Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Hospital during CMS and state inspections, most recent first.
All beds in the facility, both occupied and unoccupied, had bed rails installed without prior use of alternatives or assessment for entrapment risk. Staff interviews revealed a lack of inspection policies, outdated equipment, and no ongoing side rail assessments beyond admission. Documentation did not address entrapment risk, and staff were unaware of manufacturer guidelines for the various bed rails in use.
The facility did not provide written notification of hospital transfers or the bed hold policy to the MPOA for three residents, and also failed to notify the ombudsman for two of these residents. These omissions were confirmed by record review and the DON.
Surveyors found multiple food items in the kitchen and dry storage areas without proper labeling or open dates, including salads, eggs, cream, and dry goods. Additionally, expired milk was discovered, and a cooler with a damaged seal was not maintaining safe temperatures for milk and juice. The Dietary Manager confirmed these deficiencies in food labeling, rotation, and temperature control.
Surveyors identified multiple infection control lapses, including the absence of a water flow diagram in the water management plan, improper storage of a soiled bath basin, oxygen tubing and cannula left in a resident's room when not in use, and a urinal not stored in an appropriate container. These deficiencies were confirmed by staff and leadership.
Surveyors found that a milk cooler used for tray line service had a damaged seal, causing it to not maintain safe temperatures for milk and juice. The Dietary Manager was unaware of the issue until it was pointed out, and temperature checks revealed that both milk and juice were above recommended safe levels. This deficiency had the potential to affect a limited number of residents.
Two residents sharing a room were not served lunch at the same time, with one resident receiving and eating his meal about 15 minutes before the other, who required staff assistance. This resulted in a lack of dignified meal service for both residents, as confirmed by staff interviews.
A medication cart with an unlocked computer screen was left unattended in a corridor while an LPN was in the employee lounge, out of sight from the cart. The DON confirmed that both the cart and computer should have been locked to maintain privacy and confidentiality.
A resident with a neurologist-confirmed diagnosis of Parkinsonism did not have this condition marked in the MDS under the Neurological section, as confirmed by the DON during review and interview.
Surveyors identified that the facility did not ensure accurate PASARR documentation for two residents. One resident's PASARR omitted diagnoses of dementia with anxiety, bipolar disorder, and depression, while another resident's PASARR incorrectly included major depressive disorder and failed to list Parkinsonism, despite these being reflected in the medical record.
Surveyors found that the facility did not develop or implement complete care plans for two residents. One resident's care plan failed to address diagnoses of Parkinsonism and a history of suicidal ideations, while another resident's care plan did not include or act on information about food preferences despite concerns about poor nutrition. The DON confirmed these omissions during interviews.
A medication cart was found unlocked and unattended in a corridor near the elevators, with its computer screen also left unlocked. An LPN responsible for the cart was in the employee lounge without a line of sight to the cart. The DON confirmed that the cart and computer should have been secured.
A resident with documented weight loss had multiple undocumented meal intake percentages over several weeks. The resident's representative reported poor eating and food dislikes, but there was no record of food preferences or input from a physician or dietician. The DON confirmed the absence of this information and noted that dietary management was handled externally.
A resident was not offered a pneumococcal vaccination after admission, with no documentation of immunizations found in their record. The DON confirmed the vaccine had been ordered but was not yet available, resulting in the resident not receiving the vaccination.
Failure to Assess and Use Alternatives Prior to Bed Rail Installation
Penalty
Summary
The facility failed to use appropriate alternatives before installing bed rails and did not assess each resident for the risk of entrapment prior to installation. Observations revealed that all beds, both occupied and unoccupied, had bed rails installed, with four different types of bed rails in use throughout the unit. The Maintenance Director confirmed that beds are not inspected prior to new admissions and there is no policy for inspecting bed rails. The Director of Nursing stated that all residents have bed rails because the bed controls are on them and acknowledged the use of various types of beds and rails, with no knowledge of the manufacturer's guidelines. Record review showed that side rail assessments and consents were only completed upon admission, with no ongoing assessments or documentation of entrapment risk. The MDS Registered Nurse confirmed that assessments are only done at admission and that the current assessment form does not address entrapment risk. No further information or documentation regarding bed rail safety or manufacturer guidelines was provided by the end of the survey.
