Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Valley Manor Care Center during CMS and state inspections, most recent first.
Failure to Use PPE for EBP Care and Soiled Linen Handling: Staff repeatedly entered rooms of residents on EBP without gowns during high-contact care such as transfers, toileting, brief changes, and catheter handling. Staff also failed to use proper PPE when handling dirty linen, with a laundry assistant loading soiled linen into a washer while only partially gloved and exposing skin to the linen.
A facility failed to answer call lights promptly for multiple residents, with several cognitively intact residents reporting waits of 20 to 30 minutes or longer for toileting and other assistance. One resident said he became incontinent in bed after waiting too long, another said she and her roommate had to yell for help in the bathroom, and another reported a missed shower after staff did not return. Survey observations and the call light log confirmed repeated delays, including unanswered call lights for 18 and 26 minutes and many logged waits of 15 minutes or more, mostly during the morning hours.
A resident’s face sheet and medication list were found in the state survey results binder in the front lobby, where the public had access to them. The documents were behind the most recent survey results and contained personal medical information, including diagnoses. The NHA said the papers were likely accidentally added when survey results were printed and placed in the binder by the regional QA coordinator.
Failure to Protect a Resident from Physical Abuse by Other Residents. A resident with severe cognitive impairment, dementia, and communication deficits was physically assaulted by one resident who had a history of aggression and later slapped by another resident during a separate altercation. Staff intervened after both events, but the report shows the resident was not kept free from resident-to-resident physical abuse despite known vulnerability and prior behavior concerns.
Two residents remained on duloxetine without timely action on pharmacist-recommended GDRs, and the facility did not address the recommendations for about two months. One resident had COPD, anxiety, dysphagia, and moderate cognitive impairment, while the other had COPD, dementia, depression, and severe cognitive impairment. The DON stated monthly pharmacy recommendations were reviewed and sent to the medical director, but the record showed delayed follow-up and no specific documentation of medication modification requests for one resident.
Failure to Report Allegations of Abuse: The facility did not timely report suspected abuse involving an LPN and one resident, did not report a separate abuse allegation from another resident involving the same LPN, and did not report a representative’s allegation that an OT kicked a resident’s foot during therapy. The residents had significant medical and functional needs, and staff records showed the concerns were discussed internally, but the allegations were not reported to the State Agency as required.
Failure to Thoroughly Investigate Abuse Allegations: The facility did not thoroughly and timely investigate two abuse allegations involving an LPN and an OT. One resident reported rude treatment, slammed medication, and being grabbed and pushed back into his room, while his roommate corroborated parts of the event; the concern was handled as a grievance and medication issue rather than a full abuse investigation. A second resident’s representative reported that an OT kicked the resident’s foot during therapy, but the record showed only informal discussion and no documented abuse investigation.
A resident with left-sided hemiplegia, muscle weakness, and limited ROM was found without his brace on repeated observations, and staff could not locate it in his room. The resident said he had used a left arm brace before but had not seen it in a long time and did not recall staff doing ROM exercises except during PT over a year earlier. Records showed the restorative plan called for PROM twice daily and brace use, but documentation showed PROM was completed only 12 of 30 days and splinting only 2 of 30 days, with staff unsure whether the brace was still available or whether the ROM provided was active or passive.
A resident with severe cognitive impairment in the memory care unit allegedly consumed liquid citalopram that had been left on top of an unattended med cart. The medication was prescribed to another resident and had been discontinued but not removed for destruction. The resident was found in the common area, was alert at baseline, and had no distress or change in LOC.
Bed Rail Assessment and Monitoring Failure: A resident with multiple chronic conditions and dependence for several ADLs had a quarter bed rail placed for turning assistance, but the facility did not complete a bed rail safety assessment before installation and did not document attempts at less restrictive measures. The resident reported using the rail to reposition in bed and wanting another rail for added support, while the DON stated a new assessment should have been completed after the device was installed.
A resident with severe cognitive impairment and a history of wandering exited the facility undetected and was later found offsite by a CNA. The facility's care plan did not address elopement risk, and malfunctioning alarm and pager systems, along with inconsistent staff monitoring, contributed to the incident.
Two residents in an LTC facility experienced significant weight loss due to inadequate nutrition and hydration management. One resident, with severe protein-calorie malnutrition, lost 19% of their body weight over four months, while another resident with dementia experienced a 6.7% weight loss in three months. The facility failed to implement and document person-centered nutritional interventions, did not consistently monitor weights, and did not ensure adequate fluid intake. Staff interviews revealed issues with documentation accuracy and responsibility for monitoring nutritional intake.
