Inspection Reports for Montrose Health Center INC
400 South 7th Street, IA, 526390248
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 4, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to a survey ending on October 2, 2025, with certification of compliance effective October 9, 2025.
Findings
The facility was found to be in substantial compliance based on the credible allegation and plan of correction submitted, resulting in certification of compliance.
Report Facts
Survey end date: Oct 2, 2025
Certification effective date: Oct 9, 2025
Inspection Report
Annual Inspection
Census: 36
Deficiencies: 1
Oct 2, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaint #1729874-C, which did not result in a deficiency.
Findings
The facility failed to administer the correct amount of fluid and liquid nutrition to a resident dependent on tube feeding, based on record review, observations, and staff interviews.
Complaint Details
Complaint #1729874-C was investigated and did not result in a deficiency.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to administer the correct amount of fluid and liquid nutrition to a resident dependent on tube feeding. | D |
Report Facts
Resident census: 36
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Administered tube feeding and interviewed regarding feeding orders. |
| Staff A | Advanced Registered Nurse Practitioner (ARNP) | Interviewed regarding nutritional and flushing orders for Resident #1. |
| Staff A | Registered Nurse (RN) | Interviewed about flushing orders and liquid nutrition. |
| Director of Nursing | Confirmed staff compliance with orders for liquid nutrition and flushes. |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 13, 2025
Visit Reason
A complaint investigation for complaint #125648-C was conducted.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint #125648-C was investigated and found to be in substantial compliance.
Inspection Report
Re-Inspection
Deficiencies: 0
Nov 14, 2024
Visit Reason
A revisit of the survey ending September 9, 2024 was conducted from November 13 to November 14, 2024 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective October 8, 2024.
Inspection Report
Annual Inspection
Census: 36
Deficiencies: 4
Sep 19, 2024
Visit Reason
The inspection was conducted as the facility's annual recertification survey combined with an investigation of complaint #122974-C.
Findings
The facility failed to meet several regulatory requirements including timely and accurate submission of Minimum Data Set (MDS) assessments, comprehensive care plan revisions, medication administration per physician orders, and ensuring a safe environment free from accident hazards. Specific deficiencies involved incomplete MDS submissions, inadequate care plan updates for residents with diabetes and burns, and failure to prevent a resident burn injury from hot liquid.
Complaint Details
The visit included investigation of complaint #122974-C. The complaint was substantiated based on findings related to resident care and safety issues.
Deficiencies (4)
| Description |
|---|
| Failure to electronically transmit complete and accurate MDS data within required timeframes. |
| Care plans were not revised timely or accurately to address residents' needs, including diabetes management and injury care. |
| Medication administration did not consistently follow physician orders, specifically for digoxin and insulin. |
| Facility failed to ensure a resident with severely impaired cognition remained free from burn injury caused by hot liquids. |
Report Facts
Census: 36
Resident MDS record age: 120
Resident MDS assessment score: 6
Resident MDS assessment score: 15
Resident MDS assessment score: 7
Hot water temperature: 168
Burn area size: 0.4
Inspection Report
Re-Inspection
Deficiencies: 0
May 23, 2024
Visit Reason
A revisit of the survey ending April 25, 2024 was conducted on May 22, 2024 to May 23, 2024 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective May 10, 2024.
Inspection Report
Annual Inspection
Census: 36
Deficiencies: 9
Apr 25, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey, investigation of complaints #118424-C, #118693-C, and #119912-I, and a facility-reported incident.
Findings
The facility was found to have multiple deficiencies including failure to ensure residents were free from abuse and neglect, inaccurate assessments, inadequate quality of care, failure to prevent pressure ulcers, medication errors, and insufficient staff training. Several residents exhibited behavioral issues and physical altercations were documented. The facility failed to provide timely interventions and appropriate pain management for residents with wounds.
Complaint Details
Complaints #118424-C, #118693-C, and #119912-I were substantiated as part of the investigation.
