Below 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 And Rehabilitation Center during CMS and state inspections, most recent first.
The South unit of the facility was found to have cleanliness issues, including dirty floors, radiators, and chipped paint, as well as feces on a toilet and a brown liquid spill. Additionally, a resident received a meal tray with lime deposit stains on the cup and utensils due to hard water, which the facility had not addressed with a water softener. The Director of Housekeeping and Maintenance and the Director of Food Services acknowledged these issues, citing a lack of regular maintenance and repair schedules.
The facility did not meet the minimum staffing requirements for CNAs on 10 out of 28 days, leading to challenges in providing timely care to residents. Interviews with CNAs highlighted difficulties in ensuring resident safety and meeting care needs due to understaffing. The facility's Staffing Coordinator and Administrator acknowledged the issue, citing last-minute callouts as a contributing factor.
The facility did not complete annual performance appraisals for CNAs, as required. During a survey, it was found that there was no documentation of appraisals for five CNAs. The DON acknowledged the requirement and their responsibility for completing these appraisals, but they were not conducted.
The facility failed to store food according to professional standards, with multiple items in the refrigerators, walk-in freezer, and dry storage lacking labels and expiration dates. The Director of Food Services acknowledged the issue, noting that staff were expected to label and date all products.
The facility failed to implement proper infection control measures for two residents, including the absence of transmission-based precautions for a resident with Clostridium Difficile and inadequate infection surveillance documentation. A housekeeper was observed not following proper protective protocols, and the facility lacked a centralized tool to track infections, hindering effective infection control.
The facility failed to maintain an effective pest control program, resulting in rodents in one unit and the physical therapy department. Despite sightings documented in the Pest Control Logbook, there was no follow-up or monitoring to assess intervention effectiveness. Observations revealed a mouse trap in a resident's room with food items, and the Director of Rehabilitation reported mouse droppings in the therapy department. The Director of Maintenance/Housekeeping did not review reports or conduct rounds to check for mice, assuming the pest control company managed the issue.
Two residents experienced a lack of dignity in their care. An LPN was observed standing while feeding a resident, contrary to policy, and another resident's urinary catheter bag was left uncovered, visible to others. Both actions violated the residents' rights to a dignified experience.
The facility failed to complete the Level 1 PASRR screening for two residents prior to admission, leaving several questions unanswered. One resident had diagnoses of Cerebral Palsy, Seizure Disorder, and Dysphagia, while the other had Chronic Obstructive Pulmonary Disease, Insomnia, and Depression. The Covering Social Worker acknowledged the incomplete screens and noted that audits could have identified these issues.
A resident with a history of falls and cognitive impairments did not have Bilateral Fall Mats in place as required by their care plan. Observations revealed the absence of these mats, and interviews with staff and family indicated a lack of awareness and communication regarding their necessity. This oversight led to a deficiency in the facility's fall prevention measures.
A facility failed to provide consistent dialysis care and communication for a resident requiring hemodialysis. The communication book, meant to ensure information exchange between the facility and the Dialysis Center, was often incomplete. Staff interviews revealed a lack of awareness and oversight, with the Medication Nurse admitting to not always completing necessary documentation. The Assistant Administrator at the Dialysis Center was unaware of these issues, leading to a deficiency in care.
The facility exceeded the acceptable medication error rate, with errors involving two residents. One resident received an incorrect dosage of Tums due to an oversight by an LPN, while another resident did not receive Vitamin C as prescribed, despite it being signed off as administered. The DON acknowledged the need for better adherence to physician orders.
A resident with severe cognitive impairment and multiple chronic conditions was given several medications not prescribed for them by an LPN, including an antibiotic, diabetes medication, heart medication, diuretic, and others. The error was recognized and reported immediately, and the resident was monitored before developing chest pain and being sent to the hospital for evaluation.
