Average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 General Elderly Care during CMS and state inspections, most recent first.
Infection prevention and control failures were observed in the dining room and with EBP implementation. Residents were served lunch without hand hygiene being offered or performed, and an NA set up one tray then immediately handled another. In addition, multiple rooms had EBP signs but were missing the pink dot used on name plates, staff were unclear on the dot system, and two roommates with EBP orders, including one with a PEG tube and a history of severe sepsis and one with a history of ESBL, initially had no EBP signage on their door.
A resident’s privacy curtain was observed soiled with a brown dried matter, and a housekeeper confirmed it was dirty and needed replacement. Surveyors also observed the B Bath shower room with peeling and missing paint, missing caulking around the toilet and shower area, a brownish substance around the toilet, and rust on a shower caddy; an AIT stated the shower rooms are addressed yearly.
Failure to follow weight monitoring policy and MD orders affected multiple residents. One resident did not receive weekly weights as ordered, another had a significant weight loss without timely re-weighing, and a third resident with severe sepsis and a PEG tube had marked weight loss while NPO and on tube feedings, with no documentation that the MD was notified of the decline. The DM and ADON confirmed the missed or delayed weight monitoring and related documentation issues.
A resident was not treated with dignity during lunch when an NA yelled across the dining room for a "baby spoon" and another NA confirmed that was the spoon requested. The resident was on a NAS, puree diet with a small color-coated spoon and suction lip plate, and staff noted the resident sometimes eats with fingers. The facility stated it did not have a dignity policy and followed state guidelines.
A resident experienced significant weight loss, dropping from 160 lbs to 144 lbs in about four weeks and later to 141 lbs. The facility’s policy required notifying the POA or legal representative when significant weight loss occurred, but the record had no documentation that the resident’s POA was notified. The ADON stated the POA frequently visited and attended care plan conferences, but could not find documentation of notification.
An LPN left a med cart and computer unlocked and unattended while getting a medication from the med room, leaving a resident's name and information visible on the screen for about three minutes. Facility policy required carts and computers to be locked and secured before stepping away for any length of time, and the Administrator stated staff know the policy.
A facility failed to revise comprehensive care plans when a resident’s weight-monitoring order changed from monthly to weekly after significant weight loss, and when another resident developed repeated wandering, verbal aggression, medication refusals, and other behavior changes. The ADON confirmed the care plans had not been updated to reflect these changes until survey review.
Facility failed to provide scheduled shower care for a resident who was dependent on staff for bathing and other ADLs and had dementia/Alzheimer's. Record review showed multiple missed showers despite a set shower schedule, and the Administrator confirmed the resident had not received showers as required.
An LPN left a med cart and computer unlocked and unattended in the main hallway while retrieving a medication from the med room. Surveyors observed a resident's name and information displayed on the screen, and the cart drawers could be opened while the cart was left unattended for about three minutes. Facility policy stated carts and computers must be locked and secured before stepping away for any length of time.
Failure to Notify Physician of Significant Weight Loss: A resident had significant wt loss over several weeks, but the chart did not show that the attending MD was notified when the loss was identified. The resident was later seen by the MD, and the progress note did not mention the wt loss. The ADON stated she could not locate documentation that the MD had been informed or was aware of the resident’s wt loss.
Expired and Delayed Food Handler Cards for Dietary Staff. Record review and staff interview showed the facility did not ensure all kitchen staff had current food handler cards. Two cook/aides had cards completed only after hire, and another cook/aide had an expired card, as confirmed by the CDM.
Improper Food Labeling and Storage: Surveyors found multiple food items in the walk-in with missing labels or use-by dates, along with several expired items such as lettuce, potato salad, peas and carrots, and pasta salad. An LTC dietary leader confirmed the findings, and facility policy required daily checks of food storage and removal of items past the used-by date.
Inaccurate medical records were identified for two residents. One resident's chart contained conflicting diet instructions regarding mildly thickened versus thin liquids, while another resident's physician order listed DNR but the POST form in the record indicated resuscitation. The discrepancies were found during record review and staff interview, and the administrator acknowledged the orders were not aligned.
