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 Montrose Healthcare Center during CMS and state inspections, most recent first.
A resident with prostate cancer, palliative care needs, and a prior cerebral infarction had an order for O2 at 2 L/min via NC, titrated up to 5 L/min if O2 saturation fell below 95%. MAR readings were repeatedly below 95%, but nursing notes did not document titration, monitoring, or the rationale for the oxygen flow used. An LVN stated the nurses did not titrate the oxygen, and an RN and the DON confirmed the record lacked documentation showing the ordered oxygen adjustments were performed.
Inaccurate MDS coding was found for two residents when Section O recorded restorative nursing days for bed mobility and transfer training that were not supported by orders or observed care. One resident with respiratory failure, spina bifida, and ROM limitations had RNA orders for AROM and PROM, but no bed mobility training order; the MDS Nurse Coordinator stated the code should have been zero days. Another resident with CVA, dementia, dysphagia, and severe cognitive impairment had RNA orders for AAROM, PROM, and splints, but no transfer training was performed during observation; the MDS Nurse Coordinator stated the transfer code should have been zero days.
Failure to Provide and Follow Ordered ROM and Splinting Services: A resident with PT discharge recommendations for BLE ROM did not have an RNA order for that program; another resident with ROM limitations had knee splinting ordered without documented PT trials or a safe wear time, and the annual OT JMS was overdue; a third resident with severe cognitive and mobility impairments was observed wearing a right knee splint even though PT later stated the RNA order had been discontinued and the splint was no longer recommended.
Annual competency checks for two RNAs did not include putting on and taking off splints and braces, even though those skills were part of their daily RNA duties. During an observation, an RNA completed ROM exercises for a resident and then applied a right elbow splint, right knee splint, and right pressure relief AFO. The DSD confirmed the competency checklists did not assess this skill, while the DON stated RNA staff should be competent to carry out the RNA program.
Unsafe food storage and contaminated ice machine drainage were observed in the kitchen and staff lounge. One seasoning salt lacked an open/use-by date, a dirty meal tray was placed on top of clean cups in a clean food cart, and the ice machine air gap was blocked with a black slimy substance with water dripping from the drainage pipe. The DS and MS both acknowledged the drainage condition was not sanitary, and the facility policy required ice machines to be maintained in a clean and sanitary manner.
Overflowing Exterior Dumpsters: Two exterior garbage containers were observed overflowing with lids left open, with trash bags, loose garbage, and discarded gloves on the ground around the dumpster area. The MS confirmed that dumpster lids must remain closed and secured and that trash should not overflow. The facility P&P for Sanitation required refuse containers to be properly contained with lids secured and disposal areas kept free from waste and pests.
Delayed and inaccurate PT JMS documentation affected two residents with significant neurologic impairment, severe cognitive deficits, ROM limitations, and dependence for ADLs. PT JMS entries were completed well after their effective dates, and the PT stated that late completion could make the assessments inaccurate because the effective date did not reflect when the ROM assessment was actually performed. Observations showed RNA staff providing PROM and applying splints and a PRAFO to support the residents’ limited mobility.
Failure to Obtain Informed Consent for Donepezil: A resident with dementia and severely impaired cognition was prescribed donepezil for dementia, but the chart and EHR did not contain a signed informed consent. The MDS Coordinator and DON both confirmed that informed consent was required before or upon initiation of the medication and that it was missing from the medical record.
Incorrect Wall Clock Time in Resident Room: A resident’s room clock displayed the wrong time, and a CNA confirmed it was incorrect. The resident said she wanted the clock set correctly so she could know the time in her room. The resident had diagnoses including Alzheimer’s disease, anxiety disorder, and schizophrenia, and the H&P stated she lacked decision-making capacity while the MDS indicated intact cognition. The DON stated the correct time is important because the wrong time could confuse the resident, and the facility policy required a safe, clean, comfortable, and orderly homelike environment.
A resident with dementia and severely impaired cognition was transferred to the GACH for a change of condition, but the facility did not have a completed bed-hold document in the resident's chart. The SSD and DON both confirmed there was no documentation showing the resident and/or representative received the required written bed-hold policy notification before transfer.
Inaccurate RNA Care Plan: A resident with CVA, hemiplegia, hemiparesis, and severe cognitive impairment had current RNA orders for ROM exercises and splinting, but the care plan was not updated to match the resident’s revised treatment program. Staff observed the resident receiving PROM and wearing a right elbow splint, right knee splint, and right PRAFO, while PT and the DOR stated the right knee splint order had been discontinued. The MDS Coordinator and DON stated the care plan was not accurate and should reflect current treatments and interventions.
Improper Administration of Oral Medication and Eye Drops: An LVN did not remain with a resident until a chewable Simethicone tablet was swallowed and did not apply tear duct pressure after administering Cyclosporine eye drops. The resident had muscle weakness, dysphagia, hypertension, and intact cognition, and the facility policy required staff to stay with the resident until oral medication was swallowed and to apply gentle pressure to the tear duct after ophthalmic administration.
Failure to provide ordered bite-sized diet texture: A resident with dx including DM, Alzheimer’s disease, psychosis, and dysphagia had a physician-ordered soft and bite-sized diet, and ST documented coughing/choking with oral intake and aspiration risk. During tray observation, the IPN found grilled cheese that was not cut into bite-sized pieces, and the DS confirmed that bite-sized foods must be prepared before leaving the kitchen.
A deficiency was cited when a resident's care plan did not include all necessary needs, lacked measurable timetables, and failed to specify actions, resulting in incomplete planning and documentation for the resident's care.
Surveyors found that two residents were not provided safe medication storage: one was allowed to keep and self-administer Flonase without authorization, and another had Lorazepam, a controlled drug, stored with non-controlled medications instead of in a separately locked compartment. Additionally, a resident with diabetes received insulin from pens that were not labeled with expiration or discard dates and were administered past their effective period, contrary to facility policy.
Surveyors identified improper food handling practices, including staff plating food without gloves or handwashing and failure to label potentially hazardous foods in the refrigerator and freezer with use by dates. The Dietary Supervisor confirmed that use by dates were not routinely applied, contrary to facility policy, increasing the risk of foodborne illness.
A resident with cognitive impairment and multiple medical conditions was left waiting for her meal tray for at least 20 minutes after others at her table had been served, resulting in her eating alone. Staff could not explain the delay, and the dietary supervisor noted that the dining room resident list was not always updated, leading to the deficiency in providing dignified and equal care.
A licensed nurse documented the administration of multiple medications, including aspirin, for a resident before actually giving them, resulting in the resident not receiving the prescribed aspirin dose. The MAR was signed prior to medication administration, contrary to facility policy, and the omission was later acknowledged by the nurse and confirmed by the DON.
