Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 New York State Veterans Home At Montrose during CMS and state inspections, most recent first.
A resident with Parkinson’s disease, mild cognitive impairment, gait disorder, and a known history of frequent falls was repeatedly identified as high risk for falls but continued to experience multiple falls over several months in their room and hallway, often while ambulating or reaching for items. The care plan contained general fall-prevention measures and short-term post-fall monitoring (e.g., neuro checks, frequent checks), but documentation repeatedly lacked timely, long-term revisions to address the specific circumstances of new falls. Despite family concerns and questions about environmental modifications and devices, there was no clear evidence of individualized environmental assessment or consistent implementation of additional safety devices beyond hip protectors and reminders to use the call bell. Ultimately, the resident fell backward in their room while interacting with CNAs, struck their head on a nightstand, and sustained a scalp laceration requiring stitches, constituting actual harm related to inadequate supervision and fall-prevention interventions.
The facility failed to honor resident self-determination when a memory care unit day room, which included a sensory room and bathrooms, was closed for heating repairs and all residents were moved to the dining room for leisure time. Over a weekend, 20 cognitively impaired residents, including individuals with Alzheimer's dementia, dementia, anxiety disorder, chronic kidney disease, and hypertension, experienced a disruption in their usual routine and loss of access to the sensory room. Families and resident representatives, who typically participate in care planning for these severely cognitively impaired residents, were not notified in advance or involved in deciding how residents would spend their leisure time, and some residents became upset and distraught by the change.
Two residents and their representatives were not afforded the opportunity to file written grievances regarding unresolved concerns about medication regimens, falls, and other aspects of care, despite the facility’s policy guaranteeing the right to voice grievances and receive prompt investigation and written resolution. Instead, staff addressed these concerns informally through care plan meetings and discussions with the IDT and administration, without initiating or documenting formal grievance investigations, and no written grievance records existed for these cases.
A resident with severe cognitive impairment, Alzheimer’s dementia, and traumatic brain injury, who required staff assistance for personal care and was on one-to-one supervision due to agitation and aggressive behaviors, was physically abused by a CNA in the resident’s room. Hidden camera footage obtained by the resident’s representative showed the CNA striking the resident on the head with a broom, grabbing the resident by the neck and roughly placing the resident into a reclining wheelchair, and then striking the resident on the neck after the resident attempted to push the CNA away. The resident verbalized pain during the incident. Facility staff, including an LPN and an RN, later viewed the footage and confirmed the CNA’s actions, and a non-clinical staff member assigned to supervise the resident was seen on hallway video handing a broom to the CNA at the room doorway. The facility’s investigation determined that abuse occurred and that the resident experienced psychosocial harm.
The facility did not consistently meet its minimum CNA staffing requirements, resulting in delays in resident care such as assistance with toileting and oxygen, and causing residents to feel degraded and dissatisfied. Staff reported frequent overtime requests, rushed care, and increased complaints from residents and families due to these staffing shortages.
A resident with severe cognitive impairment and multiple diagnoses, who required a two-person assist for transfers per their care plan, was transferred by a CNA alone using a sit-to-stand lift. This action, which did not follow the documented care plan, resulted in the resident sustaining two skin tears and a head abrasion. Staff interviews confirmed the resident's transfer status had not changed and that the CNA was aware of the two-person assist requirement but did not seek help.
A resident was improperly administered an intramuscular antipsychotic injection by staff after wandering and entering other residents' rooms. Despite being cognitively intact and having no documented medical symptoms or assessment for the medication, staff physically restrained the resident and administered the injection. The attending physician was informed of the resident's agitation and paranoia, leading to the order for the injection, but was unaware of the surveillance footage and stated that other interventions should have been attempted first.
A resident in a LTC facility was improperly restrained by staff after wandering the halls and entering other residents' rooms. Despite being cognitively intact, the resident was forcibly placed in a wheelchair and restrained by multiple staff members, resulting in psychosocial harm. The facility's policy of being restraint-free was not followed, and the incident was not reported to the administrator until days later.
A resident with Parkinsonism and mood disorders was physically restrained by multiple staff members, including a security officer, CNA, LPN, and RN, after wandering and exhibiting agitation. Despite facility policy prohibiting restraints and care plans focused on verbal support, staff held the resident's extremities, forcibly placed them in a wheelchair, and administered medication, resulting in psychosocial harm and the potential for serious injury.