Failure to Provide Required Transfer Notifications and Bed Hold Policy
Penalty
Summary
The facility failed to provide required written notifications and documentation related to resident transfers to the hospital for three residents. Specifically, for one resident, there was no evidence that the Medical Power of Attorney (MPOA) was notified in writing of the transfer, nor was the bed hold policy provided. For two additional residents, the facility did not provide written notification to the MPOA regarding the hospital transfer, did not provide the bed hold policy, and failed to send notification to the ombudsman. These deficiencies were confirmed through record review and staff interviews, with the Director of Nursing acknowledging the absence of the required forms and notifications in the residents' charts.
Deficient Food Labeling and Temperature Control in Kitchen
Penalty
Summary
Surveyors observed multiple instances of improper food labeling and storage in the facility's kitchen and dry stock areas. Specifically, two salads, a carton of pasteurized eggs, a carton of heavy whipping cream, and a carton of cream of wheat were found in the walk-in cooler without any dates or labels. Additionally, a bag of flour, a bag of cheesecake mix, and a bag of Tostito corn chips in the dry stock room were missing open dates. The Dietary Manager confirmed these items were not labeled correctly. Further, a carton of milk with a use-by date that had already passed was found in the kitchen, and the Dietary Manager acknowledged it had been missed during milk rotation. During the same inspection, a cooler with a damaged seal was found, resulting in improper temperature control. The milk inside the cooler was measured at 41.4°F, cranberry juice at 57.6°F, and the cooler itself at 51°F, all above the recommended holding temperature of under 40°F. The Dietary Manager confirmed the cooler was not maintaining proper temperatures due to the broken seal and was unsure about the handling of the juice. These findings indicate failures in food labeling, rotation, and temperature control, with the potential to affect more than a limited number of residents in the facility.
Infection Control Lapses in Environmental and Equipment Storage
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices as evidenced by several observed deficiencies. During a review of the facility's water management plan, it was found that there was no water flow diagram available, a fact confirmed by both an employee and the Administrator. Additionally, a soiled bath basin was observed on the floor under the sink in a resident's room, and staff confirmed that it should not have been stored there. Further observations included oxygen tubing and a cannula left on a table and hanging onto the floor in a resident's room, despite the resident not using oxygen. This was acknowledged by nursing staff and the DON as improper storage. In another instance, a urinal was found hanging on a commode handle without being placed in an appropriate storage container, which was also confirmed by staff as incorrect practice. These findings were based on direct observation, staff interviews, and documentation review.
Failure to Maintain Proper Cooler Seals Resulting in Unsafe Food Temperatures
Penalty
Summary
The facility failed to ensure that the tray line milk cooler maintained proper seals, resulting in its inability to keep milk and juice at safe temperatures below 40 degrees Fahrenheit. During an initial kitchen tour, surveyors observed that the cooler's seal was damaged, causing a gap and preventing the cooler from sealing correctly. Further inspection revealed that the milk inside the cooler did not feel very cold to the touch. When interviewed, the Dietary Manager was unaware of the damaged seal and, upon checking, found the milk temperature to be 41.4°F, the cranberry juice at 57.6°F, and the inside of the cooler at 51.0°F. The Dietary Manager confirmed that the cooler was not properly holding temperatures due to the broken seal. This deficiency was identified as a random opportunity for discovery and had the potential to affect a limited number of residents in the facility, which had a census of 28 at the time.
Failure to Serve Meals Simultaneously to Roommates Compromises Resident Dignity
Penalty
Summary
During a lunch meal observation, two residents who shared a room were not served their meals at the same time, resulting in one resident receiving and consuming half of his food before the other was served. The time difference between meal service for the two residents was approximately 15 minutes. Staff interviews confirmed that the delay occurred because one resident required staff assistance to eat, and as a result, was served later than his roommate. This practice failed to ensure that both residents were served in a dignified manner, as required by resident rights regulations.