A resident with significant medical needs and requiring maximal assistance with ADLs was left in a wet, foul-smelling incontinent brief for over eight hours without being changed. Staff failed to communicate during shift change, resulting in the resident not receiving timely perineal care as outlined in the care plan and facility policy.
A resident with a history of Stage 4 pressure injury did not receive required daily and weekly skin assessments or consistent repositioning, as documented in the care plan and facility policy. Staff failed to document skin condition changes and left the resident in the same position for extended periods, resulting in significant skin redness and increased risk for pressure injury recurrence.
A resident with dementia, Alzheimer's disease, and a history of falls was observed walking unsupervised with eyes closed and hands outstretched, repeatedly running into a wall without staff assistance. Despite being identified as high risk for falls and requiring increased supervision due to new behaviors related to eye irritation, the care plan was not updated and interventions were not implemented, resulting in inadequate supervision and increased risk of harm.
A resident with a suprapubic catheter was not properly monitored for signs and symptoms of UTI, and staff failed to document specific symptoms or interventions when issues were noted. The catheter was observed unsecured and leaking, with pinkish, foul-smelling urine, and staff did not consistently report or follow up on these findings as required by facility policy and physician orders.
A resident with dementia and atherosclerotic heart disease did not receive physician-ordered ASA 81 mg for CVA prophylaxis when an LVN overlooked the order during medication administration, despite the resident questioning the omission. The error was confirmed through observation, interview, and record review, and facility policy required medications to be administered as prescribed.
Staff did not document vital signs, updated care plans, or provided treatments for a resident with dementia and diabetes who was in declining condition and being considered for hospice care. Despite frequent monitoring reported by the LVN, there were no recorded vital signs or progress notes for several days before the resident was found unresponsive, leaving the clinical record incomplete and not in accordance with facility policy.
A CNA did not wear required PPE while entering the room and touching the belongings and person of a resident on Enhanced Barrier Precautions for a history of MDRO infection. The CNA was aware of the resident's EBP status but failed to follow facility policy, which required PPE for contact with potentially contaminated surfaces and the resident. Facility leadership confirmed that PPE should have been used in this situation.
The facility failed to ensure call lights were within reach for two residents at risk for falls. Both residents had care plans requiring accessible call lights, but observations revealed the call lights were placed out of reach. Staff acknowledged the issue and the importance of accessible call lights for resident safety.
The facility failed to ensure a homelike environment for two residents due to the disruptive behavior of their roommate, who frequently yelled and cursed, disturbing their sleep and well-being. Despite complaints, the issue persisted, impacting the residents' ability to rest and function daily.
The facility failed to post actual worked nursing hours at the start of each shift, resulting in an inaccurate reflection of the number of staff providing direct care to residents. The Director of Staff Development admitted to posting projected numbers the night before and not updating them for call-offs or staffing changes.
The facility failed to ensure the medication room was free from expired medications. Two bottles of undated opened Gabapentin oral solution were found in the medication refrigerator, labeled for two residents. The MDSC and DON confirmed that the facility's policy requires opened medications to be labeled with the date they were opened and discarded after 30 days to ensure resident safety.
The kitchen staff failed to follow infection control policies by not wearing a hair net in the food preparation area. The Dietary Supervisor admitted to forgetting the hair net, which is required to prevent food contamination. The facility's policy mandates wearing a hair net at all times.
The facility failed to provide information about Advance Directives to a resident readmitted with dysphagia and prostate cancer. The Social Service Director admitted forgetting to screen the resident for AD, violating the facility's policy and potentially leading to treatment against the resident's will.
A facility failed to follow professional standards and its own policy on documenting medication administration immediately after administering Ceftriaxone IV to a resident. The RN did not sign the MAR immediately, which was acknowledged as a lapse by both the RN and the DON. The resident had diagnoses including dysphagia and hypertension and was prescribed Ceftriaxone for a bacterial infection.
A facility failed to provide appropriate care for a resident with an indwelling catheter, resulting in the catheter tubing being cloudy with white sediments and touching the trash bin. The resident's care plan required monitoring for signs of UTI, but observations and interviews revealed that the facility did not follow its policy on urinary catheter care, leading to potential delayed care and treatment for a UTI.
A resident receiving Ceftriaxone IV for a bacterial infection had an unlabeled IV site, contrary to the facility's policy requiring rotation every 96 hours. The registered nurse confirmed the importance of labeling and rotating the IV site to prevent infections.
A resident received oxygen therapy without a physician's order, and the nasal cannula tubing was observed touching the trash bin, posing an infection risk. The facility's policy requires a doctor's order for oxygen and proper storage of tubing to prevent contamination.
A facility failed to protect a resident's personal and medical information by leaving a computer screen unattended and logged on in a hallway. The LVN admitted to forgetting to log out, and the DON confirmed the requirement to protect resident records at all times.
The facility failed to ensure that a resident with cognitive impairments, including schizophrenia, Alzheimer's disease, and bipolar disorder, had the capacity to understand and make an informed decision before signing a Binding Arbitration Agreement. The Business Office Manager and Director of Nursing acknowledged that the staff should not have allowed the resident to sign the document, and the facility lacked a Policy and Procedure for such agreements.
The facility failed to follow infection control practices by not placing a resident with a PICC line on Enhanced Barrier Precautions (EBP). The resident had multiple diagnoses and was dependent on staff for daily activities. The Infection Preventionist admitted to forgetting to implement EBP, which could lead to the spread of infection.
Failure to Titrate Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to ensure a resident received continuous oxygen therapy that was titrated according to the physician’s order to keep oxygen saturation above 95%. The resident was admitted with diagnoses including prostate cancer, palliative care, and cerebral infarction, and the H&P stated the resident did not have the capacity to understand and make decisions. The physician’s order summary directed oxygen at 2 liters per minute via nasal cannula and to titrate up to 5 liters per minute for oxygen saturation less than 95%. The MAR showed oxygen saturation readings below 95% on multiple shifts, including readings of 93%, 92%, 94%, and 90%, but the licensed nurses’ notes did not document oxygen titration, monitoring, or clinical justification for the oxygen flow rate administered. During interviews, an LVN stated the nurses did not titrate the oxygen and believed the resident was on 2 liters per minute. An RN stated there was no documentation showing how many liters per minute were being administered and that the oxygen should have been titrated as ordered. The DON stated the resident’s oxygen should have been titrated based on respiratory status to maintain saturation at 95% or above, and that no documentation was found showing assessment of oxygen needs or titration in accordance with the ordered parameters.