A resident with Parkinsonism, anxiety, and depression was physically restrained by multiple staff members and administered an intramuscular antipsychotic after refusing oral medication, despite no documented medical symptom or assessment justifying the use of a chemical restraint. The facility's policy prohibits such restraints, and care plans did not document specific non-pharmacological interventions prior to the incident.
A resident in a LTC facility was improperly restrained by staff, including a security officer, LPN, RN, and CNA, after wandering the hallways and entering other residents' rooms. Despite attempts to redirect the resident, staff physically restrained them by holding their extremities and administering an injection while the resident was held against a wall. The incident was captured on surveillance footage, and the resident reported feeling traumatized. The facility's abuse prevention policy was not followed, and the resident's care plans lacked specific interventions for behavioral issues.
A resident with dementia and agitation sustained a skin tear after allegedly hitting a staff member with a walker. The facility failed to document an incident report or conduct a thorough investigation, despite the family's concerns of potential abuse. The resident's family removed them from the facility against medical advice due to the lack of communication and documentation.
A facility failed to report an alleged abuse incident involving a resident within the required 24-hour timeframe. The resident, who exhibited behavioral issues, was reportedly assaulted by staff, but the incident was initially categorized as a behavioral episode. This miscommunication delayed the investigation and reporting process to the New York State Department of Health.
Repeated Falls and Inadequate Individualized Fall-Prevention Measures Resulting in Head Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and necessary devices to prevent accidents for a resident with Parkinson’s disease and a known history of falls. The resident had mild cognitive impairment, short-term memory deficits, impaired mobility related to Parkinson’s, and required partial to moderate assistance with toileting, hygiene, bathing, and other ADLs. Despite being identified as high risk for falls on multiple Fall Risk Assessments and having a care plan for falls initiated and periodically updated, the resident experienced eight falls over several months, including falls in their room, in the hallway, and while attempting to ambulate or reach for items. The resident’s care plan initially included general interventions such as gradual position changes, monitoring psychotropic medications, psychiatric consultation as needed, and later a fall risk identifier, but these measures did not prevent repeated falls. Following specific fall events, documentation shows that the facility often implemented only short-term post-fall monitoring such as neuro checks and frequent checks for limited periods, without consistently revising the long-term fall prevention care plan to address the causes and circumstances of each new fall. After the fall on 10/18/2025, when the resident hit their head and required hospital evaluation, there was no documented evidence of updated interventions to the care plan. After the fall on 10/31/2025, the care plan note documented injuries and short-term monitoring, but again no documented long-term interventions to prevent additional falls. Subsequent falls on 01/02/2026 and 02/07/2026 similarly lacked documented revisions to the fall-related care plan, despite repeated confirmation that the resident remained at high risk for falls. Although hip protectors were provided and reminders to use the call bell were documented, there was no evidence of systematic adjustment of interventions in response to the pattern and circumstances of the falls. The resident’s final documented in-facility fall on 03/17/2026 occurred in their room while they were ambulating and interacting with two CNAs, during which the resident refused to sit and then fell backward, striking their head on a nightstand and sustaining a scalp laceration requiring six stitches. Witness statements from the CNAs described the resident walking around the room, telling staff not to touch them, and then spinning around and falling. The physician later documented that the resident, who had a gait disorder, was walking with a walker and reaching for a wheelchair when they fell backward and hit their head. Interviews with the complainant and facility leadership revealed that there had not been meaningful care plan meetings with the resident and family to discuss fall risk and prevention, and that the DON was unsure what devices PT had recommended or whether environmental safety measures such as floor mats or a reacher had been assessed or implemented. Staff interviews indicated awareness that the resident was at high risk for falls and that frequent monitoring and prompt response to call bells were expected, but there was no clear specification of monitoring frequency or individualized fall-prevention strategies beyond general rounding and basic positioning measures. This pattern of repeated falls, limited care plan revision, and lack of documented individualized environmental or device-based interventions led to the resident sustaining actual harm from the head laceration.
