Inspection Reports for
Montezuma Specialty Care

The facility was certified in compliance effective May 15, 2026, based on acceptance of the credible allegation of substantial compliance and Plan of Correction.

The facility failed to maintain adequate kitchen sanitation and failed to update a resident's care plan to reflect exit-seeking behavior. Additionally, the facility did not ensure proper respiratory care and oxygen administration for a resident, and failed to prevent a significant medication error related to anticoagulant medication.

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.

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.

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.

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.

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 facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective May 26, 2024.

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.

The facility failed to report an allegation of abuse involving a staff member instructing a resident to defecate in her brief instead of providing a bedpan. The facility suspended the staff member and was completing an investigation. The facility policy on abuse prevention was reviewed and found to include appropriate directives.

Investigation of complaint #110661-C was conducted during the survey; no deficiencies were cited indicating substantial compliance.

The facility was found to be in substantial compliance with the applicable regulations under 42 CFR, Part 483, Subpart B-C.

This was a revisit for a complaint survey. All deficiencies were corrected.

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.

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 facility failed to complete neurological checks as scheduled and did not notify the provider timely after Resident #3's fall, resulting in delayed treatment for a subdural hematoma and brain bleed. Staff failed to follow fall protocols and notify the provider or family promptly.

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.

The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.

The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.

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.