The facility failed to address grievances regarding staff treatment, as residents reported CNAs being rough and rushing through care. Despite these concerns being raised in resident council meetings, there was a lack of documented follow-up or resolution. Resident interviews confirmed issues with staff attitudes and inadequate care, which were not effectively addressed by the facility's grievance process.
The facility failed to ensure proper hand hygiene during meal times in dining rooms and a kitchenette. Residents were not offered hand hygiene before meals, even after touching potentially contaminated surfaces. Staff, including Cook #3, did not consistently perform hand hygiene when handling food or after touching high-contact surfaces. Training records showed dietary staff received hand hygiene training, but it was not effectively implemented during meal service.
A facility failed to ensure a resident's legal representative signed the Medical Orders for Scope of Treatment (MOST) form. The resident, with severe cognitive impairment, had a Medical Durable Power of Attorney (MDPOA) document appointing two family members for medical decisions. However, the MOST form was signed by an unauthorized family member. Staff interviews revealed a lack of clear procedures for verifying the MDPOA, with responsibilities falling on floor nurses and no established process for confirmation.
Two residents with severe cognitive impairments were involved in a physical altercation, highlighting the facility's failure to prevent abuse. The care plans for both residents were not updated with effective interventions following the incident. Staff interviews indicated that resident-to-resident incidents were common due to dementia, and a lack of consistent activities, especially in the evenings, may have contributed to increased agitation and altercations.
A resident with dementia was inappropriately restrained using a gait belt by an RN, contrary to facility policy. The resident, who was at high risk for falls, was observed attempting to stand and walk but was repeatedly pulled back into her wheelchair by the RN. Staff interviews revealed a lack of awareness about specific fall interventions and inappropriate use of the gait belt, which was not reported by other staff members.
The facility failed to engage two residents with dementia in meaningful activities, leading to resident-to-resident abuse. Observations showed residents were often left unattended or asleep during activities, with minimal staff interaction. Care plans were not updated with effective interventions following altercations, and staff interviews revealed inconsistent activity provision, particularly during the evening shift.
The facility failed to discontinue PRN psychotropic medications after 14 days for two residents, contrary to its policy. One resident with Alzheimer's and dementia was prescribed Lorazepam for extended periods without physician documentation. Another resident with dementia and cerebrovascular disease was given Seroquel and Lorazepam beyond 14 days without justification. Staff interviews confirmed the lack of documentation for these extended prescriptions.
The facility failed to provide residents with food that was palatable and at safe temperatures. Residents reported issues with cold meals, tough meat, and overcooked vegetables. Observations confirmed improper food handling, with temperatures often below safe levels. Equipment malfunctions and staff training deficiencies contributed to the problem.
The facility failed to properly disinfect a shared mechanical lift and slings between residents, leading to a deficiency in infection control. Observations showed that the lift and sling were not cleaned after use with a male resident before being used for a female resident. Staff interviews revealed inconsistencies in infection control practices, with some staff believing disinfection was unnecessary if slings only touched clothing. The regional infection preventionist stressed the need for disinfection after each use, highlighting a gap in practice and understanding.
Failure to Use PPE for EBP Care and Soiled Linen Handling
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program on two units by not ensuring staff used PPE during enhanced barrier precautions (EBP) and while handling dirty linen. The report states that EBP was required for residents with high-contact care needs, including residents with wounds, indwelling medical devices, or infections, and that gown and glove use was required for activities such as bathing, transferring, hygiene, changing linens, toileting, device care, and wound care. The infection preventionist said the facility used door signs to alert staff to EBP requirements and that staff education and walking rounds were still being arranged. Surveyors observed multiple instances in which staff entered rooms of residents on EBP without donning gowns during high-contact care. CNA #7 and CNA #8 transferred one resident with an indwelling urinary catheter and collection bag without gowns, and later transferred another resident with a Hoyer lift without gowns while handling the resident’s catheter and bag. RN #2 assisted another resident in the bathroom without a gown. CNA #1 and CNA #2 also transferred a resident from a recliner to a wheelchair via Hoyer lift without gowns while handling the resident’s catheter and collection bag. In another observation, CNA #4 changed a resident’s brief in a room marked for EBP without gloves or a gown. The facility also failed to ensure proper PPE use when handling soiled linen. A laundry assistant was observed loading dirty linen into a washing machine while wearing one glove that did not fully cover the hand, and the linen contacted the worker’s wrist, forearms, and ungloved hand. Facility policy stated that potentially contaminated linen was to be handled with appropriate measures to prevent cross-transmission, and staff interviews confirmed that PPE was expected when handling soiled linens. The infection preventionist stated that PPE should be worn when handling visibly soiled linens and that there was a risk of cross contamination without PPE.