Inaccurate MDS Coding for Restorative Nursing Services
Penalty
Summary
The facility failed to accurately code Section O of the MDS for two residents by recording restorative nursing aide program days for services that were not supported by the residents’ orders or observed care. For Resident 8, the MDS dated [DATE] and 3/17/2026 indicated one day of restorative nursing program training and skill practice in bed mobility, but review of the resident’s orders showed RNA services for BUE AROM and BLE PROM only, with no order for bed mobility training. The MDS Nurse Coordinator reviewed the assessment and stated the Section O coding was incorrect and should have been coded as zero days because Resident 8 did not receive RNA bed mobility training. Resident 8’s record showed diagnoses including acute and chronic respiratory failure with hypoxia and spina bifida. The resident was cognitively intact, had ROM limitations in one upper extremity and both lower extremities, and required assistance with eating, oral hygiene, toileting, bathing, lower body dressing, and bed-to-chair transfers. The care plan addressed ROM and mobility needs with RNA treatment as ordered, including BUE AROM and BLE PROM, but did not include bed mobility training. During observation, Resident 8 was in bed, could reach for the TV remote with the right arm, stated staff completed exercises with the arms and legs, and said she could move her arms but needed help moving her legs. For Resident 3, the MDS dated [DATE] indicated three days of restorative nursing program training and skill practice in transfers, but the resident’s orders included RNA for BUE AAROM, BLE PROM, and knee splints, with no order for transfer training. During observation, RNA treatment consisted of PROM to the BUE and BLE and application of knee splints and heel protectors; no transfer training was performed. The MDS Nurse Coordinator stated the transfer coding was not accurate and should have been zero days. Resident 3 had diagnoses including cerebrovascular disease, dementia, and dysphagia, was severely impaired in cognitive skills for daily decision making, had ROM limitations in both upper and lower extremities, and required dependent assistance with oral hygiene, toileting, bathing, lower body dressing, and bed-to-chair transfers.
Failure to Provide and Follow Ordered ROM and Splinting Services
Penalty
Summary
The facility failed to ensure appropriate ROM and mobility services for three residents. For one resident with diagnoses including myocardial infarction and COPD, the PT discharge summary documented an RNA program for AROM to both lower extremities after PT ended, and PT staff later stated the resident should have had an RNA ROM program to maintain lower-extremity ROM. However, the resident’s orders did not include an RNA program for ROM to the lower extremities, and MDS staff confirmed there were no such orders. The DON stated that when PT recommends an RNA program upon discharge, the program should be ordered and carried out so residents do not decline and maintain mobility. For another resident with cerebrovascular disease, dementia, dysphagia, and functional limitations in ROM in both upper and lower extremities, the record showed an RNA order for both knee splints up to four hours as tolerated five times a week. PT documentation from the evaluation, treatment encounters, and discharge summary did not show trials of knee splint wear times or tolerance, and PT stated there was no documentation that a safe wear time had been established. PT explained that splint wear is typically progressed gradually and that documentation of splint trials is part of PT treatment to determine whether the resident can safely tolerate the splint for the designated time. The resident’s OT JMS was also last completed in 2022, and staff confirmed that the JMS should be completed annually. For a third resident with cerebrovascular disease, hemiplegia, hemiparesis, severe cognitive impairment, and functional ROM limitations, the OSR included RNA orders for AAROM to both lower extremities, PROM to both upper extremities, splinting of a right PRAFO, and application of a right elbow splint. During observation, RNA staff also applied a right knee splint. PT later stated the resident’s right knee splint was no longer recommended and that there was no current RNA order to apply it. PT and the DOR stated the RNA order for the right knee splint had been discontinued, and the resident should not have been wearing it with RNA. The DON stated RNA staff should follow the therapist-ordered RNA program.
Annual RNA competency checks omitted splint and brace skills
Penalty
Summary
The facility failed to complete annual competencies for putting on and taking off splints and braces for two Restorative Nursing Aides, RNA 1 and RNA 2, who performed Restorative Nursing Aide program tasks that included these skills. During an observation in Resident 7's room, RNA 1 completed an RNA treatment session, performed passive range of motion exercises to the resident's upper and lower extremities, and then put on a right elbow splint, a right knee splint, and a right pressure relief ankle foot orthosis. During record review and interview with the DSD, the Supervised Clinical Practice competency checklists for RNA 1 and RNA 2 were reviewed, and it was stated that the annual competency checklists did not assess the skill of putting on and taking off splints and braces. The DSD stated this was a daily skill that RNAs had to perform and should be reviewed and checked annually. The DON stated RNA staff should be competent and ready to implement an RNA program, and the facility policy stated employees would be assessed for competency upon hire and annually, with each employee demonstrating competency related to skills, technique, and training necessary to provide nursing and related care and services in accordance with resident care plans.
Unsafe Food Storage and Contaminated Ice Machine Drainage
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen. One seasoning salt was not labeled with an open date and use-by date, and one dirty meal tray was placed on top of clean cups and then placed into the clean food cart. These observations were documented during the survey and were identified as practices that could allow cross-contamination. During a concurrent observation and interview in the staff lounge, the ice machine air gap was observed to be blocked with a black, slimy solidified substance that appeared very close to or extending into the drain receptor. Small droplets of water were noted, and a sewage-like odor was present. The Dietary Supervisor stated she did not know who was responsible for cleaning the air gap and acknowledged that the dripping pipe should not contact the sewage system. The Maintenance Supervisor later observed the same drainage pipe, stated it was not maintained in a clean and sanitary condition, and after wiping it with a paper napkin, thick oily black residue was seen on the napkin. Water was also observed dripping from the ice machine drainage pipe. The facility policy titled Ice Machine and Ice Storage Chests dated 4/2023 stated ice machines are to be maintained in a clean and sanitary manner to prevent contamination by microorganisms.
Overflowing Exterior Dumpsters
Penalty
Summary
The facility failed to ensure two garbage containers located outside the facility were maintained in sanitary condition, as both containers were observed overflowing with lids not closed. During a concurrent observation and interview with the Maintenance Supervisor, trash bags and loose garbage contents were seen on the ground around the dumpster area, along with discarded gloves. The Maintenance Supervisor confirmed that dumpster lids must remain closed and secured and that trash should not overflow. A review of the facility policy and procedure titled Sanitation, dated 11/2022, stated that garbage and refuse containers are to be maintained in good condition, waste is to be properly contained in dumpsters or compactors with lids secured or otherwise covered, and garbage disposal areas are to be kept free from odors and waste and maintained to prevent pests.
