Montgomery Nursing & Rehab Ctr

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure one (R1) resident was free of sexual abuse from one (R8) resident reviewed for abuse in the sample of 8. This past non-compliance occurred from 1/9/2026-1/13/2026. Findings include:On 3/23/2026 at 12:41 V3, Assistant Director of Nursing (ADON) stated R1 reported allegation to her spouse and R1's spouse notified the facility. V3 stated she came in to the facility on 1/9/2026 to do a skin assessment. V3 stated R1 had no injuries.On 3/23/2026 at 12:45PM V2 Director of Nursing (DON) stated she got a statement from R1. V2 stated R1 stated she was sitting on side of bed without any pants on. V2 stated R1 stated that R8 entered her room in his wheelchair and touched her privates. V2 stated R1 reported she slapped R8 and he left her room. V2 stated the camera footage was reviewed and R8 was observed entering R1's room in his wheelchair and exiting a short time later. V2 stated R8 was moved to the 400 hall which is a hall where would be more visibility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to properly store medication and label multi dose insulin vials and pens. This has the potential to effect all residents residing in the facility. Findings include: On 3/24/2025 at 11:12 AM the facility's 500 Hall Medication Cart was inspected. The medication cart contained the following: 1. An opened and unlabeled multi dose Lispro insulin vial. The multi-dose vial did not have a resident identifier or open date. On 3/24/2025 at 11:13 AM V20, Licensed Practical Nurse (LPN), verified that the vial was open, partially used, undated and not labeled. V20 stated that the vial should be labeled with the resident's name and open date. V20 stated that the vial belonged to R31. On 3/26/2025 at 1:56 PM V7, LPN, stated that the multi-dose vials that are not labeled are stock. V7 stated that when using the multi-dose vial it is labeled with the resident's name and open date. V7 stated that R31's insulin was discontinued October 2024. A review of R31's medical record Physician Order Sheet (POS) document no current Lispro…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the Facility failed to follow their Enhanced Barrier Precautions (EBP) policy by not posting signage or utilizing Personal Protective Equipment (PPE) when caring for residents with qualifying criteria for 4 of 4 residents (R33, R74, R75, and R230) reviewed for Transmission Based Precautions (TBP) in the sample of 40. Findings include: 1. On 3/24/2025 at 10:10 AM, R75 was observed in a low bed with a catheter bag attached. The catheter bag was rested on the floor. There was no signage or Personal Protective Equipment outside R75's room or near the vicinity of R75's room. On 3/24/2025 at 3:18 PM, V20, Licensed Practical Nurse (LPN) stated R75 had a catheter but she removed it because he was pulling at it. V20 stated R75 still has a nephrostomy tube that gets flushed every day by the nurses. R75's Progress Notes dated 3/23/2025 at 10:27 AM documents R75's nephrostomy tube and catheter were in place. R75's Progress Notes dated 3/23/2025 at 1:58 PM documents R75's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to provide dignity for two of six (R3 and R19) residents reviewed for dining in a sample of 40. Findings include: On 3/24/2025 at 11:00 AM, V4, Certified Nursing Assistant (CNA), was at a half round table, in the assistive dining room, where there were 3 residents that needed feeding assistance. She was standing up feeding R3 from behind the half round table. V1, Administrator, asked V4 to sit down when she was feeding the resident. V4 stated that she was too short to reach R3. V1 walked away. She continued to feed R3 standing up instead of sitting down next to her. Another CNA asked V4 to switch her tables and feed R19. V4 did so, sat down and could not reach R19 across the table so she stood up instead of sitting next to R19 and gave her bites of food. R3's Minimum Data Set (MDS), dated [DATE] documented that she was rarely or never understood and that she was dependent upon staff for eating. R3's Care Plan, dated 11/24/2020, documented,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to administer a Gastrostomy Tube (G-tube) feeding according to standards of care for 1 of 1 residents (R230) reviewed for tube feedings in the sample of 40. Findings include: R230's Face sheet dated 3/26/2025 documents R230 has a Gastrostomy Tube (G-tube). R230's Care Plan dated 3/18/2025 