Delayed Call Light Response and Lack of Timely Assistance
Penalty
Summary
The facility failed to provide care to residents in a manner that promoted dignity and timely assistance because call lights were not answered promptly for multiple residents. The deficiency involved Resident #3, Resident #6, Resident #55, and Resident #61, all of whom reported prolonged waits after activating call lights. The facility policy stated that all call lights must be answered promptly, whether or not staff were assigned to the resident, and that residents should not be made to feel staff were too busy to assist them. Resident #3 was cognitively intact, dependent on staff for toileting, oral hygiene, bathing, and footwear, and required substantial assistance with personal hygiene and dressing. He reported that staff usually took a long time to respond, often 10 to 15 minutes or more, and that he frequently waited 20 to 30 minutes for help. He said he sometimes had to yell for assistance and described an incident in which he became incontinent of bowel in bed after waiting so long for staff to respond. He also stated he felt frustrated and embarrassed when he could see his bathroom from his bed but could not get help in time. Resident #6 was cognitively intact and required substantial assistance with toileting and moderate assistance with bathing. She reported frequently waiting over 20 minutes after pressing her call light, including waits of up to 30 minutes in the bathroom, sometimes requiring her and her roommate to yell for help. Resident #55 was cognitively intact and dependent on staff for transfers, bathing, toileting, hygiene, dressing, and footwear. She reported waiting 20 to 30 minutes for assistance, said a shower was missed after she chose to bathe later in the day, and stated staff told her they no longer had time. Resident #61 had moderate cognitive impairment and required supervision or touching assistance with toileting and bathing. She reported waiting over 20 minutes after using the call light multiple times, said the problem happened most often at night, and recalled having to scream for help from the toilet. Survey observations and record review confirmed the pattern of delayed response. During observation, one call light was unanswered for 18 minutes and another for 26 minutes. The call light response log from 3/25/26 through 4/8/26 showed 71 instances of waits of 15 to 20 minutes, 59 instances of 20 to 30 minutes, 13 instances of 30 to 40 minutes, six instances of 40 to 50 minutes, and seven instances of 50 minutes or longer. The majority of prolonged response times occurred between 12:00 a.m. and 12:00 p.m. Staff interviews indicated CNAs were responsible for answering call lights while also providing baths, and they described difficulty responding promptly when one CNA was off the floor bathing a resident. Leadership acknowledged awareness of prior complaints and audits showing long wait times, including waits of 20 to 40 minutes, and stated they were not aware that prolonged response times over 30 minutes were occurring almost every day.
Resident Medical Information Left in Public Survey Binder
Penalty
Summary
The facility failed to keep Resident #20’s medical information private and confidential when the resident’s face sheet and medication list were found in the state survey results binder located in the front lobby, an area accessible to the public. The documents were discovered behind the most recent survey results in the binder, and the face sheet contained personal medical information including diagnoses. The nursing home administrator stated she was surprised the resident’s face sheet and medication list were in the binder and explained that only three staff members updated it: the regional quality assurance coordinator, the DON, and herself. She said the documents likely remained on the printer when the survey results were printed and were accidentally placed in the binder with the survey materials. The administrator confirmed the information was removed after discovery, and the DON and administrator later stated the regional quality assurance coordinator likely included the resident’s documents when updating the binder.
Failure to Protect a Vulnerable Resident from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to keep one resident free from physical abuse by other residents. The report states that Resident #7, who had Lewy body dementia with mood disturbance, anxiety, depression, severe cognitive impairment, and required maximum assistance with ADLs, was identified as vulnerable to abuse because of dementia and communication deficits. The resident’s care plan called for observation to minimize and prevent recurrence, and the record also documented that Resident #7 had a superficial scratch to the jawline after the first incident. In one incident, Resident #70, who had dementia with severe agitation and behavioral disturbances, severe cognitive impairment, and a history of verbal and physical aggression toward staff and other residents, came up behind Resident #7, grabbed her neck, pushed and slapped her, and caused a superficial wound to the jawline. The investigation documented that staff witnesses confirmed the assault, the nurse was not in the unit at the time, and the facility determined the behavior was new for Resident #70. The investigation also documented that the residents were to be kept separated by at least six feet as much as possible, but the event had already occurred before staff intervened. In a second incident, Resident #64, who had dementia, anxiety, depression, severe cognitive impairment, and no documented behaviors on assessment, slapped Resident #7’s hand after Resident #7 attempted to take a blanket from her. Resident #7 then attempted to retaliate physically, and staff intervened to separate the residents. The observation and investigation documented that the residents were in the common area when the altercation occurred, and the report states that Resident #64 had a history of wandering into other residents’ rooms and that staff were to remove her to an area away from others when inappropriate behaviors occurred.
