Average — CMS composite of the measures below.
The next survey window likely opens around September 2026
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 Health Center during CMS and state inspections, most recent first.
A resident with COPD, pneumonia, and respiratory failure was transferred to the hospital for acute respiratory distress and later deemed medically ready for discharge, but the facility delayed readmission by three days due to staffing and admission timing practices. Facility staff, including an RN, MDS coordinator, ADON, DON, and Administrator, reported that they avoided weekend and evening admissions, required two nurses for admissions, and were concerned about entering medication orders into the EMR in time for pharmacy delivery when only one nurse was on duty. They did not notify the provider about the planned discharge back, did not arrange alternative pharmacy or transport options, and cited shared transport and lack of additional nurses as reasons the readmission was not feasible, despite the facility’s stated commitment to 24-hour nursing care and medication management.
Incorrect PEG tube feeding and flush administration. A resident with intact cognition, malnutrition, dysphagia after CVA, and a PEG tube was ordered strict NPO, 120 mL water flushes before and after feeds, and Osmolite 1.5 Cal 270 mL QID. An RN administered 60 mL water before and after the feeding and gave 235 mL of formula instead of 270 mL, stating she interpreted the flush order as split doses and had continued the prior formula amount.
A resident with severely impaired cognition sustained burns from hot liquids on two occasions due to inadequate supervision and ineffective interventions. Despite being provided with lidded cups, the resident often removed the lids, leading to spills and burns. The facility's care plan did not specifically address the risk of burns from hot liquids, and staff were unsure if hot liquid assessments were conducted.
A facility failed to submit MDS assessments within the required timeframes for a resident, resulting in a record over 120 days old. The resident's Quarterly MDS assessment and an assessment for death in the facility were submitted late. The delay was due to an oversight where a system question was not updated. The facility lacked a specific policy for MDS submission, relying on CMS guidelines.
The facility failed to update care plans for three residents following significant health changes. A resident with impaired cognition suffered a burn from a hot liquid spill, but the care plan did not address this risk. Another resident with diabetes did not have the condition included in their care plan, despite being on medication. A third resident was incorrectly documented as having diabetes, while they actually had steroid-induced hyperglycemia. The facility lacked a policy for care plan revisions.
A resident with intact cognition had a physician's order for digoxin with instructions to hold the medication if the pulse was below 60. Despite this, the medication was administered on two occasions when the resident's pulse was below the specified threshold. A RN acknowledged the standard practice of holding the medication if the pulse was below 60, and the DON confirmed that the medication should have been held and the provider contacted. The facility's policy on medication administration was not followed.
The facility failed to provide timely assessment and intervention for changes in condition for two residents. One resident with COPD experienced severe respiratory distress that was not promptly addressed, leading to an emergency hospital transfer. Another resident experienced an unwitnessed fall that was not properly assessed or documented, resulting in a hip fracture and subsequent hospitalization.
A resident with a history of arterial ulcers experienced significant pain during wound care, but the facility failed to provide adequate pain management. Despite having orders for pain medications, the resident reported that Tylenol was ineffective, and no as-needed pain medications were administered. Observations and interviews revealed a lack of responsiveness from staff and a failure to notify the provider for increased pain.
A facility failed to prevent and manage a pressure ulcer for a resident with a left fibular fracture and cam boot. The care plan lacked guidance on boot use, and there was no order to monitor the skin. The resident developed a blister that worsened into a deep tissue injury and became unstageable. Inconsistent documentation and unclear staff management contributed to the deficiency.
The facility failed to prevent resident-to-resident altercations, resulting in multiple incidents of physical and verbal aggression among residents with severe cognitive impairments. Despite interventions such as medication administration, monitoring, and separating residents, the facility was unable to effectively protect residents from abuse and ensure their safety.
A facility failed to accurately code a resident's pressure ulcers on the MDS assessment. Despite documentation of multiple stage II pressure areas on the resident's left toes, lateral foot, and heel, the MDS assessment incorrectly indicated no unhealed pressure ulcers. The MDS Coordinator acknowledged the oversight.
The facility failed to ensure the safety of residents during wheelchair transport by not using foot pedals, leading to potential fall risks. A resident with intact cognition and at risk for falls was observed being transported without foot pedals on two occasions. Another resident with severely impaired cognition and a high risk for falls experienced a fall due to the absence of foot pedals. Despite staff education, the resident was later observed self-propelling without foot pedals. A third resident, at high risk for falls, was also observed being pushed in a wheelchair without foot pedals.