Failure to Involve Cognitively Impaired Residents and Representatives in Leisure-Time Changes During Unit Repairs
Penalty
Summary
The facility failed to honor residents' rights to self-determination and participation in planning of care and services when repairs were conducted on the Fair Haven Unit day room, which included a sensory room and two bathrooms. On 03/06/2026, the Deputy Administrator became aware of a malfunctioning heater in the Fair Haven day room and directed staff to relocate all 20 residents of the unit, including residents with severe cognitive impairment, to the dining room for leisure time on 03/07/2026 and 03/08/2026. Activities and a television were brought into the dining room, but residents were kept there for their leisure time before and after lunch and dinner, resulting in a disruption of their usual daily routine and how they typically spent their leisure time. The Fair Haven Unit is a memory care unit with residents who have impaired cognitive abilities, including residents diagnosed with Alzheimer's dementia, dementia, anxiety disorder, chronic kidney disease, and hypertension. Minimum Data Set assessments documented that several residents were severely cognitively impaired and had family or significant others participate in their assessments. Despite this, there was no documented evidence that resident representatives were notified in advance or involved in choosing how the residents would spend their leisure time during the repairs. A grievance dated 03/09/2026 indicated concerns that residents had been kept in the dining room over the weekend, and a resident representative reported that some residents were upset and distraught by the disruption, noting that the alternatives did not include access to a de-escalation area such as the sensory room. The Deputy Administrator acknowledged that families and representatives were not informed prior to the change in routine and that residents and their representatives were unable to choose how leisure time was spent during the affected days.
Failure to Offer and Process Written Grievances for Care and Medication Concerns
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents and their representatives were afforded the right to file grievances and have those grievances formally investigated and resolved in writing, as required by facility policy and regulation. The facility’s Resident Rights policy dated 09/2022 stated that residents had the right to voice grievances about care or services and could expect prompt investigation and attempts at resolution. For one resident with Alzheimer’s dementia and diabetes mellitus, the MDS dated 12/08/2025 showed severe cognitive impairment and family participation in assessment and discharge planning. Medical and social work documentation from late December 2025 and January 2026 showed that the resident’s representative expressed concerns about the resident’s medication regimen, specifically the continued use of Klonopin despite the representative’s request to discontinue it, and that these concerns were discussed in care plan meetings with the IDT and the Administrator. However, there was no documented evidence that the representative was offered the opportunity to file a written grievance regarding these care and medication concerns. The deficiency also involved another resident with Parkinson’s disorder and depression, whose MDS dated 12/18/2025 documented short-term memory deficits but independence in decision-making, a history of falls in the prior two to six months, and a need for partial/moderate assistance with toileting. Nursing and social work notes from December 2025 documented the resident’s request not to have a specific CNA assigned due to the aide’s skin color and an incident in which the resident demanded latanoprost eye drops be administered at times differing from the MD order. The resident’s representative later reported concerns about the resident’s medication regimen and number of falls, and stated these concerns had not been addressed or resolved. There was no documentation that the resident or representative was offered the opportunity to file a written grievance for unresolved care and medication concerns. In interviews, the assigned social worker and the Administrator acknowledged that concerns were handled through care plan meetings and communication, and that written grievances were not initiated or documented for either resident, and no grievance investigations were on file for them.
Failure to Protect a Resident From Physical Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a CNA, despite having an abuse prohibition policy and identifying the resident as being at risk for abuse. The resident had Alzheimer’s dementia, diffuse traumatic brain injury, and was severely cognitively impaired, requiring staff assistance for toileting, showering, and personal hygiene. The resident’s care plan documented they were at risk of being a victim of abuse related to aggressive behavior and were to be monitored for safety, including one-to-one supervision after a recent hospital readmission. Nursing notes around the time of the incident documented episodes of agitation, wandering, cursing, and attempts to strike staff and another resident. On the date of the incident, the resident’s representative had a hidden camera in the resident’s room to identify triggers for the resident’s behavior. Video footage from that camera showed the CNA in the resident’s room raising a small black broom and striking the resident on the top of the head, then later grabbing the resident by the neck and roughly placing them into a reclining wheelchair. When the resident used their arms to shove the CNA away, the CNA used their left hand to strike the resident on the left side of the neck. The resident was heard saying “Ouch” and “Ow” multiple times and cursing during the interaction. The CNA then positioned the resident in the wheelchair with it tilted back, preventing the resident from getting up without staff assistance. Facility staff, including an LPN and an RN, viewed the hidden camera footage on the representative’s phone and confirmed seeing the CNA strike the resident on the left side of the neck. Hallway surveillance showed a non-clinical staff member assigned to supervise the resident handing a broom and dustpan to the CNA at the doorway of the resident’s room, though this staff member reported not hearing any commotion or altercation. The resident’s representative and medical provider later stated that, if the resident were cognitively intact, the interaction would be expected to cause fearfulness and agitation. The facility’s internal investigation, based on staff review of the video, concluded that physical contact and abuse did occur, resulting in psychosocial harm to the resident.