Failure to Address Pharmacist-Recommended GDRs for Two Residents
Penalty
Summary
The facility failed to ensure two residents were free from unnecessary psychotropic medication use and were receiving the least restrictive approach for their needs because pharmacist-recommended gradual dose reductions (GDRs) were not addressed for about two months. The deficiency involved Resident #21 and Resident #44, both of whom were receiving duloxetine and had pharmacy consultant recommendations dated 12/9/25 to attempt a GDR to 30 mg daily or document a clinical contraindication. Resident #21 was readmitted with diagnoses including COPD, anxiety, and dysphagia. Her 3/12/26 MDS showed moderate cognitive impairment with a BIMS score of 11 out of 15 and maximum assistance needed with ADLs. The record showed duloxetine 60 mg twice daily was ordered on 6/17/24 and discontinued on 2/10/26, with a new order for duloxetine 30 mg daily on 2/10/26. The EMR showed the facility did not address the pharmacist’s 12/9/25 recommendation for approximately two months. Resident #44 was readmitted with diagnoses including COPD, dementia, and depression. Her 2/9/26 MDS showed severe cognitive impairment with a BIMS score of 1 out of 15 and maximum assistance needed with ADLs. The record showed duloxetine 60 mg at bedtime was ordered on 6/12/25 and discontinued on 2/6/26, with a new order for duloxetine 30 mg daily on 2/6/26. The EMR showed the facility did not address the pharmacist’s 12/9/25 recommendation for approximately two months, and there was no documentation of specific requests for medication modification for Resident #44.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to timely report suspected abuse and failed to report two additional allegations of abuse involving staff and residents. The deficiency involved three residents: one resident who reported rude, aggressive, and physically forceful behavior by an LPN; a second resident who reported that the same LPN shoved pills into her mouth while she was asleep; and a third resident whose representative reported that an OT kicked the resident’s foot during therapy. The facility’s abuse reporting policy required suspected mistreatment to be immediately reported to a supervisor, Administrator/Executive Director, or designee. For the first incident, a resident with diagnoses including adult failure to thrive, chronic atrial fibrillation, and stage 3 kidney disease, and with moderate cognitive impairment, reported that an LPN slammed pills on the table, yelled at him, and grabbed and pushed him back into his room after he asked about his medications. His roommate corroborated that the LPN was mad, slammed the pills, and that pills went everywhere. The resident said he reported the incident to front office staff the next morning and later filed a grievance. The facility did not report the allegation to the State Agency until several days after the incident, after the resident had already reported it to staff and submitted a grievance. Staff interviews showed the SSD was aware of the concern early, but the NHA and DON did not treat it as reportable at the time because they believed there was no intent to harm and no injury. For the second incident, a cognitively intact resident with dysphagia, osteoporosis, cognitive communication deficits, and anxiety reported that the same LPN woke her while she was asleep, shoved pills into her mouth, and checked her body for patches. The grievance form documented the resident’s concern that she could have choked and did not want to be awakened that way. The SSD stated that the word “shoved” would have triggered reporting and investigation, but the facility did not report the allegation to the State Agency. The grievance was handled internally, and the DON and NHA stated they did not consider it abuse because the resident later said she was comfortable with the LPN and had made amends. For the third incident, a resident who had been admitted for therapy after a left femur fracture and who had mobility impairment and dependence for transfers had a representative report that an OT kicked the resident’s foot during a therapy session. An OT note documented the resident telling the OT not to push him around like that, and the OT ending the session because he did not feel safe continuing. The facility discussed the concern internally, but the State Agency portal did not show that the allegation of abuse was reported. The NHA later stated the concern was considered resolved and that the incident was not reported or investigated as alleged abuse.
Failure to Thoroughly Investigate Abuse Allegations
Penalty
Summary
The facility failed to thoroughly and timely investigate allegations of abuse involving two residents. One allegation involved an LPN and a resident who had moderate cognitive impairment, a BIMS score of 10 out of 15, and diagnoses including adult failure to thrive, chronic atrial fibrillation, and kidney disease stage three. The resident reported that the LPN responded rudely when he asked what pills he was taking, slammed the pills on the table, and later grabbed his arm and pushed him back into his room when he came into the hallway in his underwear. His roommate said he saw the nurse slam the pills and was upset by the interaction. The resident and roommate both completed grievance forms describing the incident. The facility’s documentation showed that the DON spoke with the LPN about the medication concern and that the grievance was treated as partially confirmed, but the record did not show a thorough abuse investigation. The resident’s progress notes did not document the incident, and staff interviews showed the event was handled as a medication and communication issue rather than as a possible abuse allegation. The SSD said the incident was not discussed with the IDT and that the facility did not interview other residents or fully explore whether the resident felt abused. The NHA and DON stated they believed the matter had already been looked into and did not initially view it as abuse, despite the resident’s report that he felt the interaction was abusive and the roommate’s corroborating observations. A second allegation involved an OT and a resident who had been admitted for therapy after a displaced left femur fracture, had gait and mobility abnormalities, was cognitively intact with a BIMS score of 14 out of 15, and was dependent for transfers. The resident’s representative reported that she observed the OT kick the resident’s foot during therapy and that the therapist yelled at the resident and said he would not work with him anymore. The OT note from the same day documented that the resident yelled, told the OT not to push him around like that, and that the OT ended the session and assisted him back to his room. Facility staff later described the foot contact as the OT sliding or lifting the resident’s foot, but the record showed no documented investigation of the physical abuse allegation. The SSD stated the concern was discussed in a care conference and by email, but the NHA later acknowledged that the incident was not investigated as alleged abuse and that she was not aware of the OT note documenting the resident’s statement.
