Montgomery Nursing and Rehabilitation Center

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents remained free from abuse for one of two residents (Resident #57) reviewed for abuse. Specifically, Resident #49's comprehensive care plan was not reviewed or revised after increased agitation, paranoia, hallucinations and verbal aggression on 04/15/2026. Subsequently, on 04/17/2026, Resident #49 physically assaulted Resident #57 while in the dining room, by grabbing their neck and placing Resident #57 in a choke hold. This resulted in actual physical and psychosocial harm to Resident #57 that was not Immediate Jeopardy.

Inspectors wroteBased on observation and interview the facility failed to ensure that kitchen equipment and floors were maintained in a sanitary condition to prevent food contamination and safety hazards. Specifically, pooling water was present on the kitchen floor and in a closed floor drain and loose flaking residue was noted on the food slicer meat grip.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that the resident environment remained as free from accident hazards as possible for two of seven residents (Resident #103 and Resident #104) reviewed for accidents. Specifically, there was no documented evidence that routine maintenance and filter replacement and/or cleaning was performed prior to a 04/14/2025 oxygen concentrator fire in the room of Resident #103 with a physician's order for continuous oxygen via nasal cannula. Following the incident, Resident #103 and roommate Resident #104 were sent to the hospital for evaluation of possible smoke inhalation and later returned to the facility. Additionally, the facility did not have documented evidence that a timely thorough investigation was completed after the 04/14/2025 incident.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain essential electrical equipment in a safe and functional operating condition. Specifically, the plastic covering on an electrical outlet near the kitchen oven was broken and contained visible live electrical wires and components.

Inspectors wroteBased on observation and interview during the recertification survey conducted from 1/7/25 to 1/14/25, the facility did not ensure a clean and home like environment was maintained for 1 of 2 nursing units (South unit). Specifically, (1) the floor and radiators in room [ROOM NUMBER], #129 and #130 were dirty, the walls and closet trim in room [ROOM NUMBER] had chipped and scuffed paint, room [ROOM NUMBER] had feces on the toilet and room [ROOM NUMBER] had a brown liquid spill on the floor and (2) a meal tray was provided to Resident #24 and contained a hot beverage cup and utensils with a build up of lime deposit stains.

Inspectors wroteBased on record review and interview conducted during the recertification survey from 1/7/25 to 1/14/25, the facility did not ensure sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility did not meet minimum staffing requirements for Certified Nurse Aides as documented on the Facility Assessment on 10 of 28 days reviewed.

Inspectors wroteBased on record review and interview during the recertification survey from 1/7/25 to 1/14/25, the facility did not ensure Certified Nurse Aide performance appraisals were completed at least once every 12 months for 5 of 5 Certified Nurse Aides reviewed. Specifically, performance appraisals were not documented every 12 months for Certified Nurse Aides #1, #2, #3, #4, and #5.

Inspectors wroteBased on observation and interview conducted during the recertification survey from 1/7/25 to 1/14/25, the facility did not ensure food was stored in accordance with professional standards for food service safety. Specifically, 1. the refrigerators contained food and/or packages that were unlabeled, had no received on date, and did not contain an expiration date, 2. the walk-in freezer contained food and/or packages that were unlabeled and not properly sealed to prevent freezer burn, and 3. the dry storage pantry contained food products that did not contain expiration dates.

Inspectors wroteBased on observation, record review, and interview during the recertification survey from 1/7/25 to 1/14/25, the facility did not ensure infection prevention and control program designed to prevent the development and transmission of communicable diseases and infection was maintained for 2 of 8 residents ( #49, and #66) reviewed for Infection Control. Specifically, 1) the facility did not properly implement transmission-based precautions for Resident #49 and 2) the facility did not ensure an infection surveillance plan was implemented for identifying, tracking, and monitoring infections, communicable diseases, and outbreaks for Resident #49 and # 66

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated surveys (NY00359070 ) from 1/7/2025 to 1/14/2024, the facility did not ensure that an effective pest control program was maintained so that the facility was free of rodents on 1 of 2 units (South) and the physical therapy department. Specifically, there was no documented evidence of facility follow up/monitoring to assess ongoing need and/or effectiveness of interventions put in place by the pest control company to eradicate and/or contain mice.

Inspectors wroteBased on observation, interview, and record review conducted during a recertification survey from 01/07/25 to 01/14/25, the facility did not ensure residents had the right to a dignified experience for 2 of 2 residents (Residents # 65 and Resident # 341) reviewed for dignity. Specifically, 1) Licensed Practical Nurse # 31 was observed standing over Resident # 65 while feeding them their lunch meal and 2) Resident # 341's urine collection bag was observed uncovered and visible to other residents and visitors.