The facility failed to timely notify the provider of changes in a resident's urine and catheter, despite multiple instances of abnormal findings such as brown sedimentation and fecal matter in urine. The resident's care plan and urology office instructions were not consistently followed, leading to delayed follow-up and inadequate catheter care.
The facility failed to ensure that a rehired RN completed communication and behavioral health training before working independently with residents. The Administrator confirmed the absence of proof for these trainings during orientation, and the facility assessment did not include these training requirements for all employees.
A resident received medications prescribed to another resident due to a failure to properly identify the resident before administration. The error was documented, and the resident's vital signs were monitored without immediate adverse effects. The facility's procedures for resident identification were not followed.
Delayed Hospital Readmission Due to Insufficient Nursing Staff and Admission Practices
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff and related processes to support the timely readmission of a hospitalized resident, resulting in a three-day delay in the resident’s return. The resident had moderately impaired cognition, with a BIMS score of 12/15, and medical diagnoses including COPD with acute exacerbation, pneumonia, and respiratory failure. The resident was transferred to the hospital after staff observed labored respirations, use of accessory muscles, diaphoresis, an oxygen saturation of 85% on room air, and wheezing, with improvement after oxygen was applied but continued labored breathing. Hospital records show the resident was admitted and later determined medically stable and ready for discharge, with documentation that the patient was planned for discharge but was not accepted back to the facility due to timing issues and would remain in the hospital over the weekend. Hospital progress notes documented that the resident was medically ready for discharge and that discharge was planned but not completed because the facility would not accept the resident later in the day. A hospital case management/social work note indicated confirmation that the facility could take the patient on the day the resident ultimately returned. The facility’s EHR showed the resident’s billing status changed to STOP BILLING on the date of hospital transfer and back to active several days later, corresponding to the delayed readmission. The resident reported spending three days in the hospital before being able to return to the facility. Multiple staff interviews described facility practices that contributed to the delay in readmission. An RN stated the facility tried not to do admissions on weekends and did not want admissions after 2 p.m. so nurses could complete admission tasks and enter medications into the computer in time for pharmacy delivery. The MDS Coordinator stated the facility liked residents readmitted before 2 p.m. to obtain medications, that the hospital had informed them the resident would not return until early evening, and that the facility needed two nurses in the building for an admission; the coordinator also stated the facility did not do admissions on weekends and was unsure about using another pharmacy or family to obtain medications. The ADON and DON both stated that with only one nurse on duty, a readmission later in the day was not feasible due to the time needed for admission assessments and medication entry, and they cited concerns about not having medications on time and the workload of one nurse caring for existing residents and completing a readmission. The DON further stated the facility did not accept evening or Saturday admissions for safety reasons, did not notify the provider about the planned discharge back to the facility, and did not explore hospital-supplied medications or alternative transport options, while acknowledging the presence of on-call nurses. The Administrator confirmed that with only one nurse, a readmission was considered not doable. The facility lacked written transportation or readmission policies and relied on general CMS and Resident Rights guidance, while its Resident Handbook stated residents receive individualized 24-hour nursing care and medication management.
Incorrect PEG Tube Feeding and Flush Administration
Penalty
Summary
The facility failed to administer the correct amount of fluid and liquid nutrition to a resident dependent on PEG tube feeding. The resident had a history of transient ischemic attack, malnutrition, and dysphagia following a cerebral infarction, and the MDS indicated cognition was intact, eating was not attempted due to medical condition or safety concern, and a feeding tube was used. The care plan identified the resident as requiring PEG tube feeding and water flushes, with interventions stating the resident was dependent with tube feedings and flushes and that current feeding orders should be followed. Physician orders included strict NPO, flush the PEG tube with 120 mL of water before and after feeding administration, and give Osmolite 1.5 Cal 270 mL four times daily. During observation, an RN administered 60 mL of water, then 235 mL of Osmolite, then another 60 mL of water through the PEG tube. In interviews, the RN stated she believed the 120 mL flush order meant 60 mL before and 60 mL after, and she confirmed she had been giving 235 mL of formula instead of the ordered 270 mL. The ARNP confirmed the flush order meant 120 mL before and 120 mL after, and the dietician stated she had documented 270 mL for the Osmolite and wanted the 120 mL water flushes before and after feeding to meet the resident’s fluid needs. The DON confirmed the RN should have followed the ordered amounts, and the Administrator stated the facility did not have a tube feeding policy and followed doctor’s orders.
