Montrose Healthcare Center

In the surveyor’s words

From the most serious findings on record at Montrose Healthcare Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF641Apr 30, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF688Apr 30, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF726Apr 30, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF812Apr 30, 2026

  Based 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). […]

• No harm, potential for more than minimal, patternF814Apr 30, 2026

  Based 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. Findings: During a concurrent observation and interview on 4/27/2026 at 8:20 AM with Maintenance Supervisor (MS), two exterior garbage containers were observed overflowing with lids not closed. The Trash bags and loose garbage contents were observed on the ground surrounding the dumpster area, along with discarded gloves. […]