Montrose Healthcare Center

Inspectors wroteBased on interview and record review the facility failed to ensure informed consent for psychotropic medications were obtained and properly documented prior to administration for four of four sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4) in accordance with the facility's Policy and Procedure (P&) titled Psychotropic Medication Use. This deficient practice resulted in the administration of psychotropic medications without documented evidence of residents informed decision-making and acknowledgement of the associated risks, benefits, and alternatives.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were administered according to physician's order for two of four sampled residents (Resident 3 and Resident 4) by failing to: Ensure Resident 3 and Resident 4's medications were consumed and not left at the resident's bedside for later self-administration in accordance with the facility's Policy and Procedure (P&P) titled Self Administration of Medications. Ensure Resident 4 had an order for Pepto-Bismol (a popular over-the-counter pink medicine used to soothe an unhappy stomach) prior to the administration of this medication in accordance with the facility's P&P titled Administering Medications. This deficient practice had the potential to result in missed doses, medication errors, or unauthorized access to medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of three (3) sampled residents (Resident 1) received continuous oxygen therapy that was titrated (adjusting the dose, amount, or flow rate of a medication or treatment based on the resident's condition) to ensure the resident's oxygen saturation (is how much oxygen your blood is carrying indicating whether your body is getting enough oxygen to your organs and tissues , normal oxygen saturation ranges from 95% - 100%) is above 95% in accordance with the physician's orders. This deficient practice had the potential to result in inadequate oxygenation, shortness of breath, respiratory distress, and a decline in the resident's overall respiratory status. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS, resident assessment tool) for two of 15 sampled residents (Resident 8 and 3) by failing to:1. For Resident 8, accurately code Section O for number of days Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) provided bed mobility training on MDS dated [DATE] and 3/17/2026.2. For Resident 3, accurately code Section O for number of days RNA program provided transfer training on MDS dated [DATE]. This deficient practice had the potential to cause inaccurate care planning and provision of appropriate services for Residents 3 and 8.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of five sampled residents (Residents 21, 3, and 7) received appropriate services to prevent a decline in range of motion (ROM, full movement potential of a joint) and mobility by failing to: 1. For Resident 21, provide a Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) for active range of motion (AROM, movement at a given joint when the person moves voluntarily) to both lower extremities (BLE, hip, knee, ankle/foot) upon discharge of Physical Therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) services on 4/30/2025. 2a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete annual competencies for putting on and taking off splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) and braces (an external device to support, align, or correct a movable part of the body) for two of two Restorative Nursing Aides (RNA 1 and RNA 2) who perform Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) tasks that include putting on and taking off splints and braces. This deficient practice had the potential to result in injury, worsening contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion), and skin breakdown for residents who require splints and braces during RNA.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices were followed in the kitchen by failing to: 1. Ensure one seasoning salt was labeled with an open date and use by (the last date recommended for consuming a product at peak quality and safety), date. 2. Ensure one dirty meal tray was not placed on top of clean cups placed and then placed into the clean food cart. This deficient practice had the potential to result in cross- contamination and expose resident to foodborne illness (any sickness caused by consuming food or beverages contaminated with harmful microorganisms, toxins, or chemicals).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two garbage containers located outside of the facility was maintained in sanitary condition without garbage contents overflowing outside of the garbage container. This failure had the potential to attract pests and rodents, create foul odors, and contribute to environmental contamination, increasing the risk of infection transmission.

Inspectors wroteBased on observation , interview and record review, the facility failed to maintain timely and accurate completion of residents medical records for 2 of eight sampled residents (Residents 3 and 7) when: 1. Resident 3's Physical Therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) Joint Mobility Screens (JMS, assessment of joint range of motion to monitor changes in ROM) dated 4/28/2025 and 10/28/2025 were not completed and documented until 11/4/2025 and the PT JMS dated 7/28/2025 was not completed until 9/22/2025. 2. Resident 7's Physical Therapy Joint Mobility Screen dated 3/3/2025 was not completed and documented until 4/2/2025 and the PT JMS dated 6/2/2025 was not completed and documented until 11/4/2025. [...]

