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 Montgomery Nursing & Rehab Ctr during CMS and state inspections, most recent first.
A resident with moderately impaired cognition and significant ADL assistance needs reported that a male resident with severe dementia entered her room in his wheelchair while she was partially undressed and touched her genital area, prompting her to slap him and for him to leave. The incident was disclosed by the resident to her spouse, who informed staff, and subsequent review of video footage by the DON and administrator confirmed the male resident entering and exiting the room around the reported time. During interviews, the male resident admitted entering the room without permission and touching the other resident’s perineal area. This occurred despite facility policies on abuse prevention and resident rights that require residents be free from abuse, neglect, and exploitation.
The facility failed to properly store and label medications, including multi-dose insulin vials and pens, affecting all residents. An LPN confirmed that an opened and unlabeled Lispro insulin vial was found, and the insulin for the resident had been discontinued months prior. Additionally, an RN acknowledged that a Lantus vial and Basaglar Pen were undated. A medicine cup with pills was also found unattended, identified as a resident's medication.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with qualifying conditions, such as catheters, IV therapy, and pressure ulcers. Observations revealed a lack of signage and PPE usage, with staff not donning gowns during high-contact care activities. The Assistant Director of Nursing acknowledged the oversight in EBP implementation.
The facility failed to maintain dignity for two residents during dining. A CNA was observed standing while feeding residents, despite instructions to sit, due to difficulty reaching them. Both residents required significant assistance with eating due to medical conditions. Interviews revealed inconsistent feeding practices among CNAs, and the facility's policy emphasized not standing over residents while feeding.
A facility failed to administer a G-tube feeding according to standards of care for a resident. The resident had a G-tube and was at risk for complications such as aspiration. The physician's orders specified a tube feeding of 237 milliliters over 60 minutes, four times a day. An LPN administered the feeding while the resident was lying flat, without elevating the head of the bed, which is standard practice to prevent aspiration. The Director of Nursing confirmed the LPN's failure to elevate the bed. The resident subsequently developed aspiration pneumonia. The facility's policy did not address the need to elevate the head of the bed during tube feeding.
A resident with severe cognitive impairment sustained second-degree burns after spilling hot coffee on herself due to inadequate supervision. The resident, who required set-up assistance for eating, was allowed to eat in her room, leading to the incident. Staff interviews revealed that the facility's policy on serving hot beverages was not effectively implemented.
Failure to Protect Resident From Sexual Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident. A cognitively moderately impaired resident with hemiplegia, weakness, and impaired mobility reported to her spouse that, in the early morning hours, a male resident entered her room in his wheelchair while she was sitting on the side of her bed without pants and touched her genital area. The resident stated she slapped the male resident, who then left her room. The spouse notified facility staff of the allegation later that day, and the Assistant DON performed a skin assessment, finding no injuries. The DON obtained a statement from the resident, who reiterated that the male resident had entered her room and touched her privates without permission. Review of facility camera footage by the DON and the administrator showed the male resident entering the resident’s room at approximately the reported time and exiting a short time later. The administrator and DON interviewed the male resident, who admitted entering the room without permission and touching the resident in the perineal area, and stated it would not happen again. Record review showed that the abused resident required partial to moderate assistance with ADLs, including toileting, bathing, dressing, and personal hygiene, and had a BIMS score indicating moderately impaired cognition. The male resident who committed the abuse had a diagnosis of unspecified dementia with severely impaired cognition (BIMS score of 3) and required substantial to maximal assistance with several ADLs. Despite the facility’s written Abuse Prevention Program and Resident Rights policies, which guarantee residents freedom from abuse, neglect, and exploitation, the facility did not prevent the male resident from entering the female resident’s room and sexually touching her, resulting in a substantiated incident of sexual abuse.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to properly store and label medications, specifically multi-dose insulin vials and pens, which could potentially affect all residents. During an inspection of the 500 Hall Medication Cart, an opened and unlabeled multi-dose Lispro insulin vial was found. A Licensed Practical Nurse (LPN) confirmed that the vial was open, partially used, undated, and not labeled with a resident identifier or open date. It was later revealed that the insulin for the resident in question had been discontinued months prior, and there was no current order for Lispro for that resident. Additionally, the 100 Hall Medication Cart contained an opened, partially used, and undated multi-dose Lantus vial and an unlabeled and undated multi-dose Basaglar Pen. A Registered Nurse (RN) acknowledged that these medications should have been dated. Furthermore, a clear medicine cup with a large white pill and an oblong red, white, and blue pill was observed on a food tray in the hallway. An LPN identified these as a resident's Tylenol and potassium pills, which the resident had apparently spit out. The Assistant Director of Nursing stated that staff are required to label multi-dose vials or pens with the resident's name and the date opened, as this information is crucial for determining the medication's expiration. The facility's pharmacy policies and procedures manual also mandates that medications be stored safely and securely, with proper labeling and expiration dating, which was not adhered to in these instances.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precautions (EBP) policy, as evidenced by the lack of signage and Personal Protective Equipment (PPE) usage for residents requiring Transmission Based Precautions (TBP). Specifically, four residents with qualifying criteria for EBP were not provided with appropriate precautions. For instance, a resident with a catheter and nephrostomy tube was observed without any signage or PPE outside their room, and the urinary bag was improperly placed on the floor. Additionally, a Licensed Practical Nurse (LPN) did not wear a gown while performing care, contrary to the facility's policy. Another resident receiving intravenous therapy for bacteremia was also not provided with the necessary EBP signage or PPE. A Registered Nurse (RN) entered the resident's room and donned gloves but failed to wear a gown while administering IV antibiotic medication. Similarly, a resident with a gastrostomy tube and dependent on dialysis did not have EBP signage or PPE available. An LPN administered tube feeding without wearing a gown, despite the resident's care plan indicating the need for EBP. Furthermore, a resident with a pressure ulcer on the left heel did not have EBP signage on their door. The Assistant Director of Nursing (ADON) provided wound care without the required precautions. The facility's policy mandates the use of EBP for residents with chronic wounds, indwelling medical devices, and during high-contact care activities. The failure to implement these precautions was acknowledged by the ADON, who admitted to not being fully aware of the EBP requirements for certain conditions.
