Montgomery General Elderly Care

Inspectors wroteBased on observation, record review, and staff interview the facility failed to maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This failed practice was a random opportunity for discovery and had the potential to effect all residents currently residing in the facility during the Long-Term Care Survey Process. Facility Census: 57. Findings Include: a) Dining room Continuous observation of the dining room on [DATE] from 11:30 AM to 12:01 PM, revealed that at 12:01 PM, (3) three residents at the round table were served their lunch meal. During the continuous observation no hand hygiene was offered and/or performed with the residents in the dining room area. [...]

Inspectors wroteBased on observation and staff interview the facility failed to maintain a safe, clean, comfortable, and homelike environment by not providing a clean privacy curtain for Resident #27, and ensuring the residents' shower area for B Bath did not have paint peeling, missing caulking and rust on a shower caddy. These failed practices had the potential to affect more than a limited number of residents. Resident Identifier: #27. Facility Census: 57.

Inspectors wroteBased on record review and staff interview the facility failed to provide care and services in accordance with current standards of practices by not following its policy and physicians orders related to weights. This failed practice was found true for (3) three of (6) six residents reviewed for nutrition during the Long-Term Care Survey Process. Resident identifiers: #55, #9, and #11. Facility Census: 57. Findings Include: a) Weight monitoring policy A review on 11/25/25 at 10:30 AM, of the policy titled {Weight Monitoring}, Section 2, C, reads: If there is a noticeable discrepancy in the current weight vs previous weight, the resident shall be re-weighted and the charge nurse shall follow-up accordingly. b) Resident #55 A record review on 11/24/25 at 2:32 PM, revealed that on 11/05/25 Resident #55 weighted 173 pounds (lbs.), and weighed 183 lbs. on 11/10/25. [...]

Inspectors wroteBased on observation and staff interview, 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. This failed practice had the potential to affect a limited number of residents and was a random opportunity for discovery. Resident Identifier: #8. Facility Census: 57.

Inspectors wroteBased on record review and staff interview, the facility failed to document the resident's Medical Power of Attorney was notified when the resident experienced significant weight loss. This deficient practice had the potential to affect one (1) of four (4) residents reviewed for the care area of nutrition. Resident identifier: #11. Facility census: 57. a) Resident #11 The facility's policy and procedure titled Weight Monitoring with effective date January 2004 and most recent revision date April 2016 stated the Power of Attorney (POA) or legal representative would be notified when the resident experienced significant weight loss. Review of Resident #11's medical records revealed on 09/09/25 the resident weighed 160 pounds (lbs). On 10/07/25, the resident weighed 144 lbs. This is a 10 percent (%) weight loss in approximately four (4) weeks. [...]

Inspectors wroteBased on Observation, Interviews and record review the facility failed to ensure residents private and confidential information was kept safe. This was a random opportunity for discovery during the long term care survey process with the potential to affect more than a minimal number of residents. Facility census: 57 On 11/25/2025 at 9:20 AM while conducting rounds this surveyor observed a medication cart and computer left unlocked and screen open while the nurse went to get medication from the med room. A resident's name and information was left on screen and easily viewable to anyone who passed by. The cart left approx. three min unattended. On 11/25/25 at 9:26 AM in an interview with LPN #72 stated that they had to get a med the resident needed to complete a med pass. I was only gone for a minute. [...]

Inspectors wroteThe facility failed to ensure residents' comprehensive care plans were revised when changes occurred to the residents' interventions and residents' behaviors. This deficient practice had the potential to affect two (2) of 20 residents reviewed during the long-term care survey process. Resident Identifiers: #11 and #2. Facility census: 57.

Inspectors wroteBased on record review, staff interview, and resident interview, the facility failed to provide Activities of Daily Living (ADL) care related to showers for dependent residents. This failed practice was found to be true for one (1) of three (3) residents reviewed for ADL care during the long term care survey process. Resident identifier:#27 Facility Census: 57 Resident identifier #27 Facility census #57.

Inspectors wroteBased upon Observation, Interviews and record review the facility failed to ensure the facility remains free from accident hazards due to a medication cart and computer being left unlocked and in the main hallway A. This was a random opportunity for discovery during a long-term survey. Census:

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents' care was supervised by a physician. The facility failed to document the physician was aware of Resident #11's significant weight loss. This deficient practice had the potential to affect one (1) of four (4) residents reviewed for the care area of nutrition. Resident Identifier: #11. Facility Census: 57.

Inspectors wroteBased on record interview and staff interview, this facility failed to ensure all kitchen staff were up to date with their food handler cards. This failed practice was a random opportunity for discovery during the Long Term Care survey process. Employee identifiers: #4, #48, #55. Facility census: 57.

