Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Montezuma Specialty Care during CMS and state inspections, most recent first.
Kitchen sanitation was not maintained in 2 of 2 observations. Cabinets, drawers, and cupboards contained heavy crumbs, food debris, dust, splatters, black debris, a dead winged insect, and what appeared to be a black human hair. The DM stated staff were expected to wipe down drawers and cupboards and guessed they had not been cleaned recently, although they were supposed to be cleaned daily.
Care plan failed to reflect a resident’s exit-seeking behavior and related window tampering. The resident had dementia, bipolar disorder, depression, and moderately impaired cognition, and records showed repeated statements about wanting to leave, including attempts to remove screws from the window and screen so she could get out. Despite these documented behaviors, the care plan did not include the resident’s desire to leave or her history of removing parts of the window.
Failure to administer oxygen in accordance with the physician order occurred for a resident on continuous O2 therapy. The resident, who had an irregular heartbeat and intact cognition, was observed with portable O2 that was not delivering oxygen because the tank valve was not connected correctly; the resident was unaware the tank was not working, and the DON later found the O2 saturation was 91%. Staff reported that the CNA had set up the portable O2, while the RN stated nurses regulate and administer O2.
A resident with atrial fibrillation and a dislocated knee had apixaban ordered to be held before orthopedic surgery, but the anticoagulant was still administered instead of being withheld. Staff later discovered the error, notified the surgical team, and the surgery was postponed. Interviews confirmed confusion about the hold order and that the medication was not properly removed from the med cart.
The facility failed to treat residents with dignity and respect, affecting four residents. A CNA yelled at residents during a dining incident and made inappropriate comments, contrary to care plans. One resident felt bad after being told his falls were recurring, and another was avoided by the CNA for weeks after an incident. The facility's policy on dignity and respect was not followed, and reported concerns were not adequately addressed.
The facility failed to address concerns about staff treatment of residents, involving incidents where a CNA yelled at residents and avoided providing care. Despite reports and written statements from staff, there was no documentation of follow-up by the administration. The facility's policy on dignity and respect was not upheld, affecting residents with varying cognitive conditions.
The facility failed to conduct effective QAPI activities, lacking documentation and structured processes to address quality deficiencies related to resident treatment and dignity concerns. From January to October, there was no evidence of ongoing QAPI program activities, monitoring, or evaluation of corrective actions. The facility's policy outlined the QAPI committee's responsibilities, but the Administrator admitted that past citations had not been discussed in QA meetings.
A resident with multiple health conditions, including risk for pressure injuries, did not receive the prescribed double protein diet as ordered. Despite the care plan and dietary instructions, observations showed meals lacking the required protein portions. Interviews with dietary staff revealed a failure to implement the diet order correctly.
A resident with a history of mobility issues and a recent fracture was observed being pushed in a wheelchair with only one foot pedal, contrary to safety expectations. The CNA acknowledged the missing pedal, and the ADON confirmed the requirement for both pedals for safe transport. The resident expressed frustration over the missing pedal since admission.
The facility failed to treat two residents with dignity by not assisting them with the bedpan and instructing them to urinate or defecate in their incontinent briefs. Multiple staff members confirmed the residents' complaints, but the facility's grievance log did not contain any records of these issues. The staff member involved has been suspended pending investigation.
A facility failed to report and investigate an allegation of abuse where a staff member instructed a resident to urinate and defecate in her brief instead of assisting her with a bedpan. Multiple staff members were aware of the incident but did not document or investigate it properly, leading to a deficiency in compliance with federal requirements.
A resident with a tibia fracture reported that a night shift staff member instructed her to urinate and defecate in her incontinent brief instead of providing a bedpan. This was corroborated by another resident and multiple staff members, but the facility failed to document and investigate the allegations properly, violating their abuse prevention and dignity policies.
The facility failed to create interventions based on root cause analysis of falls to prevent future falls for a resident with severe cognitive impairment and a history of falls. Despite multiple documented falls resulting in injuries, the resident's care plan lacked specific interventions, and the clinical record did not show any analysis or preventive measures.
Kitchen sanitation not maintained
Penalty
Summary
The facility failed to maintain adequate kitchen sanitation in 2 of 2 kitchen observations. During an observation on 4/21/2026 at 10:29 a.m., small plates and dishes were found face down in a cupboard covered with heavy crumbs, and cabinets on the left side and back wall of the kitchen were sticky to the touch and partially covered with red and dark colored splatters and food debris. Styrofoam plates sat in a cupboard on a coating of heavy dust, and multiple drawers and cupboards contained serving scoops, slotted serving spoons, ladles, muffin tins, cookie sheets, pans, and other kitchen tools sitting in layers of crumbs, food debris, red droplets, black debris, and what appeared to be a black human hair. A small, dead, winged insect was also observed on the floor of one cupboard near the cookie sheets. Multiple pitchers were stored on bare wood in a cupboard below the coffee maker, and the wood was stained black. On 4/22/2026 at 9:50 a.m., the drawers and cupboards remained unchanged from the prior observation. The facility policy Sanitation, revised October 2008, stated staff would maintain a clean and sanitary food service area and clean surfaces such as shelves frequently enough to prevent the accumulation of grime. On 4/23/26 at 9:20 a.m., the Dietary Manager stated she expected staff to wipe down drawers and cupboards and said she guessed they had not been cleaned recently, adding that they were supposed to be cleaned daily.
