Montrose Health Center

In the surveyor’s words

From the most serious findings on record at Montrose Health Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Apr 25, 2024

  Based on clinical record review, resident interview, staff interviews, and facility policy review, the facility failed to appropriately provide assessment and interventions for the necessary care and services during a change in condition for 2 of 3 residents (Resident #3 and #6) reviewed for condition change. The facility failed to promptly identify change in respiratory condition and intervene in a timely manner for a resident with known history of chronic obstructive pulmonary disease (COPD) and respiratory failure. (Resident #6) found unresponsive with no palpable carotid or radial pulse and required emergency transport to the hospital. Resident #6 diagnosed with respiratory distress, respiratory syncytial virus (RSV) and respiratory failure with hypercapnia at hospital. […]

• Immediate jeopardy, isolatedF689Nov 9, 2022

  Based on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to identify the causal factors of falls to implement appropriate interventions to prevent further falls and evaluate the current fall interventions for effectiveness for 1 (Resident #25) of 3 residents reviewed for falls. Resident #25 sustained 46 falls from 11/02/21 through 11/02/22. This failure resulted in the resident sustaining falls with injuries including a fractured right ankle on 1/10/22, a small hematoma on the back of the head on 1/15/22, and a fractured hip on 1/20/22. […]

• Actual harm, isolatedF689Sep 19, 2024

  Based on observation, interview, and record review the facility failed to ensure a resident with severely impaired cognition remained free from a burn from hot liquids when the resident sustained a second degree burn (involving the first two layers of skin) to the thigh from a hot beverage believed to have occurred on 7/8/24, and had a second hot liquid spill from a beverage on 9/17/24 resulting in redness to the skin for one of four residents reviewed for accidents (Resident #11). This deficient practice resulted in tenderness of burn area and documented voiced discomfort during treatment. The facility reported a census of 36 residents. […]

• Actual harm, isolatedF686Apr 25, 2024

  Based on clinical record review, observations, and staff interviews the facility failed to prevent pressure ulcer development, failed to ensure accurate assessment of a pressure ulcer, and failed to implement timely interventions to prevent the development and worsening of a pressure ulcer for one of one resident reviewed for pressure ulcers (Resident #4). The facility reported a census of 36 residents. Findings include: Review of the Minimum Data Set (MDS) assessment for Resident #4 dated 11/16/23 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated intact cognition. […]

• Actual harm, isolatedF697Apr 25, 2024

  Based on observation, resident interviews, provider interview, staff interviews, and clinical record review, the facility failed to identify and adequately treat pain related to an open ulcer on a residents right ankle during wound care for 1 of 2 residents (Resident #8) reviewed for pain management. The facility reported a census of 36 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Diagnoses included: atherosclerosis of native arteries of right leg with ulceration, non-pressure chronic ulcer of right ankle with fat layer exposed, and arthritis. […]