Delayed and Inaccurate PT ROM Documentation
Penalty
Summary
The facility failed to maintain timely and accurate completion of PT Joint Mobility Screens for two residents. For Resident 3, PT JMS entries with effective dates of 4/28/2025 and 10/28/2025 were not completed and documented until 11/4/2025, and the PT JMS with an effective date of 7/28/2025 was not completed until 9/22/2025. Resident 3’s record showed diagnoses including cerebrovascular disease, dementia, and dysphagia, and the MDS indicated severe cognitive impairment, functional ROM limitations in both upper and lower extremities, and dependence for oral hygiene, toileting, bathing, lower body dressing, and bed-to-chair transfers. During observation, Resident 3 was in bed while an RNA provided PROM to both upper and lower extremities and applied knee splints and soft heel protectors. The PT stated that PT is responsible for monitoring ROM, that JMS should be completed and documented on time, and that if completed very late it may not be accurate. The PT also stated the effective date was not accurate because the assessment was not performed until the day the JMS was documented. For Resident 7, PT JMS entries with effective dates of 3/3/2025 and 6/2/2025 were not completed and documented until 4/2/2025 and 11/4/2025, respectively. Resident 7’s record showed diagnoses including cerebrovascular disease, hemiplegia, and hemiparesis following cerebral infarction, and the MDS indicated severe cognitive impairment, ROM limitation on one side of the upper and lower extremities, and dependence for oral hygiene, toileting, bathing, dressing, and bed-to-chair transfers. During observation, an RNA performed PROM to the resident’s upper and lower extremities and applied a right elbow splint, right knee splint, and right PRAFO; the RNA stated the resident could not move the right arm and leg that much.
Failure to Obtain Informed Consent for Donepezil
Penalty
Summary
The facility failed to obtain informed consent for Resident 20’s donepezil, a medication prescribed for dementia. Resident 20 was admitted with diagnoses including dementia and type 2 diabetes mellitus, and the History & Physical signed and dated 3/30/2026 stated that the resident did not have the capacity to understand and make decisions. The MDS dated 4/4/2026 indicated the resident’s cognition was severely impaired, and the Order Summary Report dated 12/8/2023 showed a physician order for donepezil 5 mg, 1 tablet by mouth at bedtime for dementia. During a concurrent interview and record review on 4/29/2026, the MDS Coordinator stated that Resident 20’s physical chart and EHR did not contain signed informed consent for donepezil and acknowledged that signed informed consent is required prior to initiation of such medications and must be maintained in the medical record. The DON also confirmed that residents prescribed psychotropic or cognition-affecting medications are required to have signed informed consent in the medical record prior to or upon initiation of the medication, and that Resident 20 did not have a signed informed consent present. The facility’s Informed Consent policy revised 12/2024 stated that residents and/or their representatives must be fully informed of the benefits, risks, frequency/duration, and alternatives before initiating psychotherapeutic drugs or physical restraints, and that the prescriber must sign an informed consent form that is maintained in the clinical record.
Incorrect Wall Clock Time in Resident Room
Penalty
Summary
The facility failed to provide a homelike, orderly environment for one resident when the wall clock inside the resident’s room displayed the wrong time. During observation, the clock in the room showed 11:50 AM even though the actual time was 8:52 AM. A CNA present in the room stated that the clock was wrong and should show the correct time. The resident stated that she preferred the clock be set correctly so she could know the correct time while in her room. Resident 43’s record showed diagnoses including Alzheimer’s disease, anxiety disorder, and schizophrenia. The resident’s H&P dated 2/11/2026 stated that the resident does not have the capacity to understand and make decisions, while the MDS dated 3/10/2026 indicated intact cognition. The facility’s Maintenance Supervisor stated that if the clock shows the wrong time, it must be fixed and adjusted to show the correct time, and the DON stated that it is important for the resident’s clock to be orderly by displaying the correct time because the wrong time could confuse the resident. The facility policy on Homelike Environment stated that residents are to be provided a safe, clean, comfortable, and homelike environment, and that homelike characteristics include a clean, sanitary, and orderly environment.
Failure to Provide Written Bed-Hold Notification Before Hospital Transfer
Penalty
Summary
The facility failed to ensure that Resident 61, who was transferred to a GACH on 3/28/2026 for a change of condition, was provided a written bed-hold policy notification before transfer. Resident 61 was admitted with diagnoses including a right femur fracture and dementia, and the H&P signed 3/24/2026 stated the resident did not have the capacity to understand and make decisions. The MDS dated 3/28/2026 indicated the resident's cognition was severely impaired, and the physician discharge summary dated 3/28/2026 stated the resident was transferred for an elevated sodium level. A review of the resident's hard chart and electronic chart on 4/28/2026 found no bed-hold documentation. During concurrent interviews, the SSD confirmed that a completed 7-day bed-hold document was not present in either the physical or electronic chart and stated she was unable to provide documentation showing that the resident and/or resident representative had been given or acknowledged receipt of the required written bed-hold policy notification prior to transfer. The DON also confirmed that the completed 7-day bed-hold document was not present and stated that implementation of the bed-hold policy prior to transfer or discharge was necessary to ensure residents and/or responsible parties are informed of their rights during hospitalization.
Inaccurate RNA Care Plan
Penalty
Summary
The facility failed to update Resident 7’s restorative nursing aide (RNA) care plan to reflect the resident’s current RNA treatment program. Resident 7 had diagnoses including cerebrovascular disease, hemiplegia, and hemiparesis following cerebral infarction affecting the right dominant side, and the MDS dated 2/27/2026 indicated severe cognitive impairment and functional limitation in ROM of one upper extremity and one lower extremity, with dependent assistance needed for oral hygiene, toileting, bathing, dressing, and bed-to-chair transfers. The resident’s order summary showed current RNA orders for active assistive ROM to both lower extremities, passive ROM to both upper extremities, right PRAFO splinting, and a right elbow splint. However, the care plan still reflected older or inaccurate interventions, including a right knee splint and a left PRAFO, and did not match the updated RNA program. During observation, an RNA performed PROM to the resident’s upper and lower extremities and applied a right elbow splint, right knee splint, and right PRAFO, while stating the resident had three splints and wore them for up to six hours or as tolerated. During interview, PT and the DOR stated PT had discontinued the right knee splint order and that the resident did not have an active order for a right knee splint. The MDS Coordinator stated the RNA care plans did not reflect the resident’s new RNA treatment orders and were not accurate. The DON stated care plans were created by an interdisciplinary team, included treatments, and should be developed, revised, and updated based on changes to the resident’s care. Facility policies stated restorative goals are individualized and outlined in the plan of care, and that the care plan will be developed and revised as needed to include specific interventions to maintain or improve mobility and ROM.
Improper Administration of Oral Medication and Eye Drops
Penalty
Summary
Medication administration was not carried out as ordered for one resident with muscle weakness, dysphagia, and hypertension who was admitted with intact cognition per the MDS. The resident’s physician orders included Cyclosporine emulsion 0.05% to be instilled as 1 drop in both eyes twice daily for dry eyes and Simethicone 80 mg chewable tablets to be given by mouth four times daily for gas. During a medication administration observation, an LVN administered the Cyclosporine eye drops but did not apply pressure to the resident’s tear duct afterward. During the same observation, the LVN placed a Simethicone tablet in the resident’s mouth, but when the resident stuck out his tongue and the tablet was still visible, the LVN stated he was done with the medication administration and left the room before confirming the resident had swallowed it. In interview, the LVN stated he forgot to wait until the resident swallowed the Simethicone and said nurses must ensure the medication is completely swallowed before leaving. The DON stated that nurses must ensure oral medications are swallowed before leaving the bedside and that tear duct pressure should be applied after eye drop administration; facility policy also directed staff to remain with the resident until medication is swallowed and to apply gentle pressure to the tear duct after ophthalmic administration.
