Above 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 Place Nursing Center during CMS and state inspections, most recent first.
The facility did not employ a full-time Certified Dietary Manager for its 38 residents, as required by its policy. During a survey, it was observed that the dietary manager, Dietary Staff BB, was still enrolled in a Certified Dietary Manager course and had not completed it. This deficiency placed residents at risk of inadequate nutrition.
The facility failed to maintain sanitary conditions in the kitchen, affecting food preparation and storage for 38 residents. Observations revealed improper food storage, a cracked light cover, and lint-covered air conditioning equipment blowing towards the food prep area. These conditions violated the facility's food safety policies, placing residents at risk for foodborne illness.
A facility failed to update a resident's care plan with individualized interventions for dementia care, despite the resident's documented behaviors such as wandering and agitation. The care plan lacked specific strategies to address these behaviors, and staff did not consistently document or monitor the resident's actions as required. This deficiency placed the resident at risk for uncommunicated care needs.
A facility failed to create an individualized dementia care plan for a resident with Alzheimer's, dementia, and other conditions, relying on medications without exploring non-pharmacological interventions. The resident exhibited behaviors like wandering and aggression, but staff did not consistently document these or the interventions used. This deficiency risked the resident's quality of life, as the facility did not follow its policy on behavior management for dementia care.
A Consultant Pharmacist failed to identify and report out-of-parameter blood pressures for a resident with multiple health conditions, including hypertension and atrial fibrillation. The resident received metoprolol despite systolic blood pressures being below the physician-ordered parameters on several occasions. The CP's review did not document these discrepancies, and facility staff confirmed the medication was administered outside of parameters, placing the resident at risk for complications.
A resident with multiple health conditions received blood pressure medication despite physician orders to hold it if systolic blood pressure was below 110 mmHg. The MAR showed several instances where the medication was administered outside these parameters. Staff interviews confirmed the oversight, and the facility's policy on medication administration was not followed, placing the resident at risk.
A resident with Alzheimer's, dementia, depression, and Parkinson's was prescribed quetiapine fumarate without appropriate documentation of the rationale or unsuccessful non-pharmacological interventions. The facility's policy required clear physician orders for antipsychotic medications, which was not followed, placing the resident at risk for adverse side effects.
Deficiency in Dietary Management Staffing
Penalty
Summary
The facility failed to employ a full-time Certified Dietary Manager for its 38 residents, which was identified as a deficiency during a survey. The observation on 02/04/25 at 08:18 AM revealed that the kitchen staff was finishing the morning meal and preparing the midday meal. During this time, Dietary Staff BB, who identified as the dietary manager, reported being enrolled in a Certified Dietary Manager course but had not yet completed it. This situation was contrary to the facility's Dietary Services policy, which requires the employment of a qualified dietitian or nutritional professional on a full-time or consultant basis. The absence of a fully qualified dietary manager placed the residents at risk of not receiving adequate nutrition.
Unsanitary Food Storage and Preparation Conditions
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which affected the preparation and storage of food for 38 residents. During an inspection, it was observed that the double-door stainless steel refrigerator had sliced ham stored on a middle shelf with gallons of milk and a large bowl of yellow pudding directly above it, along with unpasteurized eggs on the same shelf. Additionally, the fluorescent plastic light cover above the food prep area was cracked, and the window air conditioner above a small freezer had a gray/blackish lint-type material on the air outlet levers. A fan with grey/brown lint material on its front guard was positioned in front of the air conditioner, directing airflow towards the food prep area. Dietary Staff BB confirmed the presence of the cracked light cover and the lint-type material on the air conditioner and fan, which were blowing towards the food prep area. The facility's undated Food Safety Requirements policy emphasized the importance of storing, preparing, distributing, and serving food according to professional standards to prevent foodborne illness. However, the facility did not adhere to these standards, as evidenced by the improper storage of food and unsanitary conditions in the kitchen, placing residents at risk for foodborne illness.
Failure to Revise Care Plan for Dementia Care
Penalty
Summary
The facility failed to revise and update the care plan for Resident 35 with individualized, person-centered interventions for dementia care. Despite the resident's documented diagnoses of Alzheimer's disease, dementia, depression, and Parkinson's disease, the care plan lacked specific interventions to address the resident's behaviors. The care plan directed staff to monitor and document mood or behavior changes, but it did not include a treatment plan for when the resident exhibited behaviors such as wandering or delusions. Observations and records indicated that Resident 35 exhibited behaviors such as wandering at night, confusion, agitation, and aggression. The resident's behaviors were documented in nurse's notes, but the care plan was not updated to reflect these behaviors or to provide specific interventions. Staff interviews revealed that while some staff were aware of the resident's behaviors, there was a lack of consistent documentation and monitoring as required by the care plan. The facility's failure to revise the care plan and adequately monitor and document Resident 35's behaviors placed the resident at risk for uncommunicated care needs. The facility's policy required an individualized interdisciplinary plan of care, but this was not followed, leading to a deficiency in providing appropriate care for the resident's dementia-related needs.