Failure to Ensure Privacy and Confidentiality During Medication Administration
Penalty
Summary
The facility failed to maintain privacy and confidentiality of residents' personal and medical records during medication administration. An observation revealed that a medication cart was left unlocked in the corridor by the elevators, with the computer screen also left unlocked and unattended. The LPN responsible for the cart was found in the employee lounge, out of line of sight from the cart, and stated they were getting a drink. The Director of Nursing confirmed that both the medication cart and computer should have been locked.
Failure to Accurately Document Parkinsonism Diagnosis in MDS
Penalty
Summary
The facility failed to provide an accurate Minimum Data Set (MDS) diagnosis for a resident with a documented medical condition. Record review showed that a neurologist had diagnosed the resident with Parkinsonism, as indicated in a consultation record. However, when reviewing the resident's MDS, completed several months after the neurologist's diagnosis, Parkinsonism was not marked under the Neurological section. This omission was confirmed by the Director of Nursing during an interview, verifying that the diagnosis was not identified in the MDS.
Inaccurate PASARR Documentation for Two Residents
Penalty
Summary
The facility failed to provide accurate Pre-admission Screening and Resident Review (PASARR) documentation for two residents. For one resident, the PASARR completed did not include three active diagnoses: unspecified dementia with anxiety, bipolar disorder in partial remission with the most recent episode depressed, and unspecified depression. For the second resident, the PASARR inaccurately listed major depressive disorder, which was not an active diagnosis, and failed to identify Parkinsonism, which was present in the resident's medical record. These discrepancies were confirmed through record review and staff interviews, indicating that the PASARRs did not accurately reflect the residents' current diagnoses at the time of review.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement complete care plans addressing all identified needs for two residents. For one resident, the medical record listed diagnoses of Parkinsonism and a history of suicidal ideations, but neither diagnosis was included in the resident's person-centered care plan. The Director of Nursing confirmed these omissions. For another resident, concerns about poor eating and specific food dislikes were raised by the resident's representative. Although the care plan included an intervention to assess food preferences and provide desired food choices, the facility did not have a documented list of the resident's likes and dislikes, and the Director of Nursing acknowledged that this information was not maintained by the facility. These findings were based on record reviews, staff interviews, and resident interviews during the survey process.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A deficiency was identified when a medication cart was observed unlocked and unattended in the corridor near the elevators, with its computer screen also left unlocked. At the time of the observation, the LPN responsible for the cart was in the employee lounge and did not have a line of sight to the cart, stating they were getting a drink. The Director of Nursing confirmed that both the medication cart and computer should have been locked.
Failure to Document Meal Intake and Address Weight Loss
Penalty
Summary
The facility failed to document all meal intake percentages for a resident identified with weight loss, as evidenced by missing documentation for several meals over a period of time. The resident experienced a 5.1% weight loss within one month, with weights recorded at multiple intervals showing a consistent decline. The resident's representative expressed concern about poor eating and specific food dislikes, but there was no documentation of food preferences or dislikes in the resident's records. Additionally, there was no documentation from the facility physician or registered dietician regarding the resident's nutritional status or interventions. The Director of Nursing acknowledged the lack of information on food preferences and indicated that dietary management was handled by another facility.
Failure to Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to offer a pneumococcal vaccination to one resident, as identified during a review of five residents under infection control. The resident in question was admitted to the facility and, upon interview, inquired about receiving a pneumonia shot. Record review revealed no documentation of any immunizations received by the resident. Further interview with the DON confirmed that although the vaccine had been ordered, it had not yet arrived, and the resident had not been offered the pneumococcal vaccination since admission.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Montgomery
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Montgomery General Elderly Care | 0.1 mi | ★★★★★ | 14 | 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.