Failure to Provide Ordered Bite-Sized Diet Texture
Penalty
Summary
The facility failed to follow the prescribed diet order for one sampled resident, Resident 66, when the resident’s meal tray contained food that was not prepared in the ordered soft and bite-sized texture. Resident 66 had diagnoses including diabetes mellitus, Alzheimer’s Disease, and psychosis, and the history and physical stated the resident did not have the capacity to understand and make decisions. Speech therapy documentation dated 4/23/2026 indicated the resident exhibited dysphagia, coughing or choking during oral intake, and was at risk of aspiration, with a recommendation for a soft and bite-sized diet. The physician’s order also directed a NAS diet with soft and bite-sized texture and thin consistency, and the baseline care plan included soft and bite-sized texture with an intervention to provide diet and fluids as ordered. During a concurrent observation and interview on 4/27/2026, the Infection Preventionist Nurse observed Resident 66’s meal tray and stated it contained grilled cheese that was not bite size. The IPN stated the grilled cheese should have been cut into bite-sized pieces before leaving the kitchen. The Dietary Supervisor stated it was the cook’s responsibility to prepare food items in accordance with each resident’s dietary requirements and that food ordered as bite-sized must be cut up before it leaves the kitchen. The DON stated the resident’s diet is ordered for safety and nutritional needs and that the texture must match the diet order because not following it could pose a choking hazard.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records and care plans, which did not contain all necessary elements to ensure comprehensive care as required.
Medication Storage, Labeling, and Security Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage, labeling, and security of medications for several residents. One resident, with diagnoses including dementia and atherosclerotic heart disease, was found to be storing two bottles of Flonase nasal spray in his nightstand drawer and self-administering the medication without a physician's order or assessment for self-administration. The resident reported using the medication more frequently than prescribed, and staff confirmed there was no care plan or interdisciplinary team discussion regarding self-administration. The facility's policy required medications to be stored in locked compartments and only accessible by authorized staff, which was not followed in this case. Another resident, with epilepsy and psychosis, had Lorazepam, a controlled medication, stored in a medication refrigerator alongside non-controlled medications. Although the refrigerator and storage room were locked, the controlled medication was not kept in a separately locked compartment as required by facility policy and federal regulations. The DON acknowledged the importance of separate storage for controlled substances to prevent diversion and ensure proper tracking. Additionally, a third resident with diabetes was found to have insulin pens (Novolog FlexPen and Glargine) stored in the medication cart without expiration or discard dates labeled, despite being opened beyond the recommended 28-day period. The pens were administered past their effective date, and staff confirmed that expired medications had been given to the resident. Facility policy required proper labeling and immediate disposal of expired medications, which was not adhered to in this instance.
Improper Food Handling and Labeling in Kitchen
Penalty
Summary
Surveyors observed multiple deficiencies in food handling practices within the facility's kitchen. During a tour, it was noted that plastic cups containing whole milk and juice were labeled only with the date they were poured, lacking any use by or expiration date. Similarly, items in the freezer, such as a bag of green beans and a chocolate cream pie, were labeled with only the date they were stored, without any indication of when they should be used by. Lunch meat boxes also lacked use by dates. The Dietary Supervisor confirmed that the facility does not routinely apply use by or expiration dates to food items, despite the facility's policy requiring all refrigerated and frozen items to be properly covered, dated, and labeled. Additionally, during meal preparation, a kitchen staff member was observed plating food without wearing gloves or washing hands. The staff member acknowledged that gloves are required for food safety and to prevent contamination. These practices were inconsistent with professional standards and the facility's own policies, potentially exposing residents to foodborne illness due to improper food handling and inadequate labeling of potentially hazardous foods.
Delayed Meal Service Compromises Resident Dignity
Penalty
Summary
A deficiency occurred when a resident was not provided with respect and dignity during a meal service. The resident, who was moderately cognitively impaired and required supervision or assistance with eating, was observed waiting for her lunch tray for at least 20 minutes after other residents at her table had already received their meals and begun eating. The resident expressed dissatisfaction and stated that this was not the first time her tray was served late. Staff present in the dining room were unable to explain why the resident's tray was delayed, and the dietary supervisor acknowledged that the list of residents eating in the dining room was not always updated, which contributed to the delay. The resident's medical history included heart failure, schizophrenia, and hypertension. Facility policy required that residents at each table be served together and that all residents be treated with kindness, respect, and dignity. However, the failure to deliver the meal tray in a timely manner resulted in the resident eating alone, after the others had finished, and did not honor her right to dignified and equal care.
Failure to Accurately Document and Administer Scheduled Medication
Penalty
Summary
A licensed nurse failed to accurately and timely document medication administration for a resident with diagnoses including dementia and atherosclerotic heart disease. The resident was prescribed several medications, including daily aspirin (ASA) for stroke prophylaxis. On the morning in question, the nurse prepared seven medications for the resident's scheduled 9 AM administration, but did not include ASA among them. Despite not administering the ASA, the nurse signed the Medication Administration Record (MAR) at 8:53 AM, indicating that all scheduled medications, including ASA, had been given. The nurse later admitted to signing the MAR before actually administering the medications, which was not in accordance with facility policy. The nurse also acknowledged overlooking the physician's order for ASA and failing to double-check the orders before documenting administration. The facility's policy requires that the individual administering medications initials the MAR after giving each medication and before administering the next. The Director of Nursing confirmed that signing the MAR before medication administration could result in inaccurate documentation and medication errors. As a result of these actions, the resident did not receive the prescribed ASA as scheduled, and the MAR inaccurately reflected that it had been administered.
Failure to Provide Timely Incontinence and ADL Assistance
Penalty
Summary
Facility staff failed to provide timely assistance with activities of daily living (ADLs) and incontinence care for one resident who was unable to perform these tasks independently. The resident, who had a history of sepsis, obstructive and reflux uropathy, and anemia, was cognitively intact but required substantial to maximal assistance with toileting hygiene, bathing, and personal hygiene due to muscle weakness and other medical conditions. The resident's care plan specified the need for assistance with toileting and incontinence care after episodes of incontinence. On the day in question, the resident was observed wearing a wet incontinent brief with pink-colored urine and a foul smell that had not been changed from 7 a.m. to 3:10 p.m. The resident confirmed that the last change and cleaning occurred around 7 a.m. and sometimes had to remind staff for care. Staff interviews revealed a lack of communication between CNAs during shift change, resulting in the resident being left in soiled conditions for several hours. Facility policy required that residents unable to perform ADLs independently receive necessary assistance to maintain hygiene and grooming, which was not followed in this instance.
