Inspection Reports for
Montezuma Specialty Care

The complaint investigation focused on allegations that Staff F treated residents disrespectfully, including yelling and making residents feel bad. Resident #6 reported Staff F did not provide care for three weeks after an incident. Multiple staff statements corroborated inappropriate behavior by Staff F. The facility administration lacked documentation of follow-up or investigation of these concerns. The Administrator acknowledged the issues and stated staff should treat residents respectfully.

The facility failed to ensure residents were treated with respect and dignity, with multiple residents reporting inappropriate staff behavior. Additionally, the administration failed to adequately follow up on these concerns and lacked an effective Quality Assurance and Performance Improvement (QAPI) program to address such issues.

Complaint #122749-C was substantiated. Complaint #121981-C was not substantiated.

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.

The facility failed to provide double the protein as ordered for Resident #28, contrary to dietitian and physician orders. Additionally, the facility failed to ensure safe wheelchair transport for Resident #18, who had only one wheelchair pedal, posing a safety risk.

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.

The complaint involved a staff member (Staff A, CNA) who told Resident #5 to defecate in her incontinent brief and refused to provide a bedpan despite the resident's need. Resident #6, the roommate, corroborated hearing Staff A make similar statements. Staff and administration interviews confirmed the incident and the staff member was suspended pending investigation.

The facility failed to treat 2 of 9 residents reviewed with dignity by not assisting them properly with toileting and instructing them to urinate/defecate in their briefs. The facility also failed to timely report and investigate the allegation of abuse related to this incident for 1 resident. The facility suspended the staff member involved and was conducting an investigation.

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.

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.

Complaints #107977-C and #108336-C were substantiated. Facility Self-Reported Incidents #106361-I and #107413-I were substantiated.

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.

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.

Complaint #82383 was substantiated; Complaint #86813 was not substantiated.

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.