Inspectors wroteBased on record review and interview during the recertification survey from 1/7/25 to 1/14/25, the facility did not ensure that a Level 1 Screen was thoroughly completed prior to admission to the nursing home for 2 of 23 residents (Resident #1 and #30) reviewed for Pre-admission Screening. Specifically, questions #23 through #27 were left blank on the Level 1 Screen for Resident #1,and questions #27 through #35 were left blank on the Level 1 Screen for Resident #30.

Inspectors wroteBased on observation, record review and interview conducted during the recertification survey from 1/7/25 to 1/14/25, the facility did not ensure that the comprehensive person-centered care plan was followed for 1 of 4 residents (Resident #11) reviewed for Accidents. Specifically, for Resident #11, the use of Bilateral Fall Mats were not implemented as per Care Plan after a 10/8/24 fall. The Findings Include: The undated Policy and Procedure titled Accident/Fall Prevention documented a plan of care to prevent falls/injury would be developed. The plan of care would include but not limited to floor mattress, low bed. Each resident would be provided a fall prevention device as needed and the staff would ensure that they were in working order. Resident #11 was admitted with diagnoses including but not limited to Encephalopathy, Dementia, and Chronic Obstructive Pulmonary Disease. [...]

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 1/07/2025 from 1/14/2025, the facility did not ensure residents who required dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) received services consistent with professional standards of practice for 1 of 1 resident (Resident #68) reviewed for Dialysis. Specifically, there was no documented evidence of consistent assessment and oversight before, during and after dialysis treatment for Resident #68 who received Hemodialysis treatments at a community-based Dialysis Center. Additionally, communication and collaboration between the facility and the Dialysis Center was not consistently documented

Inspectors wroteBased on observation, record review, and interview conducted during the recertification survey from [DATE] to [DATE], the facility did not ensure a medication error rate of no more than 5%, 2 of 35 opportunities (5.71%) for 2 of 4 residents (Resident #34 and Resident #31) reviewed for Medication Administration. Specifically, 1) Resident #34 was administered one Tums 200 mg/ Calcium 500 mg chewable tablet instead of two as per physician order, and 2) Resident #31 did not receive Vitamin C as per physician order.

Inspectors wroteBased on record review and interview during the recertification and abbreviated surveys (NY00360214) conducted from 1/7/25 to 1/14/25, the facility did not ensure residents were free from significant medication errors for one of one resident (Resident #70) reviewed for Neglect. Specifically, staff administered medications to Resident #70 including Doxycycline 100 mg (antibiotic), Metformin 500 mg (diabetes pill), [NAME] 95-100 mg ( heart pill), Torsemide 20 mg (water pill), Metoprolol ER 75 mg (blood pressure pill), and Farxiga 10 mg (kidney pill), which were not physician prescribed for Resident #70 resulting in Resident #70 developing chest pain and being transferred to an acute care hospital for evaluation.

Inspectors wroteBased on observation, record review and interview conducted during an abbreviated survey (NY00358461) on 10/28/24, the facility did not ensure each resident received treatment and care in accordance with professional standards of practice for 1(Resident #1) of 3 residents reviewed for accidents. Specifically, a left hip x-ray was not performed as per the 10/20/24 physician order after Resident #1 who was admitted status post (previous) left hip open reduction and internal fixation (hip fracture repair) sustained a fall 3 days after admission.

Inspectors wroteBased on observation, record review and interviews conducted during an abbreviated survey (NY00358461) the facility did not ensure each resident received adequate supervision consistent with resident's needs goals and care plan to prevent accidents. This was evident for 1 (Resident #1) of 3 residents reviewed for accidents. Specifically, Resident #1 who was assessed as having suicidal ideation and a high risk for falls on admission had a physician's order for 15-minute safety checks. There was no documented evidence that 15-minute safety checks were consistently done as per the 10/18/24 physician's order. The certified nursing aide care instructions did not include the order for 15-minute safety check. Resident #1 was found on the floor in their room on 10/20/24.

Inspectors wroteBased on record review and interviews conducted during the abbreviated survey (NY00358461), the facility did not ensure that a resident received appropriate behavioral care intervention to address suicidal ideation for 1 (Resident #1) of 3 residents reviewed for behavioral health care. Specifically, Resident #1, was admitted with a diagnosis of depression and verbalized having suicidal ideation with no plan of self-harm on 10/18/2024. A physician's order dated 10/18/2024 for 15-minute safety checks documented no indication for the order. 2)The 15-minute safety check was not listed as an intervention on the suicidal ideation history care plan or included on the certified nurse aide instruction. The 15-minute safety checks were not consistently documented by staff per the physician's order. [...]