The facility failed to ensure residents could voice grievances freely without fear of reprisal, as observed during a resident council meeting. Only one resident knew how to file a grievance, while others showed signs of apprehension when asked about fear of retaliation, indicating a potential systemic failure in maintaining a supportive environment for grievance reporting.
The facility failed to provide an environment free from abuse for two residents. One resident with a history of dementia and aggressive behaviors was involved in multiple altercations, and the facility lacked effective interventions. Another resident reported verbal abuse from an LPN, with witness statements confirming inappropriate conduct. The facility's investigation was inconclusive, and policies on abuse and neglect were not effectively implemented.
The facility failed to implement its abuse policy, as evidenced by incidents involving a resident with dementia who exhibited aggressive behaviors and another resident who reported verbal abuse by an LPN. The facility's investigation was incomplete, lacking thoroughness and corrective actions, and the behavioral care plan was not resident-centered.
The facility failed to report and investigate allegations of abuse and neglect involving two residents. One resident experienced discomfort and perceived derogatory comments from staff, while another resident with dementia exhibited aggressive behavior towards others. The facility lacked effective interventions and documentation, and specific policies for dementia care were absent.
The facility failed to thoroughly investigate allegations of verbal and physical abuse involving two residents. One resident reported verbal abuse by an LPN, while another resident with dementia was involved in a physical altercation. The investigations were incomplete, with no corrective actions identified, and the facility lacked specific policies for dementia care and behavioral monitoring.
The facility failed to develop comprehensive care plans for several residents, omitting critical diagnoses such as vascular dementia and COPD. Additionally, care plan interventions were not implemented for two residents, leading to escalated behaviors and risk of pressure ulcers. Staff interviews confirmed these deficiencies, with the administrator acknowledging the issues.
The facility failed to provide appropriate care for two residents. One resident consistently refused medications without physician intervention, despite high blood pressure readings. Another resident, with multiple diagnoses, was not offered hospice services despite end-of-life symptoms. The facility lacked documentation and policies for addressing these issues, as confirmed by the DON.
A facility failed to provide adequate pain management for a resident with multiple diagnoses, including dementia and anxiety. The resident's pain was not properly assessed or documented, and non-pharmacological interventions were not attempted or recorded. Despite a change in medication from Tramadol to Roxanol, the facility did not consistently document pain levels or the effectiveness of the medication, as required by their policy. Interviews revealed that pain was only documented for as-needed medications, not scheduled ones, leading to inadequate monitoring and management of the resident's pain.
The facility failed to maintain accurate and complete records for four residents. A resident's POST form was missing a preparer's signature and date, while another's activity record inaccurately showed participation during active dying. A pneumococcal vaccination was not documented in the electronic medical record, and another resident's POST form lacked a healthcare provider's signature, potentially impacting end-of-life care.
A facility failed to notify the State Ombudsman of a resident's discharge to the hospital. During a survey, it was found that a resident was transferred for an extended hospital stay without the required notification being sent. The LSW admitted to not sending the notification, citing a lack of awareness of the requirement.
A facility failed to update a resident's care plan to include hospice-specific interventions and coordination with the hospice provider. The resident, with severe cognitive impairment and receiving hospice care, had an incomplete care plan lacking guidance on end-of-life needs. The DON acknowledged that hospice details were kept separately and not integrated into the facility's documentation, leading to a risk of inconsistent care delivery.