documents R230 currently has a feeding tube in place, placing him at risk for complications, including aspiration (inhaling fluid into the lungs). R230's Physician's Orders dated 3/19/2025 documents R230 gets a tube feeding at 237 milliliters over 60 minutes four times a day via G-tube. On 3/24/2025 at 4:00 PM, V6, Licensed Practical Nurse (LPN) entered R230's room to administer his tube feeding. V6 donned gloves, but no gown. V6 connected the tube feeding to R230's G-tube and began the feeding at 237 milliliters per hour. R230 was laying flat in bed. V6 did not elevate the head of R230's bed. On 3/25/2025 at 7:58 AM, V2 Director of Nursing (DON) stated she would expect the nurse administering a tube feeding to elevate the head…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to discard insulin pens after being in use for longer than 28 days, remove and dispose of expired medications, and not store food items in the medication refrigerator. This failure has the potential to affect all 75 residents residing in the Facility. Findings include: On 03/10/24 at 8:40 AM, The front medication room was inspected. The unlocked refrigerator, in the medication room contained the following: 1. There was a container of personal food and a 2% milk. 2. An unopened box of Tylenol suppository's 650mg (milligrams) with an expiration date of 12/2023. 3. R68's opened Lansprazole suspension 3mg/ml (milligrams/milliliter) with no open date or discard noted to the bottle. On 03/10/24 at 8:43 AM, 12, Registered Nurse (RN) stated the Lansprazole suspension should have an open date on it and there shouldn't be any food in the medication storage refrigerator. On 03/10/24 at 8:45 AM, The stock medication cabinet was inspected and contained the following: 1. Oyster Shell calcium Vitamin 250mg expiration date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed supervise and assist with meals for 1 of 1 (R45) residents reviewed for nutrition in a sample of 38. Findings include: R45's Face sheet, print date of 03/12/24, documents R45 has diagnoses of other specified eating disorder and dysphagia (difficulty swallowing), oropharyngeal phase. R45's Minimum Data set (MDS), dated [DATE], documents, R45 is severely cognitively impaired and requires partial/moderate assistance with eating. R45's Care Plan, last care conference date of 10/26/23, documents, Goal: R45 will consume 75% of all meals and will remain free from significant weight loss. Approach list but is not limited to protein supplement three times a day with med pass, fortified ice cream with lunch and dinner, routine weights, record, notify doctor (MD)/registered dietitian (RD) of any significant changes in weight, and selective menu choices. Substitutions available for food dislikes. R45's Weights for the past six months are as follows:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident's call lights were within easy reach for 1 of 11 residents (R2) reviewed for call lights in a sample of 11. Findings include: R2's Face Sheet, print date of 09/26/23, documents R2 has diagnoses of Hemiplegia, unspecified affecting left nondominant side, Epilepsy, and Gastroesophageal reflux disease, (GERD). R2's Minimum Data Set, (MDS), dated [DATE], documents R2 is moderately cognitively impaired and requires extensive assistance, two plus person physical assist with bed mobility, transfer, dressing, toilet use, personal hygiene, and he is frequently incontinent of bowel and bladder. On 09/20/23 at 10:50 AM, R2's call light was observed to be lying on the floor beside his bed where he was unable to reach it. When this surveyor questioned R2 about his call light, he stated it's supposed to be hooked to the bed, but sometimes they will drop it on the floor, and he is unable to reach it and he must scream for someone to come…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain the resident's environment in a clean and sanitary condition for 1 of 11 residents (R2) in a sample of 11. Findings include: R2's Face Sheet, print date of 09/26/23, documents R2 has diagnoses of Hemiplegia, unspecified affecting left nondominant side, Epilepsy, and Gastroesophageal reflux disease (GERD). R2's Minimum Data Set, (MDS), dated [DATE], documents R2 is moderately cognitively impaired and requires extensive assistance, two plus person physical assist with bed mobility, transfer, dressing, toilet use, personal hygiene, and he is frequently incontinent of bowel and bladder. On 09/20/23 at 10:50 AM, upon entry to R2's room, a strong odor of urine was noted; there were two urinals hanging on the side of the trash can with urine in them. One had approximately 500 milliliters, (ml), of dark yellow urine in it and the other had approximately 200ml of dark yellow urine in it. The trash can was full of trash/food wrappers.