A resident who had undergone hip fracture repair and sustained a fall did not receive a physician-ordered left hip x-ray. The RN Supervisor endorsed the order to the next shift, but it was not sent to the x-ray company. The DON confirmed the oversight, and the RN Unit Manager could not find the x-ray result, indicating a lapse in following professional standards of practice.
A resident with suicidal ideation and high fall risk did not receive consistent 15-minute safety checks as ordered. The resident was found on the floor after attempting to transfer out of bed. Staff interviews revealed a lack of awareness and communication about the safety checks, and documentation was incomplete.
A resident with depression and Alzheimer's dementia expressed suicidal ideation, but the facility failed to consistently document 15-minute safety checks as ordered by a physician. The checks were not included in the care plan, and the resident was found on the floor after attempting to transfer themselves. Interviews revealed lapses in documentation and communication regarding the safety checks and their discontinuation.
Deficiencies in Cleanliness and Meal Service in South Unit
Penalty
Summary
The facility failed to maintain a clean and homelike environment in the South unit, as observed during a recertification survey. Specifically, rooms #128, #129, and #130 had dirty floors and radiators, chipped and scuffed paint on walls and closet trim, feces on a toilet, and a brown liquid spill on the floor. The Director of Housekeeping and Maintenance acknowledged these issues during a tour with survey staff and admitted that the rooms had not been cleaned due to a lack of regular maintenance and repair schedules. The Director also noted that the unit had not been renovated since reopening after COVID, and there were no logs of repairs made throughout the facility. Additionally, a meal tray provided to a resident contained a hot beverage cup and utensils with lime deposit stains. The Kitchen Manager and Director of Food Services confirmed the presence of lime build-up due to hard water and stated that the facility lacked a water softener, which could help prevent such stains. The Administrator was aware of the lime build-up issue and mentioned that new cups and utensils had been purchased, but the problem persisted. The appearance of lime deposit stains was acknowledged as not being homelike, and the need for a water softener had been discussed with Administration in the past.
Facility Fails to Meet CNA Staffing Requirements
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of residents, as evidenced by not meeting the minimum staffing requirements for Certified Nurse Aides (CNAs) on 10 out of 28 days reviewed. The Facility Assessment Staffing Plan required a specific number of licensed nurses and CNAs for each shift, but actual staffing records from December 9, 2024, to January 6, 2025, showed multiple instances where the number of CNAs fell short. For example, on several occasions, there was only one CNA available on a unit during shifts that required more, leading to challenges in providing timely care and assistance to residents. Interviews with CNAs revealed the difficulties faced due to understaffing, such as being unable to answer call bells promptly and struggling to meet the care needs of approximately 40 residents. The CNAs expressed that working with fewer staff made it hard to ensure resident safety and provide necessary care, such as toileting assistance. The facility's Staffing Coordinator and Administrator acknowledged the staffing issues, attributing them to last-minute callouts and indicating awareness of the failure to meet staffing requirements.
Failure to Conduct Annual CNA Performance Appraisals
Penalty
Summary
The facility failed to ensure that performance appraisals for Certified Nurse Aides (CNAs) were completed at least once every 12 months, as required. During the recertification survey conducted from January 7 to January 14, 2025, it was found that there was no documented evidence of annual performance appraisals for five CNAs. The Director of Nursing acknowledged the requirement for these appraisals and admitted responsibility for their completion, yet they were not conducted as mandated.
Improper Food Storage Practices Observed
Penalty
Summary
The facility failed to ensure that food was stored in accordance with professional standards for food service safety, as observed during a recertification survey. The survey revealed multiple instances of improper food storage practices in the facility's refrigerators, walk-in freezer, and dry storage pantry. Specifically, the refrigerators contained items such as American cheese, beef meatballs, eggs, thawed chicken thighs, and grape jelly that were either unlabeled or lacked expiration dates. Similarly, the walk-in freezer had items like sausage patties, French fries, tater tots, and meatballs that were either not covered properly or lacked labeling and expiration dates. In the dry storage area, several food products, including tuna, spaghetti sauce, sweet and sour sauce, oatmeal pies, graham crackers, curry powder, chicken paste, gravy packet, and dry pasta, were found without expiration dates. During an interview, the Director of Food Services acknowledged the issue, stating that the kitchen staff was trying to reduce the number of boxes in storage areas, which might have led to the removal of expiration dates. The Director also mentioned that the kitchen staff was expected to label and date all products, and that the facility received weekly food deliveries, implying that no products should be expired.