Care Plan Not Updated for Exit-Seeking Behavior
Penalty
Summary
The facility failed to update Resident #6’s care plan to reflect exit-seeking behavior and related unsafe actions. The resident’s MDS dated 12/19/25 listed diagnoses of non-Alzheimer’s dementia, bipolar disorder, and depression, and identified a BIMS score of 11 out of 15, indicating moderately impaired cognition. The facility policy stated that care plans would incorporate risk factors associated with identified problems. Clinical documentation showed repeated statements and behaviors related to wanting to leave the facility. An 8/8/25 encounter note stated the resident expressed a strong desire to leave the care facility. A 2/17/26 nurses note stated the resident told a family member she tried to remove the window in her room so she could get out, and inspection found she had removed a screw from the window track to open the window fully. A 3/2/26 encounter note stated the family reported the resident’s cognition was worsening and that she had recently removed screws from the screen in her room because she wanted to try to climb out her window. On 4/20/26, the resident again stated she wanted to be released from the facility and said she wanted to leave and maybe would just go out the window. As of 4/21/26, the care plan did not include her desire to leave the facility or her history of removing a part of the window.
Failure to Administer Portable Oxygen Correctly
Penalty
Summary
Facility staff failed to administer oxygen in accordance with physician orders for one resident who had a diagnosis of an irregular heart beat and was identified in the MDS as receiving continuous oxygen therapy. The resident had intact cognition with a BIMS score of 15 out of 15. During an observation, the resident was sitting in a recliner with the oxygen tubing in her nose and the concentrator set at 1 liter, and she was seen taking deep breaths while relaxing. During a later observation, the resident was in the dining room for breakfast and the portable oxygen tank level indicator was not in the red area, which indicated an inadequate to no supply of oxygen. The resident was unaware that the tank was not administering oxygen. When the DON assessed the resident, the oxygen saturation was 91%. The Administrator checked the portable oxygen tank and stated it looked pressurized. Staff C, a CMA, used an O2 key to open the portable tank, but the key was not lined up correctly with the valve, causing oxygen to release around the connection with a high hissing sound. The DON then demonstrated the correct connection and, once properly connected, oxygen was delivered through the meter and tubing cannula to the resident's nose. Staff C stated she had put the portable oxygen on and turned it to 1 liter, and Staff A, an RN, stated the CNA had not brought any residents who used portable oxygen to her and that nurses regulate and administer oxygen.
Failure to Hold Anticoagulant Before Scheduled Surgery
Penalty
Summary
Ensure that residents are free from significant medication errors. The facility failed to hold apixaban, an anticoagulant, as ordered for a resident with atrial fibrillation and a dislocated right knee with a bone fragment concerning for fracture. The resident had an orthopedic surgery scheduled for the right knee, and the orthopedic surgeon documented that the blood thinner had to be stopped five days before surgery or anesthesia could not be given. The medication administration record showed apixaban was ordered to be held from 4/19/26 to 4/21/26, but the medication was still administered on the morning of 4/19/26 and continued twice daily. Progress notes showed the surgery was scheduled for 4/22/26 and later staff documented confusion about the hold order and the surgery date. A pharmacist requested a note to hold the blood thinner for 3 days prior to surgery, and on 4/21/26 staff discovered the resident had received the morning dose on 4/20/26 and that the evening dose from 4/19/26 was not in the medication card. Staff notified the surgical team, and the surgery was rescheduled for 4/27/26. Interviews with nursing staff and the DON confirmed the medication error occurred, that the hold order had been entered into the computer, and that the resident’s blood thinner was not properly removed from the medication cart or held as intended.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, affecting four out of twelve residents reviewed. Resident #8, with intact cognition, was directed to be spoken to face-to-face to reduce confusion due to schizophrenia. However, Staff F was reported to have yelled at her during a dining incident, telling her that the conversation was none of her business. Resident #12, with moderately impaired cognition, was directed to receive positive interaction due to her emotional state. Staff F also yelled at her during the same dining incident. Resident #11, who had intact cognition and was diagnosed with depression, anxiety, and paraplegia, reported feeling bad after Staff F commented on his recurring falls. This interaction was contrary to the care plan, which directed staff to speak to him calmly. Additionally, Resident #6, with intact cognition and requiring assistance for bed mobility, reported that Staff F accused her of resisting during care and subsequently avoided her room for three weeks, leaving her care to other staff. The facility's policy on Residents Rights-Dignity and Respect was not adhered to, as evidenced by multiple staff statements and resident interviews. Staff D reported that Staff F yelled at residents and made inappropriate comments, which were documented and submitted to the Administrator but not addressed. The Administrator acknowledged the lack of additional documentation related to grievances or staff concerns, indicating a failure to investigate and address the reported issues adequately.
