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 Care Center during CMS and state inspections, most recent first.
The facility failed to provide routine podiatry care for four residents, resulting in overgrown and unkempt toenails. A resident with cerebral infarction and vascular dementia had toenails curling under the toes, while another with multiple sclerosis had jagged nails. A third resident with multiple sclerosis had overgrown toenails despite intact cognition, and a fourth with COPD and diabetes experienced discomfort from untrimmed nails. The facility's nail care policy was not adhered to, leading to this deficiency.
The facility failed to label eye drops with open dates for two residents and did not timely dispose of narcotics for two discharged residents. Eye drops for glaucoma were found without open dates, confirmed by an LPN and an RN. Narcotics for discharged residents were still stored in the medication cart, as verified by the DON, contrary to the facility's policy on medication disposal.
The facility failed to obtain authorization to manage the personal funds of two cognitively intact residents, despite acting as their representative payee. Both residents had multiple medical conditions, and the facility's policy required a signed authorization to be filed, which was not done. This deficiency was confirmed by the Administrator.
A facility failed to ensure accurate hearing assessments for a resident, who was cognitively intact and had multiple medical conditions. The MDS assessments inaccurately indicated minimal hearing difficulty and hearing aid use, despite the resident reporting hearing issues and not using hearing aids. Staff interviews confirmed the inaccuracy, as the information was incorrectly transferred and continued to populate on subsequent assessments.
The facility failed to conduct quarterly care conferences for two residents. One resident with cerebral infarction and vascular dementia did not have a care conference in the third quarter of 2024, while another resident with COPD and diabetes did not receive one in the first quarter of 2024. The facility's policy mandates quarterly care conferences, but this was not followed.
A resident with a history of cerebrovascular disease and other conditions experienced difficulty hearing and was not timely seen by an audiologist, despite requests from their power of attorney and brother. The facility's audiologist had not visited since several months prior, and the resident was not seen during that visit. The facility's policy on specialized rehabilitation services was not effectively implemented for this resident.
A facility failed to change oxygen tubing per physician orders for a resident with COPD, major depressive disorder, and type two diabetes. The resident's care plan required weekly tubing changes, but observations revealed the tubing was over a month old and dirty. An LPN confirmed the outdated condition, indicating non-compliance with the facility's oxygen administration policy.
A resident with anxiety disorder reported inadequate cleaning of her room, including unclean furniture, unswept areas, and a dirty toilet. Observations confirmed the presence of dirt, food particles, and a urine ring. Housekeeping staff admitted to incomplete cleaning, and the facility's cleaning policy was not adhered to.
Failure to Provide Routine Podiatry Care
Penalty
Summary
The facility failed to provide routine podiatry care for four residents, leading to overgrown and unkempt toenails. Resident #20, who was admitted with cerebral infarction, vascular dementia, and chronic kidney disease, had toenails that were grossly overgrown and curling under the toes. Despite being on a care plan for total assistance with personal hygiene, the resident's toenails were neglected, and the facility lacked the necessary equipment to address the issue, requiring a podiatrist's intervention. Resident #21, diagnosed with multiple sclerosis and dementia, also had overgrown and jagged toenails. The resident, who required total assistance with personal hygiene, expressed a desire for nail care, which was confirmed as necessary by the DON. Similarly, Resident #02, with multiple sclerosis and major depressive disorder, had overgrown toenails that were not addressed despite having intact cognition and a care plan that included substantial assistance with hygiene. Resident #14, with chronic obstructive pulmonary disease, congestive heart failure, and type two diabetes, had not received podiatry care as scheduled. The resident's toenails were overgrown and jagged, causing discomfort, and the skin on the feet was extremely dry and flaking. The facility's policy on nail care, which includes regular trimming and cleaning, was not followed, contributing to the deficiency in providing adequate foot care for these residents.
Medication Labeling and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure that eye drops were labeled with an open date, affecting two residents who had been prescribed eye drops for glaucoma. One resident with severe cognitive impairment was prescribed Brimonidine Tartrate, and the medication was found on the medication cart without an open date. This was confirmed by an LPN. Another resident with intact cognition was prescribed Dorzolamide-HCl-Timolol Mal Solution, which also lacked an open date on the bottle, as verified by an RN. Additionally, the facility did not timely dispose of narcotics for two residents who were no longer in the facility. One resident, who had been discharged, had Restoril still stored in the narcotic box inside the medication cart. Another discharged resident had Lorazepam and Morphine Sulfate still present in the narcotic box. The DON confirmed that nurses should notify the unit manager to dispose of narcotics when residents are discharged. The facility's policy stated that unused controlled substances should be securely stored until disposed of according to state and federal guidelines.
Failure to Obtain Authorization for Managing Resident Funds
Penalty
Summary
The facility failed to obtain authorization to manage the personal funds of two residents, which is a violation of their rights. Resident #23, who was cognitively intact, had a range of medical conditions including flaccid hemiplegia, chronic obstructive pulmonary disease, type two diabetes mellitus, and vascular dementia, among others. Despite being cognitively intact, there was no signed authorization from the resident or their representative allowing the facility to manage their personal funds. This oversight was confirmed during an interview with the Administrator, who acknowledged the absence of the necessary authorization. Similarly, Resident #34, also cognitively intact, had medical conditions such as dysphagia following cerebral infarction, hemiplegia, and congestive heart failure. Like Resident #23, there was no signed authorization for the facility to manage their personal funds. The facility's policy, revised in March 2021, clearly states that a copy of the resident's or representative's authorization should be filed in the resident's financial record, which was not adhered to in these cases. The Administrator confirmed that the facility acted as the representative payee for both residents without obtaining the required authorization.