Failure to Consistently Provide ROM Exercises and Brace Use
Penalty
Summary
The facility failed to ensure a resident with limited ROM received appropriate treatment and services to maintain or improve ROM and prevent further decrease in ROM. Resident #3 had diagnoses including cerebral infarction with left-sided hemiplegia/hemiparesis, muscle weakness, chronic pain, and functional limitations to ROM in the left upper and lower extremities. The resident was cognitively intact, dependent on staff for several ADLs, and reported that his left arm did not listen to him anymore. He also stated he previously had a blue brace for his left arm and a smaller white brace for his right hand, but the blue brace had gone missing a long time ago and he did not know where it was. Observations showed Resident #3 repeatedly without a brace on either hand. On one observation, his left arm was flaccid and his hand rested in a closed fist position, though he could reposition the arm and open the fingers with his right hand. During another observation, he again had no brace in place. CNAs searched his room and personal storage areas but could not locate the braces. Resident #3 also stated he did not remember staff completing ROM exercises with him other than when he was receiving PT over a year ago. Record review showed the restorative nursing care plan directed staff to provide PROM to the left upper extremity twice daily and to apply a splint/brace to the left hand and forearm after evening PROM and before putting it on in the morning. However, CNA task records documented PROM was completed only 12 of the last 30 days, and the splinting task was documented only 2 of the last 30 days. Staff interviews confirmed uncertainty about whether the brace was still present, whether it was being applied, and whether the ROM provided was active or passive. The director of rehabilitation and DON stated the resident had not received PT or OT in over a year and could not confirm the restorative interventions were still appropriate without reassessment.
Medication Left on Cart and Consumed by Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure an environment free from accident hazards when Resident #44 allegedly ingested liquid citalopram that had been left on top of a medication cart that was unattended. The resident was in the memory care unit, had severe cognitive impairment with a BIMS score of 1 out of 15, and required maximum assistance with ADLs. The resident was unable to describe where or how the medication was obtained. The facility investigation documented that the citalopram had been prescribed to another resident and had been discontinued, but it had not been removed from the cart immediately for destruction. The investigation stated that RN #2, an agency nurse, had started the process of medication destruction and was pulled away from the cart without returning the medication inside the cart before leaving the unit. The facility determined the nurse most likely left the medication on top of the cart unattended, and the resident then grabbed it when the nurse was not present. A progress note documented that the resident was found in the common area after the incident and had consumed liquid medication. The note stated the resident was alert at baseline, without distress, denied pain, and had no change in level of consciousness. The attending provider ordered monitoring of pulse, temperature, vital signs, and level of consciousness, and the consulting pharmacist noted a possible interaction with the resident’s duloxetine and that citalopram overdose often causes mild to moderate symptoms, particularly under 600 mg.
Bed Rail Assessment and Monitoring Failure
Penalty
Summary
A bed rail safety assessment was not completed before a quarter bed rail was placed on Resident #74's bed, and less restrictive measures were not documented as attempted before the bed rail was used. Resident #74 was admitted for a respite stay and had diagnoses including restless leg syndrome, osteoporosis, macular degeneration, chronic kidney disease, atherosclerotic heart disease, COPD, generalized anxiety disorder, and chronic pain. The baseline care plan showed the resident was dependent on staff for toileting, bathing, and transfers and required substantial assistance with footwear and upper and lower body dressing. Resident #74 told the surveyor that a staff member installed the quarter bed rail a few days after arrival and that she used it to reposition herself in bed because of left hand and finger contractures. She said she would have liked another quarter bed rail on the right side and was worried about rolling out of bed when turning to the right. The CPO included an order for a left assist bar for turning assistance, and the DON stated the bed rail was placed after the assessment and that a new assessment should have been completed once the assistive device was installed. The facility's review also indicated the quarter bed rail was installed after the assessment.
