05-23 | 2018-06-18 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-05-23 | 2018-06-18 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-05-23 | 2018-06-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-05-23 | 2018-06-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-05-23 | 2018-06-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-05-23 | 2018-06-18 | N |