Inaccurate Hearing Assessment for Resident
Penalty
Summary
The facility failed to ensure the accuracy of assessments related to hearing for a resident, which was identified during a review of medical records, staff interviews, and policy review. The resident, who was cognitively intact, had multiple diagnoses including cerebrovascular disease, hypothyroidism, and major depressive disorder, among others. The Minimum Data Set (MDS) assessments indicated that the resident had minimal difficulty with hearing and used hearing aids. However, during an interview, the resident reported difficulty hearing and stated he was waiting for hearing aids. It was observed that the resident had trouble hearing during the interview. Further interviews with facility staff revealed that the resident had not used hearing aids while at the facility, and the MDS Coordinator noted that the information about hearing aid use was inaccurately transferred and continued to populate on subsequent assessments. The facility's policy on certifying the accuracy of resident assessments required that the information captured reflects the resident's status during the observation period, which was not adhered to in this case.
Failure to Conduct Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure that care conferences were completed quarterly for residents, affecting two of the three residents reviewed. Resident #20, who was admitted with diagnoses including cerebral infarction with dominant left side hemiplegia and hemiparesis, vascular dementia, and chronic kidney disease, did not have a care conference offered or completed in the third quarter of 2024. Although care conferences were offered in the first and second quarters, and one was conducted in the fourth quarter, there was no documented evidence of a care conference for the third quarter. This was confirmed by the Social Services Designee and the Administrator. Resident #14, diagnosed with chronic obstructive pulmonary disease, major depressive disorder, and type two diabetes, did not receive a care conference in the first quarter of 2024. Although the resident had intact cognition with a BIMS score of 15, and care conferences were conducted in October 2023, April 2024, and November 2024, the resident declined the need for a care conference in July 2024. The facility's policy requires care conferences to be held quarterly, but this was not adhered to for Resident #14 in the first quarter of 2024.
Failure to Arrange Timely Audiology Services
Penalty
Summary
The facility failed to timely arrange for audiology services for a resident, affecting their ability to communicate effectively. The resident, who was cognitively intact, had a history of cerebrovascular disease, hypothyroidism, spastic hemiplegia, major depressive disorder, and other medical conditions. The resident was noted to have minimal difficulty with hearing and used hearing aids. Despite the resident's power of attorney requesting audiology services and the resident being listed for an audiology visit, the resident was not seen by the audiologist. The resident's brother also requested an assessment for hearing aids, but the resident continued to experience difficulty hearing. Interviews with facility staff revealed that the audiologist had last visited the facility several months prior, and the resident was not seen during that visit. The Social Service Designee confirmed that the audiologist was unable to see every resident on the list and that another visit was scheduled for a later date. The facility's policy on specialized rehabilitation services indicated that they provided such services by qualified professionals, including audiology, but this was not effectively implemented for the resident in question.
Failure to Timely Change Oxygen Tubing for Resident
Penalty
Summary
The facility failed to timely change oxygen tubing per physician orders for a resident receiving oxygen therapy. Resident #14, who has diagnoses including chronic obstructive pulmonary disease (COPD), major depressive disorder, and type two diabetes, was affected by this deficiency. The resident's care plan included interventions for oxygen therapy related to asthma, COPD, and shortness of breath, with a physician order specifying the use of supplemental oxygen as needed to maintain oxygen saturation above 90%. Additionally, there was a specific physician order to change and date the oxygen and nebulizer tubing weekly on Tuesday night shift. Observations on two consecutive days revealed that Resident #14's oxygen tubing was dated over a month prior and appeared dirty, indicating that the tubing had not been changed as per the physician's order. An interview with an LPN confirmed the outdated and dirty condition of the tubing. The facility's policy on oxygen administration, which was reviewed, outlines the need for staff to verify physician orders and assemble necessary equipment, but the failure to adhere to the tubing change schedule resulted in this deficiency.
Failure to Maintain Clean and Sanitary Environment for Resident
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for Resident #12, who was cognitively intact and had a diagnosis of anxiety disorder. The resident reported that housekeeping staff did not adequately clean her room, including failing to wipe down furniture, sweep under the bed, or take out the trash. The resident also described her toilet as dirty and having a urine ring. Observations confirmed the resident's complaints, revealing dirty walls with an unknown black substance, dirt, food particles, and hairballs. The bathroom floor was also dirty, and the toilet had a urine ring around its base. Housekeeping Aide #289 was observed cleaning the resident's room with the blinds closed and lights out, and admitted to only mopping the main areas and pathways, neglecting areas under the walker, trash can, and bed. The aide acknowledged missing areas with dirt and food particles and confirmed the presence of a dirt pile, hairball, and urine ring. Floor Technician #242 also noted the presence of black scuff marks and stated that the resident was not particular about moving personal items for cleaning. The facility's policy on cleaning and disinfection was reviewed, indicating that non-critical surfaces should be cleaned regularly, but the policy was not followed in this instance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 958 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cincinnati
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Twin Lakes | 0.7 mi | ★★★★★ | 0 | 0 |
| Blue Ash Health & Rehab | 1 mi | ★★★★★ | 4 | 0 |
| Courtyard At Seasons | 1.1 mi | ★★★★★ | 16 | 0 |
| Kenwood Terrace Healthcare Center | 1.3 mi | ★★★★★ | 0 | 0 |
| Meadowbrook Care Center | 2.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Montgomery Care Center.
100% money-back within 48 hours.
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.