Severity Breakdown
Level 1: 1
Level 2: 3
Level 3: 5
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to ensure residents remained free from abuse and neglect, including verbal, mental, sexual, or physical abuse. | Level 3 |
| Inaccurate coding of pressure ulcers on the Minimum Data Set (MDS) and failure to provide appropriate assessments. | Level 2 |
| Failure to provide necessary care and services during a change in condition for residents with chronic obstructive pulmonary disease (COPD) and respiratory failure. | Level 3 |
| Failure to provide adequate treatment and care to prevent pressure ulcers and promote healing. | Level 3 |
| Failure to ensure residents were free of significant medication errors. | Level 2 |
| Failure to provide adequate training for staff on communication and behavioral health. | Level 2 |
| Failure to ensure residents were free from accident hazards, including inadequate supervision and assistance devices to prevent accidents. | Level 3 |
| Failure to provide adequate pain management related to an open ulcer on a resident's right ankle. | Level 3 |
| Failure to provide adequate nursing services under 24-hour direction of qualified nurses, including medication and treatment. | Level 1 |
Report Facts
Census: 36
Fine Amount: 30000
Fine Amount: 6000
Fine Amount: 8250
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mallory Orton | Facility Administrator | Signed the citation and plan of correction documents. |
| Staff E | Licensed Practical Nurse (LPN) | Reported resident behaviors and provided interventions related to Resident #18. |
| Staff F | Registered Nurse (RN) | Responded to Resident #6's unresponsive episode and assisted with care. |
| Staff B | Licensed Practical Nurse (LPN) | Reported on resident falls and nursing expectations. |
| Staff C | Registered Nurse (RN) | Performed wound care and assessments for Resident #8. |
| Staff G | Certified Nursing Assistant (CNA) | Assisted with Resident #3 after a fall and reported observations. |
| Director of Nursing (DON) | Director of Nursing | Oversaw nursing interventions, education, and facility responses. |
| Staff D | Registered Nurse (RN) | Involved in medication administration and staff training. |
| Nurse Practitioner (NP) | Nurse Practitioner | Provided clinical assessments and communicated with facility staff. |
Inspection Report
Re-Inspection
Deficiencies: 0
Jul 26, 2023
Visit Reason
A revisit of the survey ending May 24, 2023 was conducted to verify correction of previous deficiencies.
Findings
All deficiencies identified in the prior survey were corrected and the facility was found to be in substantial compliance effective May 31, 2023.
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 1
May 24, 2023
Visit Reason
The inspection was conducted as an investigation of complaints #113030-C from May 21, 2023 to May 24, 2023.
Findings
The facility failed to carry out assessments and interventions for a change in condition for 2 of 3 residents reviewed, resulting in substantiated complaints. Deficiencies included lack of timely assessment, documentation, and notification of changes in resident conditions, leading to delayed medical evaluation and treatment.
Complaint Details
Complaints #113030-C were substantiated based on investigation findings.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to carry out assessments and interventions for a change in condition for 2 of 3 residents reviewed. | SS=G |
Report Facts
Census: 38
Complaint number: 113030
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maury Orton | Administrator | Signed the report on 06/19/2023. |
| Staff A | Certified Nursing Assistant (CNA) | Interviewed regarding resident condition and care. |
| Staff B | Registered Nurse (RN) | Interviewed regarding resident care and assessments. |
| Staff C | Certified Medication Assistant (CMA) | Interviewed regarding resident care and medication administration. |
| Staff D | Certified Nursing Assistant (CNA) | Interviewed regarding resident care. |
| Staff E | Registered Nurse (RN) | Interviewed regarding resident care and emergency response. |
| Staff F | Certified Nursing Assistant (CNA) | Interviewed regarding resident care and observations. |
| Staff G | Registered Nurse (RN) | Interviewed regarding resident care and concerns. |
| Nurse Practitioner (NP) | Interviewed regarding notification expectations for seizure activity. | |
| Director of Nursing (DON) | Interviewed regarding resident care, assessments, and communication. |
Inspection Report
Re-Inspection
Deficiencies: 0
Feb 14, 2023
Visit Reason
A revisit of the survey ending November 9, 2022 was conducted to verify correction of previously cited deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance as of the documented compliance dates, with the latest date being December 14, 2022.
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 6
Nov 9, 2022
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaint #105400-C from November 1 to November 9, 2022.
Findings
The facility was found to have multiple deficiencies including failure to notify responsible parties of room changes, failure to protect residents from abuse by other residents, failure to report and investigate alleged abuse in a timely manner, incomplete care plans especially related to anticoagulant medication and fall prevention, and inadequate infection control practices. Several residents were involved in incidents of physical abuse and falls, and the facility failed to implement appropriate interventions and documentation.
Complaint Details
Complaint #105400-C was substantiated. The complaint investigation was part of the annual recertification survey conducted November 1-9, 2022.
Severity Breakdown
SS=D: 4
SS=E: 1
SS=J: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to notify responsible party of room change for Resident #16. | SS=D |
| Failure to protect residents from physical abuse by other residents (Residents #3, #8, #14, #34, and #42). | SS=E |
| Failure to report and investigate alleged abuse involving Residents #15 and #42 timely and thoroughly. | SS=D |
| Failure to develop and implement comprehensive care plans for residents, including anticoagulant medication monitoring and fall prevention. | SS=D |
| Failure to ensure infection prevention and control program was properly implemented, including cleaning and storage of BiPAP equipment. | SS=D |
| Failure to ensure resident environment was free of accident hazards and adequate supervision and assistance devices were provided to prevent accidents. | SS=J |
Report Facts
Resident census: 42
Number of residents reviewed for abuse: 6
Number of residents reviewed for fall interventions: 5
Number of falls for Resident #25: 46
Number of falls for Resident #25 after 8/09/22: 19
Number of residents reviewed for anticoagulant medication monitoring: 5
Inspection Report
Renewal
Census: 32
Deficiencies: 5
Aug 19, 2021
Visit Reason
The inspection was conducted as a Recertification Survey and Facility Reported Incidents review, including incidents #96429 and #97643, to assess compliance with federal regulations.