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00305611), the facility did not ensure that the resident and/or their representative was informed in advance of treatment risks and benefits, options, and alternatives when a medication was changed for 1 of 3 (Resident #1) residents reviewed. Specifically, Resident #1's representative was not informed of the risks, benefits, and treatment alternatives prior to increasing the Clonazepam 0.5mg from once daily to twice daily. Resident #1 was on palliative care, had 2 recent falls from bed, was confused and agitated.

Inspectors wroteBased on observation, record review, and interview conducted during the abbreviated survey (NY00318405), the facility did not ensure residents were free from abuse for 1of 3 residents (Resident#1) reviewed. Specifically, on 6/14/2023 a Licensed Practical Nurse (LPN#1) was witnessed by another resident (Resident #2-witness) grasping Resident#1 who was severely impaired by their shirt collar twice and pulled their body to the back of their wheelchair as Resident#1 was leaning forward/ and was attempting to self-transfer. Resident#1 had a history of confusion and restlessness. Resident#2 informed Certified Nurse Aide (CNA#1) who reported incident to the Registered Nursing Supervisor (RNS) and Resident #1 was assessed with no injuries.

Inspectors wroteBased on observations, interviews and record review conducted during a 7/22/2022-7/15/2022 Recertification Survey, the facility did not ensure that the comprehensive person-centered care plan was developed for 1 of 2 residents (#3) reviewed for mood and/or behaviors. Specifically, a comprehensive care with measurable goals and interventions was not developed to address chewing behaviors for Resident #3. The finding is: Resident #3 was admitted to the facility 10/26/18 and had diagnoses including but not limited to Non-Alzheimer's Dementia, Anemia, and Hypertension. The 7/2/2021 Annual Minimum Data Set (MDS; a comprehensive resident assessment tool) documented Resident #3 had severely impaired cognition, behavioriol symptoms occurring 1-3 days, received extensive assist of one staff for hygiene and dressing, and received no antipsychotics or psychology services. [...]

Inspectors wroteBased on record review and interview during the recent recertification survey, the facility did not ensure that care plans were developed with appropriate goals and interventions to address specific care needs of the residents. This was evident for 2 of 22 sampled residents. There was no evidence of Care Planning related to cellulitis for Resident #25 as well as wounds and a venous ulcer for Resident #75.

Inspectors wroteBased on interview and record review conducted during the most recent recertification survey, it cannot be ensured that the facility notified the designated representative in writing of the facility's bed hold policy. This was evident for 1 of 3 residents reviewed for hospitalization (Resident #61).

Inspectors wroteBased on observation, interview and record review conducted during a recertification survey, it cannot be ensured that comprehensive care plans for 2 of 22 sampled residents were revised to address status changes. Specifically, the Care Plans did not include changes in skin condition for Resident #2 and hearing ability for Residents #2 and #25.

Inspectors wroteBased on observation, record review and interview conducted during the recertification survey, it could not be ensured that residents received proper treatment and assistive devices to maintain hearing ability. This was evident for 1 resident out of 3 residents (Resident #2) reviewed for vision and hearing.

Inspectors wroteBased on observation, interview and record review conducted during a recertification survey, it cannot be ensured that the facility provided pharmaceutical services to assure accurate acquiring, receiving and administration of medications to meet the needs of each resident. Specifically, expired medications were found on one of six medication carts and in one of two medication rooms.

Inspectors wroteBased on observation and interview during the recertification survey, the facility was not in compliance with Section 915 of the 2015 edition of the International Fire Code as adopted by New York State, which requires the installation of carbon monoxide detectors in buildings with fuel-fired appliances. Carbon monoxide detectors were not installed in mechanical rooms containing fuel fired equipment (laundry room, boiler room, generator room, etc) or in previously approved locations.

Inspectors wroteBased on observation and interview during a Recertification survey it could not be ensured that the facility adhered to infection prevention and control program practices.

Inspectors wroteBased on observation and interview conducted during the most recent recertification survey, the facility did not ensure that the residents' environment was maintained in a clean manner. Specifically, floors, doors, baseboard trims and ceiling tiles were not being maintained in a clean condition. This was noted on 2 of 2 units (North and South units), in the Main Dining Room and the lobby area.

Inspectors wroteBased on record review and interview during the most recent recertification survey, it cannot be ensured that the facility notified residents' representatives in writing when transferred to the hospital. This was evident for 3 of 3 residents (Residents #9 , #61 and #76) reviewed for hospitalization.