Infection Prevention and Control Failures in Dining Room and EBP Use
Penalty
Summary
The facility failed to maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During continuous observation of the dining room, three residents at a round table were served lunch without hand hygiene being offered or performed in the dining room area. A Nursing Assistant stated that wet wipes were supposed to be placed on the table but were not there that day. During the same meal observation, one Nursing Assistant served and set up one resident’s tray and then immediately grabbed another tray to set up another resident’s tray, stating, “Oh, I forgot.” The facility also had problems with its Enhanced Barrier Precautions (EBP) process. Multiple rooms were observed with EBP signs on the doors, but six of twenty rooms were missing the pink dot used to identify EBP on resident name plates. Staff interviews showed inconsistent knowledge of the dot system and where the color chart was kept. Record review showed the facility’s EBP policy required regular weekly rounds for accuracy, and an in-service listed the facility’s color dots, but the pink dot was not included in that training. Resident #9, who had a PEG tube and a history of severe sepsis, had an order for EBP, and Resident #4, who had a history of ESBL, also had an EBP order; both roommates initially had no EBP signage on their door. The NHA stated she was not aware that a feeding tube required EBP, and signage was later observed on the door.
Soiled Privacy Curtain and Poorly Maintained Shower Room
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment by leaving Resident #27’s privacy curtain soiled with a brown dried matter and by not maintaining the B Bath shower room in clean condition. During observation, the privacy curtain for Resident #27 was found dirty, and the House Keeper confirmed it was dirty and required replacement. In the B Bath shower room, surveyors observed peeling paint in the shower area and bathroom floor area, missing caulking around the toilet and in the shower area, a large ring of missing paint with a brownish substance around the toilet, missing paint from the base of the walls, and rust on a shower rack/caddy. These conditions were confirmed by Nursing Assistant #19 and the Administrator in Training stated the shower rooms are addressed yearly.
Failure to Follow Weight Monitoring Orders and Policy
Penalty
Summary
The facility failed to provide care and services in accordance with current standards of practice by not following its weight monitoring policy and physician orders related to resident weights. The policy titled Weight Monitoring stated that if there is a noticeable discrepancy in the current weight versus the previous weight, the resident shall be re-weighed and the charge nurse shall follow up accordingly. Survey review found that this process was not followed for multiple residents reviewed for nutrition. Resident #55 had a physician order for weekly weights on Tuesdays, but the record showed weights on 11/05/25 at 173 pounds and 11/10/25 at 183 pounds, with no re-weigh until 11/18/25 when the resident weighed 173.5 pounds. The Assistant Director of Nursing confirmed the resident had not been weighed weekly per physician order and that the policy had not been followed. Resident #11 weighed 160 pounds on 09/09/2025 and 144 pounds on 10/07/2025, a 10 percent weight loss in about four weeks, but was not re-weighed when the discrepancy occurred; the Certified Dietary Manager confirmed the resident was re-weighed a week later. Resident #9 was admitted for rehab after discharge from an acute care facility with severe sepsis without septic shock and a PEG tube in place. The resident was NPO and ordered Vital 1.5 bolus tube feedings with weekly weights, but her weight declined from 183 pounds on admission to 165.5 pounds on 11/17/25 and 158.0 pounds on 11/18/25. The resident’s nutritional assessment identified high risk, the care plan addressed nutritional concerns, and progress notes documented nausea, vomiting, and feeding tolerance issues, but there were no notes showing the physician had been notified of the significant weight loss. The ADON acknowledged the care plan was not personalized for the resident and was unsure whether the physician had been contacted about the weight loss.
Failure to Maintain Resident Dignity During Dining
Penalty
Summary
The facility failed to treat a resident with respect and dignity during the dining experience by referring to the resident’s adaptive spoon as a "baby spoon." During lunch meal service, a Nursing Assistant yelled across the dining room to the dietary window, "Throw me a baby spoon," and another Nursing Assistant confirmed that the spoon requested was a baby spoon. The resident involved was on a NAS, puree diet with special instructions for a color suction lip plate and a small color-coated spoon, and staff also reported that the resident sometimes eats with her fingers. The Administrator in Training stated the facility did not have a policy and procedure for dignity and followed state guidelines for dignity. The facility’s Dining Program Policy and Procedure stated its purpose was to provide residents with a fine dining experience as close to home dining as possible.
