Lake Montgomery Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Lake Montgomery Health and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF569Jun 10, 2021

  Based on interview and record review, the facility failed to notify residents when the amount in the resident's account reached $200 less than the SSI (Social Security Income) resource limit for 3 of 5 residents reviewed, Residents #37, #24, and #72, in a total sample of 40 residents. Findings: Review of Resident #37's Resident Trust Statement from 5/1/2020 to 6/3/2021 revealed an opening balance of $850.00 and an ending balance of $4,910.38. There was no documentation in the residents financial file informing the responsible party that the resident was over Medicaid resource limit. Review of Resident #24's Resident Trust Statement from 6/1/2020 to 6/4/2021 revealed an opening balance of $3511.80 and an ending balance of $8,212.42. […]

• No harm, potential for more than minimal, isolatedF580Jan 29, 2026

  Based on interview and record review, the facility failed to ensure the resident's representative was notified of the resident's refusal of medication administration for 1 of 4 residents, Resident #1, reviewed for medication administration.Findings include:Review of Resident #1's admission Data documented the resident was admitted on [DATE] with medical diagnoses to include type 2 diabetes mellitus with foot ulcer; difficulty in walking, not elsewhere classified; and non-pressure chronic ulcer of other part of right foot with necrosis of muscleReview of Resident #1's MDS (Minimum Data Set) Evaluation, quarterly assessment dated [DATE], documented the resident had a BIMS (Brief Inventory of Mental Status) Score of 09 out of 15, which indicated some cognitive impairment.Review of Resident… […]

• No harm, potential for more than minimal, isolatedF655Jan 29, 2026

  Based on record review and interview, the facility failed to ensure resident care plans regarding advanced directives were updated for 1 of 4 residents, Resident #1, reviewed for accuracy of care plans.Findings include:Review of Resident #1's admission Data documented the resident was admitted into the facility on [DATE] with an Advanced Directive of Full Code status (if a resident is absent of life the health care team is to use all available and necessary life-saving measures to resuscitate).Review of Resident #1's Care Plan read, Focus: Advanced Directives: Resident has an established CPR [cardiopulmonary resuscitation] (Full Code) order in place. Date Initiated: [DATE]. […]

• No harm, potential for more than minimal, isolatedF842Jan 29, 2026

  Based on interview and record review, the facility failed to ensure complete and accurate records for 1 of 4 residents, Resident #1, reviewed for medication administration. Findings include:Review of Resident #1's MAR (Medication Administration Record) for 11/01/2025 - 11/30/2025 read, HumaLOG KwikPen (an insulin pen) 100 UNIT/ML (100 units per milliliter) solution pen injector: Inject as per sliding scale: if [blood sugar reading] 151 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10 Call MD, subcutaneously before meals and at bedtime for DM (diabetes mellites) - Start Date 09/08/2025 0630 (6:30 AM) -D/C (discontinue) Date 12/22/2025 1232 (12:32 PM). […]

• No harm, potential for more than minimal, isolatedF641Jul 31, 2025

  Based on record review and interview, the facility failed to ensure resident assessments were accurate for 1 (Resident #19) of 3 residents reviewed for respiratory services.Review of Resident #19 Minimum Data Set (MDS) titled Quarterly dated 7/10/2025 documented resident did not use oxygen therapy.Review of Resident #19 vital task for oxygen saturations documented on 7/8/2025 at 12:53 PM oxygen via nasal cannula, on 7/7/2025 at 6:05 AM oxygen via nasal cannula, 7/5/2025 at 5:16 AM oxygen via nasal cannula, 7/4/2025 at 12:42 AM oxygen via nasal cannula, and 7/3/2025 at 3:38 AM oxygen via nasal cannula.Review of Resident #19 nurses notes dated 7/8/2025 read, O2 [oxygen] sats [saturation]: 97% Method: Oxygen via Nasal Cannula.Review of Resident #19 physician order dated 4/8/2025 read, Oxygen… […]