Inspectors wroteBased on observations, staff interview and policy review this facility failed to store food in accordance with professional standards for food service safety. This failed practice was a random opportunity of discovery during the Long Term Care survey process. Facility Census:

Inspectors wroteBased on record reviews and staff interviews the facility failed to ensure medical records were accurate for Resident #11 regarding DNR (do not Resuscitate) POST (Physician Orders for Scope of Treatment) and Resident #45 orders to offer thin liquids if refused thicken liquids. These failed practices were random opportunities for discovery and had the potential to affect more than a minimal number of residents residing in the long term care facility. Resident identifier: #11 and #45 Facility Census: 58 a) Resident #45 During record review of Resident #45's orders, revealed the following Diet order Start date: 11/04/25- End Date: Open Ended Description: REGULAR, MILDLY THICK LIQUIDS, PUREE Further [NAME] review of Resident #45's care plan revealed the following; Problem- start date 07/07/2022 Category: Nutritional status: [...]

Inspectors wroteBased on observations and resident council interviews, the facility failed to uphold residents' rights to voice grievances freely, without fear of reprisal, as required by CMS standards. This deficiency poses a potential risk to more than a limited number of who currently reside in the facility by creating an environment where individuals may hesitate to utilize the grievance process. Faiclity Census: 58. Findings Included: a) Resident Council Meeting On 10/22/24 at 2:04 PM, a special resident council meeting was held in the facility's main dining room, attended by the activities coordinator (permitted by the residents) and this surveyor. The meeting followed a standard agenda to review ongoing and new matters. During the meeting, the surveyor asked residents if they understood how to file an official grievance. [...]

Inspectors wroteBased on record review, resident interview and staff interview, the facility failed to provide an environment free from abuse. This was true for 2 (two) of 4 (four) residents reviewed during the Long Term Care Survey process. Resident identifiers: Resident #158, #30, #15. Facility census: 58.

Inspectors wroteBased on record review, resident interview and staff interview, the facility failed to implement the facility Abuse policy and procedure. This was true for 2 (two) of 4 (four) residents reviewed during the Long Term Care Survey Process. Resident identifiers: Resident #158, Resident #30 and Resident #15. Facility census: 58.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure all allegations of abuse and or neglect were reported to appropriate state agencies as required. This was true for two (2) of four (4) residents reviewed for the care area of abuse during the long term care survey. Resident Identifiers: #4 and #158. Facility Census: 58. Findings Include: a) Resident #4 A review of the facilities grievance and concerns on 10/22/24 at 5:38 PM, revealed a concern that reads as follows: (Resident #4 named) wanted put in bed during mealtime and two staff have to put her in bed and most staff were feeding other residents and told her soon as they could put her to bed they would. Resident stated that a nurse said Poor Thing to her because she was ready to go to bed and stated her hips were hurting from the wheelchair. The staff that made the comment received verbal disciplinary action. [...]

Inspectors wroteBased on record review, resident interview, observation and staff interview, the facility failed to complete a through and complete investigation regarding allegations of verbal abuse for Resident #15 and physical abuse for Resident #158. This was true for two (2) of four (4) residents reviewed under the care area of abuse. Resident Identifiers: #15 and #158. Facility Census: 58. Findings Include: a) Resident #15 On 10/21/24 at 1:30 PM, a review of the facility's reported incidents (FRI) was completed. The review found a FRI dated 09/16/24 for Resident #15 (however, the date range for the incident is noted from 09/13/24 through 09/15/24). The information obtained from the FRI, stated verbal abuse from Licensed Practical Nurse (LPN) #73. Resident #15 stated, LPN #73 was fussing at her and became loud and was yelling at the resident. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to develop the care plan which includes all diagnoses for Resident #54, Resident #15 and Resident #16; and implement the care plan for Resident #15 and Resident #29. This was true for four (4) of 18 residents reviewed during the survey process. Resident Identifiers: #54, #15, #16 and #29. Facility Census: 58. Findings Included: a) Resident #54 On 10/22/24 at 1:00 PM, the care plan was reviewed for Resident #54. The care plan did not include the following diagnoses: --Vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to provide treatment and care in accordance with professional standards of practice. Resident #23 refuses all AM and PM medications and has had no physician intervention since 05/24. In addition the facility failed to offer hospice to Resident #158. This failed practice was found true for (2) two of 18 sample residents reviewed during the long term care survey process. Resident identifier: #23 and #158. Facility Census 58. Finding Included: a) Resident #23 A record review on 10/21/24 at 2:06 PM, revealed Resident #23 had multiple notes from 05/24 to present of refusing AM and PM medications. The notes also revealed Resident #23 was educated on the risk of refusing the medications; however Resident #23's Brief Interview for Mental Status (BIMS) score is 99. [...]