Inspectors wroteBased on interview, and record review, the facility failed to obtain an informed consent (a process of communication between a person and the health care provider that often leads to agreement or permission for care, treatment, or services) for psychotropic/psychotherapeutic (any drug that affects behavior, mood, thoughts, or perception) drug for one of three sampled resident (Resident 20) who was prescribed Donepezil (cholinesterase inhibitor (drug used to manage cognitive symptoms) medication used for dementia). This deficient practice violated Resident 20's rights to be informed when choosing the type of care or treatment to be received, making decisions on alternative measures that the resident or responsible party preferred, which can negatively affect Resident 20's quality of life. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike, orderly environment for one out of three sampled residents (Resident 43) when the resident's wall clock inside the room showed an incorrect time. This deficient practice compromises the comfort and orderliness of the resident's environment. During a review of Resident 43's admission Record (AR), the AR indicated that the resident was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included Alzheimer's disease (a brain disorder affecting memory, thinking, and behavior), anxiety disorder (persistent, excessive fear or worry that interferes with daily life), and schizophrenia (a mental health condition that affects how people think, feel and behave). [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure for one of three sampled residents (Resident 61) that a written bed-hold policy was provided to the resident and/or resident representative prior to transfer to the General Acute Care Hospital (GACH) on 3/28/2026 for a change of condition (COC). This deficient practice resulted in Resident 61 and/or their representatives not being informed of their rights regarding bed reservation during hospitalization, which could lead to confusion and disruption in continuity of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update one of 15 sampled residents (Resident 7) Restorative Nursing Aide program's (RNA, nursing aide program that help residents to maintain their function and joint mobility) care plan to reflect Resident 7's updated and current RNA treatment program. This deficient practice had the potential for Resident 7 to receive improper treatment and services and minimize the facility's ability to review the effectiveness of Resident 7's RNA program.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication was adequately administered as ordered for one out of three sampled residents (Resident 15), by failing to: Ensure licensed vocational nurse (LVN) 1 remained with Resident 15 until the entire administered medication, Simethicone (medication used to relieve symptoms of excess gas, such as bloating) tablet chewable 80 MG (milligram, a unit of measuring weight), was swallowed. Ensure LVN 1 applied pressure over Resident 15's tear duct after the administration of Cyclosporine (eye drop medication that is administered directly to the eyes and is used to increase tear production) eye drops. This deficient practice placed Resident 15 at risk of not receiving the intended effects of the medications and could lead to the mismanagement of the resident's diseases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the prescribed diet order for one out of four sampled residents (Resident 66) when the resident's meal tray contained food items that did not follow the physician's order and resident care plan of Soft and Bite sized texture diet due to difficulty swallowing. This deficient practice placed the resident at risk of choking. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), had a comprehensive, person-centered care plan created for known behaviors related to the diagnosis of dementia. During the investigation, Resident 1 had known behaviors that included noncompliance with safety interventions, such as the resident's inability to consistently remember to use the call light and repeated attempts to get out of bed or chair without seeking staff assistance. Despite a documented history of three prior falls, Resident 1's care plans lacked individualized interventions and measurable goals to effectively manage Resident 1's behaviors. This failure has further potential to result in a decline in the resident' physical and psychosocial well- being due to the lack of individualized and effective care.

Inspectors wroteBased on observation, interview, and record review the facility failed to store medications safely, labeled with expiration or discard date and store controlled drugs (medications that can create mental and physical addiction or dependency) in a locked in compartments that are separately locked in storage of controlled drugs for two of two sampled residents receives (Residents 37 and 40) in accordance to the facility's policy and procedure (P&P) titled, Storage of Medications. by failing to ensure: 1. Resident 37 does not store two bottles of Flonase nasal suspension (a nasal spray that treats allergy symptoms like sneezing, itching and a runny or stuffy nose) in his nightstand drawer who was not a candidate for Self Medication Adminitration. 2. [...]