Failure to Maintain Minimum CNA Staffing Levels
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of every resident, as required by their own Facility Assessment and state regulations. On multiple occasions, the number of Certified Nurse Aides (CNAs) scheduled for the day shift fell below the minimum required, with documented shortfalls on specific dates. Staff interviews confirmed that these shortages led to rushed and stressful care, with CNAs frequently being asked to work overtime or cover additional units due to callouts. The Staffing Coordinator and Director of Nursing acknowledged that minimum staffing requirements were not met on certain days, primarily due to staff callouts and restrictions on overstaffing to cover absences. Residents reported negative impacts from the staffing shortages, including delays in assistance with toileting and oxygen needs, and feelings of degradation when left to use adult briefs due to lack of timely help. Staff also reported that the reduced number of CNAs resulted in frequent complaints from residents and family members about long wait times and delays in care. The facility's staffing levels were adjusted based on census, but the minimum required numbers were not consistently maintained, contributing to the deficiencies observed during the survey.
Failure to Provide Required Two-Person Assist During Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple diagnoses, including Parkinson's Disease, Anxiety, and Vascular Dementia, did not receive the required level of assistance during a transfer. The resident's care plan, updated several months prior, specified that a total body lift with the assistance of two staff members was necessary for all transfers. However, on the day of the incident, a Certified Nurse Aide (CNA) transferred the resident alone using a sit-to-stand lift, contrary to the care plan instructions. During this transfer, the sling rubbed against the resident's arm, resulting in two skin tears and a 1 cm by 1 cm abrasion to the head. The CNA later admitted to being aware of the two-person assist requirement but did not seek assistance or check the CNA instructions prior to the transfer. Interviews with facility staff confirmed that the resident's transfer status had not changed and that the care plan and CNA instructions clearly documented the need for two-person assistance. The CNA had previously provided two-person assistance to the resident on earlier dates, as documented in facility records. The incident was discovered when a nurse observed the injuries and questioned the CNA, who then acknowledged transferring the resident without help. The lack of adherence to the care plan and failure to provide adequate supervision and assistance directly led to the resident sustaining injuries during the transfer.
Improper Use of Chemical Restraint on Resident
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints imposed for purposes of discipline or convenience, which were not required to treat the resident's medical symptoms. The incident involved a resident who was observed wandering the unit and entering other residents' rooms. Despite being cognitively intact and having no documented medical symptoms or appropriate assessment for the use of antipsychotic medication, the resident was administered an intramuscular antipsychotic injection by staff members. The facility's policy, which emphasizes a restraint-free environment, was not adhered to in this situation. The sequence of events began with the resident wandering and entering another resident's room, followed by attempts by staff to redirect the resident. The resident was then seen writing on a piece of paper at the nursing cart and later sitting in a recliner in the common area. Staff attempted to administer oral medication, which the resident refused and subsequently spit out. The situation escalated when staff physically restrained the resident against a wall, and an injection was administered without documented evidence of medical necessity or prior assessment. Interviews with facility staff and the attending physician revealed that the physician was informed of the resident's agitation and paranoia, leading to an order for an intramuscular antipsychotic injection after oral medication was refused. However, the attending physician was not aware of the surveillance footage and stated that other interventions should have been attempted first. The facility's failure to follow its own policy and the lack of documented medical justification for the use of chemical restraint resulted in a deficiency that had the potential for serious harm to the resident.