Inadequate Infection Control and Surveillance
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper implementation of transmission-based precautions for two residents. Resident #49, who tested positive for Clostridium Difficile, did not have a Contact Precaution sign on their door, and there was no personal protective equipment available outside their room. During an observation, a housekeeper was seen in Resident #49's room wearing gloves but not a gown and did not perform hand hygiene after leaving the room. The Director of Nursing acknowledged that a sign should have been posted and that staff and visitors should have been alerted to wear appropriate protective gear. Additionally, the facility did not have a centralized infection surveillance plan to track and monitor infections, communicable diseases, and outbreaks. The Director of Nursing admitted that they could not provide documentation of the number of residents with urinary tract infections and that Resident #49, who had a recurrent infection, was not included in the infection tracking tool. Similarly, Resident #66, who had a chronic urinary tract infection, was not documented in the infection tool. This lack of documentation hindered the facility's ability to identify clusters of infections and implement effective control measures.
Deficient Pest Control Program Leads to Rodent Presence
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of rodents in one of the two units and the physical therapy department. The facility's pest control policy, last reviewed in March 2024, mandates an ongoing program to keep the building free of insects and rodents. However, the Pest Control Logbook documented multiple sightings of mice and a mole in various rooms and the maintenance shop between February 2024 and January 2025. Despite these sightings, there was no documented evidence of follow-up or monitoring by the facility to assess the effectiveness of interventions implemented by the pest control company. Observations and interviews revealed that a mouse trap was found in a resident's room, where food items were also present, potentially attracting pests. The Director of Rehabilitation reported seeing mouse droppings in the physical therapy department, but no mice were observed. The Director of Maintenance/Housekeeping admitted to placing traps but did not review reports to determine their effectiveness or conduct rounds to check for mice. Additionally, there was no documentation of follow-up actions regarding the issue, and the Director of Maintenance/Housekeeping assumed the pest control company was handling the situation. Licensed Practical Nurse #14 was unaware of any mice sightings in April 2024 and stated that maintenance concerns were verbally reported without formal documentation.
Failure to Maintain Resident Dignity During Care
Penalty
Summary
The facility failed to ensure a dignified experience for two residents during a recertification survey. For one resident, a Licensed Practical Nurse was observed standing over the resident while feeding them their lunch meal, which is against the facility's policy that requires staff to sit while assisting residents with meals to ensure comfort and dignity. The resident had severely impaired cognition and required assistance with eating, as documented in their care plan and assessment. Another resident, who was cognitively intact and had an indwelling urinary catheter, was observed multiple times with their urine collection bag uncovered and visible to others. The facility's care plan for this resident required the use of a privacy bag for the catheter when the resident was out of bed. Despite the availability of privacy covers and staff education on their use, the catheter bag was not covered, compromising the resident's dignity.