Failure to Document POA Notification After Significant Weight Loss
Penalty
Summary
The facility failed to document that Resident #11’s Medical Power of Attorney was notified when the resident experienced significant weight loss. Resident #11 weighed 160 lbs on 09/09/25 and then 144 lbs on 10/07/25, which reflected a 10% weight loss in about four weeks. The resident continued to lose weight and weighed 141 lbs on 11/17/25. The facility’s Weight Monitoring policy stated that the POA or legal representative would be notified when a resident experienced significant weight loss, but the medical record contained no documentation that the POA was notified after the weight loss was identified. During interview on 11/25/25, the ADON stated the resident’s POA attended care plan conferences and frequently visited the resident, but she was unable to locate documentation showing the POA had been notified when the resident lost weight.
Unsecured med cart and open computer exposed resident information
Penalty
Summary
The facility failed to keep residents' private and confidential information secure when a medication cart and computer were left unlocked and unattended while an LPN went to get medication from the med room. During this time, a resident's name and information remained open on the screen and was easily viewable to anyone passing by, and the cart was left unattended for approximately three minutes. The LPN stated that they had to get a medication the resident needed to complete a med pass and said they were only gone for a minute. Record review showed the facility's New employee/Med cart and Resident Privacy policies required all carts and computers to be locked and secured before stepping away for any length of time. The Administrator stated that staff know the policy and know better.
Care plans not revised for changed weights and behaviors
Penalty
Summary
The facility failed to ensure comprehensive care plans were revised when residents’ interventions and behaviors changed. The deficiency involved two residents reviewed during the survey. One resident had a care plan focus for potential nutritional problems with monthly weights ordered starting 07/15/25. The resident weighed 160 lbs on 09/09/25 and 144 lbs on 10/07/25, reflecting a 10% weight loss in four weeks. On 10/10/25, an order was written for weekly weights, but the care plan was not updated to reflect the change from monthly to weekly weights. The ADON confirmed on 11/25/25 that the care plan had not been revised when the weight-monitoring frequency changed. The second resident’s care plan addressed behaviors such as taking items from other residents, manipulating others, and crying when redirected. The resident’s MDS assessment with ARD 11/04/25 coded physical behavioral symptoms toward others, verbal behavioral symptoms toward others, other behavioral symptoms not directed toward others, and daily wandering. Nursing notes documented repeated refusals of medications and care, wandering into other residents’ rooms, verbal aggression, combative behavior during care, attempts to grab staff, and taking other residents’ belongings. These behaviors were documented across multiple shifts in late October and November. When the surveyor requested the care plan on 11/25/25, it had been revised that same day to include verbal behavioral symptoms toward staff, medication refusals, and frequent roaming into other residents’ rooms. The ADON confirmed on 11/25/25 that the resident’s wandering, verbal aggression, and medication refusals had not been included in the comprehensive care plan until that date.
Failure to Provide Scheduled Showers for a Dependent Resident
Penalty
Summary
Facility failed to provide ADL care related to showers for a dependent resident. Resident #27, who had diagnoses of dementia/Alzheimer's and required moderate to maximum assistance with ADLs, was documented as extensive total dependence with one person assisting for showers and dependent on staff for bathing, transfers, and hygiene. The facility's shower schedule showed the resident was to receive showers on Tuesdays and Thursdays on day shift, but record review showed missed showers on 10/28/25, 10/30/25, 11/18/25, and 11/20/25, with showers documented on 11/04/25, 11/06/25, 11/11/25, and 11/13/25. On 11/25/25, the Administrator confirmed the resident had not received showers as required, and no other documentation was provided before the survey exit.