Improper Use of Physical Restraints on Resident
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints imposed for purposes of discipline or convenience, which were not required to treat the resident's medical symptoms. On the specified date, a resident was observed on surveillance footage wandering the hallway and entering other residents' rooms. Security personnel and nursing staff attempted to restrain the resident by grabbing their wrists and physically holding them in place. Despite the resident's attempts to propel themselves away in a wheelchair, staff members continued to restrain the resident by holding onto their extremities. The resident, who was cognitively intact and had a history of mood issues, was negatively impacted by increased confusion and sundowning. The care plan for the resident included monitoring their mood and providing support, but specific approaches for managing the resident's behavior were not documented. During the incident, the resident was forcibly placed in a wheelchair and restrained by multiple staff members, which resulted in psychosocial harm and the potential for serious injury. Interviews with staff revealed that the resident was agitated and paranoid, believing that staff were trying to harm them. Despite attempts to administer medication, the resident refused oral medication and was given an intramuscular injection. The staff's actions, including physically restraining the resident and administering medication without proper consent, were not in line with the facility's policy of being a restraint-free environment. The incident was not reported to the facility administrator until three days later, indicating a delay in addressing the deficiency.
Failure to Prevent Use of Physical Restraints on Resident
Penalty
Summary
A resident with diagnoses including Parkinsonism, anxiety disorder, and depression, who was cognitively intact at admission, was observed wandering the facility, entering other residents' rooms, and exhibiting behaviors such as confusion and agitation. Staff attempts to redirect the resident were unsuccessful, and the resident was seen on surveillance footage being physically restrained by multiple staff members, including a security officer, CNAs, LPNs, and RNs. The staff held all four of the resident's extremities while the resident attempted to propel themselves away and resisted the restraint, including kicking and swinging at staff. The resident was forcibly placed in a wheelchair, physically restrained, and transported back to their room while staff continued to hold their limbs. The facility's policy, last revised in September 2023, stated that it is generally a restraint-free environment and that physical or chemical restraints are not used. The resident's care plans addressed psychosocial well-being and mood issues, with interventions focused on verbal support, monitoring, and involvement of significant individuals, but did not include specific approaches for managing wandering or aggressive behaviors. Despite these care plans, staff resorted to physical restraint and administration of medication (oral Ativan, which was refused, and intramuscular Haldol) after the resident was reported to be agitated and combative. The incident was documented in an incident report and investigated by the facility, with staff interviews confirming the use of physical restraint to control the resident's movement and behavior. The administrator and several staff members acknowledged that the resident was physically restrained by multiple staff members, with some expressing uncertainty about the necessity of the intervention. The resident later reported to family members that they had been forcibly restrained, and the facility's investigation confirmed the use of restraint. The deficiency was cited for failure to ensure the resident was free from physical restraints imposed for purposes of discipline or convenience and not required to treat a medical symptom, resulting in psychosocial harm and the potential for serious injury.
Failure to Prevent Unnecessary Use of Chemical Restraint
Penalty
Summary
Facility staff failed to ensure that a resident was free from chemical restraints not required to treat a medical symptom. On the date in question, a resident with diagnoses including Parkinsonism, anxiety disorder, and depression, and who was documented as cognitively intact, was observed wandering the unit and entering other residents' rooms. Staff attempted to redirect the resident and administer oral medication, which the resident refused and subsequently spit out. Despite the resident's refusal, staff proceeded to physically restrain the resident against a wall with the assistance of multiple staff members, including CNAs, LPNs, RNs, and a security officer, in order to administer an intramuscular antipsychotic injection. The resident's medication list at admission did not include any antipsychotics, and there was no documented evidence of a medical symptom or appropriate assessment justifying the use of the antipsychotic medication. The care plans in place addressed the resident's psychosocial well-being and mood issues, with interventions focused on verbal support, monitoring, and redirection, but did not document specific non-pharmacological approaches or escalation protocols for behavioral disturbances. The facility's policy stated that it is generally restraint-free and that chemical or physical restraints are not used, except to ensure safety and maintain functioning in the least restrictive environment. Interviews with staff and the attending physician revealed that the physician was contacted after the resident became agitated and combative, and initially ordered oral Ativan, followed by intramuscular Haldol when the oral medication was refused. The physician relied on staff reports that other interventions had been attempted and failed, but did not review surveillance footage. Staff interviews confirmed that the resident was physically restrained in order to administer the injection. There was no documentation of alternative interventions being attempted or of a medical necessity for the use of a chemical restraint.