Resident with Impaired Cognition Sustains Burns from Hot Liquids
Penalty
Summary
The facility failed to ensure a resident with severely impaired cognition remained free from burns caused by hot liquids. The resident, who scored 06 out of 15 on a Brief Interview for Mental Status (BIMS) exam indicating severely impaired cognition, sustained a second-degree burn to the thigh from a hot beverage on two separate occasions. The first incident occurred on 7/8/24, and the second incident occurred on 9/17/24, resulting in redness to the skin. The resident required set-up or cleanup assistance with eating, as noted in the Minimum Data Set (MDS) assessment. The resident's care plan, revised on 5/29/24, did not specifically address the risk of burns from hot liquids, despite the resident's history of cognitive deficits and physical limitations. Observations revealed that the resident was provided with cups with lids, but the resident often removed the lids. The facility's interventions included providing the resident with a lidded cup and diluting hot tea with ice or tap water. However, these measures were not consistently effective, as the resident continued to spill hot liquids, leading to burns. Interviews with staff indicated that the resident was known to enjoy hot tea and had a history of removing lids from cups. Despite education provided to the resident about the need for lids on cups, the resident's short-term memory issues required frequent reminders. The facility did not have a specific policy addressing accidents and hazards related to hot liquids, and staff were unsure if hot liquid assessments were conducted. The facility's failure to implement effective interventions and adequately supervise the resident contributed to the repeated incidents of burns from hot liquids.
Failure to Submit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were submitted within the required regulatory timeframes for a resident reviewed under the Resident Assessment Instrument Task. The resident in question had an MDS record that was over 120 days old, and not all assessments were documented as accepted or submitted. The resident was initially admitted to the facility on May 8, 2024, and was discharged on an unspecified date. A Quarterly MDS assessment with an Assessment Reference Date (ARD) of August 6, 2024, was submitted late on September 18, 2024. Additionally, an MDS assessment completed for the resident's death in the facility with an ARD of August 19, 2024, was accepted on September 18, 2024. The Nurse Consultant acknowledged the oversight, explaining that a question in the system was not updated, which delayed the submission. The facility did not have a specific policy for MDS submission and followed CMS guidelines.
Care Plan Deficiencies for Residents with Health Changes
Penalty
Summary
The facility failed to revise care plans for three residents following significant changes in their health status. Resident #11, who had severely impaired cognition, experienced a hot liquid spill resulting in a burn, but the care plan did not address the risk of hot liquids. Despite interventions being implemented, the care plan was not updated to reflect these changes. Resident #26, with intact cognition and a diagnosis of diabetes mellitus, did not have diabetes addressed in their care plan, even though they were prescribed medication for the condition. The facility lacked a policy for care plan revisions, relying instead on CMS guidelines. Resident #139 was incorrectly documented as having insulin-dependent diabetes mellitus in their care plan, despite not having a diabetes diagnosis. Instead, the resident had steroid-induced hyperglycemia, which required insulin management. The care plan failed to accurately reflect this diagnosis and the necessary interventions. The facility's Nurse Consultant acknowledged the error and the absence of a written policy for care plan revisions was noted by the Facility Administrator.
Failure to Adhere to Digoxin Administration Parameters
Penalty
Summary
The facility failed to adhere to professional standards of quality in administering digoxin to a resident, as evidenced by a review of clinical records, interviews, and facility policy. A resident with intact cognition, as indicated by a perfect score on the Brief Interview for Mental Status exam, had a physician's order for digoxin with specific instructions to hold the medication if the pulse was below 60. However, the Medication Administration Records showed that the medication was administered on two occasions when the resident's pulse was below the specified threshold: once with a pulse of 59 and another time with a pulse of 55. During an interview, a Registered Nurse acknowledged the standard practice of holding the medication if the pulse was below 60, and the Director of Nursing confirmed that the medication should have been held and the provider contacted. The facility's policy on medication administration, which mandates adherence to physician orders, was not followed in this instance.
