Montezuma Specialty Care

In the surveyor’s words

From the most serious findings on record at Montezuma Specialty Care, in the surveyor’s own words.

• Actual harm, isolatedF684Jan 3, 2023

  Based on observation, record review, staff and family interviews, the facility failed to provide adequate assessment and timely intervention for 1 of 4 residents reviewed (Resident #3). On 9/2/22 at 12:15 a.m. Resident #3 had an unwitnessed fall to the floor and was found face down with a hematoma (a mass of blood that forms in tissue as a result of a broken blood vessel) on the left side of her forehead and swelling to the left eye. Facility staff initiated Neurological checks but failed to complete as scheduled and failed to notify the provider. Resident #2 had a Neurological check at 4:00 a.m., but staff failed to complete the next check scheduled at 12 Noon. The next Neurological assessment was completed at 6:00 p.m., 14 hours after the 4:00 a.m. check. […]

• No harm, potential for more than minimal, widespreadF812Apr 23, 2026

  Based on observation, clinical record review, policy review, and staff interview, the facility failed to maintain adequate kitchen sanitation for 2 of 2 observations of the kitchen. The facility reported a census of 31 residents. Findings: Observations on 4/21/2026 at 10:29 a.m. revealed the following concerns:a. Small plates and dishes placed face down in a cupboard covered with heavy crumbs.b. Cabinets on the left side and back wall of the kitchen sticky to the touch. The cabinets were partially covered with red and dark colored splatters and food debris.c. Styrofoam plates sat in a cupboard on a coating of heavy dust.d. Twelve large serving scoops sat in a layer of heavy crumbs and food debris in the 3rd drawer on the right of the entry door.e. […]

• No harm, potential for more than minimal, patternF550Oct 3, 2024

  Based on clinical record review, written staff statements, policy review, and staff and resident interviews, the facility failed to ensure residents were treated with respect and dignity for 4 out of 12 residents reviewed for dignity(Residents #6, #8, #11, #12). The facility reported a census of 28 residents. Findings: 1. The Minimum Data Set (MDS) assessment tool, dated 8/21/24, listed diagnoses for Resident #8 which included heart failure, diabetes, and anxiety. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. […]

• No harm, potential for more than minimal, patternF835Oct 3, 2024

  Based on clinical record review, written staff statements, policy review, and staff and resident interviews, facility administration failed to follow-up on concerns with staff treatment of residents for 4 out of 12 residents reviewed for dignity (Residents #6, #8, #11, #12). The facility reported a census of 28 residents. Findings: 1. The Minimum Data Set (MDS) assessment tool, dated 8/21/24, listed diagnoses for Resident #8 which included heart failure, diabetes, and anxiety. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. […]

• No harm, potential for more than minimal, patternF865Oct 3, 2024

  Based on review of Quality Assurance and Performance Improvement (QAPI) meeting documentation, policy review, and staff interview, the facility failed to carry out Quality Assurance (QA) activities to obtain feedback, use data, and take action to conduct structured, systematic investigations and analysis of underlying causes or contributing factors of problems affecting facility-wide processes that impact quality of care, quality of life, and resident safety. The facility reported a census of 28 residents. Findings: The Centers for Medicare and Medicaid Services (CMS) 2567, dated 5/9/24, listed, in part, the following concern: F550. The current survey, conducted 10/1/24-10/3/24 also identified the above concern. […]