Inspection Reports for Montezuma Specialty Care
316 Meadow Lane Drive, Montezuma, IA, 501711114
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 10, 2025 found the Montezuma Specialty Care Nursing Home in compliance with applicable health survey requirements and cited no deficiencies. Earlier inspections showed a mixed pattern, with prior reports noting deficiencies related to resident dignity and respect, dietary services, safe transport, and quality assurance programs. Substantiated complaints involved issues such as mistreatment, inadequate fall prevention, failure to report abuse allegations, and insufficient nursing coverage, but enforcement actions like fines or license suspensions were not listed in the available reports. Complaint investigations were often substantiated, particularly regarding resident rights and care, while some complaints were unsubstantiated. The facility appears to have addressed many prior deficiencies, as indicated by the clean findings in the most recent survey.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
4.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
5% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
28 residents
Based on a October 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 10, 2025
Visit Reason
The inspection was conducted as a Recertification Survey to assess compliance with 42 CFR Part 483 Health Survey Requirements for Long Term Care Facilities.
Findings
The Montezuma Specialty Care Nursing Home was found to be in compliance with the applicable health survey requirements during the recertification survey conducted from April 7, 2025 to April 10, 2025.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 18, 2024
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, and certification in compliance is effective as of October 18, 2024.
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 3
Date: Oct 3, 2024
Visit Reason
The inspection was conducted as a result of investigations into complaints #122749-C and #121981-C, with the purpose of determining compliance with resident rights and facility administration standards.
Complaint Details
Complaint #122749-C was substantiated. Complaint #121981-C was not substantiated.
Findings
The facility was found to have failed in ensuring residents were treated with respect and dignity, particularly in relation to resident rights and administration. Deficiencies were noted in staff treatment of residents, documentation, and the facility's Quality Assurance and Performance Improvement (QAPI) program.
Deficiencies (3)
Failure to ensure residents' rights to dignity and respect, evidenced by staff behavior and lack of proper documentation.
Failure in administration to effectively use resources to maintain residents' well-being and address concerns.
Deficiencies in the Quality Assurance and Performance Improvement (QAPI) program, including lack of documentation and monitoring of corrective actions.
Report Facts
Residents reviewed for dignity: 12
Residents affected by dignity issues: 4
Census: 28
Frequency of audits: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Certified Nursing Assistant (CNA) | Named in findings related to resident mistreatment and grievances. |
| Staff D | Certified Nursing Assistant (CNA) | Provided written statements regarding concerns about Staff F. |
| Staff A | Certified Nursing Assistant (CNA) | Reported concerns about Staff F's refusal to enter Resident #6's room. |
| Staff B | Certified Nursing Assistant (CNA) | Reported concerns about Staff F's refusal to enter Resident #6's room. |
| Staff C | Certified Nursing Assistant (CNA) | Reported concerns about Staff F's refusal to enter Resident #6's room. |
| Staff E | Former Director of Nursing (DON) | Interviewed regarding Staff F and resident concerns. |
| Administrator | Facility Administrator | Provided statements on documentation and corrective actions. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 29, 2024
Visit Reason
The document is a Plan of Correction submitted following a survey to address deficiencies and demonstrate substantial compliance for certification.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective June 29, 2024.
Inspection Report
Annual Inspection
Census: 31
Deficiencies: 2
Date: May 29, 2024
Visit Reason
The inspection was conducted as the facility's Annual recertification survey from May 29, 2024 to May 30, 2024.
Findings
The facility failed to meet professional standards of quality related to nutrition and dietary services for Resident #28, specifically not providing the ordered double protein diet. Additionally, the facility failed to ensure safe transport of Resident #18 in a wheelchair with both foot pedals, posing accident hazards.
Deficiencies (2)
Failure to provide the diet as ordered for Resident #28, specifically not providing double protein as recommended by the Registered Dietitian and physician order.
Failure to ensure safe transport of Resident #18 in a wheelchair with both foot pedals, resulting in unsafe conditions.