Failure to Provide Timely Assessment and Intervention for Changes in Resident Condition
Penalty
Summary
The facility failed to appropriately provide assessment and interventions for necessary care and services during a change in condition for two residents. Resident #6, with a known history of chronic obstructive pulmonary disease (COPD) and respiratory failure, experienced a significant decline in respiratory condition that was not promptly identified or addressed. Despite multiple documented instances of respiratory distress, including shortness of breath, low oxygen saturation, and increased anxiety, the facility staff did not consistently notify the provider in a timely manner. This led to Resident #6 being found unresponsive and requiring emergency transport to the hospital, where they were diagnosed with respiratory distress, respiratory syncytial virus (RSV), and respiratory failure with hypercapnia. Interviews with staff revealed inconsistencies in understanding when to notify the provider and reliance on placing non-emergent issues in a communication binder rather than immediate notification for acute changes in condition. Resident #3 experienced an unwitnessed fall that was not properly assessed or documented by the facility staff. The resident, who had a history of falls and required assistance with mobility, fell while attempting to get into bed. Despite the resident's complaints of pain and the fall being reported by the resident and their roommate, there was no immediate nursing assessment or documentation completed. It was only three days later that an x-ray was ordered, revealing a non-displaced left sub-capital hip fracture. The resident was subsequently admitted to the hospital for surgical repair of the hip fracture. Interviews with staff indicated a lack of adherence to the facility's fall assessment protocol, which requires immediate assessment, documentation, and notification of the provider and relevant parties. The deficiencies in both cases highlight a failure in the facility's processes for monitoring and responding to changes in resident conditions and ensuring timely medical intervention. The lack of immediate and appropriate response to Resident #6's respiratory distress and Resident #3's fall resulted in significant adverse outcomes for both residents. The facility's policies and staff training on these critical aspects of care were found to be inadequate, contributing to the deficiencies observed during the survey.
Removal Plan
- Education provided to all staff nurses on the following topics: Documentation in real time, When to notify the provider via phone call, Acceptable notifications to be left in the provider binder, Physician notification as soon as acute change is noted.
- A review of respiratory assessment parameters and when to notify the provider completed with staff nurses, which included the development of respiratory assessment guidelines to notify the provider of any of the following that aren't resolved with interventions already in place: Respiratory rate greater than 22 respirations/minute with complaints of shortness of breath, Oxygen saturation less than 90%, unless otherwise specified in orders, Acute lung sound changes, including: wheezing, rhonchi, rales, and crackles.
- Audits of the provider binder to be completed by Director of Nursing.
Inadequate Pain Management for Resident with Ankle Ulcer
Penalty
Summary
The facility failed to identify and adequately treat pain related to an open ulcer on a resident's right ankle during wound care. The resident, who had intact cognition and a history of arterial ulcers, experienced significant pain during dressing changes. Despite having orders for pain medications such as Gabapentin, Tylenol, and Ibuprofen, the resident reported that Tylenol was ineffective, and no doses of as-needed pain medications were administered in April 2024. Observations revealed that the resident exhibited signs of severe pain during wound care, including gasping, screaming, and biting her tongue, yet staff did not offer pain medication or take breaks to alleviate her discomfort. The resident's clinical records and interviews indicated a history of pain complaints related to the ankle wound, which had worsened over time. The wound had increased in size, exhibited signs of infection, and caused significant discomfort during dressing changes. Despite these issues, the facility's staff did not consistently administer pain medication or notify the provider for increased pain. The Nurse Practitioner acknowledged the resident's pain during wound care and suggested pre-medication, but this practice was not consistently followed by the nursing staff. Interviews with the Director of Nursing and other staff members revealed a lack of awareness and responsiveness to the resident's pain. The DON believed that the resident would voice her need for pain medication, despite the resident's reports of frequent and severe pain. The facility lacked a policy or procedure related to pressure ulcers/injuries, contributing to the inadequate pain management and failure to address the resident's discomfort effectively.