Unlocked Med Cart and Computer Left Unattended
Penalty
Summary
The facility failed to ensure the area remained free from accident hazards when a medication cart and computer were left unlocked in the main hallway A while an LPN stepped away to retrieve a medication from the med room. During surveyor observation on 11/25/25 at 9:20 AM, the cart was unattended for approximately three minutes, the computer screen displayed a resident's name and information, and the cart drawers could be opened. In an interview shortly afterward, the LPN stated the medication was needed to complete a medication pass and said, "I was only gone for a minute." Review of the facility's Med cart and Resident Privacy policies showed that carts and computers are to be locked and secured before stepping away for any length of time. The Administrator stated in interview that staff know the policy and know better.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to ensure Resident #11’s care was supervised by a physician when it did not document that the attending physician was notified of the resident’s significant weight loss. The resident weighed 160 lbs on 09/09/2025 and 144 lbs on 10/07/2025, which reflected a 10% weight loss in approximately four weeks, and later weighed 141 lbs on 11/17/2025. The facility’s Weight Monitoring policy stated the attending physician would be notified when a resident experienced significant weight loss, but the medical record contained no documentation that the physician was notified when the weight loss was identified on 10/07/2025. The resident was seen by the physician on 11/24/2025, and the progress note did not mention the weight loss. On 11/25/2025, the ADON stated she was unable to locate documentation that the physician had been notified or was aware of the resident’s weight loss.
Expired and Delayed Food Handler Cards for Dietary Staff
Penalty
Summary
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on record review and staff interview, the facility failed to ensure all kitchen staff were up to date with their food handler cards. A record review on 11/25/25 at 1:45 PM of dietary staff and food handler cards showed Cook/aide #4 had a hire date of 03/17/23 with a food handler card completed on 11/24/25, Cook/aide #48 had a hire date of 08/26/23 with a food handler card completed on 11/25/25, and Cook/aide #55 had an expired card as of 05/10/25. During interview on 11/25/25 at 2:00 PM, the Certified Dietary Manager confirmed the hire dates and expiration dates.
Improper Food Labeling and Storage
Penalty
Summary
Food was not stored in accordance with professional standards for food service safety. During a kitchen inspection in the walk-in refrigerator, surveyors observed multiple items with missing labels and/or missing use-by dates, including a container of pineapples, a container of sliced cake, a pan of mashed potatoes, a container of chocolate pudding, and a container of sliced cheese. Surveyors also found several items with expired use-by dates, including lettuce dated 11/16/25, potato salad dated 11/17/25, and peas and carrots and pasta salad dated 11/21/25. A staff member confirmed these findings during the observation, and the Certified Dietary Manager later confirmed the out-of-date food and missing labels. The CDM stated that most generally items are tossed after 7 days. Facility policy stated that cooks will check food storage daily and remove items that are past the appropriate used-by date.
Inaccurate resident medical records for diet and resuscitation orders
Penalty
Summary
Medical records were not kept accurately for two residents. For Resident #45, the chart contained a diet order for regular, mildly thick liquids, and pureed foods, while the care plan stated the resident required a mechanically altered diet and thickened liquids due to difficulty chewing and swallowing, with an approach directing staff to offer thickened liquids first and, if refused, it was acceptable to give regular liquids. The administrator later confirmed the order needed to be updated and stated the clarification would be obtained from the doctor. For Resident #11, the physician's orders included a DNR order, but the resident's POST form in the medical record, signed by the Medical Power of Attorney before admission, indicated the resident was to receive resuscitation in the event of cardiac or respiratory arrest. The administrator stated the MPOA had reported wanting the resident to be DNR due to a decline in condition and had brought in the POST form from home, but the facility did not notice that the form indicated resuscitation.
Failure to Uphold Residents' Grievance Rights
Penalty
Summary
The facility failed to uphold residents' rights to voice grievances freely and without fear of reprisal, as required by CMS standards. During a special resident council meeting, attended by the activities coordinator and a surveyor, residents were asked if they understood how to file an official grievance. Only one resident, identified as the council president, responded, indicating the location of the grievance folder, while other residents remained silent, displaying hesitant or reserved body language. When asked if they feared reprisal for filing grievances, multiple residents showed signs of apprehension, such as crossing arms, nodding affirmatively, or verbally confirming a fear of staff retaliation. This reluctance and collective unease suggest that residents may not feel safe or supported in expressing concerns, potentially undermining the efficacy of the facility's grievance process. The observed discomfort and hesitation to voice concerns indicate a potential systemic failure by the facility to maintain an open, supportive environment for grievance reporting.