Failure to Prevent and Monitor Pressure Injuries
Penalty
Summary
A deficiency occurred when staff failed to provide necessary care and interventions to prevent the development or recurrence of pressure injuries for a resident with a history of a Stage 4 pressure injury. The resident, who was cognitively intact and required partial to moderate assistance with mobility, was identified as being at risk for pressure injuries based on a Braden Scale score and care plan. The care plan required daily and weekly skin assessments, regular repositioning, and use of a low air loss mattress, but documentation and implementation of these interventions were lacking. Record reviews revealed that after an initial skin assessment in December, there were no further documented skin assessments, and the Braden Scale was not updated after December. The weekly nurse note only referenced the use of a low air loss mattress as an intervention, omitting other required measures such as regular repositioning and skin checks. Observations and staff interviews confirmed that the resident was left in the same position for extended periods, with one instance where the resident remained on her back from morning until afternoon without repositioning. Staff were unsure about the frequency of repositioning and failed to document skin assessments or interventions when redness was observed. The facility's policy required daily skin inspections, individualized repositioning schedules, and documentation of any changes in skin condition. However, these procedures were not followed, as evidenced by the lack of documentation, inconsistent repositioning, and failure to assess and report skin changes. These actions and omissions led to the resident developing significant skin redness and placed her at risk for further skin breakdown.
Failure to Provide Adequate Supervision for High-Risk Resident with Visual Impairment and Dementia
Penalty
Summary
A deficiency occurred when the facility failed to provide an environment free from accident hazards and did not ensure adequate supervision and monitoring for a resident with significant fall risk and cognitive impairment. The resident, who had diagnoses of dementia, Alzheimer's disease, and a history of fractures, was assessed as being at high risk for falls due to unsteady gait, poor safety awareness, and impaired cognition. The care plan identified the need for interventions such as regular fall risk assessments and supervision, but these were not consistently implemented. On observation, the resident was seen walking unsupervised in her room with her eyes closed and hands outstretched, repeatedly running into a wall near the restroom area. No staff were present to assist or redirect her, and no bed or chair alarm was heard during the incident. Interviews with staff confirmed that the resident had recently developed new behaviors, including walking with her eyes closed due to eye irritation, which further increased her fall risk. Staff acknowledged that the resident required increased assistance and supervision, including 1:1 supervision for safety, but this was not provided at the time of the incident. Review of facility policies indicated that maintaining resident safety and providing adequate supervision are facility-wide priorities, with individualized interventions required to address specific risks. However, the care team did not update the care plan to address the resident's new behavior of walking with eyes closed, and interventions to mitigate the increased risk were not implemented or documented. This lapse in supervision and failure to modify interventions as needed led to the resident being left unsupervised despite her high risk for falls and injury.
Failure to Monitor and Document Catheter Care and UTI Signs
Penalty
Summary
The facility failed to provide appropriate monitoring and care for a resident with a suprapubic catheter, as required by both physician orders and facility policy. The resident, who had a history of sepsis, obstructive and reflux uropathy, and anemia, was identified as being at risk for urinary tract infection (UTI) due to the use of a suprapubic catheter. The care plan and physician orders specified that staff should monitor and document urine characteristics such as color, consistency, odor, and presence of blood, as well as secure the catheter with an anchor to prevent dislodgement. However, documentation in the Treatment Administration Record (TAR) indicated signs and symptoms of UTI on multiple dates, but did not specify what symptoms were observed or what interventions were provided. Additionally, there was no evidence in the nursing progress notes or catheter assessment that these symptoms were followed up with appropriate care or physician notification. Direct observations and staff interviews revealed further lapses in care. On one occasion, the resident's suprapubic catheter was observed to have pinkish urine output and a foul smell, and the catheter was not secured with an anchor, resulting in leakage. The resident reported being unable to monitor her own urine output and was not informed by nursing staff about her condition. Staff members, including a CNA and treatment nurse, confirmed that the catheter was not properly secured and that the odor was noticeable, but the treatment nurse was unaware of the pink urine until later in the day. The Director of Nursing acknowledged that the catheter should have been anchored at all times and that staff should have reported abnormal findings immediately. Interviews with nursing staff indicated a lack of detailed documentation and follow-up regarding the signs and symptoms of UTI noted in the TAR. Staff admitted that documentation was incomplete and that interventions were not clearly recorded. Facility policy required that catheter care include securing the catheter, observing for complications, and recording detailed information about urine characteristics and any unusual findings. These requirements were not met, resulting in a failure to accurately monitor and respond to potential UTIs and catheter-related complications for the resident.
Failure to Administer Ordered Aspirin for CVA Prophylaxis
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to administer aspirin (ASA) 81 mg as ordered by the physician for a resident with diagnoses including dementia and atherosclerotic heart disease. The resident was admitted with a physician's order for daily ASA for cerebrovascular accident (CVA) prophylaxis, and the medication was scheduled to be given at 9 AM. During medication administration, the LVN prepared and administered seven other medications but omitted ASA. The resident noticed the omission and questioned the LVN, who incorrectly stated that ASA was not part of the regimen. The LVN later acknowledged overlooking the physician's order in the Medication Administration Record (MAR) and did not double-check when the resident raised the concern. Further review revealed that the licensed nurses did not check the physician's order and were unaware that the resident was supposed to receive ASA. The facility's policy required medications to be administered safely, timely, and as prescribed, within one hour of the scheduled time. The failure to administer ASA as ordered resulted in the resident not receiving the medication as prescribed, as confirmed by observation, interview, and record review.
Failure to Document Vital Signs and Care for Resident with Declining Condition
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records for a resident with dementia and diabetes who was experiencing a declining condition and was being considered for hospice care. The staff did not document vital signs, updated plan of care, or the treatment and services provided to the resident, despite the resident being in a critical state that required frequent monitoring. The assigned LVN reported checking the resident every hour and performing vital sign checks every two hours during the night shift, but admitted to not documenting these assessments or the resident's condition in the progress notes. There were no recorded vital signs from the morning prior to the resident being found unresponsive, and no progress notes documenting the resident's condition or care for several days before the resident's death. The facility's policy and procedure on charting and documentation required that all services, progress toward care plan goals, and any changes in the resident's condition be documented in the medical record. However, interviews with facility staff, including the MDS nurse and DON, confirmed the absence of documentation regarding the resident's deteriorating condition, the plan for comfort or hospice care, and the care and services provided to the resident and family. This lack of documentation meant that the resident's clinical record did not accurately reflect the care delivered or the resident's status prior to being found unresponsive.
