Montage Creek

A revisit survey was completed on 3/17/25 for all previous deficiencies cited on 11/19/24. The facility is in compliance with all deficiencies that were cited. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A relicensure survey with complaint #CO34139 was completed on 11/19/24. Deficiencies were cited. Based on interview and record review, the residence failed to ensure the administrator and qualified medication administration persons supervisor completed and documented audits of the accuracy and completeness of medication administration records, medication error reports, and medication disposal records, affecting eight of 10 sample residents (#2-#7, #9, #10).Findings include:On 11/19/24 at 8:49 p.m., documentation of the residence' s quarterly medication audit was requested but not provided.On 11/19/24 at 11:54 a.m., the administrator stated she knew the regulations well, but she had not completed a quarterly medication audit because of the recent turnover in the nursing position. Based on interview and record review, the residence failed to ensure the administrator completed the required administrator training, affecting 87 current residents.Findings include:On 11/19/24 at 8:39 a.m., the administrator training certificate was requested. At approximately 9:00 a.m., an administrator training certificate of the business office coordinator was presented. On 11/19/24 at 9:11 am, the administrator stated she had a National Healthcare Association certification and was unaware that she needed 40 hours of administrator training before assuming an administrator position. Based on interview and record review, the residence failed to obtain a named-based criminal history report conducted by the Colorado Bureau of Investigation (CBI) for staff members before hire and on-boarding for two of three sample staff (#2, #3), affecting 87 current residents.Findings include:The staff file for Staff #2 revealed a hire date of 5/4/22. A CBI criminal background check was completed on 5/5/22. The staff file for Staff #3 revealed a hire date of 10/1/19. The staff file did not include a CBI criminal background check.On 11/19/24 at 3:45 p.m., the business office coordinator stated, "We do not have a background check for Staff #3." THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.25.9 Each resident shall be re-assessed to determine his or her continued need for a secure environment every six (6) months and whenever the resident' s condition changes from baseline status. (A) As part of the secure environment re-assessment, the assisted living residence shall consult with the resident' s attending practitioner, family, and/or resident' s representative and review service documentation dating back to the most recent comprehensive assessment.

A licensure revisit was completed on 1/26/23 for all previous deficiencies cited on 9/17/21. A deficiency was cited. Based on record review and interview, the residence failed to be responsible for complying with authorized practitioner' s orders associated with medication administration, affecting one of five sample residents (#21). Findings include: The residence' s Medication Refills policy, dated 6/21/21, read in part: "Medications are never allowed to run out unless directed to by the physician."Resident #21 was admitted to the residence on 8/5/20 with diagnoses including dementia.A written practitioner' s order, dated 8/18/22, directed the residence to administer acetaminophen 1000 mg four times daily. However, the January 2023 medication administration record read the resident was not administered the medication for the 6:00 a.m., 12:00 p.m., and 6:00 p.m. doses on 1/16, and for the 12:00 a.m. and 6:00 a.m. doses on 1/17/23 for a total of five missed doses due to the medication being out of stock. On 1/26/23 at 7:41 a.m., Staff #1 stated residents should never run out of prescribed medication.On 1/26/23 at approximately 12:00 p.m., the administrator designee confirmed Resident #21 had missed doses of her medication. The administrator designee acknowledged that residents should not miss doses of prescribed medications.