Failure to Prevent and Manage Pressure Ulcer
Penalty
Summary
The facility failed to prevent the development and worsening of a pressure ulcer for a resident who was admitted with a left fibular fracture and wore a cam boot. The resident's initial care plan did not include guidance on the schedule for applying and removing the cam boot, and there was no order to monitor the skin underneath the boot. Despite the resident being at moderate risk for pressure ulcer development, the facility did not implement timely interventions to prevent pressure ulcers, leading to the development of a blister on the resident's left heel, which later worsened into a deep tissue injury (DTI) and eventually became unstageable with necrotic tissue. The resident's care plan was revised multiple times to reflect the worsening condition of the pressure ulcer, but the facility's documentation and assessment practices were inconsistent and incomplete. The facility's records lacked detailed documentation of the wound's presence, type, and measurements on several occasions. Additionally, there were discrepancies in the documentation of the resident's skin condition, with some notes indicating intact skin while others documented the presence of blisters and discoloration. The facility also failed to notify dietary services about the resident's pressure ulcer, which could have impacted the resident's nutritional support for wound healing. Interviews with staff revealed a lack of clarity and consistency in the management of the resident's pressure ulcer. Staff members were unsure about the resident's initial skin condition upon admission and the appropriate care for the cam boot. The facility's consultant acknowledged the need for an order to remove the boot each shift and inspect the skin, which was not in place. The facility administrator confirmed that there was no pressure ulcer policy in place at the time of the incident, indicating a systemic issue in the facility's approach to pressure ulcer prevention and management.
Failure to Prevent Resident-to-Resident Altercations
Penalty
Summary
The facility failed to ensure residents remained free from resident-to-resident altercations, resulting in multiple incidents of physical and verbal aggression among residents. Resident #18, who had severe cognitive impairment and a history of physical and verbal behaviors, was involved in several altercations. These included a male resident smacking her buttocks, a verbal altercation over a sandwich, and physical contact with another resident. Despite interventions such as medication administration and monitoring, Resident #18 continued to exhibit aggressive behaviors, including running over another resident's foot with a wheelchair and hitting another resident's leg. The facility's interventions included moving residents to different areas and planning a care conference to discuss other placement options for Resident #18's safety and the safety of others. Resident #141, who had moderately impaired cognition and a history of verbal and physical behaviors, was also involved in multiple altercations. These included hitting another resident on the shoulder, hitting another resident's leg, and being hit by Resident #18 after having her foot run over by a wheelchair. The facility's interventions for Resident #141 included assisting her to a recliner or bed between meals to increase supervision and decrease altercations. Despite these interventions, Resident #141 continued to exhibit aggressive behaviors, leading to further incidents. Resident #1 and Resident #5, both with severely impaired cognition, were also involved in altercations with Resident #141. Resident #1 was hit on the shoulder three times by Resident #141, and Resident #5 was hit on the leg twice by Resident #141. The facility's interventions included separating the residents immediately and assisting them to their rooms or recliners. However, the facility failed to prevent further incidents, indicating a lack of effective measures to protect residents from abuse and ensure their safety.
Failure to Accurately Code Pressure Ulcers on MDS Assessment
Penalty
Summary
The facility failed to ensure accurate coding of pressure ulcers on the Minimum Data Set (MDS) assessment for a resident with severely impaired cognition. The resident, who scored 5 out of 15 on a Brief Interview for Mental Status (BIMS) exam, was at risk for developing pressure ulcers. Despite this, the MDS assessment indicated that the resident did not have any unhealed pressure ulcers or venous/arterial ulcers. However, the Nursing Admission Screening/History form and subsequent Skin/Wound Evaluations documented multiple pressure areas, including a stage II pressure area on the left toes, left lateral foot, and left heel, all present since the resident's readmission to the facility. These discrepancies were not reflected in the MDS assessment, which was acknowledged as an oversight by the MDS Coordinator who followed the Resident Instrument Assessment (RAI) Manual. The resident's medical records indicated that the pressure areas were present on admission and had been documented as early as 11/18/23. The Health Status Note also mentioned the resident's non-compliance with wearing heel protectors, which were necessary for the treatment of the wound on the left heel. The MDS Coordinator admitted to the oversight during an interview, explaining that the wounds were not listed in the MDS assessment. This failure to accurately code the resident's pressure ulcers on the MDS assessment constitutes a deficiency in ensuring accurate resident assessments.