Report Facts
Resident census: 31
Dates of survey: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Dietary Manager (CDM) | Interviewed regarding double protein diet for Resident #28 |
| Staff B | Registered Dietitian (RD) | Interviewed regarding dietary orders and protein portions for Resident #28 |
| Staff C | Certified Nursing Assistant (CNA) | Observed pushing Resident #18 in wheelchair |
| Administrator | Acknowledged wheelchair pedal issue for Resident #18 | |
| Assistant Director of Nursing | ADON | Relayed expectation for wheelchair foot pedals for Resident #18 |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 26, 2024
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of credible allegation of substantial compliance and certification of the facility.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective May 26, 2024.
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 3
Date: May 9, 2024
Visit Reason
The inspection was conducted as a result of complaints #117789-C and Facility Reported Incident #118086-I, both of which were substantiated. The investigation focused on resident rights, abuse allegations, neglect, and fall prevention.
Complaint Details
Complaint #117789-C and Facility Reported Incident #118086-I were substantiated. The complaint involved mistreatment and abuse allegations related to resident #5 and failure to assist with toileting. The facility failed to report and investigate the abuse allegation timely and adequately.
Findings
The facility failed to protect resident rights and dignity by not assisting residents with toileting needs and incontinence care, resulting in mistreatment. The facility also failed to report and investigate an allegation of abuse involving a staff member and a resident. Additionally, the facility failed to implement adequate interventions to prevent falls for a resident, resulting in multiple injuries.
Deficiencies (3)
Failure to treat residents with dignity and respect, including failure to assist with bedpan and incontinence care for residents #5 and #11.
Failure to report and investigate an allegation of abuse involving a staff member and resident #5.
Failure to create interventions based on root cause analysis to prevent future falls for resident #4, resulting in multiple injuries.
Report Facts
Resident census: 31
Number of residents reviewed for rights dignity deficiency: 9
Number of residents reviewed for abuse allegation: 1
Number of residents reviewed for fall prevention deficiency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Named in abuse and mistreatment findings involving resident #5 |
| Staff B | Certified Nursing Assistant (CNA) | Reported mistreatment by Staff A to former Director of Nursing |
| Staff C | Certified Nursing Assistant (CNA) | Reported refusal by Staff A to provide bedpan to resident #5 |
| Staff D | Registered Nurse (RN) | Administered suppository to resident #5 and reported concerns to Assistant Director of Nursing |
| Staff E | Former Director of Nursing (DON) | Received reports about Staff A and educated staff about resident care |
| Administrator | Suspended Staff A and initiated investigation | |
| Assistant Director of Nursing (ADON) | Received reports and conducted rounds related to abuse allegations | |
| Director of Nursing (DON) | Reported on root cause analysis and interventions for resident falls |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 9, 2023
Visit Reason
An annual recertification survey and investigation of complaint #110661-C were conducted from 3/6/2023 to 3/9/2023.
Complaint Details
Investigation of complaint #110661-C was conducted during the survey; no deficiencies were cited indicating substantial compliance.
Findings
The facility was found to be in substantial compliance with the applicable regulations under 42 CFR, Part 483, Subpart B-C.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 13, 2023
Visit Reason
An on-site revisit was conducted for the complaint survey ending January 03, 2023.
Complaint Details
This was a revisit for a complaint survey. All deficiencies were corrected.
Findings
All deficiencies were corrected and the facility is in substantial overall compliance effective January 26, 2023. The Denial of Payment for New Admits (DPNA) was not effectuated.
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 4
Date: Jan 3, 2023
Visit Reason
The inspection was conducted as an investigation of Complaints #103880-C, #107977-C, #108336-C and Facility Self-Reported Incidents #106361-I and #107413-I from December 19, 2022 to January 3, 2023.
Complaint Details
Complaints #107977-C and #108336-C were substantiated. Facility Self-Reported Incidents #106361-I and #107413-I were substantiated.