Failure to Provide Abuse-Free Environment
Penalty
Summary
The facility failed to provide an environment free from abuse for two residents, as evidenced by multiple incidents involving Resident #158 and Resident #15. Resident #158, who has a history of hallucinations, vascular dementia, Alzheimer's disease, major depressive disorder, delusional disorders, and anxiety, was involved in several physical altercations with other residents. The medical records and nursing notes indicate that Resident #158 exhibited aggressive behaviors, such as hitting, grabbing, and yelling at other residents and staff. Despite these behaviors, the facility did not have specific policies and procedures related to dementia care and behavioral monitoring/interventions, and the interventions documented were ineffective in managing the resident's behaviors. Resident #15 reported verbal abuse from an LPN, who allegedly made derogatory comments about the resident's weight and threatened to send her to another facility. The resident, who has a BIMS score indicating moderate impairment, was visibly upset and emotional distress was noted. Witness statements from staff and the resident's roommate confirmed that the LPN was loud and reprimanding, but the facility's investigation was inconclusive due to a lack of witnesses and evidence. The facility's response to the incident was inadequate, as the resident continued to be upset and the care plan interventions were not followed by the LPN. The facility's investigation into these incidents was found to be lacking, with no thorough or complete corrective action identified. The facility's policies on suspected abuse and neglect were not effectively implemented, as evidenced by the lack of documentation and follow-up on the incidents. The facility's failure to address the residents' behaviors and the staff's inappropriate conduct contributed to an environment that was not free from abuse, neglect, and mistreatment.
Failure to Implement Abuse Policy and Incomplete Investigation
Penalty
Summary
The facility failed to implement its abuse policy and procedure, as evidenced by incidents involving two residents. Resident #158, who has a history of hallucinations, vascular dementia, Alzheimer's disease, major depressive disorder, delusional disorders, and anxiety, was involved in multiple altercations with other residents. Despite being on medications such as Xanax, Lamictal, Zyprexa, and Mirtazapine, Resident #158 exhibited aggressive behaviors, including hitting, grabbing, and yelling at other residents and staff. The facility's documentation showed that interventions were ineffective, and there was no specific policy or procedure related to dementia care and behavioral monitoring/interventions. Another incident involved Resident #15, who reported verbal abuse by an LPN. The resident, who has a BIMS score indicating moderate impairment, claimed that the LPN made derogatory comments about her weight and threatened to send her to another facility. Witness statements from staff and the resident's roommate were inconclusive, and the facility's investigation did not substantiate the allegations. However, the resident remained visibly upset, indicating a failure to address her emotional distress adequately. The facility's investigation into these incidents was found to be incomplete and lacking thoroughness. There were no corrective actions noted in the follow-up of the investigation involving the two residents. The facility's administrator and social worker acknowledged the deficiencies in the investigation process, including the lack of statements from staff or witnesses and the absence of a resident-centered approach in the behavioral care plan.
Failure to Report and Investigate Abuse and Neglect
Penalty
Summary
The facility failed to report all allegations of abuse and neglect to the appropriate state agencies as required. This deficiency was identified during a long-term care survey, affecting two of the four residents reviewed for abuse. One resident expressed discomfort and pain from being left in a wheelchair during mealtime, and a staff member's comment was perceived as derogatory. The facility administrator acknowledged the incident but had not reported it to the state agency until the survey. Another resident, with a history of hallucinations, dementia, and aggressive behavior, was involved in multiple incidents of physical altercations with other residents and staff. Despite these occurrences, the facility's documentation showed that interventions were ineffective, and there was no evidence of a thorough investigation or corrective action. The facility lacked specific policies and procedures for dementia care and behavioral monitoring, which contributed to the ongoing issues with this resident. The facility's failure to report and investigate these incidents thoroughly was further compounded by inadequate documentation and ineffective interventions. The Director of Nursing acknowledged that the interventions were not resident-centered and that the facility did not provide documentation of any effective measures to ensure the safety of other residents. Additionally, an incident on November 8th was not reported or investigated, highlighting a systemic issue in handling and documenting abuse and neglect allegations.