Failure to Address Staff Misconduct and Resident Dignity Concerns
Penalty
Summary
The facility administration failed to address concerns regarding staff treatment of residents, specifically involving four residents. Resident #8, with intact cognition, was directed to have consistent routines to reduce confusion, yet experienced an incident where Staff F yelled at her during dinner. Resident #12, with moderately impaired cognition, was directed to receive positive interactions, but was also yelled at by Staff F. Resident #11, with intact cognition and paraplegia, was made to feel bad by Staff F after a fall, as Staff F commented on the recurring nature of the falls. Resident #6, with intact cognition and requiring assistance for bed mobility, reported that Staff F accused her of resisting care and subsequently avoided her room for three weeks. The facility's policy on Residents Rights-Dignity and Respect, which mandates respectful and considerate care, was not adhered to in these instances. Written statements from Staff D CNA detailed multiple incidents where Staff F displayed inappropriate behavior, such as yelling at residents and making derogatory comments. Despite these reports, there was a lack of documentation indicating that the administration followed up on these concerns, and Staff D's written statements placed in the Administrator's mailbox did not receive a response. Interviews with various staff members revealed that Staff F's behavior was known among the staff, and there was an awareness of his reluctance to care for Resident #6. The former DON acknowledged awareness of the situation with Resident #6 but could not recall other concerns about Staff F. The Administrator admitted to not having additional documentation related to grievances or staff concerns and stated that the way Staff F spoke to residents was unacceptable.
Lack of Effective QAPI Activities
Penalty
Summary
The facility failed to conduct effective Quality Assurance and Performance Improvement (QAPI) activities, as evidenced by a lack of documentation and structured processes to address quality deficiencies related to resident treatment and dignity concerns. The review of QAPI/QA documentation from January to October revealed an absence of evidence for ongoing QAPI program activities in these areas. The facility did not document any monitoring or evaluation of the effectiveness of corrective actions or performance improvement activities, nor did it revise these activities as needed. The facility's policy on QAPI Program Governance and Leadership, revised in March 2020, outlined the responsibilities of the QAPI committee to identify and resolve negative outcomes and coordinate performance improvement projects. However, the Administrator admitted that since his tenure, past citations had not been discussed in QA meetings.
Failure to Provide Prescribed Double Protein Diet
Penalty
Summary
The facility failed to provide the diet as ordered for a resident reviewed for nutrition. The resident, who had a diagnosis of hyponatremia, COPD, pulmonary embolism, and osteoarthritis, was at risk for pressure injuries and was on a therapeutic diet. The care plan directed staff to provide double protein twice a day, but the resident reported receiving a large amount of starches instead. The resident also mentioned receiving foods high in vitamin K, which she needed to avoid due to being on a blood thinner. Observations confirmed that the resident's meals lacked the prescribed double protein portions. On two separate occasions, the resident received only a single protein source at lunch. Interviews with dietary staff revealed a misunderstanding or failure to implement the diet order correctly, as the dietary manager and registered dietitian both acknowledged the requirement for double protein but did not ensure it was provided. The registered dietitian reviewed the diet order and menu but did not rectify the issue before the surveyor's observation.
Deficiency in Safe Wheelchair Transport
Penalty
Summary
The facility failed to ensure the safe transport of a resident in a wheelchair, leading to a deficiency. Resident #18, who has intact cognition and a history of arthritis, osteoporosis, a cerebrovascular accident, and a fractured right humerus, was observed being pushed in a wheelchair by a Certified Nursing Assistant (CNA) with only one foot pedal. The resident's care plan indicated the need for a wheelchair for mobility and assistance due to a recent fracture, with a non-weight-bearing restriction on the right upper extremity. During the observation, the CNA expressed a wish to find the missing wheelchair pedal and instructed the resident to keep their feet up. The Assistant Director of Nursing (ADON) confirmed that the expectation is for both foot pedals to be present for safety when pushing a wheelchair. The resident reported having only one pedal since arriving at the facility, which was upsetting. The facility's assessment identified the resident's mobility issues and the need for proper transfer equipment, including a wheelchair.