Failure to Prevent Elopement Due to Inadequate Supervision and Care Planning
Penalty
Summary
A deficiency occurred when the facility failed to implement adequate interventions to prevent an elopement for a resident identified as high risk for elopement. The resident, who had severe cognitive impairment, dementia with behavioral disturbances, and a history of wandering and exit-seeking behaviors, was found off facility grounds in a supermarket parking lot by a CNA. The facility was unaware that the resident had left until notified by the CNA, who encountered the resident while off duty. The last known sighting of the resident within the facility was approximately an hour before the elopement was discovered. The facility's policies required elopement risk assessments and care planning for residents at risk of wandering or elopement. Although the resident's assessments and progress notes documented exit-seeking behaviors and a risk for elopement, the comprehensive care plan did not include a focus or interventions specifically addressing elopement risk. Additionally, there were gaps in monitoring at the front door, which was the exit point used by the resident. The front door was only alarmed with an audio alert during certain hours, and the pager system used to notify staff of door openings was not functioning correctly, only indicating the front door regardless of which door was opened. Staff interviews revealed that pagers were often ignored due to this malfunction, and there was not always staff present to monitor the front door. Observations during the survey also found that alarms on other doors were sometimes deactivated for convenience, and not always promptly reactivated, leaving those exits unmonitored. Staff interviews confirmed that the resident frequently wandered, especially in the afternoons, and that staff relied on informal methods to redirect him rather than consistent, documented interventions. The lack of a current, active care plan for elopement risk and the failure to ensure functioning alarm systems and adequate supervision directly contributed to the resident's ability to leave the facility undetected.
Failure to Ensure Adequate Nutrition and Hydration
Penalty
Summary
The facility failed to ensure adequate nutrition and hydration for two residents, leading to significant weight loss. Resident #17, diagnosed with chronic obstructive pulmonary disease, chronic respiratory failure, and severe protein-calorie malnutrition, experienced a severe weight loss of 19% over four months. Despite a physician's order to weigh the resident weekly, the facility did not consistently monitor the resident's weight. The only nutritional intervention implemented was a supplement, which was not consistently provided or documented. The care plan was not updated with person-centered interventions after the resident's weight loss. Resident #39, diagnosed with dementia, cardiomegaly, and chronic kidney disease, also experienced significant weight loss. The facility failed to document new interventions in the care plan after the weight loss was identified. The resident was not reweighed after issues with the scale were noted, and no additional interventions were implemented to prevent further weight loss. The facility did not ensure the resident consumed the estimated required amount of fluids to maintain physical function. Interviews with staff revealed a lack of clarity and responsibility regarding the documentation and monitoring of nutritional intake. The registered dietitian expressed concerns about the accuracy of documentation and the process for assessing the effectiveness of nutritional interventions. The director of nursing acknowledged the need for improved documentation and education to enhance resident record accuracy. The facility's failure to implement and document appropriate nutritional interventions contributed to the residents' significant weight loss and inadequate hydration.
Facility Fails to Address Resident Grievances on Staff Treatment
Penalty
Summary
The facility failed to effectively address and resolve grievances concerning staff treatment towards residents, as highlighted by the resident council meetings and individual interviews. Residents repeatedly expressed concerns about CNAs being rough, rushing through care, and not taking the time to ensure all their needs were met. Despite these grievances being raised in resident council meetings, there was a lack of documented follow-up or sustainable plans for resolution. The facility's grievance/concern tracking logs did not reflect these ongoing issues, indicating a failure in the grievance process. Resident interviews further corroborated the issues raised in the resident council meetings. Several residents reported that staff had an attitude, rushed through care, and did not communicate effectively. Some residents felt uncomfortable and neglected, as staff would leave them on the toilet for extended periods or fail to assist them fully before leaving the room. These interviews highlighted a pattern of inadequate care and communication from the staff, which was not adequately addressed by the facility's grievance process. The facility's internal processes for handling grievances were found to be lacking. The SSD and other staff members acknowledged that grievances were not consistently followed up on, and there was a decrease in grievance cards generated. The facility's QAPI meetings did not effectively address these concerns, and there was a lack of oversight in the grievance process. The facility's failure to document and follow up on grievances contributed to the ongoing dissatisfaction and unresolved concerns among residents.