Findings
The facility failed to develop comprehensive care plans for 3 of 14 residents reviewed, including failure to address medication use, hospice care, catheter care, and related interventions. Observations and interviews confirmed these deficiencies.
Deficiencies (5)
| Description |
|---|
| Failed to develop a comprehensive care plan for 3 of 14 residents reviewed, including failure to address anti-coagulant, diuretic, and anti-depressant medication use and interventions. |
| Care plan failed to document hospice care except for an intervention stating hospice nurse awareness of weight loss. |
| Care plan failed to document resident receiving Lorazepam and having anxiety and interventions. |
| Care plan failed to document a urinary catheter and interventions for Resident #24. |
| Facility lacked a Care Plan policy. |
Report Facts
Residents reviewed: 14
Residents with deficient care plans: 3
Census: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Memory Orton | Laboratory Director or Provider/Supplier Representative | Signed the statement of deficiencies and plan of correction |
| Director of Nurses (DON) | Stated expectation for MDS Coordinator to address medications on care plan and expressed expectation that care plans contain focus areas for residents with catheters and hospice care | |
| Staff A | Certified Nurse Aide | Reported Resident #11 yells out and can be difficult to calm down; reported Resident #24 had a catheter since admission |
| MDS Coordinator | Reported catheter information should be on care plans and hospice should be on care plan and updated the care plan |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 1
Nov 3, 2020
Visit Reason
The inspection was conducted as a Focused Infection Control Survey and Complaint #94097 from October 22, 2020 through November 3, 2020. The complaint was substantiated.
Findings
The facility failed to establish and maintain an effective infection prevention and control program to mitigate the spread of COVID-19. The facility cohorting of COVID positive and negative residents in the same rooms, allowing COVID positive staff to care for negative residents, and failure to implement effective screening and isolation protocols led to a cumulative total of 21 out of 28 residents testing positive for COVID-19.
Complaint Details
Complaint #94097-C was substantiated. The complaint related to infection control failures during the COVID-19 outbreak.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to exhaust all efforts to mitigate the spread of COVID-19 including cohorting COVID positive and negative residents in the same room and allowing COVID positive staff to care for negative residents. | F |
Report Facts
Residents positive for COVID-19: 21
Staff positive for COVID-19: 9
Date of survey completion: Nov 3, 2020
Correction completion date: Dec 18, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Nurse Aide | Named in infection control findings related to working while symptomatic and testing positive for COVID-19. |
| Staff B | Maintenance | Named in infection control findings related to symptoms and testing positive for COVID-19. |
| Staff C | Registered Nurse | Named in infection control findings related to testing positive for COVID-19 and working while symptomatic. |
| Staff D | Licensed Practical Nurse | Named in infection control findings related to testing positive for COVID-19. |
| Staff F | Licensed Practical Nurse / Medication Aide | Named in infection control findings related to testing positive for COVID-19 and passing medications to negative residents. |
| Staff G | Registered Nurse | Named in infection control findings related to refusal to cover overnight shift during outbreak. |
| Staff J | Registered Nurse | Named in infection control findings related to refusal to cover overnight shift during outbreak. |
| Director of Nursing | Director of Nursing | Interviewed regarding staff screening and infection control practices. |
| Administrator | Administrator | Interviewed regarding infection control protocols, staffing, and outbreak management. |
Inspection Report
Routine
Census: 31
Deficiencies: 0
Jun 10, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals 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: 31
Inspection Report
Annual Inspection
Census: 32
Deficiencies: 4
Feb 27, 2020
Visit Reason
The inspection was conducted as the annual health survey of Montrose Health Center to assess compliance with federal regulations.
Findings
The facility failed to provide written notice of the bed hold policy upon transfer of a resident, had outdated food items in refrigerators, lacked adequate infection control policies and procedures, and failed to safely store hot coffee. Multiple deficiencies were identified related to bed hold notice, food safety, infection control, and environmental safety.
Deficiencies (4)
| Description |
|---|
| Failure to provide written notice of the bed hold policy for a resident upon transfer to the hospital. |
| Failure to dispose of outdated food items from refrigerators. |
| Inadequate infection prevention and control program policies and procedures, including lack of annual review and documentation. |
| Failure to safely store hot coffee, with coffee temperatures exceeding safe levels. |
Report Facts
Census: 32
Slices of cheese: 50
Temperature of hot coffee: 154.5
Time spent on infection control duties: 4
Number of residents identified as independently mobile and cognitively impaired: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator | Reported responsibility for issuing bed hold notice and verified lack of documentation |
| Dietary Supervisor | Dietary Supervisor | Present during kitchen tour and reported expectations for checking outdated food items |
| Infection Preventionist | Infection Preventionist | Reported hours spent on infection control duties and awareness of need for Medical Director review |
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