Federal health inspectors visited Montrose Healthcare Center on May 29, 2026, responding to a complaint.
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Federal health inspectors cited the facility on May 29, 2026, for failing to provide care that was trauma-informed and culturally competent.
Federal inspectors documented both failures during a June 2026 inspection of the facility at 414 E State Street.
The family received no call about the collapse.
The resident, identified in inspection records only as Resident 119, was in bed at the time.
That is what federal inspectors found when they investigated a complaint at Spring Creek Post-Acute Rehabilitation Center in Murray, Kentucky.
The resident, identified in inspection records only as Resident 6, lives at Parsons Presbyterian Manor.
The incontinence care observation began at 10:00 AM.
The dishwasher at the facility sanitizes through heat, which means staff are supposed to log wash and rinse temperatures at every meal to confirm it's working.
The cart belonged to the Cherrytree unit, the facility's memory care floor.
The resident, identified in the inspection report as Resident #59, was admitted to Jena Nursing and Rehabilitation Center in July 2025.
The second cream, triamcinolone, a corticosteroid prescribed to reduce inflammation, was already gone.