Deficient Hand Hygiene Practices During Meal Service
Penalty
Summary
The facility failed to maintain proper hand hygiene practices during meal times in two of three dining rooms and one kitchenette. Observations revealed that residents were not offered hand hygiene before meals, even after touching potentially contaminated surfaces such as wheelchair wheels and walker handles. Hand hygiene supplies were not readily available on dining room tables, and staff did not encourage or provide hand hygiene to residents before they ate. In the memory care unit dining room, multiple instances were observed where residents were not offered hand hygiene before meals. Some residents used their hands to eat food after touching their noses or other potentially contaminated surfaces. Staff did not intervene when residents touched each other's food, increasing the risk of cross-contamination. Additionally, hand hygiene was not consistently performed by staff when handling food or after touching high-contact surfaces. Cook #3 was observed failing to perform hand hygiene after touching door handles and before handling food and clean dishes. The cook also did not wash hands before donning gloves to serve food. Training records indicated that dietary staff, including Cook #3, had received hand hygiene training, but the training did not appear to be effectively implemented during meal service. Interviews with staff and the regional infection preventionist highlighted the lack of a structured hand hygiene process before meals, contributing to the observed deficiencies.
Failure to Ensure Legal Representative Signed MOST Form
Penalty
Summary
The facility failed to ensure that a resident's legal representative was given the opportunity to exercise the resident's rights, specifically regarding the signing of the Medical Orders for Scope of Treatment (MOST) form. Resident #30, who had severe cognitive impairment due to Alzheimer's disease and dementia, had a Medical Durable Power of Attorney (MDPOA) document that legally appointed two family members to act on their behalf for medical decisions. However, the MOST form was signed by a family member who was not one of the designated MDPOAs, thus not legally authorized to make such decisions. Interviews with facility staff revealed a lack of clear procedures for verifying the MDPOA. Registered Nurse (RN) #1 admitted uncertainty in confirming the MDPOA's accuracy, while the Social Services Director (SSD) and Director of Nursing (DON) acknowledged that the responsibility for completing the MOST forms fell on the floor nurses during admission. The SSD noted that MOST forms were reviewed during care conferences but not routinely by social services, and the DON confirmed there was no established process for verifying the MDPOA, indicating a systemic issue in ensuring the correct legal representative was involved in decision-making.
Failure to Prevent Resident-to-Resident Abuse in Memory Care Unit
Penalty
Summary
The facility failed to protect residents from abuse, specifically in the case of two residents who were involved in a physical altercation. Resident #6, who was severely cognitively impaired and had a history of behavioral issues, physically abused Resident #66, who also had severe cognitive impairment and behavioral disturbances. The incident occurred when Resident #66 attempted to enter a room to use the bathroom, and Resident #6 responded by grabbing and slapping Resident #66. The facility did not assess the residents immediately after the incident to ensure there were no injuries, and the incident was not reported in a timely manner. The care plans for both residents were not updated with effective interventions to prevent further abuse. Resident #66's care plan included interventions for her dementia and behavioral issues, but it was not revised following the altercation to include personalized strategies to prevent future incidents. Similarly, Resident #6's care plan lacked a vulnerability care plan and an individual abuse prevention plan, failing to address the risk of resident-to-resident abuse. Interviews with staff revealed that resident-to-resident incidents were common in the memory care unit, attributed to the residents' dementia. Staff noted that keeping residents separated could help prevent incidents, but there was a lack of consistent activities, especially in the evenings, which may have contributed to increased agitation and altercations. The memory care coordinator acknowledged the need for more structured activities and supervision during the evening shift to reduce such incidents.
Inappropriate Use of Gait Belt as Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, specifically through the inappropriate use of a gait belt. The resident, identified as Resident #50, was observed repeatedly attempting to stand and walk, only to be restrained by a registered nurse (RN #2) using the gait belt to pull her back into her wheelchair. This occurred multiple times over a period of observation, with the nurse using the gait belt to prevent the resident from standing and walking, despite the resident's apparent desire and attempts to do so. The resident's care plan indicated she had unspecified dementia without behavioral disturbances and was at high risk for falls. However, the care plan did not include specific interventions for when the resident was constantly standing and sitting or when she pulled her wheelchair behind her as she walked. Staff interviews revealed that some staff members were aware of the inappropriate use of the gait belt but did not report it, and there was a lack of awareness about the specific fall interventions in place for the resident. The facility's policy on physical devices and bedrails emphasized that devices should only be used to treat a medical symptom or condition that endangers the resident's safety, with a physician's order and consent. The policy also stated that devices should not be used as restraints. Despite this, RN #2 used the gait belt in a manner that effectively restrained the resident, contrary to the facility's policy and the training provided to staff.