Inspectors wroteBased on observation, Interview, and record review the facility failed to ensure proper food handling practices by: Failing to prepare food in a manner to prevent food born illness by using bare hand contact while plating food. Failing to label with the Use by Date potentially hazardous food in the refrigerator and freezer. These deficient practices had the potential to result in foodborne illness for those who receive and consume food prepared from the facility kitchen.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to provide respect and dignity to one of 18 sampled residents (Resident 1) who received a meal tray 20 minutes after the other residents she was seated with in the dining table received their trays. When Resident 1 received her meal tray, she ate by herself. This deficient practice violated the rights of Resident 1 to have dignified, equal care and potentially affect Resident 1's self-esteem and self-worth.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the licensed nurse to document the accurately and timely after medications were administered to one of four residents (Resident 37) in accordance with the facility ' s policy and procedure (P&P) titled, Administering Medications, as evidenced by: 1. Document Resident 37's medications that were scheduled at 9 AM as administered on the Medication Administration Record (MAR) before the actual medication administration. 2. Document Resident 37's ASA (Aspirin medication that thins the blood to prevent blood clot to form) that was not administered, as administered on the MAR. The deficient practices had result in Resident 37 not receiving ASA as scheduled and put him at risk for medication error, including overdosing and underdosing on medications.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to assist one of three sampled residents (Resident 9) who unable to carry out activities of daily living (ADLs) and incontinent (no control) of bladder and bowel receives assistance with perineal care and changed incontinent brief timely. Resident 9 was observed with wet incontinent brief with pink colored urine and had foul smell that was not changed from 7am to 3:10 pm on 4/7/2025. This deficient practice had the potential to place Resident 9 at risk for infection and skin breakdown and to negatively impact Resident 9's self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and interventions to prevent development or recurrence of pressure injury (PI-localized damage to the skin and/or underlying tissue usually over a bony prominence) for one of three sampled residents (Resident 9) who was not repositioned and turned, skin was not assessed and documented in the resident's clinical record the skin condition daily and weekly as indicated in the residents care plan, and facility ' s policy and procedures titled Prevention of Pressure Injuries. These deficient practices placed Resident 9 and all other residents at risk for skin breakdown to develop PI or reopening of a healed PI that could lead to discomfort, pain and infection.

Inspectors wroteBased on observation, interview, record review, the facility failed to provide an environment free of accident and hazard, monitoring and supervising as indicated in the facility's policy and procedure and resident's care plan for one out of 4 residents (Resident 2) who was at risk for fall due to poor safety awareness and unable to see clearly due to an eye infection and wandering behavior (walking in places aimlessly), Resident 2 was walking in the room with eyes closed and hands outstretched, running into wall several times near the restroom area without staff present to assist or redirect the resident. This failure had the potential to result in serious physical harm, psychosocial isolation, and unmet care needs, compromising both the resident ' s safety and quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately monitor signs and symptoms of urinary tract infection (UTI- an infection in the bladder/urinary tract) for one of one sampled resident with suprapubic catheter (SPC- a tube that is used to drain urine from the bladder through a cut in the abdomen) was secured with anchor (a catheter securement device) as indicated in the facility ' s policy and procedure titled Catheter Care, Urinary by failing to ensure: 1. Resident 9 was monitored for presence of foul urine smell and pink urine stain in the incontinent brief (undergarment used due to incontinence (no control) bladder and bowel. 2. Resident 9 ' s suprapubic catheter was secured with an anchor to prevent or minimize dislodging. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to administer aspirin (ASA, a drug used to treat pain, fever and reduce the risk of heart attack) 81 milligram (mg, a unit of measurement) one tablet for one of four residents (Resident 37) as ordered by the physician. The deficient practice had resulted in Resident 37 not receiving ASA as physician ' s order which put the resident at risk for cerebrovascular accident (CVA, also known as a stroke, which occurs when blood flow to the brain is interrupted, leading to long-term disability or death).

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with the updated facility ' s policy and procedure (P&P) titled, Charting and Documentation, for one of three residents (Resident 52). The facility staff did not document vital signs (measurement of the blood pressure, heart rate, respiratory rate and body temperature) updated plan of care, and document the treatment and services provided completely and accurately on Resident 52 ' s clinical record with declining condition and was being considered for hospice care (end of life care) by the family and was found unresponsive on [DATE]. This deficient practice had the potential to negatively impact the delivery of services to Resident 52 and other potential residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed implement the facility ' s policy and procedure to Certified Nursing Assistant (CNA) 1 wear personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) during care activities for one of four sampled residents (Resident 33) who was placed on enhanced barrier precaution (EBP- an infection control measure designed to reduce transmission of multidrug-resistant organisms [MDROs-a germ that is resistant to many antibiotics.]) This deficient practice had the potential to result in the spread to infection in the facility that could affect the well being of the residents, staffs and visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodation of need for two of four sampled resident (Resident 27 and Resident 14) who were at risk for fall, by failing to ensure the residents call light was within reach as indicated in the facility's policy and procedure, titled Call Lights and resident's Care Plan. These deficient practices had the potential for Resident 27 and Resident 14 not to receive or received delayed care to meet the necessary care and services that could result in fall and accident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of four sampled resident (Residents 51 and 54) were provided a homelike environment to maintain a comfortable noise level in accordance with the facility ' s Policy and Procedure (P&P), when Resident 12 ' s disruptive behavior of yelling cursing and swearing kept Residents 51 and 54 awake at night and disturbed their sleep. This failure resulted in residents 51 and 54 to feel tired and/or frustrated that could potentially result the residents to experience a decline in their health, quality of life and psychosocial (mental and emotional) wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to post actual worked nursing hours at the start of each shift in the nursing stations visible to the residents and visitors according to the facility ' s Policy and Procedure. This failure resulted in the facility inaccurately reflecting the number of staff providing direct care to the residents which could result in the residents not receiving the necessary care they needed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication room free from expired medications for one out of one medication storage room. During a review of the facility ' s policy and procedure, titled, Labeling of Medication Containers, revised 3/2023, indicated, Labels for individual resident medications include all necessary information, such as: the expiration date when applicable. This failure had the potential to result in the residents to recieve medications that are not effective to treat their diseases and result in a worsened health condition.