Failure to Implement PPE Use for Resident on Enhanced Barrier Precautions
Penalty
Summary
A Certified Nursing Assistant (CNA) failed to follow the facility's policy and procedure regarding the use of personal protective equipment (PPE) while in the room of a resident placed on Enhanced Barrier Precautions (EBP) due to a history of multidrug-resistant organism (MDRO) infection. During an observation, the CNA entered the resident's room, which had an EBP sign posted, and did not wear PPE while touching the resident's nightstand, table, and the resident, who was sitting in a wheelchair. The CNA acknowledged being aware of the EBP status and that PPE should have been worn, as instructed by the Infection Preventionist Nurse (IPN). The resident involved had diagnoses including Parkinson's Disease, difficulty walking, and dysphagia, and required substantial to maximal assistance with daily activities. The facility's policy required staff to perform hand hygiene and wear gowns and gloves for any care activity involving contact with environmental surfaces likely contaminated by the resident. The Director of Nursing (DON) confirmed that PPE use was necessary not only for direct care but also when touching the resident's bedside and surroundings, as these areas were likely contaminated.
Failure to Ensure Call Lights Were Within Reach for Residents at Risk for Falls
Penalty
Summary
The facility failed to provide reasonable accommodation for two residents, Resident 27 and Resident 14, who were at risk for falls. For Resident 27, the facility's records indicated a history of falling and a care plan that required the call light to be within easy reach. However, during an observation, the call light was found placed at the head of the bed, out of Resident 27's reach. Resident 27 confirmed the inability to reach the call light and expressed a need for assistance. Registered Nurse 1 acknowledged that the call light was not within reach and emphasized its importance for Resident 27's safety. Similarly, Resident 14, who had Alzheimer's disease and a history of falling, was also found to have the call light placed out of reach, hanging on a cabinet next to the bed. Resident 14 confirmed the inability to reach the call light. Certified Nurse Assistant 1 and the Director of Nursing both acknowledged that the call light was not within reach and stressed the necessity of having it accessible to ensure Resident 14's safety. The facility's policy and procedure also mandated that call lights should be within the resident's reach, which was not adhered to in these cases.
Failure to Maintain Homelike Environment Due to Disruptive Resident Behavior
Penalty
Summary
The facility failed to ensure a homelike environment for two residents, identified as Residents 51 and 54, due to the disruptive behavior of their roommate, Resident 12. Resident 12, who was admitted with multiple diagnoses including a fracture of the right femur and difficulty in walking, exhibited frequent outbursts of yelling, cursing, and swearing. These behaviors were observed to disturb the sleep of Residents 51 and 54, who both reported feeling tired and frustrated as a result. Despite repeated complaints to the staff, the disruptive behavior continued over several days, affecting the residents' ability to rest and their overall well-being. Interviews with the affected residents and staff confirmed the ongoing issue. Resident 51 and Resident 54 both expressed their frustration and the negative impact on their sleep and daily functioning. The Social Services Designee (SSD) acknowledged that the behavior of Resident 12 did not provide a homelike environment and was not conducive to the well-being of the other residents. The facility's Policy and Procedure on maintaining a homelike environment, which includes ensuring comfortable sound levels, was not adhered to in this case, leading to the deficiency noted in the report.
Failure to Accurately Post Nursing Hours
Penalty
Summary
The facility failed to post actual worked nursing hours at the start of each shift in the nursing stations visible to the residents and visitors, as required by the facility's Policy and Procedure. During an interview and record review with the Director of Staff Development (DSD), it was found that the Daily Staffing Posting for the morning shift indicated only 7 Certified Nursing Assistants (CNAs) were working, while the staffing assignment showed 10 CNAs were actually assigned. The DSD admitted to posting the projected number of staff the night before and not updating the posting if there were call-offs or staffing changes. This discrepancy resulted in inaccurate reflection of the number of staff providing direct care to the residents.
Expired Medications Found in Storage Room
Penalty
Summary
The facility failed to ensure the medication room was free from expired medications. During an inspection of the medication storage room, two bottles of undated opened Gabapentin oral solution were found in the medication refrigerator. One bottle was labeled with Resident 40's name and the other with Resident 13's name. The Minimum Data Set Coordinator (MDSC) confirmed that the prescribed medication should have a label indicating the opened date to ensure it is not used past its expiration date. The facility's policy requires that opened medications be labeled with the date they were opened and discarded after 30 days to ensure resident safety. Resident 40, who was readmitted with diagnoses including dysphagia and hemiplegia, had severely impaired cognition and was dependent on staff for daily activities. Resident 13, readmitted with diagnoses including dysphagia and cerebral infarction, had moderately impaired cognition and was also dependent on staff for daily activities. Both residents were prescribed Gabapentin oral solution for neuropathic pain. The Director of Nursing (DON) confirmed that all opened medications should be labeled with the date they were opened and discarded after 30 days, as per the facility's policy, to protect resident safety.
Infection Control Policy Violation in Kitchen
Penalty
Summary
The facility's kitchen staff failed to follow infection control policies by not wearing a hair net in the food preparation area. During an observation, the Dietary Supervisor (DS) was seen working without a hair net. In a concurrent interview, the DS admitted to forgetting to wear the hair net and acknowledged that it is required to prevent hair from falling into food and causing contamination. The facility's policy, revised in 2019, mandates that food service employees wear a hair net or head covering at all times to maintain sanitary conditions.
Failure to Provide Information on Advance Directives
Penalty
Summary
The facility failed to provide information about Advance Directives (AD) to a resident, which is a written preference regarding treatment options and a process of communication for future healthcare decisions. This deficiency was identified during an interview and record review of a resident who was readmitted with diagnoses including dysphagia and malignant neoplasm of prostate cancer. The resident's Minimum Data Set indicated that the resident had clear speech and was able to make themselves understood. However, the Social Service Director (SSD) admitted that they forgot to screen the resident for AD and acknowledged the importance of providing this information to respect the resident's medical treatment wishes. The facility's policy and procedure on Advance Directives, revised in September 2022, states that residents have the right to formulate an AD and that this should be inquired about prior to or upon admission. The SSD's failure to provide this information to the resident or their responsible party was a direct violation of this policy. This oversight had the potential to result in medical or surgical treatment being administered against the resident's will, thereby violating the resident's rights.