Failure to Implement Individualized Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized dementia treatment plan for a resident diagnosed with Alzheimer's disease, dementia, depression, and Parkinson's disease. The resident, identified as R35, was admitted with intact cognition but later exhibited severely impaired cognition, wandering, and delusions. Despite these changes, the care plan lacked specific interventions for the resident's behaviors, relying instead on pharmacological treatments such as antidepressants and antipsychotics without adequately exploring non-pharmacological approaches. Observations and interviews revealed that the facility's staff did not consistently document the resident's behaviors or the interventions used in response. The resident exhibited behaviors such as wandering at night, agitation, and aggression, yet the care plan did not include individualized strategies to address these issues. Staff members were unsure of the specific interventions to use, and documentation in the electronic medical record was inconsistent, failing to provide a clear picture of the resident's needs and responses to interventions. The facility's policy on behavior management for dementia care emphasized the importance of monitoring and documenting behaviors to develop a person-centered care plan. However, the facility did not adhere to this policy, as evidenced by the lack of documentation and individualized interventions for R35. This deficiency placed the resident at risk for a decreased quality of life, as pharmacological interventions were used without first attempting non-pharmacological methods, contrary to best practices for dementia care.
Consultant Pharmacist Fails to Report Out-of-Parameter Blood Pressures
Penalty
Summary
The Consultant Pharmacist (CP) failed to identify and report out-of-parameter blood pressures for a resident, referred to as R35, during a monthly drug regimen review. R35 had a history of hypertension, atrial fibrillation, Alzheimer's disease, depression, and Parkinson's disease. The resident was receiving metoprolol succinate ER for atrial fibrillation, with specific physician orders to hold the medication if the systolic blood pressure (SBP) was less than 110 mmHg. Despite this, the Medication Administration Record (MAR) documented multiple instances in December 2024, January 2025, and February 2025 where the medication was administered when the SBP was below the ordered parameters. The CP's Medication Regimen Review dated January 19, 2025, did not document these out-of-parameter blood pressures. Interviews with facility staff, including a Certified Medication Aide and a Licensed Nurse, confirmed that the medication was administered outside of the physician's parameters and that the CP had not notified the administrative nurse of this issue. The facility's policy required the CP to review the MAR and physician orders monthly to ensure proper documentation and administration of medications, which was not adhered to in this case. This oversight placed the resident at risk for physical decline and medication-related complications.
Failure to Adhere to Blood Pressure Medication Parameters
Penalty
Summary
The facility failed to adhere to physician-ordered parameters for administering blood pressure medication to Resident 35, who had a history of hypertension, atrial fibrillation, Alzheimer's disease, depression, and Parkinson's disease. The resident's care plan required staff to follow specific orders and parameters for blood pressure medications, which included holding the medication if the systolic blood pressure (SBP) was less than 110 mmHg. Despite these instructions, the Medication Administration Record (MAR) documented multiple instances in December 2024, January 2025, and February 2025 where the resident received metoprolol succinate ER 24 hour even when the SBP was below the ordered threshold. Observations and interviews revealed that the Certified Medication Aide (CMA) administered the medication without incident, and the Licensed Nurse (LN) confirmed that the medication was given when the SBP was out of parameters. The Administrative Nurse acknowledged that the medication was not held as per the physician's orders and noted that the Consultant Pharmacist had not informed her of the issue. The facility's policy stated that medications should be administered as ordered, with adherence to holding and notification parameters, which was not followed in this case, placing the resident at risk for physical decline and other related complications.
Failure to Document Rationale for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that a resident, identified as R35, did not receive antipsychotic medication without an appropriate indication or the required physician documentation for its use. R35 was admitted with diagnoses including Alzheimer's disease, dementia, depression, and Parkinson's disease. The resident's care plan and medical records lacked documentation of unsuccessful attempts at non-pharmacological interventions and a risk versus benefit analysis for the continued use of the antipsychotic medication, quetiapine fumarate. The resident's medical records showed that quetiapine fumarate was prescribed and increased over time without a documented physician rationale or indication for its use. The facility's policy required that all physician orders for antipsychotic medications include a diagnosis, condition, or indication for use, which was not adhered to in this case. Interviews with staff revealed that the medication was started at the family's request, and there was a lack of clarity among staff regarding the resident's behaviors and the documentation of such behaviors. The facility's failure to document the rationale for the antipsychotic medication and to ensure non-pharmacological interventions were attempted placed the resident at risk for adverse side effects. The facility's policy on antipsychotic drugs was not followed, as the orders lacked clear and accurate documentation, and the consultant pharmacist's review of the medication's appropriateness was not evident in the records.
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Independence
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medicalodges Independence | 2.1 mi | ★★★★★ | 0 | 0 |
| Advena Living Of Cherryvale | 8.5 mi | ★★★★★ | 24 | 0 |
| Medicalodges Coffeyville On Midland | 12.3 mi | ★★★★★ | 10 | 0 |
| Neodesha Care And Rehab | 15 mi | ★★★★★ | 21 | 0 |
| Parsons Presbyterian Manor | 24.6 mi | ★★★★★ | 4 | 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.