Incomplete PASRR Screening for Two Residents
Penalty
Summary
The facility failed to ensure that the Level 1 Pre-Admission Screening and Resident Review (PASRR) was thoroughly completed for two residents prior to their admission. Specifically, for one resident, questions #23 through #27 were left unanswered on the Level 1 Screen, and for another resident, questions #27 through #35 were left blank. This oversight was identified during a recertification survey conducted from January 7 to January 14, 2025. The facility's policy, effective since March 2019 and last reviewed in March 2024, mandates that all residents must have a PASRR Screen upon admission and when there is a significant change affecting their specialized service needs. The first resident was admitted with diagnoses including Cerebral Palsy, Seizure Disorder, and Dysphagia, and was documented as cognitively intact with unclear speech. The second resident had diagnoses of Chronic Obstructive Pulmonary Disease, Insomnia, and Depression, and was also documented as cognitively intact with clear speech. The Covering Social Worker acknowledged the incomplete screens and noted that audits could have identified these issues. The social workers responsible for the admissions of these residents were no longer employed at the facility at the time of the survey.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that the comprehensive person-centered care plan was followed for a resident reviewed for accidents. Specifically, the care plan for a resident, who had a history of falls and was diagnosed with conditions such as Encephalopathy, Dementia, and Chronic Obstructive Pulmonary Disease, included the use of Bilateral Fall Mats after a fall on 10/8/24. However, during multiple observations in January 2025, the resident was found resting in bed without the required fall mats in place, indicating a failure to implement the care plan as documented. Interviews with staff and the resident's family revealed a lack of awareness and communication regarding the necessity of the fall mats. A Certified Nurse Aide admitted to not checking the care guide prior to providing care, relying instead on familiarity with the resident. The Unit Manager confirmed that the care guide and care plan included interventions for fall mats but was unaware of why they were not present in the resident's room. This oversight highlights a breakdown in communication and adherence to the established care plan, resulting in a deficiency in the facility's fall prevention measures.
Inadequate Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received services consistent with professional standards of practice. Specifically, there was no documented evidence of consistent assessment and oversight before, during, and after dialysis treatment for a resident who received hemodialysis treatments at a community-based Dialysis Center. The facility's policy required ongoing communication between the interdisciplinary team and the dialysis center through a communication book, which was not consistently completed. The communication book, which was supposed to accompany the resident to each dialysis treatment, was found to have missing entries from both the facility and the dialysis center on multiple occasions. Interviews with facility staff revealed a lack of awareness and oversight regarding the completion of the communication book. The Unit Manager and Director of Nursing stated that the Medication Nurse was responsible for filling out the pre-dialysis section and checking the book upon the resident's return. However, the Medication Nurse admitted to not always completing the post-dialysis section and having to call the Dialysis Center to remind them to complete their section. The Assistant Administrator at the Dialysis Center was unaware of any communication issues. This lack of consistent documentation and communication between the facility and the Dialysis Center led to the deficiency.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 5.71% error rate during the recertification survey. Two residents were affected by medication administration errors. Resident #34, who has diagnoses including Atrial Fibrillation, Dysphagia, and Hypertension, was supposed to receive two Tums 200 mg/Calcium 500 mg chewable tablets for heartburn as per the physician's order. However, during a medication administration observation, only one tablet was administered by LPN #21, who later admitted to not realizing the need to administer two tablets and acknowledged the oversight. Resident #31, with diagnoses including Atrial Fibrillation, Congestive Heart Failure, and Pleural Effusion, did not receive the prescribed Vitamin C 500 mg tablets. Although the Medication Administration Record indicated that Vitamin C was administered, LPN #20 admitted to signing off on the medication before actually administering it. The LPN explained that the Vitamin C bottle was expired and needed replacement, which led to the error. The Director of Nursing acknowledged that medications must be administered as prescribed and emphasized the need for improved nursing practices.
Significant Medication Error: Resident Administered Unprescribed Medications
Penalty
Summary
A resident with a history of cerebral vascular accident, type 2 diabetes, and peripheral vascular disease, and documented severe cognitive impairment, was administered multiple medications that were not prescribed for them. The medications given included Doxycycline, Metformin, Entresto, Torsemide, Metoprolol, and Farxiga. The error occurred when an LPN self-reported having given the wrong medications to the resident. The incident was immediately recognized, and the medical provider was notified. The resident's vital signs and blood glucose were closely monitored following the administration of the incorrect medications. Despite initial monitoring, the resident later developed chest pain and was transferred to an acute care hospital for evaluation. Emergency room records confirmed the resident had received another resident's medications and experienced symptoms including feeling faint and chest pain. Interviews with facility staff, including the administrator, physician, DON, and LPN supervisor, confirmed the sequence of events and that the error was considered significant due to the administration of medications not prescribed for the resident, including a diuretic.