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This has the potential to affect all 69 residents in the facility. Findings include: On 2/6/2023 at 3:00 PM, V2, Director of Nursing (DON), stated, There was a few times in the last month that the facility has not been staffed with an RN for 8 hours in a 24-hour period. On 2/9/23 at 11:00 AM, V1, Administrator, stated, I am having difficulty getting RNs who want to work full time. I am aware that I am supposed to have an RN for 8 hours 7 days a week. The Staffing schedules were reviewed for the past month. On the dates of 1/4/2023, 1/28/23 and 1/29/2023 the facility did not have a RN for 8 consecutive hours. The Facility's Daily Staffing Information policy, dated 7/2014, documents, It is the policy of (this company) that, as required by CMS, to post daily staffing information in the facility. This must be posted in a prominent place, readily accessible to residents and visitors at the start of each shift. DON's and ADON's (any nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the Facility failed to provide services to maintain resident's personal hygiene for residents who are dependent upon staff for hygiene for 4 of 4 residents (R26, R15, R35, R44) reviewed for assistance with activities of daily living in a sample size of 31. Findings include: 1. R35's Minimum Data Set (MDS), dated [DATE], documents a R35 has moderately impaired cognition. MDS documents R35 requires extensive assistance with bathing, dressing, toileting, transfers, and personal hygiene. On 2/5/23 at 9:30 AM, R35 stated the call light times are longer on the weekends; he must wait long times for showers, he hasn't had assistance with shaving, and he only gets shaved on shower days, but would like to get shaved every day. On 2/5/23 at 9:30 AM, R35 was sitting in chair with facial hair stubble. On 2/5/23 at 1:00 PM, R35 was sitting in chair with facial hair stubble. On 2/6/23 at 9:30 AM, R35 was sitting in chair with facial hair stubble. R35 states he would like to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to limit the use of PRN (as needed) psychotropic medications to 14 days unless justification is provided by physician for 4 of 4 residents (R8, R46, R61 and R24) reviewed for psychotropic medication use in the sample of 31. Findings include: 1. R24's Face Sheet, undated, documents R24's diagnoses in part as major depressive disorder, single episode, and generalized anxiety disorder. On 2/8/23 at 9:00 AM, R24's Physician's Order (PO), with a start date of 9/13/2022, documents alprazolam 0.25 MG take 1 tab PO (orally) BID (twice a day) PRN RE-EVALUATE 3/10/23. R24's medical record contains pharmacy recommendation, dated 9/1/21, that documents end date re-eval 3/10/22, with no rationale indicated for extended use of the alprazolam. R24's Care Plan, Problem, dated 9/13/22, documents, Anti-Anxiety med use: she receives anti-anxiety med Xanax as needed, as she does become anxious, placing her at risk for significant side effects from med (medication). The Care Plan Approach, dated 9/13/22, documents Administer med…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the Facility failed to ensure appropriate care and placement of indwelling urinary catheter drainage bags and tubing to prevent infection for 2 of 4 residents (R34, R52) reviewed for catheter care in the sample of 31. Findings include: 1. R34's undated Face Sheet documents the diagnoses to include, Urinary tract infection (UTI), site not specified, Neuromuscular dysfunction of bladder, and Retention of urine. R34's Care Plan documents goal for R34 will remain free from s/s (signs/symptoms) of UTI thru next review. Interventions: Position the collection bag below the bladder, ensure the bag and tubing are off the floor at all times. On 2/9/23 at 8:05 AM, R34's Minimum Data Set (MDS), dated [DATE], documents R34 requires extensive assist with bed mobility, dressing, and dependent on staff for toileting, transfers and personal hygiene. On 2/5/23 at 10:00 AM, V4, Certified Nursing Assistant (CNA), and V10, CNA, transferred R43 to bed with full body lift. V4 placed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.