Inspectors wroteBased on record review and staff interview the facility failed to identify, treat, monitor, and manage the resident's pain to the extent possible in accordance with the comprehensive assessment and care plan, current professional standards of practice, and the resident's goals and preferences. This is due to the facility ' s failure to implement a formal pain assessment process and develop a comprehensive, individualized pain management plan. This was true for 1 (one) of 2 (two) resident's reviewed for the Long Term Care Survey Process. Resident identifier: Resident #158. Facility census: 58.

Inspectors wroteBased on record review and staff interview, the facility failed to maintain an accurate and complete record for Resident #15's Physician's Orders for Scope of Treatment (POST) form, Resident #54's activity participation record, Resident #16's administration of the pneumococcal vaccination, and Resident #37's POST form. This was true for four (4) of 18 residents reviewed during the survey process. Resident Identifiers: #15, #54, #16, and #37. Facility Census: 58. Findings Included: a) Resident #15 On [DATE] at 11:00 AM, a record review was completed for Resident #15. The review found the POST form did not include the Preparer's signature and date. On [DATE] at 11:50 AM, the Administrator was notified and confirmed the POST form was incomplete. b) Resident #54 On [DATE] at 4:15 PM, a record review was completed for Resident #54. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to notify the State Ombudsman of a discharge to the hospital. This failed practice was found true for (1) one of (2) two residents reviewed for hospitalizations during the Long-Term Care Survey Process. Resident identifier: #49. Facility Census 58.

Inspectors wroteBased on record review and staff interview, the facility failed to promptly develop and update Resident #37's care plan to include hospice-specific interventions and care coordination with the hospice provider. This deficiency led to an incomplete care plan lacking essential guidance for staff on the resident's end-of-life needs, creating a risk for inconsistent care delivery and unmet needs. Resident Identifier: #37. Facility Census: 58. Findings Included: a) Resident #37 During an annual recertification survey on 10/22/24, at 11:50 AM, this surveyor observed Resident #37, who was admitted on [DATE] with a BIMS score of 4, indicating severe cognitive impairment. The resident, currently receiving hospice care, responded only with nonverbal sounds, demonstrating limited capacity to participate in care planning. [...]

Inspectors wroteBased on record review, staff interview, and resident interview the facility failed to protect Residents from mental, physical, and sexual abuse resulting in actual harm, including physical pain, mental anguish and psychosocial harm to multiple residents, as perpetrated by Resident #49's ongoing pattern of irrational and aggressive behaviors. This was true for seven (7) of 58 residents. Two (2) residents had to be sent to the hospital for physical harm resulting from Resident #49's actions. Several residents complained of living in fear of Resident #49 which is psychosocial harm. Resident #49 was found in another residents room in their bed completely nude and touching the other resident which is a form of sexual abuse. Resident identifiers: Resident #49, Resident #31, Resident #27, Resident #52, Resident #16, Resident #20, Resident #44 and Resident # 54. Facility census: 58. [...]

Inspectors wroteBased on record review, staff interview and resident interview the facility failed to address Resident #49's dementia care needs, resulting in the resident's inability to achieve her highest level of functioning and maintain her psychosocial well-being. Resident identifiers: #49. Facility census: 58. Findings Included: a) Progress Notes regarding Resident #49's behaviors affecting other residents. During a record review on 12/13/22 Resident #49 medical record revealed the following progress notes: -10/18/2022 at 6:57 AM Typed as writtenResident went into room A11-2. Scratched resident in bed 11-2 on arm. Resident redirected back into own room. -10/13/22 at 2:33 PM typed as written Resident has been going in resident rooms on b hall. These residents have yelled at her to get out. Some resident's are scared of her. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure resident to resident altercations resulting in falls and an elopement were reported to the appropriate state agencies within the required time frame. These were random opportunities for discovery during the long-term care survey. Resident Identifiers: Resident #49, Resident # 31, and Resident #27. Facility Census: 58 Findings Included: a) A review of a facility policy titled Resident Abuse/Neglect read as follows: I. POLICY: .to ensure that residents are not subjected to abuse by staff, other residents, consultants, volunteers, staff or other individuals. II. PURPOSE: It is the purpose of this policy to define forms of abuse and neglect in order to facilitate education, recognition and reporting III. DEFINITIONS: [...]

Inspectors wroteBased on medical record review, staff interviews, and the guidance of the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to ensure Resident #50, received pressure ulcer care, consistent with professional standards of practice. Specifically, the facility failed to monitor and access the existing pressure ulcers weekly. This was true for one (1) of one (1) resident investigated for pressure ulcers. Resident Identifier: #50. Facility census was 58.