Inadequate Investigation and Behavioral Management in LTC Facility
Penalty
Summary
The facility failed to conduct a thorough and complete investigation regarding allegations of verbal abuse for one resident and physical abuse for another. In the first case, a resident reported verbal abuse by an LPN, who allegedly made derogatory comments about the resident's weight and threatened to send her to another facility. Despite multiple witness statements and the resident's visible distress, the facility's investigation was deemed inconclusive due to a lack of corroborating witnesses and evidence. The LPN was suspended and later returned to work under a Last Chance Agreement, but the investigation did not substantiate the resident's claims. In the second case, a resident with a history of dementia and behavioral disturbances was involved in a physical altercation with another resident, resulting in bruising. The facility's documentation revealed a pattern of aggressive behavior by the resident, including hitting, kicking, and verbal aggression towards staff and other residents. Despite these ongoing issues, the facility lacked specific policies and procedures for dementia care and behavioral monitoring, and the investigation into the incident was incomplete, with no corrective actions identified. The facility's failure to adequately investigate and address these incidents highlights deficiencies in their handling of abuse allegations and behavioral management. The lack of thorough investigations and effective interventions for residents with behavioral issues contributed to the deficiencies identified by the surveyors.
Care Plan Deficiencies and Implementation Failures
Penalty
Summary
The facility failed to develop comprehensive care plans that included all diagnoses for several residents, leading to deficiencies in care. Resident #54's care plan omitted multiple diagnoses, including vascular dementia, pain, shortness of breath, and chronic kidney disease, among others. Similarly, Resident #15's care plan did not include diagnoses such as constipation, hypothyroidism, and COPD. Additionally, Resident #16's care plan was missing diagnoses like heart failure, anemia, and atrial fibrillation. These omissions were confirmed through record reviews and staff interviews, where it was noted that the care plans lacked specific medical terms and descriptions. Furthermore, the facility failed to implement care plan interventions for Resident #15 and Resident #29. For Resident #15, an intervention to maintain a calm environment during behavioral episodes was not followed, resulting in an escalation of the resident's behavior. In the case of Resident #29, the care plan required the resident to wear moon boots at all times to prevent pressure ulcers, but observations revealed that the resident was not wearing them, and staff were unaware of their location. These failures were acknowledged by the facility's administrator and staff during the survey process.
Failure to Provide Appropriate Care and Hospice Services
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for two residents. Resident #23 consistently refused both AM and PM medications from 05/24 to the present, with no physician intervention since 05/24. Despite being educated on the risks of refusing medications, Resident #23 continued to refuse them, and the care plan only included encouragement and masking the taste of medications. The resident's blood pressure was recorded as high 44 times since 06/01/24, yet no further physician intervention was documented. The Assistant Director of Nursing acknowledged the lack of documentation regarding actions taken for the resident's medication refusal. Resident #158 was involved in a physical altercation with another resident, resulting in bruising. The resident had multiple diagnoses, including hallucinations and vascular dementia, and was on a regimen of medications for pain management. Despite the resident's deteriorating condition and the presence of end-of-life symptoms, the facility failed to offer hospice services. The Director of Nursing confirmed that there was no policy or procedure related to hospice services, and the resident was not informed of the available hospice services, nor was there documentation of a care plan addressing end-of-life care. The deficiencies identified in the report highlight the facility's failure to provide appropriate interventions and care planning for residents refusing medications and those requiring end-of-life care. The lack of physician intervention and the absence of hospice service offerings contributed to the deficiencies noted during the survey process.