Failure to Assist Residents with Toileting and Maintain Dignity
Penalty
Summary
The facility failed to treat two residents with dignity by not assisting them with the bedpan and instructing them to urinate or defecate in their incontinent briefs. Resident #5, who had a tibia fracture and required substantial assistance for toileting, reported that a night shift staff member repeatedly told her to defecate in her brief instead of providing a bedpan. This made Resident #5 feel dirty and humiliated. Resident #6, who was present during the incident, corroborated Resident #5's account and stated that the staff member, identified as Staff A, made similar comments on two separate occasions. Resident #3 also reported hearing Staff A instruct another resident, Resident #11, to urinate in her pants about a year ago. Resident #11 required extensive assistance for toileting due to limited mobility from a hip fracture. Multiple staff members, including CNAs and an RN, confirmed that Resident #5 had reported the issue to them, and they had escalated the concern to the former Director of Nursing (DON) and the Assistant Director of Nursing (ADON). However, the facility's grievance log did not contain any records of these complaints. The former DON stated that she had educated Staff A about ensuring residents were not wet but did not recall being informed about the specific issue of instructing residents to soil themselves. The current Administrator only became aware of the situation recently and suspended Staff A pending an investigation. The facility's policy on dignity, revised in February 2021, emphasized that staff should care for residents in a manner that promotes their well-being and self-esteem.
Failure to Report and Investigate Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a staff member who allegedly instructed a resident to urinate and defecate in her incontinent brief instead of assisting her with a bedpan. Resident #5, who had a tibia fracture and required substantial assistance for toileting, reported that a night shift staff member repeatedly told her to go in her brief and even reached into her brief to check if she was wet enough. This incident was corroborated by Resident #6, who was Resident #5's roommate and witnessed the staff member's behavior on two separate occasions. Despite multiple staff members, including CNAs and an RN, being aware of the incident and reporting it to higher authorities such as the former Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the facility failed to document or investigate the complaint properly. The facility's grievance log did not contain any concerns related to the incident, and the former DON claimed she was unaware of the specific allegations. The Administrator only became aware of the situation after the survey team initiated their investigation. The facility's policy on abuse, neglect, and exploitation, which mandates the identification, investigation, and reporting of all possible incidents, was not followed. The policy also emphasizes the importance of maintaining a culture of compassion and caring for all residents, which was evidently not upheld in this case. The failure to report and investigate the abuse allegation promptly led to a deficiency in the facility's compliance with federal requirements for resident care and safety.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of abuse and ensure protection from further abuse for a resident. Resident #5, who had a tibia fracture and required substantial assistance for toileting, reported that a night shift staff member instructed her to urinate and defecate in her incontinent brief instead of providing a bedpan. This incident was corroborated by Resident #6, who witnessed the staff member's actions on two separate occasions. Despite these reports, the facility's grievance log did not contain any concerns related to this issue, indicating a failure to document and investigate the allegations properly. Multiple staff members, including CNAs and an RN, confirmed that Resident #5 had reported the abuse to them, and they had relayed the information to the former Director of Nursing (DON) and the Assistant Director of Nursing (ADON). However, the former DON stated she did not recall receiving such a report and would have investigated it if she had. The ADON also confirmed that she had reported the incident to the former DON after being informed by the residents during her rounds. The facility's policy on abuse prevention and dignity required the identification, investigation, and reporting of all possible incidents of abuse, neglect, and mistreatment. However, the facility failed to adhere to these policies, as evidenced by the lack of documentation and investigation into the reported abuse. The Administrator only became aware of the situation after the survey team began their investigation, leading to the suspension of the implicated staff member and the initiation of an investigation.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to create interventions based on root cause analysis of falls to prevent future falls for a resident with a history of falls and severe cognitive impairment. The resident, who had diagnoses including pelvic fracture, non-Alzheimer's dementia, and heart failure, was dependent on staff for transfers and had a history of falls resulting in injuries such as fractures and lacerations. Despite multiple falls documented in incident reports, the resident's care plan lacked specific interventions to address the falls, and the clinical record did not show any facility analysis of the root causes of each fall or interventions implemented to prevent future falls. The facility's policies on assessing falls and managing fall risks required identifying possible causes of falls and implementing specific interventions to prevent them. However, observations and staff interviews revealed that the facility did not adhere to these policies for the resident in question. The Director of Nursing acknowledged that the lack of care plan interventions for the resident was not in line with the facility's expectations, indicating a failure to follow established protocols for fall prevention.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Montezuma
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brooklyn Community Estates | 11.8 mi | ★★★★★ | 1 | 0 |
| St Francis Manor | 14.1 mi | ★★★★★ | 4 | 0 |
| Mayflower Home | 14.5 mi | ★★★★★ | 1 | 0 |
| Northern Mahaska Specialty Care | 19.4 mi | ★★★★★ | 9 | 0 |
| Oskaloosa Care Center | 20.7 mi | ★★★★★ | 11 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.