Failure to Provide Meaningful Activities for Dementia Residents
Penalty
Summary
The facility failed to provide appropriate treatment and services to residents diagnosed with dementia, specifically for two residents who were not engaged in meaningful activities, leading to resident-to-resident abuse. The facility's memory support program, which operates under a person-centered model, was not effectively implemented. Observations revealed that residents were often left unattended or asleep during activities, with minimal staff interaction. For instance, during a video activity about bees, most residents, including one of the affected residents, were asleep, indicating a lack of engagement. The care plans for the two residents involved were not updated with effective interventions following a resident-to-resident altercation. One resident, who had severe cognitive impairment and experienced hallucinations and behavioral symptoms, was not provided with meaningful activities as outlined in her care plan. The care plan included interventions such as crafts, religious shows, and outdoor activities, but these were not implemented effectively. Similarly, the other resident, who also had severe cognitive impairment and behavioral disturbances, was not engaged in activities that matched her interests, such as sports on TV, and her care plan was not updated to prevent further altercations. Interviews with staff revealed a lack of consistent activity provision, particularly during the evening shift. The activity aide assigned to the memory care unit admitted to waiting for activities to do, resulting in residents being left to sleep in recliners. The memory care coordinator acknowledged the need for more supervision during the evening shift, as this was when more problematic behaviors occurred. The director of nursing noted that the facility was trying to approve a dedicated activity aide position for the memory care unit to ensure residents received consistent and meaningful engagement.
Failure to Discontinue PRN Psychotropic Medications After 14 Days
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications, specifically regarding the use of PRN (as needed) orders for two residents. The facility's policy, revised in August 2023, states that PRN orders for psychotropic medications are limited to 14 days unless extended by a physician. However, the facility did not adhere to this policy for two residents, resulting in the administration of psychotropic medications beyond the 14-day limit without documented justification from a physician. Resident #30, an 87-year-old with Alzheimer's disease and dementia, was prescribed Lorazepam, an anti-anxiety medication, on a PRN basis for periods exceeding 14 days on multiple occasions. The medication was ordered for 90 days in June 2023, 90 days in October 2023, and 60 days in May 2024, without any documentation from a physician justifying the extended use. Similarly, Resident #21, who was over 65 years old and had dementia, cerebrovascular disease, and insomnia, was prescribed Seroquel and Lorazepam on a PRN basis for more than 14 days without documented justification. Interviews with facility staff, including the pharmacist, director of nursing, and corporate consultant, confirmed that there was no documented reason for the extended use of PRN psychotropic medications for these residents. The staff acknowledged that the facility's practice was against regulations, which require a documented reason for extending PRN psychotropic medication orders beyond 14 days.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to ensure that residents consistently received food that was palatable in taste, texture, appearance, and temperature. Multiple residents reported issues with the meals served, including cold food, tough meat, overcooked vegetables, and a lack of seasoning. Observations during meal preparation and service confirmed these issues, with food temperatures often falling below safe levels, indicating improper handling and preparation. During observations, it was noted that the kitchen staff did not consistently maintain appropriate food temperatures. For instance, the temperature of the mashed potatoes, hamburger patties, and carrots were recorded below the required holding temperature, with some items falling into the danger zone. Additionally, the facility's steamer, which was crucial for maintaining food temperatures and preventing overcooking, was not functioning correctly, contributing to the issues with food quality. Interviews with staff revealed that there were ongoing concerns with food preparation and equipment maintenance. The dietary manager acknowledged the problems with food temperatures and preparation, citing issues with the steamer and the need for staff retraining. Communication barriers and insufficient oversight were also identified as contributing factors to the deficiency, with the charge cook requiring additional training to ensure proper cooking methods were followed.
Inadequate Disinfection of Shared Mechanical Lift and Slings
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper cleaning and disinfection of a shared mechanical lift and slings between residents on two units. Observations revealed that after a male resident was assisted to the bathroom using a mechanical lift with a small sling, the lift and sling were not wiped down before being returned to the common area. Subsequently, the same sling was used for a female resident without disinfection, and the mechanical lift was handed over to another staff member without being cleaned. Interviews with staff members highlighted inconsistencies in understanding and implementing infection control procedures. LPN #4 stated that mechanical lifts were cleaned at the end of each shift rather than after each use, and believed that slings did not require disinfection as they touched residents' clothes, not skin. In contrast, the memory care coordinator and other staff members acknowledged the need for disinfection after each use. The regional infection preventionist emphasized the importance of wiping down the lift and shared slings, regardless of whether they touched skin or clothing. This inconsistency in practice and understanding contributed to the deficiency in infection control.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 21 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Montrose
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hope Springs Care Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Colorow Care Center | 11.8 mi | ★★★★★ | 7 | 0 |
| Willow Tree Care Center | 20.4 mi | ★★★★★ | 14 | 0 |
| Horizons Care Center | 25.2 mi | ★★★★★ | 1 | 0 |
| Paonia Care And Rehabilitation Center | 31.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 August 2026) and official state health department websites.