Montrose Springs Skilled Nursing & Wellness Center

In the surveyor’s words

From the most serious findings on record at Montrose Springs Skilled Nursing & Wellness Center, in the surveyor’s own words.

• Actual harm, isolatedF600Mar 28, 2025

  Based on interview, and record review the facility failed to ensure one of three sampled residents (Residents 1) were free from physical abuse by Certified Nurse Assistant (CNA) 1 by failing to: 1. Protect Resident 1 when Responsible Party (RP) 1 observed CNA 1 being rough during Resident 1 ' s peri care (also known as perineal care, refers to the cleaning and maintenance of the genital and anal areas), on 3/14/2025 and informed CNA 1 to be gentler. RP 1 reported to the facility ' s Infection Preventionist (IP) Nurse witnessing CNA 1 was rough during Resident 1 ' s peri care and complained of vaginal pain on 3/14/2025. 2. […]

• Actual harm, isolatedF600Mar 12, 2025

  Based on observation, interviews, and record reviews, the facility failed to implement the facility's policy and procedure to prevent, protect, report timely and thoroughly investigate the any allegation of abuse for one or the three sampled residents (Resident 1) who reported to the facility on [DATE] that a certified nursing assistant who provided care to him during ADL (activities of daily living) was rough but dismissed his request even after he requested from the staff to be gentle due to his severe contractures (a fixed tightening of muscle, tendons, ligaments, or skin that prevents normal movement of the associated body part that result in pain) of the arms and legs. […]

• Actual harm, isolatedF635May 10, 2024

  Based on interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one of three sampled residents (Resident 1) with diagnosis of Diabetes Mellitus (DM, a chronic disease where a person has high blood sugar [glucose] levels because the body does not produce or use insulin [a type of hormone] normally and required blood sugar monitoring and/or medications to lower blood sugar levels) by failing to ensure to: 1. All appropriate discharge orders for diabetes management from the General Acute Care Hospital (GACH 1) were verified with the attending physician/Medical Doctor (MD) 1 upon admission to the skilled nursing facility on [DATE]. 2. […]

• Actual harm, isolatedF580Dec 23, 2021

  Based on interview and record review, the facility failed to ensure the physician was immediately consulted and notified when there was a change in the resident's condition, in accordance with the facility's policy for one of two sampled residents (Resident 1). On 9/6/2021 at 11:00 PM, Resident 1's head bandage dressing (a pad or compress applied to a wound) was noted to be dry and intact, but one (1) hour after on 9/7/2021 at 12:00 AM, Resident 1's head bandage was noted to have been saturated with blood (indication of active bleeding from the wound) but Registered Nurse 1 (RN 1) did not call Resident 1's attending physician to notify of the increase in bleeding from the wound on Resident 1's head. […]

• No harm, potential for more than minimal, patternF578Jul 24, 2026

  Based on interview and record review, the facility failed to ensure three of 25 sampled residents (Residents 91, 75 and 3) or the resident's representatives (RP) received information on how to execute an Advanced Directive (AD-a legal document indicating resident preference on end-of-life treatment decisions) in accordance with State law and the facility's Policy and Procedure (P&P) for Advanced Directive. This deficient practice had the potential for care and services to be provided in a manner inconsistent with the resident's and/or family wishes. Findings: 1. […]