Failure to Document Medication Administration Immediately
Penalty
Summary
The facility failed to follow the professional standard of care and its own policy on documenting medication administration immediately after administering the medication. During an observation on 4/20/2024, RN 2 administered Ceftriaxone intravenously to Resident 6 but did not sign the Medication Administration Record (MAR) immediately afterward. RN 2 acknowledged this lapse during an interview, stating that the MAR should be signed right after administering medication to avoid errors and potential harm to the resident. The Director of Nursing (DON) confirmed that medication administration should follow the 'five rights' including right documentation, and that staff should sign the MAR immediately after giving medication to prevent errors such as double dosing. Resident 6, who was readmitted with diagnoses including dysphagia and hypertension, was prescribed Ceftriaxone 1 gram IV every 24 hours for a bacterial infection in the urine. The resident's Minimum Data Set (MDS) indicated that they had clear speech and the ability to understand and make themselves understood. The facility's policy on administering medications, revised in 3/2023, also required that the date and time of medication administration, along with the signature and title of the person administering the drug, be recorded in the resident's medical record immediately after administration.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling catheter, as evidenced by the presence of white sediments and cloudiness in the urine, and the catheter tubing touching the trash bin. The resident, who was admitted with diagnoses including a urinary tract infection (UTI) and urinary retention, had a care plan that required monitoring for signs and symptoms of UTI, such as changes in urine character and the presence of sediments. However, during an observation, it was noted that the catheter tubing was cloudy and contained white sediments, and was in contact with the trash bin, which could lead to cross-contamination and infection. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that the catheter should be monitored every eight hours for signs of infection and should not be in contact with the trash bin. The facility's policy on urinary catheter care, which aims to prevent catheter-associated complications, was not followed. The policy specifies using aseptic techniques and ensuring that catheter tubing and drainage bags are kept off the floor. The failure to adhere to these guidelines resulted in the potential for the resident to receive delayed care and treatment for a urinary tract infection.
Failure to Label and Rotate IV Site
Penalty
Summary
The facility failed to ensure that a resident received care and services for parenteral antibiotic administration consistent with professional standards of practice and the facility's policy. During an observation, it was noted that the resident's IV site was not labeled with the date of insertion, which is necessary for staff to know when to change the IV site to prevent infections. The registered nurse confirmed that the IV site should be labeled and rotated every three days to control infections, and failure to do so could lead to infection and worsen the resident's health condition. The resident, who was readmitted with diagnoses including dysphagia and hypertension, was prescribed Ceftriaxone IV daily for a bacterial infection. The facility's policy indicated that IV peripheral sites should be rotated at least every 96 hours, with extensions not recommended to exceed seven days. However, the resident's IV site was not labeled, and there was no indication that the site had been rotated as required, leading to a potential risk of infection.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to ensure that Resident 49 received oxygen therapy in accordance with the facility's policy and procedure. Specifically, Resident 49's nasal cannula tubing was observed touching the trash bin, which poses a risk of infection. Additionally, Resident 49 was receiving oxygen therapy without a physician's order, which is against the facility's policy that requires a doctor's order for oxygen administration to ensure accurate oxygen therapy. These observations were confirmed by interviews with CNA 2, RN 1, and the Director of Nurses (DON), who all acknowledged the importance of keeping oxygen tubing off the floor and the necessity of a physician's order for oxygen therapy. Resident 49 was admitted to the facility with diagnoses including acute respiratory failure with hypoxia and pneumonia. The Minimum Data Set (MDS) indicated that Resident 49 had intact cognition and required supervision for various activities of daily living. Despite these needs, the Order Summary Report (OSR) did not include an order for oxygen therapy. The facility's policy and procedure for oxygen administration, which was reviewed during the investigation, clearly stated that oxygen use requires a physician's order and that oxygen tubing should be stored in a clean bag when not in use to prevent cross-contamination and infection.
Unattended Computer Screen Exposes Resident Information
Penalty
Summary
The facility failed to follow its policy and procedure titled 'Management and Protection of Protected Health Information' by leaving a computer screen unattended and logged on, exposing a resident's identifiable, personal, and medical information. This incident involved a resident who was admitted with diagnoses including anemia and neoplasm-related pain. The resident's Minimum Data Set indicated moderately impaired cognition and total dependence on staff for various daily activities. During an observation, a computer screen displaying this resident's information was left unattended in a hallway, accessible to unauthorized persons. The Licensed Vocational Nurse (LVN) responsible for the computer admitted to forgetting to log out, acknowledging it as a HIPAA violation. The Director of Nursing (DON) confirmed that staff are required to protect residents' personal records at all times to prevent unauthorized access. The facility's policy, revised in 2014, mandates that all personnel ensure the management and protection of resident information to prevent unauthorized release or disclosure.
Failure to Ensure Resident Capacity for Binding Arbitration Agreement
Penalty
Summary
The facility failed to ensure that a resident, who signed a Binding Arbitration Agreement, had the capacity to understand and make an informed decision. Resident 14, who had multiple diagnoses including schizophrenia, Alzheimer's disease, and bipolar disorder, was admitted to the facility and was found to be moderately impaired in cognitive skills according to the Minimum Data Set (MDS). Despite this, Resident 14 signed the Binding Arbitration Agreement, which was not appropriate given their cognitive impairment as indicated in their History and Physical (H&P) record. The Business Office Manager (BOM) acknowledged that the staff should not have allowed Resident 14 to sign the document, as residents who lack the capacity to understand and make decisions cannot comprehend what they are signing. The Director of Nursing (DON) confirmed that staff should not ask residents to sign arbitration agreements if their H&P indicates they do not have the capacity to understand and make decisions. Additionally, the facility did not have a Policy and Procedure (P&P) in place regarding having residents sign arbitration agreements. This oversight had the potential to result in Resident 14 being unable to make an informed decision and having their rights denied.
Failure to Implement Enhanced Barrier Precautions for Resident with PICC Line
Penalty
Summary
The facility failed to ensure infection control practices per the facility's Policy and Procedure (P&P) were followed to prevent the transmission of disease and infection for one of five sampled residents. Specifically, the facility did not place a resident with a Peripherally Inserted Central Catheter (PICC) on Enhanced Barrier Precautions (EBP), which involves wearing a gown and gloves during high-contact resident care activities. This oversight was identified during a review of the resident's Admission Record and Minimum Data Set, which indicated the resident had multiple diagnoses, including peritonitis, stomach cancer, and surgical aftercare following stomach surgery. The resident was also moderately impaired in cognitive skills and dependent on staff for daily activities such as toileting, dressing, and bathing. The care plan for the resident indicated the need for enhanced standard precautions, but these were not implemented as required. During an observation and interview with the Infection Preventionist (IP), it was confirmed that the resident had a PICC line and should have been on EBP to protect against multidrug-resistant organism (MDRO) infections. The IP admitted to forgetting to place the resident on EBP, which could potentially lead to the spread of infection. The facility's P&P on Enhanced Barrier Precautions clearly stated that residents with indwelling medical devices, such as a PICC line, should be assessed for EBP upon admission and as needed. However, this protocol was not followed, resulting in a failure to protect the resident from potential infection risks.
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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 Montrose
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Usc Verdugo Hills Hospital Dp/snf | 0 mi | — | 0 | 0 |
| Montrose Springs Skilled Nursing & Wellness Center | 1.2 mi | ★★★★★ | 7 | 0 |
| La Crescenta Healthcare Center | 2 mi | ★★★★★ | 15 | 0 |
| Oakpark Healthcare Center | 3.6 mi | ★★★★★ | 24 | 0 |
| Autumn Hills Health Care Center | 3.8 mi | ★★★★★ | 7 | 0 |
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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.