Resident Abuse Due to Improper Restraint by Staff
Penalty
Summary
The facility failed to ensure that a resident was free from abuse, as evidenced by an incident involving multiple staff members physically restraining a resident. The incident occurred when the resident, who was cognitively intact and required assistance with mobility, was seen wandering the hallways and entering other residents' rooms. Despite attempts to redirect the resident, staff members, including a security officer, LPN, RN, and CNA, physically restrained the resident by holding their extremities and administering an injection while the resident was held against a wall. The facility's surveillance footage captured the sequence of events, showing the resident attempting to propel themselves away in a wheelchair while being restrained by staff. The resident was seen resisting and attempting to free themselves from the staff's hold. The facility's abuse prohibition policy, which aims to prevent abuse by identifying and correcting situations where abuse is likely to occur, was not adhered to in this instance. The resident's care plans did not include specific interventions to address the resident's behavioral issues, which may have contributed to the incident. Interviews with staff and the resident's representative revealed that the resident felt traumatized by the incident and reported being forcibly restrained. The facility's administration was made aware of the incident days later, and the investigation into the incident lacked a clear conclusion. The staff involved in the incident stated their actions were intended to keep the resident safe, but the methods used were inappropriate and resulted in the resident feeling abused.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who sustained a skin tear on their left hand. The facility's policy requires immediate notification and investigation of any suspected abuse, but in this case, there was no incident report or documented skin assessment related to the incident. The resident, who had a history of dementia, agitation, and wandering, was admitted to the facility and was noted to have physical behavior symptoms directed towards others. Despite these behaviors, the facility did not document any investigation into the cause of the skin tear. Interviews with staff revealed that the resident attempted to leave the unit and allegedly hit a staff member with their walker, resulting in the skin tear. The Licensed Practical Nurse treated the injury and documented a behavior note but did not notify the physician or complete an incident report. The Social Worker reported the incident during a morning meeting, and the resident's family was informed of the injury. However, the family alleged that the resident was abused and decided to take the resident home against medical advice. The Director of Nursing stated that an incident report was not necessary because the skin tear was observed and attributed to the resident's behavior. However, there was no documentation of the resident's refusal to have a skin assessment upon admission, which should have been recorded. The family representative expressed concerns about the lack of communication from the facility and the absence of an incident report, leading to their decision to remove the resident from the facility.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident within the required 24-hour timeframe. The incident occurred when a resident, who was cognitively intact but exhibited physical and verbal behaviors, was reportedly assaulted by staff. The resident's representative informed the facility of the alleged assault via email, but the Administrator was not notified until two days after the incident. The facility's policy requires immediate notification of the Administrator or designee in such cases, but this protocol was not followed. The incident involved the resident walking around the unit and entering other residents' rooms, which led to staff intervention. The resident was administered medication and restrained by staff members, who held onto the resident's arms and legs while transporting them back to their room. The resident was later transferred to the hospital and returned to the facility the same day. Despite these events, the incident was initially categorized as a behavioral episode rather than an abuse incident, delaying the investigation and reporting process. Interviews with facility staff revealed a lack of communication and understanding of the incident's severity. The Administrator and Director of Nursing were not informed of the physical interventions used by staff until the resident's representative raised concerns. The Registered Nurse involved did not complete an incident report, believing the situation was merely a behavioral issue. This miscommunication and failure to adhere to reporting protocols resulted in a delay in notifying the New York State Department of Health about the alleged abuse.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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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) |
|---|---|---|---|---|
| Springvale Nursing & Rehabilitation Center | 0.8 mi | ★★★★★ | 29 | 0 |
| Sky View Rehabilitation & Health Care Center L L C | 2.3 mi | ★★★★★ | 6 | 0 |
| Northern Riverview Health Care, Inc | 3.9 mi | ★★★★★ | 23 | 0 |
| The Emerald Peek Rehabilitation And Nursing Center | 4 mi | ★★★★★ | 0 | 0 |
| Helen Hayes Hospital R H C F | 4 mi | ★★★★★ | 0 | 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.