Montezuma Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Montezuma Health and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF656Nov 30, 2023

  Based on interviews and record reviews, the facility failed to ensure that the care plan was followed for Activities of Daily Living (ADL) ensuring that care was provided by the appropriate number of staff, to prevent accidents, for one resident (R3), and that the care plan for wound treatments was followed related to treatments being provided as ordered by the physican, for one resident (R5), from a total sample of eight residents. Actual harm was identified to have occurred on 10/9/2023, when a Certified Nursing Assistant (CNA) provided ADL care to R3 by herself, instead of with the required two-person assistance. R3 fell from the bed and sustained a hematoma to the right side of the face. Findings include: 1. […]

• Actual harm, isolatedF689Nov 30, 2023

  Based on interviews and record reviews, the facility failed to ensure that Activities of Daily Living (ADL) care was provided by the appropriate number of staff, to prevent accidents, for one resident (R3), from a total sample of eight residents. Actual harm was identified to have occurred on 10/9/2023, when a Certified Nursing Assistant (CNA) EE provided ADL care to R3 by herself, instead of with the required two-person assistance. R3 fell from the bed and sustained a hematoma to the right side of the face. Findings include: Review of the clinical record for R3 revealed that she was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, Alzheimer's, cerebral infarction, and age-related osteoporosis. […]

• No harm, potential for more than minimal, widespreadF812Jul 2, 2023

  Based on observation, staff interviews, and a review of the facility's policy titled, Cleaning and Sanitizing, the facility failed to demonstrate the proper procedure to wash dishware in the three compartment sink to prevent food borne illness. The facility census was 69, with 67 residents consuming an oral diet. Findings include: Review of the facility policy titled Cleaning and Sanitizing revealed that for three compartment sink, items should be fully submerged in the sanitizer solution per manufacturer guidelines. Review of EcoLab Oasis 146 Multi-Quat Sanitizer Product Specification Document revealed: Expose all surfaces to the sanitizing solution for a period of not less than one minute. Observation on 7/1/2023 at 10:40 a.m. […]

• No harm, potential for more than minimal, patternF812Jan 18, 2026

  Based on observations, interview, and the policy titled Storage Areas, the facility failed to ensure food items were properly labeled, dated, and stored under sanitary conditions to prevent foodborne illness. The deficient practice had the potential to affect all 68 residents. Findings include:Review of the policy titled Storage Areas, dated 12/27/2024, documented under Guideline: Items should be covered, sealed, labeled and dated appropriately.The initial kitchen tour with the Dietary Manager (DM) on 1/16/2026 from 8:15 AM through 8:43 AM revealed the following concerns:Reach-in freezer contained a box of turkey sausage patties, and traditional cinnamon roll dough that were not labeled or dated. […]

• No harm, potential for more than minimal, patternF761Jul 2, 2023

  Based on observations, staff interviews, and a review of the facility's policies titled Medication Storage in the Care Center, and Insulin Administration, a review of latanoprost ophthalmic solutions manufacturer packet insert, the facility failed to ensure drugs and biologicals used in the facility were labeled and stored properly for four of five medication carts (South Hall Certified Medication Aide (CMA) cart one, South Hall Nurse cart, South Hall CMA cart two, and North Hall Nurse cart). Findings include: A review of the policy titled Medication Storage in the Care Center, revealed the intent was to ensure medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. […]