Failure to Use Wheelchair Foot Pedals During Resident Transport
Penalty
Summary
The facility failed to ensure the safety of residents during wheelchair transport by not using foot pedals, leading to potential fall risks. Resident #9, with intact cognition and at risk for falls due to muscle weakness and edema, was observed being transported without foot pedals on two occasions. Similarly, Resident #92, with severely impaired cognition and a high risk for falls, experienced a fall when their sock got caught on the wheelchair due to the absence of foot pedals. Despite staff education on the use of foot pedals, the resident was later observed self-propelling in the wheelchair without foot pedals. Resident #7, who has intact cognition and is at high risk for falls due to a history of cerebral vascular accident, polyarthritis, and long-term use of anticoagulants, was also observed being pushed in a wheelchair without foot pedals. The resident's feet skimmed across the floor during transport. The facility's policy on falls did not address the use of wheelchair foot pedals, contributing to the deficiency.
Failure to Timely Notify Provider of Changes in Urine and Catheter
Penalty
Summary
The facility failed to identify and notify the provider in a timely manner of changes in urine and catheter for a resident with an indwelling catheter. The resident, who had diagnoses including vesicointestinal fistula, neurogenic bladder, and renal insufficiency, required close monitoring for signs of infection and other complications. Despite multiple documented instances of abnormal findings such as brown sedimentation, fecal matter in urine, and catheter leakage, the facility did not consistently notify the provider or follow up with the urology office as instructed in the care plan and by the urology office's orders. The resident's care plan, revised on 04/15/24, specifically instructed staff to monitor, document, and report any signs of urinary tract infection or urethral trauma. However, progress notes revealed several instances where abnormal findings were either not reported promptly or not followed up adequately. For example, on 02/27/24, brown sedimentation was observed in the catheter tubing, and although the provider and urology office were notified, the follow-up appointment was delayed until 05/22/24. Additionally, on 03/03/24, feces were present in the drainage bag, but the provider advised waiting until the next day to notify urology, and there was no documentation of immediate follow-up. Interviews with the Nurse Practitioner and Director of Nursing revealed a lack of awareness and inconsistent communication regarding the resident's symptoms. The NP stated that changes in urine color might not require immediate notification unless accompanied by other symptoms, while the DON confirmed that the urology office had instructed nursing to call for changes such as brown sedimentation in urine. This inconsistency in following the care plan and provider instructions contributed to the deficiency in timely and appropriate catheter care for the resident.
Failure to Ensure Timely Staff Training
Penalty
Summary
The facility failed to ensure that training for communication and behavioral health was completed before a staff member worked independently with residents. Specifically, a Registered Nurse (Staff D) was rehired on an unspecified date, but the training records showed that communication training was completed on 11/6/20 and behavioral health training on 9/3/22. On 4/25/24, the facility's Administrator confirmed via email that there was no proof of these trainings being provided during orientation for Staff D. Additionally, the facility assessment updated on 2/13/24 did not include requirements for behavioral health or communication training for all employees.
Significant Medication Error Due to Failure to Identify Resident
Penalty
Summary
The facility failed to ensure that a resident received medications only prescribed to them, resulting in a significant medication error. Specifically, Resident #14 was administered medications that were prescribed to Resident #10. The error was documented in a Medication Error Report and confirmed through a review of the Medication Administration Record (MAR) for both residents. Resident #14, who had intact cognition as indicated by a BIMS score of 13 out of 15, received multiple medications not listed on their MAR, including Risperdal, Atrovastatin, Calcium plus Vitamin D, Corlanor, Depakote, and Midodrine. The error was identified when the resident's vital signs were monitored, and the Nurse Practitioner was informed. The resident did not report any immediate discomfort or adverse effects at the time of the incident. The Director of Nursing and the MDS Coordinator explained that the facility had procedures in place for identifying residents, such as using pictures and asking residents their names depending on their BIMS score. However, the error occurred due to a failure to properly identify the resident before administering the medication. The facility's Medication Administration Pocket-Guide emphasized the importance of verifying the right drug, dose, time, route, and resident, but this protocol was not followed in this instance. The facility had a census of 36 residents at the time of the incident.
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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) |
|---|---|---|---|---|
| River Hills Village In Keokuk | 6.4 mi | ★★★★★ | 6 | 0 |
| Southeast Iowa Healthcare Center | 7.3 mi | ★★★★★ | 6 | 0 |
| Birkwood Village Of Fort Madison | 7.3 mi | ★★★★★ | 6 | 0 |
| Mississippi Valley | 7.3 mi | ★★★★★ | 1 | 0 |
| Aspire Of Donnellson | 11.5 mi | — | 0 | 0 |
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