Inadequate Pain Management and Documentation
Penalty
Summary
The facility failed to provide adequate pain management for a resident, as evidenced by the lack of a formal pain assessment process and a comprehensive, individualized pain management plan. The resident, who had a history of hallucinations, vascular dementia, Alzheimer's disease, major depressive disorder, delusional disorders, and anxiety, was not properly assessed for pain levels despite exhibiting signs of pain such as yelling out, moaning, and facial grimacing. The facility's policy required regular pain assessments and collaboration between the physician, nursing staff, and the resident or their significant others to develop and reassess the pain management plan, which was not adhered to in this case. The resident was initially prescribed Tramadol for pain, which was not effective, leading to a change in medication to Roxanol. Despite this change, the facility did not document the resident's pain levels or the effectiveness of the medication consistently. The resident's care plan included interventions such as administering Roxanol as ordered, documenting its effectiveness, and implementing non-pharmacological measures like gentle rubbing, massage, and repositioning. However, there was no documentation of non-pharmacological interventions being attempted or their effectiveness. Interviews with the Director of Nursing revealed that the facility only documented pain if the resident was receiving as-needed pain medication, not for scheduled medications. This practice led to a lack of documentation and monitoring of the resident's pain levels and the effectiveness of the pain management plan. The deficiency was further highlighted by the absence of documentation of non-pharmacological interventions, which were part of the resident's care plan.
Incomplete and Inaccurate Resident Records
Penalty
Summary
The facility failed to maintain accurate and complete records for four residents during the survey process. For one resident, the POST form was missing the preparer's signature and date, which was confirmed by the administrator. Another resident's activity participation record inaccurately indicated active participation during a period when the resident was actively dying, a discrepancy that the Activities Director could not explain and was confirmed by the administrator. Additionally, a resident's pneumococcal vaccination was not documented under the immunization tab in the electronic medical record, despite having a signed physician's order and other relevant details recorded elsewhere. The Director of Nursing acknowledged this oversight. Furthermore, another resident's POST form was incomplete, lacking a healthcare provider's signature and date, which was confirmed by the administrator. This incomplete documentation could potentially impact the delivery of end-of-life care for the resident.
Failure to Notify Ombudsman of Hospital Discharge
Penalty
Summary
The facility failed to notify the State Ombudsman of a resident's discharge to the hospital. This deficiency was identified during a Long-Term Care Survey Process, where it was found that one of two residents reviewed for hospitalizations did not have the required notification sent. Specifically, Resident #49 was transferred to the hospital for an extended stay, and upon record review, it was discovered that no notification had been sent to the State Ombudsman. During an interview, the Licensed Social Worker admitted to not sending the notification, stating a lack of awareness of the requirement.
Failure to Integrate Hospice Care into Resident's Care Plan
Penalty
Summary
The facility failed to promptly develop and update a resident's care plan to include hospice-specific interventions and care coordination with the hospice provider. During an annual recertification survey, it was observed that the resident, who was admitted with severe cognitive impairment and was receiving hospice care, had an incomplete care plan. The care plan lacked essential guidance for staff on the resident's end-of-life needs, such as pain management protocols, emotional support resources, and end-of-life preferences. The Director of Nursing acknowledged that hospice coordination details were maintained separately in a binder and not integrated into the facility's care documentation for the resident. The Medication Administration Record (MAR) only included contact information for the hospice provider, without further entries addressing coordinated hospice care. This oversight does not meet the standards established under F657, which require prompt and precise updates to the care plan, creating a risk for inconsistent care delivery and unmet needs.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 92 citations issued within 25 miles in the last 12 months — 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Montgomery
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Montgomery General Hospital | 0.1 mi | ★★★★★ | 0 | 0 |
| Glasgow Hills Of Journey | 5.4 mi | ★★★★★ | 3 | 0 |
| Ansted Center | 12.9 mi | ★★★★★ | 19 | 0 |
| Marmet Center | 13.1 mi | ★★★★★ | 19 | 0 |
| Fayetteville Healthcare Center | 15 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.