Inspectors wroteBased on observation, interview and record review, the facility's kitchen staff failed to follow the facility's infection control policies to ensure the department operates under sanitary conditions at all times by failing to wear a hair net (a net worn over the hair to keep it in place) in food preparing area. This failure had the potential to result in food contamination and food-borne illnesses (illness caused by consuming food or beverages containing disease causing organisms) to the residents.

Inspectors wroteBased on interview and record review, the facility failed to provide information of Advance Directive (AD, a written preferences regarding treatment options, a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions.) for one out of two sample residents (Resident 36). This failure had the potential to result in the violation of the residents right and the facility staffs to provide medical or surgical treatment against the resident's will.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the professional standard of care and the facility's policy and procedure on documenting the medication as given right after medication was administered for one out of five residents (Resident 6). This failure had the potential to result in medication error and a potential for the residents not to receive medications as prescribed by the physician or the same medication causing decline in the resident health condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide indwelling catheter (foley catheter - a tube inserted in the bladder to drain urine into a drainage bag) and ensure foley catheter touching the trash Bin as indicated in the facility ' s policy and procedure, titled Urinary Catheter Care and the resident ' s care plan for one of one sampled residents ( Resident 48) by failing to ensure: 1. Resident 48 was assessed and monitored the presence of white sediments (visible particles in the urine that may contain red or white blood cells, casts, bacteria, fungi, parasites in the urine that could indicate presence of infection or dehydration [fluid deficit]) and cloudiness in the urine. 2. The indwelling catheter was not touching the trash bin. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 6) received care and services for parenteral (liquid solution administered into the vein) antibiotic (a drug used to treat infections caused by bacteria and other microorganisms) consistent with professional standards of practice and the facility's policy and procedure titled General Policy for IV therapy on documentation of intravenous catheter (IV-a plastic device inserted into the vein used to deliver fluids) insertion date This deficient practice had the potential for the resident to develop infection and worsen health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 49) received oxygen in accordance with the facility's policy and procedure by failing to: 1. Resident 49's nasal cannula tubing (flexible plastic tubing with prongs [small opening] used to deliver oxygen through nostrils and fitted over the patient ' s ears) and was touching the trash bin. 2. Resident 49 was receiving oxygen therapy without a physician's order. This deficient practice had the potential to increase the risk of the spread of infection to Resident 49 and at risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues) which can lead to serious complications.

Inspectors wroteBased on observation, interview, and record review, facility failed to follow the facility ' s policy and procedure titled Management and Protection of Protected Health Information, by ensuring one of one sample residents (Resident 34) identifiable, personal and medical information were not exposed on the computer screens unattended and in view of unauthorized persons to view and access confidential information without the resident ' s consent or knowledge. This deficient practice resulted in Resident 34 ' s violation of resident ' s right for privacy.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 14), who signed a Resident - Facility Arbitration Agreement (Binding Arbitration Agreement- is a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds), had the capacity to understand and make an informed decision. Resident 14 signed a Binding arbitration Agreement but did not have the capacity to understand and make decisions. This failure had the potential to result in Resident 14 to not be able to make an informed decision and/or her rights to be denied.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices per facility's Policy and Procedure (P&P) were followed to prevent the transmission of disease and infection for one of five sampled residents (Residents 52). The facility failed to place Resident 52 who had a Peripherally Inserted Central Catheter (PICC, a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) on Enhanced Barrier Precautions (EBP, wearing gown and glove during high contact with resident care activities). This failure had the potential to result in the spread of infection to Resident 52 while residing at the facility.