Failure to Perform Ordered X-ray After Resident Fall
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. Specifically, a physician-ordered left hip x-ray was not performed for a resident who had recently undergone hip fracture repair and sustained a fall shortly after admission. The resident, who had diagnoses including dementia and metabolic encephalopathy, was found on the floor after attempting to transfer themselves. Although the physician ordered a left hip x-ray following the incident, there was no documented evidence that the x-ray was completed. Interviews revealed that the Registered Nurse Supervisor assessed the resident after the fall and endorsed the x-ray order to the oncoming shift. However, the order was not sent to the x-ray company, and the Director of Nursing confirmed that the Diagnostic Imaging Company was not notified. The Registered Nurse Unit Manager was unable to find the x-ray result and acknowledged that the order was not sent. The Director of Nursing stated that the Registered Nurse Supervisor should have ordered the x-ray on the Diagnostic Imaging website and that the Unit Manager should have followed up to ensure the order was processed.
Failure to Conduct and Document Safety Checks for High-Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision and adherence to care plans for a resident assessed with suicidal ideation and a high risk for falls. The resident had a physician's order for 15-minute safety checks, which were not consistently documented as completed. The certified nursing aide care instructions did not include the order for these checks, and the resident was found on the floor after attempting to transfer out of bed. The incident report noted that the resident was last seen by staff at 9:30 PM, despite the requirement for 15-minute checks, and was found on the floor at 11:00 PM. Interviews with staff revealed a lack of awareness and communication regarding the 15-minute safety checks. Certified Nurse Aide #1 and Licensed Practical Nurse #1 were unaware of the specific order for frequent checks, relying on shift reports for such information. Registered Nurse #2, who worked the night shift, could not recall details about the checks and acknowledged omissions in the Medication Administration Record. The Director of Nursing confirmed that the checks should have been documented, indicating a lapse in supervision and documentation protocols.
Failure to Provide Adequate Behavioral Health Care for Suicidal Resident
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident who exhibited suicidal ideation. The resident, admitted with diagnoses including depression and Alzheimer's dementia, expressed thoughts of wanting to die and had a history of leaving assisted living facilities. A physician's order was issued for 15-minute safety checks, but the order lacked an indication for its necessity. The safety checks were not consistently documented, and the intervention was not included in the resident's care plan or certified nurse aide instructions. On one occasion, the resident was found on the floor after attempting to transfer themselves without assistance, indicating a lapse in the 15-minute safety checks. The facility's policy on suicidal precautions required that all staff be informed of suicide threats and document any changes in behavior, but this was not adequately followed. The Medication Administration Record showed that the 15-minute checks were only documented once per shift, and there was no documentation during certain night shifts. Interviews with the Director of Nursing and other staff revealed that the 15-minute safety checks were not properly documented, and there was no recorded reason for discontinuing the checks. The Director of Nursing acknowledged that the order should have included a reason, and the discontinuation should have been documented. The Registered Nurse Supervisor admitted to forgetting to document the reason for discontinuing the safety checks, highlighting a breakdown in communication and documentation within the facility.
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What surveyors actually found near you
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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.
Illustrative
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Nursing homes near Montgomery
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Campbell Hall Rehabilitation Center Inc | 6.7 mi | ★★★★★ | 19 | 0 |
| Sapphire Nursing At Meadow Hill | 8.5 mi | ★★★★★ | 0 | 0 |
| Middletown Park Rehab & Health Care Center | 9.8 mi | ★★★★★ | 1 | 0 |
| Highland Rehabilitation And Nursing Center | 11.2 mi | ★★★★★ | 3 | 0 |
| Sapphire Nursing And Rehab At Goshen | 11.5 mi | ★★★★★ | 0 | 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.