Findings
The facility was found to have substantiated complaints and self-reported incidents involving failure to promptly notify family and physician of resident changes, inadequate fall and neurological assessments, failure to provide adequate nursing coverage, and improper handling and documentation of controlled substances. The facility failed to ensure timely interventions and notifications related to resident falls and head injuries, and failed to provide adequate Registered Nurse coverage seven days a week.
Deficiencies (4)
Failure to promptly notify family and physician of resident changes and emergent hospital transfers.
Failure to complete timely neurological checks and assessments after a resident fall with head injury.
Failure to provide eight consecutive hours of Registered Nurse coverage seven days a week as required.
Failure to ensure proper labeling, storage, and destruction documentation of controlled substances.
Report Facts
Census: 59
Deficiencies cited: 4
Registered Nurse coverage hours: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Documented resident condition and fall; failed to notify family. |
| Staff B | Licensed Practical Nurse (LPN) | Documented fall and notification issues; failed to complete neurological checks. |
| Administrator | Administrator | Confirmed expectations for notification and staffing; reviewed staffing sheets. |
| Assistant Director of Nursing | ADON | Provided directives for family notification; confirmed failures in notification and assessments. |
Inspection Report
Annual Inspection
Census: 17
Deficiencies: 5
Date: Aug 23, 2021
Visit Reason
The inspection was the facility's annual health survey conducted from 08/23/2021 to 08/26/2021 to assess compliance with food safety regulations.
Findings
The inspection found deficiencies related to food safety, including unsealed frozen foods, unlabeled and undated items in refrigerators and freezers, and cutting boards with deep grooves that could harbor contamination. The facility implemented corrective actions including removal of non-compliant items and staff training on proper food labeling and storage.
Deficiencies (5)
Cutting boards with deep grooves not sanitizable
Pureed cake desserts in refrigerator not covered or dated
Diced chicken not labeled or dated in refrigerator
Turkey not labeled or dated in freezer
Frozen biscuits not sealed, labeled, or dated
Report Facts
Census: 17
Cutting boards: 6
Frozen biscuits: 20
Inspection dates: Inspection conducted from 08/23/2021 to 08/26/2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cook | Acknowledged unlabeled and undated items in refrigerator and freezer | |
| Dietary Manager | Acknowledged items and staff expectations for labeling and storage | |
| Facility Administrator | Acknowledged items and staff expectations for policy compliance |
Inspection Report
Routine
Census: 18
Deficiencies: 0
Date: Dec 2, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals from 11/30/20 to 12/2/20 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 21
Deficiencies: 0
Date: Jun 15, 2020
Visit Reason
A COVID 19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on 6/15/2020 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 21
Inspection Report
Renewal
Census: 25
Deficiencies: 4
Date: Jan 12, 2020
Visit Reason
The inspection was conducted as a Recertification Survey and investigation of Complaints #82383 (substantiated) and #86813 (not substantiated).
Complaint Details
Complaint #82383 was substantiated; Complaint #86813 was not substantiated.
Findings
The facility failed to submit a PASARR for review with evident mental health diagnosis for one resident, failed to provide a baseline care plan summary to a resident and their family, failed to implement care plan interventions related to smoking, and failed to ensure respiratory care including oxygen tubing changes were properly documented and performed.
Deficiencies (4)
Failed to submit a PASARR for review with evident mental health diagnosis for one resident.
Failed to provide the resident and their representative with a summary of the baseline care plan.
Failed to develop and implement a comprehensive care plan including care plan interventions related to smoking.
Failed to ensure respiratory care including oxygen tubing changes were properly documented and performed according to protocol.
Report Facts
Census: 25
Residents reviewed: 4
Residents reviewed: 3
Residents reviewed: 1
Residents reviewed: 1
Oxygen tubing change frequency: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in relation to acknowledging PASARR needed resubmission, baseline care plan issues, smoking care plan, and oxygen tubing protocol. | |
| Social Worker Designee | Named in relation to acknowledging PASARR needed resubmission. |
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