Failure to Maintain Resident Dignity During Dining
Penalty
Summary
The facility failed to provide dignity to two residents during dining, as observed by surveyors. A Certified Nursing Assistant (CNA), identified as V4, was seen standing while feeding a resident, R3, from behind a half-round table in the assistive dining room. Despite being instructed by the Administrator, V1, to sit down while feeding, V4 continued to stand, citing her height as a reason for not being able to reach the resident while seated. Later, V4 switched to feeding another resident, R19, and again stood up to feed her due to difficulty reaching across the table. Both residents, R3 and R19, were documented as rarely or never understood and required significant assistance with eating due to their medical conditions, including Alzheimer's, delusional disorders, dysphagia, dementia, and hemiplegia. Interviews with other CNAs revealed a mix of practices regarding feeding residents, with some stating they sit down to make eye contact, while others admitted to standing when necessary. The facility's policy on assisting residents with meals, dated June 2016, explicitly states that residents should not be fed while standing over them, emphasizing the importance of safety, comfort, and dignity. The Administrator, V1, clarified that staff were not instructed to sit behind the table and could sit next to residents to assist with meals, indicating a possible miscommunication or misunderstanding among staff regarding proper feeding procedures.
Failure to Elevate Head of Bed During G-tube Feeding
Penalty
Summary
The facility failed to administer a Gastrostomy Tube (G-tube) feeding according to standards of care for a resident. The resident, identified as R230, had a G-tube and was at risk for complications such as aspiration. The physician's orders specified that the resident should receive a tube feeding of 237 milliliters over 60 minutes, four times a day. On March 24, 2025, a Licensed Practical Nurse (LPN) administered the tube feeding while the resident was lying flat in bed, without elevating the head of the bed, which is a standard practice to prevent aspiration. The Director of Nursing confirmed that the LPN did not elevate the head of the bed during the feeding. Subsequently, the resident developed aspiration pneumonia. The facility's policy did not address the need to elevate the head of the bed prior to initiating a tube feeding.
Inadequate Supervision Leads to Resident Burns
Penalty
Summary
The facility failed to adequately supervise a resident with severe cognitive impairment, resulting in the resident spilling hot coffee on herself and sustaining second-degree burns. The incident occurred when the resident attempted to stand up using the bedside table, causing the coffee on her breakfast tray to spill onto her lap. Immediate assessment revealed redness to the right upper thigh, and subsequent medical follow-up noted the development of blisters on both thighs, requiring treatment with Silvadene cream. The resident, who has dementia, atrial fibrillation, hypertension, and anxiety, was known to require set-up assistance for eating. Despite this, she was allowed to eat in her room, which led to the incident. The care plan indicated that the resident needed extensive staff assistance with activities of daily living due to her mobility issues and confusion. However, the supervision provided was insufficient to prevent the accident. Interviews with staff revealed that the dietary manager and CNAs were aware of the need to monitor the temperature of hot beverages. However, the coffee served to the resident was not adequately cooled, leading to the burn incident. The facility's policy on serving hot beverages was not effectively implemented, contributing to the resident's injury.
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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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Nursing homes near Hillsboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillsboro Rehab & Hcc | 4.4 mi | ★★★★★ | 7 | 0 |
| Avenues At Litchfield | 10.1 mi | ★★★★★ | 2 | 0 |
| Litchfield Health & Rehab Center | 10.4 mi | ★★★★★ | 0 | 0 |
| Greenville Nursing & Rehab | 15.4 mi | ★★★★★ | 2 | 0 |
| Staunton Health And Rehab Ctr | 17 mi | ★★★★★ | 3 | 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.