Deficiency Records for Montrose Springs Skilled Nursing and Wellness Center
Updated as of April 01, 2019
This is not the most recent data for Montrose Springs Skilled Nursing and Wellness Center. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-02-21 | 2019-02-26 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-02-15 | 2019-02-25 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-01-25 | 2019-01-31 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-09-11 | 2018-09-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-07-16 | 2018-07-23 | Y |
| 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 |
| 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 ne | 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 |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2018-05-24 | 2018-07-09 | Y |
| 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 |
| 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 | 2018-01-21 | 2018-02-05 | Y |
| Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. | Health | 2017-11-02 | 2017-11-10 | Y |
| Maintain comfortable and safe temperature levels. | Health | 2017-06-27 | 2017-07-18 | Y |
| Keep all essential equipment working safely. | Health | 2017-06-27 | 2017-07-18 | Y |
| Meet other general requirements. | Fire Safety | 2017-05-26 | 2017-06-19 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-05-26 | 2017-06-19 | N |
| Have exits that are accessible at all times. | Fire Safety | 2017-05-26 | 2017-06-19 | N |
| Install proper backup exit lighting. | Fire Safety | 2017-05-26 | 2017-06-19 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2017-05-26 | 2017-06-19 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2017-05-26 | 2017-06-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-05-26 | 2017-06-19 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2017-05-26 | 2017-06-19 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2017-05-26 | 2017-06-19 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-05-25 | 2017-06-19 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2017-05-25 | 2017-06-19 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2017-05-25 | 2017-06-19 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-05-25 | 2017-06-19 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-05-25 | 2017-06-19 | N |
| Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. | Health | 2017-05-25 | 2017-06-19 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-05-25 | 2017-06-19 | N |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2017-05-25 | 2017-06-19 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-05-25 | 2017-06-19 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-05-25 | 2017-06-19 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2017-05-25 | 2017-06-19 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-05-25 | 2017-06-19 | N |
| Meet other general requirements. | Fire Safety | 2017-01-17 | 2017-02-27 | Y |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2017-01-17 | 2017-02-27 | Y |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2017-01-17 | 2017-02-27 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-02-16 | 2017-02-24 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2016-12-29 | 2017-01-12 | Y |
| Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. | Health | 2016-12-29 | 2017-01-12 | Y |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2016-10-24 | 2016-11-01 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2016-10-17 | 2016-10-26 | Y |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2016-10-17 | 2016-10-26 | Y |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-10-17 | 2016-10-26 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-10-05 | 2016-10-10 | Y |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2016-08-12 | 2016-08-24 | Y |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2016-08-08 | 2016-08-16 | Y |
| Properly sized and located linen or trash receptacles. | Fire Safety | 2016-05-11 | 2016-06-06 | N |
| Proper facilities for the use and storage of combustible liquids. | Fire Safety | 2016-05-11 | 2016-06-06 | N |
| Weekly inspections and monthly testing of generators. | Fire Safety | 2016-05-11 | 2016-06-06 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2016-05-17 | 2016-06-06 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2016-05-17 | 2016-06-06 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2016-05-17 | 2016-06-06 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2016-05-17 | 2016-06-06 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-05-17 | 2016-06-06 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-05-17 | 2016-06-06 | N |
| Ensure that residents receive proper treatment and assistive devices to maintain their vision and hearing. | Health | 2016-05-17 | 2016-06-06 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2016-05-17 | 2016-06-06 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-05-17 | 2016-06-06 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2016-05-17 | 2016-06-06 | N |
| Give each resident enough fluids to keep them healthy and prevent dehydration. | Health | 2016-05-17 | 2016-06-06 | N |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2016-05-17 | 2016-06-06 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2016-05-17 | 2016-06-06 | N |
| Develop policies and procedures for influenza and pneumococcal immunizations. | Health | 2016-05-17 | 2016-06-06 | N |
| Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. | Health | 2016-05-17 | 2016-06-06 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-05-17 | 2016-06-06 | N |
| Give or get specialized rehabilitative services per the patient's assessment or plan of care. | Health | 2016-05-17 | 2016-06-06 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2016-05-17 | 2016-06-06 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-05-17 | 2016-06-06 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-05-17 | 2016-06-06 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2016-05-17 | 2016-06-06 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2016-05-17 | 2016-06-06 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-05-17 | 2016-06-06 | N |
| Provide bedrooms that hold no more than 4 residents per room. | Health | 2017-05-25 | Not Fixed | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2017-05-25 | Not Fixed | N |
| Provide bedrooms that hold no more than 4 residents per room. | Health | 2016-05-17 | Not Fixed | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2016-05-17 | Not Fixed | N |
